Information infrastructure and quality person-centred support in supported accommodation: An integrative review

ObjectivesTo integrate findings on the information infrastructure for people with intellectual or developmental disability (I/DD) living in supported accommodation, to understand how documentation use impacts person-centred support.MethodsWe conducted an integrative literature review. Following screening by two independent reviewers, we included English language peer-reviewed empirical studies (n = 34) on documentation use for people with I/DD in domestic-scale supported accommodation. We appraised quality and extracted information for iterative comparative thematic and content analysis.ResultAll studies reported written documentation regarding either the person with disability or the residence. Eighteen studies focused on health-specific information. We identified three key themes impacting on the person-centred support; 1) level of inclusion and independence of people with I/DD, 2) the culture of support within group homes, and 3) the quality use of information.ConclusionsInformation infrastructure is closely aligned with the support culture in residences and can affect whether and to what extent key stakeholders (i.e., people with I/DD, family members) are involved in making decisions about healthcare and support needs.Practice implicationsSurveying local service health information infrastructure can provide crucial insights which can be leveraged to improve the safety and quality of supports provided for people living in supported accommodation.     

Multiple-family group treatment as an effective intervention for children with psychological disorders

An estimated 20% of children suffer from psychological disorders and only 10-20% receive adequate treatment. A lack of empirically supported treatments is one reason why relatively few children receive treatment for their psychological difficulties. Multiple-family group treatment (MFGT) is an empirically supported intervention for adults with chronic mental illnesses that may be an effective treatment for children with psychological disorders. This article reviewed the adult MFGT model and its empirical support. The quantity and quality of child MFGT research was then reviewed. Child MFGT models are compared with one another and to the adult MFGT model. All studies provided initial support of MFGT as an appropriate treatment for childhood disorders. However, the child literature as whole was relatively limited, unfocused, and lacked replication. Suggestions for future research are made, focusing on a structured and scientific approach to establishing MFGT as an empirically supported intervention for children.     

What should we expect from psychotherapy?

In addressing the very general question of what we should expect from psychotherapy, this article begins by discussing what constitutes relevant evidence on which to base the efficacy and effectiveness of psychotherapy. In this context, an important distinction is made between empirically supported treatments and evidence-based practice. Although there is evidence that psychotherapy does indeed work, there are also findings that there are times when our patients are harmed by our interventions. It is noted that the therapeutic alliance plays an extremely important role in the change process, and that ruptures in the alliance can contribute to our therapeutic failures. In pointing to directions for the future, modifications of how we investigate the outcome of treatment, as well as how to close the gap between research and practice, are offered.     

Recommendations for a cost-offset model of psychotherapy allocation using generalized anxiety disorder as an example

As inexpensive interventions gain empirical support, there is an increasing risk that such data may be used by health maintenance organizations to unfairly restrict the number and type of therapy sessions reimbursed for all clients, even those less likely to benefit from economical treatments. As a result, it is important to identify clients who may not respond to specific therapies and to empirically support ways to treat them. Successful treatment of nonresponders is also valuable because predictors of treatment failure tend to predict cost related to medical and disability expenses. Using generalized anxiety disorder as an example, this article suggests a flexible and comprehensive approach to cost-benefit analysis in psychotherapy that includes clients who may not improve in response to current data-based interventions. In addition, suggestions are made for the identification of alternative treatment approaches, and a potential treatment allocation model is recommended.     

Distinguishing Scientific From Pseudoscientific Psychotherapies: Evaluating the Role of Theoretical Plausibility,With a Little Help From Reverend Bayes

[Clin Psychol Sci Prac 18: 105–112, 2011] In their stimulating article, David and Montgomery (2011) underscore the importance of identifying pseudoscientific and potentially harmful psychotherapies, and observe that the criteria for empirically supported therapies neglect to take into account the theoretical support for treatment packages. They propose a framework for evidence‐based therapies that includes empirical support for both the efficacy of the treatment and the theory that spawned it. I discuss several challenges to this and similar frameworks, including (a) the absence of convincing data regarding how most current therapies work, (b) the underdetermination of theory by data, making it difficult to strongly corroborate models of therapeutic change mechanisms using only a small number of studies, and (c) the risk of false negatives, viz., efficacious treatments derived from nonexistent or flawed theories. As a friendly amendment, I propose a Bayesian alternative to David and Montgomery’s classification that incorporates the role of theoretical plausibility while minimizing the aforementioned difficulties.     

Cognitive Behavior Therapies for Psychotic Disorders: Current Empirical Status and Future Directions

Although cognitive behavior therapy (CBT) has strong empirical support for treating a diverse array of psychological conditions, only recently has research begun to examine its efficacy in treating the symptoms associated with schizophrenia and other psychotic disorders. Several randomized controlled trials have been conducted on CBT for psychosis with some positive results, but trials comparing CBT to other nonspecific interventions have yielded less impressive findings. No well-controlled trial to date has attempted to dismantle the components of CBT for psychosis, to compare it to another empirically supported psychosocial intervention for this population, or to identify the specific mechanisms responsible for treatment effectiveness. In this paper, a review of the empirical status of CBT for psychosis is presented. In addition, promising but preliminary new research in this area is reviewed, including prevention and early intervention approaches and acceptance/mindfulness-based strategies. Within this context, limitations in the current literature are reviewed, and recommendations for future research are discussed.     

Empirically Validated Treatments: Reality and Resistance

Although not free from methodological problems, the Task Force report represents an important step toward identifying effective treatments for major clinical disorders. The commitment to empirical research that this report embodies is part of what could be an overdue move toward greater accountability in clinical training and practice. The time-honored reliance on therapists' clinical judgments in formulating individual treatment plans needs to be critically examined in the light of their well-documented limitations and the informed use of empirically supported, manual-based treatments. The reality of common factors across different treatments does not conflict with the effectiveness of specific treatments for particular disorders.     

Behavioral Health Treatment Redesign in Managed Care Settings

This article addresses the general trends and research directions taking place in managed care behavioral health care settings. Such challenges as the demands for accountability and cost-effectiveness have led to the pressing need for (a) sound outcomes measurement systems, (b) standardization of empirically supported treatment protocols, and (c) more concerted efforts to bridge the gap in psychology between efficacy research occurring in controlled, often academic settings, and effectiveness research whereby tested protocols are implemented and evaluated within actual practice settings. The treatment literature of three diagnostic groups—anxiety, mood disorders, and eating disorders—is discussed regarding present empirical support and research directions.     

Empirically supported treatments or type I errors? Problems with the analysis of data from group-administered treatments

When treatments are administered in groups, clients interact in ways that lead to violations of a key assumption of most statistical analyses-the assumption of independence of observations. The resulting dependencies, when not properly accounted for, can increase Type I errors dramatically. Of the 33 studies of group-administered treatment on the empirically supported treatments list, none appropriately analyzed their data. The current authors provide corrections that can be applied to improper analyses. After the corrections, only 12.4% to 68.2% of tests that were originally reported as significant remained significant, depending on what assumptions were made about how large the dependencies among observations really are. Of the 33 studies, 6-19 studies no longer had any significant results after correction. The authors end by providing recommendations for researchers planning group-administered treatment research.     

Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5

This article provides an overview of the process of developing the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association with a focus on issues related to the trauma-related disorders, particularly the dissociative disorders (DD). We also discuss the highlights of research within the past 5 years in the assessment, treatment, and neurobiological basis of trauma disorders. Recent research shows that DD are associated with severe symptoms as well as a higher rate of utilization of mental health treatment compared with other psychiatric disorders. As a result, DD, like other complex posttraumatic disorders, exact a high economic as well as personal burden for patients and society. The latest research indicates that DD patients show a suboptimal response to standard exposure-based treatments for posttraumatic stress disorder as well as high levels of attrition from treatment. An emerging body of research on DD treatment, primarily of naturalistic and open trials, indicates that patients who receive specialized treatment that addresses their trauma-based, dissociative symptoms show improved functioning and reduced symptoms. Recent studies of the underlying neurobiological basis for dissociation support a model of excessive limbic inhibition in DD that is consistent with the phenomenology and clinical presentation of these patients. We are optimistic that the forthcoming DSM-5 will stimulate research on dissociation and the DD and suggest areas for future studies.     

The promise and pitfalls of the internet for cognitive behavioral therapy

Internet-administered cognitive behavior therapy is a promising new way to deliver psychological treatment. There are an increasing number of controlled trials in various fields such as anxiety disorders, mood disorders and health conditions such as headache and insomnia. Among the advantages for the field of cognitive behavior therapy is the dissemination of the treatment, being able to access treatment from a distance, and possibilities to tailor the interventions. To date, studies in which large effects have been obtained have included patient support from a clinician. Recent trials suggest that this support may come from non-clinicians and that therapist effects are minimal. Since studies also suggest that internet-delivered cognitive behavior therapy can be equally effective as face-to-face cognitive behavior therapy, this is a finding that may have implications for CBT practitioners. However, there are other aspects to consider for implementation, as while clinicians may hold positive attitudes towards internet-delivered CBT a recent study suggested that patients are more skeptical and may prefer face-to-face treatment. In the present work, I argue that internet-delivered CBT may help to increase adherence to treatment protocols, that training can be facilitated by means of internet support, and that research on internet interventions can lead to new insights regarding what happens in regular CBT. Moreover, I conclude that internet-delivered CBT works best when support is provided, leaving an important role for clinicians who can incorporate internet treatment in their services. However, I also warn against disseminating internet-delivered CBT to patients for whom it is not suitable, and that clinical skills may suffer if clinicians are trained and practice mainly using the internet.     

The current status of energy psychology: Extraordinary claims with less than ordinary evidence

Proponents of energy psychology techniques, such as Thought Field Therapy and Emotional Freedom Techniques, have sought “empirically supported therapy” status despite an unsupported and implausible theoretical basis and claims in response of representing a “pseudoscientific” movement. Two major reviews of the supportive evidence which has accumulated over the past 30 years have been published recently. This current status report describes the history, theory, techniques, claims, and implications of the energy psychology movement, examines support for its theoretical base, its current outcome study support, and offers conclusions and recommendations as to its research and clinical prospects. It is concluded that there is scant support for the radical theories underlying energy psychology techniques, and that empirical support for their efficacy is methodologically weak, and has not been able to demonstrate an effect beyond nonspecific or placebo effects, or the incorporation of known‐effective elements. The only dismantling studies to date have been disconfirmatory. Further research is highly unlikely to be scientifically productive, and scientist practitioners are advised to continue to adhere to well‐established cognitive and behavioural principles.     

Does Phasic Trauma Treatment Make Patients With Dissociative Identity Disorder Treatment More Dissociative?

Proponents of the iatrogenic model of the etiology of dissociative identity disorder (DID) have expressed concern that treatment focused on direct engagement and interaction with dissociated self-states harms DID patients. However, empirical data have shown that this type of DID treatment is beneficial. Analyzing data from the prospective Treatment of Patients With Dissociative Disorders (TOP DD) Study, we test empirically whether DID treatment is associated with clinically adverse manifestations of dissociated self-states: acting so differently that one feels like different people, hearing voices, and dissociative amnesia. We show that, over the course of the study, there were significant decreases in feeling like different people and hearing voices. These results indicate that this form of DID treatment does not lead to symptomatic worsening in these dimensions, as predicted by the iatrogenic model. Indeed, treatment provided by TOP DD therapists reduced, rather than increased, the extent to which patients experienced manifestations of pathological dissociation. Because severe symptomatology and impairment are associated with DID, iatrogenic harm may come from depriving DID patients of treatment that targets DID symptomatology.     

Psychotherapy research with ethnic minorities: empirical, ethical, and conceptual issues

There is an increasing demand for psychotherapy among ethnic minority populations. Yet, there is not adequate evidence that empirically supported therapies (ESTs) are effective with ethnic minorities. Ethical guidelines suggest that psychotherapies be modified to become culturally appropriate for ethnic minority persons. Conceptual approaches have identified interdependence, spirituality, and discrimination as considerations for culturally sensitive therapy (CST). However, there is no more empirical support for the efficacy of CSTs than there is for the efficacy of ESTs with ethnic minority populations. The chasm between EST and CST research is a function of differences between methods and researchers in these 2 traditions. Specific recommendations for research collaboration between CST and EST researchers are offered.     

Possible mechanisms for why desensitization and exposure therapy work

Rosen and Davison [Rosen, G.M. and Davison, G.C. (2003). Psychology should list empirically supported principles of change (ESPs) and not credential trademarked therapies or other treatment packages. Behavior Modification, 27, 300-312] recommended that empirically supported principles be listed instead of empirically supported treatments because the latter approach enables the creation of putatively new therapies by adding functionally inert components to already listed effective treatments. This article attempts to facilitate inquiry into empirically supported principles by reviewing possible mechanisms responsible for the effectiveness of systematic desensitization and exposure therapy. These interventions were selected because they were among the first empirically supported treatments for which some attempt was made at explanation. Reciprocal inhibition, counterconditioning, habituation, extinction, two-factor model, cognitive changes including expectation, self-efficacy, cognitive restructuring, and informal network-based emotional processing explanations are considered. Logical problems and/or available empirical evidence attenuate or undercut these explanations. A connectionist learning-memory mechanism supported by findings from behavioral and neuroscience research is provided. It demonstrates the utility of preferring empirically supported principles over treatments. Problems and limitations of connectionist explanations are presented. This explanation warrants further consideration and should stimulate discussion concerning empirically supported principles.     

Toward a Functional Analytic Approach to Psychologically Complex Patients: A Comment on Ruscio and Holohan (2006)

Ruscio and Holohan (2006 ) address the challenges of applying empirically supported treatments (ESTs) with complex patients (e.g., those with comorbid conditions). Many clinicians, in such instances, abandon ESTs on the assumption that treatment manuals do not apply. In the present commentary I argue that although ESTs provide the best available guidance for how to treat many psychological disorders, effective treatment does not require rigid adherence to treatment manuals if the clinician is able to develop a case formulation on the basis of a functional analysis of behavior and apply empirically supported treatment procedures accordingly. The development of exposure and response prevention for obsessive-compulsive disorder is presented as an example of how knowledge of basic cognitive and behavioral processes transcends ESTs and their manuals. I conclude that it is important for beginning therapists to learn to apply principles based on these processes rather than to rely exclusively on treatment manuals.     

Sleep and posttraumatic stress disorder: a review

Research seeking to establish the relationship between sleep and posttraumatic stress disorder (PTSD) is in its infancy. An empirically supported theory of the relationship is yet to emerge. The aims of the present paper are threefold: to summarise the literature on the prevalence and treatment of sleep disturbance characteristic of acute stress disorder (ASD) and PTSD, to critically review this literature, and to draw together the disparate theoretical perspectives that have been proposed to account for the empirical findings. After a brief overview of normal human sleep, the literature specifying the relation between sleep disturbance and PTSD is summarized. This includes studies of the prevalence of sleep disturbance and nightmares, content of nightmares, abnormalities in rapid eye movement (REM) sleep, arousal threshold during sleep, body movement during sleep, and breathing-related sleep disorders. In addition, studies of the treatment of sleep disturbance in individuals with PTSD are reviewed. We conclude that the role of sleep in PTSD is complex, but that it is an important area for further elucidating the nature and treatment of PTSD. Areas for future research are specified. In particular, a priority is to improve the methodology of the research conducted.     

Empirically supported treatments in pediatric psychology: where is the diversity?

OBJECTIVE: To examine the extent to which studies used to support empirically supported treatments for asthma, cancer, diabetes, and obesity address issues of cultural diversity. METHOD: We chose original articles (71) of treatments used to support empirically supported treatments (ESTs) published as part of a special series on ESTs in the Journal of Pediatric Psychology. Trained coders reviewed each study to determine if the following were reported: race/ethnicity and socioeconomic status (SES) of the sample, moderating cultural variables, cultural assumptions or biases of the treatment, larger cultural issues, and measurement or procedure bias. RESULTS: Results revealed that few studies addressed cultural variables in any way. Only 27% of the studies reported the race or ethnicity and 18% reported the SES of research participants. Additionally, 6% discussed potential moderating cultural variables. The remaining variables were addressed in 7% or less of the studies. CONCLUSIONS: These data support the criticism that ESTs fail to address important issues of culture and call into question the external validity of ESTs to diverse populations. Future research should explicitly address cultural issues according to the nine recommendations described here.     

Assessing the Role of Treatment Manuals: Have They Become Necessary but Nonsufficient Ingredients of Change?

We argue that the controversies and ambivalence surrounding treatment manuals are in part due to three somewhat inconsistent functions that these manuals serve, or may soon be serving: (1) to provide detailed guidelines to clinicians, (2) to operationalize developmental steps in psychotherapy research programs, and (3) to serve as a list of options that might soon be guiding, and potentially dictating, treatment reimbursements. We also argue that although the slow pace of scientific development is at odds with the immediate needs of clinicians, the inconsistency between the first and second functions of treatment manuals is not a problem per se—it simply reflects the intrinsic dilemma underlying the Boulder model. A key problem, however, is the possibility that our current state of empirical knowledge might be used in the near future as the main basis for prescribing psychotherapy (i.e., the inconsistency between the second and third functions of manuals). Treatment manuals are described as necessary but nonsufficient tools that may be best used as the "first line of attack" in narrowly defined treatment conditions. The creation of a new task force is suggested to delineate such treatment conditions, to generate possible guidelines for addressing clinical situations that have not yet been empirically investigated, and to recommend future research directions to improve psychotherapy effectiveness. Finally, clinicians and researchers are encouraged to use a treatment strategy that has been empirically supported to entice third-party payers to fund future psychotherapy research.