Distinctive activities of cognitive-behavioral therapy. A review of the comparative psychotherapy process literature

The present review examined the comparative psychotherapy process literature in order to identify the distinctive activities of cognitive-behavioral (CB) treatment. Six techniques and interventions were found to distinguish CB from psychodynamic-interpersonal (PI) therapy: (1) use of homework and outside-of-session activities; (2) direction of session activity; (3) teaching of skills used by patients to cope with symptoms; (4) emphasis on patients' future experiences; (5) providing patients with information about their treatment, disorder, or symptoms; and (6) an intrapersonal/cognitive (C) focus. Identifying the distinctive features of CB therapy can improve the measurement of process-outcome correlations by more accurately specifying and operationalizing the treatment-specific processes of CB treatment, help researchers differentiate between common and treatment-specific factors, and aid in development of more psychometrically sound instruments assessing adherence and competence in CB therapy. In addition, this review can improve training of CB therapists by providing a guide for clinical practice.     

Coding system of therapeutic focus on action and insight

This study (a) used an established comprehensive process measure to uncover a latent pattern of therapeutic focus in cognitive-behavioral and psychodynamic-interpersonal sessions; (b) used these results to develop the coding system of Therapeutic Focus on Action and Insight, which makes it possible to evaluate therapists' relative emphasis on the Constructing Meaning and Facilitating Action domains of in-session focus; and (c) evaluated its reliability and validity.     

Emotion and Psychotherapy

Although cognitive-behavioral therapy has been criticized for not addressing the importance of emotion in psychotherapy, recent trends indicate a growing interest in this issue. So-called "Third Wave" approaches suggest that "cognitive" processes are often of little importance. In this article, I describe how learning theory, models of emotional processing, exposure treatments, criticisms of "extinction," and even emotion-based approaches rely on cognitive and representational constructs. An attempt is made to integrate emotion and cognition in emotional schema therapy.     

Psychotherapy of childhood anxiety disorders: A meta-analysis

BACKGROUND: The present study compared the efficacy of psychotherapy for childhood anxiety disorders (excluding trials solely treating post-traumatic stress disorder or obsessive-compulsive disorder). METHODS: The meta-analysis included studies that met the basic CONSORT (consolidated standards of reporting trials) criteria. Several outcome variables (e.g. effect sizes, percentage of recovery) were analyzed using completer and intent-to-treat analyses during post-treatment and follow-up assessment. Twenty-four studies published by March 2005 were included in this meta-analysis. RESULTS: In all the included studies, the active treatment condition was cognitive-behavioral. The overall mean effect of treatment was 0.86. No differences in outcome were found between individual and group treatments or child- and family-focused treatments. Follow-up data demonstrated that treatment gains were maintained up to several years after treatment. CONCLUSIONS: These findings provide evidence that anxiety disorders in children can be treated efficaciously. The gathered data support the clinical utility of cognitive-behavioral therapy in this regard. Randomized controlled trial studies investigating treatments other than cognitive-behavioral therapy are missing.     

Combined Psychotherapy and Pharmacotherapy for the Treatment of Major Depressive Disorder

Studies comparing the efficacy of combined psychotherapy and pharmacotherapy to single treatment (i.e., either psychotherapy or pharmacotherapy alone) for major depression have not found consistent differences in outcome, resulting in a range of conclusions regarding the efficacy of combined treatment. In order to clarify the efficacy of combined treatment for depression, the authors conducted both a meta-analytic and qualitative review. Our findings suggest that combined treatment is associated with a small improvement in efficacy, and that this finding appears consistent across studies. Trends in the literature suggest that adding psychotherapy to antidepressant medication may be particularly efficacious among chronic or severely depressed patients. Further, adding cognitive-behavioral therapy to medication may be particularly efficacious in preventing relapse, particularly among individuals discontinuing medication use. The authors propose an illness-cognition model for better understanding outcomes in combined treatment.     

Psychotherapy in two-plus-one sessions: outcomes of a randomized controlled trial of cognitive-behavioral and psychodynamic-interpersonal therapy for subsyndromal depression

A total of 116 clients with a range of subsyndromal depression received 3 therapy sessions: 2 sessions 1 week apart followed by a 3rd session 3 months later (the 2 + 1 model). Clients were stratified for severity on the Beck Depression Inventory (BDI) as stressed, subclinical, or low-level clinically depressed. In a 2 x 2 design, they received either cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) therapy, either immediately or after a 4-week delay. An initial advantage for the immediate condition disappeared once the delayed-condition clients received treatment. Improvement rates at the end of treatment were 67% (stressed), 72% (subclinical), and 65% (low-level clinically depressed). There were no significant differences between CB and PI treatment methods, with the exception at 1-year follow-up, when the BDI showed a significant advantage for CB. Implications for designing very brief planned interventions are discussed.     

The efficacy of cognitive-behavioral therapy and the problem of drop-out

Treatment drop-out is a common problem in the everyday practice of psychotherapy. In the cognitive-behavioral psychology literature, there are scant data on drop-out from therapy and the data available vary widely according to the definition of drop-out and the intensity of treatment. This study presents results obtained in the Behavioural Therapy Unit of the University of Barcelona. Of the 203 patients seen in the unit, 89 (43.8%) dropped out, mostly in the early stages of the intervention. The most common reasons for this were low motivation and/or dissatisfaction with the treatment or the therapist (46.7%), external difficulties (40%), and patients' feeling of improvement (13.3%). Patients who dropped out differed from those who continued; they more often presented affective or eating disorders or problems with impulse control. The observed drop-out rate is in line with figures reported for psychotherapy in general and by those studies which have considered cognitive-behavioral therapy in particular.     

Reflections on relevance: Psychotherapy and Psychosomatics in 2005

This article focuses on the mission and relevance of articles published in Psychotherapy and Psychosomatics in 2005. Four areas of articles relevant to the mission of Psychotherapy and Psychosomatics are reviewed: (1) new (psycho-)therapies; (2) cognitive-behavioral therapy; (3) new or newly defined psychopathology, and (4) the impact of or impairment due to various illnesses or treatments. In addition, other clinically important and relevant issues, such as the need for new treatments, suicide during psychotherapy, technological innovations used in psychotherapies and methodology of psychotherapy trials are discussed.     

BRIEF PSYCHODYNAMIC-INTERPERSONAL THERAPY FOR PATIENTS WITH SEVERE PSYCHIATRIC ILLNESS WHICH IS UNRESPONSIVE TO TREATMENT

ABSTRACT The authors are currently conducting a large randomized controlled trial of the effectiveness of brief psychodynamic-interpersonal psychotherapy with outpatients who have been unresponsive to conventional psychiatric treatment. In this paper we describe the study and the psychodynamic-interpersonal model of therapy employed in the treatment limb of the study. We also describe therapeutic work with three patients whose presentation is representative of the outpatients recruited into the study.     

USE OF FAREWELL LETTERS IN THE CONTEXT OF BRIEF PSYCHODYNAMIC-INTERPERSONAL THERAPY WITH IRRITABLE BOWEL SYNDROME PATIENTS

ABSTRACT Irritable bowel syndrome patients being treated by brief psychodynamic-interpersonal therapy were given a farewell letter written by the therapist in the final session. The context was a randomized controlled trial to assess the cost-effectiveness of psychotherapy and antidepressant treatment for painful functional bowel disorders. A year after the end of treatment patients completed a questionnaire to evaluate their perceptions of the usefulness of farewell letters. Five case vignettes illustrate different ways in which patients reacted to the farewell letters during and after treatment. Patients who benefited from therapy found the letter helpful as a means of sharing their experiences with others, continuing the work of therapy and dealing with the ending. The letter seemed to act as an embodiment of the therapist or transitional object, facilitating the continued assimilation of problematic experiences. Where therapeutic outcome was poor there was less evidence of helpfulness. Preliminary impressions suggest that farewell letters may be a helpful tool enhancing the benefits of brief therapy.     

Psychodynamic-lnterpersonal Treatment of Generalized Anxiety Disorder

Roemer and Orsillo's proposed integration of acceptance-based techniques with cognitive-behavioral treatments for generalized anxiety disorder (CAD) focuses on worry as a form of avoidance. In a psychodynamic-interpersonal approach to CAD, this avoidance is conceptualized in terms of defense mechanisms. The interpersonal determinants of the avoided feelings are addressed through formulation and interpretation of core conflictual relationship themes. Because CAD is a chronic, refractory disorder involving multiple elements, it is likely that treatment of CAD will ultimately necessitate therapist implementation of a broad array of techniques originating out of the cognitive, behavioral, interpersonal, psychodynamic, and acceptance literatures.     

Psychotherapy in Iran: a case study of cognitive-behavioral family therapy for Mrs. A

Family plays a significant role in the development and maintenance of depression. It has also been shown that cognitive-behavioral therapy (CBT) can be effective in treating depression. The prominent role of family in Iranian culture makes the application of CBT in family context preferable. In this article, we describe the evolution of psychotherapy in Iran and illustrate it through a case of CBT family therapy for Mrs. A.     

Fundamental Considerations in the Psychotherapy of an Identical Twin

Identical twins encounter unique psychological and maturational difficulties alien to the experiences of single children. A brief review of the literature on these points is presented, emphasising both the tormenting and gratifying aspects of a twin who has in the outside world another identical self that the world notices and confuses with him. Such aspects need to be taken into consideration when engaging an identical twin in analytical psychotherapy. 'Fallout' from psychotherapy can have repercussions on those close to the patient but in the case of identical twins the effects on the twin not in therapy can be disastrous. In particular, when psychotherapy-by-proxy ensues it appears possible for the co-twin to establish strong links to the analyst through his narcissistic relationship with his twin, which appear transferential in nature. A clinical vignette is presented which elaborates on the issues of twin transference and the fallout effects on the twin not in therapy. A question is put forward: whether it is realistic to analyse identical twins individually and not together when their narcissistic dependency and defensive hostility are paramount to internal processes. The author takes the view that a psychoanalytical orientation to the psychotherapy of an identical twin is the most recommended but cautions against individual psychoanalytical psychotherapy where the real drive is the assassination of the internal and external twin-object as a means to individuation from the twinship. The nature of this object - whether selfobject or transformational object - is tentatively discussed.     

The Harmful Effects of Psychotherapy: When the Therapeutic Alliance Fails

A good therapeutic alliance has been found to be the best predictor of outcome in psychotherapy, but psychotherapists also need to develop an understanding of the mechanisms by which that alliance is created and the factors that may damage that alliance and contribute to harmful effects of psychotherapy. I explore these factors in three contexts: the nature of the therapy itself, the characteristics of the therapist, and the dynamics of the patient–therapist relationship. I discuss the research that suggests that potentially harmful processes can be avoided by a dynamic‐agentive systems model, which views psychotherapy as a conversation, in which turn‐taking, rupture and repair, and perspective‐taking are the intersubjective tools that help to build the therapeutic alliance and that can be the focus for further study into the mechanisms by which psychotherapy is helpful or harmful. The neuroscience research that supports this model is summarized.     

The Dose and Delivery of Psychotherapy: A Commentary on Hansen et al.

Hansen et al. provide important data on the dose of psychotherapy received in clinical practice. For their sample of over 6,000 patients, they found the median number of sessions of psychotherapy received was three, with a recovery rate of 6.5%. In contrast, data from controlled clinical trials reviewed by Hansen et al. indicated patients received an average of 13 sessions of treatment, with half the sample achieving remission. In this commentary, potential reasons for this rift between research and clinical practice are discussed, with attention to factors associated with engagement in treatment. In particular, every controlled trial reviewed by Hansen et al. involved cognitive-behavioral interventions, whereas application of these programs of treatment is relatively rare in clinical practice. Elements of the treatment and treatment context are identified that may be useful for enhancing the dose of psychotherapy.     

中国传统心理治疗理论与实践

现代"心理治疗"一词来源于西方,但中国古代医学中就有十分丰富的心理治疗的思想与技术。将这些传统心理治疗的思想与技术置于现代心理学的视野中也有其自己的特色与价值。具体体现在:将心理治疗理解为积极心理与消极心理不断获得平衡的过程;治疗中充分利用患者自身的心理资源,即倡导"七情互治"理论与技术;注重治疗中心理、生理、社会三因素的整体协调。     

The Therapist as a Neglected Variable in Psychotherapy Research

Research on psychotherapy has increased in both quantity and quality over the past 30 years and has tended to focus on the evaluation of outcome. The major emphasis has been on studies comparing different forms of psychotherapy. The recent emphasis on training manuals has reinforced this pattern. On the other hand, the importance of the therapist's contribution to outcome and the related matter of therapist variability have been given inadequate attention. These issues are discussed and evaluated in the articles that follow.     

Patients’ Perceptions of Corrective Experiences in Naturalistically Delivered Psychotherapy

Corrective experiences (CEs), which suggest transformative experience(s) for the psychotherapy patient, have a rich theoretical history; yet there is little empirical information on patients’ own perceptions of what gets “corrected” from therapy, and what is “corrective” (i.e., the mechanisms driving the CE). To address this gap, we investigated 14 patients’ posttreatment accounts of both CE elements in the context of naturalistically delivered individual psychotherapy, using a consensual qualitative research methodology. Extending prior research focused on patients’ accounts of CEs while still engaged in treatment (Heatherington et al., 2012), the present results revealed that patients retrospectively identified an array of categories that were deemed corrected, such as positive changes in cognitions, interpersonal problems, self‐concepts, symptoms, and behaviors. Patients also identified CEs that may have led to those shifts/transformations, including their therapist's actions (especially giving feedback), their own agentic actions (especially engaging in the therapeutic process), and the patient–therapist collaborative and engaged relationship. Clinical practice implications are discussed.