Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol

Objective: In the past decade, variation in outcomes between therapists (i.e., therapist effects) have become increasingly recognized as an important factor in psychotherapy. Less is known, however, about what accounts for differences between therapists. The present study investigates the possibility that therapists' basic therapy-related interpersonal skills may impact outcomes. Method: To examine this, psychotherapy postgraduate trainees completed both an observer- and an expert-rated behavioral assessment: the Therapy-Related Interpersonal Behaviors (TRIB). TRIB scores were used to predict trainees' outcomes over the course of the subsequent five years. Results: Results indicate that trainees' with more positively rated interpersonal behaviors assessed in the observer-rated group format but not in a single expert-rated format showed superior outcomes over the five-year period. This effect remained controlling for therapist characteristics (therapist gender, theoretical orientation [cognitive behavioral or psychodynamic], amount of supervision, patient's order within therapist's caseload), and patient characteristics (patient age, gender, number of comorbid diagnoses, global severity, and personality disorder diagnosis). Conclusions: These findings underscore the importance of therapists' interpersonal skills as a predictor of outcome and source of therapist effects. The potential utility of assessing therapists' and therapists-in-training interpersonal skills are discussed.

RELAXAMENTO PSICOFÍSICO EM CRIANÇAS

Trabalho de natureza monográfica bibliográfica investiga o relaxamento psicofísico na área da saúde, em crianças, por um intervalo de oito anos, entre janeiro de 1997 e novembro de 2004. Inicialmente, com base em literatura neuropsicológica, descreve o papel do relaxamento na busca da homeostase e da consciência corporal saudável, enfocando comportamentos de prazer e dor. A seguir, descreve e analisa diversas técnicas de relaxamento, Relaxamento Progressivo de Jacobson, Autógeno de Schultz e Relaxamento de Michaux. A fim de desenvolver sua pesquisa utiliza-se de 27 bases de dados, devido a pouca produção encontrada sobre o tema, por base. Como resultados, levanta ao todo 500 artigos sobre relaxamento, sendo 200 em crianças. São artigos nacionais e internacionais, com predomínio do idioma inglês. A seguir, classifica esses artigos por ano de produção, constatando um crescimento significativo, porém não sistemático em seu número, de 14 artigos em 1997, para 39, em 2004. Quanto à temática, os dados revelam em primeiro lugar, um interesse em dor, em segundo em problemas respiratórios, e, em terceiro lugar, em ansiedade. Os artigos sobre dor, por serem os mais numerosos levantados, sofrem análise mais detalhada, com discriminação da quantidade de artigos por ano e dos tipos de situação e de patologia caracterizados por quadro álgico. Finalmente é feita uma classificação dos artigos segundo a utilização do relaxamento junto à problemática clínica predominantemente física, a de fundo psíquico afetivo-emocional, sem utilização de fármacos e, a de fundo psíquico, com intervenção psiquiátrica farmacológica. Na discussão dos resultados, vários artigos pesquisados são também comentados. Dada a riqueza dos dados, evidenciando interesse crescente de profissionais da área da Saúde na literatura levantada, sugere-se pesquisa complementar.

RELAXAMENTO PSICOFÍSICO EM CRIANÇAS

Trabalho de natureza monográfica bibliográfica investiga o relaxamento psicofísico na área da saúde, em crianças, por um intervalo de oito anos, entre janeiro de 1997 e novembro de 2004. Inicialmente, com base em literatura neuropsicológica, descreve o papel do relaxamento na busca da homeostase e da consciência corporal saudável, enfocando comportamentos de prazer e dor. A seguir, descreve e analisa diversas técnicas de relaxamento, Relaxamento Progressivo de Jacobson, Autógeno de Schultz e Relaxamento de Michaux. A fim de desenvolver sua pesquisa utiliza-se de 27 bases de dados, devido a pouca produção encontrada sobre o tema, por base. Como resultados, levanta ao todo 500 artigos sobre relaxamento, sendo 200 em crianças. São artigos nacionais e internacionais, com predomínio do idioma inglês. A seguir, classifica esses artigos por ano de produção, constatando um crescimento significativo, porém não sistemático em seu número, de 14 artigos em 1997, para 39, em 2004. Quanto à temática, os dados revelam em primeiro lugar, um interesse em dor, em segundo em problemas respiratórios, e, em terceiro lugar, em ansiedade. Os artigos sobre dor, por serem os mais numerosos levantados, sofrem análise mais detalhada, com discriminação da quantidade de artigos por ano e dos tipos de situação e de patologia caracterizados por quadro álgico. Finalmente é feita uma classificação dos artigos segundo a utilização do relaxamento junto à problemática clínica predominantemente física, a de fundo psíquico afetivo-emocional, sem utilização de fármacos e, a de fundo psíquico, com intervenção psiquiátrica farmacológica. Na discussão dos resultados, vários artigos pesquisados são também comentados. Dada a riqueza dos dados, evidenciando interesse crescente de profissionais da área da Saúde na literatura levantada, sugere-se pesquisa complementar.

A Meta-Analytic Review of Mindfulness-Based Interventions on Symptom Reduction: A Critique and Guide for Future Investigation.

Over the past decade, mindfulness practices have been used with increasing frequency as therapeutic components within cognitive behavioral treatment regimens. As is standard practice, prescriptive uses of mindfulness intervention are incorporated to improve end-state functioning by ameliorating problematic symptoms and conditions. Common change-targets include the control of cognitive and emotional content for purposes of enhancing psychological self-regulation and physical well-being. The term mindfulness applies to a heterogeneous range of practices, methods, and techniques. While there is no singular agreed upon definition for mindfulness, as a process concept, the term connotes an immediate, non-thetic access to events, wherein each occasioning event is experienced in toto within the broader contextual event-field, and distinct from intervening conceptual themes being noticed. Training in mindfulness practices may be conducted using individual, group, or small class formats. The current paper provides a meta-analytic review of 44 treatment outcome studies (extracted 1982 through 2006), which examines the clinical utility of mindfulness as the primary therapeutic approach. Results indicated that average effect sizes for mindfulness based interventions fell within the medium range for construct category variables examined (d = .56). These findings suggest that mindfulness training is a cost-effective treatment for a wide array of contemporary psychological problems and diagnoses, in addition to fostering positive psychology attributes such as quality and satisfaction with life. A critique of the research and recommendations for future research, including a need to examine the role of mindfulness as a tool for cultivating increased psychological acceptance and life satisfaction, is presented.

The Impact of Prefrontal Cortex "Warm Up" on Immediate Cognitive Reappraisal Ability in Older Adolescents with Elevated Symptoms of Depression

Cognitive Reappraisal (CR) is a central component of Cognitive Behavioral Therapy for adolescent depression. Yet, previous research indicates that a brain region highly associated with successful CR in adults, the Prefrontal Cortex (PFC), is not fully developed until early adulthood. Thus, there is growing concern that CBT interventions directed at building CR abilities in depressed teens might be constrained by PFC immaturity. However, CR is an effective strategy for regulating affect. The current study evaluated an intervention aimed at enhancing CR performance through PFC “warm up” with a working memory task. Additionally, the study examined moderators of intervention response, as well as cognitive correlates of self-reported CR use. Participants included 48 older adolescents (mean age=19.1, 89% female) with elevated symptoms of depression who were randomly assigned to a lab-based WM or control activity followed by a CR task. Overall, results failed to support the effectiveness of “warm up” to augment CR performance. However, current level of depression predicted negative bias and sadness ratings after CR instructions, and this effect was qualified by an interaction with condition. The moderator analysis showed that depressive symptoms interacted with condition such that in the control condition, participants with higher depressive symptoms had significantly lower negative bias scores than individuals with lower depressive symptoms, but this pattern was not found in the experimental condition. Contrary to hypotheses, history of depression did not moderate treatment response. Additional analyses explored alternative explanations for the lack of intervention effects. There was some evidence to suggest that the WM task was frustrating and cognitively taxing. However, irritation scores and overall WM task accuracy did not predict subsequent CR performance. Lastly, multiple cognitive variables emerged as correlates of self-reported CR use, with cognitive flexibility contributing unique variance to self-reported CR use. Results pointed to new directions for improving CR performance among youth with elevated symptoms of depression.

Group-Based Symptom Trajectories in Indicated Prevention of Adolescent Depression

Background: Adolescent depression prevention research has focused on mean intervention outcomes, but has not considered heterogeneity in symptom course. Here, we empirically identify subgroups with distinct trajectories of depressive symptom change among adolescents enrolled in two indicated depression preven- tion trials and examine how cognitive-behavioral (CB) interventions and baseline predictors relate to trajectory membership. Methods: Six hundred thirty-one participants were assigned to one of three conditions: CB group intervention, CB bibliotherapy, and brochure control. We used group-based trajectory modeling to identify trajectories of depressive symptoms from pretest to 2-year follow-up. We examined associations between class membership and conditions using chi- square tests and baseline predictors using multinomial regressions. Results: We identified four trajectories in the full sample. Qualitatively similar trajectories were found in each condition separately. Two trajectories of positive symptom course (low-declining, high-declining) had declining symptoms and were dis- tinguished by baseline symptom severity. Two trajectories of negative course (high-persistent, resurging), respectively, showed no decline in symptoms or de- cline followed by symptom reappearance. Participants in the brochure control condition were significantly more likely to populate the high-persistent trajectory relative to either CB condition and were significantly less likely to populate the low-declining trajectory relative to CB group. Several baseline factors predicted trajectory classes, but gender was the most informative prognostic factor, with males having increased odds of membership in a high-persistent trajectory rel- ative to other trajectories. Conclusions: Findings suggest that CB preventive interventions do not alter the nature of trajectories, but reduce the risk that adolescents follow a trajectory of chronically elevated symptoms.

Group-Based Symptom Trajectories in Indicated Prevention of Adolescent Depression

Background: Adolescent depression prevention research has focused on mean intervention outcomes, but has not considered heterogeneity in symptom course. Here, we empirically identify subgroups with distinct trajectories of depressive symptom change among adolescents enrolled in two indicated depression preven- tion trials and examine how cognitive-behavioral (CB) interventions and baseline predictors relate to trajectory membership. Methods: Six hundred thirty-one participants were assigned to one of three conditions: CB group intervention, CB bibliotherapy, and brochure control. We used group-based trajectory modeling to identify trajectories of depressive symptoms from pretest to 2-year follow-up. We examined associations between class membership and conditions using chi- square tests and baseline predictors using multinomial regressions. Results: We identified four trajectories in the full sample. Qualitatively similar trajectories were found in each condition separately. Two trajectories of positive symptom course (low-declining, high-declining) had declining symptoms and were dis- tinguished by baseline symptom severity. Two trajectories of negative course (high-persistent, resurging), respectively, showed no decline in symptoms or de- cline followed by symptom reappearance. Participants in the brochure control condition were significantly more likely to populate the high-persistent trajectory relative to either CB condition and were significantly less likely to populate the low-declining trajectory relative to CB group. Several baseline factors predicted trajectory classes, but gender was the most informative prognostic factor, with males having increased odds of membership in a high-persistent trajectory rel- ative to other trajectories. Conclusions: Findings suggest that CB preventive interventions do not alter the nature of trajectories, but reduce the risk that adolescents follow a trajectory of chronically elevated symptoms.

A randomized controlled trial of intensive neurophysiology education in chronic low back pain

Objectives: Cognitive-behavioral pain management programs typically achieve improvements in pain cognitions, disability, and physical performance. However, it is not known whether the neurophysiology education component of such programs contributes to these outcomes. In chronic low back pain patients, we investigated the effect of neurophysiology education on cognitions, disability, and physical performance. Methods: This study was a blinded randomized controlled trial. Individual education sessions on neurophysiology of pain (experimental group) and back anatomy and physiology (control group) were conducted by trained physical therapist educators. Cognitions were evaluated using the Survey of Pain Attitudes (revised) (SOPA(R)), and the Pain Catastrophizing Scale (PCS). Behavioral measures included the Roland Morris Disability Questionnaire (RMDQ), and 3 physical performance tasks; (1) straight leg raise (SLR), (2) forward bending range, and (3) an abdominal drawing-in task, which provides a measure of voluntary activation of the deep abdominal muscles. Methodological checks evaluated non-specific effects of intervention. Results: There was a significant treatment effect on the SOPA(R), PCS, SLR, and forward bending. There was a statistically significant effect on RMDQ; however, the size of this effect was small and probably not clinically meaningful. Discussion: Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability. The results suggest that pain neurophysiology education, but not back school type education, should be included in a wider pain management approach.

Safety behaviors and dysfunctional beliefs about sleep: Testing a cognitive model of the maintenance of insomnia

Objective: Our aim was to determine if insomnia severity, dysfunctional beliefs about sleep, and depression predicted sleep-related safety behaviors. Method: Standard sleep-related measures (such as the Insomnia Severity Index; the Dysfunctional Beliefs About Sleep scale; the Depression, Anxiety, and Stress Scale; and the Sleep-Related Behaviors Questionnaire) were administered. Additionally, 14 days of sleep diary (Pittsburg Sleep Diary) data and actual use of sleep-related behaviors were collected. Results: Regression analysis revealed that dysfunctional beliefs about sleep predicted sleep-related safety behaviors. Insomnia severity did not predict sleep-related safety behaviors. Depression accounted for the greatest amount of unique variance in the prediction of safety behaviors, followed by dysfunctional beliefs. Exploratory analysis revealed that participants with higher levels of depression used more sleep-related behaviors and reported greater dysfunctional beliefs about their sleep. Conclusion: The findings underlie the significant influence that dysfunctional beliefs have on individuals' behaviors. Moreover, the results suggest that depression may need to be considered as an explicit component of cognitive-behavioral models of insomnia. (c) 2006 Elsevier Inc. All rights reserved.

A naturalistic comparison of two right unilateral electroconvulsive therapy dosing protocols: 2-3X seizure threshold versus fixed high-dose

The aim of this study was to compare the outcomes associated with two differing right unilateral (RUL) electroconvulsive therapy (ECT) dosing protocols: 2-3X seizure threshold (2-3X ST) and fixed high dose (FHD) at 353 mC. A retrospective chart review was performed to compare patient outcomes during the implementation of two different dosing protocols: 2-3X ST from October 2000 to May 2001 and FHD from June 2001 to February 2002. A total of 56 patients received ECT under the 2-3X ST protocol, and 46 received ECT under the FHD protocol. In total, 13.6% of patients receiving ECT according to the 2-3X ST protocol received more than 12 ECT, whereas none of the FHD group received more than 12 ECT. The mean number of ECT per treatment course reduced significantly from 7.6 to 5.7 following the switch from the 2-3X ST protocol to the FHD protocol. There were no significant differences between the two groups in the incidence of adverse cognitive effects. ECT practitioners adhered to the 2-3X ST protocol for only 51.8% of ECT courses, with protocol adherence improving to 87% following introduction of the FHD protocol. Although this naturalistic retrospective chart survey had significant methodological limitations, it found that practitioners are more likely to correctly adhere to a fixed dose protocol, therefore, increasing its 'real world' effectiveness in comparison to titrated suprathreshold dosing techniques. The FHD protocol was associated with shorter courses of ECT than the 2-3X ST protocol, with no significant difference between the two protocols in clinically discernable adverse cognitive effects.

RELAXAMENTO PSICOFÍSICO EM CRIANÇAS

Trabalho de natureza monográfica bibliográfica investiga o relaxamento psicofísico na área da saúde, em crianças, por um intervalo de oito anos, entre janeiro de 1997 e novembro de 2004. Inicialmente, com base em literatura neuropsicológica, descreve o papel do relaxamento na busca da homeostase e da consciência corporal saudável, enfocando comportamentos de prazer e dor. A seguir, descreve e analisa diversas técnicas de relaxamento, Relaxamento Progressivo de Jacobson, Autógeno de Schultz e Relaxamento de Michaux. A fim de desenvolver sua pesquisa utiliza-se de 27 bases de dados, devido a pouca produção encontrada sobre o tema, por base. Como resultados, levanta ao todo 500 artigos sobre relaxamento, sendo 200 em crianças. São artigos nacionais e internacionais, com predomínio do idioma inglês. A seguir, classifica esses artigos por ano de produção, constatando um crescimento significativo, porém não sistemático em seu número, de 14 artigos em 1997, para 39, em 2004. Quanto à temática, os dados revelam em primeiro lugar, um interesse em dor, em segundo em problemas respiratórios, e, em terceiro lugar, em ansiedade. Os artigos sobre dor, por serem os mais numerosos levantados, sofrem análise mais detalhada, com discriminação da quantidade de artigos por ano e dos tipos de situação e de patologia caracterizados por quadro álgico. Finalmente é feita uma classificação dos artigos segundo a utilização do relaxamento junto à problemática clínica predominantemente física, a de fundo psíquico afetivo-emocional, sem utilização de fármacos e, a de fundo psíquico, com intervenção psiquiátrica farmacológica. Na discussão dos resultados, vários artigos pesquisados são também comentados. Dada a riqueza dos dados, evidenciando interesse crescente de profissionais da área da Saúde na literatura levantada, sugere-se pesquisa complementar

RELAXAMENTO PSICOFÍSICO EM CRIANÇAS

Trabalho de natureza monográfica bibliográfica investiga o relaxamento psicofísico na área da saúde, em crianças, por um intervalo de oito anos, entre janeiro de 1997 e novembro de 2004. Inicialmente, com base em literatura neuropsicológica, descreve o papel do relaxamento na busca da homeostase e da consciência corporal saudável, enfocando comportamentos de prazer e dor. A seguir, descreve e analisa diversas técnicas de relaxamento, Relaxamento Progressivo de Jacobson, Autógeno de Schultz e Relaxamento de Michaux. A fim de desenvolver sua pesquisa utiliza-se de 27 bases de dados, devido a pouca produção encontrada sobre o tema, por base. Como resultados, levanta ao todo 500 artigos sobre relaxamento, sendo 200 em crianças. São artigos nacionais e internacionais, com predomínio do idioma inglês. A seguir, classifica esses artigos por ano de produção, constatando um crescimento significativo, porém não sistemático em seu número, de 14 artigos em 1997, para 39, em 2004. Quanto à temática, os dados revelam em primeiro lugar, um interesse em dor, em segundo em problemas respiratórios, e, em terceiro lugar, em ansiedade. Os artigos sobre dor, por serem os mais numerosos levantados, sofrem análise mais detalhada, com discriminação da quantidade de artigos por ano e dos tipos de situação e de patologia caracterizados por quadro álgico. Finalmente é feita uma classificação dos artigos segundo a utilização do relaxamento junto à problemática clínica predominantemente física, a de fundo psíquico afetivo-emocional, sem utilização de fármacos e, a de fundo psíquico, com intervenção psiquiátrica farmacológica. Na discussão dos resultados, vários artigos pesquisados são também comentados. Dada a riqueza dos dados, evidenciando interesse crescente de profissionais da área da Saúde na literatura levantada, sugere-se pesquisa complementar.

Treatment moderation and secondary outcomes: Results from a randomized clinical trial

The present study pursued two objectives in the context of a randomized clinical trial of cognitive-behavioral therapy with parent (CBT/P) and group (GCBT) involvement. The first objective was to examine the variability in treatment outcome. There were three specific aims within the first objective, to evaluate: (1) youth characteristics (age, depressive, and externalizing disorders) as moderators of treatment outcome; (2) the differential outcome of the treatment approaches as a function of youth characteristics; and (3) the relative efficacy of the treatment approaches at each level of the moderators. ^ The second objective was to evaluate the efficacy of anxiety treatments along secondary depressive symptoms and externalizing behaviors. There were five specific aims within the second objective, to evaluate: (1) whether anxiety treatment yields reductions in secondary problems, (2) the efficacy of anxiety treatments in reducing secondary problems as a function of approach and youth characteristics, (3) whether reductions in anxiety symptoms significantly mediate changes in secondary problems, (4) the directionality of change in the hypothesized mediated relations, and (5) whether the hypothesized mediated relations are moderated by treatment approach and youth characteristics. The specific aims were pursued using data collected from 183 youth and their mothers. Research questions were tested using multiple regressions and structural equation modeling. ^ Age, depressive, and externalizing disorders were significant moderators. CBT/P relative to GCBT lowered anxiety more for younger than older youth. GCBT relative to CBT/P lowered anxiety more for older than younger youth. GCBT relative to CBT/P lowered anxiety more for depressed youth than non-depressed youth. GCBT relative to CBT/P lowered anxiety less for externalizing youth than non-externalizing youth. Treatment reduced depressive symptoms and externalizing problem behaviors. Reductions in anxiety mediated changes in depressive symptoms and externalizing problem behaviors. Reversed directionality was found in the relation between social anxiety and depressive symptoms. In CBT/P the direction of change was from depressive to social anxiety. The opposite was true in GCBT. Reductions in social anxiety mediated posttreatment changes in depressive symptoms in GCBT but not CBT/P. The reverse was true at follow-up. Reductions in social anxiety mediated changes in depressive symptoms for girls but not boys.^

Evaluation of a mentored self -help intervention for the management of psychotic symptoms

Cognitive behavioral therapy has been shown to be promising for the treatment of individuals experiencing psychotic symptoms, who are often diagnosed with schizophrenia. Using a non-random non-equivalent comparison group design (n = 26), this study explores whether an individually mentored self-help and self-paced intervention based upon cognitive behavioral approaches to auditory hallucinations or "hearing voices" makes a significant positive difference for individuals with major mental disorder diagnoses and psychotic symptoms who are residing in the community and receiving community mental health services. The mentored self-help intervention uses a workbook (Coleman & Smith, 1997) that stemmed from the British psychiatric survivor and "voice hearers"' movements and from cognitive behavioral approaches to treating psychotic symptoms. Thirty individuals entered the study. Pre- and post-intervention assessments of 15 participants in the intervention group and 11 participants in the comparison group were carried out using standardized instruments, including the Rosenberg Self-Esteem Scale, the Brief Psychiatric Rating Scale, and the Hoosier Assurance Plan Inventory - Adult. Four specific research questions address whether levels of self-esteem, overall psychotic symptoms, depression-anxiety, and disruption in life improved in the intervention group, relative to the comparison group. Pre- and post-assessment scores were analyzed using repeated measures analysis of variance. Results showed no significant difference on any measure, with the exception of the Brief Psychiatric Rating subscale for Anxious Depression, which showed a statistically significant pre-post difference with a strong effect size. A conservative interpretation of this single positive result is that it is due to chance. An alternative interpretation is that the mentored self-help intervention made an actual improvement in the level of depression-anxiety experienced by participants. If so, this is particularly important given high levels of depression and suicide among individuals diagnosed with schizophrenia. This alternative interpretation supports further research on the intervention utilized in this study. ^

The effectiveness of an enhanced congnitive behavioral intervention in improving behavioral outcomes related to HIV prevention

This study analyzed outcomes of an enhanced cognitive-behavioral intervention with dually diagnosed severely mentally ill adults. It specifically addressed the improvement of attitudes, skills, self-efficacy to use condoms and the heightening of condom use. The data were analyzed via a randomized three-group repeated measures design composed of the experimental (E-CB), standard care (SC) comparison or a no-treatment control condition as the between-subjects variable and pre-post measure as the within-subjects variable. The ECB focused on cooperative, application, hands-on, skill-building and role-playing activities for sexual assertiveness, negotiation in risk-taking and proper condom use. The SC comparison, was didactic in its approach and addressed risk- taking and proper condom use in one session, but did not involve application approaches to problem-solving risky situations or condom use. Multiple assessments were conducted at pre-, post- and six months post-intervention. The analysis indicated that the E-CB intervention led to more favorable attitudes toward condoms and to improved and maintained skills regarding their use by participants six months after the intervention compared to the standard care and control groups. No significant improvements in self-efficacy were found. A repeated measures ANOVA conducted on the transformed values of percentage of vaginal condom use indicated no significant differences between the experimental and standard care conditions but both had a significantly higher mean percentage vaginal condom use than the control group, averaged across pre- and six-month post-intervention. No gender differences were seen in attitudes, skills or self-efficacy to use condoms. This study shed light upon the effectiveness of the instructional approach for the enhancement of attitudes, skills and self-efficacy outcomes related to HIV prevention. For heightened effectiveness, future approaches must address multiple factors impacting learning in this population.