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Clients' Experiences of Returning to the Trauma Site during PTSD Treatment: An Exploratory Study

Background: Visits to the location of the trauma are often included in trauma-focused cognitive behavioural therapy (TF-CBT) for post-traumatic stress disorder (PTSD), but no research to date has explored how service users experience these visits, or whether and how they form an effective part of treatment. Aims: The study aimed to ascertain whether participants found site visits helpful, to test whether the functions of the site visit predicted by cognitive theories of PTSD were endorsed, and to create a grounded theory model of how site visits are experienced. Method: Feedback was collected from 25 participants who had revisited the scene of the trauma as part of TF-CBT for PTSD. The questionnaire included both free text items, for qualitative analysis, and forced-choice questions regarding hypothesized functions of the site visit. Results: Overall, participants found the site visits helpful, and endorsed the functions predicted by the cognitive model. A model derived from the feedback illustrated four main processes occurring during the site visit: “facing and overcoming fear”; “filling in the gaps”; “learning from experiences” and “different look and feel to the site”, which, when conducted with “help and support”, usually from the therapist, led to a sense of “closure and moving on”. Conclusions: Therapist-accompanied site visits may have various useful therapeutic functions and participants experience them positively.

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Exposure-based cognitive–behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: randomised controlled trial

Exposure-based cognitive–behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: randomised controlled trial | Cognitive & General Psychotherapy Research | Scoop.it

Background In DSM-5 two new diagnoses, somatic symptom disorder (SSD) and illness anxiety disorder (IAD), have replaced DSM-IV hypochondriasis. There are no previous treatment studies for these disorders. Cognitive–behavioural therapy (CBT) delivered as therapist-guided or unguided internet treatment or as unguided bibliotherapy could be used to increase treatment accessibility.  Aims To investigate the effect of CBT delivered as guided internet treatment (ICBT), unguided internet treatment (U-ICBT) and as unguided bibliotherapy.  Method A randomised controlled trial (RCT) where participants (n = 132) with a diagnosis of SSD or IAD were randomised to ICBT, U-ICBT, bibliotherapy or to a control condition on a waiting list (trial registration: Clinicaltrials.gov identifier NCT01966705).  Results Compared with the control condition, all three treatment groups made large and significant improvements on the primary outcome Health Anxiety Inventory (between-group d at post-treatment was 0.80–1.27).  Conclusions ICBT, U-ICBT and bibliotherapy can be highly effective in the treatment of SSD and IAD. This is the first study showing that these new DSM-5 disorders can be effectively treated.

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Analysis of trends in adolescent suicides and accidental deaths in England and Wales, 1972–2011

Analysis of trends in adolescent suicides and accidental deaths in England and Wales, 1972–2011 | Cognitive & General Psychotherapy Research | Scoop.it

(Available in free full text) Background Previous analyses of adolescent suicides in England and Wales have focused on short time periods.  Aims To investigate trends in suicide and accidental deaths in adolescents between 1972 and 2011.MethodTime trend analysis of rates of suicides and deaths from accidental poisoning and hanging in 10- to 19-year-olds by age, gender and deprivation. Rate ratios were estimated for 1982–1991, 1992–2001 and 2002–2011 with 1972–1981 as comparator.  Results Suicide rates have remained stable in 10- to 14-year-olds, with strong evidence for a reduction in accidental deaths. In males aged 15–19, suicide rates peaked in 2001 before declining. Suicide by hanging is the most common method of suicide. Rates were higher in males and in 15- to 19-year-olds living in more deprived areas.  Conclusions Suicide rates in adolescents are at their lowest since the early 1970s with no clear evidence that changes in coroners' practices underlie this trend.

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A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescen...

A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescen... | Cognitive & General Psychotherapy Research | Scoop.it

(Available in free full text) Objectives To determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults.  Data sources We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Trials Registers, which includes trials from routine searches of all the major databases. Searches were conducted from inception to 31 December 2014.  Review methods We undertook a systematic review and network meta-analysis (NMA) of the clinical effectiveness and acceptability of available treatments. Outcomes for effectiveness included mean differences in the total scores of the Yale–Brown Obsessive–Compulsive Scale or its children’s version and total dropouts for acceptability. For the cost-effectiveness analysis, we developed a probabilistic model informed by the results of the NMA. All analyses were performed using OpenBUGS version 3.2.3 (members of OpenBUGS Project Management Group; see www.openbugs.net).   Results We included 86 randomised controlled trials (RCTs) in our systematic review. In the NMA we included 71 RCTs (54 in adults and 17 in children and adolescents) for effectiveness and 71 for acceptability (53 in adults and 18 in children and adolescents), comprising 7643 and 7942 randomised patients available for analysis, respectively. In general, the studies were of medium quality. The results of the NMA showed that in adults all selective serotonin reuptake inhibitors (SSRIs) and clomipramine had greater effects than drug placebo. There were no differences between SSRIs, and a trend for clomipramine to be more effective did not reach statistical significance. All active psychological therapies had greater effects than drug placebo. Behavioural therapy (BT) and cognitive therapy (CT) had greater effects than psychological placebo, but cognitive–behavioural therapy (CBT) did not. BT and CT, but not CBT, had greater effects than medications, but there are considerable uncertainty and methodological limitations that should be taken into account. In children and adolescents, CBT and BT had greater effects than drug placebo, but differences compared with psychological placebo did not reach statistical significance. SSRIs as a class showed a trend for superiority over drug placebo, but the difference did not reach statistical significance. However, the superiority of some individual drugs (fluoxetine, sertraline) was marginally statistically significant. Regarding acceptability, all interventions except clomipramine had good tolerability. In adults, CT and BT had the highest probability of being most cost-effective at conventional National Institute for Health and Care Excellence thresholds. In children and adolescents, CBT or CBT combined with a SSRI were more likely to be cost-effective. The results are uncertain and sensitive to assumptions about treatment effect and the exclusion of trials at high risk of bias.  Limitations The majority of psychological trials included patients who were taking medications. There were few studies in children and adolescents.  Conclusions In adults, psychological interventions, clomipramine, SSRIs or combinations of these are all effective, whereas in children and adolescents, psychological interventions, either as monotherapy or combined with specific SSRIs, were more likely to be effective. Future RCTs should improve their design, in particular for psychotherapy or combined interventions.

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Performance of DSM-5 Persistent Complex Bereavement Disorder Criteria in a Community Sample of Bereaved Military Family Members

Performance of DSM-5 Persistent Complex Bereavement Disorder Criteria in a Community Sample of Bereaved Military Family Members | Cognitive & General Psychotherapy Research | Scoop.it

Objective: The purpose of this article was to examine the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder in identifying putative cases of clinically impairing grief and in excluding nonclinical cases. Performance of criteria sets for prolonged grief disorder and complicated grief were similarly assessed.  Method: Participants were family members of U.S. military service members who died of any cause since September 11, 2001 (N=1,732). Putative clinical and nonclinical samples were derived from this community sample using cutoff scores from the Inventory of Complicated Grief and the Work and Social Adjustment Scale. Items from a self-report grief measure (Complicated Grief Questionnaire) were matched to DSM-5 persistent complex bereavement disorder, prolonged grief disorder, and complicated grief criteria. Endorsed items were used to identify cases.  Results: Criteria sets varied in their ability to identify clinical cases. DSM-5 persistent complex bereavement disorder criteria identified 53%, prolonged grief disorder criteria identified 59%, and complicated grief criteria identified more than 90% of putative clinical cases. All criteria sets accurately excluded virtually all nonclinical grief cases and accurately excluded depression in the absence of clinical grief.  Conclusions: The DSM-5 persistent complex bereavement disorder criteria accurately exclude nonclinical, normative grief, but also exclude nearly half of clinical cases, whereas complicated grief criteria exclude nonclinical cases while identifying more than 90% of clinical cases. The authors conclude that significant modification is needed to improve case identification by DSM-5 persistent complex bereavement disorder diagnostic criteria. Complicated grief criteria are superior in accurately identifying clinically impairing grief.

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Attention-Deficit/Hyperactivity Disorder in Young Adulthood

Attention-Deficit/Hyperactivity Disorder in Young Adulthood | Cognitive & General Psychotherapy Research | Scoop.it

Importance  Attention-deficit/hyperactivity disorder (ADHD) is now recognized to occur in adulthood and is associated with a range of negative outcomes. However, less is known about the prospective course of ADHD into adulthood, the risk factors for its persistence, and the possibility of its emergence in young adulthood in nonclinical populations.  Objective  To investigate childhood risk factors and young adult functioning of individuals with persistent, remitted, and late-onset young adult ADHD.Design, Setting, and Participants  The study sample was the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative birth cohort of 2232 twins born in England and Wales from January 1, 1994, to December 4, 1995. Evaluation of childhood ADHD (ages 5, 7, 10, and 12 years) included prenatal and perinatal factors, clinical characteristics, and aspects of the family environment. Among participants aged 18 years, ADHD symptoms and associated impairment, overall functioning, and other mental health disorders were examined. Data analysis was conducted from February 19 to September 10, 2015.  Main Outcomes and Measures  Attention-deficit/hyperactivity disorder according to DSM-IV diagnostic criteria in childhood and DSM-5 diagnostic criteria in young adulthood.  Results  Of 2232 participants in the E-Risk Study, 2040 were included in the present analysis. In total, 247 individuals met diagnostic criteria for childhood ADHD; of these, 54 (21.9%) also met diagnostic criteria for the disorder at age 18 years. Persistence was associated with more symptoms (odds ratio [OR], 1.11 [95% CI, 1.04-1.19]) and lower IQ (OR, 0.98 [95% CI, 0.95-1.00]). At age 18 years, individuals with persistent ADHD had more functional impairment (school/work: OR, 3.30 [95% CI, 2.18-5.00], home/with friends: OR, 6.26 [95% CI, 3.07-12.76]), generalized anxiety disorder (OR, 5.19 [95% CI, 2.01-13.38]), conduct disorder (OR, 2.03 [95% CI, 1.03-3.99]), and marijuana dependence (OR, 2.88 [95% CI, 1.07-7.71]) compared with those whose ADHD remitted. Among 166 individuals with adult ADHD, 112 (67.5%) did not meet criteria for ADHD at any assessment in childhood. Results from logistic regressions indicated that individuals with late-onset ADHD showed fewer externalizing problems (OR, 0.93 [95% CI, 0.91-0.96]) and higher IQ (OR, 1.04 [95% CI, 1.02-1.07]) in childhood compared with the persistent group. However, at age 18 years, those with late-onset ADHD demonstrated comparable ADHD symptoms and impairment as well as similarly elevated rates of mental health disorders.  Conclusions and Relevance  We identified heterogeneity in the DSM-5 young adult ADHD population such that this group consisted of a large, late-onset ADHD group with no childhood diagnosis, and a smaller group with persistent ADHD. The extent to which childhood-onset and late-onset adult ADHD may reflect different causes has implications for genetic studies and treatment of ADHD.

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Lessons (for therapists) from emerging research on how people develop excellence

Lessons (for therapists) from emerging research on how people develop excellence | Cognitive & General Psychotherapy Research | Scoop.it

This sub-section of a longer talk argues that, with increased understanding of how people in general develop expertise, there are exciting new insights into how counsellors & psychotherapists can improve in how helpful they are for their clients.

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The Relationship Between Therapist Effects and Therapy Delivery Factors: Therapy Modality, Dosage, and Non-completion

The Relationship Between Therapist Effects and Therapy Delivery Factors: Therapy Modality, Dosage, and Non-completion | Cognitive & General Psychotherapy Research | Scoop.it

(Available in free full text) To consider the relationships between, therapist variability, therapy modality, therapeutic dose and therapy ending type and assess their effects on the variability of patient outcomes. Multilevel modeling was used to analyse a large sample of routinely collected data. Model residuals identified more and less effective therapists, controlling for case-mix. After controlling for case mix, 5.8 % of the variance in outcome was due to therapists. More sessions generally improved outcomes, by about half a point on the PHQ-9 for each additional session, while non-completion of therapy reduced the amount of pre-post change by six points. Therapy modality had little effect on outcome. Patient and service outcomes may be improved by greater focus on the variability between therapists and in keeping patients in therapy to completion.

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Some counsellors & psychotherapists are more effective than others

This is the third in a sequence of blog posts - "Therapist drift: black heresy or red herring - maybe not so important?", "Psychotherapy is helpful but has developed shockingly poorly over the last 30 yearsand now this one "Some counsellors & psychotherapists are more effective than others."  As you can see from the slide below, identification and study of highly successful therapists' methods and characteristics is an obvious area to explore much more fully, as it is almost certain to give leads on how we might make general improvements in psychotherapy's helpfulness ...

 

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Emotion regulation mediates the effect of childhood trauma on depression

Emotion regulation mediates the effect of childhood trauma on depression | Cognitive & General Psychotherapy Research | Scoop.it

Background Childhood trauma increases the risks of both depression and dysfunctional emotion regulation, which is a factor that has been strongly linked to depression. Because of these demonstrated relationships, it can be hypothesized that dysfunctional emotion regulation is a mediator of the association between childhood trauma and depression. Methods To test this hypothesis, we assessed the indirect effect of emotion regulation (Emotion Regulation Skills Questionnaire) on the relationship between childhood trauma (Childhood Trauma Questionnaire) and depression severity (24-item Hamilton Rating Scale for Depression) as well as depression lifetime persistency (i.e., lifetime percentage spent in major depressive episodes; assessed via SCID and Life Chart Interviews) in 269 patients with major depressive disorder (MDD). Results Bootstrapping-enhanced mediation analyses indicated that deficits in general emotion regulation mediated the association of childhood trauma to both depression severity and depression lifetime persistency. Further exploratory analyses indicated that specific emotion regulation skills (such as the ability to mindfully observe, accept, and tolerate undesired emotions or the willingness to voluntarily confront situations that prompt negative emotions in order to attain personally relevant goals) significantly mediated the association between childhood trauma and depression severity. Willingness to confront was a mediator for both depression outcomes (depression severity and lifetime persistency). Limitations The employed mediation analyses are cross-sectional in nature, which limits any firm conclusions regarding causality. Conclusions The findings support the assumption that a sophisticated emotion regulation may help prevent the onset or unfavorable course of depression in individuals who have experienced childhood trauma.

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Therapist drift: black heresy or red herring - maybe not so important?

Therapist drift: black heresy or red herring - maybe not so important? | Cognitive & General Psychotherapy Research | Scoop.it

I'm scheduled to give a talk at the Psychologists Protection Society AGM entitled "Therapist drift: black heresy or red herring?".  It seems the society has a Continuing Professional Development arm. They invite people to give lectures (there are a couple at this AGM) and then post them onto their Professional Practitioner online resource.  I was approached to talk and given a list of eight potential topics to choose from.  I said I'd talk on "Therapist drift", not least because I had come across Glen Waller & Hannah Turner's recent article "Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track" and I wanted to have an opportunity to explore the issues they were presenting more thoroughly.  Though as you can see from the "Key points" slide, the talk fairly rapidly morphed into a rather larger overview looking at the effectiveness of psychotherapy more generally ...

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The Contribution of Therapist Effects to Patient Dropout and Deterioration in the Psychological Therapies

The Contribution of Therapist Effects to Patient Dropout and Deterioration in the Psychological Therapies | Cognitive & General Psychotherapy Research | Scoop.it

Background: In the psychological therapies, patient outcomes are not always positive. Some patients leave therapy prematurely (dropout), while others experience deterioration in their psychological well-being. Methods: The sample for dropout comprised patients (n = 10 521) seen by 85 therapists, who attended at least the initial session of one-to-one therapy and completed a Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at pre-treatment. The subsample for patient deterioration comprised patients (n = 6405) seen by the same 85 therapists but who attended two or more sessions, completed therapy and returned a CORE-OM at pre-treatment and post-treatment. Multilevel modelling was used to estimate the extent of therapist effects for both outcomes after controlling for patient characteristics. Results: Therapist effects accounted for 12.6% of dropout variance and 10.1% of deterioration variance. Dropout rates for therapists ranged from 1.2% to 73.2%, while rates of deterioration ranged from 0% to 15.4%. There was no significant correlation between therapist dropout rate and deterioration rate (Spearman's rho = 0.07, p = 0.52). Conclusions: The methods provide a reliable means for identifying therapists who return consistently poorer rates of patient dropout and deterioration compared with their peers. The variability between therapists and the identification of patient risk factors as significant predictors has implications for the delivery of safe psychological therapy services. Key Practitioner Message: * Therapists play an important role in contributing to patient dropout and deterioration, irrespective of case mix. * Therapist effects on patient dropout and deterioration appear to act independently. * Being unemployed as a patient was the strongest predictor of both dropout and deterioration. * Patient risk to self or others was also an important predictor.

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

Unpacking the therapist effect: Impact of treatment length differs for high- and low-performing therapists | Cognitive & General Psychotherapy Research | Scoop.it

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<.001). In addition, patients' trajectories of change were a function of their therapist's average outcome as well as the patient's duration of treatment (interaction coefficient=0.060, 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.

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The mediating role of perceived peer support in the relation between quality of attachment and internalizing problems in adolescence: a longitudinal perspective

The mediating role of perceived peer support in the relation between quality of attachment and internalizing problems in adolescence: a longitudinal perspective | Cognitive & General Psychotherapy Research | Scoop.it

The study was aimed to verify, from a longitudinal perspective, whether perceived peer support would mediate the relationship between attachment and internalizing problems. Longitudinal participants included 482 adolescents (245 boys) aged 14-15 years in Wave 1 and 17-18 years in Wave 2. Participants in Wave 1 completed the Relationship Questionnaire, and those in Wave 2 completed the Social Support Questionnaire and the Youth Self-Report. Results showed that secure attachment positively predicted high levels of perceived peer support and negatively predicted internalizing problems, whereas fearful and preoccupied attachment negatively predicted perceived peer support and positively predicted internalizing problems. The mediation models showed that perceived peer support partially mediated the relationship between secure attachment and internalizing problems as well as between preoccupied attachment and internalizing problems and between fearful attachment and internalizing problems. Our results confirm the role of subjective perception of peer support in contributing to the prediction of internalizing problems beyond attachment styles.

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Exercise and internet-based cognitive–behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up

Exercise and internet-based cognitive–behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up | Cognitive & General Psychotherapy Research | Scoop.it

Background Evidence-based treatment of depression continues to grow, but successful treatment and maintenance of treatment response remains limited.  Aims To compare the effectiveness of exercise, internet-based cognitive–behavioural therapy (ICBT) and usual care for depression.  Method A multicentre, three-group parallel, randomised controlled trial was conducted with assessment at 3 months (post-treatment) and 12 months (primary end-point). Outcome assessors were masked to group allocation. Computer-generated allocation was performed externally in blocks of 36 and the ratio of participants per group was 1:1:1. In total, 945 adults with mild to moderate depression aged 18–71 years were recruited from primary healthcare centres located throughout Sweden. Participants were randomly assigned to one of three 12-week interventions: supervised group exercise, clinician-supported ICBT or usual care by a physician. The primary outcome was depression severity assessed by the Montgomery–Åsberg Depression Rating Scale (MADRS).  Results The response rate at 12-month follow-up was 84%. Depression severity reduced significantly in all three treatment groups in a quadratic trend over time. Mean differences in MADRS score at 12 months were 12.1 (ICBT), 11.4 (exercise) and 9.7 (usual care). At the primary end-point the group × time interaction was significant for both exercise and ICBT. Effect sizes for both interventions were small to moderate.  Conclusions The long-term treatment effects reported here suggest that prescribed exercise and clinician-supported ICBT should be considered for the treatment of mild to moderate depression in adults.

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Why are women so vulnerable to anxiety, trauma-related and stress-related disorders? The potential role of sex hormones

Why are women so vulnerable to anxiety, trauma-related and stress-related disorders? The potential role of sex hormones | Cognitive & General Psychotherapy Research | Scoop.it

Summary: Increased prevalence, severity, and burden of anxiety, trauma-related and stress-related disorders in women compared with men has been well documented. Evidence from a variety of fields has emerged suggesting that sex hormones, particularly oestradiol and progesterone, play a significant part in generation of these sex differences. In this Series paper, we aim to integrate the literature reporting on the effects of sex hormones on biological, behavioural, and cognitive pathways, to propose two broad mechanisms by which oestradiol and progesterone influence sex differences in anxiety disorders: augmentation of vulnerability factors associated with anxiety disorder development; and facilitation of the maintenance of anxious symptoms post-development. The implications for future research, along with novel approaches to psychological and pharmacological treatment of anxiety disorders, are also considered.

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November: CBT, Stress & Well-Being Relevant Research, Blog Posts & Other Resources

November: CBT, Stress & Well-Being Relevant Research, Blog Posts & Other Resources | Cognitive & General Psychotherapy Research | Scoop.it

Early November and here’s an autumn newsletter with abstracts & links to many recently published research articles relevant to CBT & psychotherapy, depression, mindfulness & compassion, healthy living & healthy aging, and positive psychology (and photos from last weekend's walk up Kinnoull Hill in Perth).  There are also eight blog posts.  Five are inspired by thoughts about how we could increase the effectiveness of psychotherapy.  A couple are about kidney donation (an unusual subject for this newsletter, but a current personal journey), and one is a post on recent research that has been published in the last few months (see below).  Finally there are links to a library of freely downloadable handouts, questionnaires, and courses.  All information described in this newsletter is offered as a free resource for health professionals and for others interested in evidence-based approaches to stress, health & well-being.  If you no longer wish to receive these mailings, please use this link to unsubscribe.  If you would like to update your contact details or ask for the newsletter to be sent to a friend or colleague as well please follow this link.  I hope you’ll find that this mailing is interesting & useful for you both professionally & personally.

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Cognitive and Dynamic Therapies for Major Depressive Disorder

Cognitive and Dynamic Therapies for Major Depressive Disorder | Cognitive & General Psychotherapy Research | Scoop.it

Importance  Dynamic psychotherapy (DT) is widely practiced in the community, but few trials have established its effectiveness for specific mental health disorders relative to control conditions or other evidence-based psychotherapies.  Objective  To determine whether DT is not inferior to cognitive therapy (CT) in the treatment of major depressive disorder (MDD) in a community mental health setting.  Design, Setting, and Participants  From October 28, 2010, to July 2, 2014, outpatients with MDD were randomized to treatment delivered by trained therapists. Twenty therapists employed at a community mental health center in Pennsylvania were trained by experts in CT or DT. A total of 237 adult outpatients with MDD seeking services at this site were randomized to 16 sessions of DT or CT delivered across 5 months. Final assessment was completed on December 9, 2014, and data were analyzed from December 10, 2014, to January 14, 2016.Interventions  Short-term DT or CT.  Main Outcomes and Measures  Expert blind evaluations with the 17-item Hamilton Rating Scale for Depression.  Results  Among the 237 patients (59 men [24.9%]; 178 women [75.1%]; mean [SD] age, 36.2 [12.1] years) treated by 20 therapists (19 women and 1 man; mean [SD] age, 40.0 [14.6] years), 118 were randomized to DT and 119 to CT. A mean (SD) difference between treatments was found in the change on the Hamilton Rating Scale for Depression of 0.86 (7.73) scale points (95% CI, −0.70 to 2.42; Cohen d, 0.11), indicating that DT was statistically not inferior to CT. A statistically significant main effect was found for time (F1,198 = 75.92; P = .001). No statistically significant differences were found between treatments on patient ratings of treatment credibility. Dynamic psychotherapy and CT were discriminated from each other on competence in supportive techniques (t120 = 2.48; P = .02), competence in expressive techniques (t120 = 4.78; P = .001), adherence to CT techniques (t115 = −7.07; P = .001), and competence in CT (t115 = −7.07; P = .001).  Conclusions and Relevance  This study suggests that DT is not inferior to CT on change in depression for the treatment of MDD in a community mental health setting. The 95% CI suggests that the effects of DT are equivalent to those of CT.

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Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial

Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial | Cognitive & General Psychotherapy Research | Scoop.it

Importance  To our knowledge, this is the first placebo-controlled randomized clinical trial to evaluate the efficacy of antidepressant pharmacotherapy, with and without complicated grief psychotherapy, in the treatment of complicated grief.  Objective  To confirm the efficacy of a targeted complicated grief treatment (CGT), determine whether citalopram (CIT) enhances CGT outcome, and examine CIT efficacy without CGT.  Design, Setting, and Participants  Included in the study were 395 bereaved adults who met criteria for CG recruited from March 2010 to September 2014 from academic medical centers in Boston, Massachusetts; New York, New York; Pittsburgh, Pennsylvania; and San Diego, California. Co-occurring substance abuse, psychosis, mania, and cognitive impairment were exclusionary. Study participants were randomized using site-specific permuted blocks stratified by major depression into groups prescribed CIT (n = 101), placebo (PLA; n = 99), CGT with CIT (n = 99), and CGT with PLA (n = 96). Independent evaluators conducted monthly assessments for 20 weeks. Response rates were compared under the intention-to-treat principle, including all randomized participants in a logistic regression with inverse probability weighting.Interventions  All participants received protocolized pharmacotherapy optimized by flexible dosing, psychoeducation, grief monitoring, and encouragement to engage in activities. Half were also randomized to receive manualized CGT in 16 concurrent weekly sessions.  Main Outcomes and Measures  Complicated grief–anchored Clinical Global Impression scale measurments every 4 weeks. Response was measured as a rating of “much improved” or “very much improved.”  Results  Of the 395 study participants, 308 (78.0%) were female and 325 (82.3%) were white. Participants’ response to CGT with PLA vs PLA (82.5% vs 54.8%; relative risk [RR], 1.51; 95% CI, 1.16-1.95; P = .002; number needed to treat [NNT], 3.6) suggested the efficacy of CGT, and the addition of CIT did not significantly improve CGT outcome (CGT with CIT vs CGT with PLA: 83.7% vs 82.5%; RR, 1.01; 95% CI, 0.88-1.17; P = .84; NNT, 84). However, depressive symptoms decreased significantly more when CIT was added to treatment (CGT with CIT vs CGT with PLA: model-based adjusted mean [standard error] difference, −2.06 [1.00]; 95% CI, −4.02 to −0.11; P = .04). By contrast, adding CGT improved CIT outcome (CIT vs CGT with CIT: 69.3% vs 83.7%; RR, 1.21; 95% CI, 1.00-1.46; P = .05; NNT, 6.9). Last, participant response to CIT was not significantly different from PLA at week 12 (45.9% vs 37.9%; RR, 1.21; 95% CI, 0.82-1.81; P = .35; NNT, 12.4) or at week 20 (69.3% vs 54.8%; RR, 1.26; 95% CI, 0.95-1.68; P = .11; NNT, 6.9). Rates of suicidal ideation diminished to a substantially greater extent among participants receiving CGT than among those who did not.Conclusions and Relevance  Complicated grief treatment is the treatment of choice for CG, and the addition of CIT optimizes the treatment of co-occurring depressive symptoms.

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The impact of posttraumatic stress disorder on the symptomatology of borderline personality disorder

The impact of posttraumatic stress disorder on the symptomatology of borderline personality disorder | Cognitive & General Psychotherapy Research | Scoop.it

(Available in free full text) Background Previous findings on the impact of co-occurring posttraumatic stress disorder (PTSD) in patients with borderline personality disorder (BPD) have revealed inconsistencies, which may have been related to small sample sizes or differences in the presence of childhood sexual abuse (CSA). In this study, the potentially aggravating impact of PTSD and the role of CSA were examined in a large cohort of BPD patients.  Methods BPD patients with current PTSD (n = 142) were compared to BPD patients without PTSD (n = 225) regarding different BPD features such as non-suicidal self-injury. Further, we examined the potentially confounding role of CSA.  Results BPD patients with PTSD showed elevated affect dysregulation, intrusions, dissociation, history of suicide attempts and self-mutilation compared to those with only BPD. The effects of PTSD on BPD patients regarding dissociation and the history of suicide attempts were at least partially related to CSA.  Conclusions The additional diagnosis of PTSD in BPD patients can aggravate some, but not all BPD features. With respect to dissociation and suicide attempts, at least some of the impact seems to relate to CSA.

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Lessons (for therapists) from emerging research on how people develop excellence

Lessons (for therapists) from emerging research on how people develop excellence | Cognitive & General Psychotherapy Research | Scoop.it

I recently gave a talk entitled "Therapist drift: black heresy or red herring?" where I began by arguing that therapist drift isn't of great importance and rapidly segued into a series of rather more fundamental issues - see the blog posts "Therapist drift: black heresy or red herring - maybe not so important?""Psychotherapy is helpful but has developed shockingly poorly over the last 30 yearsand "Some counsellors & psychotherapists are more effective than others" Also linked to these points are the posts "Using involvement in group discussions for (self-) assessment and learning", "Truly excellent therapists have 'grace under interpersonal pressure' - Fascinating new research" and "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous" Today's post is the final one in this interlinked cluster - "Lessons (for therapists) from emerging research on how people develop excellence".

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Exercise as a treatment for depression: A meta-analysis

Exercise as a treatment for depression: A meta-analysis | Cognitive & General Psychotherapy Research | Scoop.it

Abstract Background This meta-analysis of randomized controlled trials (RCTs) examines the efficacy of physical exercise as treatment for unipolar depression, both as an independent intervention and as an adjunct intervention to antidepressant medication. Methods We searched PsycINFO, EMBASE, MEDLINE, CENTRAL, and Sports Discus for articles published until November 2014. Effect sizes were computed with random effects models. The main outcome was reduction in depressive symptoms or remission. Results A total of 23 RCTs and 977 participants were included. Physical exercise had a moderate to large significant effect on depression compared to control conditions (g=−0.68), but the effect was small and not significant at follow-up (g=−0.22). Exercise compared to no intervention yielded a large and significant effect size (g=−1.24), and exercise had a moderate and significant effect compared to usual care (g=−0.48). The effects of exercise when compared to psychological treatments or antidepressant medication were small and not significant (g=−0.22 and g=−0.08, respectively). Exercise as an adjunct to antidepressant medication yielded a moderate effect (g=−0.50) that trended toward significance. Limitations Use of the arms with the largest clinical effect instead of largest dose may have overestimated the effect of exercise. Conclusions Physical exercise is an effective intervention for depression. It also could be a viable adjunct treatment in combination with antidepressants.

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Psychotherapy is helpful but has developed shockingly poorly over the last thirty years

Psychotherapy is helpful but has developed shockingly poorly over the last thirty years | Cognitive & General Psychotherapy Research | Scoop.it

I wrote a blog post recently on "Therapist drift: black heresy or red herring?" where I argued that current research evidence does not suggest that "therapist drift" is of much significance for either increasing or decreasing the effectiveness of psychotherapy.  As you can see from the slide though, I felt that the whole debate about therapist drift is something of a red herring when one considers the huge challenges faced by psychotherapy as a whole.

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Psychotherapists: Using involvement in group discussions for (self-) assessment and learning

Psychotherapists: Using involvement in group discussions for (self-) assessment and learning | Cognitive & General Psychotherapy Research | Scoop.it

I recently gave a talk on "Therapist drift: black heresy or red herring?".  Although that was the title, the talk rapidly segued into an exploration of the current state of psychotherapy and what we might do to improve our results.  I argued that an excessive focus on comparing different types of psychotherapy (e.g. CBT, psychodynamic, interpersonal, behavioural, and so on) has directed us away from a potentially more productive area - researching why some psychotherapists are more helpful than others and what we can learn from these significant differences.  One issue that I discussed in some detail is the recently emerging research on the importance of therapist interpersonal skills when assessed not by self-report, but by observing actual behaviour in challenging situations.  The slide lists four fascinating, relevant research studies ...

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Are therapists uniformly effective across patient outcome domains? A study on therapist effectiveness in two different treatment contexts.

As established in several studies, therapists differ in effectiveness. A vital research task now is to understand what characterizes more or less effective therapists, and investigate whether this differential effectiveness systematically depends on client factors, such as the type of mental health problem. The purpose of the current study was to examine whether therapists are universally effective across patient outcome domains reflecting different areas of mental health functioning. Data were obtained from 2 sites: the Research Consortium of Counseling and Psychological Services in Higher Education (N = 5,828) in the United States and from primary and secondary care units (N = 616) in Sweden. Outcome domains were assessed via the Outcome Questionnaire-45 (Lambert et al., 2004) and the CORE-OM (Evans et al., 2002). Multilevel models with observations nested within patients were used to derive a reliable estimate for each patient’s change (which we call a multilevel growth d) based on all reported assessment points. Next, 2 multilevel confirmatory factor analytic models were fit in which these effect sizes (multilevel ds) for the 3 subscales of the OQ-45 (Study 1) and 6 subscales of CORE-OM (Study 2) were indicators of 1 common latent factor at the therapist level. In both data sets, such a model, reflecting a global therapist effectiveness factor, yielded large factor loadings and excellent model fit. Results suggest that therapists effective (or ineffective) within one outcome domain are also effective within another outcome domain. Tentatively, therapist effectiveness can thus be conceived of as a global construct.

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