Brief Communications

Abstract

Evidence-based psychotherapy is typically based on treatment outcome for the “average” patient in aggregate designs; reports on individual non-responders are rarely published. In this observational study, we explored factors that might have contributed to non-response in long-term dynamic group psychotherapy. Eight patients (14%) who did not change were compared with 48 treatment responders on clinical variables, and their case stories were retrospectively scrutinized for explanatory factors. The non-responders had less initial distress, stayed for shorter durations in therapy, and were more dissatisfied with their group and therapists. Based on detailed case stories, attempts are made to tease out idiographic hypotheses why each patient did not change during group analysis.     

Practice-based evidence: patients who did not respond to group analysis

Evidence-based psychotherapy is typically based on treatment outcome for the "average" patient in aggregate designs; reports on individual non-responders are rarely published. In this observational study, we explored factors that might have contributed to non-response in long-term dynamic group psychotherapy. Eight patients (14%) who did not change were compared with 48 treatment responders on clinical variables, and their case stories were retrospectively scrutinized for explanatory factors. The non-responders had less initial distress, stayed for shorter durations in therapy, and were more dissatisfied with their group and therapists. Based on detailed case stories, attempts are made to tease out idiographic hypotheses why each patient did not change during group analysis.     

Not starting psychotherapy is more often initiated by the therapist than the patient

The phenomenon of not starting psychotherapy is seldom investigated. The present study of psychotherapy in the Swedish mental health services differentiates between patients applying for and being offered psychotherapy but choosing not to start (n = 69), patients recommended to receive no treatment, another type of treatment or treatment at another clinic (n = 133), and therapy starters (n = 1294). After the initial assessment, nearly twice as many patients did not start based on the therapist’s decision than on the patient’s. Cases of not starting psychotherapy decided by the therapist were more frequent among patients whose occupational status was less stable, presented a danger to others, had lower levels of initial therapeutic alliance, and by therapists with lower levels of psychotherapy training and those at less structured and more unstable clinics. Patients choosing not to start therapy had lower levels of mental ill-health than both starters and therapist-initiated nonstarters. The most frequently presented reason for a patient-initiated decision to not start therapy was “patient wished another treatment or therapist,” whereas the most common therapist-initiated reason was “recommended or referred to another treatment or clinic”.     

Coping strategies used by middle-aged males with noise-induced hearing loss,with and without tinnitus

Abstract

The aim of this study was to examine the relationship between general coping strategies and specific communication strategies, adopted by males with noise-induced hearing loss (NIHL) in order to deal with stressful events and demanding auditory situations. The sample included 72 males with NIHL; 22 without tinnitus, 26 with mild tinnitus, and 24 with severe tinnitus. The following variables were measured: “active coping” “escape coping” and “passive acceptance” (general coping strategies), and “maladaptive behaviours”, “verbal strategies” and “nonverbal strategies” (specific communication strategies). The results showed that males without tinnitus or with mild tinnitus combined “active coping” and “passive acceptance”, whereas males with severe tinnitus supplemented these strategies with “escape coping”. The relationship between general coping and specific communication strategies was weak, although giving a significant correlation between “escape coping” and “maladaptive behaviours”. The results indicate that the hypothesis that a person's general pattern of coping has influence on his/her ability to cope effectively with a hearing impairment can not be supported. Further research should concentrate on the contribution of personality factors as well as environmental factors to the variance in coping with NIHL and tinnitus.     

Social-Exchange Theory: Cognitive Restructuring in Marital Therapy

Problems arise in marital relationships when any of the following conditions are not met: first, that the couple have correspondence of their beliefs, or rules, as to what behaviors constitute “value messages” or “devalue messages”; second, that they depend primarily upon nonpainful channels for sending and receiving value messages; and third, that each partner's required quota of value messages from the other be of a reasonable quantity, not inflated by unrealistic fear of abandonment or devaluation. Problems in any of these areas may present in a variety of seemingly disparate fashions. Each of these problems is amenable to cognitive restructuring strategies. Different demands are placed on the therapeutic alliance and the marital alliance by the elucidation of each of these three types of problems; proper timing of interventions is therefore necessary.     

The Role of Fear-Avoidance Cognitions and Behaviors in Patients with Chronic Tinnitus

The current study investigated the role of fear-avoidance—a concept from chronic pain research—in chronic tinnitus. A self-report measure the “Tinnitus Fear-Avoidance Cognitions and Behaviors Scale (T-FAS)” was developed and validated. Furthermore, the role of fear-avoidance behavior as mediator of the relationship between anxiety sensitivity and tinnitus handicap was investigated. From a clinical setting, N = 373 patients with chronic tinnitus completed questionnaires assessing tinnitus handicap (Tinnitus Handicap Inventory), anxiety, depression (Hospital Anxiety and Depression Scale), anxiety sensitivity (Anxiety Sensitivity Index-3), personality factors (Big Five Inventory-10), and fear-avoidance. To analyze the psychometric properties, principal component analysis with parallel component extraction and correlational analyses were used. To examine a possible mediating effect, hierarchical regression analysis was applied. The principal component analysis resulted in a three-factor solution: Fear-avoidance Cognitions, Tinnitus-related Fear-Avoidance Behavior, and Ear-related Fear-Avoidance Behavior. Internal consistency was satisfactory for the total scale and all subscales. High correlations between tinnitus-related handicap scales, depressive and anxiety symptoms, and the T-FAS were found, whereas associations with personality factors were low. Moreover, results indicate a significant partial mediation of fear-avoidance behaviors in the relationship between anxiety sensitivity and the cognitive dimension of tinnitus handicap. Results show that fear-avoidance behavior plays an important role in tinnitus handicap. More attention should be paid to this concept in research and clinical practice of psychotherapy for chronic tinnitus.     

Neurocognitive impairment does not predict treatment outcome in obsessive-compulsive disorder

There is conflicting evidence pertaining to whether or not neurocognitive task performance at baseline predicts treatment response in obsessive-compulsive disorder (OCD). In the present study, we administered a set of executive neurocognitive tests with a putative sensitivity for treatment outcome to a sample of 138 OCD patients. Additionally, subjective neurocognitive dysfunction was determined via a questionnaire. All patients participated in a cognitive-behavioural treatment program (CBT). Results showed that responders (n = 73) did not differ from non-responders (n = 65) on any of the parameters except for decreased performance on the delayed alternation test (p < .1, effect size: .61). A subsidiary analysis revealed that slowing on the Trail-Making Test A and an enhanced rate of perserveration errors on the Wisconsin Card Sorting Test predicted poor outcome for the treatment of compulsions. It is concluded that neurocognitive impairment does not represent a reliable early warning sign for non-response to CBT.     

Psychoanalysis: Practical and Research Aspects by Willi Hoffer

The outcome of clients who saw one of four “expert” professional group therapists selected by peer nomination or four “natural helper” nonprofessionals nominated by students is contrasted in a 15-session psychotherapy group. Process measures tapping specific group and “common factors” were drawn from sessions 3, 8, and 14; outcome was assessed at pre-, mid-, posttreatment, and a 6-month follow-up. Results were examined by leader condition (professional vs. nonprofessional therapists) and time (group development). Virtually no reliable differences were found on measures of outcome primarily because of a floor effect on several measures. Therapist differences on the process measures tapping the “common factors” of therapeutic alliance, client expectancy, and perception of therapists were either nonsignificant or disappeared by the end of treatment. A complex picture of differences on one therapeutic factor (insight), common factor measures, and subtle variation in the outcome data suggests a distinct pattern of change, however. Methodological limitations are also addressed including problems inherent in large-scale clinical-trial studies, ethical concerns raised by using nonprofessional leaders, and problems with generalizability, given the absence of significant psychopathology in group members.     

The Therapeutic Alliance in Couple Therapy for Depression: Predicting Therapy Progress and Outcome from Assessments of the Alliance by the Patient, the Spouse, and the Therapists

This study examined Couple Therapy (CT) for depression in a naturalistic setting. It looked at the associations between the therapeutic alliance and subjective distress, and between the alliance and depression outcome. Twenty-nine depressive patients and their spouses were treated via CT. Treatments were adapted in accordance with the patient’s need. The couples assessed the alliance and their subjective distress at every session. In addition, the therapists assessed the alliance at every session. The patient’s depression outcome was assessed at baseline and at 6, 12, 18, and 24 months post-baseline. The Outcome Rating Scale, The Session Rating Scale, and the Beck Depression Inventory were used. At any given session, the patients’ and spouses’ deviations from their average subjective distress ratings predicted their deviations from their average alliance ratings in the same session. At any given session, the patients’ and spouses’ deviations from their average alliance ratings predicted their deviations from their average subjective distress in the next session. The therapy-system alliance was significantly associated with the patients’ depression outcome, explaining 19.4 % of the variance in the patients’ depression change. The results indicate the importance of taking into account the association between the alliance and subjective distress during the treatment, and confirm the usefulness of routine evaluation of the therapeutic process as an indicator of the association between alliance and therapy outcome in everyday CT for depression.     

La psychothérapie assistée par la MDMA dans la prise en charge du syndrome de stress post-traumatique

Posttraumatic stress disorder (PTSD) is estimated to remain chronic and severe for 25–50% of patients despite psychotherapeutic treatment. Part of the reasons is that patients with PTSD can have difficulties in establishing a good therapeutical alliance with the therapist. Moreover, they often fail to re-think the content of the trauma without being overwhelmed by negative emotions and tend to rely on avoidance strategies and/or to abandon the therapy. MDMA (“ecstasy”) is a drug classified as an entactogen (en “within”, tactus “touch”, and gen “produce”), an amphetamine with psychedelic properties that possesses psychopharmacological properties to overcome these issues. Indeed, MDMA triggers the release of oxytocin, which favors the establishment of interpersonal relationship based on kindness and trust. Moreover, MDMA diminishes the activity of the amygdale, allowing patients to work on challenging memories with less fear and anxiety. Finally, MDMA may also provide access to meaningful spiritual experiences, release of tensions and a sense of healing on a non-verbal level that are not completely understood. But are viewed as important by patients. Today, there is no evidence that the use of MDMA in a clinical setting has bad neurologic, psychological or cognitive consequences. Results of phase II trials in the United States and Europe confirm that MDMA favors psychotherapy's outcome without severe adverse effects. Phase III trials are underway. The Multidisciplinary Association for Psychedelic Studies (MAPS) has published online a method proposal and trains therapists in MDMA-assisted psychotherapy.ConclusionFood and Drug Administration (FDA) and European Medicines Agency (EMA) could approve this therapeutic tool in the coming years.     

Internet-delivered cognitive behavioral therapy for panic disorder with or without agoraphobia: a systematic review and meta-analysis

ABSTRACT

The current systematic review and meta-analysis examined the efficacy and effectiveness of internet-delivered cognitive behavioral therapy (iCBT) on panic disorder and agoraphobia symptom severity. Twenty-seven studies were identified. Results from nine randomised controlled trials (RCTs) showed that iCBT outperformed waiting list and information controls for panic (g = 1.22) and agoraphobia (g = .91) symptoms, but the quality of RCTs varied and heterogeneity was high. Results from three RCTs suggested iCBT may have similar outcomes to face-to-face CBT in reducing panic and agoraphobia symptoms. Within-group effect sizes between baseline and post-treatment were large for panic (n = 29, g = 1.16) and medium for agoraphobia symptom severity (n = 18, g = .73). Subgroup analyses of within-group pre/post treatment effect sizes showed larger within-group effect sizes for efficacy studies (n = 15) compared to effectiveness studies (n = 14) for panic severity (g = 1.38 vs. g = .98) but not agoraphobia severity. There was no impact of program length, inclusion or arousal reduction techniques, or degree of clinician support. Within-group effects of iCBT suggest the reduction in panic and agoraphobia symptom severity is maintained at 3–6 month follow-up (n = 12).     

Internet-delivered cognitive behavior therapy for anxiety and insomnia in a higher education context

Background and Objectives: Anxiety and insomnia can be treated with internet-delivered Cognitive Behavioral Therapy (iCBT). iCBT may be well-suited to students who are known to be poor help-seekers and suffer these symptoms. iCBT can offer easy access to treatment and increase service availability. The aim of this study was to evaluate the efficacy of anxiety and insomnia iCBT programs in students. Design: A randomized, controlled study. Methods: Students were randomly allocated to intervention (“Anxiety Relief”: n?=?43; “Insomnia Relief”: n?=?48; control: n?=?47). Interventions lasted six weeks. Outcome measures were the State-Trait Anxiety Inventory and the Pittsburgh Sleep Quality Index. Results: Significant within-group reductions in anxiety (t(31)?=?2.00, p?=?.03) with moderate between-groups (compared to control) effect size (d?=?.64) and increases in sleep quality (t(31)?=?3.46, p?=?.002) with a moderate between-groups effect size (d?=?.55) were found for completers of the anxiety program from pre- to post-intervention. Significant within-group increases in sleep quality were found for completers of the insomnia program from pre- to post-intervention (t(35)?=?4.28, p?>?.001) with a moderate between-groups effect size (d?=?.51). Conclusions: Findings support the use of iCBT for anxiety and insomnia in students, and indicate that further research is needed.     

Ambulant oder stationär?

A central issue in psychosomatic-psychotherapeutic consultations is whether to recommend outpatient or inpatient psychotherapy. In a prospective field study at a psychosomatic outpatient unit sociodemographic and clinical variables were compared for patients for whom outpatient treatment (N = 129) or inpatient treatment (N = 112) had been recommended. The assessments of the therapeutic alliance were made by the referring therapist and the therapist who conducted the therapy. The main findings were: The decision about what type of treatment to recommend was based mainly on the type and severity of the disorder, including the patient's functional level and personality structure. There was no difference between the patient groups in how the referring therapists assessed the initial therapeutic alliance, but there was a difference in how the treating therapists did, the relationship to the inpatients being rated significantly less favorably. The importance of the different treatment settings in interaction with the severity of the disorder is discussed. The initial therapeutic alliance in the consultation did not enable a prognosis about the therapeutic alliance during therapy.     

Salivating,and Thinking in Different Languages

This study investigated age, sex, and title of therapist as determinants of patients' preferences. In general it was found that (a) “psychologists” and “psychiatrists” were preferred to “behavioral consultants,” “emotional counselors,” and “psychoanalysts” who, in turn, were preferred to “social workers”; (b) male therapists were preferred to female therapists; and (c) 40-year-old therapists were preferred to 55-year-old therapists who, in turn, were preferred to 25-year-old therapists.     

The Evaluative Consequences of Hedges,Hesitations, and Intensifies Powerful and Powerless Speech Styles

This article examines the separate and combined impact of hedges, hesitations, and intensifiers on perceptions of authoritativeness, sociability, character, and similarity, and the extent to which messages containing one or more of these language variables differs from a “prototypically” powerless message in evaluative consequences. A “prototypically” powerless message is one that contains not only hedges, hesitations, and intensifiers, but also contains polite forms and meaningless particles, such as “oh, well” and “you know.” Two studies indicated that hedges and hesitations individually affected perceptions of authoritativeness and sociability, but interactions among the variables were not found in the studies. Furthermore, only high intensifiers/low hedges/low hesitations and low intensifiers/low hedges/low hesitations messages differed significantly from the “prototypically” powerless message. The second study revealed that speaker status interacted to affect evaluative consequences. The results are discussed in terms of their implications for the power of speech style construct.     

A preliminary examination of the role of psychotherapist fidelity on outcomes of cognitive processing therapy during an RCT for military sexual trauma-related PTSD

While cognitive processing therapy (CPT) is an effective evidence-based treatment for many veterans with military-related post-traumatic stress disorder (PTSD), not all veterans experience therapeutic benefit. To account for the discrepancy in outcomes, researchers have investigated patient- and research design-related factors; however, therapist factors (e.g. fidelity) have received less attention. The present study is a preliminary examination of the effect of psychotherapists’ fidelity during CPT on clinical outcomes during a randomized clinical trial (RCT) for military sexual trauma-related PTSD. PTSD symptoms, trauma-related negative cognitions (NCs), and depression symptoms were assessed for 72 participants at baseline, and 1-week, 2-month, 4-month, and 6-month posttreatment. Of the four CPT therapists, two were found to have significantly poorer (i.e. “below average”) treatment fidelity scores compared to the other two therapists who had “good” treatment fidelity scores. To examine possible therapist effects on outcomes, hierarchical linear modeling was utilized with therapist fidelity entered as a Level 2 predictor. Participants treated by a therapist with “good” treatment fidelity experienced significantly greater reductions in PTSD symptoms, NCs, and depression symptoms than patients treated by a therapist with “below average” treatment fidelity. Our preliminary findings highlight the importance of monitoring, maintaining, and reporting fidelity in psychotherapy treatment RCTs.     

Hemispheric specialization for emotional word processing is a function of SSRI responsiveness

Vulnerability to depression and non-response to Selective Serotonin Reuptake Inhibitors (SSRIs) are associated with specific neurophysiological characteristics including greater right hemisphere (RH) relative to left hemisphere (LH) activity. The present study investigated the relationship between hemispheric specialization and processing of emotional words using a divided visual field paradigm administered to never-depressed and previously-depressed individuals, who were subdivided into SSRI responders and non-responders. SSRI responders and never-depressed participants were similar in their left hemispheric lateralization for evaluating emotional words. In contrast, SSRI non-responders showed a relative shift towards RH processing of negative words, and a strong bias toward negative evaluation of words presented to the RH. The results are discussed within the context of a biological-cognitive model of vulnerability to depression.     

Therapeutic popularity and personality: Association between peer therapist nominations and the “Big Five” personality factors

The “Big Five” personality factors of three groups of psychology students differing in popularity as therapist among their peers were compared (n=33). In agreement with earlier research, popular therapists are “agreeable”, “conscientious” and “stable”. However, popular therapists are not “surgent/extravert” and especially not “dominant” and “talkative”. No support was found for the hypothesis that similarity in “agreeableness” or dissimilarity in “surgency” (the complementarily hypothesis derived from interpersonal theory) predicts therapist popularity. However, similarity between client and therapist in “stability” was predictive of nominations for therapist. On the assumption that therapist popularity predisposes good therapeutic alliances, the results indicate that therapists agreeableness, conscientiousness and emotional stability are relative to success in therapeutic interventions.     

Ambivalence and Alliance Ruptures in Cognitive Behavioral Therapy for Generalized Anxiety

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.     

Relationship between self‐worrying and self‐critical messages in clients with generalised anxiety engaging in emotion‐focused worry dialogues

Emotion‐focused therapy (EFT) has recently been adapted as a treatment for generalised anxiety disorder (GAD). One intervention used in this adaptation is a worry dialogue, in which the client enacts worry in one chair (“worrier”) and is facilitated to experience the impact of this worry in another chair (“experiencer”). Although not formally studied, anecdotal observations from therapists in the EFT for GAD treatment development study suggested that within worry dialogues there might be a link between client's self‐worrying and self‐critical messages. This study used data from 47 worry dialogues from fourteen study clients who received EFT for GAD. An observation based qualitative analysis of clients' self‐directed messages as present in in‐session worry dialogues was conducted using video/audio recordings of relevant sessions. Results indicate a relationship between self‐worrying and self‐critical messages. A total of 90 paired self‐worry and self‐critic messages across the 47 worry dialogues were logged. Six recurring clusters of themes/relationships were observed: (a) I need to be prepared for future negative events because… I'm weak and a failure; (b) I need to stop worrying… I'm flawed for being a worrier; (c) People will negatively judge me if I engage with them… because I'm not good enough; (d) If I don't worry, there will be negative consequences… and I will be responsible and will be unable to bear it; (e) I worry/ruminate that I cause(d) some damage… because I'm incompetent; and, (f) I must always be prepared against others taking advantage of me… because I'm weak. Given the observed close link between self‐critical and worry processes, it is important that therapists differentiate between these processes and remember to address both in therapy for GAD.