A receiver operator characteristics analysis of treatment outcome in binge eating disorder to identify patterns of rapid response

The purpose of this study was to perform a receiver operator characteristics (ROC) analysis on a treatment sample from a randomized controlled treatment trial of participants with binge eating disorder (BED). An ROC analysis was completed with 179 adults in a 20-week treatment trial for BED to predict abstinence from binge eating at end of treatment. Percent reductions in binge eating episodes were examined following weeks 1 through 10 of treatment. The rate of percent decrease in binge eating episodes during treatment for BED was a significant predictor of clinical outcome at end of treatment. Participants who demonstrated a 15% reduction in binge eating episodes at week one were more likely to respond positively to treatment and achieve clinical remission. Findings from the current study suggest that a significant reduction in binge eating during the first week of treatment may be predictive of end of treatment remission in those with BED.     

Distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility

A large percentage of individuals who enter residential substance abuse treatment drop out before completing treatment. Given that early treatment dropout places individuals at an increased risk for relapse, identifying the mechanisms underlying treatment dropout would have several important theoretical and clinical implications. In the current study, the authors examined levels of psychological and physical distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility. In a sample of 122 individuals entering a residential substance abuse treatment facility, level of psychological distress tolerance was predictive of early treatment dropout above and beyond relevant self-report variables. There was no relationship between physical distress tolerance and early treatment dropout. Implications for future studies and treatment development or modification are discussed.     

"I need to talk about it": a qualitative analysis of trauma-exposed women's reasons for treatment choice

A significant proportion of individuals suffering from posttraumatic stress disorder do not seek or receive effective treatment. Understanding the reasons why an individual chooses to seek treatment or prefers one treatment to another is a critical step to improve treatment seeking. To begin to understand these reasons, we conducted a qualitative analysis of the reasons women gave for choosing a cognitive-behavioral treatment, prolonged exposure (PE), or a pharmacological treatment, sertraline (SER). A community sample of women with trauma histories were asked to view standardized rationales, to choose among PE, SER, or no treatment, and to give 5 reasons for their choice. Women indicated that they were more likely to prefer the psychotherapy to the medication. Across reasons given, the most commonly cited reason for treatment preference highlighted why or how the treatment worked (e.g., I need to talk about it); and this reason emerged as the strongest predictor of preference for PE. Understanding this role of perceived treatment mechanism may aid clinicians and public health policy officials to identify and address help-seeking barriers regarding treatment.     

MULTIPLE TREATMENT INTERFERENCE IN THE ALTERNATING TREATMENTS DESIGN AS A FUNCTION OF THE INTERCOMPONENT INTERVAL LENGTH

In experimental designs requiring the administration of more than one treatment to the same subject(s), the effect of one treatment may be influenced by the effect of another treatment (Campbell & Stanley, 1963), a phenomenon known as multiple treatment interference. We conducted two studies in which multiple treatment interference in an alternating treatments design was shown to be a function of the length of the intercomponent interval (ICI) separating treatment conditions. In the first study, we evaluated the effects of four different treatments on the mouthing of a severely retarded boy. Under a 1-min ICI no consistent differential responding to treatment was obtained. Differential responding emerged when the ICI was increased from 1 min to 120 min, thus suggesting multiple treatment interference in the lack of differential responding under a 1-min changeover interval. Functional control of the nondifferential and differential responding as a function of the ICI length was replicated in a reversal phase. In the second study, we compared two treatment procedures for the disruptive noncompliant behavior of a moderately retarded boy. Multiple treatment interference (i.e., the lack of differential responding) occurred with the 1-min intercomponent interval. An increase to a 120-min ICI again resulted in differential responding. A replication of multiple treatment interference by a reversal to a short interval phase was not achieved in the second subject. Results of this study support much of the basic literature on discrimination and multiple treatment interference. Major findings of this study are twofold: Multiple treatment interference can depend on the length of the changeover interval between treatments and multiple treatment interference can take the form of a lack of differential responding to various treatments. Implications for future research are discussed.     

The effects of positive patient testimonials on PTSD treatment choice

Despite the existence of effective treatment options for PTSD, these treatments are failing to reach those that stand to benefit from PTSD treatment. Understanding the processes underlying an individual's treatment seeking behavior holds the potential for reducing treatment-seeking barriers. The current study investigates the effects that positive treatment testimonials have on decisions regarding PTSD treatment. An undergraduate (N = 439) and a trauma-exposed community (N = 203) sample were provided with videotaped treatment rationales for prolonged exposure (PE) and sertraline treatments of PTSD. Half of each sample also viewed testimonials, detailing a fictional patient's treatment experience. All participants then chose among treatment options and rated the credibility of – and personal reactions toward – those options. Among treatment naïve undergraduates, testimonials increased the proportion choosing PE alone; and among treatment naïve members of the trauma-exposed community sample, testimonials increased the proportion choosing a combined PE plus sertraline treatment. These effects were not observed for those with prior history of either psychotherapeutic or pharmacological treatment. Major barriers exist that prevent individuals with PTSD from seeking treatment. For a critical unreached treatment sample, those who are treatment naïve, positive patient testimonials offer a mechanism in which to make effective treatments more appealing and accessible.     

A Psychodynamic Treatment for Severe Personality Disorders: Issues in Treatment Development

We describe a psychodynamic treatment modified for patients with severe personality disorders identified as borderline personality disorder in DSM-IV, Axis II, and understood as borderline personality organization from a psychoanalytic perspective. This treatment is labeled transference-focused psychotherapy (TFP) in order to highlight the centrality of working with these patients in the here-and-now treatment interaction. The empirical development of TFP is described, including the generation of a treatment manual, the utility of various methods to teach the treatment, and preliminary data on efficacy. The latest step in the development of this treatment is an ongoing randomized clinical trial comparing the efficacy of TFP to a cognitive-behavioral and a supportive treatment.     

Does fear of coercion keep people away from mental health treatment? Evidence from a survey of persons with schizophrenia and mental health professionals

Mental health consumer advocates have long argued that involuntary treatment frightens persons with mental disorder and thus deters them from voluntarily seeking help. We surveyed 85 mental health professionals and 104 individuals with schizophrenia spectrum conditions to assess their experience with and perceptions of involuntary treatment and other treatment mandates. Of the clinicians, 78% reported that overall they thought legal pressures made their patients with schizophrenia more likely to stay in treatment. Regarding involuntary outpatient commitment, 81% of clinicians disagreed with the premise that mandated community treatment deters persons with schizophrenia from seeking voluntary treatment in the future. Of the consumer sample, 63% reported a lifetime history of involuntary hospitalization, while 36% reported fear of coerced treatment as a barrier to seeking help for a mental health problem-termed here "mandated treatment-related barriers to care." In bivariate analyses, reluctance to seek outpatient treatment associated with fear of coerced treatment (mandated treatment-related barriers to care) was significantly more likely in subjects with a lifetime history of involuntary hospitalization, criminal court mandates to seek treatment, and representative payeeship. However, experience with involuntary outpatient commitment was not associated with barriers to seeking treatment. Recent reminders or warnings about potential consequences of treatment nonadherence, recent hospitalization, and high levels of perceived coercion generally were also associated with mandated treatment-related barriers to care. In multivariable analyses, only involuntary hospitalization and recent warnings about treatment nonadherence were found to be significantly associated with these barriers. These results suggest that mandated treatment may serve as a barrier to treatment, but that ongoing informal pressures to adhere to treatment may also be important barriers to treatment.     

A Pilot Study of a Functional Contextual Treatment for Bulimia Nervosa

This paper describes the initial development of a treatment for bulimia nervosa using a functional contextual treatment approach. Seven women (6 with a diagnosis of bulimia nervosa and 1 with a diagnosis of eating disorder not otherwise specified) completed 12 sessions of functional contextual treatment. Participants were assessed with the Eating Disorders Examination at baseline and following treatment. The intervention produced significant reductions in binge eating, purgative behavior, dietary restraint, and eating concerns. A functional contextual treatment holds promise for the treatment of bulimia nervosa. However, the treatment needs to be refined further and will need to be tested in controlled clinical trials with long-term follow-up.     

The Incubator Treatment Development Model: The SAFETY Treatment for Suicidal/Self-Harming Youth

Youths who make suicide attempts or engage in repetitive self-harm are at risk for future suicide attempts and death by suicide or self-harm. This treatment development report focuses on the Safe Alternatives for Teens and Youth (SAFETY) treatment. SAFETY is a 12-week outpatient child and family-centered cognitive-behavioral treatment, informed by dialectical-behavior therapy, and designed to promote safety following a suicide attempt or repeated episodes of self-harm. Previous reports have described results of small open and randomized treatment development trials. Here, we describe our “incubator” treatment development model. Combining scientific rigor with attention to the community context in which treatment is delivered, the incubator model emphasizes laboratory-based treatment development trials and quantitative and qualitative data generated through partnerships with community treatment sites and youth and parent consumers of care. Aims of this approach are to: (1) integrate information from our partners throughout the treatment development process; (2) create a more feasible and easily transportable “youth” and “family” centered treatment; and (3) accelerate the pace with which laboratory-based treatment advances can be incorporated into improvements in community care. We describe our incubator treatment development model and how data generated through our treatment development process and interactions between the laboratory and community teams contributed to the development of the SAFETY treatment.     

Effectiveness of Imagery Rehearsal Therapy for the Treatment of Combat-Related Nightmares in Veterans

Imagery Rehearsal Therapy (IRT) has been shown to be efficacious in reducing nightmares, but the treatment has not been well-studied in veterans. The effectiveness of IRT was assessed from a chart review of veterans seeking outpatient treatment for chronic, trauma-related nightmares. Of those offered IRT, veterans who completed a full course of treatment for PTSD in the past year were more likely to initiate treatment. However, completion of IRT was not related to previous treatment, demographic variables, or nightmare severity reported at the first treatment session. Treatment completers reported significant reductions in nightmare frequency and intensity, severity of insomnia, and subjective daytime PTSD symptoms. Insomnia and PTSD symptoms, on average, were below clinical cutoffs following treatment, and 23% of patients showed a complete treatment response (≤ 1 nightmare/week). Findings suggest IRT may be an effective short-term treatment for nighttime and daytime PTSD symptoms among veterans who complete a full course of treatment.     

Identifying predictors of treatment response

This article provides a rationale for considering predictors of growth in a treatment group as inadequate to identifying predictors of treatment response. When we interpret predictors of growth in a treatment group as synonymous with predictors of treatment response, we implicitly attribute all of the treated children's growth to the treatment, an untenable assumption under most conditions. We also contend that the use of standard scores in predictors of growth studies does not allow us to differentiate growth from treatment, from growth from other factors. We present two research methodologies that are appropriate methods of identifying predictors of treatment response: (a) single-subject experimental logic utilized to identify the specific participants in which treatment responses (not just growth) were found, combined with follow-up group comparison logic to identify the characteristics on which responders and nonresponders differ, and (b) statistical interactions among child/family/context characteristics and randomly assigned group membership. Principles for selecting potential predictors of treatment response are provided.     

Acceptability bias: The effects of treatment acceptability on visual analysis of graphed data

Vignettes depicting a mildly or severely self-abusive child with profound mental retardation who received either a differential reinforcement of other behavior or a contingent electric shock treatment were presented to 161 undergraduates. After subjects rated the acceptability of the given treatment on the Treatment Evaluation Inventory (TEI), they evaluated the efficacy of the given treatment based upon six AB data graphs. Visual analytic judgments were not significantly effected by type of treatment, severity of self-injurious behavior (SIB), or the treatment × SIB interaction. TEI scores differed significantly according to type of treatment. Simple and multiple correlations computed between TEI scores and graph evaluations provided evidence ofacceptability bias, such that more favorable appraisals of treatment acceptability were related to perceptions of greater treatment effectiveness.     

Community-based co-occurring disorder (COD) intermediate and advanced treatment for offenders

Against a backdrop of increasing concern about the adequacy of treatment for co-occurring substance use and mental disorders (typically known as "co-occurring disorders," or COD) in the criminal justice system, this article attempts to provide empirical evidence for a typology of levels of COD treatment for offenders in both prison and community settings. The paper investigates two levels of treatment programs for COD; "intermediate" programs, in which treatment programming has been designed primarily for offenders with a single disorder, and "advanced" programs, in which programming has been designed to provide integrated substance abuse treatment and mental health services. Findings from a national survey of program directors indicated that both intermediate and advanced COD treatment programs were similar in their general approach to substance abuse treatment, but differed considerably in their treatment of mental disorders, where the advanced programs employed significantly more evidence- and consensus-based practices. Results provide support for the distinction between intermediate- and advanced-level services for offenders with COD and support a typology that defines advanced programs as integrating a range of evidence- and consensus-based practices so as to modify treatment sufficiently to address both diseases.     

Providing a treatment rationale for PTSD: Does what we say matter?

Little is understood about the factors that influence a woman's preference for a particular type of treatment after an assault. Furthermore, it remains unclear the extent to which providing detailed information such as the mechanism underlying a treatment or its side effects can affect a client's treatment preference for psychotherapy or pharmacotherapy. The current study of 324 women with varying degrees of trauma exposure and posttraumatic stress symptoms experimentally manipulated the content of treatment rationales for two common PTSD treatments: sertraline (SER) and prolonged exposure (PE). Specifically, both information regarding the hypothesized mechanism of the treatment and treatment side effects were manipulated. In general, personal reactions were more positive and credibility was stronger for psychotherapy than pharmacotherapy. This preference for the psychotherapy persisted regardless of specific information presented in the treatment rationale. For those reporting heightened hyperarousal and those of minority status, there was an increased likelihood of more positive reactions to sertraline. The results highlight assessment of treatment-related beliefs and preferences early on in the therapeutic process. Ultimately, understanding the factors that shape treatment preferences may contribute to the development of personalized treatment strategies that integrate preferences and attitudes about treatment as a way of bolstering adherence and outcome.     

Community treatment of severe, refractory obsessive-compulsive disorder

Despite the existence of effective psychological and pharmacological interventions for obsessive-compulsive disorder (OCD), there are a large proportion of individuals for whom intervention is not effective. The study reports on the results of a community treatment service for individuals with treatment-refractory OCD who have not benefitted from previous cognitive behavioural or pharmacological treatment by community mental health services. A total of 205 individuals accepted for treatment by a specialist community OCD treatment service in London were provided with a combination of behavioural, cognitive, and pharmacological treatment within a specialist OCD service, with 158 completing treatment. Treatment was associated with significant reduction in clinician-rated and self-reported OCD symptoms after 12 weeks, with further reductions in OCD symptoms over a subsequent 12-week period. A significant reduction in symptoms of depression was also observed after 12 and 24 weeks. Approximately 40% of individuals treated experienced clinically significant improvement in their symptoms, with approximately 10% deemed to have recovered by the end of treatment. Our results add to previous research into refractory OCD, and provide support for the existence of specialist community treatment services which may provide assistance to individuals who have not responded to previous treatment.     

Parent Motivation to Participate in Treatment: Assessment and Prediction of Subsequent Participation

Treatment motivation is required for virtually all psychosocial treatments because clients must participate actively in the treatment process. In child and family treatments, it is the parent who must be motivated to manage treatment participation; however, no measures are currently available for evaluating parent motivation for treatment. The authors developed and evaluated a brief rating scale, the Parent Motivation Inventory (PMI), to measure parent motivation to participate in treatment. Results supported a uni-dimensional measure with strong internal consistency and test-retest reliability. Increases in parent motivation predicted the perception of fewer barriers to treatment participation, which was significantly associated with greater treatment attendance. The PMI provides a reliable and valid method of assessing parents’ motivation to participate in treatment and has implications for the prediction and potential modification of barriers to treatment and treatment participation.     

Treatment outcome in personality disorder: The effect of social,psychological and behavioural variables

The study followed-up 245 patients referred to the Henderson Hospital (194 admitted for treatment and 51 not admitted) and for whom information had been collected on their social background and certain psychological variables allowing a classification and typology of personality disorder to be worked out. The study indicates that the therapeutic community treatment is effective with selected individuals showing the antisocial behaviour associated with such disorder. In particular this treatment is of benefit to the offenders with only one conviction and who are able to persevere with treatment for a period of 6 months for treatment to be maximally effective. The variation of psychological types within the broad category of personality disorder was demonstrated and this has a bearing on the outcome of treatment, the extrapunitive neurotic being of poorest prognosis with or without treatment. Yet even in this group, therapeutic community treatment can be effective.     

Homework Compliance Counts in Cognitive-Behavioral Therapy

Background: Prior research has demonstrated that there is some association between treatment engagement and treatment outcome in behavioral therapy for anxiety disorders. However, many of these investigations have been limited by weak measurement of treatment engagement variables, failure to control for potentially important baseline variables, and failure to consider various treatment engagement variables simultaneously. The purpose of the present study is to examine the relationship between two treatment engagement variables (treatment expectancy and homework compliance) and the extent to which they predict improvement from cognitive-behavioral therapy (CBT) for anxiety disorders. Methods: 84 adults with a DSM-IV-defined principal anxiety disorder took part in up to 12 sessions of CBT or acceptance and commitment therapy. Pre- and post-treatment disorder severity was assessed using clinical severity ratings from a semi-structured diagnostic interview. Participants made ratings of treatment expectancy after the first session. Homework compliance was assessed each session by the treating clinician. Results: Contrary to hypotheses, treatment expectancy and homework compliance were poorly correlated. Regression analyses revealed that homework compliance, but not treatment expectancy, predicted a significant portion of the variance in treatment outcome (10%). Conclusions: The present research suggests that although treatment expectation and homework compliance likely represent unique constructs of treatment engagement, homework compliance may be the more important treatment engagement variable for outcomes. The present research suggests that improvement of homework compliance has the potential to be a highly practical and effective way to improve clinical outcomes in CBT targeting anxiety disorders.