The Value of Research Methods in Psychotherapy Research: A Reply to the Commentary of Dr Norton

Norton's commentary on our article has prompted us to think further about the purpose of psychotherapy research. We agree with his suggestion that researchers have much work to do to understand when and for whom interventions are most efficacious. We hope that our field will make progress in this regard. In this reply, we further describe why we believe careful attention to research methods, such as those highlighted in our article, is key to making progress in psychotherapy research.     

Comprehensive Behavioral (ComB) Treatment of Trichotillomania: A Randomized Clinical Trial

ObjectiveThis study is the first controlled trial of comprehensive behavioral (ComB) treatment of trichotillomania (TTM). ComB provides individualized treatment based on factors triggering and maintaining hair pulling. Method: Participants (N = 36) were adults (M = 34.08 years old, SD = 12.26) meeting DSM5 criteria for TTM. A majority were female (80%) and Caucasian (75%), whereas 17% were African American and 19% Hispanic/Latinx. In a parallel-group design, participants were randomly assigned to (a) Immediate ComB (12 sessions) or (b) Minimal Attention Control (MAC), followed by delayed ComB after week 12. Follow-up continued through week 38. Primary outcomes were self-report (Massachusetts General Hospital Hair pulling Scale; MGH-HPS) and interviewer-rated (NIMH-Trichotillomania Impact Scale and Trichotillomania Severity Scale; TIS/TSS) TTM symptom severity, as well as diagnosis (Trichotillomania Diagnostic Interview).ResultsImmediate efficacy of ComB (vs. MAC) was statistically significant (p = .03) for self-reported symptoms, with an effect size d = −.78, but not significant for interviewer-rated symptoms or diagnostic status. Immediate ComB was significantly more likely than MAC (27% vs. 0%) to lead to complete abstinence from hair pulling at week 12. Follow-ups showed good maintenance of effects.ConclusionsEfficacy of ComB was established for self-reported symptoms. Future research is needed to establish whether the lack of more widespread effects stems from limitations of the model or to a need for more extensive therapist training, as secondary analyses suggested stronger results among therapists with more TTM experience.     

Behavioral Approach System (BAS) Sensitivity and Bipolar Spectrum Disorders: A Retrospective and Concurrent Behavioral High-Risk Design

In this article, we tested the vulnerability hypothesis of the behavioral approach system (BAS) hypersensitivity model of bipolar disorders. We examined whether self-reported BAS sensitivity predicts lifetime bipolar spectrum diagnoses as well as symptoms and personality characteristics associated with bipolar disorder using a retrospective and concurrent behavioral high-risk design. Participants with high (HBAS; n=28) or moderate (MBAS; n=24) BAS sensitivity were selected and given a lifetime psychiatric diagnostic interview and self-report measures of proneness to bipolar symptoms, current symptoms, and personality characteristics relevant to bipolarity. HBAS participants were significantly and substantially more likely to have a lifetime bipolar spectrum disorder diagnosis than were MBAS participants, but did not differ from MBAS participants in their likelihood of a unipolar depression diagnosis. Also, the HBAS group exhibited higher impulsivity and proneness to hypomanic symptoms than the MBAS group, and BAS-reward responsiveness predicted hypomanic personality characteristics. Finally, high behavioral inhibition system (BIS) sensitivity was associated with proneness to and current depressive symptoms.

Telehealth for Dialectical Behavioral Therapy: A Commentary on the Experience of a Rapid Transition to Virtual Delivery of DBT

Telehealth has been rapidly adopted to provide continuity of delivery of mental health services in light of COVID-19. However, the remote implementation of intensive treatments like dialectical behavioral therapy (DBT) has been vastly understudied. The aim of the current commentary is to describe potential obstacles, propose solutions, and discuss advantages of transitioning from traditional in-person to a virtual delivery format for full model DBT. We speak to these points at multiple levels of relevance to clinical scientists and practitioners: (1) considerations about the virtual delivery format, (2) considerations for the virtual delivery of DBT specifically, and (3) person-level considerations (e.g., client, clinician). We illustrate the commentary using examples of obstacles encountered and solutions identified during our DBT team’s rapid transition to telehealth in response to COVID-19-related shut-downs and discuss considerations for the extension of telehealth delivery of DBT going forward. We are hopeful that the rapid transition to telehealth delivery of mental health services in response to COVID-19 serves as a call to action for clinicians to adapt and leverage technology to deliver DBT on a broader scale to improve patient health outcomes.     

Methodological Challenges in Causal Research on Racial and Ethnic Patterns of Cognitive Trajectories: Measurement, Selection, and Bias

Research focused on understanding how and why cognitive trajectories differ across racial and ethnic groups can be compromised by several possible methodological challenges. These difficulties are especially relevant in research on racial and ethnic disparities and neuropsychological outcomes because of the particular influence of selection and measurement in these contexts. In this article, we review the counterfactual framework for thinking about causal effects versus statistical associations. We emphasize that causal inferences are key to predicting the likely consequences of possible interventions, for example in clinical settings. We summarize a number of common biases that can obscure causal relationships, including confounding, measurement ceilings/floors, baseline adjustment bias, practice or retest effects, differential measurement error, conditioning on common effects in direct and indirect effects decompositions, and differential survival. For each, we describe how to recognize when such biases may be relevant and some possible analytic or design approaches to remediating these biases.     

Striving Towards Empowerment and Medication Adherence (STEP-AD): A Tailored Cognitive Behavioral Treatment Approach for Black Women Living With HIV

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted.     

Chess as a Behavioral Model for Cognitive Skill Research: Review of Blindfold Chess by Eliot Hearst and John Knott

This multifaceted work on chess played without sight of the pieces is a sophisticated psychologist's examination of this topic and of chess skill in general, including a detailed and comprehensive historical account. This review builds on Hearst and Knott's assertion that chess can provide a uniquely useful model for research on several issues in the area of cognitive skill and imagery. A key issue is the relationship between viewing a stimulus and mental imagery in the light of blindfold chess masters' consistent reports that they do not use or have images. This review also proposes a methodology for measuring and quantifying an individual's skill shortfall from a theoretical maximum. This methodology, based on a 1951 proposal by Claude Shannon, is applicable to any choice situation in which all the available choices are known. The proposed “Proficiency” measure reflects the equivalent number of “yes—no” questions that would have been required to arrive at a best choice, considering also the time consumed. As the measure provides a valid and nonarbitrary way to compare different skills and the effects of different independent variables on a given skill, it may have a wide range of applications in cognitive skill research, skill training, and education.     

Outcomes for Children and Adolescents After Residential Treatment: A Review of Research from 1993 to 2003

The focus of this research review is to determine what factors increase the likelihood that positive individual and systemic changes occur for children and adolescents following discharge from residential treatment. Residential treatment outcome studies from 1993 to 2003 that fulfilled predetermined criteria were located through 4 on-line databases using key word combinations. The research selected was: (a) 7 studies that measured outcome immediately upon completion of treatment and discharge, and (b) 11 studies where outcome progress was assessed at one or more follow-up dates after discharge. Results showed that children and adolescents with severe emotional and behaviour disorders can benefit and sustain positive outcomes from residential treatment that is multi-modal, holistic and ecological in its approach. Similar to the clinical child psychotherapy research, conclusions must be tempered due to the limited number of studies and methodological weaknesses. Future considerations highlight how research results can more realistically reflect intervention effectiveness when elements of the ecological and systemic landscape of care are addressed.     

The Body and Mind (Including of the Analyst) in the Treatment of a Psychotic State: Some Reflections: Commentary on Paper by Riccardo Lombardi

Riccardo Lombardi's paper is considered from a British (Independent) object relations perspective. Although the paper deals with the experience of shame and its relationship to fantasies about sex and death and how these are experienced (including in the body), shame is also a profoundly object related mental state, perhaps one of the most damaging when suffered in infancy, leading to reflexive functioning. The nature of shame is touched upon and its impact on personality development, and how this is handled in the transference and countertransference by Riccardo Lombardi with his particular patient. Although the patient's struggle to own his own hate is Lombardi's principal focus in the clinical account, this author suggests that Lombardi was attuned primarily to the patient's developmental failings due to the impact of shame and, by working primarily in the countertransference, was able to facilitate growth of certain personality functions for the first time.     

When Self-Blame Is Rational and Appropriate: The Limited Utility of Socratic Questioning in the Context of Moral Injury: Commentary on Wachen et al. (2016)

In this commentary, we argue that a generally sound therapeutic technique—Socratic questioning—is ill-suited to address a common variant of combat-related emotional and psychological distress. Specifically, moral injury is a term used to describe a syndrome of shame, self-handicapping, anger, and demoralization that occurs when deeply held beliefs and expectations about moral and ethical conduct are transgressed. Importantly, moral injury can and often does result from instances of intentional perpetration. We contend that challenging the accuracy of self-blame in such cases is conceptually problematic and potentially harmful. Such an approach is based on a questionable premise—i.e., that self-blame and resulting guilt are inherently illogical or inaccurate. Though this is often the case, it is not invariably so. We briefly describe an alternate approach—Adaptive Disclosure—that allows for accurate and legitimate self-blame when warranted but also promotes the possibilities of self-forgiveness, compassion, and moral reparation.     

抑郁症神经成像研究的临床转化:预防、诊断和治疗的新取向

抑郁症的预防、诊断和治疗是临床所面临的主要问题,其效果的提升有待超越传统方法,寻求新的方法和技术。其中抑郁症的神经成像转化研究为此提供了一个新的突破口,该研究取向旨在将抑郁症的神经成像基础研究的发现转化为临床运用。文章综述了其在抑郁症的预防、诊断和治疗上的潜在运用价值。未来方向需要更好地促进抑郁症神经成像转化研究的双向自由流通、强调将新的方法转化到日常的临床实践和健康决策上去、促进多学科的合作和相关人才的培养,以及进一步探究转化过程中所面临的特定基础和临床主题。     

Conducting a qualitative research on suicide in Ghana using Interpretative Phenomenological Analysis (IPA): A reflection after a decade

Interpretative Phenomenological Analysis (IPA) set of guidelines allow a researcher to gain access to the meaning of a phenomenon (e.g. suicide) through the individual person's lived and personal experiences. In this paper I have discussed that the ethical challenges that confront researching suicide in Ghana the challenges of pursuing an idiographic rigor using the IPA may arise from the pervasive normative self-construal within Ghanaian communities. Though I admit the IPA has been useful in various studies within the African context, I have also interrogated such idiography within the normative social arrangement of such setting where sociocentric perspectives abound. This essay is a reflexivity on the IPA in a normative context after a decade, where suicidal behaviour is strongly proscribed and personhood is deeply shared. I have recommended that one way of addressing this challenge is to use a ‘funnel’ approach in interviewing from the general: the community, to the particular: the individual.     

Youth as Partners, Participants or Passive Recipients: A Review of Children and Adolescents in Community-Based Participatory Research (CBPR)

Community-based participatory research (CBPR) is an orientation to research that places value on equitable collaborations between community members and academic partners, reflecting shared decision making throughout the research process. Although CBPR has become increasingly popular for research with adults, youth are less likely to be included as partners. In our review of the literature, we identified 399 articles described by author or MeSH keyword as CBPR related to youth. We analyzed each study to determine youth engagement. Not including misclassified articles, 27 % of percent of studies were community-placed but lacked a community partnership and/or participatory component. Only 56 (15 %) partnered with youth in some phase of the research process. Although youth were most commonly involved in identifying research questions/priorities and in designing/conducting research, most youth-partnered projects included children or adolescents in several phases of the research process. We outline content, methodology, phases of youth partnership, and age of participating youth in each CBPR with youth project, provide exemplars of CBPR with youth, and discuss the state of the youth-partnered research literature.     

Editor's Note: Societal changes and expression of concern about Rekers and Lovaas' (1974) Behavioral Treatment of Deviant Sex-Role Behaviors in a Male Child

In an early study in the Journal of Applied Behavior Analysis, Rekers and Lovaas (1974) evaluated the Behavioral Treatment of Deviant Sex-role Behaviors in a Male Child. They investigated the use of reinforcement and punishment to target non-gender-conforming behaviors of a 5-year-old male child. This study was considered by some to be controversial and concerning, even near the time of publication (Nordyke et al. 1977; Winkler, 1977). The concerns focused on the ethicality of selecting non-gender-conforming behavior as a target response and the use of punishment for this type of response, particularly at the behest of parents when the young child was not seemingly distressed. The study has subsequently been used as empirical support for conversion therapy creating concerns about misinterpretation of the original article and harm to the LGBTQ+ community. This editorial reviews the concerns originally presented by Nordyke et al. (1977) and Winkler (1977) and issues an official Expression of Concern about the various harms that have been associated with this paper.     

心理健康的测量与评估:大学生与成人及住院病人的纵向横向研究

对国内有关大学生心理问题比一般成人更严重的研究结论提出了质疑。使用总量4268人的样本,应用自编的心理健康评定量表(PHS)进行了纵向与横向研究。研究发现,大学生人群与一般成人同期相比,心理问题并非更严重。5项分量表中3项(抑郁、焦虑、躯体化)成人却明显比大学生人群要高,另外两项(强迫和精神病性)二者没有显著差异。但是,10年后的大学生与10年前的大学生在所有分量表上均见非常显著的差异,说明10年的变迁中,大学生的心理问题有非常明显的增长趋势,日见复杂化,虽然不能说比成人更严重,但是也足够引起我们的高度重视。将不同人群样本的数据按心理障碍严重性进行排列,依次是:住院精神障碍患者、成人、大学生。