The efficacy of systemic therapy with adult patients: a meta-content analysis of 38 randomized controlled trials

Systemic therapy is a widely used psychotherapy approach. Yet there exist few systematic reviews on its efficacy. A meta-content analysis was performed to analyze the efficacy of systemic therapy for the treatment of mental disorders in adulthood. All randomized (or matched) controlled trials (RCT) evaluating systemic/systems oriented therapy in various settings (family, couple, individual, group, multifamily group therapy) with adult index patients suffering from mental disorders were identified by database searches and cross-references in other reviews. Inclusion criteria were: index patient diagnosed with a DSM or ICD listed mental disorder, trial published in any language up to the end of 2008. The RCTs were content analyzed according to their research methodology, interventions applied, and results. Thirty-eight trials published in English, German, Spanish, and Chinese were identified, 34 of them showing systemic therapy to be efficacious for the treatment of mood disorders, eating disorders, substance use disorders, mental and social factors related to medical conditions and physical disorders, and schizophrenia. Systemic therapy may also be efficacious for anxiety disorders. Results were stable across follow-up periods of up to 5 years. There is a sound evidence-base for the efficacy of systemic therapy for adult index patients with mental disorders in at least five diagnostic groups.     

Schematherapie

Schema therapy is a cognitive behavioral therapy (CBT) development mainly for the treatment of personality disorders and other chronic mental disorders. It is characterized by an integration of cognitive, emotional and behavioral intervention methods derived from different therapeutic approaches with an emphasis on a specifically supportive therapeutic relationship. The original approach focused mainly on early maladaptive schemas. Current developments, however, concentrate on the concept of schema modes, describing different schema-associated emotional states. The schema mode approach is also used for specific case concepts for personality disorders. Effectiveness of schema therapy has been shown for borderline personality disorder. Current studies investigate the effectiveness of schema therapy for patients with other chronic mental conditions and as a group therapy approach. This paper provides an overview about case conceptualization and treatment, presents main research findings and discusses open questions and problems.     

Transference focused psychotherapy: overview and update

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non-analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.     

Safety behaviour does not necessarily interfere with exposure therapy

There has been much recent controversy regarding whether or not the use of safety and other neutralizing behaviour interferes with exposure-based therapy. The aim of this study was to examine the role of safety behaviour in the treatment of specific phobia. Sixty-two snake-fearful participants were randomized to a 45-min exposure session with or without the use of safety gear, such as gloves and goggles. During the treatment, participants in the safety behaviour group were able to achieve a significantly closer initial distance of approach to the snake compared to controls. When tested post-treatment without any safety gear, both groups demonstrated comparable treatment gains involving significant reductions in fearful cognitions and subjective anxiety, as well as significant improvements in distance of approach. Results suggest that reliance on safety behaviour during exposure therapy for anxiety disorders may not interfere with treatment outcome.     

The Efficacy of Systemic Therapy for Childhood and Adolescent Externalizing Disorders: A Systematic Review of 47 RCT

Systemic (family) therapy is a widely used psychotherapy approach. However, most systematic efficacy reviews have focused solely on “family‐based treatment” rather than on the theoretic orientation “systemic therapy.” We systematically review trials on the efficacy of systemic therapy for the treatment of childhood and adolescent externalizing disorders. All randomized (or matched) controlled trials (RCT) evaluating systemic/systems‐oriented therapy in various forms (family, individual, group, multi‐family group therapy) with child or adolescent index patients (0–17 years) suffering from mental disorders were identified by data base searches and cross‐references. Inclusion criteria were as follows: index patient diagnosed with a DSM‐ or ICD‐listed mental disorder, and trial published in any language up to the end of 2011. The RCTs were analyzed for their research methodology, interventions applied, and results (postintervention; follow‐up). A total of 47 trials from the United States, Europe, and China, published in English, German, and Mandarin, were identified. A total of 42 of them showed systemic therapy to be efficacious for the treatment of attention deficit hyperactivity disorders, conduct disorders, and substance use disorders. Results were stable across follow‐up periods of up to 14 years. There is a sound evidence base for the efficacy of systemic therapy for children and adolescents (and their families) diagnosed with externalizing disorders.     

An Evaluation of the Effects of Diagnostic Composition on Individual Treatment Outcome Within Transdiagnostic Cognitive–Behavioral Group Therapy for Anxiety

Recently, studies have supported the efficacy of treating anxiety disorders utilizing a transdiagnostic, or non-diagnosis-specific, framework (Erickson, D. H. (2003). Group cognitive behavioural therapy for heterogeneous anxiety disorders. Cognitive Behaviour Therapy, 32, 179–186; Garcia, M. S. (2004). Effectiveness of cognitive-behavioural group therapy in patients with anxiety disorders. Psychology in Spain, 8, 89–97; Norton, P. J., & Hope, D. A. (2005). Preliminary evaluation of a broad-spectrum cognitive-behavioral group therapy for anxiety. Journal of Behavior Therapy and Experimental Psychiatry, 36, 79–97). Transdiagnostic group treatment packages focus on the common aspects inherent across the anxiety disorders such as behavioral and cognitive avoidance, and faulty cognitive appraisals of threat potential or meaning (Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205–230). Although research supports the overall efficacy of transdiagnostic cognitive behavior therapy (CBT) for anxiety disorders (Norton, P. J., & Philipp, L. M. (2008). Transdiagnostic approaches to the treatment of anxiety disorders: A quantitative review. Psychotherapy: Theory, Research, Practice and Training, 45, 214–226), the effect of diagnostically mixed group composition on individual outcomes is less clear. This study investigated the relationship between group composition and treatment outcome within diagnostically heterogeneous groups with the purpose of determining if diagnostic heterogeneity differentially impacted treatment outcome for 84 individuals during a 12-week transdiagnostic cognitive–behavioral group anxiety treatment program (Norton, P. J. (2012a). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. New York: Guilford). The diagnostic makeup of the treatment group was examined at the beginning of treatment and at the end of treatment, and the results indicated that the diagnostic makeup of the treatment group had no significant impact on individual treatment outcome. These findings have direct implications for the delivery of transdiagnostic treatments, and are discussed in terms of their global implications for the transdiagnostic approach to the treatment of anxiety disorders.     

Randomized controlled trial of false safety behavior elimination therapy: a unified cognitive behavioral treatment for anxiety psychopathology

We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders. This group treatment protocol, termed false safety behavior elimination therapy (F-SET), is a cognitive-behavioral approach designed for use across various anxiety disorders such as panic disorder (PD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). F-SET simplifies, as well as broadens, key therapeutic elements of empirically validated treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology. Patients with a primary anxiety disorder diagnosis (N=96) were randomly assigned to F-SET or a wait-list control. Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties (i.e., PD, SAD, GAD) by relatively inexperienced clinicians. Findings are discussed in the context of balancing treatment efficacy and clinical utility.     

Group Process and Therapeutic Protocol of Intensive Transdiagnostic Group Cognitive-Behavioral Therapy for Anxiety and Personality Disorders in a Day Clinic

This brief report presents group processes and the treatment protocol of intensive, transdiagnostic group cognitive-behavior therapy for anxiety with comorbid personality disorders in a day clinic. It describes the history of and rationale for the development of this 3-month, 15-hour a week group treatment and the utilization of group processes during this therapy. The authors argue that the group format presented here allows the treatment of personality disorders that are frequently comorbid with anxiety disorders.     

Psychodynamik und Psychotherapie psychotischer St?rungen

This article gives a review of the options for psychodynamic treatment of patients with psychoses. The various settings for individual treatment as well as group and family therapy will be presented with a special emphasis on modified analytical long-term therapy. For a psychodynamic understanding, which is the basis for this treatment, the most important psychoanalytical models for psychotic disorders will be presented. In addition the current empirical results of non-explicit psychodynamic-oriented research will be referred to, which emphasize the significance of traumatic events in the early phases of life and the importance of narrative elements, whereby the psychodynamic approach experiences both complementation and confirmation.     

The comparative efficacy of Milan family therapy for disturbed children and their families

This paper describes a study comparing the efficacy of Milan family therapy with that of other treatments routinely used in an out-patient child psychiatry department. Some 118 subjects were allocated on a random, prospective basis to one of two treatment groups, the Milan family therapy group or the other treatments group. The methods of assessment included semi-structured interviews, questionnaires, visual analogue scales and standardized therapy schedules. The results showed that whilst subjects in both treatment groups achieved comparable symptomatic improvement at the end of treatment and at six-month follow-up, the Milan approach produced more changes for family members other than the referred child as well as requiring less treatment time than the other treatments.     

Influence of stuttering therapy on clinicians'' disfluencies: Effects of client modeling

This study investigated whether student clinicians working with stutterers subsequently produce more disfluencies than student clinicians providing therapy to clients with other speech and language disorders. Seventeen graduate students working in a 6-wk summer camp setting were divided into two groups: eight who provided treatment for stutterers (group 1) and nine who provided therapy for clients with other communication disorders (group 2). All student clinicians were recorded during spontaneous speaking and oral reading tasks prior to camper arrival and following camper departure. An eight-category classification system was used to determine disfluency types. Findings revealed that Group 1 clinicians significantly decreased their total disfluencies between pre- and post-camp recordings on the spontaneous speaking task. Unexpectedly, this same group also substantially increased part-word repetitions and sound prolongations. The possibilities of incidental learning, reverse modeling, and overidentification with stuttering clients are discussed.     

Die Praxis der Konzentrativen Bewegungstherapie (KBT)

In a survey the 458 members of the German Association for Concentrative Movement Therapy (DAKBT) were asked in a questionnaire, to answer the question how the actual therapeutic practice of Concentrative Movement Therapy (KBT) in Germany looks like. They were asked about their therapeutic setting, the patients diagnoses and the duration of treatment. 67.5% of the questionnaires were sent back. 191 of those who answered, are working as professional psychotherapists, 62.8% of them with out-patients, 51.3% in hospitals, 17.8% in both therapeutic fields. Besides group psychotherapy most of them offer individual therapy, especially with out-patients. It is shown, that besides psychosomatic disorders (being a wellknown indication) KBT is also applied in a broad variety of other psychic disorders. Half of the outpatient treatments is finished within 50 meetings. Female patients and patients with personality or eating disorders show up a greater number of contacts in out-patient individual treatment. The results verify that in practice KBT is no longer confined to a supplementary group therapy.     

Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash-associated disorders were recruited from a patient organization and randomized to either a treatment or a wait-list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10-session protocol emphasizing values-based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants' abilities to behave in accordance with values in the presence of interfering pain and distress (psychological flexibility). After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the groups was seen in pain intensity. Improvements in the treatment group were maintained at 7-month follow-up. The authors discuss implications of these findings and offer suggestions for further research in this area.     

Family Therapy Techniques in Residential Settings: Family Sculptures and Reflecting Teams

Outcome data has shown that family therapy is highly effective in the treatment of many disorders including addiction, mood, and other issues. In working to make treatment as effective as possible, many residential treatment and outdoor behavioral healthcare (OBH) programs have adopted family therapy techniques for use in individual and peer group therapy settings. Some have also incorporated family members by inviting them to visit the residential setting and participate in treatment exercises. An article by Faddis and Bettmann (J Ther Sch Program 1(1): 57–69, 2006) outlines an example of this integrated approach to family sculptures and reflecting teams in a wilderness therapy setting for adolescents. This integrated technique has since come to be known as the four phase Familial Sculpting and Reflecting intervention. Most recently these methods have been expanded for use with young men ages 18–30 in an adventure wilderness therapy program. This article will examine the theoretical basis for both of these approaches, discuss the application of these techniques to residential OBH programs and review how these methods have been most recently adapted for use in another program.     

Electrical stimulation of the brain for psychiatric disorders

Despite advances in therapies, there remain psychiatric patients who are extremely ill and cannot be helped by classic psychiatric treatments, including psychotherapy and drug therapy. Certain of these patients may be helped by use of bilateral brain lesioning. The complication rate of standard stereotactic psychosurgery techniques is very low. The main rationale for the continued experimental use of deep brain stimulation (DBS) in neurosurgery for mental disorders is its reversibility. This reversibility is not an advantage in terms of the benefits obtained, but rather if side effects emerge. In addition, electrical stimulation may provide patients with some autonomy for their treatment. The first, very preliminary results of electrical stimulation for obsessive-compulsive disorder and for a small heterogeneous group of patients with other psychiatric disorders have been published. Electrical stimulation of the brain for psychiatric disorders may become a new treatment option for certain intractable psychiatric disorders. Nevertheless, the mechanism of action of DBS in psychiatric disorders is unknown, and the experience with this modality is extremely limited. The first results look promising, but this treatment option may prove unusable for some time because of a lack of knowledge of appropriate brain stimulation targets and technical problems such as the availability of sufficient current supply.     

Concurrent group and individual psychotherapy in a psychiatric day hospital for depressed elderly

Concurrent psychotherapy is used in various settings for patients of different diagnoses and ages. The concurrent group and individual psychotherapy of older adults with depressive disorders in a psychiatric day hospital is described, emphasizing phases of treatment and transference and countertransference themes uniquely relevant to working with depressed elderly patients in a day hospital. Case examples are offered to illustrate these issues. The special technical considerations that need to be utilized when multiple therapists and settings are present are described. The model employs the use of an integrative, interactive group therapy, along with various other group treatments and antidepressant medication, with individual therapy serving a subordinate but organizing role.     

The effects of venlafaxine and cognitive behavioral therapy alone and combined in the treatment of co-morbid alcohol use-anxiety disorders

The effects of the antidepressant venlafaxine (VEN-225 mg daily) and transdiagnostic cognitive behavioral treatment (CBT) alone and in combination on alcohol intake in subjects with co-morbid alcohol use disorders (AUDs) and anxiety disorders were compared. Drinking outcomes and anxiety were assessed for 81 subjects treated for 11 weeks with one of 4 conditions: 1) VEN–CBT, 2) VEN-Progressive Muscle Relaxation therapy (PMR), 3) Placebo (PLC)-CBT and 4) a comparison group of PLC-PMR. For subjects who reported taking at least one dose of study medication, the Time × Group interaction was significant for percent days of heavy drinking and drinks consumed per day. For the measure of percent days heavy drinking, the paired comparison of PLC-CBT versus PLC-PMR group indicated that the PLC-CBT group had greater drinking reductions, whereas other groups were not superior to the comparison group. In Week 11, the proportion of subjects in the PLC-CBT group that had a 50% reduction from baseline in percent days heavy drinking was significantly greater than those in the comparison group. Of the 3 “active treatment” groups only the PLC-CBT group had significantly decreased heavy drinking when contrasted to the comparison group. This finding suggests that the transdiagnostic CBT approach of Barlow and colleagues may have value in the management of heavy drinking in individuals with co-morbid alcoholism and anxiety.     

An Overview of Trauma-Informed Care and Practice for Eating Disorders

ABSTRACT

This article reviews concepts and principles of trauma-informed care and trauma-informed practice for those with eating disorders (EDs). EDs are not universally recognized to be associated with traumatic events, despite substantial research evidence indicating that individuals with EDs report very high rates of childhood maltreatment, other lifetime traumatic events, as well as adverse consequences from trauma. Using national representative samples, higher prevalence rates of PTSD and other trauma-related comorbidities have been reported in those with EDs, particularly those with bulimic symptoms (binge eating and/or purging). Evidence suggests that those prone to develop EDs appear to be especially sensitive to the effects of stress/adversity and have high rates of premorbid anxiety disorders, personality traits, and neuropsychological features that predispose them to PTSD and its symptoms. This article also reviews some of the important principles for treating individuals with EDs comorbid for PTSD and other trauma-related disorders, including the necessity of moving beyond sequential treatment to the development of integrated treatment protocols. Integration of existing evidence-based treatments, including family therapy, cognitive behavioral therapy, dialectical behavior therapy, cognitive processing therapy, prolonged exposure, and eye movement desensitization reprocessing are recommended. Recent research suggests that ED clinicians view integrated treatment for individuals with ED and PTSD as a top priority, yet they have several concerns about administering such a treatment. As trauma-informed care is embraced by all clinicians and treatment programs that assess and treat eating and related disorders, better outcomes are anticipated.     

The impact of an 8-day intensive treatment for adolescent panic disorder and agoraphobia on comorbid diagnoses

Previous research findings have shown positive effects of cognitive-behavioral therapy for primary anxiety disorders as well as for nonprimary, co-occurring anxiety disorders. In this study, we analyzed data from an existing randomized controlled trial of intensive treatment for panic disorder with or without agoraphobia (PDA) to examine the effects of the treatment on comorbid psychiatric diagnoses. The overall frequency and severity of aggregated comorbid diagnoses decreased in a group of adolescents who received an 8-day treatment for PDA. Results suggest that an 8-day treatment for PDA can alleviate the symptoms of some specific comorbid clinical diagnoses; in particular specific phobias, generalized anxiety disorder, and social phobia. These findings suggest that an intensive treatment for PDA is associated with reductions in comorbid symptoms even though disorders other than PDA are not specific treatment targets.