Cognitive behavioral therapy in practice: therapist perceptions of techniques,outcome measures,practitioner qualifications,and relation to research

Cognitive behavioral therapy (CBT) has a strong evidence base for several psychiatric disorders, however, it may be argued that currently there is no overall agreement on what counts as ‘CBT’. One reason is that CBT is commonly perceived as encompassing a broad range of treatments, from purely cognitive to purely behavioral, making it difficult to arrive at a clear definition. The purpose of the present study was to explore practicing therapists’ perceptions of CBT. Three hundred fifty members of two multi-disciplinary interest groups for CBT in Sweden participated. Mean age was 46 years, 68% were females, 63% psychologists and mean number of years of professional experience was 12 years. Participants completed a web-based survey including items covering various aspects of CBT practice. Overall, therapist perceptions of the extent to which different treatment techniques and procedures were consistent with CBT were in line with current evidence-based CBT protocols and practice guidelines, as were therapists’ application of the techniques and procedures in their own practice. A majority of participants (78%) agreed that quality of life or level of functioning were the most important outcome measures for evaluating treatment success. Eighty percent of therapists believed that training in CBT at a basic level was a requirement for practicing CBT. There was a medium size Spearman correlation of r_s=.46 between the perceived importance of research to practice and the extent to which participants kept themselves updated on research. Implications for training, quality assurance, and the effectiveness of CBT in clinical practice are discussed.     

Broken Bounds: Contemporary reflections on the antisocial tendency

When embarking on research into the effectiveness of psychoanalytic psychotherapy in the NHS or the application of psychoanalytic principles, researchers come up against a number of hurdles: many clinicians still see empirical research as antithetical or disruptive to the practice of psychoanalytic psychotherapy; psychoanalytic psychotherapy has previously fared poorly in evidence-based policy guidelines and this can discourage ambition, and there are technical problems of research design, measurement and standardization. Nevertheless, in a political climate which stresses service evaluation, measurable outcomes and empirical evidence, psychoanalytic psychotherapy must participate to survive. There may be gains from conducting research beyond simply meeting the requirement to provide evidence of effectiveness. Research may be viewed by some clinicians as an unwelcome intruder but it may have the potential to offer triangulation, the perspective of the ‘third’, and so strengthen the foundations of clinical practice and the development of psychoanalytic thought.     

In defence of a perspectival semantics for ‘know’

Relativism offers an ingenious way of accommodating most of our intuitions about ‘know’: the truth-value of sentences containing ‘know’ is a function of parameters determined by a context of use and a context of assessment. This sort of double-indexing provides a more adequate account of the linguistic data involving ‘know’ than does standard contextualism. However, relativism has come under recent attack: it supposedly cannot account for the factivity of ‘know’, and it entails, counterintuitively, that circumstances of evaluation have features that cannot be shifted by any intensional operator. I offer replies to these objections on behalf of the relativist. I then argue that a version of contextualism can account for the same data as relativism without relativizing sentence truth to contexts of assessment. This version of contextualism is thus preferable to relativism on methodological grounds.     

Values in Family Therapy Practice and Research: An Invitation for Reflection

Values have been shown to be a pervasive part of both marriage and family therapy (MFT) clinical practice and research. Yet, many therapists and researchers remain unclear about how values affect their work. This article examines the influence of Western philosophical assumptions and therapy traditions in light of current understandings of values in therapy. The influence of values in MFT research processes is similarly examined. Implications for how family therapy professionals can be more reflective and sophisticated in their understanding of values in clinical practice and scientific inquiry are discussed. Suggestions for addressing values in MFT training also are given.     

Some reservations concerning the current cognitive emphasis in therapy

The extent to which new treatment techniques that focus on cognition have come to dominate therapy over recent years is not consistent with the empirical outcome evidence, which suggests that it is usually the behavioural components of interventions (whether labelled ‘cognitive’ or ‘behavioural’) that are the most potent effectors of clinical improvement. In this article recent outcome studies (involving predominantly treatments derived from Beck's approach) are reviewed, and the effects of the cognitive trend on clinical practice (both positive and negative) explored. Apart from some notable exceptions, the outcome evidence suggests that cognitive techniques do not enhance the effectiveness of behavioural treatment. A number of problems and misconceptions associated with both the current cognitive emphasis and a more traditional behavioural approach in the clinical context are discussed.     

Milan systemic family therapy: a review of ten empirical investigations

Ten empirical investigations of Milan Family Therapy (MFT) are reviewed in this paper. The studies include both single and comparative group outcome trials; investigations of therapeutic process; clinical audit and consumer satisfaction surveys. Substantive findings and methodological issues are discussed in the light of family therapy and individual psychotherapy research generally. Findings indicate that MFT may lead to symptomatic change in two-thirds to three-quarters of cases and to systemic change in half the treated cases. Engagement of fathers may be important for positive outcome. Technical aspects of MFT, such as the use of screens and teams, may lead to client dissatisfaction in some cases. MFT-based consultation may be effective in resolving therapeutic impasses. Coupled with short-term residential placement, MFT may reduce the risk and complexity of cases as rated by referring social workers.     

What do clinical supervision research reviews tell us? Surveying the last 25 years

What do clinical supervision research reviews across the last 25 years tell us? That question is subsequently examined. Based on database and literature searches, 20 reviews appearing from 1995 through 2019 were identified for survey examination; consistencies, inconsistencies and other defining features were determined across reviews; and the survey findings and their implications are considered. Primary findings are as follows: (a) ‘proof’ for supervision appears to be more ‘proof by association’ than otherwise, being primarily a product of ex post facto, cross‐sectional, correlational study; (b) evidence supporting supervision impact of any type is weak at best, especially so for worker and client outcomes; (c) supervision models generally lack empirical foundation; (d) evidence‐based supervision appears to be more a hope and dream than supervision‐based reality at present; and (e) the primary methodological problems that plagued supervision research in the 1990s are still all too frequent in modern research. Some questions to entertain about supervision going forward, and some remedies for improving its research, are proposed.     

Alternative Methodologies in Research Literature Review: Links Between Clinical Work and MFT Effectiveness

Traditionally, "good outcome research" has referred to laboratory-based, controlled studies that report the efficacy of a given treatment on a specific population. Although useful and needed in the struggle to establish MFTs as accepted mental health service providers, this type of research does not address whether MFT is effective in "real world" settings. In order to highlight the clinical and professional relevance of existing effectiveness research, this article reviews 15 years of clinical research in three major family therapy journals. The results suggest that 1) MFT effectiveness is under-represented in major review articles, 2) clinicians can use a variety of methodologies to establish the effectiveness of their work, and 3) more research is needed that investigates how and why MFT works in "real world" settings. Implications for practice and future research are discussed.     

Three Conceptual Models of Patient and Public Involvement in Standard-setting: From Abstract Principles to Complex Practice

Clinical practice guidelines have been critiqued for prescribing standardized care that neglects patients’ personal circumstances and knowledge in health care decisions. To make care more patient centred, standard-setters are urged to involve patients and the public in guideline development and use. Despite widespread principled support for such Patient and Public Involvement (PPI), the underlying principles guiding PPI in standardization of care are mired on confusion and contradiction. Based on the PPI literature in general, and informed by empirical research on guideline development, it is possible to identify three rationales that justify PPI in clinical standard setting. Each rationale gives rise to a conceptual model which outlines a distinct purpose of participation, who is to be included, and what they are expected to contribute. The Consumer Choice model aims to involve autonomous consumers to personalize clinical care. The Democratic Voice model aims for health care recommendations to better reflect collective values of citizens. The Lay Expertise model aims to re-contextualize universal evidence by including experiential patient knowledge. However, these models can and should not function as ‘Gold Standards’ to be consistently followed in practice. First, the models rely on two distinct types of representation, resulting in contradictory notions of how to be a good representative. Second, imposing models on practice requires a top-down control that is practically and politically problematic. Not only is control difficult to achieve, it may compromise the participatory ideal of participants co-determine practice, and may result in excluding the values and views of ‘real’ patients and public entirely.     

Gender Biases and Therapists’ Conceptualization of Couple Difficulties

In spite of the fact that gender issues have played an important role in many family therapy training programs, little research has been developed to explore the effects of gender and gender biases in therapists’ conceptualizations of client problems. This study explores beginning and advanced marriage and family therapy (MFT) student’s inclusion of gender in the conceptualization of a clinical case. To examine clinician’s thinking, 32 therapists (18 beginning MFT students and 14 advanced MFT students) were asked to 1) view the first 20 minutes of an intake interview conducted by a sex therapist, and 2) identify the couple’s central issues. Qualitative and quantitative analyses were used to explore constructs associated with therapists considerations and inclusion of gender and cultural issues in their conceptualizations of marital difficulties. Results revealed that trained MFT students who considered gender may have analyzed gender issues more extensively than untrained MFT students. In addition, results of qualitative analysis of participant critiques revealed subtle forms of gender and cultural biases. Discussion focuses on how these biases, some of which are linked to clinical theory, can lead to differential expectations and inequality in the treatment of men and women in couple therapy. Implications for clinical training, curriculum development, and future research are also discussed.     

Ethics,Subjectivity, and Sociomaterial Assemblages: Two Important Directions and Methodological Tensions

Research that explores ethics can help educational communities engage twenty-first century crises and work toward ecologically and socially just forms of life. Integral to this research is an engagement with social theory, which helps educators imagine our shared worlds differently. In this paper I present two theoretical-methodological directions for educational research that centres ethics: Ethics and (human) subjectivity; and Ethics-in-assemblage. While both approaches might be seen as commensurable, they can also be seen as quite divergent. Using Michel Foucault’s later work on subjectivity and ethics, as well as recent work in Anthropology, I present a methodological direction for research into ethical subjectivity, how students come to see themselves as self-reflective ethical actors. Relevant here is the tension between ethics and politics, individual and collective modes of being, as both are crucial to both struggles for justice on a damaged planet. The second direction involves a sociomaterialist approach that employs Deleuze and Guattari’s concept of ‘assemblage’ as well as Karen Barad’s notion ‘entangled responsibility’ to show that ethics can also be seen to co-emerge with/in phenomena that exceed human relations. In short, exploring ethics through educational research means simultaneously examining ethics as subjectivity and ethics as co-emergent larger assemblages/phenomena.     

Training staff in multiple family therapy in a children's psychiatric hospital: from theory to practice

This article describes a systematized method for training clinical staff from a variety of mental health professions while implementing supportive, process‐oriented multiple family therapy (MFT) in a children's psychiatric hospital. The model uses a step‐by‐step approach based upon learning objectives specific to the theory and practice of MFT for each stage of the process. External consultants skilled and experienced in MFT supported tuition in the initial stages. The method employs seminars with theoretical and experiential components, highlighting the major conceptual features of group, family therapy and MFT. Advanced stages of the training model include experiential learning in small groups and ongoing peer group supervision with live families. The systematic procedure has relevance for ongoing supervision, research and best standards of clinical practice in the hospital.     

Reentry Experiences and Professional Developments of International Marriage and Family Therapy Graduates in Taiwan

Reentry research has received much less attention than research on cultural adjustment in a foreign country, especially in the marriage and family therapy (MFT) field in the United States. Lack of research on international students’ job experiences and professional developments during reentry does not provide further information to evaluate the quality of MFT education in the United States. This study was intended to extend the reentry literature and specifically to understand personal and professional reentry experiences and cross-cultural transformation of MFT returnees in Taiwan. Thirteen participants were interviewed, and the resulting data was analyzed using constructivist grounded theory. Analyses results demonstrated macro contextual factors that situated unique personal and professional reentry phenomena for international MFT graduate in Taiwan. The returnees strived to explore their MFT identity and interpret cross-cultural differences by developing four coping strategies (e.g., not wanting to fit in, doing what you were supposed to do or could do, processing with others, and therapists’ multicultural awareness) that were associated with three conditions, such as personal networks linking to professional networks, supervision, and training in MFT. Findings suggested that reentry adaption was varied and fitting into Taiwanese society might not be the final goal for the returnees. Training implications in the MFT field were provided based on the findings.     

Career guidance and therapeutic counselling: sharing ‘what works’ in practice with young people

Many young people in the UK and across the world, where austerity measures are biting deep, find themselves at a time of crisis and uncertainty in their lives. The assumptions previously held of clear and straightforward career paths are being challenged and ‘career’ has come to mean more than simply ‘work’ or ‘employment’. This has implications for career practice, where career advisers are engaging with a range of complex issues in their guidance interactions with clients. This article draws on research undertaken with therapeutic counsellors into ‘what works’ when counselling young people. It offers career practitioners the opportunity to reflect on four key emerging themes and to consider how the discipline of therapeutic counselling might inform guidance practice.     

When the survey question directs retrieval: Implications for assessing the cognitive and affective predictors of global evaluation

Research suggests that individuals do not respond to survey questions on the basis of a single, fixed set of psychological considerations. To the contrary, they respond on the basis of whatever material happens to come to mind at the moment of answering. Furthermore, the particular material that comes to mind often depends upon the nature of the question and the manner in which it is posed. This has important implications when attempting to assess the independence of beliefs and emotions as predictors of global attitude judgments. When addressing this question, it is important to consider the extent to which any given measurement procedure specifically targets ‘emotionally relevant beliefs’ in memory. Past research has failed to target this specific subset of beliefs. As a consequence, beliefs have failed to fully account for the relation between emotions and global attitude judgments. Completely different findings emerge when the researcher employs ‘decomposition’ and ‘emotionally cued recall’ to enable respondents to generate ‘emotionally relevant beliefs’. Under these conditions, beliefs fully account for the relation between emotions and global attitude judgments. However, this only occurs when one defines and operationalizes ‘emotionally relevant beliefs’ at the individual level. The theoretical and methodological implications of these results are discussed. © 1997 by John Wiley & Sons, Ltd.     

Systematic,Evidence-Based Review of Exercise,Physical Activity,and Physical Fitness Effects on Cognition in Persons with Multiple Sclerosis

Cognitive dysfunction is highly prevalent, disabling, and poorly-managed in persons with multiple sclerosis (MS). Recent evidence suggests that exercise might have beneficial effects on cognition in this population. The current systematic, evidence-based review examined the existing literature on exercise, physical activity, and physical fitness effects on cognition in MS to accurately describe the current status of the field, offer recommendations for clinicians, and identify study-specific and participant-specific characteristics for providing future direction for ongoing MS research. We performed an open-dated search of Medline, PsychInfo, and CINAHL in December 2015. The search strategy involved using the terms ‘exercise’ OR ‘physical activity’ OR ‘physical fitness’ OR ‘aerobic’ OR ‘resistance’ OR ‘balance’ OR ‘walking’ OR ‘yoga’ OR ‘training’ OR ‘rehabilitation’ AND ‘multiple sclerosis’. Articles were eliminated from the systematic review if it was a review article, theoretical paper, or textbook chapter; did not involve persons with MS; involved only persons with pediatric-onset MS; did not involve neuropsychological outcomes; did not include empirical data to evaluate outcomes; involved pharmacological interventions; or was not available in English. The selected articles were first classified as examining exercise, physical activity, or physical fitness, and were then randomly assigned to 2 independent reviewers who rated each article for level of evidence based on American Academy of Neurology criteria. Reviewers further completed a table to characterize important elements of each study (i.e., intervention characteristics), the cognitive domain(s) that were targeted, participant-specific characteristics, outcome measures, and study results. The present review resulted in 26 studies on the effects of exercise, physical activity, and physical fitness on cognition in persons with MS. This included 1 Class I study, 3 Class II studies, 8 Class III studies, and 14 Class IV studies. Of the 26 total studies, 6 were randomized controlled trials. Overall, there is conflicting evidence for the effects of exercise on cognition in MS, and overall positive, but not definitive evidence for the effects of physical activity and physical fitness, respectively, on cognition in this population. Collectively, there is insufficient well-designed research to definitively conclude that exercise, physical activity, and physical fitness are effective for improving cognition in MS. This is based, in part, on methodological issues of Class I and II studies, such as inclusion of cognition as a secondary outcome (35 % of reviewed studies), poorly-developed exercise interventions, and paucity of research that included cognitively-impaired MS samples. However, promising evidence from Class III and Class IV studies may be useful for informing the development of better intervention research.     

Reply to Robertson

Abstract

The debates of the 1980s and 1990s on methodological individualism versus methodological holism have not been adequately resolved. Within analytical Marxism, G.A. Cohen, John Roemer, Jon Elster and others have come down in favour of methodological individualism as part of the effort to make analytical Marxism more ‘scientific’ and ‘rigorous’ than earlier versions of Marxism. In doing so they have presented methodological individualism as a necessary ingredient in ridding Marxism of obscurantism. This view is here challenged from a pragmatist philosophical perspective. It is argued that, from such a perspective, the debates between the individualists and holists should have been dissolved rather than resolved in favour of the individualists. It is suggested that such dissolution would even strengthen analytical Marxism by redirecting analytical energies towards real social and political problems in the contemporary world and away from endless methodological debate.     

Children’s mental health: Time to stop using psychiatric diagnosis

Hegemonic mental health service approaches stress the need for ‘accurate’ diagnosis in order to understand what the correct ‘treatment’ should be. I review the evidence on how far diagnosis in psychiatry has helped advance scientific knowledge and clinical practice and conclude that it hasn’t. I then examine how National Institute for Health and Care Excellence (NICE) guidelines in relation to children’s behaviour problems reflects the lack of progress that results from adopting a diagnostic approach. Taking mental health practice beyond reliance on narrow non-evidence-based diagnostic algorithms can be developed by adopting existing projects such as the Partners for Change Outcome Management Systems project.     

Repression and splitting: towards a method of conceptual comparison

An attempt is made to compare two psychoanalytic concepts which by ‘belonging’ to different psychoanalytic groups have come to be defined and used differently. The paper is also an inquiry into the possibility of a comparative psychoanalytic method. The two concepts are ‘repression’ and ‘splitting of the ego’ and an examination is made of the semantic similarities and differences. Some clinical material is offered that adds indicative clinical evidence to test the semantic comparison. The aim is to answer the question: Are the terms simply alternative ones for similar clinical phenomena? The paper offers one method which could provide an answer. It represents a general method for clarifying and maybe reconciling the differing points of view of competing psychoanalytic schools.