Empirically supported psychotherapies: comment on Westen, Novotny, and Thompson-Brenner (2004)

D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004; see record 2004-15935-005) suggested that efforts to identify empirically supported treatments are misguided because they are based on assumptions that are not appropriate for some types of treatment and patients. The authors of this comment argue that Westen and colleagues are simply incorrect when they assert that empirically supported treatments require that psychopathology must be highly malleable, that treatments must be brief, or that the samples studied are unrepresentative of the kinds of patients typically encountered in clinical practice--comorbidity is common in many clinical trials. Randomized controlled trials remain the most powerful way to test notions of causal agency.     

The expression of the genes of aggressiveness in mice: The effect of androgen on aggression and sexual behavior in females

Female mice of strains selectively bred for aggressiveness or nonaggressiveness were injected with testosterone propionate (TF′) at the age of 2 days and as adults, or they were injected as adults only. Aggressive and sexual behavior was then tested with female, receptive female, and male partners before, during, and after the latter TP treatment. The females that had received both TP treatments displayed as much or as little aggression as males of the same strain, leading to the conclusion that aggressiveness genes are not linked with the male sex chromosome, even though they depend on it for their expression. The sexual behavior of the females of both strains that had received both TP treatments was altered to the male type. In the females of the aggressive strain even adult treatment alone was sufficient for this change. Aggressiveness and male sexual behavior would seem to be determined separately, although aggressiveness facilitates the display of male sexual behavior.     

Treatment-resistant panic disorder

A substantial number of patients with panic disorder and agoraphobia may remain symptomatic after standard treatment (including selective serotonin reuptake inhibitors, tricyclic antidepressants, benzodiazepines, or irreversible monamine oxidase inhibitors). In this review, recommendations for the treatment of patients with panic disorder and agoraphobia who do not respond to these drugs are provided. Nonresponse to drug treatment could be defined as a failure to achieve a 50% reduction on a standard rating scale after a minimum of 6 weeks of treatment in adequate dose. When initial treatments have failed, the medication should be changed to other standard treatments. In further attempts at treatment, drugs should be used that have shown promising results in preliminary studies, such as venlafaxine. Combination treatments may be used, such as the combination of an selective serotonin reuptake inhibitor and a benzodiazepine. Psychological treatments such as cognitive-behavioral therapy have to be considered in all patients, regardless whether they are nonresponders or not. According to existing studies, a combination of pharmacologic treatment with cognitive-behavioral therapy can be recommended.     

Exploring the positive and negative implications of facial feedback

The facial feedback effect (e.g., Strack et al., 1988) is explored in three experiments. It was found that when someone lowers their eyebrows, following instructions, their mood becomes more negative. If, however, they are instructed to raise their eyebrows they become more surprised by facts. Finally, if people are instructed to wrinkle their noses, then odors are evaluated as more unpleasant. While providing further diverse evidence for facial feedback, the experiments are also considered in the context of facial muscular paralysis induced as part of cosmetic treatments using botulinum toxin. The research presented here supports the previously suggested idea that such treatments could reduce depression, but other possible psychological impacts of such treatments are considered. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Using aptitude measurements for the optimal assignment of subjects to treatments with and without mastery scores

For assigning subjects to treatments the point of intersection of within-group regression lines is ordinarily used as the critical point. This decision rule is critized and, for several utility functions and any number of treatments, replaced by optimal monotone, nonrandomized (Bayes) rules. Both treatments with and without mastery scores are considered. Moreover, the effect of unreliable criterion scores on the optimal decision rule is examined, and it is illustrated how qualitative information can be combined with aptitude measurements to improve treatment assignment decisions. Although the models in this paper are presented with special reference to the aptitude-treatment interaction problem in education, it is indicated that they apply to a variety of situations in which subjects are assigned to treatments on the basis of some predictor score, as long as there are no allocation quota considerations.     

Digital Mental Health Interventions for Child and Adolescent Anxiety

Anxiety disorders are the most common mental health conditions in children, with approximately 13% of kids struggling with excessive anxiety. The vast majority do not have access to effective treatments and there continues to be a disjunction between treatments that are empirically supported and those that are available in the community. Digital mental health interventions (DMHI) can increase efficiency, reach, and standardization as well as reduce costs of providing of mental health care. Here we review the extant research on DMHI, including web- or cloud-based programs, mobile applications (apps), virtual reality (VR), and digital assessment methods such as ecological momentary assessment (EMA) for the delivery and/or support of evidence-based care in child anxiety. Preliminary research is promising for these tools to improve access and efficiency of evidence-based practice. However, ethics and practice guidelines are needed and questions remain regarding what level and quality of therapeutic involvement is needed to maximize treatment completion and outcomes in youth and whether DMHIs are contraindicated for certain populations or whether they are similarly effective with those with comorbid conditions is unclear.     

An internet survey of emotional health,treatment seeking and barriers to accessing mental health treatment among Chinese-speaking international students in Australia

The present internet survey examined the demographic characteristics of Chinese-speaking international students in Australia, psychological distress levels as measured by the Kessler-10 (K-10) Item scale, help-seeking history and preferences, as well as treatment barriers. Of the 144 respondents, 54% reported high psychological distress (mean K-10 score?=?23.96; SD?=?9.03). However, only 9% of those who were highly distressed reported they had sought mental health services in the past year. While the majority preferred help from informal social networks, they tended to favour mental health services over traditional culture-specific forms of help. Common barriers to accessing mental health services reported by respondents with high psychological distress included costs or transportation concerns, limited knowledge of available services, time constraints, the perception that symptoms were not severe enough to warrant treatment, language difficulties and lack of knowledge of symptoms of psychological distress. Although the majority preferred face-to-face treatments over internet treatments, a considerable percentage of respondents were willing to try either treatment modality. Chinese-speaking international students are a high risk group for developing psychological distress, yet they tend to underuse mental health services. Education about the effectiveness of face-to-face and online treatments may increase treatment seeking by this population.     

Angststörungen und Phobien im Kindes- und Jugendalter

Anxiety disorders belong to the most frequent mental disorders in childhood and adolescence. They cause severe impairment, show poor long-term outcome and they are often not recognized as a mental disorder. For a reliable and valid diagnosis and treatment outcome evaluation a multi-informant approach is essential including information from the child and the parents. Methods of choice are structured clinical interviews and questionnaires filled out by the child and the parents. Meta-analyses showed that only cognitive-behavioral treatment can be considered as a sufficiently evidence-based treatment. No differences in outcome were found between individual and group treatments or child and family focused treatments. Medication treatment with selective serotonin reuptake inhibitor (SSRI) showed short-term efficacy. Major evidence-based interventions are psycho-education, exposure techniques and cognitive restructuring strategies.     

Nonreductive Physics

This paper documents a wide range of nonreductive scientific treatments of phenomena in the domain of physics. These treatments strongly resist characterization as explanations of macrobehavior exclusively in terms of behavior of microconstituents. For they are treatments in which macroquantities are cast in the role of genuine and irreducible degrees of freedom.

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Psychological treatment of physical maltreatment and negligence in children and adolescents: a meta-analysis

The results of a meta-analysis about the efficacy of psychological treatment for children who have suffered physical maltreatment and neglect by their parents or tutors are presented. Sixteen studies that met our selection criteria were included, providing 22 treated groups and 8 control groups. The results showed an absence of clear differences among the diverse treatments, although all of them exhibited a low-to-medium practical significance. The longer they are, the more effective are the treatments and also when neglect was the type of maltreatment suffered by the children. The effect estimates do not seem to be affected by biases. Finally, the clinical implications of the results, as well as those for future research, are discussed.     

Behavioral and pharmacological treatments for tourette syndrome: A review

This article reviews the published treatment outcome research on pharmacological and behavioral treatments for Gilles de la Tourette syndrome (TS). Controlled group outcome studies of pharmacological treatments show about a 50–60% reduction in tics with haloperidol and pimozide and about a 20% reduction with clonidine. A controlled group outcome study and several within-subject design studies of behavioral treatments show about a 90% reduction in tics with habit reversal training. A large number of case studies generally confirm these results and also show benefits from other behavioral treatments such as relaxation training, self-monitoring, and contingency management. Clinical limitations of TS drugs are that they produce side effects in 50–85% of the patients and require continuous use, and long-term compliance with the medications is limited. The primary limitation of behavioral treatments is that they require a large initial time commitment. The methodological strengths of the controlled drug studies are the use of double-blind and group designs. For the behavioral studies, the strengths are rigorous recording and controlled within-subject designs.     

Self-evaluation and choice: an existential view of paradoxical treatments

The use of the term paradox in the domain of psychotherapy is fundamentally different from its use in philosophy. Paradoxical interventions are not statements that can be both true and false but rather are agents of therapeutic change. However, this reified usage of the term has made it difficult to clarify the process by which paradoxical treatments become efficacious. These treatments can be viewed as epistemological paradoxes because they challenge traditional assumptions about the nature of psychological problems. Based on this analysis, it is argued that the effects of paradoxical treatments are mediated by a self-evaluation process that leads to a change in the meaning clients attribute to their symptoms.     

Measures of effect size

Two different approaches have been used to derive measures of effect size. One approach is based on the comparison of treatment means. The standardized mean difference is an appropriate measure of effect size when one is merely comparing two treatments, but there is no satisfactory analogue for comparing more than two treatments. The second approach is based on the proportion of variance in the dependent variable that is explained by the independent variable. Estimates have been proposed for both fixed-factor and random-factor designs, but their sampling properties are not well understood. Nevertheless, measures of effect size can allow quantitative comparisons to be made across different studies, and they can be a useful adjunct to more traditional outcome measures such as test statistics and significance levels.     

Theory and therapy in stuttering: A complex relationship

There are many treatments currently available for stuttering, for both children and adults. These range from direct interventions intended to reduce the severity and/or frequency of the speech behaviors of stuttering, to those intended to alleviate the anxiety and other mental health issues that can accompany the disorder. However, as there are little supporting data for many of these treatments, there is little consensus about which to use. Another way to evaluate stuttering treatments is to explore the extent to which they address the cause of the disorder. However, the cause of stuttering is not yet known. In this theoretical paper, a 3-factor causal model is presented, to which the mechanisms thought to be driving different treatments are then aligned. The model is innovative, in that it attempts to explain moments of stuttering. It is argued that all causal factors must be operating at each moment of stuttering. The model is intended as a new way of looking at cause, and how treatments may address cause. It is hoped this will stimulate discussion and lead to further lines of inquiry.Educational objectives: The reader will be able to: (a) describe the P&A 3-factor causal model of moments of stuttering; (b) state how indirect direct stuttering treatments relate to cause, according to the P&A model; (c) describe how direct stuttering treatments relate to cause, according to the P&A model; (d) state the purpose of cognitive behavior therapy; and (e) describe at least one suggestion for further research arising from the P&A model.     

APPLICATIONS OF A SEQUENTIAL ALTERNATING TREATMENTS DESIGN

We propose the use of a combined version of the alternating treatments and multiple baseline designs in situations in which a traditional baseline (no treatment) condition either does not provide an adequate contrast condition or is not feasible or practical due to clinical constraints. We refer to this design as a sequential alternating treatments design because two treatments are initially implemented in a random or counterbalanced fashion and are followed by a sequential change in one or both treatments across settings, subjects, or tasks. The effects of the independent variables are assessed first by analyzing the two series of data points representing the different treatments (relative effects) and then by assessing changes in one or both series, as application of the alternative treatment is introduced sequentially. The sequential application of treatment provides an analysis of control in the same manner as the multiple baseline design; the initial alternating treatments phase provides a contrast condition in much the same manner as a baseline condition. Applications of this design to the assessment of peer training and self-injurious behavior are described.     

Mandatory neurotechnological treatment: ethical issues

What if neurofeedback or other types of neurotechnological treatment, by itself or in combination with behavioral treatment, could achieve a successful “rewiring” of the psychopath’s brain? Imagine that such treatments exist and that they provide a better long-term risk-minimizing strategy compared to imprisonment. Would it be ethical to offer such treatments as a condition of probation, parole, or (early) prison release? In this paper, I argue that it can be ethical to offer effective, non-invasive neurotechnological treatments to offenders as a condition of probation, parole, or (early) prison release provided that: (1) the status quo is in no way cruel, inhuman, degrading, or in some other way wrong, (2) the treatment option is in no way cruel, inhuman, degrading, or in some other way wrong, (3) the treatment is in the best interests of the offender, and (4) the offender gives his/her informed consent.     

The acceptability and preference for the psychological treatment of PTSD

The acceptability and preference of psychological treatments is important in understanding patient treatment seeking, choice, engagement and attrition and possibly treatment response in health care. The acceptability of, and preference for, 14 different types of psychological treatment for posttraumatic stress disorder (PTSD) were investigated in a student population through invitation to participate in a web-based survey. Respondents were asked to rate each treatment on 10 scales and to rank the treatments in order of preference. Respondents were also asked whether they would seek treatment themselves, recommend treatment to friends and family, feel stigmatised by suffering from PTSD, had any prior knowledge of the treatments and if this had been positive or negative and whether they had a history of psychological problems or treatment. A total of 330 respondents completed the survey. A past or current history of psychological problems and treatment was surprisingly high. Almost all respondents indicated that they would seek or recommend treatment in spite of high levels of stigmatisation. Factor analysis of the 10 scales indicated two factors: Endorsement and Discomfort. Rank ordering on preference and Endorsement scores was highly consistent. The highly preferred and endorsed treatments involved cognitive therapy, exposure or psycho-education in spite of high levels of discomfort anticipated with exposure. Treatments involving new technologies, EMDR and psychodynamic psychotherapy received the lowest Endorsement and preference. There was a modest influence of prior knowledge of a treatment.     

Transferences in parent–infant psychoanalytic treatments

In parent–infant treatments, babies sometimes exhibit symptoms such as screaming, clinging, and fearful gaze avoidance of the analyst. The paper investigates if such phenomena may be regarded as transference manifestations, and if so, if they appear both in younger and older infants. Based on three case presentations, it is concluded that some babies are capable of forming both brief and enduring transferences. The term “indirect infant transference” refers to when a baby reacts emotionally to the analyst as long as the parent's transference remains unresolved. “Direct transference” refers to when a baby reacts in a non‐mediated way to the analyst. The necessary tool of investigation for discovering these phenomena is a psychoanalytic method with an explicit, though not exclusive, focus on the baby. Discerning them in the clinical encounter may help us understand the baby's predicament and when and how to address the baby or the parent. These treatments constitute an empirical field awaiting more extensive clinical and theoretical investigation. Already now, they suggest that transference may be rooted in, and may appear during, very early developmental stages. The paper's positions are compared with those put forward by other parent‐infant clinicians.     

A Sustainable Medicine: Lessons from the Old Order Amish

Daniel Callahan's concept of a sustainable medicine is examined by looking at experiences Old Order Amish communities have had with organ and bone marrow transplantation. The Amish possess many characteristics that might make them embrace limits on the use of expensive, life-prolonging medical treatments: they believe that the good of the individual should be subordinated to the good of the community, they are suspicious of progress as a goal, and they are more comfortable with dying than many other modern Americans. However, the Amish actively pursue these treatments without the benefit of private or government insurance. Although the Amish affective response to sick individuals is worthy of emulating, their commitment to help individuals obtain and pay for transplants has had negative financial and cultural effects on some Amish communities. The Amish experience can thus teach us lessons about how to care for one another when we are sick and dying, but it can also teach us how difficult but important it is to limit some forms of expensive care for the good of our communities.