Cognitive-Behavioral Therapy for Offender Hopelessness: Lessons from Treatment of Forensic Inpatients

Patients remanded to forensic hospitals often experience a marked situational depression once initial psychotic symptoms subside and the reality of their legal situation becomes evident. Individual psychotherapy is not often used with this population due to a generally high level of impairment. It is suggested, that with modifications, the cognitive-behavioral therapy manual by Michael Thase (in: VanHasselt, Hersen (eds) Sourcebook of psychological treatment manuals for adult disorders, 1996) designed to treat depression in psychiatric inpatients can be used to treat situational depression in forensic inpatients. Modifications include the use of increased behavioral techniques, the addition of a group component, and lengthening of time limits for each treatment phase. Case examples from a first attempt to implement the new treatment program are presented.     

Systematic Review of the Effects of Religion-Accommodative Psychotherapy for Depression and Anxiety

Integrating religion into psychotherapy may improve treatment for depression and anxiety. This review systematically examines clinical trials of religion-accommodative psychotherapy for depression or anxiety. Results indicate that integrating religion into psychotherapy does not lead to significantly more improvements in depression or anxiety than equivalent therapy without religious components. However, when compared with less stringent control groups, such as supportive psychotherapy, religion-accommodative therapy may be more effective, at least immediately post-treatment. Results from the 11 studies reviewed indicate that psychotherapy integrating religion is at least as effective for treating depression and anxiety as other forms of psychotherapy. Conclusions were limited by lack of power, comparable control groups, focus on anxiety, and treatment manuals.     

A survey of parent training manuals

Twenty-six commercially available parent training manuals were surveyed with the goal of providing helpful information to the professional for selection of manuals. Included were manuals for parents as well as manuals for professionals for use in conducting individual or group treatment. The following information was given for all manuals: the characteristics of the target populations for whom the manuals were intended, readability levels, use made of technical language, provision of glossary, organization and format of the book, availability of supplementary materials such as leaders' guides, and references to reviews by other authors. In an additional section, the research literature dealing with evaluation of these manuals was reviewed and summarized as a means of acquainting the reader with the available scientific information on their effectiveness. A report on the status of each manual in terms of evaluation was provided in tabular form. The evaluation of manuals by conduct of empirical research to determine their usefulness to the consumer was emphasized.     

Antidepressants,Psychotherapy or their Combination: Weighing Options for Depression Treatments

Psychotherapy and antidepressant medications are the two preeminent treatment choices for depression. This article puts each of these treatments into perspective by presenting an overview of what is currently known about their effectiveness either singly or in combination. Discussion of placebos, common factors among therapies, relapse rates, depression severity, patient treatment preferences and exaggerations in pharmaceutical advertising provide guidance for clinicians in deciding on the best course of treatment. Overall, research reveals the importance of psychosocial factors, no matter what the mode of treatment, and the need for fostering a collaborative bond between clinicians and their patients. We argue that empirical evidence points to making psychotherapy the initial treatment choice for most cases of depression.     

Treatment manuals and the advancement of psychoanalytic knowledge: The Treatment Manual of the Tavistock Adult Depression Study

This paper has two aims: first, it seeks to understand the absence of treatment manuals in psychoanalysis. Secondly, it summarizes the treatment manual of the Tavistock Adult Depression Study, which describes the form of psychoanalytic psychotherapy whose effectiveness has been evaluated both in the Tavistock Adult Depression Study (TADS); and in the German Die Langzeittherapie bei chronischen Depressionen (LAC) Studie. Throughout the history of psychoanalysis, opinions about treatment manuals, empirical research and their antecedents have been deeply divided. After tracing the often polarized unfolding of these matters, the paper proposes that emotional and cognitive difficulties as well as scientific ones underpin their persistence. It is suggested that greater familiarity with them may lead to better combinations of outcome research and psychoanalysis: for example, the Tavistock manual seeks to match one account of the objects, aims, values, spirit and methods of psychoanalysis (as well as of connected forms of psychoanalytic psychotherapy); and also to meet what is required of treatment manuals by random allocation controlled trials. It has been a crucial element in the above studies of the outcome of long‐term psychoanalytic psychotherapies with chronically depressed patients. After describing the Tavistock Manual, the paper concludes suggesting that, if appropriately constructed, treatment manuals can make a contribution to the advancement of specifically psychoanalytic knowledge.     

Psycho-educational group treatment for the severely and persistently mentally ill: how much leader training is necessary?

Psycho-educational groups (PEGs) have been shown to be a particularly effective form of treatment for patients classified under the rubric of severely and persistently mentally ill (SPMI). However, recent surveys suggest that certain professionals, such as nurses and clinical psychologists, called on to conduct these groups may have limited to no training. This study tested three methods (self-instructional, workshop, and workshop plus clinical supervision) designed to provide on-the-job training to practicing clinicians. Specifically, training was based on two manuals; one that operationalized the basic knowledge and skills needed to run an effective PEG and the second being a commonly used PEG program for symptom management targeted at SPMI patients. Eight nurses from four adult units at a state psychiatric hospital initially received self-instructional or workshop training and then conducted a 12-session symptom management PEG composed of four to five SPMI patients (e.g., schizophrenia, schizoaffective or major depression disorders). In a second wave of additional training, nurses received workshop training or clinical supervision and then conducted a second PEG. Differences between training methods were assessed by nurse- and patient-completed measures that tapped the knowledge and skills emphasized in the symptom management and PEG (nurses only) manuals. Results indicated limited support for the superiority of the workshop method on the nurse measures alone. Implications for training working professionals in group treatments and assessing outcomes with chronic SPMI patients are discussed.     

Who's using treatment manuals? A national survey of practicing therapists

Treatment manuals are currently the most common way treatments are disseminated to practicing clinicians, although little is known about the rates with which practicing therapists incorporate these manuals into their practice. In light of a widely acknowledged research-practice gap, understanding how often therapists are using manuals is important for shaping future dissemination efforts. This study collected data on rates of manual use among a national sample of mental health clinicians representative of those likely to be targeted in dissemination efforts (N = 756), as well as predictors of use. Results indicated that few clinicians (<10%) routinely incorporated manuals into their practice, although most employed them to some degree. Predictors of manual use included greater openness to new treatments, younger age, and a cognitive-behavioral treatment orientation (ps < .05). Implications for future dissemination efforts are discussed.     

Treatment manuals: use in the treatment of bulimia nervosa

As psychology has moved toward emphasizing evidence-based practice, use of treatment manuals has extended from research trials into clinical practice. Minimal research has directly evaluated use of manuals in clinical practice. This survey of international eating disorder professionals examined use of manuals with 259 clinicians’ most recent client with bulimia nervosa. Although evidence-based manuals for bulimia nervosa exist, only 35.9% of clinicians reported using a manual. Clinicians were more likely to use a manual if they were younger; were treating an adult client; were clinical psychologists; were involved in research related to eating disorders; and endorsed a cognitive-behavioral orientation. Clinicians were less likely to use a manual if they provided eclectic psychotherapy that incorporated multiple psychotherapeutic approaches. We conclude that psychotherapy provided in clinical practice often does not align with the specific form validated in research trials, and “eclecticism” is at odds with efforts to disseminate manuals into clinical practice.     

Experimentation with Group Techniques with Ego-Disturbed Mothers

Abstract

Psycho–educational groups (PEGs) have been shown to be a particularly effective form of treatment for patients classified under the rubric of severely and persistently mentally ill (SPMI). However, recent surveys suggest that certain professionals, such as nurses and clinical psychologists, called on to conduct these groups may have limited to no training. This study tested three methods (self–instructional, workshop, and workshop plus clinical supervision) designed to provide on-the-job training to practicing clinicians. Specifically, training was based on two manuals; one that operationalized the basic knowledge and skills needed to run an effective PEG and the second being a commonly used PEG program for symptom management targeted at SPMI patients. Eight nurses from four adult units at a state psychiatric hospital initially received self–instructional or workshop training and then conducted a 12–session symptom management PEG composed of four to five SPMI patients (e.g., schizophrenia, schizoaffective or major depression disorders). In a second wave of additional training, nurses received workshop training or clinical supervision and then conducted a second PEG. Differences between training methods were assessed by nurse– and patient–completed measures that tapped the knowledge and skills emphasized in the symptom management and PEG (nurses only) manuals. Results indicated limited support for the superiority of the workshop method on the nurse measures alone. Implications for training working professionals in group treatments and assessing outcomes with chronic SPMI patients are discussed.     

Attitudes towards psychotherapy manuals among clinicians treating eating disorders

Clinicians have relatively low uptake and implementation of evidence-based psychotherapies for the eating disorders, and this problem appears to be associated with low use of manualized approaches. This study examines clinicians' positive and negative attitudes to manuals, and possible beliefs and emotional factors that might drive those attitudes. The participants were 125 psychological therapists working with eating-disordered patients. Each completed standardised measures of attitudes to manuals and emotional states. A number of beliefs about the content of manuals were associated with both positive attitudes to the outcome of treatment and negative attitudes to their impact on the treatment process. In addition, a more positive mood was associated with more positive attitudes. Suggestions are made regarding how attitudes might be made more positive, in order to facilitate the use of evidence-based therapies for eating disorders.     

The use of product owner manuals: A comparison of older versus younger consumers

The present study addresses a relatively unexplored area by examining older consumers' interface with product owner manuals. Specifically, compared to younger consumers, seniors evidenced significantly greater usage of manuals and readership of specific sections. Overall, regression analyses utilizing context, product characteristic, product familiarity, general perceptions of manuals and demographic variables as predictors of manual use found prior knowledge and the perception that manuals are helpful to be among the most significant variables explaining readership. In general, these same variables reflect the extent of overlap between factors explaining manual usage for both older and younger consumers. Relevant literature from related domains provides the context for a discussion of findings and areas for future research.The authors wish to thank Dr. Dixie Mills for her input in the early stages of this research.     

THE WIDENING WORLD OF FUNCTIONAL ASSESSMENT: COMMENTS ON FOUR MANUALS AND BEYOND

An escalating number of materials have been published recently on the topic of functional assessment and assessment‐based behavioral interventions. We review four manuals that purport to provide practical guidance for conducting functional assessment. An examination of these manuals yields encouraging evidence that the field of behavioral support has made notable progress in adopting a functional (behavior‐analytic) approach to unwanted behaviors. The content of the manuals, considered in the context of emerging perspectives in behavioral support, suggests a number of important issues and directions that should be addressed by future functional assessment research and practice.     

A pragmatic approach to measuring adherence in treatment delivery in psychotherapy

ABSTRACT

Measuring therapists’ adherence to treatment manuals is recommended for evaluating treatment integrity, yet ways to do this are poorly defined, time consuming, and costly. The aims of the study were to develop a Therapy Component Checklist (TCC) to measure adherence to manualised CBT; to test its application in research and clinical practice; to determine its validity; and consider its cost benefits. We conducted a randomised trial in 230 people with cancer evaluating effectiveness of CBT for depression. In this, therapists delivered manualised treatment. Experts agreed on key components of therapy and therapists were asked to record these after therapy sessions by ticking a TCC. Inter-rater reliability was tested using an independent rater. Therapists delivered 543 CBT sessions. TCCs were completed in 293, of which 39 were assessed by the independent rater. Self-reported TCC data suggested close adherence to the manual. Prevalence-adjusted and bias-adjusted kappa scores suggested substantial agreement, (>0.60) in 38 out of 46 items. Self-rating of adherence saved around £96 per rating. In conclusion the TCC provides a quick and cost effective way of evaluating the components of therapy delivered. This approach could be applied to other psychological treatments and may help with linking therapeutic interventions with outcome.     

Cognitive processes as mediators of the relation between mindfulness and change in social anxiety symptoms following cognitive behavioral treatment

The present study examined whether pretreatment mindfulness exerts an indirect effect on outcomes following cognitive-behavioral therapy (CBT). Cognitive processes of probability and cost bias (i.e., overestimations of the likelihood that negative social events will occur, and that these events will have negative consequences when they do occur) were explored as potential mediators of the relation between mindfulness and social anxiety symptom change. People with higher levels of mindfulness may be better able to benefit from treatments that reduce biases because mindfulness may aid in regulation of attention. Sixty-seven individuals with a primary diagnosis of social phobia identifying public speaking as their greatest fear received eight sessions of one of two types of exposure-based CBT delivered according to treatment manuals. Participants completed self-report measures of mindfulness, probability bias, cost bias, and social anxiety symptoms. Mediation hypotheses were assessed by a bootstrapped regression using treatment outcome data. Pretreatment mindfulness was not related to change in social anxiety symptoms from pre- to posttreatment. However, mindfulness had an indirect effect on treatment outcome via its association with probability bias, but not cost bias, at midtreatment. These findings were consistent across three metrics of social anxiety symptoms. Mindfulness may play a role in response to CBT among individuals with social phobia through its relation with probability bias – even when the treatment does not target mindfulness.     

A Retrospective Examination of the Similarity Between Clinical Practice and Manualized Treatment for Childhood Anxiety Disorders

The objective of this study was to facilitate the bidirectional communication between researchers and clinicians about the treatment of childhood anxiety disorders, including obsessive-compulsive disorder. Forty-four children were assessed before and after cognitive behavioral treatment with the parent versions of the Spence Child Anxiety Scale and Child Sheehan Disability Scale. In this retrospective study, treatment sessions were coded for the presence of exposures, relaxation, anxiety management, and behavior management. Results showed improved functioning within the clinical sample and suggested that treatment could be shorter, with exposure exercises implemented earlier in the course of treatment than described in manuals. Moreover, improvements in functioning were positively related to the use of exposures, and negatively related to the use of other anxiety management strategies. These results are discussed in the context of efforts to increase the availability of evidence-based treatments and are interpreted as supporting the development of more flexible treatment manuals.     

Reconsidering the ‘heresy’ of using treatment manuals

Some argue that the medical model and the experimental design that underlies the use of treatment manuals to prove the efficacy of a psychotherapeutic treatment clashes with the theoretical basis of family therapy. From the point of view of the empirically supported treatments (ESTs) movement, treatment manuals are the operationalization of the independent variable in a clinical trial; the therapist is only part of the procedure and the therapeutic relationship is a confounding variable. Applying that logic to the practice of family therapy might be considered a heresy. This article argues that paradoxically, this heresy has a lot to offer the practice of family therapy. Research is the best way to answer questions like ‘how does family therapy work?’ ‘What makes ‘good therapy’ good?’ ‘Do therapists do what they say they do'? This article recommends an alternative framework for integrating ESTs into practice by proposing empirically informed guides to practice which, being less formulaic, encourage process‐outcome research, are coherent with the systemic model and do not constrain the therapist's creativity. Such guidelines allow therapists to use manuals flexibly so that they deepen the understanding of the process of therapy. We encourage you to listen to the JFT Editor, Mark Rivett, as he interviews the author on Manuals in the Practice and Research of Family Therapy. Available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1467‐6427/homepage/jft_podcast_series.htm .