The Shattering of the Stimulus Barrier: The Case for an Integrative Approach in Short-Term Treatment of Psychological Trauma

The paper argues that the integrative psychotherapy approach is ideally suited to the treatment of psychological trauma. A brief term intervention model, devised by psychotherapists working with trauma in the South African context, is presented to illustrate this premise. It is asserted that posttraumatic stress represents a disorder in which dysfunction occurs both internally and externally, according to Freud at the interface of these two aspects of psychological functioning, i.e., at the ego boundary. Disturbance manifests in recognizable cognitive, behavioral, and somatic symptoms and in addition carries unconscious associations and anxieties. The ideal approach to treatment thus appears to be to draw on the relative strengths of both the psychodynamic and cognitive-behavioral schools. Existing trauma intervention models reflect the centrality of integration in many respects, although this does not seem to be explicitly recognized. The five components of the model referred to above are outlined and each component is explored in terms of its efficacy within both a cognitive-behavioral and a psychodynamic framework. Illustrative case material is provided to demonstrate the mechanisms at work in each case. The paper argues that the clinical success of the model lies in its integrative perspective and that psychotherapy integration should be recognized as the approach of choice in the treatment of traumatized individuals.     

Working From Home: An Initial Pilot Examination of Videoconferencing-Based Cognitive Behavioral Therapy for Anxious Youth Delivered to the Home Setting

Progress in evidence-based treatments for child anxiety has been hampered by limited accessibility of quality care. This study utilized a multiple baseline design to evaluate the pilot feasibility, acceptability, and preliminary efficacy of real-time, Internet-delivered, family-based cognitive-behavioral therapy for child anxiety delivered to the home setting via videoconferencing. Participants included 13 anxious youth (mean age = 9.85) with a primary/co-primary anxiety disorder diagnosis. Eleven participants (84.6%) completed treatment and all study procedures. Consistent with hypotheses, the intervention was feasible and acceptable to families (i.e., high treatment retention, high client satisfaction, strong therapeutic alliance, and low barriers to participation). Moreover, the novel videoconferencing treatment format showed preliminary efficacy: 76.9% of the intention-to-treat (ITT) sample and 90.9% of treatment completers were treatment responders (i.e., Clinical Global Impressions-Improvement Scale = 1 or 2 at posttreatment), and 69.2% of the ITT sample and 81.8% of treatment completers were diagnostic responders (as per the Anxiety Disorders Interview for Children). Gains were largely maintained at 3-month follow-up evaluation. Outcome patterns within and across subjects are discussed, as well as limitations and the need for further controlled evaluations. With continued support, videoconferencing treatment formats may serve to meaningfully broaden the reach of quality care for youth 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.     

Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age.

Meta-analyses support the effectiveness of behavioral interventions for the treatment of insomnia, although few have systematically evaluated the relative efficacy of different treatment modalities or the relation of old age to sleep outcomes. In this meta-analysis of randomized controlled trials (k = 23), moderate to large effects of behavioral treatments on subjective sleep outcomes were found. Evaluation of the moderating effects of behavioral intervention type (i.e., cognitive-behavioral treatment, relaxation, behavioral only) revealed similar effects for the 3 treatment modalities. Both middle-aged adults and persons older than 55 years of age showed similar robust improvements in sleep quality, sleep latency, and wakening after sleep onset. A research agenda is recommended to examine the mechanisms of action of behavioral treatments on sleep with increased attention to the high prevalence of insomnia in older individuals.     

Emotion Regulation in Youth with Emotional Disorders: Implications for a Unified Treatment Approach

Given the relationship between internalizing disorders and deficits in emotion regulation in youth, the emotion science literature has suggested several avenues for increasing the efficacy of interventions for youth presenting with anxiety and depression. These possibilities include the identification and addition of emotion-regulation skills to existing treatment packages and broadening the scope of those emotions addressed in cognitive-behavioral treatments. Current emotion-focused interventions designed to meet one or both of these goals are discussed, and the developmental influences relevant to the selection of emotion-focused treatment goals are explored using the framework of a modal model of emotion regulation. These various lines of evidence are woven together to support the utility of a novel emotion-focused, cognitive-behavioral intervention, the Unified Protocol for the Treatment of Emotional Disorders in Youth, a transdiagnostic treatment protocol that aims to treat the range of emotional disorders (i.e., anxiety and depression) simultaneously. Avenues for future directions in treatment outcome and assessment of emotion regulation are also discussed.     

An Evaluation of Pharmacological Treatment Combined with Stress Inoculation Training in the Management of oral Lichen Planus

The aim of this pilot study was to examine the effects of the inclusion of a cognitive-behavioral intervention to the pharmacological treatment of oral lichen planus (OLP). Using a randomized controlled clinical trial, 16 patients affected by OLP were treated either with a potent corticosteroid in addition with stress inoculation training or with the drug alone. There were significant differences between the groups regarding the severity of the pathology both at the end of the treatment as well as at one-month follow-up. It is concluded that a cognitive-behavioral intervention might be usefully combined with pharmacological treatment for OLP.     

Sensitivity for Treatment Effects of the Screen for Child Anxiety Related Emotional Disorders

The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a relatively new self-report questionnaire that measures DSM-defined anxiety disorders symptoms in children. The present study examined the treatment sensitivity of the SCARED. Eleven anxiety-disordered children aged 10 to 13 years received cognitive-behavioral treatment, an intervention that is generally known to be effective. Children completed the SCARED on three occasions: (1) 3 months before treatment (i.e., baseline), (2) at pretreatment, and (3) at posttreatment. Before and after treatment, scores on traditional childhood anxiety measures (i.e., State-Trait Anxiety Inventory for Children, Revised Children's Manifest Anxiety Scale, and Fear Survey Schedule for Children) were also obtained. Results showed that children's SCARED scores remained relatively stable from baseline to pretreatment. However, from pre- to post-treatment, significant decreases were evident for the SCARED and for all traditional measures. These results suggest that the SCARED reliably taps treatment effects and, thus, provide further support for its utility as a self-report index of childhood anxiety in clinical and research settings.     

Behavior Therapy and Callous-Unemotional Traits: Effects of a Pilot Study Examining Modified Behavioral Contingencies on Child Behavior

The conduct problems of children with callous-unemotional (CU) traits (i.e., lack of empathy, lack of guilt/lack of caring behaviors) are particularly resistant to current behavioral interventions, and it is possible that differential sensitivities to punishment and reward may underlie this resistance. Children with conduct problems and CU (CPCU) are less responsive to behavioral punishment techniques (e.g., time-out), whereas reward techniques (e.g., earning points for prizes or activities) are effective for reducing conduct problems. This study examined the efficacy of modified behavioral interventions, which de-emphasized punishment (Condition B) and emphasized reward techniques (Condition C), compared with a standard behavioral intervention (Condition A). Interventions were delivered through a summer treatment program over 7 weeks with an A-B-A-C-A-BC-A design to a group of 11 children (7–11 years; 91% male). All children were diagnosed with either oppositional defiant disorder or conduct disorder, in addition to attention-deficit hyperactivity disorder. Results revealed the best treatment response occurred during the low-punishment condition, with rates of negative behavior (e.g., aggression, teasing, stealing) increasing over the 7 weeks. However, there was substantial individual variability in treatment response, and several children demonstrated improvement during the modified intervention conditions. Future research is necessary to disentangle treatment effects from order effects, and implications of group treatment of CPCU children (i.e., deviancy training) are discussed.     

Papa and peers: A biosocial approach to conduct disorder

The authors seek to advance the profession's understanding of conduct disorders by illustrating that (a) inappropriate research design frequently results in faulty conclusions regarding etiology, (b) a biosocial approach is most helpful in identifying key interactive variables that place children/adolescents at risk, and (c) future treatment efficacy studies should focus on mitigating these primary risk factors as well as investigating separate intervention models for the two qualitatively distinct categories of delinquents (i.e., chronic vs. transient participation).     

Differential efficacy between cognitive-behavioral therapy and mindfulness-based therapies for chronic pain: Systematic review

Background/Objective: To assess the differential efficacy between mindfulness-based interventions and cognitive-behavioral Therapy (CBT) on chronic pain across medical conditions involving pain. Method: ProQuest, Science Direct, Google Scholar, Pubmed, and Embase databases were searched to identify randomized clinical trials. Measurements of mindfulness, pain, mood, and further miscellaneous measurements were included. Results: 18 studies met the inclusion criteria (fibromyalgia, n = 5; low back pain, n = 5; headache/migraine, n = 4; non-specific chronic pain, n = 4). In fibromyalgia, mindfulness based stress reduction (MBSR) was superior to the usual care and Fibroqol, in impact and symptoms. In low back pain, MBSR was superior to the usual care, but not to CBT, in physical functionality and pain intensity. There were no studies on differential efficacy between mindfulness and CBT for headache and non-specific chronic pain, but Mindfulness interventions were superior to the usual care in these syndromes. Conclusions: Mindfulness interventions are superior to usual cares in all diagnoses, but it is not possible to conclude their superiority over CBT. Comparisons between mindfulness interventions are scarce, with MBSR being the most studied. In central sensitization syndromes, variables associated with pain tend to improve with treatment. More research is needed to differentiate diagnosis and intervention.     

Cognitive-behavioral treatment of compulsive hoarding: a multiple baseline experimental case study

The present case study describes a cognitive-behavioral intervention directed at helping a 53 year old female suffering from compulsive hoarding decrease clutter and improve decision-making and sorting techniques. The intervention focused on decision-making training, exposure and response prevention, and cognitive restructuring. Ratios of cluttered space to overall space were calculated for floor and furniture tops for each of five rooms over a period of 17 months. Clutter decreased substantially in each of the rooms targeted for intervention, while clutter ratios remained stable for a room used as a baseline control (no intervention). In addition, D.'s scores on self-report measures of obsessive-compulsive symptomatology decreased after 9 months of intervention suggesting that the treatment protocol affected symptoms of hoarding distress, as well as clutter. Despite previously reported difficulties in the treatment of compulsive hoarding, our results provide preliminary evidence that a cognitive-behavioral intervention can be successful in reducing hoarding symptoms. Suggestions for future research include streamlining the treatment program and testing its efficacy on large clinical samples.     

Current Treatment Practices for Children and Adults With Trichotillomania: Consensus Among Experts

Very little is known regarding the efficacy of pharmacological and psychosocial treatments for children and adults with trichotillomania (TTM). Given this dearth of information, the present investigation sought to examine the treatment practices of members of the nationally recognized Trichotillomania Learning Center–Scientific Advisory Board (TLC-SAB) and practitioners known by members of the TLC-SAB to possess extensive experience working with this population. The responses of 67 practitioners to an Internet-based survey were examined. Our results clearly indicate that cognitive-behavioral treatment (CBT) is the treatment of choice for both children and adults with TTM. In particular, several components of CBT (i.e., awareness training, self-monitoring, competing response training, habit reversal training, and stimulus control) are implemented most often. Selective serotonin reuptake inhibitors (SSRIs, e.g., citalopram, fluoxetine) and serotonin-norepinepherine reuptake inhibitors (SNRIs, e.g., venlafaxine, duloxetine) were prescribed most frequently; however, these results are preliminary given our small sample of prescribing practitioners (n = 11). Taken together, these findings are a critical starting point to advancing the understanding of efficacious interventions for the treatment of individuals with TTM. Clinical and research implications, future areas of research, and study limitations are discussed.     

A cognitive-behavioral treatment for irritable bowel syndrome using interoceptive exposure to visceral sensations

BackgroundIrritable bowel syndrome (IBS) is a chronic and debilitating medical condition with few efficacious pharmacological or psychosocial treatment options available. Evidence suggests that visceral anxiety may be implicated in IBS onset and severity. Thus, cognitive-behavioral treatment (CBT) that targets visceral anxiety may alleviate IBS symptoms.MethodsThe current study examined the efficacy of a CBT protocol for the treatment of IBS which directly targeted visceral sensations. Participants (N = 110) were randomized to receive 10 sessions of either: (a) CBT with interoceptive exposure (IE) to visceral sensations; (b) stress management (SM); or (c) an attention control (AC), and were assessed at baseline, mid-treatment, post-treatment, and follow-up sessions.ResultsConsistent with hypotheses, the IE group outperformed AC on several indices of outcome, and outperformed SM in some domains. No differences were observed between SM and AC. The results suggest that IE may be a particularly efficacious treatment for IBS.ConclusionsImplications for research and clinical practice are discussed.     

Implications of research for the treatment of depressive disorders during childhood

Basic research into the prevalence, natural course, and phenomena of comorbidity of depressive disorders during childhood are reviewed and implications of this research for treating depressed youths are noted. Results of investigations into the biological aspects of depression are integrated into a multifactorial model of depressive disorders during childhood and the efficacy of pharmacological interventions is discussed. Cognitive theory is integrated with attachment theory to explain a possible avenue to the development of depressive disorders during childhood. Interpersonal therapy has emerged as a potentially effective intervention for depressed youths. Basic tenets of this treatment model are compared and contrasted to a cognitive-behavioral treatment model, and a hybrid treatment referred to as “cognitive therapy within the interpersonal context” is proposed.     

Effects of Group Functional Behavior-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Behavior in a Youth With Autism Spectrum Disorder

Individuals with Autism Spectrum Disorder (ASD) often present with comorbid Obsessive Compulsive Behaviors (OCBs), but little research exists on effective intervention for OCBs. Using a single-case experimental design, this study highlights the efficacy of a Group Functional Behavior-based Cognitive-Behavior Therapy (Fb-CBT) to reduce OCBs in an 11-year-old youth with ASD. Tailored to the individual needs of this youth, Fb-CBT included traditional CBT components (e.g., psychoeducation, cognitive-behavioral skills training, and exposure and response prevention) coupled with functional behavior assessment and intervention. Time-series parent report data and standardized measures showed clinically significant decreases in OCBs, an increase in psychosocial functioning, and high consumer satisfaction.     

The unique impact of parent training for separation anxiety disorder in children

This investigation examined the preliminary efficacy of an integrated cognitive-behavioral parent-training protocol for six families of separation-anxious children (7 to 10 years of age) using a multiple baseline design across participants. Although families were assessed on child, parent, and clinician ratings at pre- and posttreatment as well as 6-month follow-up, only parents received education and training. Although the parent-training protocol was largely effective and treatment gains were maintained at 6-month follow-up, only those child participants whose parents experienced clinically significant improvement on parental process measures (i.e., enhanced efficacy or satisfaction, reduced stress) achieved high end-state functioning. Implications regarding the importance of individualized family-based interventions for treating anxious youth are discussed.     

An open trial of a transdiagnostic cognitive-behavioral group therapy for anxiety disorder

Transdiagnostic models of anxiety, and cognitive-behavioral treatments based on these models, have been gaining increased attention in recent years. Preliminary efficacy studies generally suggest strong treatment effects, although few of these studies have examined to what extent treatment effects are similar across clients with different anxiety disorders. The purpose of the current study was to examine the efficacy of a 12-week transdiagnostic group cognitive-behavioral therapy for anxiety disorders and compare outcome across diagnoses. Mixed-effect regression modeling of data from 52 participants with anxiety disorders (predominantly panic disorder and social phobia) participating in an open outcome trial indicated that participants tended to improve over treatment, with no differential outcome for any primary or comorbid disorders. The results of this study add to the growing evidence base for transdiagnostic anxiety treatment models and provide preliminary support for the assumption that individuals with different anxiety diagnoses can be treated equally within the same treatment protocol.     

Empirically and clinically useful decision making in psychotherapy: differential predictions with treatment response models

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.     

The compensation and capitalization models: A test of two approaches to individualizing the treatment of depression

Despite long-standing calls for the individualization of treatments for depression, modest progress has been made in this effort. The primary objective of this study was to test two competing approaches to personalizing cognitive-behavioral treatment of depression (viz., capitalization and compensation). Thirty-four adults meeting criteria for Major Depressive Disorder (59% female, 85% Caucasian) were randomized to 16-weeks of cognitive-behavioral treatment in which strategies used were selected based on either the capitalization approach (treatment matched to relative strengths) or the compensation approach (treatment matched to relative deficits). Outcome was assessed with a composite measure of both self-report (i.e., Beck Depression Inventory) and observer-rated (i.e., Hamilton Rating Scale for Depression) depressive symptoms. Hierarchical linear modeling revealed a significant treatment approach by time interaction indicating a faster rate of symptom change for the capitalization approach compared to the compensation approach (d = .69, p = .03). Personalizing treatment to patients' relative strengths led to better outcome than treatment personalized to patients' relative deficits. If replicated, these findings would suggest a significant change in thinking about how therapists might best adapt cognitive-behavioral interventions for depression for particular patients.     

The Effective Treatment of Juveniles Who Sexually Offend: An Ethical Imperative

This article raises serious concerns regarding the widespread use of unproven interventions with juveniles who sexually offend and suggests innovative methods for addressing these concerns. Dominant interventions (i.e., cognitive-behavioral group treatments with an emphasis on relapse prevention) typically fail to address the multiple determinants of juvenile sexual offending and could result in iatrogenic outcomes. Methodologically sophisticated research studies (i.e., randomized clinical trials) are needed to examine the clinical and cost-effectiveness of cognitive-behavioral group interventions, especially those delivered in residential settings. The moral and ethical mandate for such research is evident when considering the alternative, in which clinicians and society are willing to live in ignorance regarding the etiology and treatment of juvenile sexual offending and to consign offending youths to the potential harm of untested interventions. Encouraging signs of a changing ethical climate include recent federal funding of a randomized clinical trial examining treatment effectiveness with sexually offending youths and the introduction of separate (i.e., developmentally informed) clinical and legal interventions for juvenile versus adult sexual offenders.