Negative Treatment Effects in Dyadic Psychotherapy: A Focus on Prevention and Intervention Strategies

Therapy holds the potential to harm as well as help. This paper highlights approaches that may help prevent or decrease the incidence of negative effects in psychotherapy. These approaches include supervision, peer consultation, ongoing assessment of the therapeutic process, therapist-client matching, and referrals and transfers. We hope that this paper will serve as a stimulus for clinicians, psychotherapy researchers, and educators to put forth collabo-rative effort into identifying variables directly associated with adverse treat- ment outcomes and determining appropriate prevention and intervention strategies.     

Habit reversal versus supportive psychotherapy in Tourette's disorder: a randomized controlled trial and predictors of treatment response

Tourette syndrome (TS) is characterized by chronic motor and vocal tics. Habit reversal therapy (HR) is a behavioral treatment for tics which has received recent empirical support. The present study compared the efficacy of HRT in reducing tics, improving life-satisfaction and psychosocial functioning in comparison with supportive psychotherapy (SP) in outpatients with TS. In addition, we investigated whether impairments in response inhibition in patients with TS predict response to HR treatment which specifically aims to inhibit tics. Thirty adult outpatients with DSM-IV TS were randomized to 14 individual sessions of HR (n = 15); or SP (n = 15). HR but not SP reduced tic severity over the course of the treatment. Both groups improved in life-satisfaction and psychosocial functioning during active treatment. Reductions in tic severity (HR) and improvements in life-satisfaction and psychosocial functioning (HR and SP) remained stable at the 6-month follow-up. The extent of pre-treatment response inhibition impairment in the HR group predicted reductions in tic-severity from pre- to post-treatment. Our results suggest that HR has specific tic-reducing effects although SP is effective in improving life-satisfaction and psychosocial functioning. Assessments of response inhibition may be of value for predicting treatment response to HR.     

Evaluation of therapist-supported parent-implemented CBT for anxiety disorders in rural children

Supplementing bibliotherapy with therapist-client communication has been shown to be an effective way of providing services to under-resourced and isolated communities. The current study examined the efficacy of supplementing bibliotherapy for child anxiety disorders with therapist-initiated telephone or email sessions, or with client-initiated contact in a randomised trial using a waitlist control. Participants were 100 anxiety-disordered children and their parents from rural and remote communities. All treatment conditions resulted in improvement on self-report measures and clinician rated severity. Telephone sessions produced superior outcomes with 79% of children being anxiety disorder free post-treatment compared with 33% of email and 31% of client-initiated participants. The results suggest that therapist supplemented bibliotherapy could provide an efficacious treatment option for families isolated from traditional treatment services.     

Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb

Studies in academic research centres with selected patients have shown that several cognitive behaviour therapies are effective in the treatment of PTSD following traumas affecting individuals or small groups. Little information is available on the extent to which these positive findings will generalize to more routine clinical settings with less selected patients or to a trauma that affects a whole community. The present study addresses these generalization issues. A consecutive series of 91 patients with PTSD resulting from a car bomb which exploded in the centre of Omagh, Northern Ireland in August 1998 were treated with cognitive therapy, along lines advocated by Ehlers and Clark (2000). There were no major exclusion criteria and 53% of patients had an additional axis I disorder (comorbidity). Therapists were NHS staff with heavy caseloads and modest prior training in CBT for PTSD. A brief training in specialist procedures for PTSD was provided. Patients received an average of eight treatment sessions. Significant and substantial improvements in PTSD were observed. Degree of improvement was comparable to that in previously reported research trials. Comorbidity was not associated with poorer outcome, perhaps because comorbid patients were given more sessions of treatment (average 10 vs 5 sessions). Patients who were physically injured improved less than those who were not physically injured. Overall, the results indicate that the positive findings obtained in research settings generalize well to a frontline, non-selective service.     

Functional Neuroimaging Studies of Cognitive Recovery After Acquired Brain Damage in Adults

The first two decades of cognitive neuroimaging research have provided a constant increase of the knowledge about the neural organization of cognitive processes. Many cognitive functions (e.g.working memory) can now be associated with particular neural structures, and ongoing research promises to clarify this picture further, providing a new mapping between cognitive and neural function. The main goal of this paper is to outline conceptual issues that are particularly important in the context of imaging changes in neural function through recovery process. This review focuses primarily on studies made in stroke and traumatic brain injury patients, but most of the issues raised here are also relevant to studies using other acquired brain damages. Finally, we summarize aset of methodological issues related to functional neuroimaging that are relevant for the study ofneural plasticity and recovery after rehabilitation. Deceased     

Sudden gains in cognitive behavioral treatment for depression: when do they occur and do they matter?

Despite the use of efficacious treatments for depression, individuals differ in both the degree to which they recover and the rate at which recovery occurs. Tang and colleagues found that depressed patients who had sudden improvements in their symptomatology not only maintained these gains, but also enjoyed more improvement and higher rates of recovery than those without sudden gains (J. Consulting Clin. Psychol. 67(6) (1999) 894; J. Consulting Clin. Psychol. 70(2) (2002) 444). Our study examined the role of sudden gains in a cognitive-behavioral group treatment for depression. Results indicated that 41.9% of patients experienced sudden gains. Furthermore, sudden gains occurring in the first third of treatment appear to have special importance. Participants enjoying early sudden gains had significantly larger changes in depressive symptom scores over the course of treatment than those without sudden gains and were marginally more likely to be treatment responders compared to those without early sudden gains. In contrast to Tang and DeRubeis (J. Consulting Clin. Psychol. 67(6) (1999) 894), however, sudden gains were not associated with cognitive changes.     

Class-consistent Differential Reinforcement And Stimulus Class Formation In Pigeons

Match-to-sample training clusters of A1 (sample): B1/B2 (comparisons), A2: B2/B1, B1: A1/A2, B2: A2/A1, B1: C1/C2, B2: C2/C1, C1: B1/B2, and C2: B2/B1 were presented to pigeons with class-consistent differential reinforcement using two dissimilar types of food reinforcers. Distinctive class-consistent response patterns occurred to the samples during the fixed-ratio 5 sample observing response requirement. Subsequent tests, modeled from the equivalence class paradigm demonstrated the emergence (80% class consistent) of the transitive-like A-C and C-A relations for 4 and 2 of 12 pigeons, respectively, and a strong trend (over 70%) for 7 and 6 others, respectively; the emergence of the reflexive-like identity relation when the nonidentical comparison was from the other class; and the disruption of the trained within-class relation with the addition of a reflexive comparison. After directional training of C1: D1/D2 and C2: D2/D1, tests indicated no emergence of the symmetric-like D-C relation or the composite D-B and D-A relations, but the B-D and A-D transitive-like relation occurred with some pigeons. Off-baseline training with class-consistent differential reinforcement contingent on responding to the D stimuli alone produced distinctive responding and, in turn, a trend to D-C symmetric-like control in 4 of 12 pigeons, as well as a shift toward class-consistent control on D-B and D-A test trials. Class-consistent differential reinforcement that produced distinctive sample behavior promoted stimulus control relations like those that circumscribe equivalence class formation. Respondent—operant interactions permit an analysis of the possible enrollment of stimulus values of distinctive responding to the discriminative stimuli forming the stimulus classes via processes corresponding to naming in humans.     

Psychotherapy and Pharmacotherapy Treatment Outcome Research in Pediatric Populations

Reviewed treatment interventions for pediatric populations involving the combination of pharmacotherapy or psychotherapy or either treatment employed alone. The literature revealed a dearth of psychotherapy and pharmacotherapy outcome studies, with the exception of investigations of children diagnosed with attention-deficit hyperactivity disorder (ADHD). Issues pertaining to design, including sample selection, treatment integrity and comparability, and placebo controls also are reviewed. A potpourri of other issues are noted including parental attitudes toward the use of medication versus psychotherapy, treatment adherence, and patient/provider relationship. For children diagnosed with ADHD, the use of stimulant medication appears to be superior to psychotherapy employed alone in managing the behavior of these children as well as their classroom functioning. Recommendations are made for multimodal trials that examine the combined and individual use of pharmacotherapies and psychotherapies for various developmental and psychiatric disorders that occur in childhood and adolescence. Future studies also need to address the durable effects of these treatment options.     

The Future of Psychology in Pain Management

Pain treatment facilities have proliferated in recent years and psychology has enjoyed considerable success in the clinical and research arenas of pain management. However, changes in the health care environment present significant challenges to the future of psychology in pain management. This article discusses concerns in three important areas of pain treatment that psychologists must address if they are to maintain a strong presence in this field: (1) evaluating and treating patients in the pain treatment setting, (2) evaluating and enhancing the efficacy of pain treatment, and (3) applying pain treatment services to other patient populations. With appropriate attention to these issues, psychology can continue to thrive in pain treatment settings.     

Letter to a genetic counselor

The author describes her personal experience terminating a pregnancy after receiving an abnormal amniocentesis result: While still waiting for the results, she and her husband attempted to deny the importance of the pregnancy, an approach which they subsequently regretted. When they received the abnormal result, they found themselves able to make necessary decisions quickly, despite being in shock. It then took some time before they realized what a major loss they had actually suffered. The painful aftermath included accepting emotional responsibility for their decision to abort, as well as explaining that difficult decision to their older children. Thoughts of a possible subsequent pregnancy could not be faced at once. Over time, the author found the support of friends and colleagues, and even of a support group, to be invaluable. All in all, the entire experience was more painful than she would have predicted, and she hopes that this account will prove helpful both to genetic counselors and to other patients who receive abnormal results from prenatal diagnosis. A list of suggested readings is appended.Rose Green is a pseudonym.