Suicide ideation as a predictor of treatment outcomes in cognitive-behavioral therapy for unipolar mood disorders

Background/Objective: Suicide ideation is common in depressed patients. However, no studies to date have examined whether pretreatment suicide ideation is associated with poorer outcomes after cognitive-behavioral therapy for adult depression. Method: 475 depressed outpatients (age: M = 39.9 years, SD = 11.71; 60.2% female) took part in a pre-treatment and a post-treatment assessment. Pre-treatment suicide ideation measured with the BDI suicide item was considered as a predictor of treatment outcomes – controlling for age, gender, number of attended therapy sessions, as well as pre-treatment depression severity. Results: Hierarchical regression revealed that age, gender, number of completed therapy sessions and depression severity at baseline could explain 25% of the variance in post-treatment BDI-scores. Adding suicide ideation significantly improved the amount of variance explained to 27%. Treatment outcomes were worse for patients with more severe depression, suicidal patients, patients receiving more therapy-sessions and older patients. Conclusions: Suicide ideation added only little incremental variance to the prospective prediction of post-treatment depression severity. Depressed patients with suicide ideation can attain almost as good treatment outcomes as patients without suicide ideation, which is a clinically encouraging result.     

Integrating clients' moment‐to‐moment ratings into psychotherapy research: A novel approach

Counselling and psychotherapy researchers have considerably advanced the field's understanding of psychotherapy processes and how they relate to treatment outcomes. Despite these advances, little is known about the client's perspective of changes in psychotherapy processes that occur throughout a given session (i.e. micro‐processes). To address this gap, this article describes the novel application of methods that assess participants' moment‐to‐moment ratings to psychotherapy research. This method entails recording psychotherapy session content that clients and other potential raters (e.g. therapists, researchers) later review while simultaneously providing continuous ratings of psychotherapy processes (e.g. helpfulness, alliance). In addition, moment‐to‐moment ratings can facilitate significant events research by prompting researchers to elicit client feedback about the moments that are rated the most and least positively. However, few studies have used these methods in the context of psychotherapy research. Studies incorporating these methods may yield findings that advance psychotherapy research, training efforts and clinical practice. For example, studies may examine how the magnitude and timing of clients' moment‐to‐moment ratings of psychotherapy processes are associated with treatment outcomes, therapist ratings and physiological processes (e.g. heart rate variability). Trainee therapists and their supervisors may also use clients' moment‐to‐moment ratings to facilitate attunement to verbal and non‐verbal indicators of moments perceived more positively and negatively. Last, these methods can produce findings that are highly relevant to clinical practice, where therapists routinely navigate fluctuations in psychotherapy processes (e.g. alliance ruptures) that can be assessed using moment‐to‐moment ratings.     

Prevalence and treatment of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis and co-morbid severe health anxiety

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) is a debilitating condition that affects 0.2–0.4% of the population. Health focussed anxiety is common across medical conditions, and may be relevant in CFS/ME. This study sought to identify the prevalence and impact of health anxiety (HA) in CFS/ME and evaluate the effectiveness of Cognitive Behavioural Therapy for HA in CFS/ME. Cross-sectional questionnaire methods and case-series design were used to achieve study aims. Analysis indicated that 41.9% of the CFS/ME clinic sample experienced threshold levels of health anxiety, which was associated with elevated symptom severity across several dimensions. Stepwise multiple regression indicated physical functioning and depression accounted for 23.8% of variance in fatigue; depression, fatigue and HA, accounted for 32.9% of variance in physical functioning. Large effect sizes and clinically significant changes were generated in the treatment study. HA is common in CFS/ME and likely to exacerbate fatigue and physical functioning. This study identifies HA as an important target for treatment, trial findings should be further replicated on a larger scale.     

A randomized clinical trial of group and individual Cognitive-Behavioral Therapy approaches for Social Anxiety Disorder

To compare the effectiveness of two Cognitive-Behavioral Therapy (CBT) interventions—an individual and a group intervention—in Social Anxiety Disorder therapy. We compared the two treatment groups against a waitlist condition in a randomized clinical trial with 86 young adults. The individual CBT intervention was Trial-Based Cognitive Therapy (TBCT) developed by De-Oliveira, a novel technique in which the therapist engages the patient in a simulated judicial trial with the goal of identifying and changing core dysfunctional beliefs. The group intervention consisted of exposition therapy based on the Hofmann and Otto protocol (Group CBT) to restructure negative and dysfunctional cognitions regarding social situations. Both interventions reduced psychiatric symptoms from pre- to post-test and primary social anxiety and depression symptoms relative to waitlist controls. The interventions were recently introduced in Brazil, and this is the first randomized control trial to compare TBCT and this Group CBT, which were effective in assessing changes in social anxiety symptoms as well as co-occurring psychiatric symptoms.     

Moving from “I” to “We”: A Grounded Theory Analysis of Couple Therapy with Liver Patients and Their Partners

Prior research indicates that couples who cope with chronic illness from a relational “we” orientation experience more positive outcomes than couples that cope individually; however, little prior research identifies clinical processes that promote reciprocity or how societal gender processes are involved. This grounded theory analysis of 25 videotaped therapy sessions with six heterosexual couples coping with chronic liver disease (LD) used a feminist-informed relational lens to focus on the clinical processes involved in shifting from an individual to a relational orientation. Findings identified three contextual barriers to attaining a “we orientation”: (a) autonomy discourse, (b) illness-related power, and (c) gendered power. Analysis detailed therapist actions that decreased the impact of barriers to reciprocity and fostered relational coping. Clinical implications attend to complex intersections among gender, caregiving, and contextual barriers to reciprocity.     

Sitting In: The Experience of Learning and Practicing Family Therapy through Being a Co-Therapist in Hong Kong

This article explores family therapy trainees’ subjective experiences of working as cotherapists with a supervisory-level therapist in a Chinese context, regarding their perceptions of and positioning in it and also their opinions on the benefits and/or pitfalls of cotherapy. Individual interviews with a total of six cotherapists revealed three themes: (1) Cotherapy was perceived as an experiential learning journey that evolved from anxiety and excitement to empowerment and nurturing; (2) a collaborative master–apprentice relationship of openness, trust, and mutual respect was developed with both sides’ interactive effort, which included common commitment and concern for the client, the supervisor’s awareness and explicit address of the role hierarchy, principle setting prior to the cooperation, and honest pre- and-postsession sharing and discussion; (3) the dual-purpose supervisor–trainee cotherapy brought direct benefits for all involved parties and for others. The findings have useful implications for integrating treatment and training for optimal training/learning outcomes and for advancing knowledge transfer from senior to junior and from academia to the field, with reference to local cultural characteristics.     

Behind the (Virtual) Mirror: Online Live Supervision in Couple and Family Therapy

Online therapy and supervision, a rapidly rising practice in couple and family therapy, has been the subject of a growing body of literature. From its early days, family therapy training has included live supervision, which has typically been conducted by a supervisor and a team of trainees situated on the other side of a one-way mirror. With the outbreak of the COVID-19 global pandemic, we—the staff of supervisors at the Barcai Institute in Tel Aviv, Israel—were compelled to find solutions to continue meeting with clients and to provide supervision for family therapy trainees. To this end, we have shifted our live supervision courses (“practicums”) to the virtual arena, adapting the popular application “Zoom” into what we call “PractiZoom.” Based on over 100 PractiZoom sessions conducted between March and May 2020, involving 14 supervisors and 28 therapists-in-training and their clients, the article reflects on this pioneering online practicum for the online live supervision of therapists with geographically distributed participants. In this article, we outline our operational methods and adaptations for conducting live behind-the-mirror supervision online. Following a short theoretical background, we outline the process of online live supervision, discuss our reflections and those of our trainees on the challenges and possibilities it poses, and offer a number of preliminary conclusions and recommendations.     

Barriers and Facilitators to Implementing Attachment-based Family Therapy into a Child Welfare Setting: A Qualitative Process Evaluation

Child welfare systems (CWSs) worldwide show increased interest in adopting empirically informed clinical strategies to increase treatment effectiveness. Many empirically supported treatments (ESTs) exist, but little is known about EST implementation barriers and facilitators in CWS. This study explored CWS providers’ experiences of implementing attachment-based family therapy (ABFT) in home-based services of the Flemish CWS (in Belgium). Sixteen CWS providers (twelve counselors and four supervisors) involved in three home-based services were interviewed. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection, coding, and analysis of interview data. Findings revealed that implementation success was related to ABFT's fit with the CWS's mission, philosophy, and existing practices. CWS providers’ belief in the compatibility between ABFT and CWS increased investment in implementation efforts and persistence to overcome challenges and setbacks. Some barriers pertained to the learning of ABFT and some barriers pertained to systems level challenges such as lack of leadership and support, poor coordination with referral sources and other youth care partners, and lack of policy support. For successful expansion of ESTs into CWS settings, various barriers at multiple systemic levels need to be addressed.     

Comparing Cognitive Behavioral Therapy and Systemic Therapy for Social Anxiety Disorder: Randomized Controlled Pilot Trial (SOPHO-CBT/ST)

This randomized controlled trial (RCT) aimed to pilot the newly developed manualized and monitored systemic therapy (ST) for social anxiety disorder (SAD), as compared to manualized and monitored cognitive behavioral therapy (CBT). We conducted a prospective multicenter, assessor-blind pilot RCT on 38 outpatients (ICD F40.1; Structured Clinical Interview for DSM (SCID); Liebowitz Social Anxiety Scale, LSAS-SR >30). The primary outcome was level of social anxiety (LSAS-SR) at the end of treatment. A total of 252 persons were screened, and 38 patients were randomized and started therapy (CBT: 20 patients; ST: 18 patients; age: M = 36 years, SD = 14). Within-group, simple-effect intent-to-treat analyses (ITT) showed significant reduction in LSAS-SR (CBT:d = 1.04; ST:d = 1.67), while ITT mixed-design ANOVA demonstrated the advantage of ST (d = 0.81). Per-protocol analyses supported these results. Remission based on reliable change indices also demonstrated significant difference (LSAS-SR: 15% in CBT; 39% in ST;h: 0.550), supported by blind diagnosticians’ ratings of those who completed therapy (SCID; 45% in CBT, 78% in ST,p = .083). No adverse events were reported. CBT and ST both reduced social anxiety, supporting patient improvement with the newly developed ST for SAD; this has yet to be verified in a subsequent confirmatory RCT.