December 2016 Research Corner
Thursday, December 15, 2016
Posted by: Troy Thompson
The Efficacy of Exposure Therapy for Anxiety-Related Disorders and Its Underlying Mechanisms: The Case of OCD and PTSD
Edna B. Foa and Carmen P. McLean, Annual Review of Clinical Psychology, Vol. 12: 1-28 (Volume publication date March 2016), DOI: 10.1146/annurev-clinpsy-021815-093533
In this review we describe the intricate interrelationship among basic research, conceptualization of psychopathology, treatment development, treatment outcome research, and treatment mechanism research and how the interactions among these areas of study further our knowledge about psychopathology and its treatment. In describing the work of Edna Foa and her colleagues in anxiety disorders, we demonstrate how emotional processing theory of anxiety-related disorders and their treatment using exposure therapy have generated hypotheses about the psychopathology of posttraumatic stress disorder and obsessive-compulsive anxiety disorder that have informed the development and refinement of specific treatment protocols for these disorders: prolonged exposure and exposure and response (ritual) prevention. Further, we have shown that the next step after the development of theoretically driven treatment protocols is to evaluate their efficacy. Once evidence for a treatment's efficacy has accumulated, studies of the mechanisms involved in the reduction of the targeted psychopathology are conducted, which in turn inform the theory and further refine the treatments. We conclude our review with a discussion of how the knowledge derived from Foa and colleagues' programmatic research together with knowledge emerging from basic research on extinction learning can inform future research on the psychopathology of anxiety disorders and their treatments.
Mechanisms of Change in Written Exposure Treatment of Posttraumatic Stress Disorder
Wisco, B. E., Baker, A. S., & Sloan, D. M.
Behavior Therapy, Volume 47, Issue 1, January 2016, Pages 66–74, doi:10.1016/j.beth.2015.09.005National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine
Received 6 April 2015, Accepted 27 September 2015, Available online 8 October 2015
•Fear activation and within- and between-session reduction may underlie exposure
•We tested these predictors of PTSD treatment response with heart rate (HR)
•Fear activation was the only HR measure that predicted treatment outcome
•Unlike HR, between-session change in self-reported fear was related to outcome
•Alternative theories of exposure mechanisms are indicated
Although the effectiveness of exposure therapy for PTSD is recognized, treatment mechanisms are not well understood. Emotional processing theory (EPT) posits that fear reduction within and between sessions creates new learning, but evidence is limited by self-report assessments and inclusion of treatment components other than exposure. We examined trajectories of physiological arousal and their relation to PTSD treatment outcome in a randomized controlled trial of written exposure treatment, a protocol focused on exposure to trauma memories. Hierarchical linear modeling was used to model reduction in Clinician Administered PTSD Scale score as a predictor of initial activation and within- and between-session change in physiological arousal. Treatment gains were significantly associated with initial physiological activation, but not with within- or between-session changes in physiological arousal. Treatment gains were associated with larger between-session reductions in self-reported arousal. These findings highlight the importance of multimethod arousal assessment and add to a growing literature suggesting refinements of EPT.
Sudden Gains in Cognitive–Behavior Therapy for Treatment-Resistant Depression: Processes of Change.
Abel, Anna; Hayes, Adele M.; Henley, William; Kuyken, Willem
Journal of Consulting and Clinical Psychology, Apr 21 , 2016, No Pagination Specified. http://dx.doi.org/10.1037/ccp0000101
Objective: Sudden gains were investigated in cognitive–behavioral therapy (CBT) for treatment-resistant depression (TRD). Client and therapist processes in sessions proximal to sudden gains were examined to better understand the antecedents of sudden gains and potential mechanisms linking them to outcome. Method: Participants were 156 adults with TRD in a randomized controlled trial of CBT as an adjunct to pharmacotherapy (Wiles et al., 2013). Depression symptoms were assessed by the Beck Depression Inventory-II at each session. In a subsample of 50 clients, audio-recordings of 125 therapy sessions were rated for hope, emotional processing, and therapist competence in case-conceptualization. Results: Sudden gains were experienced by 54% of participants. Those with gains reported significantly lower depression severity at 12-month follow-up and more remission of symptoms than those without gains. Sudden gains also predicted lower depression at follow-up, beyond the slope of linear change in symptoms across treatment. Therapists demonstrated greater competence in case conceptualization with clients who reported sudden gains, and those with gains expressed more hope in sessions prior to a gain. In addition, more hope and emotional processing in the pregain sessions predicted less depression at follow-up, controlling for depression scores in the prior session. Better therapist conceptualization skills and more client hope in the baseline and pregain sessions were also associated with more emotional processing in those same sessions. Conclusion: This study extends the phenomenon of sudden gains in CBT for depression to a treatment-resistant population and identified important therapy processes that predicted long-term outcomes: hope and emotional processing. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Implementation of Transdiagnostic Cognitive Therapy in Community Behavioral Health: The Beck Community Initiative.
Creed, Torrey A.; Frankel, Sarah A.; German, Ramaris E.; Green, Kelly L.; Jager-Hyman, Shari; Taylor, Kristin P.; Adler, Abby D.; Wolk, … Beck, Aaron T.
Journal of Consulting and Clinical Psychology, Jul 4, 2016, No Pagination Specified. http://dx.doi.org/10.1037/ccp0000105
Objective: Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP. Method: Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians’ work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity. Results: Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other). Conclusions: Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
A Randomized Clinical Trial Comparing Individual Cognitive Behavioral Therapy and Child-Centered Therapy for Child Anxiety Disorders
Jennifer S. Silk, Patricia Z. Tan, Cecile D. Ladouceur, Suzanne Meller, Greg J. Siegle, Dana L. McMakin, Erika E. Forbes, Ronald E. Dahl, Philip C. Kendall, Anthony Mannarino & Neal D. Ryan; Journal of Clinical Child & Adolescent Psychology, 2016 DOI:10.1080/15374416.2016.1138408
This study compared individual cognitive behavioral therapy (CBT) and a supportive child-centered therapy (CCT) for child anxiety disorders on rates of treatment response and recovery at posttreatment and 1-year follow-up, as well as on real-world measures of emotional functioning. Youth (N = 133; ages 9–14) with anxiety disorders (generalized, separation, and/or social anxiety) were randomized using a 2:1 ratio to CBT (n = 90) or CCT (n = 43), which served as an active comparison. Treatment response and recovery at posttreatment and 1-year follow-up were assessed by Independent Evaluators, and youth completed ecological momentary assessment of daily emotions throughout treatment. The majority of youth in both CBT and CCT were classified as treatment responders (71.1% for CBT, 55.8% for CCT), but youth treated with CBT were significantly more likely to fully recover, no longer meeting diagnostic criteria for any of the targeted anxiety disorders and no longer showing residual symptoms (66.7% for CBT vs. 46.5% for CCT). Youth treated with CBT also reported significantly lower negative emotions associated with recent negative events experienced in daily life during the latter stages of treatment relative to youth treated with CCT. Furthermore, a significantly higher percentage of youth treated with CBT compared to CCT were in recovery at 1-year follow-up (82.2% for CBT vs. 65.1% for CCT). These findings indicate potential benefits of CBT above and beyond supportive therapy on the breadth, generalizability, and durability of treatment-related gains.
Integrating Motivational Interviewing With Cognitive-Behavioral Therapy for Severe Generalized Anxiety Disorder: An Allegiance-Controlled Randomized Clinical Trial.
Westra, Henny A.; Constantino, Michael J.; Antony, Martin M. Journal of Consulting and Clinical Psychology, Mar 17 , 2016, http://dx.doi.org/10.1037/ccp0000098
Objective: Although integrating motivational interviewing (MI) and cognitive–behavioral therapy (CBT) has been recommended for treating anxiety, few well-controlled tests of such integration exist. Method: In the present randomized trial for severe generalized anxiety disorder (GAD), we compared the efficacy of 15 sessions of CBT alone (N = 43) versus 4 MI sessions followed by 11 CBT sessions integrated with MI to address client resistance/ambivalence (N = 42). Clients were adults, predominantly female and Caucasian, with a high rate of diagnostic comorbidity. To control for allegiance, therapists were nested within treatment group and supervised separately by experts in the respective treatments. Results: Piecewise multilevel models revealed no between-groups differences in outcomes from pre- to posttreatment; however, there were treatment effects over the follow-up period with MI-CBT clients demonstrating a steeper rate of worry decline (γ = −0.13, p = .03) and general distress reduction (γ = −0.12, p = .01) than CBT alone clients. Also, the odds of no longer meeting GAD diagnostic criteria were ∼5 times higher at 12-months for clients receiving MI-CBT compared with CBT alone. There were also twice as many dropouts in CBT alone compared with MI-CBT (23% vs. 10%); a difference that approached significance (p = .09). The treatments were competently delivered, and intraclass correlations revealed negligible between-therapist effects on the outcomes. Conclusions: The findings support the integration of MI with CBT for severe GAD and point to the importance of training therapists in appropriate responsivity to in-session markers of resistance and ambivalence. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Effects of religious vs. standard cognitive behavioral therapy on therapeutic alliance: A randomized clinical trial
Harold G. Koenig, Michelle Pearce, Bruce Nelson, Sally Shaw, Clive Robins, Noha Daher, Harvey Jay Cohen & Michael B. King, Psychotherapy Research, 26(3), 2016, pages 365-376 DOI:10.1080/10503307.2015.1006156
Background: Treatments that integrate religious clients' beliefs into therapy may enhance the therapeutic alliance (TA) in religious clients. Objective: Compare the effects of religiously integrated cognitive behavioral therapy (RCBT) and standard CBT (SCBT) on TA in adults with major depression and chronic medical illness. Method: Multi-site randomized controlled trial in 132 participants, of whom 108 (SCBT = 53, RCBT = 55) completed the Revised Helping Alliance Questionnaire (HAQ-II) at 4, 8, and 12 weeks. Trajectory of change in scores over time was compared between groups. Results: HAQ-II score at 4 weeks predicted a decline in depressive symptoms over time independent of treatment group (B = −0.06, SE = 0.02, p = 0.002, n = 108). There was a marginally significant difference in HAQ-II scores at 4 weeks that favored RCBT (p = 0.076); however, the mixed effects model indicated a significant group by time interaction that favored the SCBT group (B = 1.84, SE = 0.90, degrees of freedom = 181, t = 2.04, p = 0.043, d = 0.30). Conclusions: While RCBT produces a marginally greater improvement in TA initially compared with SCBT, SCBT soon catches up.
Developmental demands of Cognitive Behavioral Therapy for depression in children and adolescents: Cognitive, social, and emotional processes
Garber, J., Frankel, S. A., & Herrington, C. G. (2016). Annual Review of Clinical Psychology, 12(1), 181-216. doi:10.1146/annurev-clinpsy-032814-12836
Although some treatments for depression in children and adolescents have been found to be efficacious, the effects sizes have tended to be modest. Thus, there is considerable room to improve upon existing depression treatments. Some children may respond poorly because they do not yet have the cognitive, social, or emotional maturity needed to understand and apply the skills being taught in therapy. Therefore, treatments for depression may need to be tailored to match children's ability to both comprehend and implement the therapeutic techniques. This review outlines the steps needed for such developmental tailoring: (a) Specify the skills being taught in depression treatments; (b) identify what cognitive, social, and emotional developmental abilities are needed to attain these skills; (c) describe the normative developmental course of these skills and how to determine a child's developmental level; and (d) use this information to design an individualized treatment plan. Possible approaches to intervening include: alter the therapy to meet the child's level of development, train the child on the skills needed to engage in the therapy, or apply a dynamic assessment approach that integrates evaluation into treatment and measures children's current abilities as well as their potential.
Are the Effects of Cognitive Behavior Therapy for Depression Falling? Review and Critique of the Evidence
Waltman, S. H., Creed, T. A., & Beck, A. T. Clinical Psychology: Science and Practice, Volume 23, Issue 2, pages 113–122, June 2016
Johnsen and Friborg (Psychological Bulletin 2015; doi:10.1037/bul0000015) report that modern cognitive behavior therapy (CBT) clinical trials yield less relief from depression compared to seminal trials, but methodological limitations may qualify the conclusions. Given the empirical support for CBT for depression, a closer look is warranted. High I2 coefficients were reported for a subgroup analysis, and no heterogeneity estimates were reported for the primary analyses, raising concerns about the appropriateness of meta-analysis and interpretations of the findings. Concerns are raised about the presence of CBT in comparison groups. Data regarding CBT competence were largely missing, and fidelity data were often absent. Without these data, attributions about changes in effect sizes from early studies may be premature. The proliferation of CBT may have been accompanied by modifications to the model, accompanied by variability in quality, adherence, and competence. A call to high-fidelity and high-quality CBT is made.