Anne Rees

Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy

A total of 117 depressed clients, stratified for severity, completed 8 or 16 sessions of manualized treatment, either cognitive-behavioral psychotherapy (CB) or psychodynamic-interpersonal psychotherapy (PI). Each of 5 clinician-investigators treated clients in all 4 treatment conditions. On most measures, CB and PI were equally effective, irrespective of the severity of depression or the duration of treatment. However, there was evidence of some advantage to CB on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). There was no evidence that CBs effects were more rapid than those of PI, nor did the effects of each treatment method vary according to the severity of depression. There was no overall advantage to 16-session treatment over 8-session treatment. However, those presenting with relatively severe depression improved substantially more after 16 than after 8 sessions.

Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped?

The authors attempted to replicate and extend D. M. Kivlighan and P. Shaughnessys (2000) findings of (a) 3 distinctive patterns of alliance development across sessions and (b) a differential association of one of these, a U-shaped quadratic growth pattern, with positive treatment outcome. In data drawn from a clinical trial of brief psychotherapies for depression (N = 79 clients), the authors distinguished 4 patterns of alliance development. These matched 2 of Kivlighan and Shaughnessys patterns, but not the U-shaped pattern, and none was differentially associated with outcome. However, further examination of the data identified a subset of clients (n = 17) who experienced rupture-repair sequences-brief V-shaped deflections rather than U-shaped profiles. These clients tended to make greater gains in treatment than did the other clients.

Therapist Competence and Outcome of Cognitive Therapy for Depression

The Cognitive Therapy Scale (CTS) has been widely used in cognitive therapy training Centers to assess therapist competence but competence has not previously been clearly shown to be associated with cognitive therapy outcome, possibly because an insufficient range of competence has been sampled. Competence was compared with alliance as process variables that might relate to change in therapy. A randomly selected therapy session from each of 30 courses of cognitive therapy for depression was rated using the CTS. Both therapeutic alliance and therapist competence were related to outcome. In regression analyses, the alliance remained significantly related to outcome when controlling for competence, but not vice versa. These relationships with outcome were primarily attributable to therapists rather than to clients. Associations with outcome appeared stronger for clients who completed therapy than for those who did not. These findings suggest that measurable factors both common to diverse treatments methods and specific to particular methods should be included in efforts to account for therapy outcome.

Outcomes of time-limited psychotherapy in applied settings : Replicating the second Sheffield Psychotherapy project

In a replication and extension of the Second Sheffield Psychotherapy Project (SPP2), a collaborative psychotherapy project (CPP) was carried out at 3 sites within the National Health Service of the United Kingdom. Clients (N = 36) stratified at 3 levels of severity of depression were randomly assigned to one of 2 treatment approaches (psychodynamic-interpersonal or cognitive-behavioral) of 2 time-limited durations (8 or 16 sessions). Gains in both treatment approaches were approximately equivalent and were similar for CPP and SPP2 clients when measured at the end of treatment. However, CPP patients did not maintain their gains to the extent that the SPP2 clients did at 3-month and 1-year follow-up assessments. In the CPP, clients given 16 sessions showed a statistically significant advantage over clients given 8 sessions on some measures at some assessments; in the SPP2, similar effects were noted only among some subgroups of clients.

Convergent Validity of the CORE Measures with Measures of Depression for Clients in Cognitive Therapy for Depression.

Clients (N = 77) undergoing cognitive therapy for depression were assessed before treatment with the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), which encompasses domains of subjective well-being, problems, functioning, and risk of harming self or others, along with the Beck Depression Inventory-II (BDI-II), the Hamilton Rating Scale for Depression (HRSD), the Beck Hopelessness Scale (BHS), and a measure of avoidant (Cluster C) personality problems (Inventory of Interpersonal Problems-Avoidant [IIP-Av]). The CORE-OM and the BDI-II were strongly correlated with each other and showed coherent and similar patterns of correlations with the HRSD, the BHS, and the IIP-Av. Sixty-one of the clients were repeatedly assessed during treatment with alternating versions of the CORE Short Form and with the BDI-II. Results strongly supported the convergent validity of the CORE measures with the BDI-II in across-clients comparisons of means scores and rates of improvement and in across-sessions comparisons within clients.

Convergent Validity of the Agnew Relationship Measure and the Working Alliance Inventory

The convergent validity of the Agnew Relationship Measure (ARM) and the Working Alliance Inventory (WAI) was assessed in samples drawn from 2 comparative clinical trials of time-limited psychotherapies for depression. In 1 sample, clients (n = 18) and therapists (n = 4) completed self-report versions of both measures after every session (n = 198). In the other sample, clients (n = 39) and therapists (n = 6) completed the ARM, and observers subsequently rated selected audiotaped sessions (n = 78) using the WAI. In both samples, the ARMs core alliance scales (Bond, Partnership, and Confidence) were correlated with the WAIs scales (Bond, Tasks, and Goals) strongly when assessed within client and therapist perspectives and, with some qualifications, moderately when assessed between client, therapist, and observer perspectives, supporting the assumption that the ARM and the WAI measure some of the same core constructs.

Dose-Effect Relations for Psychotherapy of Mild Depression: A Quasi-Experimental Comparison of Effects of 2, 8, and 16 Sessions

Clients (N = 105) presenting with mild depression were assigned to receive 2, 8, or 16 sessions of psychotherapy in a quasi-experimental design involving 2 clinical trials. Rates of recovery were estimated as the proportion of each group achieving reliable and clinically significant change at the end of treatment (shortly after the prescribed dose had been administered) and at a follow-up assessment 2 to 3 months later. Results supported the hypothesis that recovery from interpersonal problems typically requires higher doses of psychotherapy than does recovery from symptoms of depression or broader distress.

Components of major depression examined via the Beck depression inventory

Although more than 20 factor analytic studies have been published on the Beck Depression Inventory (BDI), only Steer and co-workers (1987) have used a sample composed exclusively of patients diagnosed with depression. The component structure found in their study of depressed patients differs in important respects from the structure summarised in several reviews. The main aim of the present study was to investigate whether this structure could be confirmed with the BDI responses of an independent sample of 139 patients diagnosed with DSM-III Major Depressive Episode. Three principal components were extracted and rotated to maximum congruence with a target based on the results of Steer et al. (1987). The significance of the fit to this target was then evaluated by rotating the same matrix of loadings to 5000 random permutations of the target. The fit was found to be highly significant, though some possible improvements could be identified ad hoc. An alternative factor structure for the BDI, derived from covariance structure analysis by Tanaka and Huba (1984), was also tested but could not be confirmed.

Utility of the HoNOS in measuring change in a Community Mental Health Care population

Background: Given that, for many community health care teams, the HoNOS is the audit tool of choice, further work is needed to establish the viability of using this instrument to assess health change. Aims: To assess the usefulness of the HoNOS in measuring change in a population on the caseloads of community mental health teams. Method: Key workers or care co-ordinators of 195 selected patients on the caseloads of a national sample of 10 generic community mental health teams rated patients on the HoNOS four times over a period of 4 – 6 months. Patients had previously received a primary diagnosis of anxiety, depression, psychosis, personality disorder, or substance misuse on the Manchester Audit Tool. Results: In this population, the HoNOS marginally discriminated amongst diagnoses, and was associated with severity and complexity but not chronicity. Scores on the HoNOS changed differentially over time according to diagnosis and severity. Conclusion: A change of 3 to 4 points on the HoNOS is small, but statistically significant, and may be a useful basis for tracking the clinical improvement of neurotic patients, and the clinical stability of those with psychosis. Declaration of interest: This study was supported by a grant from the UK Department of Healths Policy Research Branch, Human Resources and Effectiveness Programme, to Michael West, Simon Garrod, and David Shapiro.

‘It's Like Catching a Desire Before it Flies Away’: A Comprehensive Process Analysis of a Problem Clarification Event in Cognitive-Behavioral Therapy for Depression

Comprehensive process analysis (CPA) was applied to a client-selected significant event from cognitive-behavioral therapy to show how the process of moving to the specific is effectively managed. A mirroring was shown between what the client articulated as the most helpful therapist advice and the defined steps of a cognitive-behavioral intervention relating to problem clarification to (a) state the problem, (b) plan movement from negative generalized statements with specific examples, and (c) model possible functional and dysfunctional thinking. Further analysis of the effects of the event showed the therapist developing these planned solutions through homework and in the following session through work on cognitions. The CPA analysis provided evidence at the session level for the effective use of the change principles of cognitive-behavioral therapy.