James F. Boswell

A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies.

OBJECTIVEnRecent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems.nnnMETHODnThis is the first randomized controlled trial to test directly whether cognitive-behavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age = 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n = 40) or to CBT plus interpersonal and emotional processing therapy (n = 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990; Hamilton Anxiety Rating Scale; M. Hamilton, 1959; assessor severity rating; State-Trait Anxiety Inventory-Trait Version; C. D. Spielberger, R. L. Gorsuch, R. Lushene, P. R. Vagg, & G. A. Jacobs, 1983) as well as with indices of clinically significant change.nnnRESULTSnMixed models analysis of all randomized participants showed very large within-treatment effect sizes for both treatments (CI = [-.40, -.28], d = 1.86) with no significant differences at post (CI = [-.09, .07], d = .07) or 2-year follow-up (CI = [-.01, .01]), d = .12). There was also no statistical difference between compared treatments on clinically significant change based on chi-square analysis.nnnCONCLUSIONSnInterpersonal and emotional processing techniques may not augment CBT for all GAD participants. Trial Registry name: Clinical Trials.gov, Identifier: NCT00951652.

Enhancing the Personalization of Psychotherapy With Dynamic Assessment and Modeling

Clinicians have long recognized the importance of tailoring psychotherapy interventions to the needs and characteristics of the individual patient. However, traditional approaches to clinical assessment, service delivery, and intervention research have not been conducive to such personalization. Contrary to traditional nomothetic approaches, idiographic assessment and modeling of intraindividual dynamic processes holds tremendous promise for tailoring the implementation of psychotherapy to the individual patient. In this article, we (a) present an argument for assessing person-specific dynamics, (b) provide a detailed description of a method that harnesses person-specific dynamic assessment and modeling for use in routine psychotherapy, (c) present exemplar clinical cases illustrating these methods, and (d) discuss how these methods can be translated into routine clinical assessment and psychotherapy.

Mindfulness-Based Exposure Strategies as a Transdiagnostic Mechanism of Change: An Exploratory Alternating Treatment Design☆

The present study explored whether distress reduction in response to strong negative emotions, a putative transdiagnostic mechanism of action, is facilitated by mindfulness strategies. Seven patients (mean age=31.14years, SD=12.28, range 19-48 years, 43% female, 86% Caucasian) with heterogeneous anxiety disorders (i.e., panic disorder with or without agoraphobia, social anxiety, generalized anxiety) were assigned a randomized order of weeklong blocks utilizing either mindfulness- or avoidance-based strategies while ascending a 6-week emotion exposure hierarchy. Participants completed three exposures per block and provided distress and avoidance use ratings following each exposure. Anxiety severity, distress aversion, and distraction/suppression tendencies were also assessed at baseline and the conclusion of each block. Visual, descriptive, and effect size results showing exposures utilizing mindfulness were associated with higher overall distress levels, compared with those utilizing avoidance. Within blocks, the majority of participants exhibited declining distress levels when employing mindfulness strategies, as opposed to more static distress levels in the avoidance condition. Systematic changes in anxiety severity, distress aversion, and distraction/suppression were not observed. These results suggest mindfulness strategies may be effective in facilitating emotion exposure; however, a minimum dosage may be necessary to overcome initial distress elevation. Potential transdiagnostic change mechanisms and clinical implications are discussed.

The Expanding Relevance of Routinely Collected Outcome Data for Mental Health Care Decision Making

AbstractnEvidence shows that routine outcome monitoring (ROM) and feedback using standardized measurement tools enhances the outcomes of individual patients. When outcome data from a large number of patients and clinicians are collected, patterns can be tracked and comparisons can be made at multiple levels. Variability in skills and outcomes among clinicians and service settings has been documented, and the relevance of ROM for decision making is rapidly expanding alongside the transforming health care landscape. In this article, we highlight several developing core implications of ROM for mental health care, and frame points of future work and discussion.

Evidence‐based implementation practices applied to the intensive treatment of eating disorders: Summary of research and illustration of principles using a case example

Correspondence Heather Thompson-Brenner, Boston University, Cambridge, MA, USA. Email: heatherthompsonbrenner@ gmail.com Implementation of evidence-based practices (EBPs) in intensive treatment settings poses a major challenge in the field of psychology. This is particularly true for eating disorder (ED) treatment, where multidisciplinary care is provided to a severe and complex patient population; almost no data exist concerning best practices in these settings. We summarize the research on EBP implementation science organized by existing frameworks and illustrate how these practices may be applied using a case example. We describe the recent successful implementation of EBPs in a community-based intensive ED treatment network, which recently adapted and implemented transdiagnostic, empirically supported treatment for emotional disorders across its system of residential and day-hospital programs. The research summary, implementation frameworks, and case example may inform future efforts to implement evidence-based practice in intensive treatment settings.

Implementation of transdiagnostic treatment for emotional disorders in residential eating disorder programs: A preliminary pre-post evaluation

Abstract Objective: Data are lacking from empirically supported therapies implemented in residential programs for eating disorders (EDs). Common elements treatments may be well-suited to address the complex implementation and treatment challenges that characterize these settings. This study assessed the preliminary effect of implementing a common elements therapy on clinician treatment delivery and patient (Nu2009=u2009616) symptom outcomes in two residential ED programs. Method: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders was adapted to address ED and co-occurring psychopathology and implemented across sites. Therapists’ treatment fidelity was rated independently to assess implementation success. Additionally, longitudinal (pre-post) design compared treatment outcomes among patients treated before and after implementation. Patient outcomes included ED and depressive symptoms, experiential avoidance, anxiety sensitivity, and mindfulness. Results: Following training and implementation, clinicians demonstrated adequate to good fidelity. Relative to pre-implementation, post-implementation patients showed significantly greater improvements in experiential avoidance, anxiety sensitivity, and mindfulness at discharge (psu2009≤u2009.04) Relative to patients who were treated during the pre-implementation phase, patients in the post-implementation phase experienced more favorable outcomes on ED symptom severity, depression, mindfulness, and anxiety sensitivity at 6-month-follow-up (ps ≤ .001). A similar result was observed for experiential avoidance, yet this interaction effect was no longer statistically significant (p = .10) when the time x length of stay effect/covariate was added to the model. Conclusions: Preliminary pilot data support the feasibility of implementing transdiagnostic common elements therapy in residential ED treatment, and suggest that implementation may benefit transdiagnostic outcomes for patients. Clinical or methodological significance of this article: Limited data are available to guide evidence-based residential treatment for eating disorders. This study represents a unique effort to adapt, implement, and test an evidence-based therapy protocol across a large private network of intensive eating disorder treatment programs.

Mental health care consumers’ relative valuing of clinician performance information.

Background: Research demonstrates significant variability in mental health clinicians’ overall and domain-specific effectiveness with their patients. Despite calls to increase patient access to performance information, little is known about patients’ relative valuing of this information in the context of other treatment factors. Objective: We aimed to obtain an understanding of patients’ relative valuing of provider performance track records and other therapist and treatment characteristics for their mental health care decision making. Method: Participants were 403 (Mage = 41.20; 66.5% female) community mental health patients who completed a multicomponent survey that included an adapted delayed-discounting paradigm to examine the relative valuing. Multiple descriptive, quantitative indices of relative valuing were calculated, as well as an exploratory latent profile analysis to ascertain the presence of homogenous relative-valuing subgroups. Results: Overall, participants valued provider track record information. They also evidenced relatively higher preference values for working with therapists who had specific efficacy in treating their primary problem domain, charged less, and with whom there is a high likelihood of establishing a good alliance. Two latent profiles were identified: one representing higher valuing of provider performance and another consistently representing less emphasis. Participants with higher track-record valuing were younger, believed that therapists are not interchangeable, and endorsed trust in the collection and use of performance information. Conclusion: Harnessing clinician information to make more personalized and informed treatment decisions could potentially promote better treatment engagement, retention, and outcomes.

Behavioral activation strategies for major depression in transdiagnostic cognitive-behavioral therapy: An evidence-based case study.

Behavioral activation (BA) is a treatment approach that uses functional analysis and context-dependent strategies to enhance environmental positive reinforcement for adaptive, healthy behavior, and decrease behavioral avoidance. BA has gained considerable support for the treatment of depression and can be broadly applied across a wide range of settings and clinical populations. In this article, we provide a brief description of BA as a therapeutic behavioral strategy for depression and present a clinical case example illustrating the integration of BA with other components of a transdiagnostic cognitive–behavioral treatment for emotional disorders. Implications for clinical practice and avenues for future research will be discussed.

Interpersonal pathoplasticity and trajectories of change in routine adolescent and young adult residential substance abuse treatment.

Background: Partnerships between mental health care stakeholders provide a context for generalizable clinical research with implications for quality improvement. In the context of a partnership between an adolescent residential substance abuse disorder (SUD) treatment center and clinical researchers, stakeholders identified knowledge gaps (internal and the field broadly) with regard to patient interpersonal factors that influence working alliance and acute SUD residential treatment outcome trajectories. Objective: To (a) examine interpersonal pathoplasticity and identify interpersonal subtypes in a naturalistic sample of adolescent and young-adult patients presenting for routine residential SUD treatment and (b) investigate the association between identified interpersonal subtypes and working alliance and acute treatment outcome trajectories. Method: N = 100 patients (Mage = 17.39 years, 68% male, 84% White) completed self-reports of symptom and functioning outcomes, interpersonal problems, and the working alliance on multiple occasions between admission and discharge. Multiple methods were used to identify interpersonal subtypes and test pathoplasticity. Interpersonal subtype was entered as a predictor in respective multilevel models of working alliance and symptom outcome. Results: Interpersonal subtypes of vindictive and exploitable patients demonstrated pathoplasticity. Subtype did not predict working alliance trajectories; however, a significant interaction between interpersonal subtype and a quadratic effect for time demonstrated that exploitable patients with longer than average treatment lengths experienced attenuated symptom change over the course of treatment whereas vindictive patients appeared to demonstrate steady progress. Conclusions: Interpersonal assessments should be integrated into residential SUD treatment to identify patients with an exploitable interpersonal style who might require additional attention or alternative interventions.

La intersección de la implementación de la psicoterapia basada en la evidencia y la investigación orientada por la práctica

espanolLos programas residenciales y otros programas de tratamiento intensivo para los trastornos alimentarios (TAs) por lo general no utilizan intervenciones basadas en evidencia coordinadas a traves de elementos de tratamiento multimodal. Ademas, existe una necesidad apremiante de aprender mas acerca de los procesos y resultados efectivos (e ineficaces) de implementacion de la intervencion basada en la evidencia en las organizaciones prestadoras de servicios. Este estudio de casos de investigacion orientada por la practica (POR, por sus siglas en ingles) describe la implementacion de la psicoterapia basada en evidencia para TAs graves y trastornos emocionales co-ocurrentes a traves de una red de programas residenciales, de hospital de dia y de tratamiento intensivo para pacientes ambulatorios. Con base en los aportes de los participantes, la recopilacion de datos se ha incorporado durante todo el proceso de implementacion, abarcando las actitudes de los practicantes clinicos, la adherencia y competencia del facilitador del grupo y los resultados de los pacientes. Este articulo rastrea la historia de esta implementacion y el esfuerzo de la POR a traves de multiples fases, al tiempo que integra la teoria y la investigacion de la ciencia de implementacion, asi como los datos recopilados rutinariamente como resultado de este esfuerzo. Finalmente, las lecciones de este estudio de caso en curso pueden informar futuros esfuerzos (tanto internos como externos a este contexto especifico) para implementar estrategias basadas en la evidencia en dispositivos residenciales / intensivos ambulatorios. EnglishResidential and other intensive treatment programs for eating disorders (EDs) do not commonly utilize evidence-based interventions coordinated across multi-modal treatment elements. In addition, there is a pressing need to learn more about effective (and ineffective) evidence-based intervention implementation processes and outcomes in service delivery organizations. This ongoing diverse mental health care stakeholder practice-oriented research (POR) “case study” describes the implementation of evidence-based psychotherapy for severe EDs and co-occurring emotional disorders across a network of residential, day hospital, and intensive outpatient treatment programs. Based on stakeholder input, data collection has been embedded throughout the implementation process, spanning clinician-trainee attitudes, group facilitator adherence and competence, and patient outcomes. This paper traces the history of this implementation and POR effort across multiple phases, while integrating theory and research from implementation science, as well as routinely collected data from this effort. Finally, lessons from this ongoing case study may inform future efforts (both internal and external to this specific context) to implement evidence-based strategies in residential/ intensive outpatient settings.