Kelly Koerner

A Component Analysis of Cognitive-Behavioral Treatment for Depression

The purpose of this study was to provide an experimental test of the theory of change put forth by A. T. Beck, A. J. Rush, B. F. Shaw, and G. Emery (1979) to explain the efficacy of cognitive-behavioral therapy (CT) for depression. The comparison involved randomly assigning 150 outpatients with major depression to a treatment focused exclusively on the behavioral activation (BA) component of CT, a treatment that included both BA and the teaching of skills to modify automatic thoughts (AT), but excluding the components of CT focused on core schema, or the full CT treatment. Four experienced cognitive therapists conducted all treatments. Despite excellent adherence to treatment protocols by the therapists, a clear bias favoring CT, and the competent performance of CT, there was no evidence that the complete treatment produced better outcomes, at either the termination of acute treatment or the 6-month follow-up, than either component treatment. Furthermore, both BA and AT treatments were just as effective as CT at altering negative thinking as well as dysfunctional attributional styles. Finally, attributional style was highly predictive of both short- and long-term outcomes in the BA condition, but not in the CT condition.

Testing the Integrity of a Psychotherapy Protocol: Assessment of Adherence and Competence.

Manipulation checks should be used in psychotherapy trials to confirm that therapists followed the treatment manuals and performed the therapy competently. This article is a review of some strategies that have been used to document treatment integrity; also, their limitations are discussed here. Recommendations for improving these checks are presented. Specific guidelines are offered regarding when and how to assess both therapist adherence to treatment protocols and competence.

RESEARCH ON DIALECTICAL BEHAVIOR THERAPY FOR PATIENTS WITH BORDERLINE PERSONALITY DISORDER

Research evidence to date indicates that, although DBT was developed for the treatment of patients with suicidal behavior, it can be adapted to treat BPD patients with comorbid substance-abuse disorder and be extended to other patient populations and the treatment of other disorders. Across studies, DBT seems to reduce severe dysfunctional behaviors that are targeted for intervention (e.g., parasuicide, substance abuse, and binge eating), enhance treatment retention, and reduce psychiatric hospitalization. Evidence suggests that additional research is warranted to examine which components of DBT contribute to outcomes. Although preliminary, skills coaching seems to be a crucial ingredient in producing reductions in parasuicidal behavior, and specific strategies (e.g., validation, balance of change, and acceptance interventions) may play an important role in positive behavioral change. Several investigators are evaluating the efficacy of DBT. For example, Asberg et al at the Karolinska Institute in Sweden have begun a pilot study comparing DBT for women who have made multiple suicide attempts to transference focus psychotherapy, a psychodynamic therapy developed by Kernberg. They have planned a randomized clinical trial to compare DBT and transference focus psychotherapy with TAU in the community. van den Bosch has completed a randomized clinical trial for women who met criteria for BPD and substance abuse comparing DBT-S with TAU. Lynch is conducting a randomized clinical trial examining the efficacy of DBT skills training plus medication versus medication only for the treatment of moderate to severe depression in the elderly. Results from these studies should become available over the next several years, providing further empiric evidence by which to evaluate the efficacy of DBT. Additional development of DBT seems warranted to improve its efficacy, and additional investigation is needed to establish its effectiveness in public health settings. Analyses from existing data sets of factors that predict treatment response and elements of the treatment that contribute to outcome are needed. Also, longitudinal follow-up studies to determine suicide rates and maintenance of treatment gains are needed. Because DBT has been adopted in a variety of clinical settings, effectiveness studies are needed. Given the difficulty of conducting treatment research with chronically suicidal individuals, perhaps the largest challenge to further treatment development is recruiting young investigators who are willing to conduct research in this area. Nevertheless, in the 6 years since the treatment manuals were published, DBT seems to be a step toward more effective treatment for severely multidisordered patients.

Enhancing the treatment and prevention of depression in women: The role of integrative behavioral couple therapy

In this article we discuss the implications of recent theoretical work from the Stone Center ( Jordan, Kaplan, Miller, Stiver, & Surrey 1991 ) and Jack (1991) for understanding the link between womens depression and marital distress. From this heuristic framework, we describe how recent improvements to traditional behavioral couple therapy represented in integrative behavioral couple therapy may enhance the treatment and prevention of womens depression.

User-Centered Design for Psychosocial Intervention Development and Implementation

The current paper articulates how common difficulties encountered when attempting to implement or scale-up evidence-based treatments are exacerbated by fundamental design problems, which may be addressed by a set of principles and methods drawn from the contemporary field of user-centered design. User-centered design is an approach to product development that grounds the process in information collected about the individuals and settings where products will ultimately be used. To demonstrate the utility of this perspective, we present four design concepts and methods: (a) clear identification of end users and their needs, (b) prototyping/rapid iteration, (c) simplifying existing intervention parameters/procedures, and (d) exploiting natural constraints. We conclude with a brief design-focused research agenda for the developers and implementers of evidence-based treatments.

Investigating Bang for Your Training Buck: A Randomized Controlled Trial Comparing Three Methods of Training Clinicians in Two Core Strategies of Dialectical Behavior Therapy ☆

The present study examined the efficacy of online training (OLT), instructor-led training (ILT), and a treatment manual (TM) in training mental health clinicians in two core strategies of Dialectical Behavior Therapy (DBT): chain analysis and validation. A randomized controlled trial compared OLT, ILT, and TM among clinicians naïve to DBT (N=172) who were assessed at baseline, post-training, and 30, 60, and 90 days following training. Primary outcomes included satisfaction, self-efficacy, motivation, knowledge, clinical proficiency, and clinical use. Overall, ILT outperformed OLT and TM in satisfaction, self-efficacy, and motivation, whereas OLT was the most effective method for increasing knowledge. The conditions did not differ in observer-rated clinical proficiency or self-reported clinical use, which both increased to moderate levels after training. In addition, ILT was particularly effective at improving motivation to use chain analysis, whereas OLT was particularly effective at increasing knowledge of validation strategies. These findings suggest that these types of brief, didactic trainings may be effective methods of increasing knowledge of new treatment strategies, but may not be sufficient to enable clinicians to achieve a high level of clinical use or proficiency. Additional research examining the possible advantages of matching training methods to types of treatment strategies may help to determine a tailored, more effective approach to training clinicians in empirically supported treatments.

Persuasion criteria in research and practice: Gathering more meaningful psychotherapy data

Psychotherapy research should ultimately benefit the psychotherapy client. Unfortunately, traditional psychotherapy research continues to have little influence on practicing clinicians and, therefore, does not benefit psychotherapy clients. As behavior analysts begin to show interest in this area of research, they may be in a position to improve its quality. We argue that traditional psychotherapy researchers have become prematurely wedded to a methodology that does not address the concerns of clinical audiences. Furthermore, we make a case for defining and evaluating psychotherapy data in terms of its capacity to influence both researchers and clinicians. We also suggest several alternative methods for gathering psychotherapy data based on the case formulation approach. We argue that this approach may be one of the most promising methods for gathering useful psychotherapy data.

Cognitive and interpersonal factors in borderline personality disorder

Three findings emerged from the past year on cognitive and interpersonal factors associated with borderline personality disorder.Social perceptions and perhaps self-criticism distinguish depression of patients with borderline personality disorder from those with affective disorders without borderline personality disorder. Patients with borderline personality disorder report more ongoing childhood sexual abuse involving multiple perpetrators and penetration. Dialectical behavior therapy produced modest improvement in interpersonal functioning of women with borderline personality disorder.