Mary Beth Connolly Gibbons

EARLY WITHDRAWAL FROM MENTAL HEALTH TREATMENT: IMPLICATIONS FOR PSYCHOTHERAPY PRACTICE

Despite more than 50 years of research on client attrition from therapy, obstacles to the delivery and success of treatments remain poorly understood, and effective methods to engage and retain clients in therapy are lacking. This article offers a review of the literature on attrition, highlighting the methodological challenges in effectively addressing the complex nature of this problem. Current interventions for reducing attrition are reviewed, and recommendations for implementing these interventions into psychotherapy practice are discussed.

Unique and Common Mechanisms of Change across Cognitive and Dynamic Psychotherapies.

The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy.

The dependability of alliance assessments: The alliance–outcome correlation is larger than you might think.

OBJECTIVE To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance-outcome relationship. METHOD We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used. RESULTS At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3-9 explained 14.7% of outcome variance. CONCLUSION Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance-outcome relationship.

DOES THE ALLIANCE CAUSE GOOD OUTCOME? RECOMMENDATIONS FOR FUTURE RESEARCH ON THE ALLIANCE

Research has consistently documented that the quality of the therapeutic alliance is related to the outcome of diverse psychotherapies. Insufficient attention, however, has been directed at identifying the nature and magnitude of the causal relationship between the alliance and outcome. In this commentary, we discuss the major threats to causal interpretation of alliance-outcome correlations and provide suggestions for future research that would help clarify the extent to which the alliance causes positive outcomes. Assuming the alliance is a causal factor in relation to outcome, we provide recommendations for research on the alliance that would attempt to improve patient care by enhancing the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Mediators of Outcome of Psychosocial Treatments for Cocaine Dependence

This study examined endorsement of 12-step philosophy and engagement in recommended 12-step activities as a mediator of the outcomes of individual plus group counseling for cocaine dependence. Assessments of drug use outcomes and the mediator were made at baseline and monthly for 6 months. Engagement in recommended 12-step activities was found to be a partial statistical mediator of drug use outcomes of individual (plus group) drug counseling, but no evidence for change in the mediator preceding change in drug use was found. In addition, a measure of beliefs about addiction developed to test mediation of outcome of cognitive therapy was found to correlate moderately with drug use outcomes in both cognitive therapy and individual drug counseling.

Dopamine transporter levels in cocaine dependent subjects

Cocaine use is a significant problem in the US and it is well established that cocaine binds to the dopamine transporter (DAT) in the brain. This study was designed to determine if the DAT levels measured by 99mTc TRODAT SPECT (single photon emission computed tomography) brain scans are altered in cocaine dependent subjects and to explore clinical correlates of such alterations. SPECT brain scans were acquired on 21 cocaine dependent subjects and 21 healthy matched controls. There were significantly higher DAT levels in cocaine dependent subjects compared to controls for the anterior putamen (p=0.003; Cohens d effect size=0.98), posterior putamen (p<0.001; effect size=1.32), and caudate (p=0.003; effect size=0.97). DAT levels in these regions were 10%, 17%, and 8% higher in the cocaine dependent subjects compared to controls. DAT levels were unrelated to craving, severity of cocaine use, or duration of cocaine use, but DAT levels in the caudate and anterior putamen were significantly (p<0.05) negatively correlated with days since last use of cocaine.

Comparative Effectiveness of Cognitive Therapy and Dynamic Psychotherapy for Major Depressive Disorder in a Community Mental Health Setting: A Randomized Clinical Noninferiority Trial

IMPORTANCE Dynamic psychotherapy (DT) is widely practiced in the community, but few trials have established its effectiveness for specific mental health disorders relative to control conditions or other evidence-based psychotherapies. OBJECTIVE To determine whether DT is not inferior to cognitive therapy (CT) in the treatment of major depressive disorder (MDD) in a community mental health setting. DESIGN, SETTING, AND PARTICIPANTS From October 28, 2010, to July 2, 2014, outpatients with MDD were randomized to treatment delivered by trained therapists. Twenty therapists employed at a community mental health center in Pennsylvania were trained by experts in CT or DT. A total of 237 adult outpatients with MDD seeking services at this site were randomized to 16 sessions of DT or CT delivered across 5 months. Final assessment was completed on December 9, 2014, and data were analyzed from December 10, 2014, to January 14, 2016. INTERVENTIONS Short-term DT or CT. MAIN OUTCOMES AND MEASURES Expert blind evaluations with the 17-item Hamilton Rating Scale for Depression. RESULTS Among the 237 patients (59 men [24.9%]; 178 women [75.1%]; mean [SD] age, 36.2 [12.1] years) treated by 20 therapists (19 women and 1 man; mean [SD] age, 40.0 [14.6] years), 118 were randomized to DT and 119 to CT. A mean (SD) difference between treatments was found in the change on the Hamilton Rating Scale for Depression of 0.86 (7.73) scale points (95% CI, -0.70 to 2.42; Cohen d, 0.11), indicating that DT was statistically not inferior to CT. A statistically significant main effect was found for time (F1,198 = 75.92; P = .001). No statistically significant differences were found between treatments on patient ratings of treatment credibility. Dynamic psychotherapy and CT were discriminated from each other on competence in supportive techniques (t120 = 2.48; P = .02), competence in expressive techniques (t120 = 4.78; P = .001), adherence to CT techniques (t115 = -7.07; P = .001), and competence in CT (t115 = -7.07; P = .001). CONCLUSIONS AND RELEVANCE This study suggests that DT is not inferior to CT on change in depression for the treatment of MDD in a community mental health setting. The 95% CI suggests that the effects of DT are equivalent to those of CT. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01207271.

Supportive-Expressive Dynamic Psychotherapy in the Community Mental Health System: A Pilot Effectiveness Trial for the Treatment of Depression

The goal of the current article is to present the results of a randomized pilot investigation of a brief dynamic psychotherapy compared with treatment-as-usual (TAU) in the treatment of moderate-to-severe depression in the community mental health system. Forty patients seeking services for moderate-to-severe depression in the community mental health system were randomized to 12 weeks of psychotherapy, with either a community therapist trained in brief dynamic psychotherapy or a TAU therapist. Results indicated that blind judges could discriminate the dynamic sessions from the TAU sessions on adherence to dynamic interventions. The results indicate moderate-to-large effect sizes in favor of the dynamic psychotherapy over the TAU therapy in the treatment of depression. The Behavior and Symptom Identification Scale-24 showed that 50% of patients treated with dynamic therapy moved into a normative range compared with only 29% of patients treated with TAU.

Combined medication and cognitive therapy for generalized anxiety disorder

The current study assessed efficacy of combined cognitive behavioral therapy (CBT) and venlafaxine XR compared to venlafaxine XR alone in the treatment of generalized anxiety disorder (GAD) within settings where medication is typically offered as the treatment for this disorder. Patients with DSM-IV-diagnosed GAD who were recently enrolled in a long-term venlafaxine XR study were randomly offered (n=77), or not offered (n=40), the option of adding 12 sessions of CBT. Of those offered CBT, 33% (n=26) accepted and attended at least one treatment session. There were no differences between the combined treatment group and the medication only group on primary or secondary efficacy measures in any of the sample comparisons. Many patients who present in medical/psychopharmacology settings seeking treatment for GAD decline the opportunity to receive adjunctive treatment. Of those that receive CBT, there appears to be no additional benefit of combined treatment compared to venlafaxine XR alone.

Changes in Psychotherapy Utilization Among Consumers of Services for Major Depressive Disorder in the Community Mental Health System

The goal of this investigation was to explore changes in psychotherapy utilization for patients with major depressive disorder (MDD) treated in community mental health agencies across two cohorts. We used a Medicaid claims database including approximately 300,000 public sector clients. Although the use of psychotherapy alone showed a small decrease, there was a large increase in the use of combined medication and psychotherapy as a treatment for MDD. Race was a significant predictor of both treatment type received and length of treatment. African American consumers were more likely to receive psychotherapy alone than combined treatment and attended significantly fewer psychotherapy sessions.