Samuel S. Nordberg

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

OBJECTIVE Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems. METHOD This 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. RESULTS Mixed 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. CONCLUSIONS Interpersonal and emotional processing techniques may not augment CBT for all GAD participants. Trial Registry name: Clinical Trials.gov, Identifier: NCT00951652.

Therapist effectiveness: implications for accountability and patient care.

Abstract Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of “effective” and “harmful” therapists, the outcomes of 6960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d=−0.91 to −1.49) while effective therapists demonstrated large, positive treatment effect sizes (d=1.00 to 1.52). Therapist domain-specific effectiveness correlated poorly across domains, suggesting that therapist competencies may be domain or disorder specific, rather than reflecting a core attribute or underlying therapeutic skill construct. Public policy and clinical implications of these findings are discussed, including the importance of integrating benchmarked outcome measurement into both routine care and training.

AN OPEN TRIAL OF INTEGRATIVE THERAPY FOR GENERALIZED ANXIETY DISORDER

Cognitive- behavioral therapy (CBT), although effective, has the lowest average effect size for generalized anxiety disorder (GAD), when compared to effect sizes of CBT for other anxiety disorders. Additional basic and applied research suggests that although interpersonal processes and emotional avoidance may be maintaining GAD symptomatology, CBT has not sufficiently addressed interpersonal issues or emotion avoidance. This study aimed to test the feasibility and preliminary efficacy of an integrative psychotherapy, combining CBT with techniques to address interpersonal problems and emotional avoidance. Eighteen participants received 14 sessions of CBT plus interpersonal emotional processing therapy and three participants (for training and feasibility purposes) received 14 sessions of CBT plus supportive listening. Results showed that the integrative therapy significantly decreased GAD symptomatology, with maintenance of gains up to 1 year following treatment. In addition, comparisons with extant literature suggested that the effect size for this new GAD treatment was higher than the average effect size of CBT for GAD. Results also showed clinically significant change in GAD symptomatology and interpersonal problems with continued gains during the 1-year follow-up. Implications of these results are discussed.

COMPETENCY IN INTEGRATIVE PSYCHOTHERAPY: PERSPECTIVES ON TRAINING AND SUPERVISION

Increasingly, many psychotherapists identify with an integrative approach to psychotherapy. In recent years, more attention has been directed toward the operationalization and evaluation of competence in professional psychology and health care service delivery. Aspects of integrative psychotherapy competency may differ from competency in other psychotherapy orientations, although convergence is more often the case. Despite the potential differences, there exist very few formal training programs or guidelines to systematically guide clinicians in developing a competent integrative practice. This paper attempts to distill the essential elements of competent integrative psychotherapy practice and focuses on how these might be developed in training and supervision. We address most of these complex issues from a specific integrative perspective: principle-based assimilative integration.

Validating the rapid responder construct within a practice research network.

OBJECTIVE The present study was a replication and extension of prior work (Stulz, Lutz, Leach, Lucock, & Barkham, ) that identified multiple groups of clients in treatment with high-symptom severity and markedly different recovery trajectories (rapid/early response vs. little or no response). METHOD Using data collected through repeated administrations of the Depression subscale of the Treatment Outcome Package (n = 147), growth mixture modeling was employed to determine whether clients fell into discrete groups of response trajectories during 15 sessions of psychotherapy. Additionally, logistic regressions were conducted to assess possible predictors of group membership. RESULTS Three separate groups of treatment responders were identified: 2 high-symptom groups-rapid responders and nonresponders-and 1 low-symptom group of nonresponders. Elevated social conflict and suicidality predicted increased likelihood of membership in the high-symptom nonresponder group. Increased feelings of interpersonal hostility and better sexual functioning predicted increased likelihood of membership in the rapid responder group. CONCLUSION Replication of earlier results provides further evidence for the usefulness of modeling change during psychotherapy using multiple trajectories. Predictors of group membership indicate the influence of functional impairment on recovery, and support the importance of multidimensional measurement of client problems.

This is what I need a clinical feedback system to do for me: A qualitative inquiry into therapists’ and patients’ perspectives

Abstract Routine outcome monitoring and clinical feedback systems (ROM/CFSs) are promising methods of providing naturalistic research data and enhancing mental health care. However, implementation in routine care is challenging, and we need more knowledge about clinicians’ and patients’ needs from such systems. Objective: We aimed to study perspectives of clinicians and patients to explore how ROM/CFS can be helpful and acceptable to them. Method: We interviewed 55 participants in focus groups and individual interviews and analyzed the data through rigorous team-based qualitative analyses. Results: We report 3 overarching domains: (a) Shared needs, (b) Specific patient needs, and (c) Specific therapist needs. Shared needs, in which perspectives of different stakeholders converge, was the dominant domain in the material. Under each domain, we report 3 specific themes: (a1) Degree of trust in therapy, (a2) Allowing for openness, (a3) Monitoring joint objectives; (b1) Life functioning, (b2) Canary in the coal mine, (b3) Holistic report; and (c1) Emotional presence and style, (c2) Monitoring risk and symptoms, and (c3) Agency and ownership of process. Conclusions: In what should increase our confidence toward core aspects of ROM, we suggest that an integration of relational feedback concepts and stringent clinical dimension tracking into the ROM/CFS can be beneficial.

Enhancing feedback for clinical use: Creating and evaluating profiles of clients seeking counseling.

The current study explored the reliability and clinical utility of a method designed to identify latent classes of students seeking counseling, based on 8 symptom domains and their interactions. Participants were over 50,000 college students in counseling, assessed with the CCAPS-62 and -34 as part of routine clinical care. Latent profile analysis was used to group an exploratory and confirmatory sample of students by reported symptoms across the 8 CCAPS subscales. Profiles were evaluated for reliability and clinical utility, in particular for risk assessment and the prediction of treatment duration and success. Nine reliably stable latent profiles, or groups of profiles, emerged from analysis. Profiles differed significantly in reported symptoms, demographic makeup, psychosocial history, and diagnoses. Additionally, profiles appeared to capture meaningful differences between clients that had implications for relative risk of suicide, self-harm, and violence toward others as well as significant differences in the number of sessions in treatment and the effect size of treatment. Latent profiles of patients appear to capture meaningful, stable differences that could be implemented in an automated system of evaluation and feedback, and that might be useful to clinicians, administrators, and researchers.

The Counseling Center Assessment of Psychological Symptoms Distress Index: A pragmatic exploration of general factors to enhance a multidimensional scale

Objective: The authors attempted to develop and validate a general distress index for a multidimensional psychological symptom/outcome measure used in over 300 college counseling centers with more than 100,000 cases annually: the Counseling Center Assessment of Psychological Symptoms (CCAPS). Method: Four models were compared for fit indices (n = 19,247): the existing first-order factor model (without a general factor), a second-order factor model, a bifactor model, and a single factor or “total score” model. In separate clinical and non-clinical samples, concurrent and divergent validity were examined using several well-established measures of psychological symptoms, as well as two-week test–retest and treatment utilization data. Results: Second-order and bifactor models which captured a single “distress” factor both exhibited good fit to the data relative to the baseline and “total score” model. Validity data indicated that factors adequately measured meaningful clinical onstructs. Conclusion: Both the bifactor and second-order models indicated the presence of a “distress index” comprised items across many of the CCAPS subscales. This distress scale has strong applicability for benchmarking the overall severity and complexity of patients at different centers, and can be used to help identify colleges and universities with areas of clinical strength, which can be studied to improve the field. Clinically, the distress index offers a parsimonious and efficient method for clinicians to monitor patients’ progress through treatment.