Sunil Bhar

Is longer-term psychodynamic psychotherapy more effective than shorter-term therapies? Review and critique of the evidence.

Background: In 2008, Leichsenring and Rabung performed a meta-analysis of 8 studies of longer-term psychodynamic psychotherapy (LTPP). The work was published in the Journal of the American Medical Association (vol. 300, pp 1551–1565), and they concluded that LTPP was more effective than shorter-term therapies. Method: Given that such claims have the potential to influence treatment decisions and policies, we re-examined the meta-analysis and the 8 studies. Results: We found a miscalculation of the effect sizes used to make key comparisons. Claims for the effectiveness of LTPP depended on a set of small, underpowered studies that were highly heterogeneous in terms of patients treated, interventions, comparison-control groups, and outcomes. LTPP was compared to 12 types of comparison-controls, including control groups that did not involve any psychotherapy, short-term psychodynamic psychotherapy, and unvalidated treatments. Additionally, the studies failed to protect against threats to bias, and had poor internal validity. Conclusion: Overall, we found no evidence to support claims of superiority of LTPP over shorter-term methods of psychotherapy.

Changes in problem-solving appraisal after cognitive therapy for the prevention of suicide

BACKGROUND Cognitive therapy has been found to be effective in decreasing the recurrence of suicide attempts. A theoretical aim of cognitive therapy is to improve problem-solving skills so that suicide no longer remains the only available option. This study examined the differential rate of change in problem-solving appraisal following suicide attempts among individuals who participated in a randomized controlled trial for the prevention of suicide. METHOD Changes in problem-solving appraisal from pre- to 6-months post-treatment in individuals with a recent suicide attempt, randomized to either cognitive therapy (n = 60) or a control condition (n = 60), were assessed by using the Social Problem-Solving Inventory-Revised, Short Form. RESULTS Improvements in problem-solving appraisal were similarly observed for both groups within the 6-month follow-up. However, during this period, individuals assigned to the cognitive therapy condition demonstrated a significantly faster rate of improvement in negative problem orientation and impulsivity/carelessness. More specifically, individuals receiving cognitive therapy were significantly less likely to report a negative view toward life problems and impulsive/carelessness problem-solving style. CONCLUSIONS Cognitive therapy for the prevention of suicide provides rapid changes within 6 months on negative problem orientation and impulsivity/carelessness problem-solving style. Given that individuals are at the greatest risk for suicide within 6 months of their last suicide attempt, the current study demonstrates that a brief cognitive intervention produces a rapid rate of improvement in two important domains of problem-solving appraisal during this sensitive period.

Beliefs and personality disorders: an overview of the personality beliefs questionnaire

OBJECTIVE This article presents an overview of the Personality Beliefs Questionnaire (PBQ)--a 126-item self-report measure of beliefs associated with 10 personality disorders. DESIGN It consolidates the literature on the PBQ over the last 20 years to provide a summary of the psychometric status, revisions and applications of the PBQ scales. RESULTS The PBQ scales are psychometrically reliable (α = 77-94, test-retest stability r=.57-.93) and discriminate between individuals with and without a specific personality disorder. Two revisions have been made to the measure: A 14-item subscale measuring beliefs central to borderline personality disorder has been identified, and a short form version of the PBQ has been validated. The PBQ has been used to measure cognitive mechanisms of treatment outcomes, and has been found to be sensitive to changes in beliefs. CONCLUSIONS Given the proposed shift in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) to a dimensional conceptualization of psychological components of personality dysfunction, the PBQ is likely to remain relevant and useful for identifying such components in individuals with personality disorders.

ASSOCIATIONS BETWEEN OBSESSIVE-COMPULSIVE PHENOMENA, AFFECT AND BELIEFS: CROSS-CULTURAL COMPARISONS OF AUSTRALIAN AND ITALIAN DATA

Consistent with cognitive-behavioural formulations of Obsessive-Compulsive Disorder (OCD), recent research has supported the association between obsessive-compulsive phenomena, specific dysfunctional beliefs and negative affective states. However, such research has not been conducted across sufficiently different cultural contexts using the same measures in comparable samples. In the present study, university psychology students from Australia and Italy completed questionnaire measures of obsessive-compulsive phenomena, inflated responsibility, perfectionism, guilt, depression, and anxiety. Australian and Italian cultures can be seen to differ in a number of ways that could impact on the pattern of expected interrelations between these measures. Similarities in the factor structure and psychometric properties of the measures were apparent across the two cultural contexts, suggesting the appropriateness of cross-cultural comparisons in the pattern of intercorrelations. Significant interrelations were found between the measure of obsessive-compulsive phenomena, dysfunctional beliefs and negative affect in both cultural contexts. While there were some differences in the specific patterns of interrelations, these were few in number and, generally, could be explained by sociocultural factors or stereotypes, although the overall pattern of intercorrelations was stronger for the Australian cohort. The results suggest that cognitive-behavioural formulations of OCD can be generalized across these two different cultural contexts, although idiosyncratic cultural factors may need to be considered in developing cognitive-behavioural treatments.

We Do Not See Things as They Are, We See Them as We Are: A Multidimensional Worldview Model of Obsessive- Compulsive Disorder

Cognitive-behavioral models of obsessive-compulsive disorder (OCD) assign a central role to specific beliefs and coping strategies in the development, maintenance and exacerbation of obsessive-compulsive (OC) symptoms. These models also implicate perceptions of self and the world in the development and maintenance of OC phenomena (e.g., overestimation of threat, sociotropy, ambivalent or sensitive sense of self, looming vulnerability), although such self and world domains have not always been emphasized in recent research. Following recent recommendations (Doron & Kyrios, 2005), the present study undertook a multifaceted investigation of self and world perceptions in a nonclinical sample, using a coherent worldview framework (Janoff-Bulman, 1989, 1991). Beliefs regarding the self and the world were found to predict OC symptom severity over and above beliefs outlined in traditional cognitive-behavioral models of OCD. Self and world beliefs were also related to other OC-relevant beliefs. Implications of these findings for theory and treatment of OCD are discussed.

Back to basics: could behavioural therapy be a good treatment option for youth depression? A critical review

Recent findings from systematic reviews and primary research studies have shown more modest effects of cognitive behavioural therapy (CBT) for youth depression than previously shown, highlighting the need to further enhance the effectiveness of this intervention, or components of this intervention. Therefore, the aim of this review is to summarize the work that has been done to identify the different components of CBT and their varying effectiveness for young people with depression.

Introduction of a university-based counselling service for older adults

Despite the growing number of older adults in Australia, many do not access counselling, partly because of the lack of trained mental health professionals for older people. This paper describes an innovative solution for providing counselling services to older adults, and geropsychology training to postgraduate psychology students.

Befriending to Relieve Anxiety and Depression Associated with Chronic Obstructive Pulmonary Disease (COPD): A Case Report

ABSTRACT Chronic obstructive pulmonary disease (COPD) is a chronic lung disease characterized by airflow obstruction and shortness of breath, which as a result can severely limit activities of daily living. COPD sufferers are 85% more likely to develop anxiety disorders than healthy matched controls. Some of the factors that have been suggested to be associated with high anxiety in people with COPD include dyspnoea, the inability to perform daily activities or fulfil social roles, rehospitalisation and some COPD treatments. There is substantial evidence that cognitive behaviour therapy (CBT) is effective in managing mood disorders, but there is also some evidence that befriending can assist people. Befriending is an intervention that focuses on everyday conversation topics and can be delivered by volunteers with training and supervision. The case presented here illustrates the use of befriending provided over the phone for a participant with severe anxiety and depression. It was part of a larger RCT comparing CBT and befriending for the management of anxiety and depression in people with COPD. Symptoms were alleviated after a course of 8 weeks of befriending telephone calls from a volunteer. While befriending is not a substitute for CBT it may be useful in circumstances where CBT is not easily accessible.

Missed Opportunity to Rectify or Withdraw a Flawed Metaanalysis of Longer-Term Psychodynamic Psychotherapy

as they described in their letter, merely ‘suboptimal’ or ‘ambiguous’, but wildly inaccurate. We provided a power analysis of the individual randomized trials entered into their metaanalysis, appropriately calculated not on the basis of the overall sample size, but on the smaller of the intervention or comparison groups. None of the smaller groups had over 30 patients, 1 had only 10. Perhaps we should have been clearer on the implications: if LTPP indeed had a moderate effect, none of these studies had an over 50% chance of detecting it, and 1 had a less than 25% chance of detecting it. Thus, even if all of the studies tested a moderately effective form of LTPP, most should not have obtained a significant effect. That most had significant findings attests to the likelihood of publication bias. Leichsenring and Rabung claimed to have ruled out publication bias, a pervasive problem in the psychosocial intervention [5] and medical [6] literatures. They entered their miscalculated effect sizes into calculation of a failsafe-N estimate, i.e. how many studies with null results would have to be left unpublished to unseat their conclusion concerning the superiority of LTPP to shorter-term therapies. Many sources including the authoritative Cochrane Handbook [7] recommend against acceptance of the failsafe-N. Nonetheless, here as elsewhere, Leichsenring and Rabung and prepublication reviewers should have been alerted by the implausible estimate that 921 null studies had to be reclaimed from file drawers in order to unseat claims based on 8 modestsized randomized trials and 23 observational studies. Leichsenring and Rabung used summary Jadad [8] scores to rate the quality of studies entered into their metaanalysis. Yet, the Jadad checklist was developed to rate the quality in which a study is reported, not the likelihood that study results are free of bias. Moreover, summary scale scores have been empirically shown to lack validity [9] . We used Cochrane Collaboration guidelines to rate the studies and found that they lacked internal validity and the usual safeguards against bias expected of quality evidence. For instance, only 1 of 8 studies met the important criterion of being low in bias toward completeness of outcome data. Such flaws can prove particularly decisive in studies with small sample sizes, serving to undo the benefits of the study being randomized. Leichsenring and Rabung are correct that we did not consider the quality of the 23 observational studies included in their larger metaanalysis. But if we had, the quality ratings would have been even lower. Some of the observational studies lost substantial numbers of patients to follow-up [10] , with results for the final sample not being generalizable to the initial sample. It is naïve to assume that combining such similarly small and flawed studies into a metaanalysis can produce meaningful conclusions [11] . Leichsenring and Rabung included studies in their metaanalysis that were clinically heterogeneous in terms of comparison treatments and patient populations. They claimed to have demonstrated the appropriateness of combining these studies by showing a lack of statistical heterogeneity using the Q statistic. We eagerly anticipated the response by Leichsenring and Rabung to our sweeping critique [1] of their 2008 metaanalysis [2] in which they claimed longer-term psychodynamic psychotherapy (LTPP) was more effective than shorter-term psychotherapies. Yet, we were disappointed that Leichsenring and Rabung [3] , like Ehrenthal and Grande [4] , dealt with so little of the specifics of our critique. Much of the substance of the response by Leichsenring and Rabung refers to an unfinished manuscript and another, still undergoing review in some unnamed journal, limiting the opportunity for independent evaluation by anyone open-minded but skeptical about each of our perspectives. The crux of our critique was statistical and technical because it is in these areas that serious flaws in their metaanalysis initially occurred, undermining any of their substantive interpretations. Perhaps our readers were as confused as Leichsenring and Rabung seemingly were, and thus we will use the 1,000 words allotted to us to briefly summarize our critique in substantive terms. A basic criticism was that Leichsenring and Rabung consistently miscalculated summary effect sizes in a way that was grossly inflationary and favorable to LTPP. We find no basis for such an approach in the extensive literature of metaanalyses. We generated a hypothetical set of 10 studies in which there were only trivial differences in effect sizes for intervention and comparison groups. Using the computational method by Leichsenring and Rabung, we nonetheless generated a large summary effect size favoring the intervention that would have been unprecedented in the psychotherapy literature. Apparently neither Leichsenring and Rabung nor prepublication reviewers of their paper noticed that the summary effect sizes Leichsenring and Rabung claimed for LTPP were greater than any of the effect sizes for individual studies. Moreover, they claimed one implausible between-group effect size of 6.9, equivalent to 93% of the variance explained, for a set of studies in which none reported an effect size of more than approximately 2. Such figures should have aroused suspicion: their estimates were not, Received: June 21, 2010 Accepted: June 21, 2010 Published online: November 18, 2010

Brief on the role of psychologists in residential and home care services for older adults

Objective This brief examines the evidence that is currently available to inform the provision of psychological services within aged care services, considering both residential care and home care settings. Method A narrative literature review of the literature evaluating psychological approaches for common conditions in aged care settings was conducted, focusing on the assessment and treatment of common mental health disorders and dementia. Information on the current employment and training of Australian psychologists in geropsychology was also summarised. Results While further research is required, existing literature provides a clear rationale for the benefit of psychological approaches to address a range of conditions, including the management of dementia. There is only limited research focusing specifically on the home care setting, despite the increasing number of older adults who receive aged care services in their own homes. The current provision of psychological services in Australia is critically low, driven in part by funding limitations. Meanwhile, substantial gaps remain in the training provided to provisional psychologists. Conclusion A number of key recommendations are made to address the growing need for age‐specific psychological assessments and interventions to be included as part of the delivery of aged care services in this country. Given the continued high prevalence of mental health disorders and dementia within aged care settings, as well as even higher rates of subthreshold conditions, improved access to psychological services for older Australians must become a priority.