Tracey L. Smith

Examining the conceptual model of integrative cognitive-affective therapy for BN: Two assessment studies.

OBJECTIVE Two studies sought to examine predictions of the Integrative Cognitive-Affective Therapy (ICAT) model, which views bulimic symptoms in terms of inter-relations between self-concept discrepancies, negative affect, and self-directed coping styles. The present results examine assessment-related predictions of this model. METHOD Individuals with bulimic symptoms were compared to noneating disorder control participants in two studies involving central constructs of the ICAT model. RESULTS In both studies, bulimic individuals displayed higher levels of self-discrepancy and negative self-directed styles, supporting predictions of the model. Also predicted by the model, negative mood states mediated relations between bulimic status and negative self-directed coping styles in Study 2. CONCLUSION Assessment-related predictions of the ICAT model of bulimic symptoms were supported in two studies. These initial results support further tests of the model in longitudinal designs, contrasts of different clinical populations, and treatment-evaluation studies.

Dimensions of Emotion Dysregulation in Bulimia Nervosa

The goal of this study was to examine associations between dimensions of emotion dysregulation and eating disorder (ED) symptoms in bulimia nervosa (BN). This investigation used baseline data from a BN treatment study that included 80 adults (90% women) with full or subthreshold BN. Participants completed the Difficulties in Emotion Regulation Scale (DERS) and the Eating Disorders Examination interview. The Eating Disorders Examination global score was significantly correlated with the DERS total score, as well as several DERS subscales: nonacceptance, impulse and strategies. Further, the DERS goals subscale was found to be uniquely associated with frequency of purging and driven exercise, although none of the subscales were associated with frequency of objective binge eating. Findings indicate that emotion dysregulation is associated with ED symptoms in BN, suggesting the utility of interventions that address emotion regulation skills deficits in the treatment of the disorder.

Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD.

OBJECTIVE Various factors contribute to the effective implementation of evidence-based treatments (EBTs). In this study, cognitive processing therapy (CPT) was administered in a Veterans Affairs (VA) posttraumatic stress disorder (PTSD) specialty clinic in which training and supervision were provided following VA implementation guidelines. The aim was to (a) estimate the proportion of variability in outcome attributable to therapists and (b) identify characteristics of those therapists who produced better outcomes. METHOD We used an archival database of veterans (n = 192) who completed 12 sessions of CPT by therapists (n = 25) who were trained by 2 nationally recognized trainers, 1 of whom also provided weekly group supervision. Multilevel modeling was used to estimate therapist effects, with therapists treated as a random factor. The supervisor was asked to retrospectively rate each therapist in terms of perceived effectiveness based on supervision interactions. Using single case study design, the supervisor was interviewed to determine what criteria she used to rate the therapists and emerging themes were coded. RESULTS When initial level of severity on the PTSD Checklist (PCL; McDonald & Calhoun, 2010; Weathers, Litz, Herman, Huska, & Keane, 1993) was taken into account, approximately 12% of the variability in the PCL at the end of treatment was due to therapists. The trainer, blind to the results, identified the following characteristics and actions of effective therapists: effectively addressing patient avoidance, language used in supervision, flexible interpersonal style, and ability to develop a strong therapeutic alliance. CONCLUSIONS This study adds to the growing body of literature documenting the importance of the individual therapist as an important factor in the change process.

Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder.

The authors examined the link between interpretive techniques, the therapeutic relationship, and outcome in psychodynamic psychotherapy. Two independent teams of judges each coded one early session from patients diagnosed with avoidant personality disorder. Results revealed (a) an inverse association between concentration of interpretation and favorable patient outcome; (b) that small amounts of disaffiliative patient‐ therapist transactions before, during, and after interpretations were reliably or meaningfully associated with negative patient change; and (c) concentration of interpretation was positively associated with disaffiliative therapy process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists who persisted with interpretations had more hostile interactions with patients and had patients who reacted with less warmth than therapists who used interpretations more judiciously.

The functional impairment associated with personality disorders.

Personality disorder affects functioning and increases distress in nearly every realm of concern to healthcare providers. In the past year, studies of personality disorder particularly targeted the following areas related to function: co-morbidity with axis I disorders; social functioning across a range of relationships; occupational and cognitive functioning; medical utilization; prevalence and complications of personality disorders in primary care patients; violence/suicide prediction and risk; poor treatment response; substance abuse; and the costs associated with personality disorders. Personality disorders are themselves difficult to treat, and because they complicate the response to the treatment of other disorders, it is becoming ever more apparent that there is an urgent need for effective treatments for personality disorder. Studies vary greatly in the methods chosen for assessing personality disorder. This necessarily means that the reliability and validity of the conclusions are uneven. Nonetheless, we believe that overall, it is ever more apparent that there is an urgent need for effective treatments for personality disorder. Moreover, the assessment and treatment of personality pathology may be important, even in contexts in which it is not the presenting complaint.

Predictors and moderators of treatment outcome in a randomized clinical trial for adults with symptoms of bulimia nervosa

OBJECTIVE This study examined predictors and moderators of outcome in 2 treatments for bulimia nervosa (BN). METHOD Eighty adults with BN symptoms at 1 of 2 sites were randomized to 21 sessions of integrative cognitive-affective therapy for BN (ICAT-BN) or enhanced cognitive behavior therapy (CBT-E). Generalized linear models examined predictors and moderators of improvements in bulimic behavior and eating disorder psychopathology at end of treatment (EOT) and 4-month follow-up (FU). RESULTS At EOT, individuals with higher dietary restraint had greater reductions in bulimic behavior. At FU, individuals with higher weight and shape concern had greater reductions in bulimic behavior, whereas those with greater baseline depression had less improvement in eating disorder psychopathology. Individuals higher in stimulus seeking had greater reductions in bulimic behavior and eating disorder psychopathology at follow up in ICAT-BN than in CBT-E, whereas individuals lower in stimulus seeking had greater reductions in bulimic behavior in CBT-E than in ICAT-BN. Finally, individuals with higher affective lability had greater reductions in eating disorder psychopathology in ICAT-BN than in CBT-E, whereas improvements were comparable across treatments for individuals with lower affective lability. CONCLUSIONS This study identified 3 nonspecific predictors of outcome (i.e., dietary restraint, weight and shape concern, and depression) and 2 moderators (i.e., affective lability and stimulus seeking). All moderator effects emerged at FU rather than at EOT, suggesting that the moderating effects of treatment were not immediately apparent. These results suggest that individuals with higher affective lability and stimulus seeking may benefit more from treatment with a greater focus on affective states and self-regulation.

Randomized controlled equivalence trial comparing videoconference and in person delivery of cognitive processing therapy for PTSD

Introduction In an effort to improve access to and utilization of health care, the Veterans Health Administration (VHA) continues to investigate the effectiveness of video-teleconferencing (VTC) technologies for service delivery. While previous research focused on the efficacy of VTC treatment for post-traumatic stress disorder (PTSD) in Vietnam era veterans, few studies have evaluated the efficacy of this modality and treatment for the Iraq/Afghanistan era veterans. The aim of this randomized clinical trial was to evaluate equivalence between in person and VTC psychotherapy for PTSD in this newer cohort. Methods Veterans of the Iraq/Afghanistan conflict from two VHA hospitals in the United States were recruited and randomized to receive cognitive processing therapy (CPT) for PTSD either in person (IP) or over VTC. Clinician-administered and self-report measures were collected before, during, and after treatment. Results A trend was observed which suggested that CPT over VTC may be equivalent to the treatment delivered in person, as suggested by previous studies. Regardless of treatment, veterans who received the intervention in both conditions reported significant decreases on post-treatment measures. Discussion This study highlighted research and clinical challenges in providing services to the newest veteran generation in general as well as unique challenges with VTC. One complicating factor to the statistical power of this study was a treatment dropout rate twice the original estimate. Factors that could have influenced this high dropout rate are explored.

Early psychotherapy process and cluster B and C personality pathology: similarities and differences in interactions with symptomatic and interpersonal distress

Abstract In a prior study (Kolden & Klein, 1996), the authors found that the relationships between global personality pathology and early psychotherapy change processes (as defined by the Generic Model of Psychotherapy) were moderated by the extent of the patients acute symptomatic and interpersonal distress. In the current study, the authors reanalyzed the same data to examine similarities and differences between personality disorder Clusters B (dramatic, emotional, or erratic) and C (anxious or fearful) in therapy process. In general, we found that more distressed patients reported greater defensiveness. There were no significant interactions between symptomatic distress and personality pathology in the prediction of any of the process variables. However, interpersonal distress moderated relationships between Clusters B and C and some therapy processes. Patients high in Cluster B felt more open and involved in the session when they were less distressed by their interpersonal problems at the start of therapy. In contrast, openness and insight were impeded among patients high in Cluster C when they were less distressed interpersonally. Therapists generally used more direct interventions and exploration of past experiences when working with patients higher in Cluster C pathology. However, therapists used direct interventions more specifically when patients with more severe Cluster B pathology were also higher in interpersonal distress. The discussion considers implications for the facilitation of productive early therapy process in patients suffering from Cluster B or C personality pathology.

The effects of psychotherapy treatment on outcome in bulimia nervosa: Examining indirect effects through emotion regulation, self‐directed behavior, and self‐discrepancy within the mediation model

OBJECTIVE The purpose of this investigation was to examine the indirect effects of Integrative Cognitive-Affective Therapy (ICAT-BN) and Cognitive-Behavioral Therapy-Enhanced (CBT-E) on bulimia nervosa (BN) treatment outcome through three hypothesized maintenance variables: emotion regulation, self-directed behavior, and self-discrepancy. METHOD Eighty adults with BN were randomized to 21 sessions of ICAT-BN or CBT-E. A regression-based bootstrapping approach was used to test the indirect effects of treatment on outcome at end of treatment through emotion regulation and self-directed behavior measured at mid-treatment, as well as the indirect effects of treatment at follow-up through emotion regulation, self-directed behavior, and self-discrepancy measured at end of treatment. RESULTS No significant differences in outcome between treatment conditions were observed, and no significant direct or indirect effects were found. Examination of the individual paths within the indirect effects models revealed comparable treatment effects. Across treatments, improvements in emotion regulation and self-directed behavior between baseline and mid-treatment predicted improvements in global eating disorder scores but not binge eating and purging frequency at end of treatment. Baseline to end of treatment improvements in emotion regulation and self-directed behavior also predicted improvements in global eating disorder scores at follow-up. Baseline to end of treatment improvements in emotion regulation predicted improvements in binge eating and baseline to end of treatment increases in positive self-directed behavior predicted improvements in purging at follow-up. DISCUSSION These findings suggest that emotion regulation and self-directed behavior are important treatment targets and that ICAT-BN and CBT-E are comparable in modifying these psychological processes among individuals with BN.

Therapeutic Alliance in a Randomized Clinical Trial for Bulimia Nervosa

OBJECTIVE This study examined the temporal relation between therapeutic alliance and outcome in two treatments for bulimia nervosa (BN). METHOD Eighty adults with BN symptoms were randomized to 21 sessions of integrative cognitive-affective therapy (ICAT) or enhanced cognitive-behavioral therapy (CBT-E). Bulimic symptoms (i.e., frequency of binge eating and purging) were assessed at each session and posttreatment. Therapeutic alliance (Working Alliance Inventory) was assessed at Sessions 2, 8, 14, and posttreatment. Repeated-measures analyses using linear mixed models with random intercepts were conducted to determine differences in alliance growth by treatment and patient characteristics. Mixed-effects models examined the relation between alliance and symptom improvement. RESULTS Overall, patients in both treatments reported strong therapeutic alliances. Regardless of treatment, greater therapeutic alliance between (but not within) subjects predicted greater reductions in bulimic behavior; reductions in bulimic behavior also predicted improved alliance. Patients with higher depression, anxiety, or emotion dysregulation had a stronger therapeutic alliance in CBT-E than ICAT, while those with more intimacy problems had greater improvement in therapeutic alliance in ICAT compared to CBT-E. CONCLUSIONS Therapeutic alliance has a unique impact on outcome, independent of the impact of symptom improvement on alliance. Within- and between-subjects effects revealed that changes in alliance over time did not predict symptom improvement, but rather that individuals who had a stronger alliance overall had better bulimic symptom outcomes. These findings indicate that therapeutic alliance is an important predictor of outcome in the treatment of BN.