Volkmar Höfling

Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder.

Several studies have demonstrated a positive relationship between competence and outcome in CBT for depression but studies of CBT for anxiety disorders are lacking. The present study explores the relationship between competence and outcome in cognitive therapy (CT) for social anxiety disorder, using hierarchical linear modeling analyses (HLM). Data were drawn from a multicenter randomized controlled trial. Five trained raters evaluated videotapes of two therapy sessions per patient using the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP). Overall adherence to the treatment manual and patient difficulty were also assessed. Patient outcome was rated by other assessors using the Clinical Global Impression Improvement Scale (CGI-I) and the Liebowitz Social Anxiety Scale (LSAS). Results indicated that competence significantly predicted patient outcome on the CGI-I (β = .79) and LSAS (β = .59). Patient difficulty and adherence did not further improve prediction. The findings support the view that competence influences outcome and should be a focus of training programs. Further research is needed to compare different ways of assessing competence and to understand the complex relationships between competence and other therapy factors that are likely to influence outcome.

The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: secondary analysis of a randomized trial.

Meta-analyses reveal that homework compliance is associated with a better treatment outcome. However, little is known about the processes that could be responsible for patient compliance with homework. It has been proposed that therapist competence, in particular with respect to reviewing homework, is highly relevant for homework compliance. The present study is a secondary analysis of a randomized controlled trial. Altogether, 54 patients with recurrent depressive disorder (currently in remission) who were treated with maintenance cognitive therapy (MCT), were considered. One videotaped treatment session of each patient was randomly selected and therapist competence (general competence and specific competence in setting and reviewing homework) was assessed by 2 independent raters. Furthermore, both patient and therapist views of the therapeutic alliance were evaluated by questionnaire in this therapy session. Homework compliance (considering quantitative as well as qualitative aspects) in the following session was evaluated by 2 additional raters. These 2 raters were blinded regarding the ratings of the therapeutic competence. In a multilevel path analysis model, a significant association between the therapeutic competence in reviewing homework and homework compliance was detected, while the therapeutic alliance and several patient characteristics were not associated with homework compliance. We found no relationship between homework compliance and treatment outcome. Our results demonstrate that a specific therapeutic competence (i.e., competence in reviewing homework) is associated with patient compliance with homework, and therefore, provides further empirical evidence of the importance of therapist competence in the psychotherapeutic process.

Exposure therapy changes dysfunctional evaluations of somatic symptoms in patients with hypochondriasis (health anxiety). A randomized controlled trial.

Dysfunctional evaluations of somatic symptoms are considered a central factor in maintaining hypochondriasis. The aim of the current study was to investigate whether exposure therapy (ET) without cognitive restructuring is sufficient to change dysfunctional evaluations of somatic symptoms. The current study was based on a randomized controlled trial and compared patients with hypochondriasis (N=73) receiving ET or cognitive therapy (CT) to a wait list (WL) control group. In both the ET and CT groups, dysfunctional symptom evaluations changed significantly compared with the WL group. No differences between the ET and CT groups emerged. The relationship between the treatment condition (active treatment vs. WL) and reductions in health anxiety was mediated by changes in somatic symptom evaluations only in a specific card sorting procedure. We conclude that addressing dysfunctional symptom evaluations is a necessary precondition for the effective treatment of hypochondriasis. However, the results indicate that ET and CT appear to change those processes to a similar degree.

Therapist competence and therapeutic alliance are important in the treatment of health anxiety (hypochondriasis)

The role of treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) is rarely investigated in psychotherapeutic treatment for health anxiety. This study aimed to investigate the role of the assessment perspective for the evaluation of treatment delivery factors and their relevance for treatment outcome. Therapist adherence, therapist competence, and therapeutic alliance were evaluated by independent raters, therapists, patients, and supervisors in 68 treatments. Patients with severe health anxiety (hypochondriasis) were treated with cognitive therapy or exposure therapy. Treatment outcome was assessed with a standardized interview by independent diagnosticians. A multitrait-multimethod analysis revealed a large effect for the assessment perspective of therapist adherence, therapist competence, and therapeutic alliance. The rater perspective was the most important for the prediction of treatment outcome. Therapeutic alliance and therapist competence accounted for 6% of the variance of treatment outcome while therapist adherence was not associated with treatment outcome. Therapist competence was only indirectly associated with treatment outcome, mediated by therapeutic alliance. Both therapeutic alliance and therapist competence demonstrated to be important treatment delivery factors in psychotherapy for health anxiety. A stronger consideration of those processes during psychotherapy for health anxiety might be able to improve psychotherapy outcome.

Analyzing Multitrait- Multimethod Data A Comparison of Three Approaches

Assessing construct validity is a core task in psychology. Since Campbell and Fiskes (1959) seminal article on multitrait-multimethod (MTMM) analysis, several different methodological approaches for the analysis of convergent and discriminant validity of MTMM data have been developed. In this article, two MTMM approaches are transferred to the general framework of confirmatory factor analysis and compared with the extended version of the correlated trait-correlated method minus one model (Nussbeck, Eid, Geiser, Courvoisier, & Lischetzke, 2009): The multilevel MTMM model (Maas, Lensvelt-Mulders, & Hox, 2009) and the three-mode model (Oort, 2009). Assessing the construct validity of a German Big Five MTMM data set these three MTMM approaches are compared with regard to convergent and discriminant validity estimates and with regard to method effects. Advantages and limitations of each methodological approach will be discussed in detail. Campbell and Fiskes (1959) seminal article on the Conver- gent and discriminant validation by the multitrait- multimethod (MTMM) matrix had an immense impact on the process of exploring construct validity of psychological measures. They proposed to inspect the MTMM matrix, a matrix of correlations between several traits that were mea- sured by several methods, to verify the construct validity of psychological measures. In Campbell and Fiskes perspec- tive the core aspects of construct validity are convergent and discriminant validity. Convergent validity can only be assumed if different methods converge in the measurement of one trait. Discriminant validity, however, should be dem- onstrated by the nonconvergence of measurements of differ- ent traits. The application of at least two different methods for the measurement of one or more traits is necessary to separate trait and method influences for each score of a psy- chological variable (= trait-method unit, TMU). However, within the Campbell and Fiske approach trait- and method-specific influences cannot be separated from unsys- tematic measurement errors. The separation of measurement error from trait- and method-specific influences can be obtained by appropriate modern methodological approaches.

The Effects of Bug-in-the-Eye Supervision on Therapeutic Alliance and Therapist Competence in Cognitive-Behavioural Therapy: A Randomized Controlled Trial.

Live supervision enables a supervisor to have direct insight into the psychotherapeutic process and allows him or her to provide immediate feedback to the trainee. Therefore, live supervision might be superior to traditional supervisory formats that only allow for the provision of delayed feedback. When considering the different live supervision formats, bug-in-the-eye (BITE) supervision is particularly promising because of its improved and less invasive procedure. The current study compared the efficacy of BITE supervision with that of delayed video-based (DVB) supervision. In the present study, 23 therapists were randomly assigned to either the BITE supervision or DVB supervision groups. The participants were psychotherapy trainees who treated 42 patients (19 under BITE supervision and 23 under DVB supervision) over 25 sessions of cognitive-behavioural therapy. Two independent raters blind to the treatment conditions evaluated therapeutic alliance and therapist competence based on 195 videotapes. Therapeutic alliance was significantly stronger among the treatments conducted under BITE supervision than those conducted under DVB supervision. Moreover, a higher level of therapeutic competence was found in the BITE condition than in the DVB condition. However, no differences between supervision conditions were found when the results were controlled for the level of therapeutic alliance and therapist competence demonstrated in the first session. No differences were observed between the supervision conditions with respect to patient outcomes. There is evidence that BITE supervision is able to improve therapeutic alliance and therapist competence. However, these findings should be interpreted with caution because possible pre-treatment differences between therapists might explain the superiority of BITE supervision. Copyright

Assessing treatment integrity in cognitive-behavioral therapy: comparing session segments with entire sessions.

The evaluation of treatment integrity (therapist adherence and competence) is a necessary condition to ensure the internal and external validity of psychotherapy research. However, the evaluation process is associated with high costs, because therapy sessions must be rated by experienced clinicians. It is debatable whether rating session segments is an adequate alternative to rating entire sessions. Four judges evaluated treatment integrity (i.e., therapist adherence and competence) in 84 randomly selected videotapes of cognitive-behavioral therapy for major depressive disorder, social anxiety disorder, and hypochondriasis (from three different treatment outcome studies). In each case, two judges provided ratings based on entire therapy sessions and two on session segments only (i.e., the middle third of the entire sessions). Interrater reliability of adherence and competence evaluations proved satisfactory for ratings based on segments and the level of reliability did not differ from ratings based on entire sessions. Ratings of treatment integrity that were based on entire sessions and session segments were strongly correlated (r=.62 for adherence and r=.73 for competence). The relationship between treatment integrity and outcome was comparable for ratings based on session segments and those based on entire sessions. However, significant relationships between therapist competence and therapy outcome were only found in the treatment of social anxiety disorder. Ratings based on segments proved to be adequate for the evaluation of treatment integrity. The findings demonstrate that session segments are an adequate and cost-effective alternative to entire sessions for the evaluation of therapist adherence and competence.

Assessment of Implicit Health Attitudes: A Multitrait–Multimethod Approach and a Comparison Between Patients With Hypochondriasis and Patients With Anxiety Disorders

Two adaptations of the Implicit Association Task were used to assess implicit anxiety (IAT–Anxiety) and implicit health attitudes (IAT–Hypochondriasis) in patients with hypochondriasis (n = 58) and anxiety patients (n = 71). Explicit anxieties and health attitudes were assessed using questionnaires. The analysis of several multitrait–multimethod models indicated that the low correlation between explicit and implicit measures of health attitudes is due to the substantial methodological differences between the IAT and the self-report questionnaire. Patients with hypochondriasis displayed significantly more dysfunctional explicit and implicit health attitudes than anxiety patients, but no differences were found regarding explicit and implicit anxieties. The study demonstrates the specificity of explicit and implicit dysfunctional health attitudes among patients with hypochondriasis.

Assessment of patient interpersonal behavior: Development and validation of a rating scale

Abstract Objective: Patient in-session interpersonal behavior, as part of the therapeutic alliance, is an important aspect of the psychotherapy process and impacts treatment outcome. In the present study, the development and validation of a rating scale of patient in-session interpersonal behavior is described. Method: A 10-item rating scale, the Assessment Form of Patient Interpersonal Behavior (AFPIB), was developed using an inductive procedure. The AFPIB was then validated in a sample of patients with hypochondriasis (N = 30), by having two independent raters assess patients’ interpersonal behaviors shown in videotaped psychotherapy sessions (N = 60). Results: The AFPIB demonstrated good reliability and validity. Conclusions: Thus, the AFPIB seems to be a promising rating scale for the assessment of patient interpersonal behavior shown in psychotherapy sessions.

In-situation safety behaviours as a factor in the maintenance and treatment of sexual dysfunctions

In recent years, safety behaviours have received a lot of attention in cognitive-behavioural accounts of anxiety disorders, especially their role as a maintenance factor in social phobia. The present paper aims at exploring the potential of safety behaviours for furthering the understanding of sexual dysfunctions. We argue that safety behaviours, in the context of other cognitive variables such as self-focused attention and negative expectations, increase negative sexual affect (e.g. fear of failure, shame, sadness), thus maintaining sexual dysfunctions in creating a vicious circle. Important implications for treatment, clinical implications and limitations are discussed.