Through the course of this paper we discuss several fundamental issues related to the intervention competence of psychologists. Following definitional clarification and proposals for more strictly distinguishing competence from adherence, we interpret Dreyfus and Dreyfus’s (1986) five stage theory of competence development (from novice to expert) within a strictly clinical framework. Existing methods of competence assessment are then evaluated, and we argue for the use of new and multiple assessment modalities. Next, we utilize the previous sections as a foundation to propose methods for training and evaluating competent psychologists. Lastly, we discuss several potential impediments to large scale competence assessment and education, such as the heterogeneity of therapeutic orientations and what could be termed a lack of transparency in clinical training.
The belief that rigidity across relationships is related to greater symptoms and poorer functioning commonly informs the practice of many psychodynamic and interpersonal therapists. Using a profile correlation approach, we tested this hypothesis in a sample of 250 clients and 90 undergraduate control participants. Symptoms and functioning were assessed with the Inventory of Interpersonal Problems (IIP), Global Assessment of Functioning scale, and Brief Symptom Inventory. A revised version of the empirically-derived Central Relationship Questionnaire (CRQ) was used to measure interpersonal patterns. Revisions were made to the CRQ to increase the interpersonal dimensions it captured, reduce its length, and model a higher-order factor structure. The psychometric properties of the revised CRQ were found to be adequate. Rigidity as measured with the CRQ was not related to rigidity measured with the IIP (amplitude) and did not differ significantly among individuals with different interpersonal problems or DSM-IV diagnoses. Contrary to theory, however, greater rigidity across relationships was related to fewer symptoms and interpersonal problems. These relations did not appear due to the valence or the extremeness of the interpersonal patterns used in the estimation of rigidity.
relationships; interpersonal; rigidity; consistency; symptoms
The authors conducted a meta-analytic review of adherence–outcome and competence– outcome findings, and examined plausible moderators of these relations.
A computerized search of the PsycINFO database was conducted. In addition, the reference sections of all obtained studies were examined for any additional relevant articles or review chapters. The literature search identified 36 studies that met the inclusion criteria.
R-type effect size estimates were derived from 32 adherence–outcome and 17 competence–outcome findings. Neither the mean weighted adherence– outcome (r = .02) nor competence–outcome (r = .07) effect size estimates were found to be significantly different from zero. Significant heterogeneity was observed across both the adherence–outcome and competence–outcome effect size estimates, suggesting that the individual studies were not all drawn from the same population. Moderator analyses revealed that larger competence–outcome effect size estimates were associated with studies that either targeted depression or did not control for the influence of the therapeutic alliance.
One explanation for these results is that, among the treatment modalities represented in this review, therapist adherence and competence play little role in determining symptom change. However, given the significant heterogeneity observed across findings, mean effect sizes must be interpreted with caution. Factors that may account for the nonsignificant adherence– outcome and competence–outcome findings reported within many of the studies reviewed are addressed. Finally, the implication of these results and directions for future process research are discussed.
meta-analysis; therapist; adherence; competence
This meta-analysis assessed efficacy of pharmacologic and psychological interventions for treatment of perinatal depression. A systematic review identified 27 studies, including open trials (n=9), quasi-randomized trials (n=2), and randomized controlled trials (n=16) assessing change from pretreatment to posttreatment or comparing these interventions to a control group. Uncontrolled and controlled effect sizes were assessed in separate meta-analyses. There was significant improvement in depressive symptoms from pretreatment to posttreatment, with an uncontrolled overall effect size (Hedges' g) of 1.61 after removal of outliers and correction for publication bias. Symptom levels at posttreatment were below cutoff levels indicative of clinically significant symptoms. At posttreatment, intervention groups demonstrated significantly greater reductions in depressive symptoms compared to control groups, with an overall controlled effect size (Hedges' g) of 0.65 after removal of outliers. Individual psychotherapy was superior to group psychotherapy with regard to changes in symptoms from pretreatment to posttreatment. Interventions including an interpersonal therapy component were found to have greater effect sizes, compared to control conditions, than interventions including a cognitive–behavioral component. Implications of the findings for clinical practice and future research are discussed.
Postpartum; Psychotherapy; Pregnancy; Treatment; Depression; Meta-analysis
Given the data that depression is common during pregnancy and that pregnant women prefer non-medication treatment options, we hypothesize repetitive transcranial magnetic stimulation (TMS) may be a treatment option. Given the novelty of TMS, we sought to assess whether patient acceptability would be a barrier to enrolling pregnant women in TMS studies.
In Study 1, 500 pregnant women were surveyed in an outpatient, urban obstetrics clinic using the Edinburgh Depression Rating Scale (EPDS) and a treatment acceptability survey. In Study 2, 51 women were surveyed with the EPDS and acceptability survey using an informational video to increase participant knowledge about TMS.
Approximately 25% of participants had an EPDS score of ≥12 in both studies. Psychotherapy was identified as the most acceptable treatment option. TMS was considered an unacceptable treatment option to virtually all women before the informational video. After the video, 15.7% considered TMS an acceptable treatment option.
Psychotherapy is the most acceptable treatment option for depression to pregnant women. Increasing participant knowledge about TMS increased its acceptability significantly. Large-scale multi-center trials are needed for confirmation of these results.
Depression; Pregnancy; Transcranial magnetic stimulation; Treatment; Acceptability
This meta-analysis assessed the efficacy of a wide range of preventive interventions designed to reduce the severity of postpartum depressive symptoms or decrease the prevalence of postpartum depressive episodes. A systematic review identified 37 randomized or quasi-randomized controlled trials in which an intervention was compared to a control condition. Differences between treatment and control conditions in the level of depressive symptoms and prevalence of depressive episodes by 6 months postpartum were assessed in separate analyses. Depressive symptoms were significantly lower at post-treatment in intervention conditions, with an overall effect size in the small range after exclusion of outliers (Hedges' g = 0.18). There was a 27% reduction in the prevalence of depressive episodes in intervention conditions by 6 months postpartum after removal of outliers and correction for publication bias. Later timing of the postpartum assessment was associated with smaller differences between intervention and control conditions in both analyses. Among studies that assessed depressive symptoms using the EPDS, higher levels of depressive symptoms at pre-treatment were associated with smaller differences in depressive symptoms by 6 months postpartum. These findings suggest that interventions designed to prevent postpartum depression effectively reduce levels of postpartum depressive symptoms and decrease risk for postpartum depressive episodes.
Postpartum depression; Prevention; Meta-analysis
Two studies examined the relationship between maternal attitudes and symptoms of depression and anxiety during pregnancy and the early postpartum period. In the first study, a measure of maternal attitudes, the Attitudes Toward Motherhood Scale (AToM), was developed and validated in a sample of first-time mothers. The AToM was found to have good internal reliability and convergent validity with cognitive biases and an existing measure of maternal attitudes. Exploratory and confirmatory factor analyses determined that the measure comprises three correlated factors: beliefs about others’ judgments, beliefs about maternal responsibility, and maternal role idealization. In the second study, we used the AToM to assess the relationship between maternal attitudes and other psychological variables. The factor structure of the measure was confirmed. Maternal attitudes predicted symptoms of depression and anxiety, and these attitudes had incremental predictive validity over general cognitive biases and interpersonal risk factors. Overall, the results of these studies suggest that maternal attitudes are related to psychological distress among first-time mothers during the transition to parenthood and may provide a useful means of identifying women who may benefit from intervention during the perinatal period.
Parental attitudes; Pregnancy; Postpartum; Risk factors; Depression; Anxiety
Patient treatment preferences are of growing interest to researchers, clinicians, and patients. In this review, an overview of the most commonly recommended treatments for depression is provided, along with a brief review of the evidence supporting their efficacy. Studies examining the effect of patient treatment preferences on treatment course and outcome are summarized. Existing literature on what treatment options patients tend to prefer and believe to be helpful, and what factors may affect these preferences, is also reviewed. Finally, clinical implications of research findings on patient preferences for depression management are discussed. In summary, although our knowledge of the impact of patient preferences on treatment course and outcome is limited, knowing and considering those preferences may be clinically important and worthy of greater study for evidence-based practice.
treatment preferences; depression; antidepressants; psychotherapy
The study utilized a generalizability theory analysis of adherence and competence ratings to evaluate the number of sessions and patients needed to yield dependable scores at the patient and therapist levels. Independent judges’ ratings of supportive expressive therapy (n = 94), cognitive therapy (n = 103), and individual drug counseling (n = 98) were obtained on tapes of sessions from the NIDA Collaborative Cocaine Treatment Study. Generalizability coefficients revealed that, for all three treatments, ratings made on approximately five to 10 sessions per patient are needed to achieve sufficient dependability at the patient level. At the therapist level, four to 14 patients need to be evaluated (depending on the modality), to yield dependable scores. Many studies today use fewer numbers.
statistical methodology; generalizability theory; adherence; competence
Isolated sleep paralysis (ISP) has received scant attention in clinical populations, and there has been little empirical consideration of the role of fear in ISP episodes. To facilitate research and clinical work in this area, the authors developed a reliable semistructured interview (the Fearful Isolated Sleep Paralysis Interview) to assess ISP and their proposed fearful ISP (FISP) episode criteria in 133 patients presenting for panic disorder treatment. Of these, 29.3% met lifetime ISP episode criteria, 20.3% met the authors’ lifetime FISP episode criteria, and 12.8% met their recurrent FISP criteria. Both ISP and FISP were associated with minority status and comorbidity. However, only FISP was significantly associated with posttraumatic stress disorder, body mass, anxiety sensitivity, and mood and anxiety disorder symptomatology.
sleep paralysis; isolated sleep paralysis; panic disorder; anxiety; fear; parasomnia; sleep disorder
Aims of this study were (a) to summarize the psychometric literature on the Mobility Inventory for Agoraphobia (MIA), (b) to examine the convergent and discriminant validity of the MIA’s Avoidance Alone and Avoidance Accompanied rating scales relative to clinical severity ratings of anxiety disorders from the Anxiety Disorders Interview Schedule (ADIS), and (c) to establish a cutoff score indicative of interviewers’ diagnosis of agoraphobia for the Avoidance Alone scale. A meta-analytic synthesis of 10 published studies yielded positive evidence for internal consistency and convergent and discriminant validity of the scales. Participants in the present study were 129 people with a diagnosis of panic disorder. Internal consistency was excellent for this sample, α = .95 for AAC and .96 for AAL. When the MIA scales were correlated with interviewer ratings, evidence for convergent and discriminant validity for AAL was strong (convergent r with agoraphobia severity ratings = .63 vs. discriminant rs of .10-.29 for other anxiety disorders) and more modest but still positive for AAC (.54 vs. .01-.37). Receiver operating curve analysis indicated that the optimal operating point for AAL as an indicator of ADIS agoraphobia diagnosis was 1.61, which yielded sensitivity of .87 and specificity of .73.
agoraphobia; panic disorder; Mobility Inventory; psychometric; reliability; validity
To determine lifetime prevalence rates of sleep paralysis.
Keyword term searches using “sleep paralysis”, “isolated sleep paralysis”, or “parasomnia not otherwise specified” were conducted using MEDLINE (1950-present) and PsychINFO (1872-present). English and Spanish language abstracts were reviewed, as were reference lists of identified articles.
Thirty five studies that reported lifetime sleep paralysis rates and described both the assessment procedures and sample utilized were selected.
Weighted percentages were calculated for each study and, when possible, for each reported subsample.
Aggregating across studies (total N = 36533), 7.6% of the general population, 28.3% of students, and 31.9% of psychiatric patients experienced at least one episode of sleep paralysis. Of the psychiatric patients with panic disorder, 34.6% reported lifetime sleep paralysis. Results also suggested that minorities experience lifetime sleep paralysis at higher rates than Caucasians.
Sleep paralysis is relatively common in the general population and more frequent in students and psychiatric patients. Given these prevalence rates, sleep paralysis should be assessed more regularly and uniformly in order to determine its impact on individual functioning and better articulate its relation to psychiatric and other medical conditions.
sleep paralysis; isolated sleep paralysis; anxiety; fear; parasomnia; prevalence
In the context of a National Institutes of Mental Health-funded Interventions and Practice Research Infrastructure Programs (IP-RISP) grant for the treatment of depression, a partnership was developed between a community mental health organization and a team of researchers.
This paper describes the collaborative process, key challenges, and strategies employed to meet the goals of the first phase of the grant, which included development of a working and sustainable partnership and building capacity for recruitment and research.
This paper was developed through the use of qualitative interviews and discussion with a variety of IP-RISP partners.
Communication with multiple stakeholders through varied channels, feedback from stakeholders on research procedures, and employing a research liaison at the clinic have been key strategies in the first phase of the grant.
The strategies we employed allowed multiple stakeholders to contribute to the larger mission of the IP-RISP and helped to establish an ongoing research program within the mental health organization.
Mental health; psychiatry and psychology; depression; research infrastructure; community health partnerships
What options are available to mental health providers helping clients with posttraumatic stress disorder (PTSD)? In this paper we review many of the current pharmacological and psychological interventions available to help prevent and treat PTSD with an emphasis on combat-related traumas and Veteran populations. There is strong evidence supporting the use of several therapies including prolonged exposure (PE), eye movement desensitization and reprocessing (EMDR), and cognitive processing therapies (CPT), with PE possessing the most empirical evidence in favor of its efficacy. There have been relatively fewer studies of non-exposure based modalities (e.g., psychodynamic, interpersonal, and dialectical behavior therapy perspectives), but there is no evidence that these treatments are less effective. Pharmacotherapy is promising (especially paroxetine, sertraline, and venlafaxine), but more research comparing the relative merits of medication vs. psychotherapy and the efficacy of combined treatments is needed. Given the recent influx of combat-related traumas due to ongoing conflicts in Iraq and Afghanistan, there is clearly an urgent need to conduct more randomized clinical trials research and effectiveness studies in military and Department of Veterans Affairs PTSD samples. Finally, we provide references to a number of PTSD treatment manuals and propose several recommendations to help guide clinicians’ treatment selections.
PTSD; posttraumatic stress disorder; post-traumatic stress disorder; psychotherapy; psychopharmacology
Participants were 30 adult outpatients diagnosed with avoidant personality disorder or obsessive–compulsive personality disorder who enrolled in an open trial of cognitive therapy for personality disorders. Treatment consisted of up to 52 weekly sessions. Symptom evaluations were conducted at intake, at Sessions 17 and 34, and at the last session. Alliance variables were patients’ first alliance rating and “rupture-repair” episodes, which are disruptions in the therapeutic relationship that can provide corrective experiences and facilitate change. Stronger early alliances and rupture-repair episodes predicted more improvement in symptoms of personality disorder and depression. This work points to potentially important areas to target in treatment development for these personality disorders.
alliance; alliance ruptures; therapeutic alliance; personality disorders; cognitive therapy
Studies involving patients with personality disorders (PD) have not focused on improvement of core aspects of the PD. This paper examines changes in quality of object relations, interpersonal problems, psychological mindedness, and personality traits in a sample of 156 patients with DSM-IV PD diagnoses being randomized to either manualized or non manualized dynamic psychotherapy. Effect sizes adjusted for symptomatic change and reliable change indices were calculated. We found that both treatments were equally effective at reducing personality pathology. Only in neuroticism did the non manualized group do better during the follow-up period. The largest improvement was found in quality of object relations. For the remaining variables only small and clinically insignificant magnitudes of change were found.
The goal of this paper 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. The University of Pennsylvania Center for Psychotherapy Research database that 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.
Mechanism; Cognitive therapy; Dynamic therapy; Psychotherapy outcome
Using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, this article focuses on the outcomes of patients who received supportive-expressive (SE) psychodynamically-oriented psychotherapy (plus group drug counseling; GDC). Short-term SE for cocaine dependent individuals, while not the most efficacious treatment examined in the study (individual drug counseling [IDC] plus GDC was), produced large improvements in cocaine use. In addition, there was evidence that SE was superior to IDC on change in family/social problems at the 12 month follow-up assessment, particularly for those patients with relatively more severe difficulties in this domain at baseline. For patients who achieved abstinence early in treatment, SE produced comparable drug use outcomes to IDC, with mean drug use scores numerically lower for SE at all of the follow-up assessments (9, 12, 15, and 18 months). SE patients who achieved initial abstinence decreased cocaine use from a mean 10.1 days per month at baseline to a mean of 1.3 days at 12 months.
Therapists of different persuasions use various techniques. Although many of these techniques are specific to their theory of treatment, others are practiced in common among different forms of psychotherapy. Many of these common techniques have been previously described, but supportive techniques have been largely ignored. The authors distinguish between the use of supportive techniques and the therapeutic alliance. Using Luborsky's definition of supportive techniques, they examine the empirical literature on the use of these supportive techniques in various therapies. They conclude that supportive techniques are often used in different forms of psychotherapy or counseling.
This study examined the extent to which improvement from baseline to weeks 2, 3, and 4 on the Beck Depression Inventory and Beck Anxiety Inventory predict week 16 clinical remission for patients with major depressive disorder, generalized anxiety disorder, and/or obsessive-compulsive or avoidant personality disorders who were receiving manual-based psychotherapies. Logistic regression and receiver-operator characteristic analyses revealed relatively accurate identification of remitters and nonremitters based on improvement from baseline to sessions 2 to 4 in both original and cross-validation samples. Predictive success did not vary as a function of diagnosis, treatment type (cognitive or dynamic), or treatment status (short-term or long-term). The clinical implications of the results are discussed.
Cognitive Therapy; Psychotherapy, Psychodynamic; Early Sessions
The Ways of Responding (WOR) was developed to assess change in compensatory or metacognitive skills taught by cognitive therapists. Thus, one would expect WOR scores to change during cognitive therapy (CT) and to be associated with change in depression level. Twenty-seven patients with a DSM-III-R diagnosis of major depression who had received CT filled out the WOR and other measures of cognition. After 12 weeks of CT, the patients exhibited change in the WOR, the Attributional Style Questionnaire, the Dysfunctional Attitude Scale, and the Self-Control Scale. Furthermore, there were indications that change in depression was associated with changes in these measures of cognition, including the WOR. The WOR appears to be a sensitive measure of change during CT that covaries with change in depression. It remains to be tested whether change on the WOR is specific to CT.
Cognitive Therapy; Depression
The Core Conflictual Relationship Theme (CCRT) method is one of the most widely used and tested instruments developed within a psychoanalytic context for assessing central relationship patterns or characteristic patterns of relating to others. The Swedish version of the Central Relationship Questionnaire (CRQ), a recently developed self-report instrument based on the CCRT, was tested in a sample of Swedish psychology students (31 men, 60 women) and compared with responses of Swedish outpatients (15 men, 15 women) and North American students (49 men, 49 women). The subscales of the Swedish CRQ showed acceptable internal consistency and correlated with each other in a predictable fashion, displaying a pattern of intercorrelations similar to the English version. The CRQ showed meaningful patterns of correspondence with self-reported interpersonal problems as well as meaningful differences between the Swedish students and Swedish outpatients, indicating preliminary convergent and divergent validity.
Rating Instruments; Core Conflictual Relationship Theme Method; Cross-Cultural and Cross-Ethnic Studies
The role of therapist characteristics in therapy training was examined for 62 therapists in a multisite psychotherapy outcome study that included cognitive therapy (CT), supportive-expressive (SE) psychodynamic therapy, and individual drug counseling (IDC) for cocaine-dependent patients. Demographic variables and experience and competence ratings prior to training were correlated with measures of change in competence during the training phase. Higher competence ratings before training were associated with greater change in competence for SE and higher average competence for IDC. More years of experience were associated with greater change in competence for CT therapists, but more hours of pre-training supervision in the CT treatment modality were associated with less change.
Psychotherapy Training and Supervision; Therapist Characteristics; Cocaine
Although psychotherapy manuals provide treatment guidelines, detailed descriptions of therapist interventions in manual-guided therapies are lacking. The purpose of the present investigation was to evaluate the types of therapist interventions in Supportive-Expressive (SE) psychotherapy for depression by using a molecular method of assessment and then to compare the results with those attained with a molar method. Four percent of therapist statements per session early in treatment were interpretations, which most often focused on the patient's parents, significant others, and self in the present time frame. This molecular method for assessing therapist interventions did converge with the molar adherence/competence method. (The Journal of Psychotherapy Practice and Research 1998; 7:290–300)
In this naturalistic study of 55 outpatients selected for long-term psychodynamic psychotherapy, two Swedish assessment instruments are presented (the Karolinska Psychodynamic Profile and the Karolinska Scales of Personality), and the significance of psychodynamic criteria for the selection of patients is discussed. Thirty patients (55%) fulfilled criteria for a DSM-III-R diagnosis. The most prominent psychodynamically defined character pathology was found in the areas of coping with aggressive affects; dependency and separation; frustration tolerance; and impulse control. Some psychodynamically defined character traits, particularly poor frustration tolerance, were related to symptomatic suffering.