Psychotherapy and the Brain PDF

2024-11-18 Psychotherapy and the Brain Sarah E. Racine, PhD PSYC 408 Lecture 18 1 1  2024-11-18 Agenda Notable areas of the brain Cognitiv...

2024-11-18 Psychotherapy and the Brain Sarah E. Racine, PhD PSYC 408 Lecture 18 1 1  2024-11-18 Agenda Notable areas of the brain Cognitive model of anxiety/depression Neurocognitive correlates of change in CBT 2 2  2024-11-18 The Brain Cognitive Hierarchy Higher Lower 3 3  2024-11-18 Definitions Top-down processing: Slow, deliberate explicit, and strategic processing that uses rule-based knowledge ▫ Mediated by prefrontal cortex ▫ Main target in CBT Bottom-up processing: Automatic, effortless, implicit, and pre-conscious processing based on salient features or stimulus and situational cues ▫ Mediated by lower-order brain structures ▫ Also changes with CBT, though not targeted as explicitly 4 4  2024-11-18 Psychotherapy and the Brain Linden: Cognitive restructuring is thought to increase top-down cognitive control over negative emotion, whereas medication is thought to decrease bottom-up reactivity to emotional stimuli CBT primarily produces symptom reduction through its impact on higher-order executive functions ▫ Problem solving, cognitive reappraisal, self-referential thinking 5 5  2024-11-18 Psychotherapy and the Brain Depression: ▫ CBT alters activity in dorsolateral, ventrolateral, and medial prefrontal cortices as well as anterior and posterior cingulate cortices  Mostly higher-order areas  Modulation of top-down processes involved in encoding and retrieval of negative associative memories, rumination, and over- processing or irrelevant information 6 6  2024-11-18 Psychotherapy and the Brain Anxiety: ▫ CBT alters activity in the same higher-order regions as well as the amygdala, hippocampus, and anterior and medial temporal cortices  More modulation of bottom-up structures in CBT for anxiety ▫ PTSD: Increased activity in anterior cingulate cortex and decreased activity in amygdala after exposure plus restructuring ▫ Social anxiety: Decreased activity in amygdala-hippocampal region after either CBT or medication treatment ▫ OCD: Behavior therapy and medication treatment decrease activation in orbitofrontal cortex, dorsolateral prefrontal cortex, and anterior cingulate cortex 7 7  2024-11-18 Psychotherapy and the Brain Basic mechanism: Cognitive control of emotion ▫ Higher-order cortical regions are involved in cognitive control of emotion ▫ Cognitive reappraisal involves increased activation of dorsolateral and ventrolateral prefrontal cortex and anterior cingulate cortex, as well as decreased activity of amygdala ▫ Using strategies to regulate emotions in experimental studies activates top-down processes in a manner consistent with CBT 8 8  2024-11-18 Psychotherapy and the Brain More recently…. Neuroscience research has examined change in functional connectivity between relevant brain regions after therapy ▫ Shou et al. 2017: CBT increased resting state connectivity between amygdala and fronto-parietal network in patients with MDD and PTSD ▫ Young et al. 2017: Symptom improvement in either CBT or Acceptance and Commitment Therapy for SAD was correlated with increased connectivity between the amygdala and the vm/vl- PFC during an emotion regulation task ▫ Mason et al., 2016: CBT for psychosis associated with greater connectivity between amygdala and dlPFC in a social threat task 9 9  2024-11-18 Mindfulness and the Brain https://www.youtube.com/watch?v=5AqgMo1P05E Gotnik et al., 2016; Brain and Cognition ▫ Systematic review of 11 studies examining brain changes after 8 week MBSR program ▫ Increase in volume, activity, and connectivity of prefrontal cortex, cingulate cortex, insula, and hippocampus ▫ Decrease in amygdala activity and increased connectivity with prefrontal cortex 10 10  2024-11-18 Other “Brain” Interventions Psychopharmacology Selective serotonin reuptake inhibitors (SSRIs) recommended as first-line pharmacological treatment for depression ▪ Compared to previous medication generations (tricyclics and monoamine inhibitors): Side effect profile more mild Less fatal in case of overdose No evidence that they are more effective Benefit most pronounced for severe depression (otherwise, possible placebo effect) Most people discontinue use within 3 months, but course of average major depressive episode is 9 months 11 11  2024-11-18 Other “Brain” Interventions Deep-brain stimulation Neurostimulator implanted in brain sends electrical impulses to specific subcortical regions of the brain Good for research because control is built in – sham versus active stimulation Helen Mayberg, 2005: targeted subgenual cingulate in six patients with treatment-resistant depression ▪ 4/6 patients achieved sustained clinical response or remission at 6 months Being applied to other treatment-refractory conditions like OCD and anorexia nervosa 12 12  2024-11-18 Other “Brain” Interventions Reiff et al., 2020; American Journal of Psychiatry Scoping review of 161 studies on clinical application of psychedelic drugs for psychiatric disorders Psychedelics: psilocybin (serotonin agonist); lysergic acid diethylamide (LSD; serotonin agonist); ayahuasca (harmine and DMT); 3,4-Methylenedioxymethamphetamine (MDMA; many biological effects, including monoamine, serotonin, norepinephrine, and oxytocin) Psychedelic-assisted therapy: preparatory therapy, psychedelic session(s) [high-dose of drug], processed in integrative therapy 13 13  2024-11-18 Other “Brain” Interventions Dworkin, 2023; Clinical Pharmacology & Therapeutics Why combine psychedelics with psychotherapy? ▪ Psychological and physical safety ▪ May enhance magnitude and duration of benefit Are these synergistic treatments? ▪ Is the effect of the whole greater than the sum of its parts? Test using a factorial design ▪ Psychedelic + psychotherapy; Drug placebo + psychotherapy; Psychedelic + psychotherapy placebo; drug placebo + psychotherapy placebo 14 14  2024-11-18 Narratives about Psychotherapy and the Brain Perricone et al., 2024; Behavior Therapy Intervention to change belief that psychotherapy affects the mind, but not the brain Participants with elevated depression, people from general population, and mental health clinicians Pre-test (case description), biological explanation of depression (focused on serotonin) followed by randomization to one of three conditions: brain-level psychotherapy description, mind-level psychotherapy description (active control), or inactive control Biological explanation + inactive control = psychotherapy less effective; Biological explanation + brain-level psychotherapy description = psychotherapy more effective; Biological explanation + mind-level psychotherapy condition = no change 15 15  2024-11-18 What’s up next? Helping Career Professions and Graduate School 16 16  2024-11-18 Scaling Up Psychotherapy for Greater Reach Sarah E. Racine, PhD PSYC 408 Lecture 17 1 1  2024-11-18 Agenda Extending the reach of evidence-based practice Uses of technology in treatment Single-session interventions 2 2  2024-11-18 Extending the Reach of EBP Kazdin, 2017; Behaviour Research and Therapy Treatment gap: Difference in people who have a disorder and proportion who receive care ▪ WHO Mental Health Survey across 14 countries: 0.9% (Nigeria) to 15.3% (US) received treatment who needed it ▪ National Comorbidity Survey-Replication in US concluded only a third of people with psychiatric problem received adequate treatment 3 3  2024-11-18 Extending the Reach of EBP Kazdin, 2017; Behaviour Research and Therapy Reasons for treatment gap?? ▪ Treatment provided on a one-to-one basis ▪ Treatment administered by a highly trained professional ▪ Sessions held at a clinic, private office, or health-care facility (less true now) 4 4  2024-11-18 Extending the Reach of EBP Kazdin, 2017; Behaviour Research and Therapy Novel models of delivery ▪ Task shifting: Redistributing work to a broad range of individuals with less training and fewer qualifications ▪ Best-buy interventions: selected based on cost-effective, feasible, and appropriate to implement in setting ▪ Disruptive innovations: distinct change from what is being done currently; e.g., telemedicine ▪ Interventions in everyday settings: Reach people where they’re at! 5 5  2024-11-18 Extending the Reach of EBP Kazdin, 2017; Behaviour Research and Therapy Novel models of delivery ▪ Entertainment education: embed information in television or radio ▪ Use of social media: Bring interventions to people online ▪ Use of technologies: internet-based or app-based treatment delivery ▪ Community partnership model: partner with community organizations to develop action plans 6 6  2024-11-18 Uses of Technology in Treatment Psychoeducational or self-help formats ▫ Collection of “tools” designed to be educational ▫ Presented as “lessons”, rather than “sessions” Steven Hayes 7-part ACT mini-series: http://www.stevenchayes.com/ Digital treatments ▫ Retain structure and components of original treatment ▫ “Session” times set aside by user for intervention ▫ May have some degree of personalization (based on demographic group or presenting psychopathology) Developments in machine learning will make greater personalization possible ▫ User may select components of intervention that are most relevant 7 7  2024-11-18 Uses of Technology in Treatment Digital assessment ▫ Questionnaires can be automatically scored and interpreted, with information transmitted to clinician ▫ Can self-monitor thoughts, mood, activities using smartphone ▫ Can track non self-report phenomena, such as sleep, physical activity, speech, device usage, etc. ▫ Potential for “real-time” intervention Digital training and dissemination ▫ Clinical training websites with videos and demonstrations ▫ Reach more users and lower costs ▫ Standardized training provided 8 8  2024-11-18 Uses of Technology in Treatment What does the research suggest? ▫ Digital interventions are popular and reach a lot of people  ¾ million people have used MoodGYM since introduced in 2001  BUT Completion rates are low without accompanying support ▫ Online clinics can produce clinically relevant change on a large scale  In first year of operation, Australian online clinic MindSpot reached 2000 people, with 70% completing treatment ▫ Supported interventions have a greater impact than unsupported ones  Differences not always large ▫ With support, outcomes for digital interventions are similar to face- to-face interventions  Need larger scale studies to systematically test this 9 9  2024-11-18 Uses of Technology in Treatment http://www.thinkpacifica.com/cognitive-behavioral-therapy-app/ 10 10  2024-11-18 Uses of Technology in Treatment https://www.youtube.com/watch?v=wa4G25FCG6o 11 11  2024-11-18 Uses of Technology in Treatment Future research questions ▫ Does the functionality of the intervention impact its efficacy? ▫ How can interventions be tailored to the nature of the psychopathology?  Depression and concentration problems ▫ How do we evaluate the efficacy of digital interventions?  Field is arguably moving too fast for traditional RCTs ▫ How much support is necessary for improved outcomes?  Less support = more scalable 12 12  2024-11-18 Single-Session Interventions Types ▪ Pre-therapy or waitlist intervention to provide psychoeducation and/or to increase motivation for treatment ▪ Delivered after an assessment and combined with therapeutic resources ▪ Delivered online with or without support Advantages ▪ Brief, so less costly ▪ Scalable, especially if implemented online ▪ Reach people without financial resources or with other barriers to seeking traditional treatment 13 13  2024-11-18 Single-Session Interventions Schleider et al., 2022; Nature Human Behavior Nation(US)-wide RCT of online single-session interventions for adolescent depression ▪ Compared growth mindset (GM-SSI) and behavioural activation (BA-SSI) to active control ▪ Primary outcomes: hopelessness and agency post-treatment and depressive symptoms at 3 months ▪ 2,452 13-16 yos randomized to one of three conditions, 86.17% reported elevated depression ▪ Recruited via Instagram in late 2020 14 14  2024-11-18 Single-Session Interventions Schleider et al., 2022; Nature Human Behavior GM-SSI: neuroplasticity, growth mindsets to persevere, personality can change BA-SSI: values assessment, activity action plan, benefits/obstacles Control condition: supportive SSI that encourages emotion expression but does not teach behavioural skills 15 15  2024-11-18 Single-Session Interventions Schleider et al., 2022; Nature Human Behavior Results: ▪ Decreases in depression at 3 months in GM-SSI and BA-SSI, relative to control condition (between-group ds = 0.18; within-group ds = 0.43-0.47) ▪ Decreases in hopelessness, and increases in agency, at post-treatment in GM-SSI and BA-SSI, relative to control condition (between-group ds = 0.15-0.31) Implications: ▪ Small effect, but large implications considering how many youth could be reached by intervention ▪ Confirms effect size and replicability from previous uncontrolled studies ▪ Acceptability and efficacy of interventions for a diverse sample (80% of participants identified as sexual minority) 16 16  2024-11-18 What’s up next? Psychotherapy and the brain 17 17  2024-11-12 Process-Based Therapy; Personalizing Therapy Sarah E. Racine, PhD PSYC 408 Lecture 16 1 1  2024-11-12 Agenda Process-based therapy ▪ Individualizing therapy based on patient mechanisms Personalizing psychotherapy ▪ Adapting treatments to the individual in an evidence-based way 2 2  2024-11-12 Stats Primer: Mediation and Moderation Mediation Moderation Answers questions about why/how Answers questions about for ▪ Why do people experience less whom/to what extent depression when undergoing ▪ Who benefits the most from behavioural activation compared behavioural activation, compared to psychodynamic therapy? to psychodynamic therapy, in Tells us about mechanisms of terms of depressive symptoms? intervention Tells us about individual differences in response to an intervention 3 3  2024-11-12 Why target mechanisms? Historically, treatment development has focused on reduction of psychological symptoms and remission of psychological disorders What are the problems with this? ▪ Based on the DSM!! Excessive co-occurrence among psychological disorders Many risk and maintenance mechanisms are common to multiple psychological disorders ▪ Examples? 4 4  2024-11-12 Process-based therapy: Research Not what therapy works better for a specific diagnosis, on average, BUT: ▪ “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?” (Paul, 1969, as discussed in Hofmann & Hayes, 2019) Movement towards process-based therapy (vs. outcome-based therapy) ▪ How does change come about? What are the core change mechanisms? ▪ What change procedures (i.e., therapeutic techniques) are most effective at targeting core mechanisms? ▪ What specific treatment methods work best for different populations or under specific circumstances? 5 5  2024-11-12 Process-based therapy: Research From RCTs focused on outcome to studies designed to identify mediators and moderators Mediation – What process/mechanism links therapeutic technique to outcome? ▪ Need to establish that mechanism is malleable ▪ Other requirements (Kazdin, 2007; Annual Review of Clinical Psychology) Mechanism relates strongly to both intervention and outcome Effect is specific and replicable across studies A timeline is established, such that change in mechanism precedes change in outcome BUT, statistically significant mediation does not = a mechanism Moderation – What characteristics predict who will benefit from a particular treatment? ▪ Most often, demographic and other “moderators of convenience” are tested ▪ Can identify moderators based on knowledge of mechanisms, and moderator studies can further inform us about mechanisms 6 6  2024-11-12 Process-Based Therapy: Research Move from nomothetic to idiographic research methods How is the psychological behaviour maintained? What happens to the behaviour when the contingencies are changed? ▪ Functional analysis (Kazdin, 2012 chapter) Antecedent, Behaviour, Consequence Test, through experimental manipulation, each hypothesized function ▪ Using EMA and passive sensing data to create personalized models of maintaining processes Statistical approaches, like network modeling, to understand connections among processes 7 7  2024-11-12 Process-Based Therapy: Practice Examples of change processes vs. change procedures Cognitive defusion vs. mindfulness Avoidance vs. exposure Emotion regulation vs. cognitive reappraisal 8 8  2024-11-12 Process-Based Therapy: Practice Ong et al., 2023; Frontiers in Psychology 9 9  2024-11-12 Process-Based Therapy: Practice Ong et al., 2023; Frontiers in Psychology 10 10  2024-11-12 Process-Based Therapy: Practice Ong et al., 2023; Frontiers in Psychology 11 11  2024-11-12 Process-Based Therapy: Practice Ong et al., 2023; Frontiers in Psychology 12 12  2024-11-12 Personalizing Psychotherapy Stumpp & Sauer-Zavala (2021); Cognitive and Behavioral Practice Dimensions on which to personalize psychotherapy ▪ Diagnosis ▪ Specific symptoms/psychological processes ▪ Personality traits ▪ Pre-existing psychological skills (capitalization vs. compensation) ▪ Response to treatment (and reasons for lack of response) ▪ Change in psychological mechanisms over time 13 13  2024-11-12 Personalizing Psychotherapy Stumpp & Sauer-Zavala (2021); Cognitive and Behavioral Practice 14 14  2024-11-12 Unified Protocol for Emotional Disorders Core treatment modules: ▪ Understanding emotions ▪ Increasing present-focused emotional awareness ▪ Increasing cognitive flexibility ▪ Identifying and preventing patterns of emotional avoidance and maladaptive emotion-driven behaviours ▪ Increasing awareness and tolerance of emotion-related physical sensations ▪ Interoceptive and situation-based emotion-focused exposure 15 15  2024-11-12 Unified Protocol for Emotional Disorders Research Evidence ▪ Farchione et al., 2012; Behaviour Therapy  UP vs. wait-list control for patients with a principal anxiety disorder  UP improved symptoms of anxiety and depression, levels of negative and positive affect, and symptom interference in daily functioning  Effects maintained over 6-month follow-up Limitations ▪ No comparison to diagnosis-specific treatments ▪ Limited longitudinal follow-up data ▪ Limited data in other populations with problems with emotion regulation  Eating disorders, borderline personality disorder, substance use disorders 16 16  2024-11-12 Personalizing Psychotherapy Sauer-Zavala et al., 2022; Cognitive Behaviour Therapy SMART design (sequential multiple assignment randomized trial) testing personalization of unified protocol ▪ Examine effect of personalized sequence of modules on rate of symptom improvement Standard, capitalization, compensation ▪ Compare personalized selection of modules to full treatment 17 17  2024-11-12 Personalizing Psychotherapy Sauer-Zavala et al., 2022; Cognitive Behaviour Therapy 70 patients with an emotional disorder (average was three concurrent disorders) Randomized to standard, capitalization, and compensation conditions at outset After fifth or sixth session, randomized to discontinue versus receive full treatment (12 sessions) ▪ Received 2 or 3 modules vs. all 5 modules 18 18  2024-11-12 Personalizing Psychotherapy Sauer-Zavala et al., 2022; Cognitive Behaviour Therapy 19 19  2024-11-12 What’s up next? Scaling up psychotherapy for greater reach 20 20  2024-11-07 Dialectical Behavior Therapy (DBT) and its Applications Sarah E. Racine, PhD PSYC 408 Lecture 15 1 1  2024-11-07 Agenda Dialectical Dilemma and Therapist Stance Functions of DBT Components of DBT Treatment Package 2 2  2024-11-07 DBT Background Designed as a treatment for individuals with chronic suicidality or parasuicidality who did not respond favourably to CBT or other treatments ▫ Most patients with chronic suicidal behaviour have borderline personality disorder (BPD), but not all patients with BPD have suicidal behaviour Recognition that patients engage in behaviours that interfere with therapy, and that clinicians experience burnout and negative reactions to these patients 3 3  2024-11-07 DBT Background Based on Linehan’s Biosocial theory of borderline personality disorder Problems w/ Emotionally 1. Ability to An Understand & Vulnerable Invalidating Person Label feelings Environment 2. Coping skills 3. Emotion Modulation 4 4  2024-11-07 Dialectical Dilemma and Therapist Stance For patient: ▫ Emotional vulnerability vs. self-invalidation ▫ Active passivity vs. apparent competence ▫ Unrelenting crisis vs. inhibited grieving For therapist: ▫ Accept client as he/she is, but encourage change ▫ Centered and firm, but flexible when needed ▫ Nurturing, but benevolently demanding 5 5  2024-11-07 Dialectical Dilemma and Therapist Stance "Wise mind is that part of each person that can know and experience truth. It is where the person knows something to be true or valid. It is almost always quiet, It has a certain peace. It is where the person knows something in a centered way.“ - Linehan 6 6  2024-11-07 DBT Treatment Package Weekly individual therapy sessions Weekly group skills training session Telephone contact Therapist consultation team meeting Client must commit to all parts of treatment package for at least 1 year 7 7  2024-11-07 Five Functions of DBT Enhancing capabilities ▫ Improve several life skills in the context of weekly skills group session Generalizing capabilities ▫ Homework assignments to practice skills in natural environment Improving motivation and reducing dysfunctional behaviours ▫ Primarily accomplished in individual therapy 8 8  2024-11-07 Five Functions of DBT Enhancing and maintaining therapist capabilities and motivation ▫ Therapist consultation meetings provide support, validation, skill-building, and feedback Homework assignments to practice skills in natural environment Structuring the environment ▫ Want to reinforce effective behaviour/progress and not reinforce maladaptive or problematic behaviour ▫ Patients also need to modify their own environment 9 9  2024-11-07 DBT: Individual Therapy Hierarchy of therapy targets ▫ Suicidal and parsuicidal behaviours ▫ Therapy interfering behaviours ▫ Behaviours that interfere with quality of life ▫ Behaviours related to post-traumatic stress ▫ Improve self-esteem ▫ Individual targets negotiated with client ▫ https://www.youtube.com/watch?v=j_6j43zKNFw&list=PL_ L7KEOxOeQ_gwUQX8ExtaIt3jSm8XYbK&index=11 10 10  2024-11-07 DBT: Individual Therapy Diary card ▫ Track behaviours such as self-harm, suicide attempts, emotional misery ▫ Used to prioritize session time 11 11  2024-11-07 DBT: Skills Training Mindfulness Skills ▫ What skills: Observe, Describe, Participate ▫ How skills: Non-judgmentally, one-mindfully, effectively Interpersonal Effectiveness Skills ▫ Objectiveness, Relationship, and Self-respect effectiveness Emotion Regulation Skills ▫ Identify and describe emotions; Riding the wave of emotion; Opposite to emotion action https://www.youtube.com/watch?v=lXFYV8L3sHQ&index=23&list= PL_L7KEOxOeQ_gwUQX8ExtaIt3jSm8XYbK Distress Tolerance Skills ▫ Distraction; Self-soothing; Radical acceptance 12 12  2024-11-07 DBT: Research Evidence Linehan et al., 2006; Archives of General Psychiatry ▫ Dismantling study to examine specific ingredients of DBT ▫ Control for DBT non-specific factors such as hours of therapy, availability of group consultation, etc. ▫ Participants were women with BPD with recent suicidal behaviour (attempt or self-injury) ▫ Patients were matched to treatment condition on five prognostic variables ▫ Community therapists were nominated based on expertise treating difficult clients and identified as nonbehavioural or psychodynamic 13 13  2024-11-07 DBT: Research Evidence Linehan et al., 2006; Archives of General Psychiatry ▫ DBT < dropout and change in therapist than CTBE ▫ DBT half the rate of suicide attempts than CTBE ▫ No difference in non-suicidal self-injury between treatments ▫ DBT < use of crisis services and hospital admissions than CTBE ▫ Depression, suicidal ideation, and reasons for living improved in both conditions 14 14  2024-11-07 DBT: Research Evidence A shortened DBT efficacious for self-harm, suicidal ideation, and depressive symptoms for adolescents Efficacy data for BN and BED, but no evidence of superiority over CBT Preliminary evidence that DBT skills can be used as a stand-alone treatment for a variety of conditions 15 15  2024-11-07 DBT: Research Evidence Moore et al., 2018; Psychological Services ▫ 8-week skills group in jail setting for male inmates unselected for emotional or behavioural problems (n = 16 with complete data) ▫ No statistically significant changes in coping skills or emotional/behavioural dysregulation, likely owing to small sample size ▫ Participant feedback generally positive 16 16  2024-11-07 What’s up next? Process-based therapy; Personalizing psychotherapy 17 17  2024-11-04 Mindfulness-Based Therapies and Acceptance and Commitment Therapy Sarah E. Racine, PhD PSYC 408 Lecture 14 1 1  2024-11-04 Agenda What is Mindfulness? Mindfulness-based therapies Acceptance and Commitment Therapy (ACT) 2 2  2024-11-04 What is Mindfulness? “The awareness that arises from paying attention on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn, 1994) Intention Attention Attitude 3 3  2024-11-04 What is mindfulness? Kabat-Zinn’s seven attitudinal foundations of mindfulness ▫ Non-judging ▫ Patience ▫ Beginners mind ▫ Trust ▫ Non-striving ▫ Acceptance ▫ Letting go/be or non-attachment 4 4  2024-11-04 What is mindfulness? Formal mindfulness meditation practice ▫ Mindful breathing ▫ Body scan ▫ Mountain meditation ▫ Loving kindness mediation Informal practice ▫ Awareness of thoughts, emotions, bodily sensations and sensory input during everyday activities like:  Walking, Washing dishes, Brushing teeth, Eating 5 5  2024-11-04 Mindfulness-Based Stress Reduction (MBSR) Formal program developed by Kabat-Zinn Eight-week workshop with 2-3 hour group sessions each week, daily homework, and one-day retreat Not considered a formal therapy, but a compliment to traditional medical or psychological treatment To be a certified MSBR teacher, complete a 7-day course at Center for Mindfulness at U Mass Medical Center 6 6  2024-11-04 Mindfulness-Based Cognitive Therapy (MBCT) Developed in late 90s for depression relapse prevention Group treatment that integrates MBSR with CBT Move away from CBT’s emphasis on changing content of negative thinking towards attending to way in which all experience is processed Teasdale et al., 2000; Journal of Consulting and Clinical Psychology 7 7  2024-11-04 MBSR and MBCT: Evidence for Efficacy Hoffman et al., (2010); Journal of Consulting and Clinical Psychology ▫ Mindfulness-based therapy for depression and anxiety across a range of conditions ▫ Pre-post treatment: g = 0.63 for anxiety; g = 0.59 for mood ▫ In patients with mood and anxiety disorders, g =.97 for anxiety and.95 for mood, respectively Khoury et al., (2015); Journal of Psychosomatic Research ▫ MBSR in healthy individuals ▫ Pre-post mindfulness: g = 0.55; Between-group: g = 0.53 ▫ Large effects on stress; moderate effects on depression, anxiety, distress, quality of life 8 8  2024-11-04 Acceptance and Commitment Therapy (ACT) “Therapeutic approach that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility” (Hayes, Wilson, Strohasal, 1999) Traditional perspective on suffering: Humans are naturally psychologically healthy and, if we experience psychological pain, it means something is wrong and needs to be fixed ACT perspective on suffering: Negative emotions and thoughts are normal human experience; suffering is due to use of language and our attempts to control our internal human experience 9 9  2024-11-04 ACT: Philosophical Foundations Based on Relational Frame Theory (RFT) ▫ Our mind makes arbitrary connections between things, with connections based on history and context Tastes Apple Yummy Healthy Not as yummy Melon as apple 10 10  2024-11-04 ACT Model of Psychopathology and Treatment 11 11  2024-11-04 ACT Model of Psychopathology and Treatment Cognitive fusion: ▫ “Verbal dominance over behavioural regulation” OR taking your thoughts to literally ▫ Defusion: Mindfully noticing thinking as it occurs  “I am having the thought that….”  Watching thoughts go by as if they were on leaves floating down a stream Experiential avoidance ▫ Attempt to alter form, frequency, or function of private experiences, even when doing so is costly or ineffective ▫ Acceptance: Adopt an intentionally open and flexible posture about moment-to-moment experiences 12 12  2024-11-04 ACT Model of Psychopathology and Treatment Loss of flexible contact with present: ▫ Fusion and experiential avoidance lead to desire to be somewhere else ▫ Attend to what is present in a focused, voluntary, and flexible way ▫ Use language to note and describe internal events, rather than to predict and judge them Attachment to Conceptualized Self ▫ Promote contact with sense of self based on the here-and-now ▫ “Noticing self” or “Observer perspective” 13 13  2024-11-04 ACT Model of Psychopathology and Treatment Values Problems ▫ Persist or change in behaviour in the service of one’s chosen values ▫ Values: Predominant reinforcer is intrinsic to behaviour pattern itself; a direction rather than a destination ▫ Key problems in values: They are not yours; They are not clear; they are based on avoidance Inaction, impulsivity, and avoidance persistence ▫ Develop patterns of action linked to chosen values ▫ Set short-term, medium-term, and long-term concrete goals that are value-consistent 14 14  2024-11-04 ACT in Practice Due to problems with the nature of language, metaphors are used to explain ACT concepts to patients Creative hopelessness: Bring people into experiential contact with the fact that what they have done so far has not worked ▫ Chinese finger trap ▫ Tug-o-war 15 15  2024-11-04 ACT: Evidence Research support for treating: ▫ Depression ▫ Mixed anxiety conditions ▫ Obsessive-compulsive disorder ▫ Chronic pain ▫ Psychosis Research focused on testing processes of change and on functional, rather than symptom-focused, outcomes ▫ Mediation analyses that examine whether the treatment predicts change in ACT processes, which then predict change in outcome 16 16  2024-11-04 What’s up next? Dialectical Behaviour Therapy 17 17  2024-11-04 Contemporary Psychodynamic and Humanistic Therapies Sarah E. Racine PSYC 408 Lecture 13 1 1  2024-11-04 Agenda What are these therapies and what distinguishes them from CBT Examples ▫ Short-Term Psychodynamic Therapy ▫ Emotion-Focused Therapy ▫ Interpersonal Psychotherapy 2 2  2024-11-04 What are these therapies? Psychodynamic therapies ▫ Originate from Psychoanalysis ▫ Focus on unconscious processes that impact client’s present behaviour ▫ Examples: Short-term psychodynamic therapy Mentalization-based therapy Transference-focused psychotherapy 3 3  2024-11-04 What are these therapies? Humanistic/experiential therapies ▫ Originate from client-centered therapy ▫ Based on premise that individuals are “self-actualizing” ▫ Examples:  Gestalt therapy  Existential therapy  Emotion-focused therapy ▫ Other  Interpersonal psychotherapy 4 4  2024-11-04 What distinguishes these therapies? Blagys & Hilsenroth (2000) 1. A focus on affect and the expression of patient emotions  Intellectual insight not sufficient; need emotional insight  Encourage expression of emotions rather than management or control  Draw attention to feelings patient regards as uncomfortable 2. An exploration of the patient’s attempts to avoid topics or engage in activities that hinder therapy progress  Redirect conversation, not complete homework, miss session, not pay bill  Explore these disturbances to uncover unconscious meaning 5 5  2024-11-04 What distinguishes these therapies? 3. Identification of patterns in patient’s actions, thoughts, feelings, experiences, relationships  Identify patterns beyond those in thoughts  How patterns in interpersonal functioning repeat over time, settings, and people  Patterns are identified through interpretations 4. An emphasis on past experiences  Identify origin of patient difficulties and understand how they have manifested in lifetime (both past and present)  Emphasize both pre-adult and adult past  Recent trend for PI treatment to be more present-focused 6 6  2024-11-04 What distinguishes these therapies? 5. A focus on patients’ interpersonal experiences  Problematic relationships interfere with ability to fulfill needs and wishes  Compare and contrast patient functioning with that of others  Impact patient has on other people 6. An emphasis on the therapeutic relationship  Therapeutic relationship is a vehicle or medium of change  Transference = patient’s projections onto therapist  Therapist elicits feedback about client’s reactions to therapy 7. An exploration of patients’ wishes, dreams, or fantasies  Clues to unconscious functioning 7 7  2024-11-04 Short-Term Psychodynamic Therapy Goal ▫ Symptom relief AND limited, but significant, character change ▫ Work on one circumscribed area of focus Structure ▫ Once per week for less than one year (e.g., 16 sessions) ▫ Therapist must maintain therapeutic eye on chosen focus Candidature ▫ Patients should be psychologically minded, insightful, motivated ▫ Capacity to engage readily and disengage easily 8 8  2024-11-04 Short-Term Psychodynamic Therapy Techniques ▫ Supportive  Defining the therapeutic “frame”  Demonstrating genuine interest and respect  Noting gains  Maintaining here-and-now perspective ▫ Expressive  Offering empathic comments  Confrontation  Interpretation ▫ Monitoring countertransference 9 9  2024-11-04 Short-Term Psychodynamic Therapy Efficacy of short-term psychodynamic psychotherapy ▫ Steinert et al., (2017); American Journal of Psychiatry  Meta-analysis of 23 RCTs comparing psychodynamic therapy to an established treatment; both treatments using manuals  Primary outcome: target symptoms (e.g., depression); Secondary outcome: general symptoms and functioning  Tested for equivalence of two treatments  No difference between psychodynamic and comparator treatments at post-treatment (g = -0.15) and follow-up (g = -0.05)  Difference favouring psychodynamic treatment for functioning at follow-up (g = 0.16) 10 10  2024-11-04 Emotion-Focused Therapy Developed by Leslie Greenberg at York University Originally called Process-Experiential therapy 16-20 sessions Emotion is a key determinant of self-organization Emotions are useful from an evolutionary standpoint, but how we make sense of our emotional experiences is influenced by culture 11 11  2024-11-04 Emotion-Focused Therapy Types of emotions ▫ Primary: direct initial reaction (e.g., sadness from loss) ▫ Secondary: secondary to primary emotions (e.g., guilt over sadness) ▫ Adaptive: primary emotions that communicate information ▫ Maladaptive: “old familiar feelings” that do not change with situation 12 12  2024-11-04 Emotion-Focused Therapy Three principles targeted in treatment ▫ Emotion awareness  Become aware of primary adaptive emotions  Not thinking about feeling, but actually feeling the emotion  Accept rather than avoid emotional experiences  Express emotions, including what you feel in words ▫ Emotion regulation  First, work to determine which emotions need to be regulated  Teach emotion regulation sills, including tolerance and self- soothing 13 13  2024-11-04 Emotion-Focused Therapy Three principles targeted in treatment ▫ Emotion transformation  Process of changing emotion with emotion – undo a maladaptive emotional response with a more adaptive emotion ▪ “Fight fire (emotion) with fire (emotion)” Techniques used in emotion transformation: ▪ Shifting attention; Positive imagery; Remembering another emotion ▫ Other Techniques in EFT  Two-chair dialogue for self-critical conflicts  Empty-chair work for unfinished business 14 14  2024-11-04 Emotion-Focused Therapy Research Evidence ▫ EFT for major depression  Watson et al. (2004): Outcomes similar in EFT and CBT; greater decrease in interpersonal problems in EFT compared to CBT  Goldberg et al. (2006): symptom remission greater in EFT compared to client-centered therapy 15 15  2024-11-04 Interpersonal Psychotherapy Developed by Klerman and Weissman in 1970s Concerned with interpersonal context ▫ Relational factors that predispose, precipitate, and perpetuate distress Structure ▫ 12-16 sessions Suitability ▫ Secure attachment; specific interpersonal focus of distress; good support system 16 16  2024-11-04 Interpersonal Psychotherapy IPT problem areas ▫ Role transitions (e.g., move, new job, divorce) ▫ Role disputes (e.g., infidelity, unmet expectations) ▫ Grief ▫ Interpersonal sensitivity (difficulty forming and maintaining relationships) 17 17  2024-11-04 Interpersonal Psychotherapy IPT Structure ▫ Interpersonal inventory administered to choose problem area ▫ Work collaboratively to develop solutions to problem ▫ Patient implements solution(s) between session IPT Techniques ▫ Interpersonal incidents ▫ Communication analysis: https://vimeo.com/74267857 ▫ Problem solving and role-playing ▫ Encouragement of affect – content vs. process 18 18  2024-11-04 Interpersonal Psychotherapy Research Evidence ▫ Depression: Cuijpers et al., 2016; American Journal of Psychiatry  Meta-analysis of 62 RCTs of IPT for depression  d =.62 in favour of IPT compared to control treatments; d =.06 for IPT compared to other psychotherapies ▫ Bulimia nervosa (BN) and binge eating disorder (BED)  Agras et al., (2000): CBT more rapidly improves BN symptoms, compared to IPT, but those treated with IPT continue to improve post-treatment  Wilfley et al., (2000): Group IPT comparable to group CBT for BED 19 19  2024-10-23 CBT for Eating Disorders Sarah E. Racine, PhD PSYC 408 Lecture 12 1 1  2024-10-23 Agenda Transdiagnostic Formulation “Starting well” ▫ Self-monitoring ▫ Weekly weighing ▫ Regular eating Over-Evaluation of Shape and Weight Dietary Restraint/Restriction 2 2  2024-10-23 CBT-Enhanced (CBT-E) for Eating Disorders Transdiagnostic approach: ▫ Many ED features present across diagnoses (e.g., weight/shape concerns, binge eating, purging, dietary restriction) ▫ Most patients migrate across diagnoses over time ▫ Over-evaluation of shape/weight is central maintenance factor Precise form of applied treatment depends on presentation ▫ Additional “enhanced” modules can be used to address symptoms external to core ED ▫ Perfectionism, low self-esteem, major interpersonal problems ▫ Level of intensity specific to weight status BMI > 17.5, 20 sessions over 20 weeks BMI < 17.5, 40 sessions over 40 weeks 3 3  2024-10-23 “Starting Well” Engage the patient in treatment and change, increase motivation/commitment to treatment Collaboratively create a personalized formulation Psychoeducation about treatment and eating disorder Establish: ▫ Self-monitoring ▫ Weekly weighing ▫ Regular eating 4 4  2024-10-23 “Transdiagnostic” Formulation Philosophy: ED is vicious cycle maintained by interaction among thoughts, behaviours, and beliefs Goal is to understand what factors and symptoms are relevant to the patient Fairburn, 2008 5 5  2024-10-23 Self-monitoring Better understand processes maintaining the eating disorder (for therapist & patient) Accurate record of patient’s food intake Highlights key behaviours, feelings, thoughts, and the contexts in which they occur ▫ Specific examples to address in session ▫ Therapeutic work between sessions ▫ Increases patient self-awareness Encourage self-monitoring in “real time” 6 6  2024-10-23 Example Self-Monitoring Time Food Consumed Place Meal (M) Exercise Circumstances Snack (S) Binge (B) Purge (V,L) 12:00 ½ Banana Kitchen S Having a lot of trouble eating Trying not to throw up 2:30 ½ Banana Kitchen S 5:00 ½ Cantaloupe Kitchen S 6:30 Cottage cheese Kitchen B,V Almost made it pineapple Tough day peach, 1 cup My nerves are shot pasta salad Need to have this binge ½ cup Cole slaw Threw up, feel better 1 slice turkey ½ stuffed green pepper 3 meat balls 3 fat free hot dogs 1 box vanilla wafers 7 7  2024-10-23 Weekly Weighing Weight in lbs Normal Fluctuations in Weight Misinterpreting numbers or inconsequential weight fluctuations is likely to result in weight control behaviours no matter what the reading: ▫ If weight is up or the same: diet harder ▫ If weight is down: dieting reinforced, “better keep it up!” 8 8  2024-10-23 Weekly Weighing Procedure: ▫ No weighing at home (transfer to at-home weighing late in treatment) ▫ Weigh patient jointly at the beginning of each weekly session ▫ Joint plotting of weight graph ▫ Examination of trends over time “One can’t interpret a single reading” 9 9  2024-10-23 Regular Eating Prescribed pattern of regular eating 3 meals and 2-3 planned snacks No more than 3-4 hours between meals/snacks Mechanical, based on schedule, not hunger Eating takes precedence over other activities Initial emphasis on WHEN, later examine WHAT Urges to eat between meals/snacks? ▫ Problem solve, use incompatible behaviors, “surf the urge” 10 10  2024-10-23 Compensatory Behaviours Vomiting ▫ Educate on ineffectiveness (only rid self of 30-50% calories) ▫ Review consequences of vomiting ▫ Delay (use behavioural experiment to evaluate urge) Laxatives and diuretics ▫ Ineffective at preventing calorie absorption ▫ Throw away supplies or plan a schedule of withdrawal (consult with physician) 11 11  2024-10-23 Over-Evaluation of Shape and Weight Address the over-evaluation using two techniques: ▫ Develop new domains for self-evaluation Identify and try interests & activities ▫ Decrease the importance of shape and weight Body checking and avoidance, “feeling fat” 12 12  2024-10-23 Over-Evaluation of Shape and Weight Shape Checking ▫ Identify forms of shape checking; self monitor for 1-2 days (usually there is quite a bit – patients not always aware prior to monitoring) ▫ Mirror use – Think before you look What am I trying to find out? Can I find this out? Is there a risk that I will get unhelpful information? 13 13  2024-10-23 Over-Evaluation of Shape and Weight Body Avoidance ▫ Identify forms of avoidance ▫ Encourage exposure Body Comparison to Others ▫ Reduce frequency (awareness) ▫ Behavioral experiments, e.g., compare to every 5th women you pass on the street (illustrate sample bias) 14 14  2024-10-23 Over-Evaluation of Shape and Weight “Feeling Fat” ▫ Identify triggers (monitoring) & address ▫ Psychoeducation “What else am I feeling right now? 15 15  2024-10-23 Dietary Restraint and Dietary Restriction Restraint: Attempted under-eating (e.g., food rules) Restriction: Actual under-eating Restraint Avoidance of certain foods → Systematic exposure Other common rules and rituals to address ▫ Not eating after certain time ▫ Eating less in front of others ▫ Only eating food if nutrition known 16 16  2024-10-23 Dietary Restraint/Restriction Food Hierarchy Gradual exposure to feared foods Systematic exposure from easiest to most difficult Can also incorporate other fears (e.g., eating after 7pm, eating in public) Combination of in-session and home exposures Goal = Decrease patient fear of loss of control, modify distorted assumptions Plan ahead: Identify food, when, where, etc. 17 17  2024-10-23 Residual Binge Eating Regular eating should stop most binge eating (and subsequent compensatory behaviours) ▫ Identify triggers for remaining binges using “binge analysis” 18 18  2024-10-23 CBT-E for Eating Disorders: Evidence de Jong, Schoort, & Hoek, 2018; Current Opinion in Psychiatry ▫ Seven trials (5 RCTs; 2 open trials) since January 2014 ▫ Three with a BN sample; Four with a transdiagnostic sample ▫ In RCTs: CBT-E performed better than IPT, psychoanalytic therapy, and no treatment CBT-E was equivalent to integrative cognitive affective therapy; Broad and focused versions were equivalent ▫ Remission rates varied from 22.2-67.6% due to differences in sample and operationalization of clinically significant change 19 19  2024-10-23 CBT-E for Eating Disorders: Evidence Tatham et al., 2020; International Journal of Eating Disorders ▫ CBT-Ten session protocol (CBT-T) ▫ Cohort comparison between patients treated with CBT-E versus CBT-T at same clinic ▫ Differences in treatments: Focus on early parts of treatment protocol; include more exposure exercises; delivered by “assistant psychologists” ▫ Change in eating disorder symptoms and clinical impairment was similar in CBT-E vs. CBT-T ▫ Large decreases during treatment, with gains maintained at 6- month follow-up 20 20  2024-10-23 What’s up next? Exam #2 21 21  2024-10-22 Behavioural Activation for Depression Sarah E. Racine, PhD PSYC 408 Lecture 11 1 1  2024-10-22 Agenda Behavioural Models of Depression Behavioural Activation ▫ Model ▫ Treatment ▫ Evidence 2 2  2024-10-22 Behavioural Models of Depression Depression associated with a particular behaviour- environment relationship that evolves over time Focused on “if-then” contingencies – what are the consequences of the behaviour for the person? Ferster: Decreased rates of response-contingent reinforcement lead to: 1) “turning inward”; 2) “doing nothing”; 3) escape and avoidance Lewinsohn: Social avoidance core to depression 3 3  2024-10-22 Behavioural Activation: Model Behavioural responses reduce ability to experience positive reward from environment Treatment focuses on activation and processes that inhibit activation, such as escape and avoidance behaviours and ruminative thinking 4 4  2024-10-22 Behavioural Activation: Treatment Points to address when presenting treatment model: ▫ Events in your life, and how you respond, influence how you feel ▫ Lives that provide too many problems and not enough rewards can lead to depression ▫ People pull away from the world when life is less rewarding ▫ Pulling away can increase depression and make it hard to solve problems effectively ▫ Treatment is not just “doing more” but figuring out what activities would be most helpful 5 5  2024-10-22 Behavioural Activation: Treatment 6 6  2024-10-22 Behavioural Activation: Treatment Review activity monitoring form to look for contingencies maintaining behaviour ▫ Positive reinforcement from friends/family ▫ Negative reinforcement through escape/avoidance of painful feelings Use activity monitoring to design intervention ▫ What would client be doing if (s)he were not depressed? ▫ What is relationship between specific activities and ratings of mastery and pleasure? ▫ What is the relationship between specific life contexts/problems and ratings of mastery and pleasure? ▫ How are avoidance and withdrawal contributing to depression? 7 7  2024-10-22 Behavioural Activation: Treatment Activity scheduling ▫ Use monitoring forms to schedule activities for the week ▫ Help client maximize success!  Public commitment  Structure environment  Arbitrary reinforcers  Aversive contingencies ▫ Record context and consequences of activation ▫ Gather information about incomplete homework to understand barriers and avoidance patterns 8 8  2024-10-22 Behavioural Activation: Treatment ACTION! ▫ Targeting avoidance of tasks, emotions, interpersonal conflicts, etc.  Assess whether the behaviour is approach or avoidance  Choose to continue the behaviour, even if it is making you feel worse, or to try a new behaviour  Try the behaviour chosen  Integrate a new behaviour into your routine – give it a fair chance  Observe the results – monitor the effects of the new behaviour  Never give up! Change requires repeated efforts and attempts 9 9  2024-10-22 Behavioural Activation: Treatment Engagement Strategies ▫ Rumination prevents people from engaging with their activities and environments ▫ Unlike cognitive therapy, don’t care about content of rumination ▫ If client does not experience pleasure in an activity (s)he normally would, explore level of engagement ▫ Rumination can be negatively reinforced! ▫ Attention to experience 10 10  2024-10-22 Behavioural Activation: Evidence Dimidjian et al. (2017) ▫ Pragmatic effectiveness randomized controlled trial conducted at four sites across USA ▫ 163 pregnant women randomized to behavioural activation (BA) or treatment as usual (TAU) ▫ BA: 10 sessions provided in clinic, by phone, or in women’s homes by health care professionals naïve to BA ▫ Primary outcomes: change in symptoms and remission rates based on Patient Health Questionnaire (PHQ-9) ▫ Secondary outcomes: anxiety, stress, treatment satisfaction ▫ Changes in activation and environmental reward early in treatment would mediate association between treatment condition and improvement in depression symptoms 11 11  2024-10-22 Behavioural Activation: Evidence Dimidjian et al. (2017) ▫ Depression symptoms were lower in the BA vs. the TAU condition at all follow-up time points; d = 0.34 ▫ 56.3% remission in BA vs. 30.3% remission in TAU ▫ Anxiety: d = 0.41; Stress: d = 0.33 ▫ Change in engagement and environmental reward early in treatment mediated effect of treatment condition on follow-up improvement in depression symptoms ▫ BA is a scalable behavioural intervention that can help improve depression during pregnancy, consistent with women’s preferences for psychological vs. pharmacological interventions 12 12  2024-10-22 Behavioural Activation: Evidence Other Evidence ▫ Dimidjian et al. (2006): Journal of Consulting and Clinical Psychology  Among moderate-to-severely depressed patients, BA was superior to cognitive therapy and equivalent to or superior than antidepressant medicatiion ▫ Ekers et al., (2014): PLOS ONE  Meta-analysis of 26 RCTs; BA superior to control conditions and to antidepressant medication ▫ Richards et al. (2016); The Lancet  BA delivered by junior mental health workers was not inferior to CBT delivered by psychological therapists 13 13  2024-10-22 What’s up next? CBT for Eating Disorders 14 14  2024-10-07 Exposure Therapy for Anxiety Disorders Sarah E. Racine, PhD PSYC 408 Lecture 10 1 1  2024-10-07 Agenda Brief history of exposure therapy Overview of exposure therapy Proposed mechanisms of change Types of exposure Modes of delivery Typical course of therapy Advantages/disadvantages 2 2  2024-10-07 History of Exposure Therapy Developed in the 1950s Joseph Wolpe: developed systematic desensitization after being dissatisfied with existing treatments for PTSD ▫ Reciprocal inhibition ▫ Also developed Subjective Units of Distress Scale (o-100 scale to rate distress during exposure) 3 3  2024-10-07 Overview of Exposure Therapy How a fear develops: Neutral stimulus evokes fear response ▫ Avoidance/safety behaviour maintains fear Trauma/bad experience ▫ Generalize from one specific instance so that similar stimuli come to evoke fear  E.g., Get bit by dog, come to fear all dogs ▫ Benign stimuli associated with the event begin to evoke fear response  E.g., After car accident, fear response to cars, location where accident happened, individuals who were present, etc. 4 4  2024-10-07 Overview of Exposure Therapy What is exposure therapy? Set of therapeutic techniques used to teach clients to approach feared stimuli May be paired with relaxation techniques and/or prevention of compulsions or safety behaviours Goals: Allow client to learn that fear response diminishes over time Help client learn corrective information about the feared stimulus 5 5  2024-10-07 Mechanisms of Change Habituation Over time, physical sensations associated with fear or anxiety naturally reduce Extinction Feared stimulus is no longer paired with escape/avoidance behaviour Stimulus may be paired with relaxation so that new association is learned 6 6  2024-10-07 Mechanisms of Change Learning of corrective information Over repeated trials, clients learn that feared outcome does not happen, or is very unlikely Increased self-efficacy Even if fear response is not completely extinguished, client learns that he/she can handle feelings 7 7  2024-10-07 Types of Exposure Graded exposure Client slowly exposed to increasingly difficult stimuli ▫ E.g., fear of heights: start on 5th floor of building, move up to rooftop Systematic Desensitization Like graded exposure, but with the addition of relaxation techniques ❑ Cannot be relaxed and anxious at the same time ❑ Not everyone likes relaxation techniques 8 8  2024-10-07 Types of Exposure Prolonged Exposure Designed to treat PTSD Repeated revisiting of traumatic event ▫ Client recounts experience in great detail Exposure to situations/objects/individuals that are reminders of the traumatic event, but that do not pose a threat Facilitates emotional processing of event 9 9  2024-10-07 Types of Exposure One-session One extended session (up to 3hrs) Includes instruction, modelling, exposure, cognitive challenge Shown to be efficacious in adult populations, some evidence supporting use in child/adolescent populations 10 10  2024-10-07 Modes of Delivery In vivo: exposure to actual feared stimulus, or some approximation Sometimes requires creativity Imaginal: client imagines feared stimulus when it isn’t feasible to do in vivo exposure Frequently used for PTSD, GAD, phobias of uncommon stimuli Not all clients will be able to engage in this – need to have good visualization skills 11 11  2024-10-07 Modes of Delivery Virtual reality: used when in vivo isn’t feasible Good alternative to imaginal for clients who have difficulty with visualization Becoming more accessible, but still not widely used Interoceptive: exposure to physical sensations Especially useful for panic disorder or for clients who find physical anxiety symptoms to be unacceptable Clients learn that symptoms are not dangerous 12 12  2024-10-07 Modes of Delivery Modelling Not primary intervention – used as adjunct Can help to ease client into exposure Shows client that feared outcome is unlikely/impossible Shouldn’t ask client to do anything that you wouldn’t do! ▫ In fact, good idea to try out everything that clients will be doing, to know what their experience will be like 13 13  2024-10-07 Typical Course of Therapy: Exposure and Response Prevention for OCD Caroline (Himle & Franklin, 2009) Obsessions about causing harm to others through ”bad energy” or illness Engages in several compulsions to reduce her anxiety Goals for therapy: ▫ Teach Caroline to face feared situations ▫ Prevent her from engaging in compulsions ▫ Work on her maladaptive thinking 14 14  2024-10-07 Typical Course of Therapy Early sessions Assessment of symptoms and interference ▫ Caroline reports several obsessions related to causing harm to others and compulsions aimed at reducing the anxiety they cause ▫ Her symptoms are interfering in her daily life  Time consuming  Avoidance of people/situations 15 15  2024-10-07 Typical Course of Therapy Early sessions Psychoeducation ▫ Describe nature of OCD ▫ Explain how compulsions maintain anxiety Provide rationale for exposure ▫ Extinction: stop “feeding” obsessions by engaging in compulsions ▫ Improvement will take time – will actually experience more distress in the short-term ▫ Describe empirical findings that support the use of exposure ▫ Can also use example from client’s life (e.g., going on a first date with husband) 16 16  2024-10-07 Typical Course of Therapy Early Sessions Introduce symptom monitoring and SUDS ratings ▫ Shows pattern of anxiety (e.g., triggers, thoughts, distress, responses) ▫ SUDS = Subjective Units of Distress Scale Construct fear hierarchy ▫ Use SUDS ratings from monitoring to create hierarchy ▫ Start with moderately easy items (SUDS 16 sessions) durations ▫ Therapist FIS may contribute to sudden gains early in therapy 13 13  2024-09-09 Common VERSUS Specific Factors Evidence that favours common over specific factors ▫ Any therapy is better than no therapy ▫ Therapies often do not differ when pitted against one another  Differences that do exist often reduced when controlling for investigator allegiance ▫ Adherence to specific therapy techniques unrelated to outcome  Null correlation between therapist fidelity measures and patient response However…. ▫ No controlled studies exist to demonstrate that common factors are sufficient for causing therapeutic change 14 14  2024-09-09 Common VERSUS Specific Factors Lubrosky et al. (2002); Clinical Psychology: Science and Practice ▫ “The Dodo Bird Verdict is Alive and Well – Mostly” ▫ Examination of 17 meta-analyses comparing different forms of psychotherapy to one another ▫ Mean effect size: d =.21 ▫ Controlling for investigator allegiance reduces effect: d =.12 15 15  2024-09-09 Common VERSUS Specific Factors Barth et al. (2013); PLOS One ▫ Meta-analysis of 198 studies of seven psychotherapies for depression ▫ Each intervention was more effective than waitlist control: ds =.62-.92 ▫ Effect sizes similar for different interventions, with one exception 16 16  2024-09-09 Common VERSUS Specific Factors Tolin (2010); Clinical Psychology Review ▫ CBT versus other psychotherapies (interpersonal, psychodynamic, supportive) ▫ Only comparisons considered “bona fide” treatments versus “intent-to-fail” conditions ▫ 26 studies ▫ CBT superior to psychodynamic therapy: d =.28 ▫ CBT only significantly superior for depression and anxiety ▫ Investigator allegiance to CBT correlated with strength of study effect, but CBT remained superior 17 17  2024-09-09 Common VERSUS Specific Factors Mulder, Murray, & Ruckledge (2017); Lancet Psychiatry ▫ More similarities than differences  Specific factor theorists agree that common factors are important and therapeutic relationship is necessary (but not sufficient)  Common factors theorists have tightened definition of “bona fide” treatments  Common factors theorists acknowledge that some specific techniques are more effective than others for particular conditions ▪ Exposure for anxiety disorders 18 18  2024-09-09 Common VERSUS Specific Factors Mulder, Murray, & Ruckledge (2017); Lancet Psychiatry ▫ Moving forward…  Prioritize treatment process over treatment outcome research ▪ Focus not on WHAT works, but HOW it works  Remember that evidence for efficacy validity of treatment ▪ Remain skeptical!  Train students in therapeutic principles of CBT ▪ Focus on specific techniques when evidence shows therapeutic benefit 19 19  2024-09-09 Common VERSUS Specific Factors Debate between ▫ Bruce Wampold (Common Factors Theorist) ▫ Peter Fonagy (Creator of Mentalization-Based Therapy, a psychodynamic treatment for borderline personality disorder) https://www.youtube.com/watch?v=U5fhhAZnduU 20 20  2024-09-09 What’s up next? Evidence-based practice ▫ A way of marrying common and specific factors approaches 21 21  2024-09-05 Research Methods in Psychotherapy Sarah E. Racine, PhD PSYC 408 Lecture 3 1 1  2024-09-05 Agenda Steps in conducting a Randomized Controlled Trial to empirically evaluate psychotherapy Definition of an empirically-supported treatment Past and present 2 2  2024-09-05 Research on Psychotherapy With increase in types of psychotherapy, framework to evaluate psychotherapy developed Methods: Case studies Naturalistic studies Quasi-experiments Randomized controlled trials (RCTs)  Adopted from medicine  Experimental design = cause and effect 3 3  2024-09-05 Randomized Controlled Trial: Steps Step 1: Develop the protocol Step 2: Choose comparison to treatment of interest Step 3: Select participants of interest Step 4: Randomly assign participants to conditions Step 5: Administer treatment and assess fidelity Step 6: Evaluate outcomes at end of treatment Step 7: Evaluate outcomes at follow-up time points 4 4  2024-09-05 Step 1: Develop the Protocol What is the treatment? Theoretical model  May come from arm-chair theorizing, clinical observation, basic psychological research Treatment techniques  What will you do in therapy to change problems specified in theoretical model? How will the treatment be administered? Needs to be standardized  Development of treatment manuals  Training and supervision of clinicians 5 5  2024-09-05 Step 2: Choose Comparison Treatment To what will you compare the treatment of interest? Waitlist control  Not equivalent to placebo in pharmacotherapy trials  Eventually administer treatment for ethical reasons Supportive psychotherapy  Control for interaction with therapist and common factors Gold standard treatment  CBT is often gold standard to which new treatments are compared 6 6  2024-09-05 Step 3: Select Participants Who will your participants be? Balance concerns with internal versus external validity  Internal validity: quality of experimental design and control for extraneous factors  External validity: will results extend to other people and settings Ideally, want participants to be representative of population of persons to which results will be generalized  Demographic factors  Comorbid diagnoses 7 7  2024-09-05 Step 4: Random Assignment Assess baseline characteristics of participants Random assignment minimizes pre-existing differences between groups that could affect outcome e.g., gender, race, baseline levels of depression Blinding Single-blind versus double-blind Double-blind not possible in psychotherapy trials 8 8  2024-09-05 Step 5: Administer Treatment Are the therapists administering the treatment as outlined? Fidelity checks How well is the treatment being administered? Therapist factors 9 9  2024-09-05 Step 6: Evaluate Treatment What is the outcome of interest? No longer meeting DSM diagnostic criteria A decrease in target symptoms  By how much? A decrease in comorbid symptoms  e.g., decrease in anxiety in treatment for depression An increase in functioning  Occupational, social 10 10  2024-09-05 Step 6: Evaluate Treatment Statistical significance p <.05; 5% likelihood that result occurred by chance Magnitude of effect AND sample size influence statistical significance Effect size Magnitude of difference, independent of sample size Formula: Mean difference between experimental and control group/standard deviation of control group Cohen’s d: 0.2 = small; 0.5 = medium; 0.8 = large How much change is needed for clinical significance? 11 11  2024-09-05 Step 6: Evaluate Treatment Therapist and site effects Random factors unrelated to treatment must be accounted for What about people who drop-out? Intention-to-treat analyses 12 12  2024-09-05 Step 7: Follow-up What happens after treatment is withdrawn? Relapse Sleeper effect Psychological treatment more enduring than medication (DeRubeis, Siegle, & Hollon, 2008) 13 13  2024-09-05 Reporting RCT Results CONSORT Flow Diagram 14