https://www.ceunits.com/trainings/175/CEU_pdf_175.pdf

Evidence-based therapy relationships.

Background
Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.

Findings
The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths’ environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.

Conclusion
The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians’ use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

/pdf/annual-research-review-building-a-science-of-personalized-4fubxbolv0.pdf

Annual Research Review: Building a science of personalized intervention for youth mental health

Objective Although integrating motivational interviewing (MI) and cognitive-behavioral therapy (CBT) has been recommended for treating anxiety, few well-controlled tests of such integration exist. Method In the present randomized trial for severe generalized anxiety disorder (GAD), we compared the efficacy of 15 sessions of CBT alone (N = 43) versus 4 MI sessions followed by 11 CBT sessions integrated with MI to address client resistance/ambivalence (N = 42). Clients were adults, predominantly female and Caucasian, with a high rate of diagnostic comorbidity. To control for allegiance, therapists were nested within treatment group and supervised separately by experts in the respective treatments. Results Piecewise multilevel models revealed no between-groups differences in outcomes from pre- to posttreatment; however, there were treatment effects over the follow-up period with MI-CBT clients demonstrating a steeper rate of worry decline (γ = -0.13, p = .03) and general distress reduction (γ = -0.12, p = .01) than CBT alone clients. Also, the odds of no longer meeting GAD diagnostic criteria were ∼5 times higher at 12-months for clients receiving MI-CBT compared with CBT alone. There were also twice as many dropouts in CBT alone compared with MI-CBT (23% vs. 10%); a difference that approached significance (p = .09). The treatments were competently delivered, and intraclass correlations revealed negligible between-therapist effects on the outcomes. Conclusions The findings support the integration of MI with CBT for severe GAD and point to the importance of training therapists in appropriate responsivity to in-session markers of resistance and ambivalence. (PsycINFO Database Record

Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial.

Psychological reactance theory (PRT; Brehm, 1966) posits that when something threatens or eliminates people’s freedom of behavior, they experience psychological reactance, a motivational state that drives freedom restoration. Complementing recent, discipline-specific reviews (e.g., Quick, Shen, & Dillard, 2013; Steindl, Jonas, Sittenthaler, Traut-Mattausch, & Greenberg, 2015), the current analysis integrates PRT research across fields in which it has flourished: social psychology and clinical psychology, as well as communication research. Moreover, the current review offers a rare synthesis of existing reactance measures. We outline five overlapping waves in the PRT literature: Wave 1: Theory proposal and testing; Wave 2: Contributions from clinical psychology; Wave 3: Contributions from communication research; Wave 4: Measurement of reactance; and Wave 5: Return to motivation. As part of our description of Wave 5, we detail scholars’ renewed focus on motivational aspects of the framework, and the ways in which this return to PRT’s motivational roots is allowing researchers to push its accuracy and applicability forward. We use this research that is already occurring in Wave 5 to outline three specific ways in which scholars can direct the continued application of motivation science to the advancement of PRT. Finally, as we outline in a future directions sections for each Wave, the assimilation of this research illustrates the ways in which an emphasis on motivation can expand and explain PRT research in communication, clinical psychology, and measurement.

/pdf/a-50-year-review-of-psychological-reactance-theory-do-not-2hrigq61sp.pdf

A 50-year review of psychological reactance theory: Do not read this article.

A debate exists about whether the common factors or specific ingredients are critical to producing the benefits of psychotherapy. A model of the relationship, based on evolved human characteristics related to healing, is presented that integrates common factors and specific ingredients. After the initial bond is formed, the relationship involves three healing aspects: the real relationship, the creation of expectations, and participation in healthy actions.

The 2011 Leona Tyler Award Address The Relationship—and Its Relationship to the Common and Specific Factors of Psychotherapy

Psychotherapists from all professions and perspectives periodically struggle to effectively manage a patient's resistance to change. This article provides definitions and examples of patient-treatment matching applied to patient resistance or reactance. We report the results from an original meta-analysis of 12 select studies (N = 1,102) on matching therapist directiveness to patient reactance. Our findings support the hypothesis that patients exhibiting low levels of trait-like resistance respond better to directive types of treatment, while patients with high levels of resistance respond best to nondirective treatments (d = .82). Limitations of the research reviewed are noted, and practice recommendations are advanced.

John Holman

Papers

Resistance/Reactance Level

Reactance/resistance level.