Attachment--and loss.

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A Secure Base Clinical Applications Of Attachment Theory

Over the past three decades, cognitive-behavioral therapy (CBT) has become a first-line psychosocial treatment for individuals with chronic pain. Evidence for efficacy in improving pain and pain-related problems across a wide spectrum of chronic pain syndromes has come from multiple randomized controlled trials. CBT has been tailored to, and found beneficial for, special populations with chronic pain, including children and older adults. Innovations in CBT delivery formats (e.g., Web-based, telephone-delivered) and treatments based on CBT principles that are delivered by health professionals other than psychologists show promise for chronic pain problems. This article reviews (a) the evidence base for CBT as applied to chronic pain, (b) recent innovations in target populations and delivery methods that expand the application of CBT to underserved populations, (c) current limitations and knowledge gaps, and (d) promising directions for improving CBT efficacy and access for people living with chronic pain.

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Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research.

Objective: The authors conducted a meta-analytic review of adherence–outcome and competence– outcome findings, and examined plausible moderators of these relations. Method: 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. Results: 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. Conclusions: 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.

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Therapist Adherence/Competence and Treatment Outcome: A Meta-Analytic Review

OBJECTIVE Evidence-based practice involves the consideration of efficacy and effectiveness, clinical expertise, and patient preference in treatment selection. However, patient preference for psychiatric treatment has been understudied. The aim of this meta-analytic review was to provide an estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders. DATA SOURCES A literature search was conducted using PubMed, PsycINFO, and the Cochrane Collaboration library through August 2011 for studies written in English that assessed adult patient preferences for the treatment of psychiatric disorders. The following search terms and subject headings were used in combination: patient preference, consumer preference, therapeutics, psychotherapy, drug therapy, mental disorders, depression, anxiety, insomnia, bipolar disorder, schizophrenia, substance-related disorder, eating disorder, and personality disorder. In addition, the reference sections of identified articles were examined to locate any additional articles not captured by this search. STUDY SELECTION Studies that assessed preferred type of treatment and included at least 1 psychological treatment and 1 pharmacologic treatment were included. Of the 644 articles identified, 34 met criteria for inclusion. DATA EXTRACTION Authors extracted relevant data including the proportion of participants reporting preference for psychological or pharmacologic treatment. RESULTS The proportion of adult patients preferring psychological treatment was 0.75 (95% CI, 0.69-0.80), which was significantly higher than equivalent preference (ie, higher than 0.50; P < .001). Sensitivity analyses suggested that younger patients (P = .05) and women (P < .01) were significantly more likely to choose psychological treatment. A preference for psychological treatment was consistently evident in both treatment-seeking and unselected (ie, non-treatment-seeking) samples (P < .001 for both) but was somewhat stronger for unselected samples. CONCLUSIONS Aggregation of patient preferences across diverse settings yielded a significant 3-fold preference for psychological treatment. Given evidence for enhanced outcomes among those receiving their preferred psychiatric treatment and the trends for decreasing utilization of psychotherapy, strategies to maximize the linkage of patients to preferred care are needed.

Patient Preference for Psychological vs Pharmacologic Treatment of Psychiatric Disorders: A Meta-Analytic Review

Assessing intervention competence and its relation to therapy outcome: A selected review derived from the outcome literature.

The psychometric properties of the MASC in a pediatric psychiatric sample.

The influence of treatment preferences on the development of the therapeutic alliance was investigated. Seventy-five patients were followed while participating in a randomized controlled trial comparing supportive-expressive psychotherapy with sertraline or pill placebo in the treatment of major depressive disorder. Therapeutic alliance was assessed before treatment and at the 3rd, 5th, and 9th weeks of treatment. Among patients initially preferring psychotherapy, those receiving psychotherapy experienced increases in their alliance over time, whereas those receiving active medication or placebo experienced decreases. Among patients preferring pharmacotherapy, there were no differences in alliance development whether they received psychotherapy, active medication, or placebo. These relations were observed even when controlling for symptom severity. Thus, the congruence of patients' treatment preference and the treatment that they ultimately received influenced the development of the therapeutic alliance. Because alliance is a robust predictor of outcome, treatment preferences may need to be carefully considered in randomized controlled trial settings.

Treatment preferences affect the therapeutic alliance: implications for randomized controlled trials.

The relation of the therapeutic alliance with outcome is one of the most researched topics in the field of psychotherapy, with three decades of empirical research consistently linking these two variables. Horvath, Del Re, Fluckiger and Symonds (2011) showed that the correlation between alliance and psychotherapy outcome across 14,000 treatments was small to moderate (r = .27) but reliable, with no significant differences among treatment orientations. Based on these and similar findings, many scholars have posited that alliance is an active ingredient in therapy, meaning it is therapeutic in and of itself, and accounts for at least part of the variance in treatment outcome (e.g., Fluckiger, Del Re, Wampold, Symonds, & Horvath, 2012).

However, in recent years, there have been several challenges to the idea that greater alliance causes good outcomes. Namely, some researchers have proposed that good alliances may be the result of changes in symptoms, rather than the other way around (e.g., Barber, 2009; DeRubeis, Brotman, & Gibbons, 2005). Support of this hypothesis is found in studies of the alliance-outcome correlation that accounted for symptomatic change prior to alliance measurement. More specifically, some studies showed that early symptomatic change predicted alliance and that only early symptomatic change (and not alliance) could predict subsequent changes in symptoms (e.g., Barber et al., 1999). Other studies found that alliance still makes a unique contribution to the prediction of outcome, even after controlling for early symptomatic change (e.g., Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000), and that early symptomatic change does not necessarily drive subsequent changes in alliance (e.g., Klein et al., 2003)(for a review, see Crits-Christoph, Gibbons, & Mukherjee, 2013). Taken together, these studies, which control for symptomatic change early in treatment, have called into question the direction of causality between alliance and symptomatic change.

Most if not all of the studies reviewed by Crits-Christoph et al. (2013) focused on the ability of the alliance at only a single time point to predict symptomatic change. Recently, researchers have started to implement analytic methods that enable us to assess the alliance-outcome relation at more than one time point and therefore facilitate the examination of reverse causality between alliance and symptoms. Such analytic methods include autoregressive cross-lagged modeling (ARCL), which enables the exploration of temporal precedence between variables examined longitudinally (e.g., Kenny & Harackiewicz, 1979). While this method has been successfully applied to many research areas both outside of psychology and within it (including the field of psychotherapy research, e.g., Brossart, Willson, Patton, Kivlighan, & Multon, 1998; Donegan & Dugas, 2012; Liverant, Suvak, Pineles, & Resick, 2012; Smits, Rosenfield, McDonald, & Telch, 2006; Zilcha-Mano, Dinger, McCarthy, Barrett, & Barber, in press), it has seldom been used to investigate the temporal precedence between alliance and symptoms. Using the ARCL and similar methods, preliminary studies have found that in a very brief treatment (Falkenstrom, Granstrom, & Holmqvist, 2013) and in a relatively small sample size of patients treated by inexperienced therapists (Crits-Christoph, Gibbons, Hamilton, Ring-Kurtz, & Gallop, 2011), alliance may still predict symptoms while controlling for the previous symptomatic levels in individual psychotherapy (for the use of similar methods in group psychotherapy and family therapy, see Tasca & Lampard, 2012 and Marker, Comer, Abramova, & Kendall, 2013, respectively).

Building on these findings, we used the ARCL in the current study to examine whether (a) previous alliance levels could predict subsequent symptomatic levels throughout treatment while controlling for prior symptomatic levels (see Figure 1a); and (b) whether previous symptomatic levels could predict subsequent alliance levels throughout treatment, while controlling for prior assessments of alliance (see Figure 1b). In this study the temporal relationship between alliance and symptoms was examined across three treatments—supportive-expressive psychotherapy (SET), supportive clinical management combined with pharmacotherapy (CM+MED), and supportive clinical management combined with placebo (CM+PBO)—in a population of patients with major depressive disorder (MDD). Treatment type was examined as a potential moderator of the association between alliance and symptoms.



Figure 1

The examination of the temporal precedence between alliance and symptomatic levels throughout treatment (a) Predicting depressive symptoms at the current time point (HRSDT) from therapeutic alliance (WAIT-1) and depressive symptoms (HRSDT-1) at the previous ...

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Kevin S. McCarthy

Papers

Assessing intervention competence and its relation to therapy outcome: A selected review derived from the outcome literature.

The psychometric properties of the MASC in a pediatric psychiatric sample.

Treatment preferences affect the therapeutic alliance: implications for randomized controlled trials.

Does alliance predict symptoms throughout treatment, or is it the other way around?

A meta-analytic review of psychodynamic therapies for anxiety disorders.