Motivational Interviewing: Preparing People for Change

Psychological interventions to treat mental health issues have developed remarkably in the past few decades. Yet this progress often neglects a central goal-namely, to reduce the burden of mental illness and related conditions. The need for psychological services is enormous, and only a small proportion of individuals in need actually receive treatment. Individual psychotherapy, the dominant model of treatment delivery, is not likely to be able to meet this need. Despite advances, mental health professionals are not likely to reduce the prevalence, incidence, and burden of mental illness without a major shift in intervention research and clinical practice. A portfolio of models of delivery will be needed. We illustrate various models of delivery to convey opportunities provided by technology, special settings and nontraditional service providers, self-help interventions, and the media. Decreasing the burden of mental illness also will depend on integrating prevention and treatment, developing assessment and a national database for monitoring mental illness and its burdens, considering contextual issues that influence delivery of treatment, and addressing potential tensions within the mental health professions. Finally, opportunities for multidisciplinary collaborations are discussed as key considerations for reducing the burden of mental illness.

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Rebooting Psychotherapy Research and Practice to Reduce the Burden of Mental Illness

Context The place of long-term psychodynamic psychotherapy (LTPP) within psychiatry is controversial. Convincing outcome research for LTPP has been lacking. Objective To examine the effects of LTPP, especially in complex mental disorders, ie, patients with personality disorders, chronic mental disorders, multiple mental disorders, and complex depressive and anxiety disorders (ie, associated with chronic course and/or multiple mental disorders), by performing a meta-analysis. Data Sources Studies of LTPP published between January 1, 1960, and May 31, 2008, were identified by a computerized search using MEDLINE, PsyclNFO, and Current Contents, supplemented by contact with experts in the field. Study Selection Only studies that used individual psychodynamic psychotherapy lasting for at least a year, or 50 sessions; had a prospective design; and reported reliable outcome measures were included. Randomized controlled trials (RCTs) and observational studies were considered. Twenty-three studies involving a total of 1053 patients were included (11 RCTs and 12 observational studies). Data Extraction Information on study characteristics and treatment outcome was extracted by 2 independent raters. Effect sizes were calculated for overall effectiveness, target problems, general psychiatric symptoms, personality functioning, and social functioning. To examine the stability of outcome, effect sizes were calculated separately for end-of-therapy and follow-up assessment. Results According to comparative analyses of controlled trials, LTPP showed significantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. With regard to overall effectiveness, a between-group effect size of1.8 (95% confidence interval [Cl], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups (P= .002). According to subgroup analyses, LTPP yielded significant, large, and stable within-group effect sizes across various and particularly complex mental disorders (range, 0.78-1.98). Conclusions There is evidence that LTPP is an effective treatment for complex mental disorders. Further research should address the outcome of LTPP in specific mental disorders and should include cost-effectiveness analyses.

Effectiveness of Long-term Psychodynamic Psychotherapy : A Meta-analysis. Commentary

Mentalization research focuses on different aspects of this topic, highlighting individual differences in mentalizing and proposing programs of intervention for children and adults to increase this ability. The “Thought in Mind Project” (TiM Project) provides training targeted to adults―teachers or parents―to increase their mentalization and, consequently, to obtain mentalization improvement in children. The present research aimed to explore for the first time ever the potential of training for teachers based on the TiM Project, regarding the enhancement of mentalizing of an adult who would have interacted as a teacher with children. For this reason, two teachers – similar for meta-cognitive and meta-emotional skills - and their classes (N=46) were randomly assigned to the training or control condition. In the first case, the teacher participated in training on the implementation of promotion of mentalizing in everyday school teaching strategies; in the second case the teacher participated in a control activity, similar to training for scheduling and methods, but without promoting the implementation of mentalization (in both conditions two meetings lasting about three hours at the beginning of the school year and two supervisions during the school year were conducted). The children were tested by tasks assessing several aspects of mentalization (2nd and 3rd order false belief understanding, Strange Stories, Reading the mind in the Eyes, Mentalizing Task) both before and after the teacher participate in the TiM or control training (i.e. at the beginning and at the end of the school year). The results showed that, although some measured components of mentalization progressed over time, only the TiM training group significantly improved in 3rd order false belief understanding and changed - in a greater way compared to the control group - in two of the three components of the Mentalizing Task. These evidences are promising about the idea that the creation of a mentalizing community promotes the mentalization abilities of its members.

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Promoting Mentalizing in Pupils by Acting on Teachers: Preliminary Italian Evidence of the "Thought in Mind" Project.

OBJECTIVE: Policy and clinical management decisions depend on data on the health and cost impacts of psychiatric treatments under usual care, i.e., effectiveness. Clinical trials, however, provide information on treatment efficacy under best-practice conditions. An understanding of the design, analysis, and conventions of both efficacy and effectiveness studies can lead to research that better informs clinical and societal questions. METHOD: This paper contrasts the strengths and limitations of clinical trials and effectiveness studies for addressing policy and clinical decisions. These research approaches are assessed in terms of outcomes, treatments, service delivery context, implementation conventions, and validity. RESULTS: Clinical trials and effectiveness research share problems of internal and external validity despite more attention to internal validity in clinical trials (e.g., randomization, blinding, standardized protocols) and to external validity in effectiveness studies (e.g., community-base...

https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.156.1.5

Treatment research at the crossroads: the scientific interface of clinical trials and effectiveness research.

Handbook of Mentalizing in Mental Health Practice

Objective: The authors reviewed data involving the impact of providing psychotherapy for psychiatric disorders on costs of care. Method: In a search of the MEDLINE database limited to peer-reviewed papers published from 1984 through 1994, 686 articles were identified. Forty-one articles, covering 35 studies, were found in which the intervention tested was psychotherapeutic and the study included measures of outcome that had some implications for cost. The exclusion criteria for reviewing these studies included absence of a comparison group, a focus on medical disorders instead of psychiatric illnesses, and outcomes that did not include cost data or measures from which costs could be inferred. On this basis, 18 of the 35 studies were selected for analysis. The studies were categorized according to whether or not subjects were randomly assigned to study groups. Two reviewers independently read each study to identify the following characteristics: inclusion criteria, exclusion criteria, types of interventions, main outcome variables, sample size, and statistical tests for significant differences between treatments. Outcomes had to include actual cost accounting or data on medical care utilization or work functioning. Results: The findings of eight (80%) of the 10 clinical trials with random assignment and all eight (100%) of the studies without random assignment suggested that psychotherapy reduces total costs. Conclusions: Psychotherapy appears to have a beneficial impact on a variety of costs when used in the treatment of the most severe psychiatric disorders, including schizophrenia, bipolar affective disorder, and borderline personality disorder. Much of that impact accrues from reductions in inpatient treatment and decreases in work impairment. (Am J Psychiatry 1997; 154:147‐155)

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The Economic Impact of Psychotherapy: A Review

Recent studies suggest that psychotherapy can be cost-effective, especially for certain patient populations. These patients include, among others, those with schizophrenia, those with borderline personality disorder, and certain child patients, as well as certain medical patients with concomitant psychiatric illness. In addition, several surveys and actuarial studies suggest better outcomes and cost savings are attained when psychotherapy is available as medically necessary without arbitrary restrictions.

The cost-effectiveness of psychotherapy.

Though psychiatric residents are expected to be competent psychotherapists on graduation, further growth in skill and versatility requires continued experience in their ongoing career. Maturity as a psychotherapist is essential because a psychiatrist is the only mental health provider who, as a physician, can assume full responsibility for biopsychosocial patient care and roles as supervisor, consultant, and team leader. Graduating residents face an environment in which surveys show a steady and alarming decline in practice of psychotherapy by psychiatrists, along with a decline in job satisfaction. High educational debts, practice structures, intrusive management, and reimbursement policies that devalue psychotherapy discourage early career psychiatrists from a practice style that enables providing it. For the early-career psychiatrist there is thus the serious risk of being unable to develop a critical mass of experience or a secure identity as a psychiatric psychotherapist. Implementation of parity laws and the Affordable Care Act (ACA) will affect the situation in unpredictable ways that call for vigilance and active response. Additional service and administrative demands may result from the ACA, creating ethical dilemmas about meeting urgent patient needs versus biopsychosocial standards of care. The authors recommend 1) vigorous advocacy for better payment levels for psychotherapy and freedom from disruptive management; 2) aggressive action against violations of the parity act, 3) active preparation of psychiatric residents for dealing with career choices and the environment for providing psychotherapy in their practice, and 4) post-graduate training in psychotherapy through supervision/consultation, continuing education courses, computer instruction, and distance learning.

http://drewclemens.net/wp-content/uploads/2014/10/ObstaclesPDF1.pdf

Obstacles to early career psychiatrists practicing psychotherapy.

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research. The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient’s responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues.

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Susan G. Lazar

Papers

Handbook of Mentalizing in Mental Health Practice

The Economic Impact of Psychotherapy: A Review

The cost-effectiveness of psychotherapy.

Obstacles to early career psychiatrists practicing psychotherapy.

Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies