Showing papers in "Journal of Consulting and Clinical Psychology in 2011"

The impact of minority stress on mental health and substance use among sexual minority women.

Abstract: An estimated 2.3 million women in the United States describe themselves as lesbian (O’Hanlon, 1995), and between 1%–4% of all women may be sexual minorities on the basis of either behavior or self-defined identity (Sell, Wells, & Wypij, 1995). Sexual minority women (SMW) are at risk for health disparities and are a medically underserved population (U.S. Department of Health and Human Services, 2000a, 2000b). Unfortunately, the great stigma associated with sexual minority identity has precluded the development of an adequate scientific base from which to design effective interventions targeting health risks for this group (e.g., Solarz, 1999). Moreover, women have been underrepresented in the study of sexual identity (Chung & Katayama, 1996). Thus, we need relevant data based on sound theory and methodologically rigorous research to identify subgroups of SMW at greatest risk, stressors most predictive of adverse outcomes, and mechanisms through which these stressors impact health.

Nonverbal synchrony in psychotherapy: Coordinated body movement reflects relationship quality and outcome.

Abstract: Objective: The authors quantified nonverbal synchrony—the coordination of patient's and therapist's movement—in a random sample of same-sex psychotherapy dyads. The authors contrasted nonverbal synchrony in these dyads with a control condition and assessed its association with session-level and overall psychotherapy outcome. Method: Using an automated objective video analysis algorithm (Motion Energy Analysis; MEA), the authors calculated nonverbal synchrony in (n = 104) videotaped psychotherapy sessions from 70 Caucasian patients (37 women, 33 men, mean age = 36.5 years, SD = 10.2) treated at an outpatient psychotherapy clinic. The sample was randomly drawn from an archive (N = 301) of routinely videotaped psychotherapies. Patients and their therapists assessed session impact with self-report postsession questionnaires. A battery of pre- and postsymptomatology questionnaires measured therapy effectiveness. Results: The authors found that nonverbal synchrony is higher in genuine interactions contrasted with pseudointeractions (a control condition generated by a specifically designed shuffling procedure). Furthermore, nonverbal synchrony is associated with session-level process as well as therapy outcome: It is increased in sessions rated by patients as manifesting high relationship quality and in patients experiencing high self-efficacy. Higher nonverbal synchrony characterized psychotherapies with higher symptom reduction. Conclusions: The results suggest that nonverbal synchrony embodies the patients' self-reported quality of the relationship and further variables of therapy process. This hitherto overlooked facet of therapeutic relationships might prove useful as an indicator of therapy progress and outcome.

Posttraumatic stress disorder and intimate relationship problems: A meta-analysis.

Abstract: Objective: The authors conducted a meta-analysis of empirical studies investigating associations between indices of posttraumatic stress disorder (PTSD) and intimate relationship problems to empirically synthesize this literature. Method: A literature search using PsycINFO, Medline, Published International Literature on Traumatic Stress (PILOTS), and Dissertation Abstracts was performed. The authors identified 31 studies meeting inclusion criteria. Results: True score correlations (ρ) revealed medium-sized associations between PTSD and intimate relationship discord (ρ = .38, N = 7,973, K = 21), intimate relationship physical aggression perpetration (ρ = .42, N = 4,630, K = 19), and intimate relationship psychological aggression perpetration (ρ = .36, N = 1,501, K = 10). The strength of the association between PTSD and relationship discord was higher in military (vs. civilian) samples, and when the study was conducted in the United States (vs. other country), and the study represented a doctoral dissertation (vs. published article). The strength of the association between PTSD and physical aggression was higher in military (vs. civilian) samples, males (vs. females), community (vs. clinical) samples, studies examining PTSD symptom severity (vs. diagnosis), when the physical aggression measure focused exclusively on severe violence (vs. a more inclusive measure), and the study was published (vs. dissertation). For the PTSD-psychological aggression association, 98% of the variance was accounted for by methodological artifacts such as sampling and measurement error; consequently, no moderators were examined in this relationship. Conclusions: Findings highlight a need for the examination of models explaining the relationship difficulties associated with PTSD symptomatology and interventions designed to treat problems in both areas. (PsycINFO Database Record (c) 2010 APA, all rights reserved). Language: en

A meta-analysis of predictors of offender treatment attrition and its relationship to recidivism

Abstract: Objective: The failure of offenders to complete psychological treatment can pose significant concerns, including increased risk for recidivism. Although a large literature identifying predictors of offender treatment attrition has accumulated, there has yet to be a comprehensive quantitative review. Method: A meta-analysis of the offender treatment literature was conducted to identify predictors of offender treatment attrition and examine its relationship to recidivism. The review covered 114 studies representing 41,438 offenders. Sex offender and domestic violence programs were also examined separately given their large independent literatures. Results: The overall attrition rate was 27.1% across all programs (k = 96), 27.6% from sex offender programs (k = 34), and 37.8% from domestic violence programs (k = 35). Rates increased when preprogram attrition was considered. Significant predictors included demographic characteristics (e.g., age, rw = -.10), criminal history and personality variables (e.g., prior offenses, rw = .14; antisocial personality, rw = .14), psychological concerns (e.g., intelligence, rw = -.14), risk assessment measures (e.g., Statistical Information on Recidivism scale, rw =.18), and treatment-related attitudes and behaviors (e.g., motivation, rw = -.13). Results indicated that treatment noncompleters were higher risk offenders and attrition from all programs significantly predicted several recidivism outcomes ranging from rw = .08 to .23. Conclusions: The clients who stand to benefit the most from treatment (i.e., high-risk, high-needs) are the least likely to complete it. Offender treatment attrition can be managed and clients can be retained through an awareness of, and attention to, key predictors of attrition and adherence to responsivity considerations. (PsycINFO Database Record (c) 2010 APA, all rights reserved). Language: en

Mindfulness Training Increases Momentary Positive Emotions and Reward Experience in Adults Vulnerable to Depression: A Randomized Controlled Trial

Abstract: OBJECTIVE To examine whether mindfulness-based cognitive therapy (MBCT) increases momentary positive emotions and the ability to make use of natural rewards in daily life. METHOD Adults with a life-time history of depression and current residual depressive symptoms (mean age = 43.9 years, SD = 9.6; 75% female; all Caucasian) were randomized to MBCT (n = 64) or waitlist control (CONTROL; n = 66) in a parallel, open-label, randomized controlled trial. The Experience Sampling Method was used to measure momentary positive emotions as well as appraisal of pleasant activities in daily life during 6 days before and after the intervention. Residual depressive symptoms were measured using the 17-item Hamilton Depression Rating Scale (Hamilton, 1960). RESULTS MBCT compared to CONTROL was associated with significant increases in appraisals of positive emotion (b* = .39) and activity pleasantness (b* = .22) as well as enhanced ability to boost momentary positive emotions by engaging in pleasant activities (b* = .08; all ps < .005). Associations remained significant when corrected for reductions in depressive symptoms or for reductions in negative emotion, rumination, and worry. In the MBCT condition, increases in positive emotion variables were associated with reduction of residual depressive symptoms (all ps < .05). CONCLUSIONS MBCT is associated with increased experience of momentary positive emotions as well as greater appreciation of, and enhanced responsiveness to, pleasant daily-life activities. These changes were unlikely to be pure epiphenomena of decreased depression and, given the role of positive emotions in resilience against depression, may contribute to the protective effects of MBCT against depressive relapse.

Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence.

Abstract: Alcohol dependence (AD) is the most serious form of alcohol-use disorder. AD is associated with intense mental, physical, and functional impairment; high societal costs; and long-term suffering by both the dependent individual and the individual’s family members (e.g., Caetano, Nelson, & Cunradi, 2001). However, AD is also fairly widespread, with a 12-month prevalence rate of nearly 4% in the general population (Hasin, Stinson, Ogburn, & Grant, 2007). Despite the development and implementation of several empirically supported treatments, only about 25% of clients have been found to remain abstinent during the first year following treatment termination (Miller, Walters, & Bennett, 2001). Thus, there is a strong and pressing need to improve the efficacy of treatment for AD. According to the relapse prevention model proposed by Marlatt and colleagues (Marlatt & Witkiewitz, 2005), relapse is likely to occur when at-risk individuals are confronted with high-risk situations and lack the coping skills necessary to deal with such situations effectively. Consistent with this model, a number of studies have focused on identifying specific high-risk situations. Extensive evidence from these studies has shown that negative affect is one of the most prominent factors associated with relapse to maladaptive drinking. First, AD is highly associated with affect-related disorders, such as anxiety, depression, and borderline personality disorder (Gregory et al., 2008; Hasin et al., 2007), and individuals with co-occurring symptoms of these disorders display significantly higher rates of relapse after treatment (Bradizza, Stasiewicz, & Paas, 2006). Second, the majority of clients retrospectively attribute relapse to negative affective states (Lowman, Allen, & Stout, 1996; Zywiak, Connors, Maisto, & Westerberg, 1996). Third, negative affect -- such as stress/nervousness, anxiety, anger, dysphoric/depressed mood, feelings of loneliness/uselessness/boredom -- predicts subsequent desire to drink/drinking-level in epidemiological studies and relapse in treatment-outcome studies (Falk, Yi & Hilton, 2008; Gamble et al., 2010; Hodgins, el-Guebaly, & Armstrong, 1995; Swendsen et al., 2000; Willinger et al., 2002). Fourth, in laboratory paradigms, the induction of negative affect was shown to predict increased urges to drink and increased expectancies of relief after drinking (Cooney, Litt, Morse, Bauer & Gaupp, 1997; Birch et al., 2004; Sinha et al., 2009). Fifth, interventions focusing on the reduction of depressed mood or anxiety symptoms have been shown to decrease relapse and severity of alcohol use disorders (Brown, Evans, Miller, Burgess, & Mueller, 1997; Watt, Stewart, Birch, & Bernier, 2006), and interventions with a strong focus on emotion-regulation skills, such as dialectical behavioral therapy (Linehan, 1993a) have been shown to reduce substance use (including alcohol) in clients suffering from borderline personality disorder (Harned et al., 2008; Linehan et al., 2002). Finally, evidence suggests that although alcohol may initially reduce negative affect to some extent (Armeli et al., 2003; Kushner et al., 1996; Swendsen et al., 2000), maladaptive use eventually leads to the continuation and potential increase of such affect, thereby generating a vicious cycle contributing to the chronic and escalating nature of AD (Heinz et al., 1998; Koob & Le Moal, 2001; Witkiewitz & Villarroel, 2009). In line with these findings, a number of theories contend that affect regulation is a primary motive for alcohol use; such models include the affective processing model (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004), the motivational model of alcohol use (Cox & Klinger, 1988; Cooper, Frone, Russel, & Mudar, 1995), the stress and negative affect model (Colder & Chassin, 1993), the self-medication model (Khantzian, 1997), the stress response dampening theory (Levenson, Sher, Grossman, Newman, & Newlin, 1980), and the tension reduction hypothesis (Conger, 1956). The implication of these models is that emotion-regulation skills (i.e., skills relevant for “monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals”; Thompson, 1994, pp. 27-28), should be important -- if not essential -- for preventing relapse in AD. This hypothesis received preliminary support from studies demonstrating that trait emotional intelligence (defined as the ability to be aware of emotions, identify emotions correctly and modify emotions effectively) was negatively associated with alcohol-related problems (Riley & Schutte, 2003) and that emotional intelligence moderated the association between negative emotions and craving for alcohol in AD patients (Cordovil de Sousa Uva et al., 2010). Additional research has shown that abstinent alcoholics report more difficulty effectively regulating their emotions than do social drinkers (Fox, Hong, & Sinha, 2008). However, research has yet to investigate the predictive effects of emotion-regulation skills on alcohol use during and after treatment. To facilitate the utilization of the emotion-regulation framework for clinical purposes, Berking (2010) has synthesized and expanded upon previous theories (e.g., Gross, 1998; Larsen, 2000; Saarni, 1999; Greenberg, 2002) and proposed a skill-based model of emotion regulation. According to the Adaptive Coping with Emotions (ACE) Model (Berking, 2010), effective emotion regulation can be conceptualized as the situation-adapted interplay of the abilities to (a) be aware of emotions, (b) identify and label emotions, (c) correctly interpret emotion-related body sensations, (d) understand the prompts of emotions, (e) actively modify negative emotions to feel better, (f) accept negative emotions when necessary, (g) tolerate negative emotions when they cannot be changed, (h) confront (vs. avoid) distressing situations in order to attain important goals, and (i) compassionately support (encourage, self-soothe) oneself in emotionally distressing situations (in order to counterbalance potential short-term negative effects that engagement in the other skills may have on one’s emotions). Empirical studies have shown that all skills included in the ACE model are significantly associated with various indicators of mental health in clinical and at-risk populations (Berking et al., 2010; Berking, Meier, & Wupperman, 2010; Berking, Orth, Wupperman, Meier, & Caspar, 2008; Berking, Wupperman, et al. 2008; Berking & Znoj, 2008). However, research has not yet investigated whether these skills are associated with AD and whether they facilitate abstinence during or after treatment for AD. In addition, as deficient emotion-regulation skills are likely to be associated with other potential predictors of relapse, such as symptom severity (Langenbucher, Sulesund, Chung, & Morgenstern, 1996), degree of comorbidity (Tate, Brown, Unrod, & Ramo, 2004), cognitive abilities (Blume, Schmaling, & Marlatt, 2005), and negative mood (Hodgins et al., 1995), it is important to investigate whether emotion-regulation skills predict alcohol use beyond these additional factors. Moreover, there is a lack of research comparing the emotion-regulation skills of populations with alcohol-use disorders with those of other clinical populations. Although some evidence exists for the transdiagnostic nature of emotion-regulation skills (Aldao, Nolen-Hoeksema, & Schweizer, 2010), deficits in these skills may be more integral to some disorders than to others. For example, in the emotional disorders (i.e. depression and anxiety) the inability to effectively regulate dysfunctional emotions can be conceptualized as the core of these disorders (Moses & Barlow, 2006); whereas in disorders such as AD, deficits in these skills might be seen as one relevant factor among many that contribute to the onset and maintenance of the disorder (Marlatt & Donovan, 2005). Finally, few studies have assessed a broad range of emotion-regulation skills in order to identify the skills most strongly associated with (changes in) psychopathological symptoms (e.g. Berking, Wupperman, et al., 2008) -- and thus the skills that should be considered important targets in treatment. At this point, no such study is available for AD. Therefore, the major aim of the present study was to test the primary hypotheses that (1) more effective pretreatment emotion-regulation skills would negatively predict alcohol use during treatment and (2) more effective posttreatment emotion-regulation skills would negatively predict alcohol use during the three months following termination of treatment; even when controlling for other predictors potentially related to emotion regulation. Additionally, we investigated whether, (a) more effective pretreatment emotion-regulation skills would be associated with lower pretreatment AD symptom severity, (b) AD patients would report less successful emotion-regulation than did non-clinical controls, but more successful emotion-regulation than did patients meeting criteria for major depressive disorder (MDD), and (c) specific emotion-regulation skills could be identified as particularly important in negatively predicting alcohol use during and after treatment for AD.

Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review.

Abstract: Objective This study was designed to quantitatively evaluate the effectiveness of motivational interviewing (MI) interventions for adolescent substance use behavior change. Method Literature searches of electronic databases were undertaken in addition to manual reference searches of identified review articles. Databases searched include PsycINFO, PUBMED/MEDLINE, and Educational Resources Information Center. Twenty-one independent studies, representing 5,471 participants, were located and analyzed. Results An omnibus weighted mean effect size for all identified MI interventions revealed a small, but significant, posttreatment effect size (mean d = .173, 95% CI [.094, .252], n = 21). Small, but significant, effect sizes were observed at follow-up suggesting that MI interventions for adolescent substance use retain their effect over time. MI interventions were effective across a variety of substance use behaviors, varying session lengths, and different settings, and for interventions that used clinicians with different levels of education. Conclusions The effectiveness of MI interventions for adolescent substance use behavior change is supported by this meta-analytic review. In consideration of these results, as well as the larger literature, MI should be considered as a treatment for adolescent substance use.

A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety.

Abstract: The study examined the relative efficacy of online (NET) versus clinic (CLIN) delivery of cognitive behavior therapy (CBT) in the treatment of anxiety disorders in adolescents. Participants included 115 clinically anxious adolescents aged 12 to 18 years and their parent(s). Adolescents were randomly assigned to NET, CLIN, or wait list control (WLC) conditions. The treatment groups received equivalent CBT content. Clinical diagnostic interviews and questionnaire assessments were completed 12 weeks after baseline and at 6- and 12-month follow-ups. Assessment at 12 weeks post-baseline showed significantly greater reductions in anxiety diagnoses and anxiety symptoms for both NET and CLIN conditions compared with the WLC. These improvements were maintained or further enhanced for both conditions, with minimal differences between them, at 6- and 12-month follow-ups. Seventy-eight percent of adolescents in the NET group (completer sample) no longer met criteria for the principal anxiety diagnosis at 12-month follow-up compared with 80.6 in the CLIN group. Ratings of treatment credibility from both parents and adolescents were high for NET and equivalent to CLIN. Satisfaction ratings by adolescents were equivalent for NET and CLIN conditions, whereas parents indicated slightly higher satisfaction ratings for the CLIN format. Online delivery of CBT, with minimal therapist support, is equally efficacious as clinic-based, face-to-face therapy in the treatment of anxiety disorders among adolescents. This approach offers a credible alternative to clinic-based therapy, with benefits of reduced therapist time and greater accessibility for families who have difficulty accessing clinic-based CBT.

Cognitive-Behavioral Therapy, Behavioral Weight Loss, and Sequential Treatment for Obese Patients with Binge Eating Disorder: A Randomized Controlled Trial

Abstract: Binge-eating disorder (BED), a research category in the DSM-IV (American Psychiatric Association, 1994), is characterized by recurrent binge-eating accompanied by feelings of loss of control and marked distress in the absence of inappropriate weight compensatory behaviors. BED is a prevalent major health problem (Hudson, Hiripi, Pope, & Kessler, 2007). BED has diagnostic validity (Wonderlich, Gordon, Mitchell, Crosby, & Engel, 2009), differs from other eating disorders and obesity (Grilo et al., 2009; Grilo, Hrabosby, White, Allison, Stunkard, & Masheb, 2008), and is strongly associated with obesity and elevated risk for medical/psychiatric co-morbidity (Hudson et al., 2007; Wonderlich et al., 2009). The treatment literature for BED suggests that several medications have short-term efficacy relative to placebo (Reas & Grilo, 2008) and certain psychological treatments are effective (Wilson, Grilo, & Vitousek 2007). Cognitive-behavioral therapy (CBT) is the best-established treatment (NICE, 2004; Wilson, Wilfley, Agras, & Bryson, 2010). The National Institute of Clinical Excellence (2004) recommendation that CBT is the treatment-of-choice was assigned a “grade-of-A,” reflecting strong empirical evidence. Controlled trials have provided further support for the efficacy of CBT, including “treatment specificity” (Grilo, Masheb, & Wilson, 2005); however, studies have reported little difference between interpersonal psychotherapy (IPT) and CBT delivered via group (Wilfley et al., 2002) or CBT guided-self-help (Wilson et al., 2010). Although CBT generally produces remission rates of 40% to 60% and robust improvements in eating disorder psychopathology it fails to produce weight loss (Wilson et al., 2007). The association between BED and obesity (Hudson et al., 2007) and the possible heightened risk for developing future metabolic problems (Hudson et al., 2010) highlight the need to find methods to effectively reduce weight - in addition to eliminating binge-eating - in persons with BED. The existing literature of behavioral-weight-loss (BWL) for BED is equivocal and difficult to interpret in light of significant methodological shortcomings, particularly the reliance on self-report questionnaires for the assessment of binge-eating, inclusion of heterogeneous patients with varying sub-threshold levels of BED, and a lack of follow-up data (see Wilson et al., 2007; Wonderlich et al., 2009). Overall, CBT appears more effective for reducing binge-eating and associated psychopathology whereas BWL appears more effective for producing short-term weight loss (e.g., Agras et al.,1994; Wilson et al., 2010) although BWL studies in BED (e.g., Devlin et al., 2005; Grilo & Masheb, 2005) and “binge-eaters” (Goodrick, Poston, Kimball, Reeves, & Foreyt, 1998) often report minimal or no weight losses. Interestingly, the modest short-term weight-loss reported by most studies testing BWL for obese BED patients (see Wilson et al., 2007) is at odds with the greater magnitude of weight-losses reported for obese patients who do not binge-eat receiving BWL recruited for obesity trials (e.g., Foster et al., 2003) and with findings from one obesity treatment study in which a post-hoc re-analysis of outcomes for “binge-eaters” (determined by self-report) revealed superior short-term weight-losses relative to non-binge-eaters (Gladis, Wadden, Vogt, Foster, Kuehnel, & Bartlett, 1998). The current study, a randomized controlled trial to test the relative efficacy of CBT and BWL for BED and the durability of the outcomes over a 12-month follow-up period, was designed as a test of treatment-specificity and to help answer the clinically important question of whether BWL has efficacy for weight loss in this subgroup of obese patients. This study also tested the utility of a sequential treatment approach in which CBT is delivered first followed by BWL. Given findings from RCTs that binge remission was associated with greater weight losses (Devlin et al., 2005; Grilo et al., 2005; Wilfley et al., 2002), the comparison to the sequential CBT+BWL treatment follows the clinical hypothesis that once CBT reduces binge eating and associated psychopathology, patients will be able achieve greater weight loss with BWL.

Remission after acute treatment in children and adolescents with anxiety disorders: findings from the CAMS.

Abstract: An index of outcome in randomized controlled trials (RCTs) for pediatric anxiety disorders (ADs) is the response rate. Response has been defined as a meaningful improvement in symptoms. An important question for clinicians, patients, and families is, what are the chances of becoming nearly symptom free? That is, what is the chance for remission? Although there is no consensus on an operational definition of remission for childhood ADs, it is defined generally as the absence or near absence of symptoms following treatment for a predetermined period of time (Frank et al., 1991). It is considered a more stringent criterion than response. Identifying remission rates in RCTs is thus an important index of treatment outcome. Reports of remission rates after acute treatment for pediatric ADs are sparse, though initial studies reveal that remission rates are typically lower than response rates. Hudson et al. (2009) reported that posttreatment response rates (defined as the percentage of children no longer meeting criteria for their principal anxiety diagnosis) were 45% after 10 weeks of CBT; the remission rate (percentage no longer meeting criteria for any AD) was 33%. Data on remission rates are similarly sparse for pharmacotherapy trials, although they show a similar pattern. Wagner et al. (2004) reported a 78% response rate (defined as a Clinical Global Impression Improvement Scale [CGI-I] score of 1 [very much improved] or 2 [much improved]) after 16 weeks of paroxetine for youth with social phobia (SOP) and a remission rate (defined as a CGI-I of 1 or a 70% or greater reduction on a social anxiety scale) of 48% and 47%, respectively. Despite similar patterns of response and remission rates in both pharmacotherapy and cognitive behavioral therapy (CBT) trials for pediatric anxiety, variations in definitions and measurement methods undermine comparisons. The recent Child/Adolescent Anxiety Multimodal Treatment Study (CAMS; Walkup et al., 2008), which compared the efficacy of CBT (Coping Cat; Kendall & Hedtke, 2006), pharmacotherapy (sertraline [SRT]), and their combination (COMB) to pill placebo (PBO) in 488 youth with separation AD (SAD), generalized AD (GAD), and SOP, measured treatment outcome using a variety of methods. Thus, data from this trial are uniquely suited to describe remission rates (i.e., achieving a nearly symptom-free state) conferred by CBT, SRT, and COMB. The initial findings from the CAMS reported only on response rates (Walkup et al., 2008). This study (a) determined multiply defined posttreatment remission rates by treatment condition and (b) assessed predictors of remission.

Youth Top Problems: using idiographic, consumer-guided assessment to identify treatment needs and to track change during psychotherapy.

Abstract: Objective To complement standardized measurement of symptoms, we developed and tested an efficient strategy for identifying (before treatment) and repeatedly assessing (during treatment) the problems identified as most important by caregivers and youths in psychotherapy. Method A total of 178 outpatient-referred youths, 7-13 years of age, and their caregivers separately identified the 3 problems of greatest concern to them at pretreatment and then rated the severity of those problems weekly during treatment. The Top Problems measure thus formed was evaluated for (a) whether it added to the information obtained through empirically derived standardized measures (e.g., the Child Behavior Checklist [CBCL; Achenbach & Rescorla, 2001] and the Youth Self-Report [YSR; Achenbach & Rescorla, 2001]) and (b) whether it met conventional psychometric standards. Results The problems identified were significant and clinically relevant; most matched CBCL/YSR items while adding specificity. The top problems also complemented the information yield of the CBCL/YSR; for example, for 41% of caregivers and 79% of youths, the identified top problems did not correspond to any items of any narrowband scales in the clinical range. Evidence on test-retest reliability, convergent and discriminant validity, sensitivity to change, slope reliability, and the association of Top Problems slopes with standardized measure slopes supported the psychometric strength of the measure. Conclusions The Top Problems measure appears to be a psychometrically sound, client-guided approach that complements empirically derived standardized assessment; the approach can help focus attention and treatment planning on the problems that youths and caregivers consider most important and can generate evidence on trajectories of change in those problems during treatment.

Long-term effects of a personality-targeted intervention to reduce alcohol use in adolescents.

Abstract: Objective: To examine the long-term effects of a personality-targeted intervention on drinking quantity and frequency (QF), problem drinking, and personality-specific motivations for alcohol use in early adolescence. Method: A randomized control trial was carried out with 364 adolescents (median age 14) recruited from 13 secondary schools with elevated scores in Hopelessness, Anxiety-Sensitivity (AS), Impulsivity, and Sensation-Seeking. Participants were randomly assigned to a control no-intervention condition or a 2-session group coping skills intervention targeting 1 of 4 personality risk factors. The effects of the intervention on quantity/frequency (QF) of alcohol use, frequency of binge drinking, problem drinking, and motives were examined at 6, 12, 18, and 24 months postintervention. Results: Intent-to-treat repeated measures analyses revealed a significant overall intervention effect in reducing problem drinking symptoms, and a Time × Intervention effect on drinking QF and binge drinking frequency. Relative to the control group, the intervention group showed significantly reduced drinking and binge drinking levels at 6 months postintervention and reduced problem drinking symptoms for the full 24-month follow-up period (Cohen's d = 0.33). A significant Time × Intervention × Personality interaction was demonstrated for coping and enhancement drinking motives. In addition to an overall effect of intervention on coping motives, the AS group who received that intervention reported fewer coping motives compared with the AS control group at 12 and 24 months postintervention. Conclusions: This study provides further evidence showing that personality-targeted interventions reduce drinking behavior in adolescents in the short term. Novel findings were that the interventions were shown to produced long-term effects on drinking problems and personality-specific effects on drinking motives. (PsycINFO Database Record (c) 2011 APA, all rights reserved). Language: en

A combined motivation and parent-child interaction therapy package reduces child welfare recidivism in a randomized dismantling field trial.

Abstract: Objective: A package of parent–child interaction therapy (PCIT) combined with a self-motivational (SM) orientation previously was found in a laboratory trial to reduce child abuse recidivism compared with services as usual (SAU). Objectives of the present study were to test effectiveness in a field agency rather than in a laboratory setting and to dismantle the SM versus SAU orientation and PCIT versus SAU parenting component effects. Method: Participants were 192 parents in child welfare with an average of 6 prior referrals and most with all of their children removed. Following a 2 2 sequentially randomized experimental design, parents were randomized first to orientation condition (SM vs. SAU) and then subsequently randomized to a parenting condition (PCIT vs. SAU). Cases were followed for child welfare recidivism for a median of 904 days. An imputation-based approach was used to estimate recidivism survival complicated by significant treatment-related differences in timing and frequency of children returned home. Results: A significant orientation condition by parenting condition interaction favoring the SM PCIT combination was found for reducing future child welfare reports, and this effect was stronger when children were returned to the home sooner rather than later. Conclusions: Findings demonstrate that previous laboratory results can be replicated in a field implementation setting and among parents with chronic and severe child welfare histories, supporting a synergistic SM PCIT benefit. Methodological considerations for analyzing child welfare event history data complicated by differential risk deprivation are also emphasized.

Treatment of Co-Occurring Substance Abuse and Suicidality Among Adolescents: A Randomized Trial

Abstract: Objective: This study tested a cognitive-behavioral treatment protocol for adolescents with a co-occurring alcohol or other drug use disorder (AOD) and suicidality in a randomized clinical trial. Method: Forty adolescents (Mage = 15 years; 68% female, 89% White) and their families recruited from an inpatient psychiatric hospital were randomly assigned to an integrated outpatient cognitive-behavioral intervention for co-occurring AOD and suicidality (I-CBT) or enhanced treatment as usual (E-TAU). Primary measures include the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Suicide Ideation Questionnaire, Columbia Impairment Scale, Timeline Followback, Rutgers Alcohol Problem Index, and Rutgers Marijuana Problem Index. Assessments were completed at pretreatment as well as 3, 6, 12, and 18 months postenrollment. Results: In intent-to-treat analyses, I-CBT was associated with significantly fewer heavy drinking days and days of marijuana use relative to E-TAU but not with fewer drinking days. Those randomized to I-CBT in comparison to E-TAU also reported significantly less global impairment as well as fewer suicide attempts, inpatient psychiatric hospitalizations, emergency department visits, and arrests. Adolescents across groups showed equivalent reductions in suicidal ideation. Conclusions: I-CBT for adolescents with co-occurring AOD and suicidality is associated with significant improvement in both substance use and suicidal behavior, as well as markedly decreased use of additional health services including inpatient psychiatric hospitalizations and emergency department visits. Further testing of integrated protocols for adolescent AOD and suicidality with larger and more diverse samples is warranted. (PsycINFO Database Record (c) 2011 APA, all rights reserved). Language: en

Going to scale: A nonrandomized nationwide trial of the KiVa Antibullying Program for Grades 1-9

Abstract: Objective: The effects of school-based antibullying programs have typically been examined on small samples, with number of schools ranging from 1 to 78 (Farrington & Ttofi, 2009). This study investigated the effectiveness of the KiVa antibullying program in the beginning of its nationwide implementation in Finland. Method: At each time point, the participants included 888 schools with approximately 150,000 students in 11,200 classrooms in Grades 1-9 (8-16 years of age; 51% boys and 49% girls). Victims and bullies were identified with the global questions from the Revised Olweus Bully/Victim Questionnaire (Olweus, 1996), utilizing the criteria suggested by Solberg and Olweus (2003). The program effects were examined by calculating odds ratios based on a cohort-longitudinal design, correcting the standard errors for clustering. Results: During the first 9 months of implementation, the KiVa program reduced both victimization and bullying, with a control/intervention group odds ratio of 1.22 (95% CI [1.19, 1.24]) for victimization and 1.18 (95% CI [1.15, 1.21]) for bullying. Conclusions: Generalized to the Finnish population of 500,000 students, this would mean a reduction of approximately 7,500 bullies and 12,500 victims.

Mindfulness is associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems in urban firefighters.

Abstract: Objective This study investigated the association between mindfulness, other resilience resources, and several measures of health in 124 urban firefighters. Method Participants completed health measures of posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, physical symptoms, and alcohol problems and measures of resilience resources including mindfulness, optimism, personal mastery, and social support. The Mindful Awareness and Attention Scale (MAAS; Brown & Ryan, 2003) was used to assess mindfulness. Participants also completed measures of firefighter stress, number of calls, and years as a firefighter as control variables. Hierarchical multiple regressions were conducted with the health measures as the dependent variables with 3 levels of independent variables: (a) demographic characteristics, (b) firefighter variables, and (c) resilience resources. Results The results showed that mindfulness was associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems when controlling for the other study variables. Personal mastery and social support were also related to fewer depressive symptoms, firefighter stress was related to more PTSD symptoms and alcohol problems, and years as a firefighter were related to fewer alcohol problems. Conclusions Mindfulness may be important to consider and include in models of stress, coping, and resilience in firefighters. Future studies should examine the prospective relationship between mindfulness and health in firefighters and others in high-stress occupations.

The Dependability of Alliance Assessments: The Alliance-Outcome Correlation Is Larger than You Might Think.

Abstract: Objective: To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance-outcome relationship. Method: We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used. Results: At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3-9 explained 14.7% of outcome variance. Conclusion: Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance-outcome relationship.

Cognitive-behavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors.

Abstract: Objective: Women who develop symptoms of posttraumatic stress disorder (PTSD) and depression subsequent to interpersonal trauma are at heightened risk for future intimate partner violence (IPV) victimization. Cognitive–behavioral therapy (CBT) is effective in reducing PTSD and depression symptoms, yet limited research has investigated the effectiveness of CBT in reducing risk for future IPV among interpersonal trauma survivors. Method: This study examined the effect of CBT for PTSD and depressive symptoms on the risk of future IPV victimization in a sample of women survivors of interpersonal violence. The current sample included 150 women diagnosed with PTSD secondary to an array of interpersonal traumatic events; they were participating in a randomized clinical trial of different forms of cognitive processing therapy for the treatment of PTSD. Participants were assessed at 9 time points as part of the larger trial: pretreatment, 6 times during treatment, posttreatment, and 6-month follow-up. Results: As hypothesized, reductions in PTSD and in depressive symptoms during treatment were associated with a decreased likelihood of IPV victimization at a 6-month follow-up even after controlling for recent IPV (i.e., IPV from a current partner within the year prior to beginning the study) and prior interpersonal traumas. Conclusions: These findings highlight the importance of identifying and treating PTSD and depressive symptoms among interpersonal trauma survivors as a method for reducing risk for future IPV.

Psychological Treatment for Panic Disorder With Agoraphobia: A Randomized Controlled Trial to Examine the Role of Therapist-Guided Exposure In Situ in CBT

Abstract: OBJECTIVE: Cognitive-behavioral therapy (CBT) is a first-line treatment for panic disorder with agoraphobia (PD/AG). Nevertheless, an understanding of its mechanisms and particularly the role of therapist-guided exposure is lacking. This study was aimed to evaluate whether therapist-guided exposure in situ is associated with more pervasive and long-lasting effects than therapist-prescribed exposure in situ. METHOD: A multicenter randomized controlled trial, in which 369 PD/AG patients were treated and followed up for 6 months. Patients were randomized to 2 manual-based variants of CBT (T+/T-) or a wait-list control group (WL; n = 68) and were treated twice weekly for 12 sessions. CBT variants were identical in content, structure, and length, except for implementation of exposure in situ: In the T+ variant (n = 163), therapists planned and supervised exposure in situ exercises outside the therapy room; in the T- group (n = 138), therapists planned and discussed patients' in situ exposure exercises but did not accompany them. Primary outcome measures were (a) Hamilton Anxiety Scale, (b) Clinical Global Impression, (c) number of panic attacks, and (d) agoraphobic avoidance (Mobility Inventory). RESULTS: For T+ and T- compared with WL, all outcome measures improved significantly with large effect sizes from baseline to post (range = -0.5 to -2.5) and from post to follow-up (range = -0.02 to -1.0). T+ improved more than T- on the Clinical Global Impression and Mobility Inventory at post and follow-up and had greater reduction in panic attacks during the follow-up period. Reduction in agoraphobic avoidance accelerated after exposure was introduced. A dose-response relation was found for Time × Frequency of Exposure and reduction in agoraphobic avoidance. CONCLUSIONS: Therapist-guided exposure is more effective for agoraphobic avoidance, overall functioning, and panic attacks in the follow-up period than is CBT without therapist-guided exposure. Therapist-guided exposure promotes additional therapeutic improvement--possibly mediated by increased physical engagement in feared situations--beyond the effects of a CBT treatment in which exposure is simply instructed.

Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: randomized trial.

Abstract: Objective: Major depression is the most common psychiatric disorder among breast cancer patients and is associated with substantial impairment. Although some research has explored the utility of psychotherapy with breast cancer patients, only 2 small trials have investigated the potential benefits of behavior therapy among patients with well-diagnosed depression. Method: In a primarily Caucasian, well-educated sample of women (age 55.4 years, SD 11.9) diagnosed with breast cancer and major depression (n 80), this study was a randomized clinical trial testing the efficacy of 8 sessions of behavioral activation treatment for depression (BATD) compared to problem-solving therapy. Primary outcome measures assessed depression, environmental reward, anxiety, quality of life, social support, and medical outcomes. Results: Across both treatments, results revealed strong treatment integrity, excellent patient satisfaction with treatment protocols, and low patient attrition (19%). Intent-to-treat analyses suggested both treatments were efficacious, with both evidencing significant pre–post treatment gains across all outcome measures. Across both treatments, gains were associated with strong effect sizes, and based on response and remission criteria, a reliable change index, and numbers-needed-to-treat analyses, approximately ¾ of patients exhibited clinically significant improvement. No significant group differences were found at posttreatment. Treatment gains were maintained at 12-month follow-up, with some support for stronger maintenance of gains in the BATD group. Conclusions: BATD and problem-solving interventions represent practical interventions that may improve psychological outcomes and quality of life among depressed breast cancer patients. Study limitations and future research directions are discussed.

Effects of Multisystemic Therapy through Midlife: A 21.9-Year Follow-Up to a Randomized Clinical Trial with Serious and Violent Juvenile Offenders.

Abstract: Objective: Although current evidence suggests that the positive effects of multisystemic therapy (MST) on serious crime reach as far as young adulthood, the longer term impact of MST on criminal and noncriminal outcomes in midlife has not been evaluated. In the present study, the authors examined a broad range of criminal and civil court outcomes for serious and violent juvenile offenders who participated on average 21.9 (range = 18.3-23.8) years earlier in a clinical trial of MST (C. M. Borduin et al., 1995). Method: Participants were 176 individuals who were originally randomized to MST or individual therapy (IT) during adolescence and averaged 3.9 arrests for felonies prior to treatment. Arrest, incarceration, and civil suit data were obtained in middle adulthood when participants were on average 37.3 years old. Results: Intent-to-treat analyses showed that felony recidivism rates were significantly lower for MST participants than for IT participants (34.8% vs. 54.8%, respectively) and that the frequency of misdemeanor offending was 5.0 times lower for MST participants. In addition, the odds of involvement in family-related civil suits during adulthood were twice as high for IT participants as for MST participants. Conclusions: The present study represents the longest follow-up to date of an MST clinical trial and demonstrates that the positive impact of an evidence-based youth treatment such as MST can last well into adulthood. Implications of the authors' findings for policymakers and service providers are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved). Language: en

Randomized Controlled Trial of a Preventive Intervention for Perinatal Depression in High-Risk Latinas.

Abstract: Objective A randomized controlled trial was conducted to evaluate the efficacy of a cognitive-behavioral (CBT) intervention to prevent perinatal depression in high-risk Latinas. Method A sample of 217 participants, predominantly low-income Central American immigrants who met demographic and depression risk criteria, were randomized into usual care (UC; n = 105) or an 8-week CBT group intervention during pregnancy and 3 individual booster sessions during postpartum (n = 112). Participants completed measures assessing depressive symptoms (Center for Epidemiological Studies Depression Scale at baseline; Beck Depression Inventory, Second Edition [BDI-II]) and major depressive episodes (Mood Screener) at 5 time points throughout the perinatal period. Results Intent-to-treat analyses indicated that intervention participants had significantly lower depressive symptoms and fewer cases of moderate depression (BDI-II ≥ 20) at Time 2 than UC participants. These effects were stronger for women who fully participated in the intervention (≥ 4 classes). The cumulative incidence of major depressive episodes was not significantly different between the intervention (7.8%) and UC (9.6%) groups. Conclusions A CBT intervention for low-income, high-risk Latinas reduced depressive symptoms during pregnancy but not during the postpartum period. Low levels of depressive symptoms and lower than expected rates of clinical depression in both groups may partially be due to methodological issues. As perinatal depression is a significant public health problem, more work is needed to prevent perinatal depression in low-income, ethnically diverse women.

Patient Adherence Predicts Outcome from Cognitive Behavioral Therapy in Obsessive-Compulsive Disorder.

Abstract: Cognitive-behavioral therapy consisting of exposure and response prevention (EX/RP) is an effective treatment for obsessive-compulsive disorder (OCD; American Psychiatric Association, 2007). However, only about half of patients who receive EX/RP achieve minimal symptoms (Simpson, et al., 2008; Simpson, Huppert, Petkova, Foa, & Liebowitz, 2006). Treatment outcome might be improved by developing more personalized care (Insel, 2009). One approach to personalized care is to identify factors that interfere with EX/RP outcome, develop interventions to address these factors, and provide these interventions to the individuals who need them. One factor thought to affect EX/RP outcome is whether patients adhere to the treatment procedures. Specifically, EX/RP therapists help patients face feared situations (“exposures”) to promote habituation to the anxiety that these situations trigger. Patients are asked to refrain from avoidance behaviors and rituals (“response prevention”) in order to break the connection between rituals and anxiety relief. Together, these procedures help disconfirm patients’ irrational beliefs. Therapists practice these steps with patients in session and assign specific exercises for between-session practice. Adherence with between-session assignments is thought to be critical for good outcome because repeated practice in different contexts is theorized to be essential to the emotional processing of the fear structure (Foa & Kozak, 1986; Kozak & Foa, 1997). Some studies suggest that patient adherence to EX/RP procedures is associated with treatment outcome (Abramowitz, Franklin, Zoellner, & DiBernardo, 2002; De Araujo, Ito, & Marks, 1996; Tolin, Maltby, Diefenbach, Hannan, & Worhunsky, 2004). However, Woods, Chambless, and Steketee (2002) found no significant relationship between EX/RP outcome and patient homework adherence. Unfortunately, patient adherence was assessed differently across these studies, none of the adherence measures has demonstrated validity or reliability, and some studies did not measure patient adherence prospectively. Thus, the effect of patient EX/RP adherence on treatment outcome has yet to be adequately examined. To address this significant gap, the current study examined the relationship between patient adherence to between-session assignments and treatment outcome in 30 adults with OCD who received EX/RP as part of a clinical trial. We used the Patient EX/RP Adherence Scale (PEAS) to prospectively assess adherence with between-session assignments because of its excellent inter-rater reliability and good construct validity (Simpson, Maher, et al., 2010). We hypothesized that patient adherence to between-session EX/RP assignments would be inversely associated with post-treatment OCD severity. We also examined whether early patient adherence predicted post-treatment OCD severity. Finally, we explored the relationship between patient adherence and other variables that predicted outcome in this sample.

A marginal structural model analysis for loneliness: implications for intervention trials and clinical practice.

Abstract: Objective: Clinical scientists, policymakers, and individuals must make decisions concerning effective interventions that address health-related issues. We use longitudinal data on loneliness and depressive symptoms and a new class of causal models to illustrate how empirical evidence can be used to inform intervention trial design and clinical practice. Method: Data were obtained from a population-based study of non-Hispanic Caucasians, African Americans, and Latino Americans (N 229) born between 1935 and 1952. Loneliness and depressive symptoms were measured with the UCLA Loneliness Scale— Revised and Center for Epidemiologic Studies Depression Scale, respectively. Marginal structural causal models were employed to evaluate the extent to which depressive symptoms depend not only on loneliness measured at a single point in time (as in prior studies of the effect of loneliness) but also on an individual’s entire loneliness history. Results: Our results indicate that if interventions to reduce loneliness by 1 standard deviation were made 1 and 2 years prior to assessing depressive symptoms, both would have an effect; together, they would result in an average reduction in depressive symptoms of 0.33 standard deviations, 95% CI [0.21, 0.44], p .0001. Conclusions: The magnitude and persistence of these effects suggest that greater effort should be devoted to developing practical interventions on alleviating loneliness and that doing so could be useful in the treatment and prevention of depressive symptoms. In light of the persistence of the effects of loneliness, our results also suggest that, in the evaluation of interventions on loneliness, it may be important to allow for a considerable follow-up period in assessing outcomes.

Cognitive behavioral treatment of PTSD in residents of battered women's shelters: results of a randomized clinical trial.

Abstract: Objective: This study was designed to explore the acceptability, feasibility, and initial efficacy of a new shelter-based treatment for victims of intimate partner violence (IPV; ie, Helping to Overcome PTSD through Empowerment [HOPE]) Method: A Phase I randomized clinical trial comparing HOPE (n = 35) with standard shelter services (SSS) (n = 35) was conducted Primary outcome measures included the Clinician-Administered PTSD Scale (CAPS; D D Blake et al, 1995) and the Conflict Tactic Scales-Revised (M A Straus, S L Hamby, S Boney-McCoy, & D B Sugarman, 1996) Participants were followed at 1-week, 3- and 6-months postshelter Results: Participants reported HOPE to be credible and indicated a high degree of satisfaction with treatment Only 2 women withdrew from treatment Both intent to treat (ITT) and minimal attendance (MA) analyses found that HOPE treatment relative to SSS was significantly associated with a lower likelihood of reabuse over the 6-month follow-up period (OR = 51, RR = 175; OR = 126, RR = 312, respectively) Results of hierarchical linear model analyses found a significant treatment effect for emotional numbing symptom severity in the ITT sample, t(67) = -2046, p Language: en

Two Aspects of the Therapeutic Alliance: Differential Relations with Depressive Symptom Change.

Abstract: Objective: The therapeutic alliance has been linked to symptom change in numerous investigations. Although the alliance is commonly conceptualized as a multidimensional construct, few studies have examined its components separately. The current study explored which components of the alliance are most highly associated with depressive symptom change in cognitive therapy (CT). Method: Data were drawn from 2 published randomized, controlled clinical trials of CT for major depressive disorder (n 105, mean age 40 years, female 62%, White 82%). We examined the relations of 2 factoranalytically derived components of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) with symptom change on the Beck Depression Inventory—II (BDI–II; Beck, Steer, & Brown, 1996) that occurred either prior to or subsequent to the examined sessions. WAI ratings were obtained at an early and a late session for each therapist–patient dyad. Results: Variation in symptom change subsequent to the early session was significantly related to the WAI factor that assesses therapist–patient agreement on the goals and tasks of therapy but not to a factor assessing the affective bond between therapist and patient. In contrast, both factors, when assessed in a late session, were significantly predicted by prior symptom change. Conclusions: These findings may reflect the importance, in CT, of therapist–patient agreement on the goals and tasks of therapy. In contrast, the bond between therapist and patient may be more of a consequence than a cause of symptom change in CT. The implications of these results and directions for future research are discussed.

A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies.

Abstract: Objective: Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems. Method: This is the first randomized controlled trial to test directly whether cognitive-behavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n 40) or to CBT plus interpersonal and emotional processing therapy (n 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990; Hamilton Anxiety Rating Scale; M. Hamilton, 1959; assessor severity rating; State–Trait Anxiety Inventory-Trait Version; C. D. Spielberger, R. L. Gorsuch, R. Lushene, P. R. Vagg, & G. A. Jacobs, 1983) as well as with indices of clinically significant change. Results: Mixed models analysis of all randomized participants showed very large within-treatment effect sizes for both treatments (CI [.40, .28], d 1.86) with no significant differences at post (CI [.09, .07], d .07) or 2-year follow-up (CI [.01, .01]), d .12). There was also no statistical difference between compared treatments on clinically significant change based on chi-square analysis. Conclusions: Interpersonal and emotional processing techniques may not augment CBT for all GAD participants. Trial Registry name: Clinical Trials.gov, Identifier: NCT00951652.

Treatment Gain for Sexual Offenders against Children Predicts Reduced Recidivism: A Comparative Validity Study.

Abstract: Objective: To determine whether pro-social treatment change in sexual offenders would predict reductions in recidivism beyond static and dynamic risk factors measured at pretreatment and whether different methods for assessing change based on self-reports and structured clinical rating systems would show convergent validity. Method: We compared 3 methods for assessing treatment change with a sample of adult male sexual offenders against children (n = 218) who completed a prison-based cognitive-behavioral treatment program between 1993 and 2000. The methods were measures of change derived from offender self-reports on a psychometric battery administered both pre- and posttreatment, change across treatment on the Violence Risk Scale: Sexual Offender Version (VRS:SO; Olver, Wong, Nicholaichuk, & Gordon, 2007), and posttreatment ratings on the Standard Goal Attainment Scaling for Sex Offenders (SGAS; Hogue, 1994). Offenders were followed up for an average of 12.24 years after release. Results: All measures of treatment gain were positively correlated, and all significantly predicted reductions in sexual recidivism, with values for the area under the receiver-operating characteristic curve ranging from .66 (SGAS) to .70 (VRS:SO). Survival analyses showed that measures of change based on the psychometric battery significantly predicted recidivism after controlling for both static and dynamic factors measured at pretreatment, while results for the VRS:SO were similar but failed to reach significance. Conclusions: Measures of treatment change based on offender self-reports and structured clinical rating systems show convergent and predictive validity, which suggests that effective treatment that targets dynamic risk factors leads to a reduction in sexual recidivism. (PsycINFO Database Record (c) 2011 APA, all rights reserved). Language: en

Internet Therapy versus Internet Self-Help versus No Treatment for Problematic Alcohol Use: A Randomized Controlled Trial.

Abstract: Objective: Problematic alcohol use is the third leading contributor to the global burden of disease, partly because the majority of problem drinkers are not receiving treatment. Internet-based alcohol interventions attract an otherwise untreated population, but their effectiveness has not yet been established. The current study examined the effectiveness of Internet-based therapy (therapy alcohol online; TAO) and Internet-based self-help (self-help alcohol online; SAO) for problematic alcohol users. Method: Adult problem drinkers (n 205; 51% female; mean age 42 years; mean Alcohol Use Disorders Identification Test score 20) were randomly assigned to TAO, SAO, or an untreated waiting-list control group (WL). Participants in the TAO arm received 7 individual text-based chat-therapy sessions. The TAO and SAO interventions were based on cognitive– behavioral therapy and motivational interviewing techniques. Assessments were given at baseline and 3 and 6 months after randomization. Primary outcome measures were alcohol consumption and treatment response. Secondary outcome measures included measures of quality-of-life. Results: Using generalized estimating equation regression models, intention-to-treat analyses demonstrated significant effects for TAO versus WL (p .002) and for SAO versus WL (p .03) on alcohol consumption at 3 months postrandomization. Differences between TAO and SAO were not significant at 3 months postrandomization (p .11) but were significant at 6 months postrandomization (p .03), with larger effects obtained for TAO. There was a similar pattern of results for treatment response and quality-of-life outcome measures. Conclusions: Results support the effectiveness of cognitive– behavioral therapy/motivational interviewing Internet-based therapy and Internet-based self-help for problematic alcohol users. At 6 months postrandomization, Internet-based therapy led to better results than Internet-based self-help.

An Effectiveness Trial of a Selected Dissonance-Based Eating Disorder Prevention Program for Female High School Students: Long-Term Effects.

Abstract: Eating disorders, which afflict 10% of adolescent girls and young women, are marked by functional impairment, morbidity, mental health service utilization, and increased risk for future health and mental health problems (Johnson, Cohen, Kasen, & Brook, 2002; Lewinsohn, Streigel-Moore, & Seeley, 2000; Stice, Marti, Shaw, & Jaconis, 2009a; Wilson, Becker, & Heffernan, 2003). Thus, a public health priority is to develop effective eating disorder prevention programs. Efficacy trials have produced considerable empirical support for a dissonance-based eating disorder prevention program (Stice, Mazotti, Weibel, & Agras, 2000). In this selective prevention program young women at risk for eating disorders because of body image concerns critique the thin ideal espoused for women in verbal, written, and behavioral exercises. These activities theoretically produce cognitive dissonance that motivates participants to reduce their pursuit of the thin-ideal, producing reductions in body dissatisfaction, unhealthy weight control behaviors, negative affect, and eating disorder symptoms. Efficacy trials show that this prevention program produces greater reductions in eating disorder risk factors (e.g., thin-ideal internalization, body dissatisfaction, self-reported dieting, and negative affect), eating disorder symptoms, functional impairment, and future onset of eating disorders over a 3-year follow-up relative to assessment-only or alternative intervention control conditions (e.g., Stice et al., 2000; Stice, Shaw, Burton, & Wade, 2006; Stice, Marti, Spoor, Presnell, & Shaw, 2008). Efficacy trials evaluate whether preventive interventions produce effects under carefully controlled experimental conditions, in which the facilitators are methodically trained and supervised, the intervention is typically delivered in adequately staffed research clinics, and the participants are often homogenous (Flay, 1986). Efficacy trials conducted by independent labs have also found that dissonance-based eating disorder prevention programs produce greater reductions in risk factors and eating disorder symptoms relative to assessment-only control conditions and alternative interventions (e.g., Becker, Smith, & Ciao, 2005; Mitchell, Mazzeo, Rausch, & Cooke, 2007; Roehrig, Thompson, Brannick, & van den Berg, 2006; Wade, George, & Atkinson, 2009). Impressively, dissonance-based prevention programs have even reduced eating disorder risk factors and symptoms when college students deliver the intervention in dissemination research (Becker, Bull, Schaumberg, Cauble, & Franco, 2008; Becker, Smith, & Ciao, 2006; Parez, Becker, & Ramirez, 2010). Consistent with the intervention theory for the dissonance-based eating disorder prevention program, there is evidence that reductions in thin-ideal internalization mediate the effects of the intervention on change in the outcomes (Seidel, Presnell, & Rosenfield, 2009; Stice, Presnell, Gau, & Shaw, 2007b; Stice, Marti, Rohde, & Shaw, in press). In support of the notion that dissonance induction contributes to the effects of this intervention, participants assigned to high-dissonance versions of this program show significantly greater reductions in eating disorder symptoms than those assigned to low-dissonance versions of this program (Green, Scott, Divankova, Gasser, & Pederson, 2005; McMillan, Stice, & Rohde, 2011), though these trials clearly imply that intervention content and non-specific factors (e.g., perceived group support) also contribute to intervention effects. Given the empirical support for this eating disorder prevention program from efficacy trials conducted by independent labs, we initiated a large effectiveness trial of this intervention. Effectiveness trials evaluate whether interventions produce effects when delivered by endogenous providers (e.g., school counselors) who are not closely supervised under real world conditions in natural settings with heterogeneous populations (Flay, 1986). It is vital to conduct effectiveness trials because a prevention program that produces effects in highly controlled efficacy trials may be ineffective when delivered under real world conditions by endogenous clinicians. Effectiveness trials can also provide information concerning the degree of training and supervision necessary to achieve intervention effects and have the potential to reveal problems that must be resolved before the prevention program can be successfully disseminated (e.g., effectiveness trials might reveal that typical high schools do not have clinical staff with experience delivering group-based interventions). The present trial utilized several design elements consistent with effectiveness research (Roy-Byrne et al., 2003). First, we implemented this prevention program in three entire school districts rather than a subset of schools in a district. Second, high school nurses and counselors, rather than research staff, recruited participants and delivered the intervention within the school environment. Third, we standardized and streamlined facilitator training; endogenous providers completed a 4-hour training session and received limited supervision to mimic real-world conditions. We also used a new 4-session version of the intervention (versus the original 3-session version) that made it easier for endogenous providers to cover the same intervention exercises. Fourth, we minimized exclusion criteria; only adolescent females who met criteria for an eating disorder were excluded. Fifth, we used a minimal intervention educational brochure control condition because this was the only extant resource for students in local high schools, making this an ecologically valid control condition. An earlier report from the present effectiveness trial found that female high school students who were randomized to the dissonance intervention showed significantly greater decreases in thin-ideal internalization, body dissatisfaction, self-reported dieting, and eating disorder symptoms from pretest to posttest than educational brochure controls, with the effects for body dissatisfaction, dieting, and eating disorder symptoms persisting through 1-year follow-up (Stice, Rohde, Gau, & Shaw, 2009b). This is noteworthy because almost no eating disorder prevention programs have produced intervention effects for eating disorder symptoms through 1-year follow-up (Stice, Shaw, & Marti, 2007c). The first aim of the current report is to test whether intervention effects from this effectiveness trial persist through 2- and 3-year follow-up. We hypothesized that participants randomized to the dissonance intervention would show greater reductions in risk factors (thin-ideal internalization, body dissatisfaction, self-reported dieting, negative affect), eating disorder symptoms, and risk for onset of threshold and subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder relative to educational brochure controls. The second aim is to investigate the effects of this prevention program on other ecologically meaningful outcomes, including risk for overweight or obesity onset, psychosocial functioning, and mental health care utilization. The third aim is to benchmark the magnitude of the effects form this effectiveness trial against those observed in our large efficacy trial (Stice et al., 2008).