Psychotherapy Brown Bag

Treating obsessive-compulsive disorder with exposure and ritual prevention

by Joye C. Anestis

A few weeks ago, I described the symptoms, course, and correlates of obsessive-compulsive disorder (OCD).  I also briefly mentioned treatments which have empirical support for OCD.  The frontline psychotherapy for OCD is exposure and ritual prevention (also called exposure and response prevention; EX/RP).  Multiple clinical trials have demonstrated that EX/RP is more effective than a variety of control treatments (e.g.,Fals-Stewart et al., 1993; Lindsay et al., 1997; Marks et al., 1980) and antidepressants alone (Foa et al., 2005). The utility of EX/RP has also been demonstrated in real-world clinical settings (as opposed to the rigorous efficacy findings; Franklin et al., 2000).  These treatment gains are maintained at follow-up (Foa & Kozak, 1996).  Below I outline the major components EX/RP, which is a short-term cognitive-behavioral therapy specifically for OCD.

In general, EX/RP involves prolonged exposure to obsessional cues in conjunction with procedures aimed at preventing compulsive rituals.  For example, a person who fears they will accidentally burn the house down by leaving a curling iron plugged in is asked to leave the house without checking to see if the curling iron had been unplugged.  Prolonged and repeated exposure provides evidence that the feared catastrophic outcome does not occur (e.g., not checking to see if the curling iron is plugged in does not result in the house burning down).  Continued confrontation with disconfirming information promotes habituation to anxiety.  The hallmarks of EX/RP are discussed below:

• Exposure: Exposure for OCD requires clients to face a variety of fears in real life (known as in vivo exposure; e.g., the curling iron example above).  This obviously can be a very aversive idea for many clients; thus, a significant amount of education is necessary beforehand.  Before embarking on any exposure, the therapist should provide a clear rationale for why EX/RP works.  This is a time to display significant empathy for the client, as the treatment is difficult, while also building the client's confidence in their ability to engage in the therapeutic tasks.  It is also critical for clients to understand that no exposure will be done without their permission.  One misperception that people have of exposure therapies is that the client will be forced into interacting with their most feared stimuli.  For example, popular culture seems to reinforce this idea (I've seen a clip from the Maury Povich in which a woman with a pickle phobia had pickles just thrown at her with no way to escape).  In real life, exposure is done gradually and consentually.  Just as in the treatment of specific phobias, the client and therapist make a fear hierarchy, which lists the client's fears from least to most anxiety-inducing.  Exposure then progresses up this  list, beginning with moderately scary stimuli and ending with the most frightening.  It is interesting to note that it actually doesn't matter if you conduct exposure in a gradual manner or in an abrupt manner (i.e., beginning with the most feared stimuli).  There is no difference in the reduction of OCD fears between the two methods (Hodgson et al., 1972); however, clients prefer the gradual approach, and this approach serves to enhance client motivation and makes clients more likely to agree to the treatment.  Additionally, it is important for the exposure to be prolonged and continuous and for it not to end until the client experiences significant anxiety reduction.  This is more effective than short, interrupted exposure (Kozak et al., 1988). 
  
  • Imaginal: When a client fears specific consequences from refraining from compulsive rituals, these can be tackled via imaginal exposure (i.e., envisioning it in the mind).  In particular, many individuals fear consequences that cannot be created in real life (e.g., burning in hell, burning down a house).  Imaginal exposure allows clients to confront these types of thoughts.  Furthermore, often individuals with OCD engage in cognitive avoidance strategies when doing in vivo exposure, not allowing themselves to fully consider the consequences during in vivo exposure.  Imaginal exposure can help prevent this.  Imaginal exposure is not necessary for all clients receiving EX/RP, but research indicates that it may enhance long-term maintenance for some clients.
• Ritual prevention: In OCD, compulsions are utilized to counteract or neutralize the obsessive thought.  For example, the thought "I will die from touching this doorknob" could result in hand-washing or avoidance of the doorknob.  In the exposure component of EX/RP, clients are exposed to the very situations that trigger the obsessive thoughts.  At the same time, they actively avoid engaging in their compulsive rituals.  Ritual prevention does not generally involve the therapist physically preventing the ritual (e.g., manipulating water supply to prevent washing).  Instead, clients are given instructions and encouragement by the therapist in order to voluntarily refrain from ritualizing.   For example, an individual who takes 3 hour-long showers every day might be instructed to not exceed one 10-minute shower a day (many EX/RP manuals provide sample instructions for a variety of compulsions).  As you can imagine, this is not an easy task for clients to undertake!  Before embarking on ritual prevention (and exposure, for that matter), the therapist should conduct a thorough assessment of the client's obsessional content and compulsive behaviors.  Compulsions can be physical activities as well as mental rituals (e.g., counting up to a certain number).  In order to help the client fully refrain from all rituals, the therapist needs to clearly understand the nature, quantity, and frequency of the rituals.  The exposure component and the ritual prevention component work on different pieces of the OCD syndrome, thus it is the most beneficial for the client that both of these components be implemented concurrently.  This produces the greatest and most durable treatment gains (Foa et al., 1984).
• Homework: Homework is a key component of EX/RP.  Clients are instructed to engage in exposures themselves in between sessions, as well as avoid ritualistic behaviors.  Therapists work with the client to plan out homework exposures and create lists of instructions for ritual prevention out in their world.
• Home visit:  For some clients, it can be very beneficial to conduct one or more sessions in their home (how many depends on the individual client).  Home visits serve to promote generalization of skills into real life.  Depending on the client, the content of home visits can vary.  For some, it might involve contamination of the home and conducting additional exposure sessions to the home or workplace.  In another example, the client might be asked to turn the curling on and off without checking and leave the house with the therapist.  For OCD clients with hoarding rituals, almost all of the sessions may need to take place in the home.
• Family involvement: Many EX/RP manuals encourage involving the family in treatment.  The therapist can educate the family about OCD and the treatment.  Furthermore, it may be important to provide family members with instructions on how to encourage the client to engage in EX/RP activities at home, and what to do about client reassurance-seeking and/or violation of EX/RP rules in between sessions.
• Frequency of sessions:  The optimal frequency of treatment sessions has not yet been determined.  Intensive therapy programs produce excellent results by seeing clients daily over a month or so, and often for 4-5 hours a day.  Less frequent sessions are perhaps more feasible for clients and therapists and also seem to be effective.  For example, Ambramowitz et al. (2003) found that EX/RP was equally effective at post-treatment and follow-up for clients who received daily sessions for 3 weeks and clients who twice-weekly therapy for 8 weeks.

In this article, I have attempted to explain the overall protocol for EX/RP.  It is an intense and complicated treatment - but one that is so highly effective that it is worthwhile becoming proficient in.  It is actually quite amazing for both the therapist and client to witness such drastic symptom reduction in such a short amount of time!  Obviously, there are details of the treatment that I haven't discussed, and factors that differ between clients that influence the application of the treatment.  In fact, while the basic idea remains the same, the structure of EX/RP sessions will differ greatly depending on the specific obsessions and compulsions of the clients.  Below I have listed several treatment manuals which provide more information about EX/RP.  I have also listed facilities which train therapists in EX/RP (for CE credits, etc.).  And, as always, I encourage you to leave your thoughts in our comments section.  If you have specific questions, I can answer them there or in a future post!

Treatment Manuals

• Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual
• Stop Obsessing!: How to Overcome Your Obsessions and Compulsions (Revised Edition)
  

Training Opportunities

• Center for the Treatment and Study of Anxiety at the University of Pennsylvania
• The American Institute for Cognitive Therapy
• The Beck Institute for Cognitive Therapy and Research

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Zen and your mood: Mindfulness-based cognitive therapy for chronic depression

by Michael D. Anestis, M.S.

By definition, depression often leaves people feeling hopeless, as though there is no path that will lead them out of their current struggles.  This point is particularly true for individuals unfortunate enough to suffer from chronic depression.  By nature, depression is episodic, meaning that individuals will experience temporary peaks in symptomatology that will eventually either remit entirely, or fade below clinically significant levels before peaking again in the future.  For some individuals, however, depression is a constant - a lingering obstacle resistant to treatment and constantly interfering in all aspects of life.  In a recent article, we discussed Cognitive Behavioral Analysis System of Psychotherapy (CBASP), an empirically supported treatment (EST) for chronic depression.  Today, I would like to discuss another treatment approach for chronic depression that has been subject to increasing empirical attention and which has shown highly promising results: mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002).
    As the name indicates, MBCT merges mindfulness meditation as developed by John Kabat-Zinn (Kabat-Zinn, 1990) with skills utilized in cognitive behavioral therapy (CBT).  MBCT is administered in a group setting and structured much like an academic class, with significant attention given to education on the nature of negative automatic thoughts, rumination, mindfulness skills, and cognitive remediation skills.  Treatment typically lasts approximately 8 weeks and groups include 8-15 clients (Segal, Williams, & Teasdale, 2002).  As explained in Barnhofer et al. (2009), MBCT was designed in an effort to counteract a variety cognitive vulnerabilities that have been implicated in depression relapse.  Such vulnerabilities include a tendency to revert to depressive thinking patterns such as experiential avoidance when experiencing a negative mood (Hayes et al., 2004).  As we discussed in our article on mindfulness skills in dialectical behavior therapy (DBT), mindfulness teaches individuals to control their attention, focusing solely on the present moment and accepting things as they are rather than allowing ruminative spirals to consume them.  Individuals are taught exercises that increase their ability to step back and examine their thoughts objectively, thus allowing for a calmer, more effective approach towards problem solving.  Essentially, the key in mindfulness is developing the ability to refocus attention on neutral objects, thus allowing negative emotions to naturally run their course.  Mindfulness skills include focusing on breath, focusing on an image (imaginal or in the immediate environment), and mindful eating among others.
Studies on MBCT have produced impressive results.  In two randomized clinical trials comparing MBCT and treatment as usual (TAU) to only TAU, both Teasdale and colleagues (2000) and Ma and Teasdale (2002) found that MBCT plus TAU resulted in lower rates of relapse in individuals with a past history of three or more episodes of depression.  There was no difference between groups for individuals with two or fewer episodes of depression, indicating that the benefits of mindfulness skills are specific to individuals with chronic depression.  In an additional trial, Williams, Teasdale, Segal, and Soulsby (2000) found that MBCT plus TAU resulted in significant improvement in cognitive styles relative to individuals who received only TAU.  Specifically, the authors found that MBCT reduced categoric memories - the tendency to experience vague memories devoid of nuance - which has been implicated in depressive thought patterns (Williams et al., 2000).  Kuyken and colleagues (2008) found that MBCT was more successful than maintenance treatment with antidepressant medication at reducing residual symptoms of depression and psychiatric comorbidity and also resulted in greater physical and psychological improvements at 15-month follow-up.  Importantly, relapse rates in the MBCT group, while high (47%), were significantly lower than relapse rates in the group receiving maintenance treatment with antidepressant medication (60%).
    In all of these studies, MBCT was utilized as a treatment component intended to help reduce the rate of relapse.  Because of this, participants in the studies were between episodes of depression.  Other studies, however, have examined the utility of MBCT for clients currently experiencing depressive episodes.  Kenny and Williams (2007) found that MBCT resulted in significant reductions in depressive symptoms.  Contrary to their hypotheses, clients experiencing suicidal ideation also benefited from MBCT.  The authors believed that suicidal ideation would result in a level of heightened reactivity to negative moods that would interfere with participants' ability to utilize mindfulness skills, but in fact, no such difficulty was found.  Finally, Barnhofer and colleagues (2009) found that, while self-reported depressive symptoms did not improve in a TAU group, individuals receiving MBCT plus TAU self-reported significant decreases in depressive symptoms.  Additionally, the number of individuals who met criteria for depression after treatment in the MBCT plus TAU group was significantly lower than the number of individuals meeting criteria for depression in the pure TAU group.
    I realize I just listed quite a few studies in the previous two paragraphs, so let me attempt to summarize what these studies have found.  Primarily, data indicate that MBCT is highly beneficial in preventing relapse in individuals who have experienced three or more episodes of depression.  In fact, it appears to be more effective at reducing relapse than antidepressant medications.  Additionally, there is preliminary evidence that MBCT can be effective in reducing symptoms in individuals currently experiencing depressive episodes.  Importantly, however, there are limitations to the research on MBCT.  As of yet, MBCT has only been compared to one other active treatment (maintenance antidepressant medication), so the degree to which the effects of MBCT can be explained simply by the presence of a treatment is unclear.  Additionally, the data do not provide clear evidence that the mindfulness component of MBCT adds incremental value to the CBT skills that already have a rich foundation of empirical support.  That being said, there is no reason to assume that the findings for MBCT are spurious, but future research is needed to increase our confidence in the results.

If you would like to learn more about mindfulness-based cognitive therapy, we recommend the following products, all of which are available through our online store:

Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse

Mindfulness-based Cognitive Therapy for Depression [VHS]

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Additionally, if you would like to see an example of a mindfulness session led by John Kabat-Zinn, we recommend viewing the following video:

Treatment of psychopathy: oxymoron or clinically feasible?

by Joye C. Anestis

The treatment of psychopathy - seems like an oxymoron, right?  The very nature of psychopathy makes it seem like something that's not very amenable to treatment.  Can you remedy traits like pathological lack of empathy, lack of emotionality, lack of guilt and remorse?  Or can you at least change the behavioral manifestations of those traits?  In this article, I will review the psychopathy treatment literature to determine if these assumptions are true (see my previous post for clarification about what psychopathy is).

Before delving into this discussion, it is important to note that none of the treatments referred to below are considering empirically-supported treatments for psychopathy.  The psychopathy treatment literature contains multiple methodological problems (e.g., few control groups, lack of proper assessment), rendering it difficult to draw many firm conclusion.  Furthermore, there have been no rigorous randomized controlled trials for psychopathy.  We are a long way from establishing best practices for dealing with psychopathic clients.  Also, unless otherwise noted, the treatment discussed below are for adults only.  For a more in-depth discussion of this topic, see Harris & Rice's (2006) excellent chapter in Patrick's Handbook of Psychopathy.

• Therapeutic communities for offenders.  The theory behind the therapeutic community for the treatment of psychopathy is that perhaps a reshaped social milieu might alter the deviant personality characteristics and social behavior of the psychopath.  The composition of these therapeutic communities are often similar to inpatient rehabilitation facilities for substance abuse/dependence, and they have been attempted in prison, hospitals, and other institutions.  Several studies have been conducted to evaluate the utility of these communities in reducing recidivism (i.e., re-offending).  Rice, Harris, & Cormier (1992) matched 146 treated offenders with 146 nontreated offenders.  Almost all of these offenders had a history of violent crimes.  They used the Psychopathy Checklist-Revised (PCL-R; Hare 1991, 2003), considered to be the "gold standard" measure of psychopathy with incarcerated individuals, to assess psychopathy.  The study reports results after following these offenders for an average of 10.5 years.  They found that for nonpsychopaths, the treatment was effective - this group had lower violent recidivism than the nontreated group.  However, the treated psychopaths had higher rates of violent recidivism than the nontreated group.  These were very provocative findings, and the conclusions drawn from these results were/are disturbing.  In this study, it appears that both the nonpsychopaths and the psychopaths who received treatment learned more about things like emotions, empathy, the use of emotional language, being socially skilled, and the delay of gratification.  The nonpsychopaths used these skills to adjust socially and behave in prosocial manners.  The psychopaths appeared to usemthese skills to become better psychopaths, learning new ways to manipulate and exploit.  Other studies in different therapeutic communities have found that therapeutic communities at the least result in no improvement and at the worst are iatrogenic (Hobson, Shine, & Roberts, 2000; Ogloff, Wong, & Greenwood, 1990; Richards, Casey, & Lucente, 2003).  Thus, it appears that a treatment in which psychopaths learn more about emotions and appropriate social behavior enables them to be more skilled in their deviance.

• Cognitive-behavioral approaches for offenders.  Studies examining cognitive-behavioral approaches in the treatment of psychopathy are not any more promising. Seto & Barbaree (1999) found that, in a sample of sex offenders, those high in psychopathy who were rated as showing the most improvement were more likely to reoffend, especially in violent ways.  Hughes, Hogue, Hollin, & Champion (1997), using a psychiatric inpatient offender sample, found that the higher the PCL-R score, the poorer the treatment gains.  Hare, Clark, Grann, & Thornton (2000) reported that psychopathic offenders who received treatment had significantly higher rates of recidivism than nontreated offenders.

So what do we do with this discouraging news?  For those out there who are grappling with how to handle a psychopathic client, Harris & Rice (2006) offer a number of suggestions for reducing the harm produced by psychopaths.  It is important to note that their treatment recommendations have not been studied in psychopathic sample, so while they seem like reasonable techniques to try, their efficacy has not been established.

• Behavioral modification.  A variety of studies (including a meta-analysis of meta-analyses) support the use of clear behavioral contingencies to modify a wide variety of behavior (e.g., Lipsey & Wilson, 1993).  There is no reason to believe at this point that this would be an iatrogenic method by which to modify deviant behaviors in psychopaths.  In fact, token economies can effectively be implemented across facilities (e.g., an entire prison).  In this manner, reinforcement principles could reinforce the manifestation of psychopathic tendencies into more socially acceptable ways.
• Multisystemic therapy (MST).  MST has been shown to be highly effective for juvenile delinquents and has demonstrated efficacy in RCTs (Borduin, Schaeffer, Ronis, & Scott, 2003; Brown, Borduin, & Henggeler, 2001; Brown et al., 1997; Randall & Cunningham, 2003; Weisz, 2004).  MST is based on a systems theory of criminal behavior: that adolescent criminal activity is a natural response to the system in which the adolescent operates.  MST is very flexible and individualized, addressing problems within the specific systems each adolescent experiences.  Although MST has never been used in adults, it seems reasonable to hope that it can work in adult psychopaths.  Perhaps psychopathic behavior is maintained because opportunities are favorable for the occurrence of such behavior (Harris & Rice, 2006).  By invoking consequences and monitoring into these systems, perhaps the psychopathic behavior will decrease.

Finally, Harris and Rice (2006, pp. 567-577) offer the following recommendations for novice forensic clinicians encountering psychopathic clients:

1. Read Robert Hare's Without Conscience: The Disturbing World of the Psychopaths Among Us .
2. "Reputation matters..."
3. Do no rely solely on the offender's account of events.  Confirm his/her statements against records and other informants.
4. Pay attention not only to how he/she behaves toward you but how he/she treats everyone (e.g., peers, staff, family).
5. "Beware of flattery."
6. Be suspicious if the client asks you to break any rule or to maintain a confidence about something illegal.
7. Consult with trusted colleagues about your relationship with the client.  Beware if others are suspicious.

We already knew from my previous post that psychopathy is a pernicious and devastation personality syndrome.  So far, the clinical psychology world has not figured out an acceptable and efficacious way to treat these individuals and, if not remove their symptoms, at least redirect their manifestation.  There are many hypothesized reasons for this failure.  One primary problem is the nature of the beast at hand.  Psychopathic individuals rarely, if ever, present for treatment voluntarily.  Additionally, many researchers argue that psychopathy is actually an evolutionarily viable life strategy (e.g., Harris & Rice, 2006).  From this point of view, nothing is "wrong" with them in the manner of a deficit that therapy can "fix."  Another problem with the identification of treatments for psychopathy is the nature of the research.  Very few adequate studies have been conducted, leaving the clinical world scratching its head about exactly what to do.  Many studies using random assignment and control groups are needed before we can feel confident about best practices with this condition.  As of now, the conclusion to be drawn is that treatment of psychopathy seems to be an oxymoron - in fact, the treatments that have been attempted were iatrogenic.  They resulted in an increase in deviant behavior.  But we are learning more every day...

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Empirically-supported treatment for anorexia nervosa: What do we know?

by Michael D. Anestis, M.S.

Last week, a new Miss Australia was crowned.  Ordinarily, this occasion does not prompt a whirlwind of international attention; however, this year's winner has inspired a surge of controversy due to her physical stature.  The 19-year-old beauty queen stands 5 feet 11 inches tall and weighs only 108 pounds.  This means her body mass index (BMI), a standard of measurement used to determine the expected weight for an individual given his or her height, is 15.1.  To provide some context, the BMI specifies the following:

< 18.5 = underweight
18.5 - 24.9 = normal weight
25 - 29.9 = overweight
30 and above = obese

    So, according to the gold standard approach for determining the appropriateness of an individual's weight, Miss Australia was significantly underweight.  To take this point even further, the diagnostic criteria for anorexia nervosa (AN) require that an individual weight less than 85% of her expected body weight, which means a BMI of 17.5 or lower.  Fortunately, the decreasing weights of models and beauty pageant contestants has prompted concern and action.  For instance, fashion week in Madrid now requires that all models maintain a BMI of no lower than 18.  Obviously, the low end of this continuum is still dangerously close to the diagnostic criteria for AN, but a start is better than nothing.
    All that being said, the purpose of this article is not to belabor the point that standards of beauty presented in the media are often quite unhealthy, but rather to provide a resource on what we know about the treatment of AN.  Quite understandably, stories like the crowning of this year's Miss Australia can prompt significant concern on the part of the families and friends of individuals who might be suffering from AN.  In this article, I would like to provide readers with a summary of what we know about AN and, in particular, its treatment.  The findings, as you will see, are quite different for adolescents versus adults, in that the empirical support for treatment is better for the former than the latter.  For a more thorough review of the various treatments for AN, I suggest consulting Guarda (2008), listed on our references page along with all other studies referenced in articles on PBB.

Diagnostic criteria

    To warrant a diagnosis of AN, an individual must exhibit a variety of symptoms specified in the DSM-IV-TR.  They are as follows:

• Refusal to maintain a normal body weight as evidenced by weight less than 85% of that which is expected given age and height.
• Intense fear of gaining weight
• Disturbance in evaluation of weight and shape.
• Amenorrhea -- the cessation of menstrual cycles for three consecutive months in females who have already begun menstruating.  Importantly, this is a symptom, not a cause of severe weight loss.

    Additionally, the DSM-IV-TR specifies two subtypes of AN: restrictive type and binge eating/purging type.  In the former, highly controlled restriction of dietary intake is exhibited in the absence of binge eating and purging.  In the latter, binge eating and purging regularly occur.  Approximately 50% of individuals who at one point meet criteria for the restricting subtype of AN ultimately transition to either the binge eating/purging subtype of AN or to bulimia nervosa (BN; Strober, Freeman, & Morrell, 1997).  If an individual meets nearly all of the criteria for AN but is either slightly above 85% of expected weight threshold or is not experiencing amenorrhea, she will receive a diagnosis of eating disorder not otherwise specified (EDNOS).
For individuals who do not develop a chronic course of AN, recovery typically happens gradually over a period of years and often involves intermittent periods of increased symptomatology (Eckert, Halmi, Marchi, Grove, & Crosby, 1995).  Although effective treatment is pivotal for any mental illness, this is particularly true for AN, which has one of the highest early mortality rates of any mental illness (Sullivan, 1995).  This high rate of early mortality is, in large part, due to depleted nutritional states and suicide (Crisp, Callender, Halek, & Hsu, 1992).  Some have argued that the increased suicide rate in AN is due to the physical fragility caused by the disorder, which might make typically non-lethal attempts more likely to result in completed suicide.  Holm-Denoma and colleagues (2008), however, found quite the opposite.  Consistent with Joiner's (2005) interpersonal-psychological theory of suicide, which stipulates that individuals acquire the capability to die by suicide through habituation to physical pain and the fear of death, the authors found that individuals with AN tend to use methods of attempt likely to be lethal regardless of nutritional state.  This, they argue, reflects a gradual habituation to pain through chronic exposure to the physical discomfort of self-starvation.

Treatment of Anorexia Nervosa

    The treatment literature for AN involves a substantial amount of disagreement regarding the best available options and, at times, appears to signify that there are no empirically supported treatments (ESTs) for AN.  This, however, is an oversimplification that understates the utility of current approaches.  Certainly, significant improvement in our ability to actively treat AN is needed, but individuals suffering from this disorder are not without options.  Although research has indicated that pharmacological interventions are ineffective in the treatment of AN (Crow, Mitchell, Roerig, & Steffen, 2009), there is evidence that psychosocial approaches have significant utility.
    Division 12 of the American Psychological Association (APA) has comprised a list of all treatments that have empirical support for DSM-IV-TR mental illnesses.  For AN, two such treatments are listed.  Family-based treatment (FBT) for adolescents is listed as having strong research support, whereas cognitive behavioral therapy (CBT) is listed as having modest/controversial research support (see the Division 12 website for a better understanding of the meaning of these labels).  It is important to note that the empirical support for FBT is limited to adolescents, meaning the findings do not generalize to all age groups.  This makes AN unique in that it is the only DSM-IV-TR disorder for which an earlier age of onset is a better prognostic indicator.
    FBT, developed at the Maudsley hospital in London, typically involves 20 sessions over 12 months, with three phases during the course of treatment.  A shorter format, 10 sessions over 6 months, has been shown to be equally effective to the full version as well (Lock, Agras, Bryson, & Kraemer, 2005).  The primary aim of FBT is to help the parents of adolescents suffering from AN to regain control over their child's eating patterns and weight.  Importantly, this is an outpatient treatment approach, which can significantly reduce the substantial financial burden of treatment for AN. 
    In phase 1 of treatment, control over what and when the adolescent eats is given entirely to the parents.  Parents are informed that their child's AN is not their fault, but that they must be responsible for certain aspects of the recovery process.  Cooperation between parents is highly encouraged.  Phase 1 typically lasts approximately six months, with weight restoration being the primary goal.  Phase 2 involves a gradual return over eating habits for the adolescent.  Eating out with peers and on dates is acceptable during this phase, although care is taken to ensure that this does not initiate a return to maladaptive patterns of food restriction and weight reduction.  In phase 3 of treatment, which lasts only four sessions, control over eating is handed over entirely to the adolescent and treatment focuses significantly on issues tangential to eating, such as the relationship between the adolescent and parents (Rhodes, 2003).  In a long term study of the effectiveness of FBT in treating female adolescents diagnosed with AN, Paulson-Karlsson, Engstrom, and Nevonen (2009) reported that 75% of the 32 adolescents who received treatment were in full remission at 36 month follow-up, an extremely encouraging finding.

    An important consideration when examining the effectiveness of treatments for AN is the ego-syntonic nature of the disorder.  Many individuals with AN either do not believe they need treatment or desire only treatments that will help with affective difficulties without requiring weight restoration (Rieger et al., 2000).  As such, treatment compliance is an issue and motivation for treatment is quite frequently low.  Bewell and Carter (2008) found that motivation for change mediated the relationship between AN severity and treatment outcome.  In other words, although a less severe case of AN is more likely to respond to treatment, this is only because individuals with less severe symptomatology are typically more highly motivated to change.  An individual who is highly severe but highly motivated to change is more likely to respond to treatment than is a less severe individual who is ambivalent about treatment.  This is an important consideration, as it highlights two significant points.  First, because the physical danger of severe AN can require involuntary inpatient hospitalization, a substantial number of individuals in treatment are likely to be unmotivated to change and unlikely to initially respond.  Second, although at times involuntary stabilization of physical danger can be necessary, forced interventions appear unlikely to produce long term gains and, as such, should be avoided when possible (see our article on treatments that cause harm for additional examples of this point).

Conclusion

    So what do we know about the treatment of AN?  There appears to be substantial support for the utility of FBT for adolescents and limited support for a more general use of CBT.  Pharmacological interventions, as of now, appear ineffective.  Although involuntary hospitalization occurs at times when the physical dangers of AN require immediate care, FBT offers an effective outpatient approach that can diminish cost and sustain treatment gains.  Despite these positive points, the treatment of AN lags behind the treatment of other mental illnesses, including other eating disorders.  Future work is necessary in order to develop a more satisfactory set of treatment options, particularly for adults.

If you would like to learn more about the Maudsley model of family-based treatment for anorexia, we recommend the following link, provided to us by Katie Gordon, Ph.D., an assistant professor at North Dakota State University and an expert researcher on eating disorders (http://www.maudsleyparents.org/).  The site provides information for parents whose children suffer from eating disorders and was created by the founders of the Maudsley model of FBT.  We also recommend the following products, all of which are available through our online store:

• Treatment Manual for Anorexia Nervosa: A Family-Based Approach

• Eating with Your Anorexic: How My Child Recovered Through Family-Based Treatment and Yours Can Too

• Help Your Teenager Beat an Eating Disorder

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Empirically-supported treatments in the "real world": results from RCTs generalize to real-world clinical practice

by Joye C. Anestis

    One of the primary arguments raised against the categorization of empirically-supported treatments (ESTs) is a concern that the studies used to determine empirical support do not generalize to real-world therapy situations.  The primary studies required to classify a treatment as empirically-supported, known as efficacy studies, are randomized controlled trials (RCTs).  RCTs randomly assign participants into treatment or a control group.  The therapists in these trials are highly trained in the therapy and strictly adhere to treatment manuals.  Individuals generally cannot participate if they have other diagnoses besides the primary one being treated.  The purpose of these RCTs is to determine internal validity, to determine if the symptom reduction in the treatment group can be attributed to the treatment.  It has been theorized that one of the reasons ESTs are underutilized in real-world clinical practice is that these RCT findings will not generalize to real-world situations (Westen, Novotny, & Thompson-Brenner, 2004).  Clinical practice in the real world is often much messier than the one created in an RCT.  Comorbidity of diagnoses (i.e., clients having more than one mental illness) is the rule rather than the exception (Clark, Watson, & Reynolds, 1995).  Therapists are not always experts in specific ESTs, and pragmatic issues might hamper the faithful administration of an EST. 

    Luckily, another type of study aims to address this very issue.  Known as effectiveness studies, these studies focus on the external validity of their findings, with the overall goal being to determine if results from RCTs represent results in the real world.  Effectiveness studies are generally conducted at community mental health clinics, using the staff therapists administering ESTs as they normally do.  Participants in these studies are community clients presenting at the clinic.  Thus, effectiveness studies often involve routine service provided to consumers.

    On PBB, we often talk about the results of RCTs in the treatment of various mental illnesses, something we will always continue to do.  So far, we have written about interpersonal and social rhythms therapy for bipolar disorder, exposure for specific phobias, EX/RP for obsessive-compulsive disorder, CBT for generalized anxiety disorder, DBT for borderline personality disorder, CBT for PTSD, and cognitive-behavioral group therapy for social anxiety disorder.  And we have many many many more to cover!  However, it's helpful to stop every once in a while and determine if all of these results can be replicated in real world clinical situations. Unfortunately, for reasons I have never been able to understand, there are far fewer effectiveness studies conducted than efficacy studies.  This is a real shame, as the effectiveness arm of the EST campaign is essential.  However, in the past few years, the cumulative amount of effectiveness studies has grown enough to warrant a couple of studies looking at the aggregate effect size of various treatments. 

One common way to compare outcomes from effectiveness studies to those from RCTs is to use a benchmarking strategy.  Hunsley and Lee (2007) used a benchmarking strategy by identifying the best RCT (or a meta-analysis) for each mental illness.  Think of it as comparing effectiveness studies to the "gold standard" results in more rigorous studies.  Hunsley and Lee (2007) used the percentage of clients who completed treatment, percentage of client who were improved at treatment termination, and effect sizes as their standards for comparison.  They then gathered effectiveness studies for adult and childhood/adolescent conditions.  The overall results found improvements in effectiveness studies comparable to those from efficacy studies for both childhood/adolescent and adult disorders.  Clients completed treatment at a rate higher than is typically found in psychotherapeutic outcome studies and (with few exceptions) at a comparable rate to the benchmark study.  Almost all of the effectiveness studies had outcomes comparable to or greater than the benchmark study.  It's important to note that these results come from a wide variety of treatment providers, such as inpatient units, specialty clinics, independent practices, outpatient clinics, and community clinics.  Specific treatments tested:

• Cognitive therapy and CBT for depression
• CBT for panic disorder/agoraphobia
• CBT for generalized anxiety disorder
• CBT for obsessive-compulsive disorder
• CBT for social phobia
• CBT and IPT for childhood/adolescent depression
• CBT for childhood/adolescent anxiety disorders
• Parent training for disruptive behavior disorders in children
• Multisystemic therapy for adolescent conduct disorder

    Obviously, there are a lot of mental illnesses missing from that list, but it's a start.  Another interesting aggregate study of effectiveness literature is a very recent meta-analysis by van Ingen, Freiheit, and Vye (2009).  They conducted a meta-analysis of effectiveness studies for CBT for anxiety disorders.  van Ingen and colleagues found that cognitive-behavioral interventions for anxiety disorders (in this study, OCD, panic disorder with or without agoraphobia, social phobia, PTSD, and GAD) were associated with significant decreases in anxiety symptoms (mean variance-weighted effect size = 1.35).  These gains were maintained at follow-up (mean variance-weighted effect size = 1.14).  Cognitive-behavioral interventions for anxiety disorders also significant decreased concurrent depression symptoms at post-test (mean variance-weighted effect size = 0.96) as well as follow-up (mean variance-weighted effect size = 1.12).  These results are comparable with meta-analytic studies on RCTs for cognitive-behavioral interventions for anxiety disorders.

    Taken, together these two studies begin to verify the assumption long held by proponents of ESTs: that results from RCTs can generalize to treatment in the real world.  This is an important message to send out into the psychotherapy community.  ESTs, which time and again show documented and robust outcomes in clients, do work in regular clinical practice as part of routine clinical care.

If your are interested in learning more about empirically supported treatments, we recommend exploring our online store, which includes a variety of empirically supported treatment manuals aimed both for therapists and clients.  Some of these books are self-help oriented, some explain the theories behind certain treatments, and others actually detail, step-by-step, how to administer particular treatments.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Social rhythms in bipolar disorder: How daily behavioral patterns can increase vulnerability to both mania and depression

by Michael D. Anestis, M.S.

My dog got sick last night.  Why do I point this out in an article on PBB?  Quite simple, really.  As a result of my poor dog's illness, I did not get much sleep last night and, consequently, I'm experiencing a bit of a bad mood.  I suspect every person reading this article can relate to what I am feeling in this moment - a night of bad sleep leading to a morning characterized by irritability or other negative emotions.  Generally speaking, this passes within a couple hours and we forget all about it later in the day.  On a similar note, think about the last time you were extremely hungry and unable to find food.  Maybe you were rushed in the morning, missed breakfast, and went to work without time to stop and get a quick bite to eat.  Here again, I suspect everyone reading this article can think back to a time when this happened and remember feeling as though they were ready to bite the head off of the next person who asked them to do something.  Before long, these feelings fade as well, and the rest of the day typically goes smoothly.
    Researchers refer to our day-to-day routine, particularly with respect to basic processes such as eating and sleeping, as social rhythms.  Disruptions in these rhythms can cause anyone to experience a bad mood, but they are particularly problematic for individuals suffering from bipolar spectrum disorders (e.g., bipolar I, bipolar II, cyclothymia).  Research on social rhythms first gained prominence through the work of Ehlers and colleagues (1988), who published a theory referred to as the social zeitgeber theory of mood disorders.  If you are like me, you are currently thinking, "what the heck is a zeitgeber?"  Fair enough.  Zeitgebers are environmental "time setters," or cues that help regulate our circadian clock.  The simplest zeitgeber is the rising and setting of the sun, which for centuries has cued individuals to fall asleep and wake up.  Given that light is now readily available, humans now rely on a variety of other such cues.  Amazingly, simple day-to-day activities such as the timing of our meals or even our nightly schedule of television programming can have profound effects on our circadian clock (Frank, 2007).  Importantly, researchers have found that, in individuals with bipolar disorder, simple disruptions in social rhythms can prompt episodes of depression and particularly mania and prolong episodes that have already begun (Malkoff-Schwartz et al., 1998; Malkoff-Schwartz et al., 2000).  Shen, Alloy, Abramson and Sylvia (2008) found that individuals diagnosed with cyclothymia or bipolar II disorder engaged in fewer regular activities than did individuals with no mood disorder and that poor social rhythms predicted a quicker onset of mood episodes.  Ashman and colleagues (1999) found that individuals with rapid cycling bipolar disorder (four or more cycles of depression and mania/hypomania) demonstrated particularly dysregulated patterns of activity in the morning.  These findings seems to indicate that disruptions in our daily routine can make anyone vulnerable to a bad mood, but such disruptions in the lives of individuals with a bipolar spectrum disorder are particularly problematic and can lead to the onset and increased duration of both depressive and manic (or hypomanic) episodes.
    So what can be done about this?  Thankfully, an empirically supported treatment for social rhythms that can be used in conjunction with appropriate pharmacological treatment has been developed.  Interpersonal and Social Rhythms Therapy (IPSRT; Frank et al., 1994) aims to address three primary paths to relapse frequently seen in individuals with bipolar spectrum disorders:

1. Poor medication adherence
2. Stressful life events
3. Disruptions in social rhythms

IPSRT involves several components.  Clients are given medication adherence training in order to decrease the likelihood that they will cease using the mood stabilizing medications that have been shown to be, by far, the most effective means for stabilizing the dangerous mood patterns that characterize bipolar spectrum disorders, particularly bipolar I (Craighead, Miklowitz, Frank, & Vajk, 2002).  Additionally, clients are given a form on which they are taught to explore their feelings about their symptoms.  In doing this, clients are given a chance to grieve what Frank and colleagues have referred to as "the lost healthy self" in order to help them accept their current life situation and develop new perspectives and goals.  Such shifts in perspective often lead to a significant reduction in interpersonal and social role stress, which in turn can help reduce unhealthy fluctuations in social rhythms.  The goals of IPSRT can thus be summarized as ensuring the regular use of prescribed mood stabilizing medication, increasing acceptance of symptoms, developing goals based upon current life situations, and maintaining a stable, healthy pattern of eating and sleeping.
    In clinical trials, IPSRT in conjunction with proper pharmacological care has been shown to significantly increase the time between episodes of both mania and depression in individuals with bipolar I disorder (Frank et al., 2005).  In other words, when incorporated into treatment with medication, IPSRT increases the amount of time that individuals with bipolar spend symptom free.  Additionally, in bipolar I and bipolar II individuals experiencing depressive episodes, IPSRT resulted in a quicker remittance of symptoms (Miklowitz et al., 2007).  Perhaps the greatest measure of the effectiveness of a therapeutic intervention is its ability to reduce the most problematic outcomes associated with a particular ailment.  In this case, IPSRT has been shown to significantly reduce suicide attempts in individuals with bipolar disorder (Rucci et al., 2002).  IPSRT can be used both as an acute treatment for individuals currently in the midst of a depressive or manic episode or as a prophylactic treatment for individuals who are currently between episodes and seeking to maximize the amount of time spent without symptoms.  For individuals with bipolar I disorder (full manic episodes), IPSRT is best used in conjunction with mood stabilizing medication.  For individuals with bipolar II (hypomanic episodes, full depressive episodes), IPSRT can be used as a stand alone treatment if severity is not particularly extreme (Frank, 2007). 
    IPSRT consists of the following four phases, explained in more detail in Frank (2007).

Initial phase

• Obtain detailed history about the degree to which disruptions in social rhythms and interpersonal interactions have been involved in mood episodes.  This provides a rationale for treatment.
• Select area from the four interpersonal psychotherapy (IPT) modules that will be the focus of therapy (grief, role transitions, role disputes, interpersonal deficits).
• Typically lasts 3-5 sessions

Intermediate phase

• Develop healthy, regular social rhythms (e.g., sleep and eating schedule)
• Address the primary interpersonal area of concern selected during the initial phase of treatment

Continuation phase (or maintenance phase)

• Increase client's confidence that he can utilize these skills in his daily life, even when faced with life stress
• At this point, sessions are reduced from weekly to bi-monthly and, eventually, monthly.

Final phase

• Sessions are further reduced in frequency as termination becomes the goal

    The idea that regular sleep and eating patterns can impact our mood is not earth shattering news, although the empirical research examining this process certainly expands upon this point dramatically.  What is especially important to consider along these lines, however, is that individuals who are vulnerable to mood disorders must pay particularly close attention to the regularity of their schedules in order to reduce the likelihood of a mood episode.  Fortunately, as outlined above, empirically supported treatments are available that emphasize this point and train individuals to develop regular schedules that can be maintained even in times of stress.

For more information on IPSRT, we recommend the following products, all of which are available through our online store:
Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy (Guides to Individualized Evidence-Based Treatment)

For more information on bipolar disorder, we recommend the following products, all of which are available through our online store:
Cognitive-Behavioral Therapy for Bipolar Disorder, Second Edition
Managing Bipolar Disorder: A Cognitive Behavior Treatment Program Workbook (Treatments That Work)

For more information on interpersonal psychotherapy, we recommend the following products, all of which are available through our online store:
Comprehensive Guide To Interpersonal Psychotherapy
Clinician's Quick Guide to Interpersonal Psychotherapy
Mastering Depression through Interpersonal Psychotherapy: Patient Workbook (Treatments That Work)
Mastering Depression through Interpersonal Psychotherapy: Monitoring Forms (Treatments That Work)

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

One-session treatment of specific phobias

****As I predicted would happen again in my very first post for PBB, yesterday I accidentally posted the beginning of this article to the website. I apologize to those of you who received the partial post in your inbox or RSS feed reader.  I'm sure that won't be the last time I do that.

by Joye C. Anestis

(due to a loose snake, Monk is standing on a kitchen table.)
Captain Stottlemeyer: I thought you were afraid of heights.
Monk: Snakes trump heights.  It goes germs, needles, milk, death, snakes, mushrooms, heights, crowds, elevators.
 - from USA's Monk, starring Tony Shalhoub as Adrian Monk and Ted Levine as Captain Stottlemeyer

There are a variety of empirically-supported treatments available to treat specific phobias in both children and adults, including systematic desensitization, modeling, cognitive therapy, and exposure.  I recently came across a review article of one-session treatment for specific phobia (Zlomke & Davis, 2008).  This manualized, one-session treatment (OST) combines several aspects of the various specific phobia treatments into one short therapy session, and has empirical support for a variety of specific phobias, including spider phobias, small animal phobias, flying phobia, and claustrophobia.  OST involves gradual exposure to feared stimuli in a single session.  Below, I will cover the various aspects of OST for specific phobia as described by Zlomke & Davis (2008; published in Behavior Therapy).  For further information, check out the many studies and papers published by Ost & Ollendick.

Assessment: The first step of OST is a thorough assessment prior to treatment.  A functional analysis for each specific phobia is conducted to identify both etiological and maintaining factors of the specific fears.  This thorough assessment is necessary to construct a treatment plan.  Within the assessment interview, information on the client's catastrophic cognitions about the feared stimuli, avoidant response patterns, and experiences with conditioning are gathered.  Self-report measures of anxiety can be taken, and behavioral avoidance tasks can also be used.  One of the primary tasks of the assessment interview is the development of a fear hierarchy.  This hierarchy will be used to structure the treatment session.  To construct a fear hierarchy, the client first makes a list of a variety of feared stimuli within a phobia.  They then quantify the amount of anxiety each stimuli induces.  Quantification generally consists of subjective units of distress (SUDs), rating the amount of anxiety associated with each stimuli on a scale of 1-100 or 1-10.  The stimuli are then ranked in order from least to most anxiety-inducing.  For example, a sample fear hierarchy (using a 1-100 scale) for a snake phobia might look like this:

• talking about a snake - 40
• seeing a snake on TV - 50
• seeing a rubber snake - 70
• seeing a live snake -95
• touching a live snake - 100

Presentation of the treatment rationale: Before the treatment begins, the therapist must explain the rationale behind the treatment and instructions for the treatment.  The overall purpose of OST is to expose the clients to feared stimuli in a controlled manner in order to learn that the feared consequence does not occur or, if it does, the consequence is not nearly as catastrophic as feared.  Other points to cover in this discussion are:

• OST is a collaborative process.  Client and therapist will work together to face feared stimuli.
• The massed exposure session is only the start of their recovery.  Clients must continue to expose themselves to feared stimuli in their everyday lives for months to maintain and stabilize gains
• The therapist will not progress up the fear hierarchy without the client's permission.  This is an important point to make.  Exposure does not involve shoving the feared stimuli in the face of the client without them being prepared.  Each step is done with explicit permission from a prepared client.

In vivo exposure & modeling: Exposure is done in a hierarchical fashion.   Usually, an item from the middle of the fear hierarchy is selected first.  Once a stimulus for exposure is agreed upon, the therapist demonstrates the exposure first and then the client carries out the interaction.  The client maintains interaction with the stimulus without using any cognitive or behavioral avoidance.  The interaction continues until the stimulus no longer causes severe anxiety (i.e., the SUDs rating has decreased by at least 50% or is zero).  Once anxiety significantly reduces, the next item higher up on the list is confronted. In OST, exposure is structured similarly to behavioral experiments.  Before and during the exposure, the therapist elicits catastrophic cognitions (e.g., "If I see a snake, it will jump at me, bite me, and kill me.") from the client and encourages them to reach more rational conclusions from the interaction with the stimulus (e.g., "It seems unlikely that a snake wants to bite and kill me.  This one is has not bitten me.").  After each experiment, the client's success or failure is discussed before moving up the list.  Other important aspects of exposure in OST:

• Overlearning: Clients are encouraged to interact with stimuli at levels not expected in the natural environment (i.e., snake wrapping around one's neck).  It is theorized that going beyond a natural interaction will increase habituation to the stimulus and extinction of the fear. 
• Modeling:  In this treatment, the therapist models appropriate interactions with the stimulus at each step.  This is not only instructive for the client to successfully interact with the stimulus, but it serves as another level of exposure.  Seeing a trusted person interact with a feared stimulus without negative consequence provides more evidence against the catastrophic cognitions.

Maintenance:  Clients commit to continual exposure in their every day life.  Therapists can provide more specific maintenance tasks, based on specific fears.  Therapists can also give the client a video or photographs of the treatment session for them to refer to.  The key is for clients to continue to not avoid or escape interactions with feared stimuli. 

It is evident that most specific phobias can be treated in a single, massed therapy session.  This is a very efficient, cost-effective, and empirically-supported method for treating phobias - although there are other, equally effective, variations to this treatment.  Exposure techniques allow for a quick remission of severe symptoms.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Applying Joiner's interpersonal-psychological theory of suicidal behavior to physicians and medical trainees

by Michael D. Anestis, M.S.

In an earlier article, I described Joiner's interpersonal-psychological theory of suicidal behavior (Joiner, 2005).  The theory posits that, in order to engage in a lethal suicide attempt, an individual must have both the desire and the capability to do so.  Those with only the desire or the capability are unlikely to utilize lethal means in a suicide attempt.  This, in part, explains why attempts are so much more frequent that completed suicide attempts, as not every individual who desires suicide is capable of utilizing means likely to result in completion.
    The desire for suicide is comprised of two variables: thwarted belongingness and perceived burdensomeness.  Thwarted belongingness involves a sense on the part of an individual that he does not have meaningful connections with others, either because others do not care about him or others simply are not able to relate to his experiences (e.g., a veteran returning to civilian life post-deployment).  Perceived burdensomeness is a sense on the part of the individual that she does not make meaningful contributions to her world and, instead, serves as a liability to others.
    The acquired capability for suicide, the aspect of Joiner's theory that is most distinct from prior theories, involves habituation to physiological pain and the fear of death.  This capability is developed through repeated exposure to painful and provocative events, whether that involves being injured (e.g., non-suicidal self-injury, prior suicide attempts, battle wounds) or witnessing pain and gruesome injuries in others.  In a sense, individuals learn to overcome an innate biological drive towards self-preservation that typically prevents individuals from engaging in lethal self-injury.  In our prior article on this theory, we discussed these variables in greater detail, including extensive descriptions of data supporting the various components of the theory.
    In the latest issue of Archives of Suicide Research, Michelle Cornette and colleagues (2009) contributed an article that applies Joiner's (2005) theory to physicians and medical trainees.  Because it is a review article, this particular manuscript does not involve direct measurement of the three components of Joiner's (2005) theory, but it does summarize prior research consistent with the theory and provides a solid foundation for future research in this area.
The authors provided compelling rationale for their manuscript: evidence indicates that physicians exhibit a higher suicide rate than does the general population (Schernhammer & Colditz, 2004).  In fact, studies indicate that physicians may be nearly three times as likely to die by suicide than is the general population (Stack, 2004), a striking statistic given that, generally speaking, physicians are not the demographic that comes to mind when individuals think about the idea of suicide.  The obvious question raised by these numbers is why physicians would be at such a heightened risk for suicide.  Joiner's (2005) theory, the authors argue, provides a logical answer consistent with prior empirical evidence.
    The majority of the article focuses on the various ways that physicians and medical trainees might be vulnerable to elevations in the three components of the theory: thwarted belongingness, perceived burdensomeness, and the acquired capability for suicide.  The vulnerability to thwarted belongingness, they argued, is quite clear.  Medical training is a grueling, all encompassing experience that leaves little time for social interactions.  Prior studies have shown that medical students who are married or who co-habitate report better overall mental health (Brahmness, Fixdal, & Vaglum, 1991).  Additionally, the authors point out, medical students frequently endorse that spending time with friends is a pivotal coping mechanism that allows them to manage the rigors of their training (Chew-Graham, Rogers, & Yassin, 2003).  The problem with this, however, is that the training demands of medical school often do not allow for such interactions.  Additionally, medical students report feeling that seeking mental health services provided by the medical school would be stigmatizing (Chew-Graham, Rogers, & Yassin, 2003) and could potentially serve as an obstacle to future advancement  (see Craig Bryan's article on PTSD in the military for a similar example of difficulties seeking mental health services).  This situation leaves medical students in an unfortunate position, as they do not have time to seek support from peers and family and do not feel comfortable seeking support from the services provided by their school.
    With respect to perceived burdensomeness, the authors provided a more extensive list of potential vulnerabilities, including perceived or actual academic failure, academic burnout, financial burdens, and an exaggerated sense of responsibility for the lives of patients.  Henning, Ey, and Shaw (1998) reported that a significant proportion of medical students report feeling like impostors - as though they do not deserve to be in medical school and are not the intellectual equals of their classmates - and engaging in self-directed perfectionism.  Yates and James (2006) reported that 10-15% of medical students qualify as struggling academically.  Additional studies have demonstrated that academic struggles contribute to increased stressed and diminished mental health and that approximately 45% of medical students meet criteria for academic burnout (Dyrba, Thomsa, Huntington, et al., 2006).  This data presents a picture of medical students as frequently overwhelmed, highly driven to succeed, and no longer passionately engaged with the material at hand.  In addition to academic based distress, a significant proportion of medical students incur high levels of debt, which creates additional stress and can contribute to an individual's sense that he or she is a burden to others (Joiner, 2005; see Bob Leahy's article on dealing with financial worry for tips on managing finance related anxiety).  As such, there are a variety of avenues through which medical students could theoretically develop a sense that they are failing to make meaningful contributions and causing problems for other individuals in their lives.  Importantly, the perceptions involved in perceived burdensomeness and thwarted belongingness are almost always distorted and inaccurate, but their lack of validity do not diminish their influence on the individuals that experience them.
    All of these findings are compelling; however, many of them can also be applied to other high stress fields and training situations (e.g., lawyers, investment bankers).  The question then becomes, what is unique about this particular profession that would contribute to its heightened suicide rate.  The answer to this appears to rest in the vulnerability to the acquired capability for suicide.  Essentially, the authors argue that the nature of training and the day-to-day experiences for physicians involves a significant exposure to pain and death.  This repeated exposure, they argue, dampens physicians' emotional responses to pain and suffering and, in a sense, inoculates them to stimuli that, for most individuals, are highly aversive.  Empirical data seem to support this idea.  Sundin, Gaines, and Knapp (1979) found that dental students reported a greater fear of death than did medical students.  One theoretical explanation for this is that medical students experience significant exposure to death in their training and have consequently habituated to the concept whereas dental students receive no such training and consequently maintain a more normative response to the idea of death.  Charlton and colleagues (1994) found support for this by measuring medical students' attitudes towards death prior to and after their first experience dissecting cadavers.  The authors found that the students' emotional reactivity decreased in the months following this first experience, indicating the they were no longer uncomfortable with experiences involving death and dissection.  The point here is not that medical students are blunted emotionally, but rather that they simply develop a tolerance for particular stimuli that are generally highly aversive and which serve as a deterrent in suicidal and self-injurious behaviors.   
    Ultimately, Cornette and colleagues (2009) present a rich and compelling case that Joiner's interpersonal-psychological theory of suicidal behavior (2005) is a valuable framework within which to consider suicide risk in this population.  The training and day-to-day experiences of physicians by definition must involve exposure to pain and provocation, so this paper highlights the importance of understanding vulnerabilities to the desire for suicide and providing adequate, non-stigmatized interventions geared towards increasing social belongingness and decreasing physician and medical trainees' beliefs that they are burdensome to others.  The acquired capability for suicide in and of itself is not necessarily a bad thing.  When accompanied by the desire for suicide, quite obviously, the acquired capability is highly dangerous; however, routine, systematic assessments for the desire for suicide can mitigate this risk by identifying individuals who are struggling and helping them to develop sufficient coping mechanisms.  Much of the evidence put forth in this review paper discussed medical students rather than actual physicians, so future work that extends these findings to physicians would be invaluable.
    At this point, Joiner's (2005) theory is widely accepted and well supported by data, but I am curious what you think about the theory in general and its application to this particular population.  Might there be alternative explanations for the heightened suicide rate in this population?  Are there considerations left out of the theory?

If you would like to read more about the interpersonal-psychological theory of suicidal behavior or you are interested in learning how to systematically assess and treat suicide risk, we recommend the following products, all of which are available through our online store:

Why People Die by Suicide
The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients
Treating Suicidal Behavior: An Effective, Time-Limited Approach (Treatment Manuals For Practitioners)
Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach To Psychotherapy

If you are experiencing thoughts of suicide, please call 1-800-273-TALK for free, 24 hour help.  Additionally, calling 911 is a viable option.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

CBASP: How to treat chronic depression

by Michael D. Anestis, M.S.

For a beginning therapist, it is not at all uncommon to walk into the therapy room with the fear that you will not remember what you are supposed to do - that you will forget the manual entirely, make things up as you go along, and fail to help your client's symptoms improve.  This rarely actually happens, mind you, but like any negative automatic thought, its validity is not proportionate to its power.  In my first days of training, I was fortunate in this respect, as my initial supervision taught me a therapeutic intervention known as Cognitive Behavioral Analysis System of Psychotherapy (CBASP; McCullough, 2000).  In this article, I will discuss the emerging evidence that CBASP, created by James McCullough of Virgina Commonwealth University, is an effective psychotherapeutic approach, particularly for chronic depression, but first I want to explain the steps involved in the process.
    CBASP is easily the most highly structured approach I have learned.  The entire intervention revolves around worksheets that are aimed to discuss the client's interpretations, behaviors, and desired outcomes in specific, quick interpersonal interactions.  Essentially, this is an exercise in situational analysis and the underlying assumption, quite simply, is that by increasing the frequency with which an individual attains what she wants in situations, mood will improve and depressive symptoms will fade.

Structure of CBASP - Step-by-Step Description

Step 1 - Select an interaction from the previous week.  The situation should be short, lasting minutes rather than hours.  Describe this situation in factual terms (no interpretations of meaning) in no more than three or four sentences.

• Clients often resist focusing on such a small slice of time.  After all, situations relate to one another and problematic patterns have emerged in their lives.  The importance of doing so, however, is to help the client change specific thoughts and behaviors.  Not everything can be changed at once, but developing a pattern of recognizing specific ways to change can lead to general change across situations.
• Clients also often struggle to speak only in factual terms.  Saying "he treated me poorly" does not work here.  Instead, the client should say "I gave cashier a $20 bill and he only gave me change for $10."  The second example still involves poor treatment, but it provides detailed facts the client and therapist can work with later on in the worksheet.

Step 2 - What was your interpretation of the situation?

• Here, the client is instructed to write down three or four automatic thoughts that she experienced during the course of the specific situation.  It is important not to include thoughts prior to or after the situation.
• Examples of interpretations experienced during an interaction could be "she hates me," "I'm horrible at this, "why do I always fail?" or "he's a jerk."

Step 3 - What were your behaviors?

• Here again, the client is instructed to list several examples.  Behaviors include eye contact, tone of voice, delay in response, body language, and what was said during the course of the interaction.
• The client is encouraged to be thorough here.  For example, the phrase "I believe you" can mean different things if an individuals waits 10 seconds in silence before saying it, says it while rolling his eyes, or smiles while saying it.  The details will inform later steps in the worksheet.

Step 4 - Desired outcome - What did you want to happen in this situation?

• This may be the most difficult step in CBASP.  Desired outcomes are limited to things that the client can actually control.  In other words, the desired outcome can not be something that is physically impossible.  Even more importantly, the desired outcome can not be something that the client wanted somebody else to think, do, or feel. 
• It is perfectly natural to desire other people to feel or do things, but CBASP teaches the principle that, even if a situation is navigated perfectly, other individuals may respond poorly.  As such, a desired outcome could be "I wanted to do everything in my power to increase the chance that he would agree with me," but it can not be "I wanted him to agree with me."
• This is often frustrating for the client.  At times, he may even believe that he is being blamed for all that goes wrong.  This is not the case, however.  Instead, the client is being taught to simply focus on things over which he has control so that things outside of his control no longer make him feel as though he has done something wrong.

Step 5 - Actual outcome - What actually happened?

• Here, the client briefly explains what actually happened and declares whether or not this was consistent with her desired outcome.

Step 6 - Remediation

• During the remediation phase of CBASP, the client and therapist review each interpretation and behavior listed on the worksheet and determine whether it was helpful or hurtful with respect to increasing the likelihood that the client would obtain her desired outcome in that situation.
• For interpretations and behaviors that were helpful towards obtaining the desired outcome, time is spent discussing why it was helpful, what led the client to choose an adaptive behavior, and what the client might do to increase the likelihood that she will use this same approach in future situations.
• For interpretations and behaviors that were hurtful towards obtaining the desired outcome, helpful alternative approaches are designed.  This is a particularly useful exercise, as hurtful patterns are quickly recognized and the client thus practices changing bad habits that have become obstacles in his attempts to attain desired outcomes.

Some clients become skilled at this approach quite quickly while, for others, it takes more time.  Regardless of the speed of skill acquisition, CBASP involves a significant amount of homework.  Clients are given numerous worksheets and told to fill them out as often as possible, immediately following the situations they choose.  The closer to the actual occurrence the better.  This is true for two reasons: the situation is remembered more accurately and the benefits of alternative approaches are reinforced because the worksheet often creates an increase in positive affect and/or a decrease in negative affect when filled out close enough to the event that the client is still upset.  During sessions, the client and therapist will go over one or more of the worksheets completed throughout the week, discussing any difficulties the client encountered, training further in particular skills, and reinforcing the efforts of the client.

Empirical evidence for the utility of CBASP

A variety of studies have examined the utility of CBASP as a therapeutic intervention.  The most heavily cited study of CBASP, conducted by Keller and colleagues (2000), was a clinical trial comparing CBASP, nefazodone (an antidepressant medication), and combination treatment (CBASP and nefazodone) in the treatment of chronic depression.  519 participants completed the study - a 12-week acute intervention - with significant effects for all three conditions.  55% of individuals in the nefazodone condition exhibited significant reduction in depressive symptoms as measured by the Hamilton Depression Scale (HAM-D; Hamilton, 1967) compared to 52% of individuals in the CBASP condition.  Importantly, 85% of individuals who received a combination of nefazodone and CBASP exhibited significant reduction of depressive symptoms.  What is most stunning about these impressive findings is that the participants had been chronically depressed, a course that is often resistant to treatment.
    Building off of the Keller et al (2000) findings, Schatzberg and colleagues (2005) found that, for individuals who do not respond to nefazodone, switching to CBASP results in significant clinical improvement.  Similarly, for individuals who do not respond to CBASP, switching to nefazodone results in significant clinical improvement.  Klein et al (2004) found that CBASP is an effective maintenance treatment.  In this study, participants took part in 16-20 sessions during the course of a 12-week treatment period and six sessions during a 16-week continuation period.  Participants in the maintenance condition then received an additional 13 sessions during a 52-week maintenance period.  Results indicated that participants in the maintenance condition experienced a greater average reduction in depressive symptoms and were less likely to relapse.
    Cukrowicz and Joiner (2007) created a computer protocol based upon CBASP and tested its utility in a sample of undergraduates.  They compared the effects of the CBASP computer protocol to the effects of simply providing education on the nature of depression and anxiety and found that, while both education alone and education with CBASP significantly reduced depressive and anxiety symptoms, the computer CBASP condition experienced greater levels of improvement.  Importantly, only individuals with sub-clinical levels of depression and anxiety were included in the study, so further research is needed to determine the potential utility of a computer-based CBASP intervention in clinical populations, but these results are highly promising.   
    Interestingly, in light of Friday's article on therapeutic alliance, Santiago and colleagues (2005) found that therapeutic alliance and the ability to use the skills taught in CBASP both independently contributed to decreases in depressive symptoms.  Arnow and colleague (2007) compared individuals in CBASP alone, nefazodone alone, and combination treatment on dropout rate and found that individuals in the combined treatment were significantly less likely to drop out of treatment than were individuals in the medication only group and did not differ in their dropout rate compared to individuals in the CBASP only group.  For individuals receiving only CBASP, a poor therapeutic alliance predicted premature dropout (and early response to treatment did not). 
    Additional theoretical work has been done on CBASP as well.  Sperry (2005) provided a case example of CBASP in individual and couples counseling as a method to improve communication on medical issues.  Additionally, Sperry (2007) provided a case example of the utility of CBASP in managing spiritual issues that can arise during the course of therapy (e.g., "God hates me").  Future empirical testing of these ideas is necessary before conclusions can be drawn regarding the utility of CBASP in these particular domains, but this early work provides an interesting foundation.

Conclusions

    CBASP, which is essentially a highly structured, interpersonally focused version of cognitive behavioral therapy (CBT), appears to be an effective intervention for depression, particularly for individuals who have experienced chronic symptoms.  The treatment teaches clients to see each interaction as separate, thus diminishing the tendency to ruminate about the ways in which each imperfection relates to other imperfections in life.  Additionally, the treatment emphasizes desired outcomes that lie within the control of the client and the development of helpful alternatives to interpretations and behaviors that decrease the likelihood of clients attaining such desired outcomes.
    As a therapist, I admire CBASP for its structure and its ability to efficiently convey important ideas.  As a researcher, I admire the emerging empirical evidence that CBASP is not only effective, but demonstrates its effects in a population that is often treatment resistant.

If you would like to learn more about CBASP, a variety of resources are available.  We recommend the following:

Hard Copy Books:

Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach To Psychotherapy
Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)
Patient's Manual for CBASP
Treating Chronic Depression with Disciplined Personal Involvement: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)

Kindle:
Treating Chronic Depression with Disciplined Personal Involvement: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)

Additional resources are available through our online store.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Common factors of therapy: Part 3, therapeutic alliance

by Joye C. Anestis

    It's been a couple of weeks since I last tackled the topic of common factors of therapy (also known as nonspecific factors), so I thought it was time to bring them back up.  Common factors are often the crux of arguments for therapeutic equivalence, the theory that all forms of psychotherapy are equally effective (often known as the dodo bird hypothesis).  In this series, I have been evaluating the validity of this argument by examining the available scientific evidence for common factors.  Previous posts have concluded that catharsis without problem-solving is hurtful (in fact, expressive-experiential therapies, which involve a great deal of emotional release, are considered potentially harmful psychotherapies) and the research on insight is too sparse to draw any firm conclusions.  Today I address the most fervently researched common factor: the therapeutic alliance.
    The therapeutic alliance refers to "the degree to which the therapy dyad is engaged in  collaborative, purposeful work" [Hatcher & Barends (2006; p. 293) description of Bordin's (1979)  description].  The therapeutic relationship and alliance are not synonymous; however, alliance can influence the quality of the relationship between client and therapist.  In a relationship in which the alliance is strong, clients will feel safe and comfortable to discuss their concerns and engage in any therapeutic tasks required of them, and the therapist will be open, accepting, nonjudgmental, and professional.  Obviously, developing a good alliance is a goal for most therapists, but is the alliance necessary to induce client change?  It is perhaps intuitive to assume that a good therapeutic alliance would be related to better client outcome.  And in this instance, research supports our common sense notions.  In general, research finds that the better the alliance/relationship, the greater the client change (e.g., Horvath & Bedi, 2002; Horvath & Symonds, 1991; Kazdin et al., 2005; Martin et al., 2000).  Alliance also seems to be related to engagement and retention in treatment (e.g., Meier et al., 2005).
    But there are many caveats to this research on therapeutic alliance (see DeRubeis et al., 2005, for a more thorough discussion of this).  In most alliance studies, the timeline between alliance and outcome has not been established.  Alliance and outcome are measured at the end of treatment, and not before, during, and after.  Because of this, it is plausible that client improvement occurs first and that increases the quality of the alliance, and not the other way around (Kazdin, 2005).  Both alliance and outcome can be difficult constructs to measure effectively, and studies vary in how they quantify these variables.  Finally, client and/or therapist factors may mediate the relationship between alliance and outcome.  In other words, client and/or therapist characteristics may be third variables which explain the relationship between alliance and outcome.  Very few studies have investigated this possibility; however, one recent study found evidence that therapist variability, and not client characteristics, may be most important in developing alliance (Baldwin, Wampold, & Imel, 2007).
    I can't conclude that the therapeutic alliance functions in an important way across types of therapies.  Many schools of psychotherapy (e.g., client-centered therapy) argue that therapeutic relationship factors are the primary source of change.  Others (e.g., behavior therapy) acknowledge that a good alliance is necessary in order to motivate clients to engage in the more active aspects of treatment, but alliance itself is not the primary mechanism of change.  Additionally, it is still unknown if alliance causes improvement or improvement causes alliance, or if client & therapist variables mediate the alliance-outcome relationship. In fact, although the alliance consistently predicts outcome, alliance only accounts for a small amount of the variance in predicting outcome.  For example, a 2002 meta-analysis noted that the average alliance-outcome correlation is .21, indicating that alliance accounts for only 5% of the variance in outcome (Horvath & Bedi, 2002).  This means that alliance explains only a small portion of client outcome.  Think of it this way: consider the relationship between mood and test performance.  Perhaps you were in a bad mood when you took your Abnormal Psychology final.  What part of your overall test score could be accounted for by your bad mood?  Wouldn't things such as hours spent studying and class attendance account for a larger portion of your performance?  In this example, mood is not irrelevant but other factors are more influential.  Similarly, although alliance is certainly important for a number of reasons (e.g., client motivation & retention), it is not sufficient by itself to produce client outcomes.  Current research is trying to further understand the multitude of mechanisms which result in client change.  The alliance is necessary, but it is not sufficient.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.