Psychotherapy Brown Bag

Eating disorders and DSM-V

by Michael D. Anestis, M.S.

I hope everyone enjoyed their Thanksgiving holiday.  We certainly enjoyed our time off, but are excited to return to PBB.  Given the amount of time I spent thinking about food during this past week, with mashed potatoes playing a particularly prominent role in my thoughts, I figured it might make sense to keep food at the center of today's discussion.

In the current issue of the International Journal of Eating Disorders, a number of prominent researchers published articles discussing proposed changes for eating disorder diagnoses in the upcoming DSM-V.  Several articles discussed the potential inclusion of binge eating disorder in the main text of the DSM (it is currently listed as a disorder in need of further research and results in a diagnosis of eating disorder not otherwise specified) and the addition of purging disorder and night eating syndrome as well.  The article that interested me the most, however, was written by Timothy Walsh and Robyn Sysko (2009) of Columbia University and discussed a proposed overhaul of the eating disorder diagnostic system for DSM-V.

Before explaining their proposed system, Walsh and Sysko (2009) took care to explain why they believe such changes are necessary.  As it stands, the DSM formally recognizes two eating disorder diagnoses: bulimia nervosa (BN) and anorexia nervosa (AN).  As I mentioned above, binge eating disorder (BED) is listed in the appendix as a disorder in need of further research, so no formal BED diagnoses exists.  Instead, individuals who meet criteria for BED receive a diagnosis of eating disorder not otherwise specified (EDNOS).  At first glance, this might not seem all that problematic, but there are a number of other issues that clarify why this needs to be addressed.  Research has demonstrated that between 50% and 70% of eating disorder diagnoses are EDNOS (Ricca et al., 2001; Turner & Bryant Waugh, 2004).  In other words, the majority of individuals with an eating disorder do not meet criteria for one of the two eating disorders recognized by the DSM.  As such, the catch-all residual category of EDNOS accounts for an absurdly large proportion of patients.

The problems of EDNOS are not limited to the fact that it accounts for such a high percentage of eating disorder diagnoses, however.  Perhaps even more problematic than that is the fact that the category itself is so broad.  Walsh and Sysko (2009) pointed out that a 14-year-old girl who meets all of the criteria for AN except that she reports menstrual activity and a 46-year-old man with BED would both be given a diagnosis of EDNOS despite the fact that these two individuals have very little in common.  In other words, knowing that somebody has EDNOS tells us very little about who they are and what symptoms are causing them distress and/or impairment and yet this diagnosis is nonetheless what we are most likely to see listed in the case file for a patient with an eating disorder diagnosis.

Walsh and Sysko (2009) were thus determined to develop a diagnostic system for eating disorders that would result in substantially fewer individuals being given an EDNOS diagnosis but which would not reduce the validity of the diagnoses or cause a disconnect between current research and the new diagnoses.  Their proposed model, which they named the Broad Categories for the Diagnosis of Eating Disorders (BCD-ED) involves three hierarchical categories mirroring the current most researched eating disorder diagnoses and also retains a much more limited EDNOS category.  They defined the categories as follows (pg.755):

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Anorexia Nervosa and Behaviorally Similar Disorders (AN-BSD)

"An eating disorder category characterized by the restriction of food intake relative to caloric requirements resulting in the maintenance of an inappropriately low weight, not better explained by a general medical condition or another psychiatric disorder.  The prototype for this category is an individual meeting DSM-IV criteria for AN."

Bulimia Nervosa and Behaviorally Similar Disorders (BN-BSD)

"An eating disorder category characterized by recurrent out of control eating and the recurrent use of inappropriate purging methods to control eating or weight.  The prototype for this category is an individual meeting DSM-IV criteria for BN."

Binge Eating Disorder and Behaviorally Similar Disorders (BED-BSD)

"An eating disorder characterized by recurrent episodes of out of control eating.  The prototype for this category is an individual meeting DSM-IV criteria for BED."

Eating Disorder Not Otherwise Specified (EDNOS)

"A residual diagnostic category for all other individuals with a clinically significant eating disorder."

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So, Walsh and Sysko's (2009) model essentially involves shifting BED from the appendix to the main text of the DSM and including sub-threshold patients in the broader eating disorder categories rather than giving them an EDNOS diagnosis.  In other words, an individual meeting all the criteria for AN except that she reports menstrual activity would now receive an AN-BSD diagnosis instead of EDNOS and an individual who frequently binge eats and purges, but averages less than twice per week would receive a diagnosis of BN-BSD rather than EDNOS.

Without question, this would result in a smaller proportion of eating disorder patients receiving EDNOS diagnoses, but the authors acknowledged two other issues that require attention.  First, does the hierarchical structure of their model make sense?  And second, would this shift result in an over-diagnosis of eating disorders because it is so broad?

The first question, which essentially asks whether AN is more severe than BN and whether BN is more severe than BED, is difficult to answer.  For one thing, the authors could find not studies that specifically addressed that particular question.  Secondly, it would be difficult to determine the relative danger of mild AN compared to severe BN, particularly if we are not also considering comorbid diagnoses, prior history of suicidal behavior, and prior responses to treatments.  The authors openly admitted that this is a bit of a blurry issue; however, they also provided some evidence supporting their decision to structure the model in this manner.  For one thing, of all the eating disorder classifications, AN involves the highest mortality (Hoek, 2006) and medical complication (Mitchell & Crow, 2006) rates and also the poorest treatment response and greatest rate of relapse.  The picture is a bit less clear with respect to BN and BED, with some studies indicating that BN is more severe with respect to prognosis (Fairburn, Cooper, Doll, Norman, & O'Connor, 2000; Hay & Fairburn, 1998) and others not supporting any difference between the categories (Fitcher Quadfleig, & Hedlund, 2008).  So, support for listing AN-BSD as the most severe is fairly strong, but support for the hierarchical structure of BN-BSD and BED-BSD is less compelling.

The second question - whether this new system would result in the over-diagnosis of eating disorders - is equally difficult to answer, as there is no way to conclusively predict the future.  On the one hand, the broad nature of the categories might cause some clinicians to give a diagnosis they otherwise might not give.  On the other hand, these new categories do not seem any more broad than the standard EDNOS diagnosis, so I am not certain I see any reason to believe there would be a sudden surge in diagnoses unless clinicians are simply wary of diagnosing EDNOS but somehow more willing to provide an questionable diagnosis of another eating disorder (and there are no data I am aware of that indicate this is the case).  Regardless, Walsh and Sysko (2009) proposed that, in an effort to prevent over-diagnosis, the DSM-V should include specific criteria requiring functional impairment as a direct result of disordered eating.  In other words, the DSM-V should be clear about what constitutes clinically significant distress and/or impairment so as to help clinicians determine if a particular patient warrants a diagnosis (e.g., does the client exhibit an "inappropriately low" weight?  Does the client binge eat often enough?).

On the whole, I think that this model is imperfect, but a great idea.  Reducing the reliance upon EDNOS is an important goal for DSM-V.  I do, however, have a couple of concerns that went unaddressed in the Walsh and Sysko (2009) article.  First, in their definition of BN-BSD, they mentioned that the client must exhibit "purging" behaviors whereas DSM-IV requires "inappropriate compensatory behaviors."  Purging involves attempts to immediately expel what was previously consumed (e.g., self-induced vomiting, the use of laxatives) whereas the broader category of compensatory behaviors can include non-purging behaviors aimed at weight control such as excessive exercising and fasting.  Does the Walsh and Sysko (2009) model thus require a reclassification of some individuals who would otherwise meet criteria for BN and, if so, is such a change justified (e.g., do individuals with purging versus non-purging BN respond differently to different treatments?)?  Additionally, the new model does not address the issue of purging disorder.  Night eating syndrome seems likely to end up in the BED-BSD category, but purging disorder seems likely to still result in an EDNOS diagnosis.  It might be that Walsh and Sysko (2009) want to see more research conducted on purging disorder before it is added so definitively to an eating disorder diagnostic scheme, but I would have liked to see them discuss that issue in order to clarify the point.

In the other DSM-V models we have discussed on PBB (mood and anxiety disorders, personality disorders, PTSD, autism spectrum disorders), the proposed changes have been fairly radical in nature.  The eating disorders proposal, on the other hand, is fairly conservative.  Walsh and Sysko (2009) did an admirable job of proposing a system that would reduce reliance upon the EDNOS diagnosis and cluster similar behaviors with one another.  That being said, do you see any strengths and/or weaknesses that went unaddressed in this discussion?  Do you have a suggestion for an alternative model?  Do you think changes to the system are even necessary in the first place?  We look forward to hearing your thoughts.

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If you would like to learn more about eating disorders and their treatment, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• Cognitive Behavior Therapy and Eating Disorders by Christopher Fairburn

• Overcoming Binge Eating by Christopher Fairburn
  

• If Your Adolescent Has an Eating Disorder: An Essential Resource for Parents by Timothy Walsh
  

• Treatment Manual for Anorexia Nervosa: A Family-Based Approach by James Lock, Daniel le Grange, Stewart Agras, and Christopher Dare
  

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

• Dialectical Behavior Therapy for Binge Eating and Bulimia by Debra Safer, Christy Telch, and Eunice Chen
  

• Eating Disorders by Pam Keel

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

Update from 43rd Annual ABCT Conference

by Michael D. Anestis, M.S.

So far, this weekend has not fallen short in terms of nerd fun.  I spent the entire day at the conference yesterday, bouncing from talk to talk and browsing the various poster sessions and attended one talk this morning as well.  There is no way I could summarize all of the work I encountered throughout the day and, if I tried, I suspect it would not be the least bit interesting, but here are a few of the highlights thus far...

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In a clinical grand rounds presentation entitled "Cognitive Restructuring versus Cognitive Diffusion," Robert Leahy (author of the March 2009 PBB featured article) and Steve Hayes demonstrated cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) techniques on the same "patient" (actually an actress pretending to be a depressed women who recently ended a five year relationship).  Both of these treatments have an impressive evidence base indicating that they are useful in treating depression, but the demonstration helped to clarify the substantial differences between the two types of therapy.  Leahy and Hayes are luminaries in the field and pioneers in these two approaches, so this experience was extremely valuable.  My inexperience with ACT admittedly make it somewhat difficult to connect with the abstract approaches used by Dr.Hayes in this presentation, but it left me highly motivated to learn more about the specific techniques involved in this approach.  A key quote from each therapist that helped explain some of the basic tenets of CBT and ACT:

Leahy (CBT): "Sometimes we believe something so strongly we don't even bother to check out the facts."

Hayes (ACT): "We want people to look at the process of thinking and not have it dominate how they act."

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In an invited address entitled "Aaron T.Beck in discussion with Steve Hollon and Robert Leahy - An intimate look at the past, present, and future of cognitive therapy and its founder," a packed house listened to these three incredibly influential psychologists discuss a wide variety of issues.  It was an absolute pleasure to listen to Dr.Beck - the creator of cognitive therapy - as he discussed his early days as a neurologist, his training in psychoanalysis and subsequent break from that school of thought, and his early days as a pioneer in the use of data to drive our conceptualization and treatment of mental illness.  The talk covered way too many topics to summarize, but I did manage to ask a question relevant to recent PBB discussions.

I asked the presenters how they respond to individuals who claim, despite evidence to the contrary, that specific forms of treatment and treatment techniques are not important and that common factors (e.g., therapeutic alliance) account for client improvements in therapy.  We have discussed therapeutic alliance, Wampold's meta-analyses, and the dodo bird hypothesis in prior articles, but Steve Hollon and Aaron Beck provided me with answers that really added a lot to our conversations on this topic:

Steve Hollon mentioned data (sadly, I do not have the citation at the moment) indicating that, while common factors account for a substantial amount of change for individuals with mild symptoms of mental illness, their impact decreases progressively as severity increases.  In other words, for somebody with sub-clinical or mild mental illness, common factors are highly influential in treatment outcomes whereas, for individuals with severe mental illness, they are still important but account for substantially less of the progress made in therapy. 

Aaron Beck mentioned data (again, since this was a conversation in a large presentation, I do not have a citation) indicating that therapy that centers on common factors can result in quick reductions of symptoms and a sense of well-being, but that these effects are not maintained long term, whereas cognitive therapy routinely demonstrates long term benefits.  So, a good alliance can help us feel better, but it can not keep us feeling better on its own.  The skills developed through specific forms of therapy with empirical support (e.g., CBT for depression) thus appear to bestow a lifelong benefit upon the client, offering him or her a chance to not only feel better, but apply skills in times of need to prevent symptoms from coming back.  Think of this as akin to the teach a man to fish versus give a man a fish saying.

Here is an awful photo taken from my phone before I managed to find a seat:

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I browsed a large number of poster presentations covering a broad spectrum of topics and discussed the research as well as PBB with many of the presenters.  Hopefully, a number of these presenters will write up their findings for PBB readers in the coming months.

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I was honored to receive the Leonard Krasner Dissertation Award at the awards ceremony last night.  This was a truly wonderful and humbling experience.  It is not every day you get to hear folks like Robert Leahy talk about you at the same event they discuss major awards won by Edna Foa, Philip Kendall, and several other incredibly impressive psychologists.  I will look back fondly on that event for a long, long time.

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This morning, I attended a panel discussion entitled "Taking CBT, DTC: Direct-to-consumer marketing of evidence-based interventions."  David Barlow, Matthew Sanders, Jeff Szymandski, and another panelist (one of the founders of PREP - he was a last second replacement for his colleague, Scott Stanley, but I do not have his name) appeared on the panel and discussed the importance of marketing empirically supported treatments and how to do it.  This is obviously an important topic for PBB and it was a pleasure to hear tips and thoughts from people in the field. Perhaps the most telling quote came from Dr.Sanders, who said "most consumers don't know what participation in an evidence-based program looks like or feels like."  In other words, when we talk about these programs that we know work, we often forget that they are foreign to many people who could actually benefit from them.  Additionally, we sometimes for get that, as we present evidence, some people are not yet versed in what evidence means and why it is important and relevant to them.  This speaks directly to our mission here at PBB and we hope that, as time goes on, we help readers to connect with this issue.

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We may have some more updates from the conference soon - Joye is on a panel tomorrow morning - but when and if that will happen is unclear at the moment.  In the meantime, we hope everyone is enjoying their weekend and that you will share your own experiences and/or questions about the conference.

If you would like to learn more about the topics discussed on PBB, we hope you will consult our online store of scientifically-based psychological resources.

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

ABCT and Thanksgiving

Just a quick note to let everyone know that the next week and a half will be a bit chaotic on PBB.  Tomorrow morning, we head to the Association for Behavioral and Cognitive Therapies (ABCT) 43rd annual convention.  We will post periodic short updates from the conference and would love to hear about the experiences of anyone else attending the conference (or questions from those who are not).

Also, next week we will be taking a vacation to celebrate Thanksgiving.  We will return to our regular daily posts on Monday November 30th.  In the meantime, we will still publish comments as they come in and respond to them as often as we can.

We hope everyone enjoys their Thanksgiving holiday.  This year, Joye and I are thankful for many things, one of which is wonderful interactions we have enjoyed with readers.

Focusing on the "what ifs": A practical guide to worry exposure

by Joye C. Anestis

The empirically-supported treatment for pretty much any anxiety disorder involves some sort of exposure.  For obsessive-compulsive disorder, it might be exposure to germs.  For panic disorder, exposure to, say, hyperventilation.  For PTSD, exposure to a traumatic memory.  And so on.  But how do you construct an exposure session when an individual fears something which hasn't happened, is often unlikely to happen, and can't be made to happen in therapy (i.e., worries about a hypothetical situation)?  Something like worrying that if your husband isn't home by 5:15, he must have gotten into a fatal car wreck, or worrying about what would happen if you began having financial problems, even if there is no indication that this is imminent.  Constructing exposures for such worries can be a bit intimidating...but a new article in Cognitive and Behavioral Practice offers up a succinct summary to help guide therapists through worry exposure.  In this article, authors Colin van der Heiden and Erik ten Broeke note that worry exposure, a type of imaginal exposure, was developed by Craske, Barlow, and Leary (1992; here's a link to the most recent edition of this manual: Mastery of Your Anxiety and Worry).  The authors first  offer some theoretical background and a succinct explanation of the rationale behind worry exposure (the provision of which is always the first step in any exposure technique).  Then they describe the five steps of worry exposure as:

1. "Selecting the worry situation to which a patient will be exposed": The authors recommend asking patients to stop their activities at set times during the day and write down whatever they are worrying about.  Patients should also be taught the difference between worries that are amenable to problem-solving (usually involving current or actual problems) and worries that are not (unproductive worry about hypothetical situations).  Worry exposure is designed to confront those worries that cannot be addressed via problem-solving.  Although the authors don't mention it, often once a list of fears is compiled, clients are asked to rank the fears in order to ascertain which are the most concerning.
2. "Identifying the most feared expectation": Once a situation is identified, the client is asked to state the worst possible outcome from the situation.  In order to assist with this, the therapist might ask a series of "what if" questions to each of the client's responses (sometimes referred to as the downward arrow technique), asking "...and if this actually happens, what will happen next?" until the patient can no longer come up with an answer.
3. "Conjure up an image of the most feared expectation": After the most feared expectation is identified, clients are asked to conjure up a vivid mental image of it and hold it in their mind for 25 minutes (other descriptions I've read say to hold it until client anxiety decreases by at least half).  They are not allowed to try to stop worrying, to distract themselves, or to try to neutralize the image.  The whole point of exposure is to experience unpleasant sensations so that clients attenuate to these sensations.
4. "Think of alternative explanation or outcomes": After the exposure is completed, clients are asked to think of and write down as many alternative outcomes or explanations for the feared situation as possible.  They will generally be able to realize that the likelihood of the feared outcome is slim and/or that, if it were to happen, it would not be as terrible as they imagined.
5. "Evaluation": In the next therapy session, the exposure is evaluated.  Things to discuss include: did feelings change during the exposure?  If so, in what way?  Are the alternative outcomes plausible?

It generally takes a little practice for both client and therapist to become facile with this technique.  To aid therapists further, the authors go through some common obstacles to this technique, as well as suggested solutions.  When done correctly, worry exposure can be very helpful with some clients, but there is a whole host of techniques to try for chronic worry (e.g., worry time, cognitive restructuring).  Check out our online bookstore for more resources for treating worry:

• Mastery of Your Anxiety and Worry (MAW): Therapist Guide (Treatments That Work)
  

• Mastery of Your Anxiety and Worry: Workbook (Treatments That Work)
  

• The Worry Cure: Seven Steps to Stop Worry from Stopping You

• Anxiety Free: Unravel Your Fears Before They Unravel You

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

Family-based treatment for adolescent eating disorders: A detailed discussion of the data

by Michael D. Anestis, M.S.

Back in April, I wrote an article on PBB discussing the empirical support for various treatments for anorexia nervosa (AN).  The bulk of the article focused on family-based treatment (FBT) for child and adolescent AN, as this treatment has the greatest degree of research supporting its utility for this particular diagnosis.  In recent months, I have had a number of pleasant interactions with the folks at Maudsley Parents (http://www.maudsleyparents.org; follow @JaneCawley on Twitter) and have come away from those conversations feeling compelled to spread the word about the data on this matter.

If you have not read my prior FBT article, I would recommend consulting it for a detailed description of the nature and structure of the treatment.  Additionally, I would recommend reading Lock and le Grange (2005) for a summary of the nature of the treatment and earlier research supporting its efficacy in the treatment of eating disorders (see our References page for the entire citation).  That being said, the context within which to view the utility of this treatment is one of hope amidst frustration.  Empirical support for treatments for AN is elusive and, as a result, many look upon our ability to treat the disorder with a mix of emotions ranging from anger to despair.  Fortunately, results of FBT, which was designed at the Maudsley Hospital in London, have offered reason for greater optimism, at least with respect to adolescents.  The goal of today's article is to provide a greater degree of detail regarding the data supporting the efficacy and effectiveness of FBT in the treatment of eating disorders in order to help readers develop a clearer sense of why many clinicians and researchers believe we are seeing the beginning of a better age in the treatment of previously treatment resistant diagnoses.

FBT Controversy

The rationale for discussing this data stems from a the fact that some controversy - or at least some concern - surrounds FBT.  The early empirical work on this approach, as one might expect, was conducted by a single research group comprised of the researchers who developed the treatment.  As such, good science dictates that independent replications by researchers not associated with treatment originators at a location outside the Maudsley Hospital are needed in order to optimize confidence in the results.  Fortunately, such data now exist.  Additionally, some individuals find it troubling that FBT involves parents assuming control of the adolescent's eating behaviors for the first six months of treatment, as early theoretical models of AN centered around the idea that the disorder represents a misguided search for autonomy from an enmeshed family (e.g., Minuchin et al., 1978).  Loeb and colleagues (2007) noted that FBT takes an atheoretical stance on the origins of AN and focuses instead on what approaches are most likely to increase the chances of recovery.  Along these lines, they utilize the family as a resource for guidance and authority in treatment and their results make it difficult to argue with that decision.  Other criticisms of FBT center on the relatively brief nature of the treatment (one year) and its outpatient nature, as most treatment models for AN involve a chronic course involving frequent inpatient hospitalizations.  In this case, the data are all that matters, and I will present empirical evidence indicating that individuals not only recover at a high rate through FBT, but maintain these gains at long term post-treatment follow-ups.  Finally, some critiques of FBT stem from the fact that its methods do not easily map onto a standard theoretical orientation (e.g., psychodynamic, cognitive behavioral).  As a scientist, I find this critique baffling.  Although much of my training is from the CBT perspective, my devotion is to empirical investigation not CBT in particular, and if a treatment not associated with my typical theoretical viewpoint demonstrates efficacy and/or effectiveness through rigorous scientific investigations, it is unclear how the theoretical orientation of the treatment is relevant.  Think of it this way: if somebody discovered a cure for a previously incurable form of cancer and that treatment did not involve any dangerous side effects or unethical procedures, would it matter to you whether the treatment was consistent with what you expected from it?  If it would - which is reasonable - I suspect it would nonetheless matter much less than the fact that it works.

Okay, so let's discuss the evidence indicating that FBT not only works, but works outside of the Maudsley hospital itself and results in long-term improvements.  This review will focus on recent research performed outside of the Maudsley Hospital, but please note that prior research on this treatment exists as well.

Loeb et al., 2007

In an open trial conducted in a university clinic, 20 male and female adolescents (ages 12-17) were treated with manualized FBT.  All participants either met full criteria for AN or were subthreshold.  Subthreshold AN required that the participant meet the weight loss criteria (below 85% of expected body weight) but only have missed one or two menstrual periods rather than the three required for amenorrhea or that the participant miss the weight cutoff but lose enough weight to qualify for amenorrhea.  As such, subthreshold AN did not represent "mild" cases.  Participants in this study exhibited a significant increase in body weight and a significant decrease in dietary restraint and eating concerns.  They did not, however, exhibit statistically significant improvements in shape or weight concerns or depression symptoms.  Depression symptoms at baseline were mild, however, so improvement on that factor was not a primary aim of treatment.  Only two of the 20 participants self-initiated early termination from treatment, meaning that FBT did a solid job of overcoming the attrition issues that plague AN treatment.

On the whole, these findings were fairly strong.  They demonstrate that the manualized form of FBT can be implemented in a setting outside of the Maudsley hospital with a decent degree of success.  The lack of improvement on weight and shape concerns is an issue; however, the fact that the participants improved substantially on the more dangerous symptoms of AN is important to consider as well.  Additionally, the small sample size vastly diminished the statistical power of the analyses, rendering it difficult to detect even moderate sized effects.  As such, a larger sample size could help reduce fears of false negatives.

le Grange, Crosby, Rathouz, & Leventhal (2007)

In this study, the authors examined the utility of FBT in the treatment of bulimia nervosa (BN).  In prior articles, we have discussed the evidence supporting the utility of a number of other treatments for BN, including CBT, interpersonal psychotherapy, and dialectical behavior therapy (as well as the lack of evidence for other treatments such as equine assisted psychotherapy).  Here, the authors presented compelling data indicating that FBT can be useful in treating BN as well.

This study was a randomized controlled trial (RCT) comparing FBT to supportive psychotherapy in the treatment of adolescent BN.  80 participants were randomly assigned to one of the two treatments and the results for the two approaches were compared immediately post-treatment and at a six month follow-up.  Immediately following treatment, more individuals in the FBT condition (39%) were binge-purge abstinent than in the supportive psychotherapy group (18%).  Abstinence rates decreased somewhat at 6-month follow-up, but again individuals in the FBT group were more likely to be binge-purge abstinent.  Post-treatment analyses also revealed that individuals in the FBT group exhibited significantly greater reductions in objective binge episodes, subjective binge episodes, all compensatory behaviors, dietary restraint, weight concerns, shape concerns, eating concerns, and global eating disorder symptoms.  The two groups did not differ in degree of improvement on self-esteem or depression.

Clearly, these results are very promising.  The authors utilized strong methodology (RCT) to compare two active treatments and FBT demonstrated superior efficacy in a wide range of eating disorder related outcomes.  FBT was not compared to any empirically supported treatments for BN, so of course caution should be used in interpreting the degree to which FBT offers as much promise as those treatments; however, this study does provide a rationale for budding confidence and future research.

Rhodes, Baillee, Brown, & Madden (2008)

In another RCT, Rhodes and colleagues (2008) sought to examine whether the addition of a parent-to-parent consultation early in treatment would improve outcomes in the treatment of AN.  20 families were randomly assigned to standard FBT and FBT with the added parent component.  Results indicated that the addition of the parent-to-parent consultation was associated with significantly greater weight restoration in AN patients.

Paulson-Karlsson, Engstrom, & Nevonen (2009)

In the most recent study I could find on this matter, Paulson-Karlsson, Engstrom, and Nevonen (2009) tested the efficacy of FBT in the treatment of AN in a hospital in Sweden.  32 female adolescents who met criteria for AN and their parents received FBT.  At 36-month follow-up, 75% of the participants were in full remission.  In addition to the elimination of their eating disorder symptoms, the participants reported experiencing less distance from their families and a less chaotic familial environment.  The lack of a comparison group obviously renders this study far from perfect, but the results are nonetheless highly impressive.

Summary thoughts

The above mentioned studies do not represent the entirety of the work in this area, but they provide a fairly comprehensive glimpse at the evidence supporting the utility of FBT in the treatment of adolescent eating disorders, particularly with respect to AN. Skepticism regarding treatments is a healthy scientific mindset and clearly we at PBB demonstrate this rather regularly when we discuss treatments for which evidence is lacking.  That being said, skepticism towards the utility of FBT for eating disorders appears unwarranted based upon the data.  Concern that symptom improvements are not more substantial are entirely legitimate; however, the complete lack of empirically supported alternatives for this particular subset of individuals renders the gains seen through FBT highly meaningful.  As Daniel le Grange (2006) said in a commentary replying to an article criticizing the positive views of FBT (Bergh et al., 2006): "it makes little sense to dump the car that starts every other morning before you have purchased a new and potentially more reliable model!"  In other words, FBT represents progress - impressive progress at that - with a population for whom we previously had no treatments with strong empirical support.  Its imperfections do not render it useless or irrelevant, nor do they bestow upon less supported treatments any measure of enhanced efficacy.  FBT marks an emerging dawn after a long dark stretch devoid of strong treatment research on AN.  We should embrace these results even as we challenge them, test alternatives, and strive for something better.

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If you would like to learn more about family-based treatment, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• Treatment Manual for Anorexia Nervosa: A Family-Based Approach by James Lock, Daniel le Grange, Stewart Agras, and Christopher Dare

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

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

More than the baby blues: Searching for data on the treatment of postpartum mental illness

by Joye C. Anestis

When I sat down to research this post on treating postpartum mood (e.g., depression, bipolar I & II), anxiety, and psychotic disorders, I thought it would take no time to come up with some clear data on the empirically-supported treatment(s) for postpartum conditions.  After all, I reasoned, there has been so much press on the seriousness of postpartum mental illness (for example, Brooke Shields) that surely hundreds of researchers must have jumped at the opportunity and published article after article.  Disappointingly, that is not the case - treatments for postpartum illnesses are not mentioned in any lists of ESTs.  Certainly, treatment research exists (some of which I review below) but not enough to draw any firm conclusions about appropriate courses of treatment.  What concerns me most about the relative lack of research on psychotherapy for postpartum mental illness is the clear need for non-medication treatment alternatives, given the risks that could potentially arise from taking psychotropic medications while breastfeeding.  Expectant mothers are taught that breastfeeding is the best for their infant, but mothers grappling with devastating postpartum illness often must choose between the risks to herself & her family that would arise from not taking medication vs. the risks inherent in choosing medication options.  Clear, well-constructed research on effective alternatives are necessary.   That being said, I wonder if little research is done on psychotherapies for specific postpartum mental illnesses because of a general impression that there is no reason to think that treatment we already know are effective for non-postpartum mental illness wouldn't work for postpartum women (e.g., exposure & ritual prevention for OCD).  Perhaps that is the case, but it certainly flies in the face of scientific thinking to make that assumption without data to back it up - especially considering the unique situations postpartum women are in (e.g., hormonal fluctuations, sleep deprivation, the stress of changing relationships with a partner, of course the stress of having a baby to tend to).  If we are going to advocate ESTs, we need evidence that treatments work in the postpartum as well.  

So here's what I'm going to do.  Below, I'll briefly review the 2 meta-analytic studies I've found examining the handful of treatment studies that exist.  And then over the next few weeks, I'll continue to cull databases and the internet in general, looking for more information.  In the meantime, if you are aware of more data that I am missing, please let me know in the comments section!

• Cuijpers, Brannmark, & van Straten (2008) identified 17 studies that compared an intervention for postpartum depression diagnosed with a structured clinical interview &/or self-report questionnaire to a control or other active treatment condition.  The authors note that the methodological quality of the available and included studies was poor (e.g., lack of random assignment).  This meta-analysis found moderate effect sizes for psychological treatments (including interpersonal psychotherapy, counseling, and social support), but note that the effect sizes were smaller than those typically reported.  The authors stress that too few studies were found to make any definitive conclusions.
• Bledsoe & Grote (2006) identified 11 studies on prenatal and postpartum depression to include in their review.  Again, the overall quality of the literature available was poor (Only 5 of the 11 studies included were considered "high" quality by the authors.  Many studies lacked random assignment, control groups, etc.).  The treatments with significant effect sizes were (in order from largest to smallest effect size): medication + CBT; medication alone; a group therapy with cognitive-behavioral, educational, and transactional analysis components; interpersonal psychotherapy; and CBT.  Yet again it is stressed that too few studies, and too few studies of quality, exist to draw any real conclusions.

From briefly perusing theoretical articles, it appears that there is some literature on interpersonal psychotherapy for postpartum depression (I have previously written briefly about IPT during pregnancy).  This seems, in my opinion, a reasonable treatment to investigate.  Many childbirth experts (e.g., Gaskin, 2003) theorize that increases in postpartum mental illness are directly related to the decrease in social support new mothers currently receive, as our society moves further and further away from the communities our ancestors created.  I will summarize this treatment in a future post, although it's important to note that it's empirical support for postpartum depression is not definitive.  And I will continue to search for information on other postpartum disorders.  Depression seems to be the most commonly discussed postpartum mental illness, but some women are at risk for other conditions such as psychotic episodes and OCD.  So be on the lookout for future posts on this subject!

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If you would like to learn more about the topics discussed on PBB, we recommend that you consult our online store of scientifically-based psychological resources.

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

Examining self-injurious thoughts and behaviors in real time

by Michael D. Anestis, M.S.

Self-injurious thoughts and behaviors (SITBs), a category that includes both suicidal behaviors (e.g., suicidal thoughts or attempts) and non-suicidal self-injury (NSSI), have been the subject of numerous past PBB articles.   Our articles on NSSI in particular have, in large part, centered on Matt Nock and Mitch Prinstein's (2004) functional model, which presents a framework through which to understand the different reasons why individuals engage in self-injurious behaviors.  In the newest issue of the Journal of Abnormal Psychology, Nock and Prinstein, and Sonya Sterba (2009) have described some fairly remarkable new data on this topic and I would like to discuss the results of their study today.

Nock, Prinstein, and Sterba (2009) noted that past studies on SITBs have been limited by two significant factors:

1. Because the scientific process typically involves a deductive approach - specific theory-based hypotheses are generated and subsequently tested - researchers have based much of their understanding of SITBs on beliefs generated from a distance rather than from direct observation of the ways in which these phenomena naturally occur.
2. Past studies have relied upon retrospective self-report recollections and have therefore relied upon the honesty and accuracy of memories of participants.  Such methods, while valuable, are vulnerable to biases, inaccuracies, and other limitations.

Recent technological developments, particularly ecological momentary assessment (EMA) methods, have enabled researchers to take an entirely different approach to understanding these and other phenomena.  In EMA studies, participants report behaviors, emotions, and other variables in real time, often through the use of palm top computers that they carry with them over the course of numerous days or weeks.  By utilizing these methods, researchers can observe relationships in an environment much more representative of daily life than a laboratory setting.

With that in mind, the authors had four primary goals in their study:

1. To observe the basic form of SITBs (e.g., frequency, intensity, duration)
2. To observe the context of SITBs (e.g., when do these thoughts and behaviors occur? what are people typically doing at that time?  who are they typically with at that moment?)
3. To observe the proximal risk factors for SITBs (e.g., what predicts when an individual is most likely to experience SITBs?)
4. To observe the functions of SITBs (e.g., why do individuals have these experiences?)

To accomplish these goals, the authors recruited 30 adolescents and young adults from a larger community sample on NSSI.  To be included in the study, the participants had to have reported experiencing thoughts of NSSI within the previous two weeks and had to have access to a computer.  Each participant carried a personal digital assistant (PDA) palm-top computer for at least 14 days, with some individuals keeping theirs longer due to difficulty getting back to the lab in precisely 14 days.  Twice each day - at mid-day and end-of-day - the PDA would beep, signaling for the participant to complete survey information.  Additionally, participants were told to fill out those same surveys on the PDA any time they experienced a self-destructive thought or behavior.  Individuals whose responses indicated imminent risk of serious injury or who did not respond for three days were contacted by phone for risk assessments and participants who responded to at least 80% of the twice-daily prompts were paid $100 or allowed to keep the PDA.

Over the course of the 14-day study, the study revealed 1,262 thought and behavior episodes.  After analyzing these data, the authors reported a number of interesting findings.

Frequency, duration, and severity of thoughts and behavior

NSSI thoughts were reported, on average, as registering at moderate-to-severe intensity.  Suicidal thoughts, on the other hand, were typically reported as registering at mild-to-moderate severity.  Suicidal thoughts tended to last longer than did NSSI thoughts, indicating that they were a more intense and time consuming phenomenon than were NSSI thoughts.  NSSI thoughts transitioned to NSSI behavior when the thoughts were of greater intensity and when the thoughts were shorter.  In other words, short intense thoughts of self-injury were most likely to result in actual NSSI behavior.

Overlap of NSSI and suicidal thoughts

Importantly, whereas suicidal thoughts were accompanied by thoughts of NSSI 42.3% of the time, NSSI thoughts were accompanied by suicidal thoughts only 1.0%-4.2% of the time.  This clearly highlights the importance of considering these two phenomena separately from one another rather than collapsing them into a single category such as parasuicidal ideation.

Context of SITBs

When suicidal and NSSI thoughts began, participants most often reported that they were socializing, resting, or listening to music.  Participants reported using drugs or alcohol during only 0.0%-4.8% of their self-injurious thoughts, meaning that far more often than not, participants were sober while having such thoughts.

In terms of events leading up to SITBs, NSSI thoughts were most frequently preceded by worry, experiencing a bad memory, or feeling pressure.  Suicidal thoughts were frequently preceded by that same list as well as arguments with other people.  In a small minority of cases of suicidal and NSSI behaviors (1.7%-3.8%), participants reported engaging in the behavior after being encouraged by others to do so.  Even at such a low frequency rate, the authors noted that this is a disturbing finding.

In terms of emotions, NSSI thoughts were most often experienced while the participants were feeling sad/worthless, overwhelmed, or scared/anxious.  These latter two, however, did not predict NSSI behavior.  Anger towards oneself, rejection, self-hatred, numbness, and anger towards others increased the likelihood of NSSI behavior whereas feelings of sadness/worthlessness decreased the likelihood of NSSI behavior.  There was a wide range of emotional states that accompanied suicidal thoughts, with results suggesting that these thoughts were preceded by more extreme levels of negative emotions than were NSSI thoughts.

Function of NSSI

If you have not read our prior description of the functional model of NSSI, I recommend consulting that article in order to better understand this section of results.  Nock, Prinstein, and Sterba (2009) reported that, by far, the most frequently endorsed function of NSSI was intrapersonal-negative reinforcement (64.7%).  This function entails the use of a behavior in order to reduce an unwanted internal experience (e.g., negative emotions).  Participants reported that NSSI motivated by this function most often involved efforts to reduce anxiety (34.8%), sadness (24.2%), anger (19.7%), bad thoughts (28.8%), or bad memories (13.6%).  The second most common function was intrapersonal-positive reinforcement (24.5%), which entailed utilizing self-injury to increase a desired internal state (e.g., to feel something, even if it is pain).  The third most common function was interpersonal-negative reinforcement (14.7%), which entails engaging in NSSI to reduce expectations or stop the behavior of another person.  The least frequently reported function of NSSI was interpersonal-positive reinforcement (3.9%), which entails engaging in NSSI in an effort to get another individual to do something.  This, of course, flies in the face of the commonly held belief that self-injurious behavior is typically an attempt to manipulate other people and instead supports that idea that vast the majority of NSSI episodes represent efforts on the part of the individual to regulate their own emotional states.

Avoiding self-injurious behaviors

What about the individuals who experienced thoughts of self-injury but did not engage in actual behaviors?  How did they manage to avoid making that harmful transition?  The authors reported that the most frequent methods used to keep from engaging in actual self-injurious behaviors were changing thoughts, talking to someone, or engaging in distracting activities (e.g., work/homework, going out, using computer).  This, of course, provides valuable insight into how vulnerable individuals respond to dangerous thoughts and attempt to prevent themselves from acting on dangerous impulses.

So what can we learn from this study?

Nock, Prinstein, and Sterba's (2009) work provided us with a rare glimpse into the ways in which SITBs are experienced in daily life.  Like any study, there were limitations.  The degree to which these results generalize beyond adolescents and young adults already vulnerable to such outcomes is unknown and the very act of observing thoughts and behaviors could theoretically impact the manner in which they are experienced. Without question, however, the results are insightful and provide a basic foundation upon which to build future work.  The authors were careful to point out that, before we can be certain that these patterns represent common trends, they need to be replicated independently in different samples.  That being said, these observations provided some powerful insights into how often self-injurious thoughts and behaviors occur in vulnerable adolescents and young adults, what prompts such outcomes, and why such individuals feel compelled to engage in NSSI.  Additionally, they provided compelling evidence that suicidal and non-suicidal thoughts truly represent distinct phenomena better examined and conceptualized separately from one another than as part of a broader group of experiences.  I always come away incredibly impressed after reading research by these folks and this was definitely not an exception to that rule.

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If you would like to learn more about SITBs, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• Why People Die by Suicide by Thomas Joiner
  

• Treating Suicidal Behavior: An Effective, Time-Limited Approach by David Rudd, Thomas Joiner, and Hasan Rajab
  

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd

• Understanding Nonsuicidal Self-Injury: Origins, Assessment, and Treatment by Matthew Nock

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

Establishing empirical support for mental health treatments: Are we being fair to new forms of treatment?

by Michael D. Anestis, M.S.

Amidst the many articles Joye and I have written sharing findings from various psychological studies has been a scattering of articles critically examining what some believe to be unsubstantiated claims regarding both general psychological phenomena (e.g., does suicide risk assessment actually increase suicide risk?) and specific forms of treatments (e.g., equine-assisted psychotherapy; EAP).  The goal of those articles is not to criticize anyone personally nor to discourage people from investigating these phenomena.  In fact, the opposite intention is very much in play: we hope to alert readers to the lack of research on particular topics (or the presence of uninspiring research) and to encourage interested parties to empirically investigate the issues.  All that being said, our recent article on EAP sparked some interesting conversations, both in the comment section and on other websites, regarding how newer treatments are evaluated and what can be done to encourage innovation while discouraging the proliferation of treatments that lack adequate empirical support.

This morning, I received a timely email from James Coyne, co-author of the November 2009 PBB featured article, alerting me to a back-and-forth exchange published in the current issue of Behaviour Research and Therapy between Brandon Gaudiano of Brown University and Lars-Goran Ost of Stockholm University.  In Gaudiano's (2009) article, he critiques a paper published by Ost in 2008 in which he concluded that studies on Acceptance and Commitment Therapy (ACT) have not been methodologically strong relative to studies investigating Cognitive Behavioral Therapy (CBT) and that ACT studies have not fulfilled the requirements outlined by Division 12 of the American Psychological Association (APA) for a psychological treatment to be considered empirically supported for any particular diagnosis (also see Chambless & Ollendick, 2001 for a description of these criteria).  Ost's (2009) article serves as a rebuttal of Gaudiano's critique.

Today, I would like to discuss some of the issues these two authors considered in their articles, although I have no intention of coming down on one side or the other regarding their particular argument.  Instead, I want to discuss the very important question of how we should evaluate emerging treatments to ensure that innovation is pursued, but untested treatments are not practiced in a manner inconsistent with their research foundation.  As a little background, let's first consider the nature of the original Ost (2008) article that inspired this back-and-forth.  In that study, Ost examined 13 randomly controlled trials (RCTs) of ACT.  Additionally, he "matched" each of these studies with an RCT of CBT published in the same journal within one year of the publication of each corresponding ACT study.  The point of this exercise was to examine the methodological quality of RCTs of these two treatments published in identically prestigious journals during the same era of research.  Ost (2008) reported that the ACT studies had significantly lower average scores on a number of variables, including:

• Representativeness of the sample
• Reliability of diagnosis
• Reliability and validity of outcome measures
• Assignment to treatments
• Number of therapists
• Training/experience of therapists
• Assessment of treatment fidelity
• Control over concomitant treatments (e.g., medication use)

Gaudiano's (2009) criticism of Ost's (2008) original work centered on two key points (although he raised other issues as well).  First, CBT studies receive a greater average amount of grant funding relative to ACT studies.  Further, he argued that the increased funding enables CBT researchers to use more advanced methodologies in their studies.  Second, ACT is a newer form of treatment that is still in the process of establishing its empirical support.  As such, some of the studies are best thought of as pilot studies intended to provide a rationale for funding agencies considering whether or not to provide grant money for larger scale future investigations of the treatment (and, in fact, he pointed out that one such grant funded study is now underway).  Furthermore, he pointed out that APA Division 12 currently lists ACT as "probably efficacious" in the treatment of depression.  Importantly, Gaudiano was a co-author of one of the ACT studies considered by Ost (2008) as well as one of the CBT studies, so he was not approaching this from the perspective of an individual in favor of one treatment and against another, but rather as a researcher with a different perspective on the state of ACT research and the expectations of new treatments with respect to the type of data that must be collected in order to establish empirical support.

Ost's (2009) rebuttal pointed out that, although less funding can have an obvious impact on establishing the reliability of diagnosis and the degree of treatment fidelity, as doing this requires independent observers to join the team and that costs money, the funding issue would have no impact on the use of fairly representative samples, outcome measures with well-established psychometric properties, proper assignment of participants to treatment, the use of multiple therapists with training in the conditions involved in the study, and the control of concomitant treatments.  Additionally, although reliability of diagnosis can be impacted, the establishment of diagnoses does not hinge upon heavy funding.  In other words, funding is not irrelevant by any stretch, but it also does not explain all of the methodological differences between the studies evaluated in the original Ost (2008) study.  Ost (2009) maintained his original position, that ACT has not established itself as empirically supported for any diagnosis and indicated that he only found two ACT studies on depression that were available at the time of the original reports and he believes those studies are methodologically weak and actually did not establish differences between ACT and the comparison approach in treating depression.

The one area in which these two researchers agreed is that both proponents and critics of a particular treatment should be held to an equal standard.  Where disagreement exists, however, is in determining whether treatments should be held to the highest standard when they are still establishing initial efficacy.

The main issue

Ultimately, when we step away from the specific argument between Gaudiano and Ost about CBT and ACT, the central issue to consider is whether the rules applied to already established treatments should be applied to novel treatments at the earliest stage of their research development.  In other words, CBT trials that do not involve the highest methodological rigor, at this point, would generally (although not universally) be laughed out of the room.  This is because, over decades of research, the basic efficacy of CBT for a number of specific diagnoses has been well-established and research methods have been improved such that we no longer need basic info on CBT but rather more rigorous data that demonstrates specific effects across a number of populations in diverse settings.  Trials like that, no doubt, cost money, and researchers aiming to investigate CBT have a mountain of evidence to rely upon when proposing such work to funding agencies.  When a new treatment is developed, no such foundation exists, meaning that funding is hard to come by, at least to some extent.  The question thus becomes, in the absence of funding, given that certain components of ideal studies become impossible, what should still be required of work investigating the new therapy?

This issue is relevant to our discussion of equine assisted psychotherapy (EAP), which caused a bit of a stir and prompted some strong reactions, both positive and negative.  The point of that article was essentially that, because no RCTs have demonstrated that EAP is, in fact, efficacious or effective in the treatment of any specific mental illnesses, the treatment should not be practiced or marketed as though it has (the same argument was put forth in our discussions of dolphin assisted therapy, wilderness therapy, and thought field therapy).  This, of course, raises the question of how to establish that a treatment does work.  After all, in the absence of data indicating that it is useful, it still might be just that.  Ost's side of the back-and-forth seems to maintain that, once an established treatment for a particular diagnosis has demonstrated its effects through rigorous studies, a new treatment seeking to be considered empirically supported for that same diagnosis needs to be tested just as rigorously, even at the beginning.  In other words, if the treatment wants to be treated equally, it needs to be put through equally strenuous tests and thereby produce equally compelling data.  Gaudiano's side of the back-and-forth, on the other hand, seems to indicate that, when a treatment is new and grant funding is hard to come by, evaluation should be a bit more lenient so as to allow the treatment to establish a more readily accumulated research base.

Personally, I see reason in both sides, but I think that is because neither one addresses the entire question.  How we research a treatment is different than how we practice and market it.  In my opinion, if a novel treatment needs to establish some results through less rigorous study because funding is difficult to attain, that makes sense, as long as those results are not used as anything other than justification for future, more rigorous investigations to agencies considering funding future research.  In order for a treatment to be introduced into the marketplace as a form of health care capable of attaining specific effects for particular mental illnesses, I believe that the treatment approach must be subject to the highest of methodological standards.  This is not to say that I side with Ost on the ACT vs CBT argument, but I do agree with him in principle regarding many of the basic requirements set forth in order for a treatment to be considered empirically supported.

Where do you stand on these issues?  Should clinicians be able to practice forms of therapy that lack empirical evidence established through methodologically strong studies?  Should the standards of research requirements be relaxed for newer treatments and, if so, should there be limitations in how those treatments are used before further, more methodologically strong support is attained?  Independent of your answers to those questions, do you think there should be restrictions on the marketing of treatments without empirical support and, with or without such restrictions, do you think it is beholden upon proponents of empirically supported treatments to better market their findings to potential consumers so as to increase awareness of the treatments available and the research supporting their use?  Remember, this is not a discussion of ACT versus CBT but rather a broader discussion of how the arguments put forth by Gaudiano and Ost apply to all novel mental health treatments.

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If you would like to learn more about empirically supported treatments, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• A Guide to Treatments that Work by Peter Nathan and Jack Gorman

• Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual by David Barlow

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

Veterans Day: Discussing the mental health care needs of soldiers

by Michael D. Anestis, M.S.

Today is a day to honor those who have chosen to serve their country through military service.  The mental health care needs of military personnel have become a very prominent interest of mine in recent years and I have been privileged to work with talented members of that community (e.g., Craig Bryan, Chad Morrow) as well as my colleagues at Florida State University (e.g., Thomas Joiner, Eddie Selby, Ted Bender) in developing a better understanding of the situation and what we can do to help.  Today, I wold like to express my gratitude for the service of others by discussing several studies involving Charles Hoge of Walter Reed Army Institute of Research and his colleagues on the mental health needs of soldiers, obstacles that keep them and their families from seeking out the care they need, and potential solutions for the situation.

The role of stigma and barriers to care

Acknowledging that mental health difficulties exist within samples of military personnel returning from deployment overseas is important, but it does not tell the entire story.  An additional point to consider is that many individuals in need of mental health care never seek treatment.  A number of reasons exist that explain that situation, but two that have been subject to growing research attention are stigma and barriers to care.  In a study published in 2004 in the New England Journal of Medicine by Charles Hoge and colleagues examined these factors in a sample of 2,530 members of US combat units prior to deployment to Iraq and a sample of 3,671 US combat units three to four months after returning from combat duty in Iraq or Afghanistan.  In addition to finding substantially elevated rates of numerous diagnoses (e.g., depression, generalized anxiety disorder, PTSD), the authors found that individuals who met criteria for a mental illness were substantially more likely than those who did not meet criteria for a mental illness to report a belief in a stigma and barriers associated with seeking mental health care.  In other words, the individuals who actually needed care were the ones most likely to see treatment as stigmatizing and unavailable.

In a factor analysis examining the degree to which stigma and barriers to care are actually separate concepts, the Wright, Cabrera, Bliese, Adler, and Hoge (2009) confirmed that this was the case and described a screening measure that was effectively utilized to assess these variables in military personnel.  The stigma subscale consisted of eight items whereas the barriers to care subscale consisted of three.  The items were as follows:

Stigma

• It would be too embarrassing
• It would harm my career
• Members of my unit might have less confidence in me
• My unit leadership might treat me differently
• My leaders would blame me for the problem
• I would be seen as weak
• My visit would not remain confidential
• An office or NCO should not be in a leadership position if he/she is taking medication for a mental health problem

Barriers to care

• I don't know where to get help
• I don't have adequate transportation
• It is difficult to schedule an appointment

Given that the Hoge et al (2004) study revealed that individuals with mental health difficulties are the most likely to score highly on screening measures such as this, clearly this means that we have a situation in which those in need of help feel guilty about their struggles, believe that seeking help will cause them more harm than good, see their mental health difficulties as a weakness or believe others will see them that way, and have a hard time even accessing care in the first place.  Obviously, this is not ideal and it is extremely upsetting to think that, in addition to the pain of mental illness, many soldiers also carry around the burden of the types of thoughts listed in this screening measure.

In a later study, published in the Journal of Social and Clinical Psychology by researchers at Clemson University and the Walter Reed Army Institute of Research (Britt et al., 2008), the authors examined both a sample of university students and a sample of US army soldiers in an effort to better understand the implications of stigma and barriers to care.  In the university sample, they found that the relationship between stress and depression was strongest for individuals who perceived a stigma associated with seeking treatment.  In other words, stress is always a predictor of depression, but it is particularly likely to lead to depression when the stressed individual believes that seeking treatment would be perceived poorly or would represent a weakness on their part.  In the military sample, the authors found that the relationship between stress and depression was strongest for individuals who perceived barriers to seeking care.  In other words, stress was particularly strongly related to the onset of depression in individuals who felt that they did not have adequate access to care.  So, not only have we discovered that the individuals most in need of care are the ones most likely to perceive stigma and barriers to seeking treatment, we also have found that stigma and barriers to care amplify the impact of stress on the onset of mental illness.  Quite clearly, a situation has developed in which those in need of mental health services have to overcome a number of obstacles - some based on life circumstances and others based on distorted beliefs - just to get into treatment in the first place.

Another recent study by Eaton and colleagues (2008) extended this conversation to include the spouses of soldiers.  They found that spouses of soldiers experienced rates of mental illness that were comparable to the soldiers themselves.  Additionally, although a substantial number of spouses of soldiers reported concerns regarding stigma and barriers to care, they were more likely than the soldiers themselves to seek mental health care and perceived less stigma and fewer barriers than did the soldiers.  The obvious positive of this finding is the fact that stigma and barriers are reduced in spouses relative to soldiers and that help seeking behaviors were more prominent; nonetheless, the obvious negative is that a substantial degree of stigma and barriers to care were still present in this population.

What can be done to increase access to care?

In the Wright et al (2009) study mentioned above, the authors also examined factors that predicted greater help seeking behavior and better perceptions of access to care.  What they found was quite promising.  Not only did enhanced officer leadership and unit cohesion predict lower perceived stigma and decreased barriers to care, this prediction remained significant even when controlling for the severity of mental illness in the unit's personnel.  In other words, with strong leadership and a cohesive unit, the resulting supportive environment can often override the relationship between symptom severity and perceptions of stigma and barriers to care.  The importance of a finding like this would be difficult to overstate, as it appears to offer a strong target for preventative care.  By enhancing the leadership approaches of officers and working on unit cohesion, the harmful relationship between developing symptoms of mental illness and perceiving problems associated with mental health care can be undercut, thereby enhancing the likelihood that soldiers who need help will have access to trained clinicians and utilize their resources.

Obviously this is not enough and not every solider in a cohesive unit with strong leadership will have access to and seek the care they need.  That being said, it is an important beginning.  An additional angle that researchers are taking to battle this issue is the development of a better understanding of the ideal timing for mental health assessments in post-deployment personnel.  In a study published in the Journal of the American Medical Association (JAMA) by Milliken, Auchterlonie, and Hoge (2007), the authors took a longitudinal glance at the development of mental health symptoms in the months following reintegration to civilian life post-deployment.  Soldiers were screened for mental health related concerns immediately upon return from deployment to Iraq as well as three to six months later. They reported several meaningful findings, including:

• 20.3% of active soldiers and 42.4% of reserve component soldiers were identified as needing mental health services
• Interpersonal conflicts increased substantially between the two assessments
• A large number of soldiers expressed concerns regarding their use of alcohol, but few were referred for help with the behavior
• More soldiers were identified as meeting criteria for PTSD at the follow-up assessment (post-deployment health re-assessment; PDHRA) than at the initial screening (post-deployment health assessment; PDHA).
• Those who were identified as suffering from PTSD at the PDHA saw significant symptom improvement between assessments.

The authors noted three particularly important aspects of these findings.  First of all, when mental illnesses are identified at screening, symptoms do seem to improve.  This indicates that effective treatments are, in fact, being used when clients are effectively identified and referred to treatment.  Secondly, given the increase in interpersonal conflicts, services for family members of returning soldiers appear to be inadequate.  Third, symptoms of mental illness in soldiers may not be evident immediately upon returning from overseas deployment or the current screening measures might not be sensitive to these symptoms as they appear at that time.  This is consistent with the findings of Bliese, Wright, Adler, Thomas, and Hoge (2007), who found that symptoms of mental illness tend to be higher 120 days post-deployment relative to immediately after reintegration.  As such, the most effective screening approach might involve multiple assessments spread out across the initial months of reintegration.  Such a system might allow for earlier detection and a greater degree of referrals for treatment.  That being said, in order for this to work, stigma and barriers to care must be addressed.

Some concluding thoughts

As we think about our veterans today, I hope many of you will take note of the fact that many soldiers are suffering in silence.  For some, this means that fear the implications of seeking treatment.  For others, this means that effective treatment is, for one reason or another, not easily accessible.  For others, a host of other reasons explain the gap between rates of mental illness and rates of help seeking behavior.  In addition to the strong efforts by the military to address these issues, a vital consideration for all of us is the need for accurate education on a large scale and the implementation of effective treatments.  There is a sea of empirical research out there on mental illness and psychotherapy.  We know a tremendous amount about how mental illnesses impact individuals and how to go about treating them in an efficient and long-lasting manner.  Unfortunately, much of that knowledge is limited to people who spend their lives researching it and, as a result, many of those in need are unaware of all the help that is available.  Fortunately, the VA system places a heavy emphasis on the utilization of empirically supported treatments (e.g., cognitive processing therapy and prolonged exposure for PTSD), but we need to help as many people learn about this information as possible, so they can readily and accurately identify when they or their loved ones need help and then know where to turn to find treatment that actually works.  Soldiers sacrifice so much for us - we owe it to them to ensure that they receive the right care when they return.

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If you would like to learn more about empirically supported treatments for PTSD, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide by Edna Foa, Elizabeth Hembree, and Barbara Rothbaum

• Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide by Edna Foa, Kelly Chrestman, and Eva Gilboa-Schechtman
  

• Cognitive Processing Therapy for Rape Victims: A Treatment Manual by Patricia Resick and Monica Schnicke
  

• Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook by Barbara Rothbaum, Edna Foa, and Elizabeth Hembree

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

Some PBB press - Maudsley Parents names PBB their website of the month

We want to extend a warm thank you to MaudsleyParents.org for naming PBB their website of the month.  We highly recommend that readers check out their website and newsletter, both of which are great resources for information on family-based treatment.  The organization emphasizes evidence-based approaches to treatment for eating disorders and displays a simultaneous devotion both to clinical practice and an up-to-date understanding of scientific research.  In our minds, such balance embodies exactly what this field should be striving for professionally.

Thanks again.

Mike and Joye Anestis