Psychotherapy Brown Bag

PBB on Huffington Post

by Michael D. Anestis, M.S.

We are very flattered by our mention on Huffington Post as a Twitter mental health expert.  Woohoo!

Published does not mean quality and quality does not mean relevant: The importance of reading and critically reviewing research

by Michael D. Anestis, M.S.

I've had an interesting back-and-forth discussion recently regarding the empirical evidence for equine-assisted psychotherapy.  As PBB readers no doubt know, I'm not particularly impressed by the evidence-base for this approach and have been openly critical about its frequent use by clinicians in the treatment of mental illnesses.  Today, I came across a blog post on PsychCentral made by the individual with whom I have been having this back-and-forth in which a number of citations were listed as evidence of empirical research on the utility of EAP in the treatment of mental illness.  My goal here in this post is not to incite a confrontation, but to instead critically review those citations.  I will not be linking to the post because I feel as though it will be hard to do this without this article coming across as an attempt to attack the author of the blog, which truly is not my intention.  The point in doing this is to demonstrate that simply because something gets published does not mean that it is scientifically rigorous and, even if the scientific rigor is strong, it does not mean that the results support the claims of the authors themselves or those citing the article.  We have a way of (often unintentionally) discussing results in a manner that far exceeds what the data actually tell us and, unfortunately, I believe this is demonstrated quite well here.  What follows is a list of citations with a description of each and a critique of the evidence they provide for EAP as an efficacious and/or effective treatment for any mental illnesses.

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Schultz, P., Remick-Barlow, G., & Robbins, L. (2007). Equine-assisted psychotherapy: A mental health promotion/intervention modality for children who have experience intra-family violence. Health & Social Care in the Community, 15, 265-271.

In this article, 63 children who had been subjected to intra-family violence received anywhere from 1 to 116 sessions of EAP.  The authors found that global assessment of functioning (GAF) scores improved significantly over the course of treatment. On the whole, that is a positive result; however, there are a few significant issues with this study.  First, there was no comparison group.  In other words, to what degree did common factors account for any improvement.  This is particularly notable because the authors found a significant association between number of sessions and level of improvement, a red flag that, without a comparison group, points towards the simple passage of time as a major contributor to improvements. In other words, without a comparison group, it's unclear that people who received EAP improved to any greater degree or at a quicker rate than would people who received no treatment at all.  After all, in general, regression to the mean indicates that extreme scores eventually become less extreme - people improve from severe states over time.  Evidence of improvement in the abesence of a comparison group confirms that a treatment is not iatrogenic, but it does nothing to support the notion that it is a useful form of treatment.

Also, no psychometrically tested measures of psychopathology were utilized, precluding any analysis of the degree to which individuals saw improvement in their specific diagnoses.

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Trotter, K., Chandler, C., Goodwin-Bond, D., & Casey, J. (2008).  A comparative study of the efficacy of group equine assisted counseling with at-risk children and adolescents.  Journal of Creativity in Mental Health, 3, 254-284.

In this study, the authors compared EAP and classroom counseling in the treatment of problematic behaviors amongst children perceived as being at risk for poor academic outcomes.  Unfortunately, there was no random assignment.  Instead, participants chose which treatment they wanted, resulting in 126 participants in the EAP group and 38 in the classroom group.  The importance of random assignment in treatment research is paramount.  Given that the authors did not report on any between groups differences, this is a serious issue.  That being said, even if we decide to overlook that, the important point to consider here is that no participants in this study were diagnosed with a mental illness and no components of the analyses in this paper demonstrated that EAP was useful in the treatment of mental illness.

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Frewin, K. & Gardiner, B. (2005).  New age or old sage? A review of equine assisted psychotherapy. The Australian Journal of Counselling Psychology, 6, 13-17.

I have reviewed this paper at length in an earlier PBB article, so I will merely point out that the only empirical data cited in this paper come from a website that gives no information about the study itself and from an unpublished manuscript from a different study conducted more than a decade ago that nonetheless has yet to be published.

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Kaiser, L., Spence, L.J., Lavergne, A.G., & Bosch, K.L. (2004). Can a week of therapeutic riding make a difference? A pilot study. Anthrozoos, 17, 63-72.

This study examined 16 children, all of whom were judged to be physically healthy and without any mental illness and found that, after 5 days of therapeutic riding, self-reported levels of anger and frustration were decreased.  Here again, there were no comparison groups and no evidence was provided that EAP is useful in the treatment of mental illness.

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Klontz, B.T., Bivens, A., Leinart, D. & Klontz, T. (2007).  The effectiveness of equine-assisted experiential therapy: Results of an open clinical trial. Society and Animals, 15, 257-267.

In this study, 49 individuals at an EAP treatment facility agreed to take part.  Only 31 completed the 6-month follow-up portion and the authors failed to report on any results for individuals who did not respond to that final component.  This is an issue as individuals who are lost to attrition are often the ones who fail to respond to treatment and, in this case, nearly 40% of the sample fit into that group.  Taking this a step further, again there was no comparison group, meaning we're looking at the 60% of the sample that decided to continue participating and examining whether their symptoms improved without any consideration of the internal validity (e.g., did the treatment have any impact or did the passage of time or other common factors drive any significant effects?).  On the one hand, there is some preliminary evidence for symptom improvement, but on the other hand, it would be a significant stretch to view this as support for the efficacy of EAP in the treatment of mental illness (again, no documentation of diagnoses, remission rates, etc...).

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Scheidhacker, M., Friedrich, D., & Bender, W. (2002). About the treatment of anxiety disorders by psychotherapeutic riding: Long term observations and results of an experimental clinical study. Krankenhauspsychiatrie, 13, 145-152.

I was unable to find this citation.  If anyone has information on this study, I would love to hear about it.

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Zugich, M., Klontz, T., & Leinart, D. (2002).  The miracle of equine therapy.  Counselor Magazine, 3, 22-27.

This is not an empirical study.  It is an opinion piece published in a magazine.  Click here to read the article itself, which is available for free.

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So...what is my point here?  I am not saying EAP does not work, although I am not a believer in this particular treatment approach.  I am saying that there is no evidence that EAP is efficacious and/or effective in the treatment of mental illnesses.  This is not an opinion of mine, but rather a statement of fact.  Perhaps evidence will emerge indicating that EAP has empirical support for a particular set of mental illnesses, but as of yet this has not happened. 

Unfortunately, most individuals do not have training in empirical research and statistical analyses, which makes interpreting published journal articles difficult.  On top of this, few people have access to these articles, so even if they wanted to read the source material themselves, they would be unable to do so.  Because of this, when we cite articles online and write about them, it is important to make sure that we are accurately representing the nature of the results, otherwise the potential for misinformation to become widespread is problematically high.

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

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University.

Exposure plus response prevention (EXRP) for OCD: Insight into how often the "gold standard" treatment is actually used and why some avoid it

by Michael D. Anestis, M.S.

One of the tricks of psychotherapy research is ensuring that promising results found in controlled trials actually translate to real world results (click here for an example).  In other words, once we can demonstrate that a particular form of treatment is especially helpful for particular conditions within a research laboratory, we need to make sure that, in every day practice, the people in need of help benefit from that treatment as well.  Once we do that, we then need to examine how often that treatment is actually being utilized, how well it is being utilized, and, when folks in need are not receiving that (or even any) treatment, why that might be.  Unfortunately, the results on that end are not always particularly promising (click here and here for examples).  Today, I'd like to discuss a study currently in press at Behavior Therapy, published by Maria Macebo, Jane Eisen, Nicholas Sibrava, Ingrid Dyck, and Steven Rasmussen of Brown University Medical School (Butler Hospital) that addresses these issues very well. 

In this particular study, the authors examined treatment utilization, reasons for avoiding particular treatments, and reasons for dropping out of particular treatments for obsessive compulsive disorder (OCD).  The authors were particularly interested in learning whether patients with OCD were being advised to utilize the "gold standard" treatment - exposure plus response prevention (EXRP) - and, if so, whether they were actually taking that advice.  For those who did not take that advice, they were curious why not.  For those who did, but dropped out prior to completing treatment, again they were interested in what influenced that decision.

In total, the authors examined data on 202 patients diagnosed with OCD, collected over the course of a 2-year follow-up.  Here's what they found:

Psychopharmacological results:

• 83% of the sample was on a selective serotonin reuptake inhibitor (SSRI) at intake and the majority of those patients continued on an SSRI during the course of the 2-year period.
• Of those receiving psychotropic medication, 90% reported receiving treatment from a psychiatrist, 9% from their primary care physician, and 1% from another professional.

EXRP results (the authors generally referred to cognitive behavioral therapy - CBT - here, so some of these individuals may not have been receiving the true EXRP protocol, as EXRP is a variant of CBT):

• 44% of the sample (89 individuals) received EXRP at some point during the follow-up period
• 53 were already already receiving EXRP, 23 initiated EXRP for the first time during follow-up, and 13 restarted EXRP after previous experience with the treatment
• The average number of EXRP sessions attended by folks who received the treatment was 33.1
• 82% of individuals who received EXRP received treatment from a doctoral-level therapist
• 29% of the individuals who received EXRP (19% of the full sample) received a "full dose" of EXRP, defined as at least 13 weekly sessions.
• 120 participants were advised to seek out EXRP.  26% of those individuals (n = 31) failed to attend any EXRP sessions.
• 31% of the 89 individuals who attended an EXRP session dropped out prematurely, which was significantly higher than some clinical trials (e.g., Franklin et al., 2000) but not others (e.g., Abramowitz et al., 2003).
• Individuals with more severe OCD symptoms were more likely to be advised to seek EXRP and also more likely to initiate EXRP sessions.

Reasons for not initiating EXRP or dropping out early:

• Environmental barriers were the most frequently endorsed reason for not participating in treatment.  These include the inability to locate an EXRP provider, lack of funds for treatment, and difficulty scheduling appointments.
• Some individuals endorsed a belief that treatment would not be helpful
• 30% endorsed fear/anxiety about engaging in treatment (e.g., were nervous about exposure exercises designed to induce anxiety in session)
• Environmental barriers were also the most commonly endorsed reason for dropping out of treatment early; however financial reasons no longer factored into the equation, meaning that once an individual enters EXRP treatment, affordability typically is not an issue
• More that 25% endorsed dropping out due to fear/anxiety about treatment.

So what does all of this mean?  First of all, it appears that pharmacological treatments are more commonly utilized in the treatment of OCD in particular settings.  This is not particularly shocking given that many individuals receiving treatment for mental health concerns first enter the system through medical professionals. This is also not particularly troubling in this case, as SSRI's have been shown to be useful in the treatment of OCD.  That being said, what is troubling here is that, even in a sample of individuals recruited from an OCD specialty clinic in an area of the country in which finding clinicians trained in EXRP, many individuals do not receive the "gold standard" treatment, even when advised specifically to do so.  As the authors of the study noted, imagine how these results translate to areas of the country in which its hard to find any treatment for mental illness, nevermind evidence-based approaches.

Results like these highlight the difficulties inherent in the process of disseminating evidence-based mental health care within the current system.  Individuals in need of help often don't know about the evidence behind particular treatments, are often unswayed by being presented with that evidence (as are many providers not trained in that particular treatment modality), and, even when they are, many have no access to such treatment or have to overcome significant barriers in order to get there.

What do you think is the best solution here?  Better education of the public on particular treatments?  Wider training of clinicians in evidence-based care?  Development and testing of computer-based treatments available online?  Acceptance of non-evidence-based treatments?

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If you would like to learn more about this or other topics discussed on Psychotherapy Brown Bag, we recommend that you consult our online store for scientifically-based psychological resources

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University

Moderatedrinking.com - Examining the impact of a new online intervention

by Michael D. Anestis, M.S.

I'm a big fan of innovations in health care aimed towards reaching broad groups of individuals in need and helping them meet their health goals.  The bottom line is that a large proportion of individuals in need of mental health care do not have access to effective treatments for a variety of reasons (e.g., unable to travel to treatment center, no treatment centers in area offering evidence-based care) and others have access but choose not to use it.  Interventions capable of reaching these individuals and engaging them in treatment offer immense potential value.  Recently, I wrote a PBB post about telehealth treatment for PTSD and today I want to discuss another technology-based treatment: moderatedrinking.com.  

In an article published in the current issue of the Journal of Consulting and Clinical Psychology by PBB guest author Reid Hester, Harold Delaney, and PBB guest author William Campbell, the authors described an effectiveness trial comparing their new program in combination with moderation management (MM) - another online treatment tool - to MM on its own in the treatment of problem drinking.  The study included follow-ups at 3, 6, and 12 months post-baseline, allowing for an analysis of sustained benefits.

The authors had two central hypotheses:

1. Both groups would demonstrate reductions in alcohol-related problems and drinking at follow-ups
2. The individuals using moderatedrinking.com as well as MM would exhibit greater reduction in alcohol-related problems and drinking relative to individuals only using MM.

Importantly, the goals of this trial were very specific.  The authors were not claiming that individuals with severe mental illnesses would benefit from treatment or that individuals with alcohol dependence would be treated effectively through the protocol.  Rather, they were aiming to help individuals with moderate drinking problems looking to decrease the problems in their lives associated with that particular behavior.  The authors had detailed inclusion (must have in order to participate) and exclusion (must not have in order to participate) criteria:

Inclusion criteria:

1. A score on the Alcohol Use Disorder Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) greater than 7
2. Self-report that the individual is drinking at least 10 standard drinks per week during the past 30 days
3. Individual is not currently abstaining from alcohol
4. Individual expresses an interest in moderate drinking
5. Individual is at least 21 years old
6. Individual has a computer with internet access at home

Exclusion criteria:

1. History of treatment for substance abuse
2. Already member of MM
3. History of hospitalization for alcohol or drug dependence or detoxification
4. Past or current diagnosis of drug abuse or dependence
5. Evidence of past or present physical dependence
6. Current indication of psychosis or bipolar spectrum disorder
7. Evidence of significant cognitive impairment from brain dysfunction
8. Evidence of health-oriented contraindications to any further drinking
9. English reading below 8th grade level
10. Unwilling/unable to attend follow-ups
11. Unwilling/unable to provide significant other to corroborate self-report of drinking

Now, you might look at these criteria and think "hey, they're exclusing a lot of people who need treatment for alcohol use disorders!"  You're right...and the authors are up front about that.  Again, the point here is not that this treatment is going to be the best thing for everyone, but rather that, for individuals with only moderate problems with drinking, an online intervention might enable them to attain moderation in their behavior and improvement in a range of important variables.  Given that many of these individuals are not going to seek or be referred to more intensive treatment programs, either because they do not meet diagnostic criteria for dependence or because abstinance, which is the sole focus in most treatments, is not their goal, this provides a potential opportunity to use technology to reach an underserved population in need of help.

In total, 40 individuals were randomly assigned to the moderatedrinking.com + MM group and 44 were randomly assigned to the MM only group.  30 participants from the moderatedrinking.com + MM group were assessed at all four time points and 29 from the MM only group were assessed at all four time points.  Here's what they found:

Looking at both groups together, they found significant improvement from baseline through 12-months post-baseline, with evidence for increased improvement from 6 to 12 months post-baseline (meaning that the effects not only held over time, but actually continued to improve).  At baseline, participants, on average, were at the 54th percentile for women and 65th for men.  At 12 months, they were at the 29th for women and 38th for men.  Reduction in overall alcohol consumption was significant, as were increases in percentage of days abstinant and decreases in number of drinks per drinking day and blood alcohol content (BAC) on drinking days.  More specifically, average drinks per drinking day dropped from 5.35 at baseline to 3.28 at 12 months and BAC on drinking days dropped from 102 mg% to 58 mg%.

Looking at the groups separately, improvement from baseline to average at follow-ups was twice as large in the moderatedrinking.com + MM group than in the MM group.  That being said, while the improvement was significantly greater in the combined group than in the MM only group at 3 months, that difference was non-significant at the other follow-ups (meaning the two groups did not differ on level of improvement at those times).  Additionally, individuals in the combined group demonstrated a greater improvment in the number of days abstinent from alcohol than did folks in the MM only group.  Finally, lighter drinkers in the combined group had better outcomes in terms of BAC on drinking days than did folks in the MM only group, but heavier drinkers in the combined group did not have significantly better results.  This last result further supports the notion that this treatment option is not aimed at individuals with severe alcohol use problems, but rather individuals who are developing problems and would like to adjust their behavior and its associated outcomes.

Okay...I threw a lot of results at you there (and there are some I left out).  The overall point here from this study is that there is some compelling preliminary evidence that a new online intervention can, in combination with another online resource, prove incrementally useful for non-severe problem drinkers.  Again, I love that this study uses technology to reach individuals outside of the clinic.  As much as I love the idea of people in need of mental health care travelling to local clinics to receive evidence-based care, that simply is not realistic in a lot of cases, so programs like this offer another potential method of providing evidence-based care to large groups of people in need.

As I write this, I am aware that the goal of this program - and, in fact, the name itself - may seem odd to some readers.  After all, isn't abstinance the only goal in alcohol use treatment?  The short answer is that the evidence says differently - that for those who seek moderation as an outcome, this is, in fact, an attainable goal.  Keep in mind, however, that neither PBB nor moderatedrinking.com is proclaiming abstinance from drinking to be a bad goal or that all individuals with alcohol use disorders can attain a healthy level of moderate drinking.  This is simply one means towards attaining one goal that could fit for certain individuals.

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

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology program at Florida State University

Comorbid personality disorders and the course of major depression

by Joye C. Anestis

As we've mentioned before here on PBB, drastic changes to the classification of personality disorders have been proposed for the DSM-V.  As such, personality disorders are receiving quite a bit of attention lately...and I find that very exciting!  In my own clinical work, I've seen the devastation that can be wrought by personality disorders and the often myriad of problems that accompany them.  Unfortunately, it's also been my experience that some clinicians don't always consider the presence of personality pathology when assessing Axis I disorders and, as a recent article in the American Journal of Psychiatry suggests, presence of personality disorder greatly affects the course of Axis I pathology.

The present study was headed up by Andrew Skodol, M.D. (a member of the DSM-V personality & personality disorder work group) and a number of other prominent personality researchers.  The authors  used epidemiological data (from the National Epidemiologic Survey on Alcohol and Related Disorders) to investigate the influence of all 10 DSM-IV personality disorders on the course of major depressive disorder.  I've summarized the study below (as always, check back with the original article - linked above - for more details).

Method: Data were acquired from the general population and collected in two waves. 43,093 respondents were interviewed in Wave 1 (WOW!) and 34,653 were re-interviewed 3 years later in Wave 2 (WOW again! and what a retention rate!).  Out of these folks, 2,422 of the Wave 1 responders met diagnostic criteria for Major Depressive Disorder (MDD; using a structured diagnostic interview)...and 1,996 of them participated in Wave 2 and so were included in the present study.  Because of the longitudinal nature of this study, the authors were able to conceptualize two course-related outcome variables in their analyses: 1) persistent MDD - meeting full criteria for current MDD in Wave 1 (i.e., episode within last 12 months) & full criteria for the disorder during the entire 3-year follow-up period (without the occurrence of mania), and 2) recurrent MDD - meeting full criteria for MDD in Wave 1 and again in Wave 2 (i.e., episode within last 12 months, but not the in the first 24 months immediately following the Wave 1 interview).

Results:  The author's reported a large number of analyses!  Below is a quick rundown of those findings:

• They found that borderline personality disorder had the highest percentage of persistence (28.9% [SE=2.75]) and narcissistic the lowest (14.6% [SE=2.52]).  I'm surprised by this finding in regard to narcissistic PD!  Logistic regression analyses revealed that several PDs predicted persistence, including avoidant, borderline, histrionic, paranoid, schizoid, and schizotypal.  No PDs predicted recurrence.  Among the many other variables they examined, anxiety disorders and dysthymic disorder also significantly predicted persistence.
• The authors calculated population attributable risk proportions for the effects of co-occuring psychopathology and other risk factors on persistence of MDD.  Borderline (57.3%), schizoid (47.9%), and schizotypal (45.3%) PDs, as well as any anxiety disorder (43.4%) had the highest values.  Population attributable risk proportions "indicate the proportion of persistence of MDD attributable to each disorder" (p. 262). Based on this definition, about 57% of MDD in the subjects would not have persisted into the follow-up period had they not also met criteria for borderline PD.  I admit to being a bit blown away by that!
• The authors performed a number of multivariate analyses testing the associations of PDs predicting MDD persistence:
  •   Model 1: Tested individual models for each PD, controlling for demographics.  Avoidant, borderline, histrionic, paranoid, schizoid, & schizotypal PDs were all significant predictors.
  • Model 2: Tested the same models, but added Axis I comorbidity as a control variable.  Avoidant, borderline, paranoid, schizoid, & schizotypal PDs remained significant predictors.
  • Model 3: Entered demographics, Axis I comorbidity, and all 10 PDs simultaneously, in an attempt to tease out specific PD effects. Only borderline and schizoid PDs remained significant.
  • Model 4: Family history of substance use and psychiatric illness was added to the model.  The results were virtually unchanged.
  • Model 5: Other predictors of MDD persistence (i.e., treatment history, age at first onset, the number of previous episodes, & duration of current episode in Wave 1) were added to the model.  Borderline PD remained a robust predictor of MDD persistence.

Overall, this study makes a significant contribution to the literature purporting that comorbid PDs are significant, negative prognostic indicators for MDD.  When treating clients with MDD, therefore, it is imperative that we remain aware of the possibility of comorbid personality pathology and are vigilant in treating the individual appropriately.  And borderline PD is particularly virulent!  As the new dimensional model of diagnosing PDs is being tested, I am interested to see replications of such findings.  

Joye is a doctoral candidate in clinical psychology at Florida State University and an incoming intern at the Minneapolis VAMC.