Psychotherapy Brown Bag

The Wikipedia Initiative: An effort by the Association for Psychological Science to promote science education

by Michael D. Anestis, M.S.

I have been meaning to write about this for a while and today seemed like as good a time as any.  The Association for Psychological Science (APS) is making a valient effort to expand the reach of science by encouraging scientifically-minded psychologists and students to develop Wikipedia articles that promote an accurate understanding of science in psychology.  In my opinion, this is an absolutely fantastic initiative with the potential to promote significant public health gains.

I've stated this before, but let me quickly summarize what I believe to be one of if not the greatest shortcoming in the mental health field: failure to effectively market science.  As doctoral students, we are trained - and rightfully so - to develop our clinical and research skills and to promote our work through peer-reviewed articles.  This is the single most important mechanism of dissemination within the scientific community.  The problem is, the vast majority of people who are in need of the services we develop through scientific research are not members of that community, do not have years of training in interpreting statistical data and experimental designs, and do not have subscriptions for peer-reviewed journals.  As such, most potential consumers of this knowledge are unaware of its existence and lack access to it anyway.  Making the problem worse is that, in the absense of efforts on the part of scientifically-minded psychologists and students to disseminate this information to a broader audience, others have swooped in - some opportunistic and mean-spirited, but most bringing with them misguided but truly good intentions - and filled the void with compelling promotions of pseudoscientific and oftentimes ineffective (or worse) treatments.

Enter the Wikipedia Initiative.  Wikipedia is one of the most highly viewed sites on the net.  As such, it is a way to reach people who might not otherwise come across accurate mental health information and to thus increase the odds that they will find appropriate help.  By encouraging people to infuse Wikipedia with accurate, balanced articles about science in clinical psychology (with links to support claims), APS is taking an important step towards shifting the tide in this struggle and increasing the regularity of interactions between people in need and providers of evidence-based treatments.

I suspect some will see this intiative as an effort to push an agenda on readers.  To be fair, if the articles do not link to independent sources that provide detailed descriptions of the nature of the evidence supporting claims made in articles and if articles are written in a way that mislead readers, the initiative would deserve such negative views; however, that is not the intention of the effort.

I highly encourage interested readers to take part in this project.  To read more about it, click here.

What do you think about this project?  Are there ways to improve it?  Do you have other ideas for promoting science to a broader audience?

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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 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.

Participating in suicide research does not cause increases in non-suicidal self-injury, suicidal ideation, or suicidal behavior

by Michael D. Anestis, M.S.

When researchers are looking to conduct an experiment, one of the first steps they must take is seeking approval of the Institutional Review Board (IRB) at their location.  The IRB reviews study proposals to ensure that they are ethical, unlikely to cause harm, and of enough potential value to warrent the use of resources.  This is a great thing, as it helps prevent research participants from experiencing harm.  That being said, as a suicide researcher, I have often encountered significant resistence from IRBs, as members have worried that questions regarding suicide risk could actually cause the participants harm.  In addition to the inherent moral concerns inherent in such potential harm, this would obviously put the institution at great legal liability as well.

In the past, I have written on PBB about the work of Madelyn Gould, who convincingly demonstrated that assessing students for suicide risk does not increase thoughts of suicide and that, even more importantly, appears to decrease thoughts of suicide risk in depressed participants and participants with a history of suicidality (click here to read about those results in greater detail).  Providing IRB members with those data as well as a well-designed risk assessment and intervention protocol typically alleviates concerns, but you can never be too careful on this front. 

With that in mind, I'd like to very briefly summarize the results from another study today.  In this study, published in Suicide and Life-Threatening Behavior in 2010 by Phillip Smith, Erin Poindexter, and PBB guest author Kelly Cukrowicz, the authors examined whether participation in an intensive suicide research protocol would increase thoughts of suicide, suicidal behaviors, and other self-harm behaviors in a sample of depressed individuals with suicidal ideation, half of whom had at least one prior suicide attempt and half of whom had no prior attempts.

In the original study, which was testing a specific component of the acquired capability for suicide, participants were shown a number of images, including graphic images of suicide, as the authors collected psychophysiological data (affectively modulated startle reflex).  Additionally, each participant filled out a number of questionnaires related to suicidality.  Participants were then contacted at 1 and 3 months post-experiment to assess for changes in suicidal ideation, suicidal behavior, and non-suicidal self-injury.  21 (68%) of the original 31 participants participated in both follow-up sessions.

Interestingly (although in my opinion not surprisingly), the authors found that no individuals experienced an increase in suicidal ideation post-experiment and that, in fact, by far the most frequent response was a significant decrease in suicidal ideation.  Even more importantly, however, is that no individuals engaged in non-suicidal self-injury or suicidal behavior post-experiment.

Now, to be fair, there are a number of limitations to this study.  First of all, not every participant from the original study participated in the follow-ups.  What's important to note about that however, is that those who did and did not participate in follow-ups did not differ on any variables (e.g., suicidal ideation levels, past history of suicide, level of depression), so this was not a situation in which the more severe participants dropped out, thereby artificially shifting the numbers to favor the authors' hypotheses.  A second limitation is the small sample size.  A greater number of participants could have resulted in a different pattern of results.  That being said, the complete absence of increases in any of the suicide-related outcomes makes it difficult to believe that a larger sample would yield results indicating that participation in the study increased suicidality.  A final limitation worth noting is that short follow-up period.  It could be that the suicide-related outcomes might shift with more time.  The thing with that, however, is that after several months have gone by, it becomes increasingly questionable to assume that the experiment impacted those changes.

So what's the moral of the story here?  IRBs, while often annoying, are incrediby important and perform a thankless job, but the concerns of some IRB members that research on suicide might increase suicide risk appears to be unwarrented.  The answer to suicide risk is not now and never will be ignoring the topic.  Assessing for risk, asking direct questions about thoughts and behaviors, directing individuals at imminent risk to treatment facilities, and using data from one study to inform the next will always be a clearer path towards better outcomes.  It is understandable that people would want to see evidence to support that notion - clearly that's a standard we demand of others here at PBB - and hopefully this evidence will be taken to heart.

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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 (one more month!) and a doctoral candidate in the clinical psychology department at Florida State University.

Smith, P., Poindexter, E., & Cukrowicz, K. (2010).  The effect of participating in suicide research: Does participating in a research protocol on suicide and psychiatric symptoms increase suicide ideation and attempts?  Suicide and Life-Threatening Behavior, 40, 535-543.

 

Mental Health Month Blog Party 2011 - Choosing the right form of psychotherapy

by Michael D. Anestis, M.S.

Just yesterday, I noticed a flurry of folks posting a link to an NPR piece discussing the need to shop carefully when seeking psychotherapy so as to avoid ineffective (or worse) care.  My initial response was excitement, although this was admittedly tempered a bit when I saw references to treatments with suboptimal research support instead of clear references to the most well-supported options.  That being said, I appreciate baby steps, and the NPR article definitely represents a bit of progress on this front.

That being said, I thought my best contribution to the Mental Health Month Blog Party 2011 would be a quick post helping folks in need of mental health services figure out which treatments actually have research support.  After all, it's one thing to say that people should seek out treatments supported by evidence, but without a guide for doing so, that task is remarkably difficult (click here to see what I mean by "evidence").

The easiest way for somebody looking to receive evidence-based mental health care to figure out which treatments would work best for them is to go to APA Division 12's website, which explains different diagnoses and treatments, as well as the degree of research supporting them.  I have talked about this site on PBB before, but I think it would be worthwhile to revisit the topic.

Step 1: Go to the website

http://www.div12.org/PsychologicalTreatments/index.html

Step 2: Start browsing 

Now, it's important to remember not to try to diagnose yourself.   Valid and reliable diagnoses are best reached through the use of structured diagnostic interviews by clinicians trained in such procedures.  That being said, if you have been diagnosed in the past or are curious what treatments are available for particular diagnoses, click on the "disorders" tab. This will take you to a list of mental illnesses.  If you click on one diagnosis, you will see a description of its symptoms as well as a list of various treatments and the amount of research supporting each one.  You can also click on each of those treatments to learn more about them.

If you are more interested in simply learning about specific treatments rather than diagnoses, click on the "treatments" tab.  Here, you will be able to read a description of each treatment and, again, learn about the research supporting its use for specific populations.  If a treatment is not listed here, it has no empirical evidence supporting its use in the treatment of mental illness and should be avoided.

Step 3: Find a therapist that utilizes evidence-based treatments

This can be tricky, but there are a few methods that can make this easier.  Dr.Jill Holm-Denoma explained a number of these methods very well in a PBB guest post last year (click here to read).  The bottom line is, it is your right to receive the best possible care for mental illnesses, but at times this will require that you ask whether your therapist uses these methods and whether he or she was actually trained to use them.  A few other points to consider here that have been covered in earlier PBB articles:

• A more experienced therapist is not necessarily a better therapist.
• How intensely a therapist was trained makes a difference. 
• Although getting along with your therapist and having a strong "alliance" is a good thing, the alliance is NOT more important than the type of treatment you receive.
• The quality of supervision received by the therapist while he or she was trained makes a significant difference.

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Finding evidence-based mental health care can be very difficult.  First of all, because we do such a poor job of marketing these treatments, many people do not even know that they exist and believe all forms of psychotherapy are the same.  Secondly, there are many people out there - some of whom appear on TV or write blogs on popular psychology websites - who try to convince people that science is not important in considering psychotherapy and/or particular treatments with no evidence are actually supported by science.  My hope is that, as time goes by, more people who are trained in both clinical work and research will promote the use of science as a guide in mental health care.  In the meantime, if you are in need of help, I hope that this article is a positive step in connecting you with the services most likely to get you where you want to go.

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If you would like to learn about this or other topics discussed on PBB, we recommend that you visit 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.

Patients view structured diagnostic interviews more positively than clinicians believe they do

by Michael D. Anestis, M.S.

When a patient is assessed for the presence of mental illness, the interaction can look very different from setting to setting.  One of the primary sources of potential differences is the degree of structure involved in the assessment.  Structured diagnostic interviews, which involve a series of questions designed to systematically assess for the presense of specific mental illnesses, have emerged in recent years as a method for developing accurate and reliable diagnoses and for making difficult differential diagnostic decisions (e.g., Basco et al., 2000; Zimmerman & Mattia, 1999).  Scientifically-minded psychologists - in large part - agree that using these structured interviews is the gold standard method for ensuring a valid and reliable diagnosis (Joiner, Pettit, Walker, Perez, & Cukrowicz, 2005).  Another approach, however, involves the use of unstructured interviews.  In this latter approach, the clinician simply asks questions that seem relevant, developing the interview as he or she goes in an effort to determine the precise nature of a patient's diagnostic profile.

Nearly two years ago, I wrote an article on PBB discussing a study published in Behavior Therapy that examined the degree to which patients respond positively to structured interviews.  This study was needed because, despite empirical evidence supporting the greater reliability and validity of structured interviews relative to unstructured interviews, there appeared to be substantial resistence to their implementation in every day practice, some of which stemmed from clinicians' concern that patients view structured approaches negatively.  As it turns out - and you can read much more detail about this in the original PBB article - patients actually viewed the structured interview extremely positively.  On average, they found the interview to be helpful and not overly exhausting and they reported that their relationship with the therapist who administered the interview was very positive.

Today, I came across a follow-up study by the same research group (Katrin Bruchmuller, Jurgen Margraf, Andrea Suppiger, and Silvia Schneider) that is currently in press at Behavior Therapy.  In this study, the authors wanted to accomplish three main goals:

1. Determine the degree to which structured interviews are utilized in every day practice
2. Compare therapists' views of patients' views of structured interviews to the actual patients' views of structured interviews
3. Determine the reasons that therapists do not utilize structured interviews and the degree to which specific reasons are associated with not using structured interviews

This particular research team is based in Switzerland and, to access therapists, they utilized the email lists of the three main professional organizations for therapists based in that country.  Emails were sent to 1,038 psychotherapists and 889 psychiatrists.  As an incentive to participate in the email survey, participants were entered into a lottery to win a voucher worth approximately $200.  Three weeks after the initial emails were sent, a reminder email was sent thanking individuals who had participated and requesting further participation.  In total, only 25.7% (n = 495) of the therapists responded to the email and participated in the survey.  This is an obvious weakness that should be kept in mind as you consider the results.  The average age of the therapists who took part was 52, 53% were female, and they reported an average of 19 years of experience.  The therapists reported a wide range of theoretical orientations (e.g., 19% cognitive behavioral, 22% psychoanalysis, 11% depth psychotherapy, 18% systemic, 12% Rogerian, 5% gestalt).

I'll break down their findings by their relevance to the three stated purposes mentioned above.

Frequency of Use

The therapists in this study reported that they only use structured interviews with 14.8% of their patients.  Perhaps even more startling, 51.6% reported that they do not use structured interviews with any of their patients.  Surprisingly to me, psychologists and psychiatrists did not differ in the degree to which they used structured interviews.

View of Patients' Acceptance of Structured Interviews

The authors anticipated that therapists would expect patients to have much worse views of structured interviews than the patients would actually have.  To test this, they used the same measure utilized in the study described in the earlier PBB article (Suppiger et al., 2009) and directly compared the responses of the therapists in this study and the patients in the earlier study.  In the earlier study, the patients' global rating of satisfaction with the structured interview was 86.55 (out of 100).  In the current study, the therapists expected patients would report a global satisfaction rating of 49.41.  That is a HUGE discrepancy and it indicates that therapist fears about how patients will respond to structured interviews are not even particularly close to being accurate.

The global rating, while informative, does not tell the entire story.  On a specific item indicating that patients do not report everything that is bothering them in structured interviews, therapists exhibited significantly higher agreement than did the patients.  Given that patients have much more insight into the degree to which they are sharing what is on their mind than the therapists do (I'm sure some folks disagree with this, but the degree to which the opposing viewpoint violates the basic principles of science is difficult to overstate), this is a problem.  In a specific item indicating that patients feel "questioned out" by the end of a structured interview, again therapists exhibited significant more agreement with the idea than did the patients, who indicated that they did not feel exhausted or overburdened by the questions.  Additionally, patients reported that their relationship with the therapists was more positive and the interview was more helpful than the therapists believed they felt.  Overall, these results represent a fundamental disconnect between therapists and patients regarding the degree to which stuctured interviews are helpful, elicit enough information, and support a positive therapeutic relationship.

Why Therapists do not Use Structured Interviews

Perhaps the most stunning number presented in this study is that, even though 63% of the therapists agreed with the notion that structured interviews help them not overlook something, less than 15% use these tools.  The most commonly given reasons for not using structured interviews were "my clinical judgment is more useful to me" (37%...Paul Meehl weeps), "they take too long" (34%), and "they disturb the relationship to the patient (32%...and a direct contradiction of the data).

In terms of familiarity with administering structured interviews, 35% said "not at all/hardly," 42% said "a little," 17% said "quite well" and 6% said "very well."  As the authors of the study noted, these numbers reflect an impressive lack of training in and awareness of structured diagnostic interviews.

Taking things a step further, the therapists reported modest beliefs that the DSM-IV and/or ICD-10 diagnoses are helpful for their practice (1.69 out of 3), but much less belief that structured diagnostic interviews are helpful (0.99 out of 3).  In other words, they believed diagnoses may be modestly helpful (click here and here for arguments that they are, in fact, quite helpful), but did not believe structured interviews were a useful tool for making diagnostic decisions.

The final set of analyses run by the authors involved using therapist responses to predict the degree to which they utilize structured interviews.  What they found was that therapists who endorsed the following a less likely to use structured approaches:

• Clinical intuition is more valuable (again....*cringe*)
• Structured interviews disrupt the therapeutic relationship
• Lack of familiarity with structured interviews
• Patient will not respond positively to structured approaches

Now, to be fair, if a therapist believes these things, it makes functional sense that they would avoid structured approaches.  After all, what kind of health care provider would use an approach they believe could cause their client harm?  The issue here is thus the validity of those beliefs and the bottom line is that the data simply do not support any of the above mentioned notions (other than the lack of familiarity...which indicates a need for futher training by the therapists to ensure that they are well-versed in evidence-based approaches to health care).

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So what's the bottom line here?  Despite the strong evidence for enhanced validity and reliability through the use of structured approaches and the positive response of patients to such approaches, therapists typically favor unstructured interviews.  In a sense here, as is so often the case, the issue boils down to beliefs regarding the utility of science in health care and that's a debate that we at PBB take very seriously.  At the same time, these results undoubtedly reflect a sharp disconnect between how therapists perceive their clients' beliefs and what clients actually believe, which if you think about it, is a very impressive argument against the notion that the therapist's intuition is the surest path towards mental health. 

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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 department at Florida State University

As a new approach, I am going to list the references from this article here instead of on the references page.  This may become my new standard approach:

Basco, M.R., Jeff, Q.B., Davies, D., Rush, A.J., Witte, B., Hendricks, W., & Barnett, V. (2000).  Methods to improve diagnostic accuracy in a community mental health setting.  American Journal of Psychiatry, 157, 1599-1605.

Bruchmuller, K., Margraf, J., Suppiger, A., & Schneider, S. (in press).  Popular or unpopular? Therapists' use of structured interviews an their estimation of patient acceptance.  Behavior Therapy.

Joiner, T.E., Pettit, J.W., Walker, R.L., Perez, M., & Cukrowicz, K.C. (2005).  Evidence-based assessment of depression in adults.  Psychological Assessment, 17, 267-277.

Suppiger, A., In-Albon, T., Hendriksen, S., Hermann, E., Margraf, J., & Schneider, S. (2009).  Acceptance of structured diagnostic interviews for mental disorders in clinical practice and research settings.  Behavior Therapy, 40, 272-279.

Zimmerman, M., & Mattia, J.I. (1999).  Psychiatric diagnosis in clinical practice: Is comorbidity being missed? Comprehensive Psychiatry, 40, 182-191.

Guest post: Mindfulness and Positive Reappraisal

by Tim Desmond, LMFT

Mindfulness can be defined as the capacity for nonjudgmental observation of present-moment experience and dis-identifying with cognitive appraisals.

Over the past 30 years researchers have been studying the effects of mindfulness practices on symptoms ranging from chronic physical pain to anxiety and depression. Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction program has been shown to decrease subjective distress for a range of symptoms and has been widely adopted by the medical community.

 

A recent study at the University of North Carolina looked at possible cognitive mechanisms that mediate the effectiveness of mindfulness practices.

Using questionnaires, subjects (n=339) were assessed for mindfulness, positive reappraisal, catastrophizing, and subjective distress before and after an 8-week course in mindfulness-based stress reduction. They represented a large range of psychological and physical symptoms.

The Five Facet Mindfulness Questionnaire includes Likert-scale items such as:
•    “I watch my feelings without getting lost in them.”
•    “I pay attention to sensations such as the wind in my hair or the sun on my face.”
•    “I’m good at finding words for my feelings.”
•    “I tell myself I shouldn’t be feeling the way I’m feeling.” (measuring the capacity for non-judgment of experience)
•    “I find myself doing things without paying attention.”

The data analysis showed that the effect of mindfulness to decrease distress was partially meditated through increased capacity for positive reappraisal. To be totally clear, this study cannot prove anything about causation. However, the partial mediation suggests an interesting relationship between those two capacities.

As stated above, mindfulness is the ability to observe present experience (such as cognitive appraisals) without identifying with them. What this study seems to suggest is that when someone develops their capacity to observe cognitive appraisals in this way, their ability to intentionally reappraise experiences improves. Then, through their increased capacity for positive reappraisal of experience, distress is lessened.

Certainly more research should be done on this connection, but this study has the potential to demystify how mindfulness is so helpful.

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Tim Desmond is a therapist in private practice and directs a mental health program for emotionally disturbed children in Oakland, CA. He offers phone counseling through his website. Follow him at twitter.com/timdesmond

Successful implementation of empirically supported treatments in a community mental health clinic: 10-years later, science continues to benefit patients

by Michael D. Anestis, M.S.

Intense couple of weeks research-wise, so I've been a bit slow on posting here.  Today though, I wanted to quickly review a cool study coming out of my homeland at FSU.  Several years ago, PBB guest author Kelly Cukrowicz and colleagues (2005) reported on the improved patient outcomes at the FSU psychology clinic once the clinic - which sees patients from the community with no restriction on severity of mental illness - transitioned to the mandatory use of empirically supported treatments (EST's).  In this study, Cukrowicz, Katie Timmons, Kate Sawyer, Kelly Caron, Haley Gummelt, and Thomas Joiner (2011) examined whether those improved outcomes had been maintained now that 10 years have passed since the transition to an evidence-based approach to the treatment of mental illness.

In the introduction, the authors addressed a number of common concerns about the nature of EST's, the degree to which results from studies generalize to everyday practice, and other similar issues.  We've discussed those issues at length on PBB, so I won't repeat them here, but feel free to express those concerns in the comment section and we can absolutely have a conversation about those issues there (all perspectives are welcome). 

The authors analyzed data from 92 individuals treated at the clinic prior to the shift to EST's, 81 treated during the first four years after that transition (the sample considered in the initial publication), and 376 patients treated between 2002 and 2008.

As was the case in the previous study (Cukrowicz et al., 2005), the Clinical Global Impression scale (CGI; Guy, 1976) was used as the primary outcome variable.  The CGI rating measures the degree to which a therapist feels that his or her patient improved over the course of therapy.  Importantly, raters were blind to the purpose of this study.  In other words, all therapists at this clinic provide CGI ratings when they terminate a case and this was not done specifically for the purpose of this study and, additionally, the therapists were not aware that this study would take place at the time they were making the rating.  Nonetheless, there are legitimate concerns that therapists might be motivated to say their patients improved regardless of whether or not that belief is accurate.  To account for that, blind raters reviewed a randomly selected group of files and provided their own CGI ratings.  The intraclass correlation coeffecient - a measure of the degree to which two independent raters tend to agree on something - was significant, meaning that independent reviewers tended to provide highly similar ratings of improvement.

The authors' central hypothesis was that the improvements noted in the original Cukrowicz et al (2005) study would be maintained or improved upon at the 10-year mark.  This was, in fact, supported by the data.  Individuals treated after the transition to EST's exhibited better treatment outcomes than did individuals treated prior to the transition.  Additionally, individuals treated since 2002 exhibited better treatment outcomes than did the individuals treated in the immediate transition period.  This indicates that the improvements were not only maintained, but in fact increased.  Importantly, the authors also noted that individuals treated after the transition to ESTs attended fewer therapy sessions, were diagnosed with a greater number of mental illnesses in general, and were diagnosed with a greater number of personality disorders.  This is a big deal because individuals who attend fewer therapy sessions, who are diagnosed with a greater number of mental illnesses, and who meet criteria for a personality disorder have been shown to typically have worse outcomes.  In other words, these improved outcomes were found despite the fact that the client base appears to have been at greater risk for worse outcomes.

The authors also examined whether individuals treated with cognitive or behavioral therapies exhibited better outcomes than individuals treated with other approaches and, in fact, the data indicated that this was the case.

There are some important things to consider here.  Perhaps most importantly, the CGI is not the best rating.  Ideally, there would be enough patients within each diagnostic category that the authors could make more specific comparisons (e.g., did individuals with depression treated post-2002 exhibit greater improvement on the Beck Depression Inventory after accounting for their scores at intake?).  This, however, would be difficult given the divserity of the sample seen in the clinic, so the use of the CGI allowed for a comparison of a broader group of individuals.  What this means is that, in general, EST's resulted in better outcomes; however, the data did not demonstrate that specific patient populations (e.g., individuals with bulimia nervosa) improved more in response to ESTs. 

Ultimately, this study is not meant to close the book on the debate about EST's, but it is an interesting look at the impact of using evidence-based approaches in a community clinic featuring a severe group of patients.  It is another example of high quality research being conducted in a clinical setting and further support for the importance of scientific-mindedness in therapy.

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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 department at Florida State University.