Psychotherapy Brown Bag

Alternative treatment delivery: Part 1, an overview of online psychotherapy

by Joye C. Anestis

At PBB, we have spent considerable time writing about empirically-supported treatments (ESTs) for various psychological disorders.  One of the goals of PBB is to help disseminate ESTs, both to practitioners and consumers.  General awareness that such treatments exist is perhaps the first step in promoting more wide-spread use of ESTs.  A second step, however, is to determine the best ways to deliver treatments in order to reach the most potential clients.  Theoretically, if ESTs can be provided in easily accessible and cost-effective manners, this will increase their appeal above and beyond the fact that they possess a rich background of empirical support.  Of course, face-to-face psychotherapy has been the dominant treatment model for decades - and thus the majority of research on ESTs has focused on in-person interventions.  But is it the best way to provide psychotherapy?  Are there other treatment modalities that might work as well?  Today, I begin a series of articles delving into alternative treatment delivery protocols for a variety of mental illnesses.  And since PBB is using the internet to achieve its goals, I thought it appropriate to begin with online interventions.

As you can perhaps imagine, the provision of therapy via the internet is simultaneously an amazing, forward-thinking idea and one fraught with potential problems.  Online provision of treatments cuts costs and makes treatment available to a massive audience that may not otherwise be able to access it.  On the other hand, internet therapy raises a host of concerns about ethics, confidentiality, licensing, and client safety.  There seem to be two distinct type of online interventions going on, and I will focus on each in turn. 

What most people think of when contemplating e-therapy involves the use of websites, video conferencing, e-mails, instant messaging, etc.  It appears that this type of online therapy is similar to more traditional psychotherapies in that a client is communicating with a therapist, perhaps in real time.  The qualifications of these individuals, the types of therapy conducted, and the amount charged vary greatly, making it difficult to determine the safety and utility of these services.  A 2000 survey of online practitioners by Maheu & Gordon  noted that 78% (n=12) of their international respondents and 93% (n=37) of their U.S. respondents reported being licensed or certified (the overall sample size was 56), and these practitioners reported being trained as psychologists, psychiatrists, counselors, pastors, social workers, and others.  This is the common trend in e-therapies...individuals with a variety of training backgrounds and theoretical positions are providing them.  Some offered services for free, others charged a variety of rates.  Some only communicated with individual consumers on a one-time basis, whereas 50% provided 1-15 sessions.  Perhaps most interesting to me (and most important for consumers) were the respondents' admissions about adhering to licensure regulations, confidentiality, and client safety.  78% of respondents indicated that they provided services to people living in a state other than where they were licensed, even though a psychologist must be licensed in each state where he/she provides services.  In a 2003 study by Heinlen et al., 82% of the psychologists whose websites they assessed claimed to be licensed but only 34% noted in which state(s) they were licensed. This is an issue that the legal system has yet to effectively iron out.  Each state differs on its telemedicine laws.  The California Board of Psychology is a great example of a state that is clear about the role of licensure in providing services via the internet. 

Perhaps even more shocking, only half of the respondents in the study mentioned above had made any arrangements to deal with a sudden crisis (a similar rate was found in the Heinlen study).  Suicide is a fact of the provision of mental health services, and it is imperative that every therapist, regardless of theoretical beliefs, be prepared to care for and deal with suicidality in clients.  To be unprepared is unethical and dangerous and leaves the therapist wide open for significant legal problems and the client without a safety net in a moment of crisis. 

Only 48% used a consent form before providing any online service, even though informed consent for therapy is required as part of ethical practice (see the APA Ethical Principles of Psychologists and Code of Conduct for more information).  A similar finding was reported by Heinlen et al. (2003).  Finally, confidentiality of clients is a primary concern.  HIPAA protects the privacy of all medical information, including psychotherapy, and applies to records obtained via the internet.  Heinlen et al. (2003) reported that only small numbers of the sites they reviewed discussed procedures to protect communication (27% encrypted communication. 30% gave clients passwords or user identification numbers to protect privacy).   Additionally, ethical guidelines require clients to be informed at the onset of services that confidentiality can be broken if certain circumstances (cases of abuse of children, the elderly, or the disabled; clear suicide or homicide risk; court order by a judge).  Only 39% of the sites reviewed by Heinlen et al. delineated these situations. 

As you can imagine, very little research has been done on this type of online therapy, as the large variability inherent in these sites does not lend itself to standard research practices.  Furthermore, many (but not all) of these therapists do not hail from a training background that promotes research.  However, my take-home point here is not that online therapists are unethical and charlatans.  I focus on the potential negative side of online therapy because I believe the need to protect potential consumers from those without appropriate training and safeguards is of utmost importance.  That being said, there are numerous legitimate providers of mental health services online, providing much needed access for many people who live in remote locations or are unable/unwilling to seek in-person treatment.  As a field we are still learning to incorporate technology into our approaches, however, it should be noted that the comparability of e-therapy to traditional therapy has yet to be satisfactorily established.  If you are seeking a therapist via the internet, the Association of State and Provincial Psychology Boards offers guidelines to help to identify a legitimate therapy provider.  If you have an online therapy practice or are thinking of developing one, there are a number of resources to help you do so responsibly.  Check out:

• Volume 40, Issue 1/2 of Psychotherapy: Theory, Research, Practice, & Training
• the International Society for Mental Health Online

Earlier, I mentioned that there are 2 schools of thought in online psychotherapy.  The second type of e-therapy involves the adaptation and subsequent testing of ESTs into an online format.  These often involve the provision of psychoeducational materials and assessment instruments online and the use of a structured intervention for a specific illness.  These online protocols seem to rely less on direct interaction with a therapist and instead are more self-help in nature.  Other protocols utilize things like therapist-facilitated discussion groups and chat rooms.  Since a significant amount of research has been conducted on these treatments for specific mental illnesses, subsequent installments of this series will focus on treatments for different clusters of disorders (e.g., eating disorders, addiction).  Look for these upcoming articles soon.

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

Post-combat invincibility: The impact of combat exposure on subsequent risk-taking behaviors

by Michael D. Anestis, M.S.

Today's article will take another look at the impact of combat exposure on military populations as it relates to mental health outcomes.  In prior articles, we have discussed the potential impact of combat exposure on the acquired capability for suicide, as well as the risks for post-traumatic stress disorder (PTSD) and new data on effective PTSD treatment for soldiers.  I was inspired to address this issue today by a friend and colleague, Eddie Selby, a renowned researcher on borderline personality disorder (BPD), who alerted me to the publication of an article in the Journal of Psychiatric Research examining the impact of particular types of combat exposure on risk-taking behaviors in a sample of soldiers returning from Operation Iraqi Freedom (OIF; Killgore et al., 2008).

In this article, Killgore and colleagues (2008) reported on data they collected from a sample of 1,252 soldiers at two time points.  Data was first collected during each soldier's first three days back in the United States following a 12-month deployment in Iraq.  During this initial data collection phase, the researchers asked each soldier whether or not they had encountered specific types of combat exposure (e.g., "working in areas that were mined or had IEDs," "being attacked or ambushed," "handling or uncovering human remains") during their deployment.  Data was then collected from these same soldiers three months later.  During this second data collection phase, the researchers asked each soldier to what degree he or she had engaged in a wide range of risk taking behaviors (e.g., alcohol and drug use, verbal and physical aggression).

The authors hypothesized that greater combat exposure would predict a greater amount of post-deployment risk-taking behavior.  They based this hypothesis on a number of factors, and cited prior research that had linked combat exposure to a host of problematic mental health outcomes, including PTSD, depression, somatic illness, and substance abuse (Beckham et al., 1998; Helzer et al., 1987; Hoge et al., 2004; IPGSG, 1987; Jordan et al., 1991; Prigerson et al., 2002).  The authors also predicted that specific types of combat exposure - those involving exposure to or the experience of violence and death - would be more strongly related to risk-taking behaviors.  We'll return to this point later, but for those of you who have read our earlier articles on the acquired capability for suicide (see link above), this should sound familiar.

Using a principal components factor analysis, the authors found that their list of specific types of combat experiences yielded a total of seven groups (the article provides precise information on the nature of these groups and the statistics that enabled them to draw this conclusion):

• Violent combat exposure
• Human trauma exposure
• Survived close call
• Buddy killed/injured
• Killed enemy
• Killed friendly/non-hostile
• Pride in mission

After compiling all of their data, the authors reported several interesting findings.  First, overall exposure to combat did, in fact, predict a greater rate of risk-taking behavior in soldiers returning from OIF.  More specifically, greater exposure to violent combat, exposure to human trauma, and killing an enemy were all highly predictive of post-deployment risk-taking behaviors, although effect sizes were fairly small.  The relationship between these three types of combat exposure and risk-taking behaviors was also demonstrated with specific behavioral outcomes, including frequency and quantity of alcohol use and both physical and verbal aggression.  The fact that the most violent forms of combat exposure exhibited the strongest relationship with subsequent risk-taking behaviors is important, as it implicates violence as a pivotal factor in the relationship.  These findings thus point towards the idea that, when exposed to such trauma, individuals' responses to provocative stimuli change, thereby altering the value of particular types of behaviors and the manner in which such individuals evaluate potential consequences.  In other words, imagine you no longer feared the consequences of crashing your car.  In that scenario, do you think you might then feel tempted to drive extremely fast in order to experience that thrill?  Alternatively, imagine you were playing poker, but not with real money.  Without the feared risk of losing your actual money, would you be more likely to make large, risky wagers?  The same principle can be applied to a variety of other behaviors.

These findings are important for a variety of reasons.  First, it represents the continued efforts on the part of the military to systematically assess and understand vulnerabilities in soldiers, thus providing a foundation upon which effective treatments can be designed to help the men and women who serve our country in battle.  Second, they provide additional insight into a phenomenon we have discussed at length on PBB and to which I alluded earlier in this article: the acquired capability for suicide.  Recall that the acquired capability refers to the degree to which an individual is able to enact lethal self-harm, as demonstrated by habituation to both physiological pain and the fear of death (Joiner, 2005).  This capability is acquired through repeated exposure to pain and provocation and has been supported empirically in a number of published articles (e.g., Van Orden et al., 2008).  In this article, Killgore and colleagues used the term "invincibility," which I like quite a bit.  In a sense, they argue that exposure to the most gruesome elements of combat creates a sense on the part of a soldier that he or she can survive anything.  On the one hand, a sense of strength and resilience is a highly positive attribute that can reduce hopelessness.  At the same time, however, taken to an extreme, such a perspective can change the manner in which an individual evaluates the potential danger of a situation and increase the likelihood that he or she will engage in harmful behaviors.  Should these behaviors constitute painful and provocative events, this would then theoretically lead to an increase in the acquired capability for suicide and thus represent an important risk for a highly problematic outcome.

The take home message from this article is somewhat complicated.  Obviously, combat exposure has a powerful impact on soldiers.  This is not a new insight, but the particular type of impact it has is, in fact, quite novel.  Reducing combat exposure would clearly be beneficial; however, this is not a realistic option.  Given the emphasis researchers place on adapting to real world phenomena, an alternative approach thus needs to be found, as focusing purely on the benefits of not being exposed to violent combat would produce little to no effect and would not assist us in developing effective interventions for soldiers in need of help.  The authors suggest that one such alternative is for clinicians treating soldiers post-deployment to frequently assess risk-taking behaviors and to work with their clients to reduce the perceived value of such experiences in an effort to decrease the likelihood of later consequences.  An additional approach, given that the combat exposure itself is likely to significantly increase the acquired capability for suicide prior to post-deployment risk-taking behaviors, would be for clinicians to emphasize the desire for suicide by increasing soldiers' sense of belongingness with others and their belief that they are making meaningful contributions to the world around them. 

Ultimately, these findings point yet again to the powerful impact of the exposure to and experience of violence, pain, and death, on mental health outcomes.  It is easy to look at such findings and feel hopeless and distraught; however, it is important to note that there is a massive amount of research currently being conducted on this phenomenon and that there are many brilliant individuals devoting their professional lives to developing effective interventions.  Understanding how individuals become vulnerable to problematic outcomes is thus not an upsetting activity at all, but rather the first step in helping to reduce that vulnerability and restore soldiers' lives and mental health.

If you would like to learn more about the acquired capability for suicide and the impact of combat on mental health, we recommend the following products, all of which are available through our online store:

• Why People Die by Suicide

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients

• Treating Suicidal Behavior: An Effective, Time-Limited Approach (Treatment Manuals For Practitioners)

• On Killing: The Psychological Cost of Learning to Kill in War and Society

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

Attending clinical psychology conferences

Today marks the final weekday of our vacation and, as such, our final mini-post.  Beginning Monday, we will return to publishing full articles.  Today, however, I would like to provide readers with information on some upcoming conferences focused on the science of clinical psychology.

Attending these conferences can be advantageous in a number of ways for a variety of people.  If you are a graduate student or considering attending graduate school, it is an opportunity to network and learn more about topics you may pursue at that level.  If you are a clinician, you can learn more about empirically supported treatments and research-based perspectives on psychopathology while accumulating continued education credits.  If you are simply interested in clinical psychology, it is an opportunity to listen to speakers and read posters explaining new data on every psychology related topic you could imagine.  These conferences are full of the types of conversations, presentations, and information that, ideally, should be available easily on television, the internet, schools, and all other forms of media.  Although such marketing efforts have thus far largely failed, the conferences offer an opportunity for individuals to immerse themselves in knowledge.

Here is some information on several upcoming conferences.  Simply click on the name of the organization for more detailed information on the conference.  Let me know if you know of others you think should be added to this list:

Missouri Department of Mental Health (MDMH)
Show Me You Care About Suicide Prevention Conference
Jefferson City, Missouri
July 31, 2009

American Psychological Association (APA)
Toronto, Ontario
August 6-9, 2009


Obsessive-Compulsive Foundation (OCF)
Minneapolis, Minnesota
August 7-9, 2009


Awakening to Mindfulness
Seattle, Washington
October 16-17, 2009

Association for Behavioral and Cognitive Therapies (ABCT)
New York, New York
November 19-22, 2009


Anxiety Disorders Association of America (ADAA)
Baltimore, Maryland
March 4-7, 2010


American Association of Suicidology (AAS)
Orlando, Florida
April 21-24, 2010


Association for Psychological Science (APS)
Boston, Massachusetts
May 27-30, 2010


World Congress for Behavioral and Cognitive Therapies (WCBCT)
Boston, Massachusetts
June 2-5, 2010

Psychotherapy Brown Bag - Article topics

Nearly four months have passed since we launched Psychotherapy Brown Bag.  With five new articles published each week, we have now amassed a substantial library of posts on various topics relevant to clinical psychology.  As time goes on, this library will continue to grow.  We are pleased with this progress, but want to ensure that readers are readily able to find the articles most relevant to the topics that interest them.

In an effort to facilitate readers' efforts to find the most pertinent articles, we have organized the entire library by topics.  Some articles are listed under multiple topics while others are listed under only one.  In the second column, right next to the text of the daily articles, you will see a list of categories (e.g., depression, DBT, substance abuse) directly beneath the box through which you can subscribe to an email feed of Psychotherapy Brown Bag articles. 

By clicking on one of categories, you will open up a page that features every article ever written on Psychotherapy Brown Bag that was listed under that particular topic.  For some topics, there currently may be only one article.  For others, you will have several pages of articles to navigate in your search for the right one.

If the topic you are seeking is not listed on this page, let us know.  We will gladly make an effort to cover topics that have not yet been mentioned on the site.  Additionally, if you see the category you are looking for, but can not find an article that covers the particular aspect of that category that interests you, let us know and we will make a similar effort to fill that void.

Ultimately, we hope to provide readers with articles that meet their needs, so please leave your comments here and/or email us to let us know what we can do to achieve this goal.

Psychotherapy Brown Bag Featured Product - "Why people die by suicide" by Thomas Joiner, Ph.D.

Over the course of the past several months, we have mentioned Joiner's (2005) interpersonal-psychological theory of suicidal behavior on numerous occasions.  We promote this theory because of its strong empirical basis and its applicability to clinical interventions.  There are a number of published research studies supporting this theory, but there is also a book, written by Dr.Joiner, that describes the theory in a style that is much easier to read if you do not tend to read journal articles on a daily basis.
 

Why People Die by Suicide is compelling for many reasons.  In addition to describing a groundbreaking theory of suicidal behavior, the book goes to great lengths to dispel common myths about suicide and suicidal individuals (e.g., suicide is an impulsive act, individuals who attempt suicide are cowards).  On a more personal note, this book is one of the primary reasons I chose to work with Dr.Joiner as I pursue my doctoral degree.  In Chapter 1, Dr.Joiner explains that his father died by suicide and discusses the impact this had on him both personally and professionally.  Although I had already met Dr.Joiner and appreciated my interactions with him prior to reading the book, this chapter helped me appreciate how much of his heart he puts into his prolific and influential work. 

For individuals who are concerned that researching mental illness removes compassion and care and focuses purely on numbers, this book will go a long way toward changing your mind.  As you read, I am confident you will see that the merging of science and compassion in the pursuit of effective treatments for mental illness is the most caring and effective approach anyone could take in the fight to help those who struggle.

We hope you consider reading this book.  To read more about it, simply click on this link.  If you already have read the book, we hope that you will comment on this article and share your thoughts on it so other readers can encounter multiple perspectives.  If you are interested in reading other resources on suicide or other psychological topics, please refer to our online store. 

Psychotherapy Brown Bag - Featured Articles

Those of you who read our site regularly are likely already familiar with our featured articles, but for those of you who are new to Psychotherapy Brown Bag, we would like to provide a summary resource to familiarize you with this feature.  Each month, we publish an article by a prominent professional on a topic within their area of expertise.  We feel fortunate to have been able to work with such accomplished professors and therapists and believe that their contributions provide significant value for readers. 

We hope you enjoy the articles, leave comments with your thoughts, and contact us with questions or concerns.

March 2009
Robert Leahy, Ph.D.
President, Association for Behavioral and Cognitive Therapies
Director, American Institute for Cognitive Therapy
Author of The Worry Cure: Seven Steps to Stop Worry from Stopping You

Robert Leahy's PBB Article: "Living with financial anxiety: Seven steps to dealing with your worries"


April 2009
Craig Bryan, Psy.D.
Captain, United States Air Force
Clinician, Wilford Hall Medical Center

Craig Bryan's PBB Article: "Bringing mental health treatment to the troops: An empirically based process improvement for veterans with PTSD symptoms in primary care"


May 2009
Katie Gordon, Ph.D.
Assistant Professor, North Dakota State University
and
Les Gordon, M.A., LMFT
Clinician, Private practice in Coral Springs, Florida

Katie and Les Gordon's PBB Article: "Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively"


June 2009
Sarah Fischer, Ph.D.
Assistant Professor, University of Geogia

Sarah Fischer's PBB Article: "Sexual trauma and bulimia nervosa: Potential mechanisms of action and new data"

The July 2009 featured article will be contributed by Jill Holm-Denoma, Ph.D, an assistant professor at the University of Denver.  Her article will discuss the utility of discussing diagnoses with clients in an effective manner that involves education and the provision of accurate reading materials.

Future contributors have been lined up for the coming months and we look forward to posting their contributions. 

Society of Clinical Psychology - APA Division 12: How to navigate an important website

The authors of Psychotherapy Brown Bag are enjoying a brief vacation this week and, as such, we will be publishing a series of short posts regarding recommended sites, articles, and products.  We hope you will find these posts useful.  We will have limited access to the site, but will be notified of comments and will publish them as quickly as possible.  In the meantime, we hope all readers enjoy their week.

Today, I would like to help readers learn about and navigate an important website.  The site (follow this link), which presents the work of the Society of Clinical Psychology, American Psychological Association Division 12, details which therapies have research indicating they are useful for specific disorders and how strong that research is.

APA Division 12's website is useful for a variety of reasons.  Personally, I use it as a reference tool, reminding myself of the research base behind the use of particular treatments for particular disorders.  This is important as therapies do not maintain one single value.  What works for one or even a variety of mental illnesses might not work at all for another.  This site quickly describes how much research supports the use of a particular treatment in certain circumstances and mentions if controversy surrounds any findings.  Below is a description of how to utilize this site:

"I want to know which treatments have been shown to work in treating a specific disorder"

This is one of the most valuable services provided by Division 12.  Simply click on the disorders tab, and a new page will open listing a variety of conditions (e.g., depression, insomnia, chronic pain, generalized anxiety disorder).  Click on the link for the disorder that interests you and a new page will open that provides a description of the disorder and lists all empirically supported treatments (ESTs) for that disorder.  Click on the links for those particular treatments for further information on the amount of research that supports its use for that disorder and a description of the treatment itself.

"I want to learn more about a type of treatment and which mental illnesses it can be used to treat"

Division 12 provides a similar tool as that described above in order to answer this question.  Simply click on the treatments tab and a page will open that lists a variety of psychological treatments.  You can then click on the link for a particular treatment to learn more about what it entails and how much research supports its use in treating specific mental illnesses.

"I want to share my experiences with a treatment and get an answer to a question"

Division 12 encourages feedback from consumers, researchers, and clinicians regarding the material on the site or the site itself.  Simply click on their contact us link and you will be directed to information that will help you get an answer to your question or share your thoughts on a particular topic.

"What about children and adolescents?  These results are all for adults"

ESTs for child and adolescent psychopathology are promoted by APA Division 53 at this link.  This website has similar features to the Division 12 site, allowing readers to search by groups of disorders to find information on treatments.

"What information goes into these sites?  Are they just promoting one therapy and discounting others?  Is the information even current?"

The authors of these sites are not proponents of a specific therapeutic modality.  They are, instead, proponents of treatments that have evidence indicating that they actually work. In other words, they are the type of clinicians who would learn a new approach if data indicated it was better than their current practices, thereby ensuring the best treatment of their clients rather than simply aiming to protect their initial views of an alternative approach.

The information is updated as new empirical research is published, thereby ensuring that readers are provided with current information regarding whether a treatment has been shown useful in treating a particular mental illness.

"Are there other resources that provide similar information?"

Absolutely. In addition to our own articles on Psychotherapy Brown Bag, there are a variety of other sites readers can use to inform themselves about ESTs.  Simply click on the links tab on the Division 12 website and you will be directed to a variety of sites offering similar services.

Clarifying a new study which questions a genetic predictor of depression

by Joye C. Anestis

This past week, a section of the psychological/psychiatric community exploded as some divisive new findings were published by JAMA questioning the previously lauded link between the serotonin transporter gene and depression.  News outlets latched on to this reports with headlines like "Report on Gene for Depression is Now Faulted" and "Sad News for 'Depression Gene.'"  For those of you who missed the excitement, I thought I'd summarize the new study for you.

But first a little background on this issue.  The majority of the mental health field believes in a diathesis-stress model of mental illness.  Supported by a plethora of empirical studies demonstrating clear heritability for most mental illnesses, the diathesis-stress model argues that some individuals have a predisposition (the diathesis) for developing a mental illness, but the mental illness is not developed unless some environmental stressor activates the diathesis.  Put another way, if you have a diathesis for a mental illness (for example, a genetic risk or some other biological factor), you will not develop that mental illness until some stress, or combination of stresses, triggers it.  Many scientists have been attempting to identify the various diatheses which contribute to the development of specific mental illnesses. 

One such diathesis that has been proposed is the serotonin transporter gene (5-HTT).  Caspi and colleagues (2003) first reported on its potential function to predispose individuals to depression.  Particularly, they demonstrated that variation in the promoter region of the serotonin transporter gene, only in interaction with stressful life events, plays a role in the development of depression. The link also makes some logical sense when you remember that many effective antidepressants modulate serotonin expression (they are called serotonin reuptake inhibitors) and the well-established link between negative life events and depression.  As you can imagine, this finding was huge!  And other researchers quickly began attempting to replicate this finding.

At this time, enough research has been conducted to justify a meta-analysis of the data.  Meta-analysis is a statistical technique used to summarize a group of studies on a specific topic.  You can think of it as a form of averaging; you take the effects found in different studies and find the average size of the effect across all of these studies.  Neil Risch and colleagues (2009) searched for all of the studies investigating the serotonin transporter gene, life stresses, and depression.  They ended up with 24 studies.  Two meta-analyses were done, one utilizing all the participant data (14 studies, n = 14, 250) and one examining sex-specific outcomes (n = 10, 943).  The investigators found a direct link between the number of stressful life events and depression in these studies, both in the combined sample and when the analyses were conducted by sex.  A direct link between the serotonin transporter gene alone and depression was not found in the the combined sample or the sex-specific sample.  When the interaction between the gene and life stress was examined, the results did not support this particular interaction predicting depression in males alone, females alone, or when both sexes were combined.  In sum, life stresses significantly predict the development of depression, but the serotonin transporter gene or the interaction between life stress and the gene do not...at least at this time, as analyzed in this study.

I am sure that in the coming weeks and months, many rebuttal papers will be published arguing the validity and invalidity of these findings.  I believe there are several important messages we can take home from this meta-analysis, but I believe the most important is: these inconclusive findings in no way argue that genes and other biological factors do not influence the development of depression.  The Risch study only questions the effect of one particular gene.  There are many many others that may be playing a role and we may not yet have sophisticated enough techniques to fully understand the role of specific genes.  There may be more nuanced facets of the serotonin transporter gene that are not detected in all studies.  There are a plethora of plausible explanations.  When studying illnesses for which there are no pathognomonic diagnostic markers, it is incredibly difficult to pinpoint biological and genetic influences, but we are getting closer and closer to doing so.

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

Eye movement desensitization and reprocessing (EMDR): What is it and does it work?

by Michael D. Anestis, M.S.

Today's article adopts a similar theme to Monday's article on dolphin-assisted therapy (DAT): just because a treatment is popular and widely used does not mean that it actually works as advertised.  Today's focus is on eye movement desensitization and reprocessing, created by Frances Shapiro (1989) and typically known by its acronym, EMDR.  The approach was originally introduced as a novel treatment for post-traumatic stress disorder (PTSD), although it has since been adopted as a treatment for a variety of other mental illnesses, particularly other anxiety disorders.  The effectiveness of this treatment approach has been the subject of rather intense controversy, with proponents making sweeping claims about the robust impact of EMDR and skeptics pointing to data that simply offers no support for those claims.  Before detailing that data, let me first provide a quick description of the therapy itself, which is described well in an article by Cahill, Carrigan, and Frueh (1999), one of a series of articles in an issue of the Journal of Anxiety Disorders that was devoted entirely to this particular topic.

What is EMDR?

EMDR, as used to treat PTSD, requires that a client engage in a series of lateral eye movements while describing and/or imagining details of a traumatic event.  These eye movements are typically generated by following the therapist's finger as he or she moves it back and forth across the client's visual field.  After a set of 10-20 eye movements, the therapist assesses the client's current level of distress by asking them to rate their subjective units of distress (SUDS; Wolpe, 1973) from 0 to 10.  This procedure is repeated until the client's SUDS is reported to be 0 or 1.

Following this phase - desensitization - the client is told to come up with a positive thought to keep in mind in conjunction with the traumatic images and subsequent physiological sensations.  The same procedure described for the desensitization phase is then repeated until the client reports a high level of belief in the new, positive interpretation of the images and physiological sensations.

In summary, then, EMDR thus exposes clients to thoughts and descriptions of a traumatic event until they no longer experience intense anxiety and then asks them to develop alternative interpretations of those images and descriptions.  For those of you who have read our description of cognitive processing therapy and prolonged exposure therapy, this might seem familiar.  I will return to this point later, but this is, in fact, one of the central points of criticism of EMDR: that it is simply an alternative version of already validated treatments with the potentially meaningless addition of eye movements.

Does EMDR Work?

Asking whether or not EMDR works is overly simplistic.  A better approach, and one taken in several reviews of this topic (see Cahill et al., 1999 and Lohr, Lilienfeld, Tolin, & Herbert, 1999 for good examples), is to compare the impact of EMDR to a variety of other approaches and to examine whether the unique aspect of EMDR - namely, repeated lateral eye movements - adds anything to the impact of the treatment.

As noted in Cahill et al (1999), a number of studies have compared EMDR to no treatment waitlist conditions.  Comparisons to a no treatment condition are valuable for a couple of reasons.  First, they provide data indicating that a treatment's effects are not due simply to the passage of time.  If it was just time that accounted for the improvement, the no treatment condition would equal the treatment condition at the end of the study.  Second, they ensure that regression to the mean - the tendency for extreme scores to drift toward the mean across time - do not account for decreases in symptoms. 

In studies comparing EMDR to no treatment conditions, EMDR has consistently been shown to be superior, indicating that, in the treatment of PTSD (as well as multiple other anxiety disorders), EMDR is better than nothing (Boudelwyns & Hyer, 1996; Carlson et al., 1998).  This, obviously, does not mean a whole lot, but it does at least provide evidence that EMDR has positive effects and is definitively not iatrogenic.

A more stringent way to test the strength of a treatment approach is to compare it to other  unvalidated treatments.  Unvalidated treatments are treatments for which there is no data indicating that the particular approach is an effective intervention for a specific diagnostic presentation.  Studies comparing EMDR to unvalidated treatments for PTSD have been conducted on numerous occasions.  The results appear to indicate that EMDR is at least equally effective to several unvalidated treatments for PTSD, including relaxation (Carlson et al., 1998; Vaughn et al., 1994).  These results indicate that, relative to other treatments lacking empirical support for their efficacy and effectiveness, EMDR is at least equally useful.  Again, this type of comparison can be useful, but it essentially boils down to comparing a treatment approach to something less than the best available treatment.  When a client is learning about his or her options, she likely does not concern herself with how a particular treatment stacks up against treatments not recommended for everyday practice, but rather, the relative utility of a treatment compared to other treatments already shown to be effective.

A third and significantly more important way to test the strength of a treatment approach is thus to compare it to empirically supported treatments (ESTs).  There are multiple reasons for doing so, the most important of which is determining the extent to which the treatment exhibits incremental validity, value above and beyond that provided by already established approaches, relative to additional costs.  Despite numerous claims to the contrary by proponents of EMDR during the 1990's, that particular era produced no studies comparing EMDR to ESTs and, as such, claims of EMDR's superiority were based upon a complete lack of evidence.  In an effort to address this empirical void, Devilly and Spence (1999) published such a study in the same issue of the Journal of Anxiety Disorders mentioned earlier in this article.  In this particular study, Devilly and Spence (1999) compared EMDR to a form of cognitive behavioral therapy (CBT) in the treatment of PTSD.  They found that clients in the CBT condition exhibited both statistically and clinically significantly greater improvement in symptoms after treatment and that the superior impact of CBT was not only maintained at 3-month follow-up, but actually increased. This, quite obviously, presents a problem for proponents of EMDR.  Although the treatment performs better than no treatment at all and likely better than other unvalidated treatments, when compared to an EST, it fails to produce the desired effect. 

Studies examining the utility of EMDR have typically only found positive effects on self-reported measures of distress such as SUDS or on therapist rated measures of improvement.  Such measures can be useful at times, but are problematic here for a variety of reasons.  First, if the self-reported distress measure does not match up with results on validated measures of symptoms, the results can be called into question.  Additionally, in the studies that used clinician ratings, the clinicians were not blind to the treatment condition.  In other words, the researcher writing about EMDR, who was trained in EMDR, knew that the client received EMDR and was motivated to report that the client improved, as this would validate the researcher's work.  This is not to say that the researchers were lying, but rather that all people are subject to their own biases and removing those biases from measurement is important in order to ensure that results are legitimate.

What about the eye movements?  Are they useful?

Thus far, empirical evidence does not support the contention of EMDR proponents that lateral eye movements add value to treatment.  In numerous studies comparing EMDR to treatments that did not include lateral eye movements in the treatment of PTSD, no differences were found between the groups on the degree to which their symptoms improved (Boudewyns & Hyer, 1996; Dunn, Schwartz, Hatfield, & Wiegele, 1996; Renfrey & Spates, 1994).  Additionally, in a study that assessed whether adding lateral eye movements to exposure therapy in the treatment of a public speaking phobia, Carrigan and Levins (1999) found that eye movements did not positively impact treatment in any way.  In fact, the only difference between individuals who received eye movement training and those who did not was that those who did were less likely to be willing to give a speech post-treatment.  Not a positive result for EMDR.

So what does this mean?  It means that EMDR can be useful, but not because it is EMDR.  It can be useful because it utilizes several components of validated treatments, particularly CBT.  The addition of the eye movements makes the treatment seem novel and exciting, which likely explains a large portion of its popularity, but they are not actually active ingredients in the treatment of mental illness.  Here, again, we have an example of misguided priorities.  The philosophical appeal of eye movement training for some clinicians appears to distort their understanding of the purpose of therapy.  Therapy is designed to help struggling clients to reclaim their lives.  In order to do this, clinicians must offer the best available treatment, not the one that seems the most interesting, particularly if the most interesting treatment is not supported by data.

The reviews cited in this article are 10 years old...what is the story today?

There have been many studies on EMDR since the 1999 special issue devoted to the topic in the Journal of Anxiety Disorders.  A summary of these studies would be well beyond the scope of today's post.  I will make an effort to wade through all of these studies in the future and to provide readers with an update on the empirical status of EMDR.  In the meantime, however, I suggest reading the summary of the current empirical status of EMDR on the website of the Society of Clinical Psychology, American Psychological Association Division 12, the organization responsible for updating the list of currently empirically supported treatments for mental illness.

Division 12 states that the current empirical evidence remains consistent with the conclusions mentioned above and that, in the previous ten years, no new evidence has emerged to counter the data indicating that, while EMDR is better than nothing, eye movements add little or nothing to treatment and EMDR is not as effective as EST's in the treatment of mental illness.

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

• Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide (Treatments That Work)

• Cognitive Processing Therapy for Rape Victims: A Treatment Manual (Interpersonal Violence: The Practice Series)

• Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide (Programs That Work)

• Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook (Treatments That Work)

• Effective Treatments for PTSD, Second Edition: Practice Guidelines from the International Society for Traumatic Stress Studies

• Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD

• A Guide to Treatments that Work

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

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

Obsessive-compulsive personality disorder: Diagnosing and treating the overly perfectionistic

by Joye C. Anestis

As a graduate student in clinical psychology, I have come to understand, appreciate, and maybe even respect the construct of obsessive-compulsive personality disorder (OCPD).  All because I wonder if a little bit of OCPD is adaptive on some level!  Certainly, many of the successful people I have come across in upper-level academia have at least a few prominent symptoms of the disorder and they have often managed to make it work to their advantage, spurring them on to greater and greater success (although perhaps at the cost of some interpersonal relationships).  However, in the case of OCPD, a little bit goes a long way - once an individual crosses over into the full disorder, it can wreak havoc on one's interpersonal and professional life. 

My hope for this article is to provide up-to-date scientific information on OCPD - unfortunately, that does not leave me with much to write about.  Just like almost all the other PDs (borderline and antisocial are exceptions to this), OCPD has received very little research attention...luckily, my own perfectionism will not prevent me from forging ahead and summing up what we know!

What is it:  OCPD is one of the Cluster C personality disorders, grouped with avoidant and dependent personality disorders.  These disorders were lumped together due to their supposed shared tendency toward anxiety and fear (but keep in mind that the validity of this grouping has been questioned; APA, 2000).  According to the DSM-IV (APA, 2000), an individual must have at least 4 of the following symptoms to obtain the diagnosis:

• "is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost"
• perfectionism which prohibits task completion (e.g., can't complete a project because your standards are so high that they cannot be met)
• leisure activities and friendships are ignored due to excessive devotion to work and productivity (this does not apply if the devotion to work is out of economic necessity)
• "is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)"
• inability to get rid of worn-out or worthless objects even if they have no sentimental value
• "is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things"
• "adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes"
• is rigid and stubborn

First of all, can you see how a moderate amount of these symptoms might be professionally helpful?  But, is it also apparent that once these symptoms become inflexible and persistent they could cause significant impairment and subjective distress? Individuals with this disorder are so rigid and perfectionistic that they seldom complete tasks and have a hard time maintaining friendships, as other people have a hard time living up to the OCPD individual's high standards.  For a fictional (and admittedly exaggerated) example of OCPD, check out this Saturday Night Live skit...

How common is it?: Prevalence estimates vary but generally suggest that OCPD occurs in 1% of community samples (although higher community prevalence rates have been observed, e.g., Grant et al., 2005) and 3-10% in clinical samples (APA, 2000).  There is some evidence toward differential prevalence rates by race/ethnicity, with Grant et al. (2004) observing that OCPD is more common in Whites than in Asians or Hispanics.

Diagnostic Problems and Comorbidity: By looking at the criteria,  you probably noticed how problematic this particular symptom set can be diagnostically.  First of all, there is considerable symptom overlap with other personality disorders.  For example, one must differentiate between OCPD perfectionism and the perfectionism often seen in narcissistic personality disorder.  Both OCPD and schizoid personality disorder share a tendency toward social detachment, although the function of the detachment differs between disorders.  Of course, the biggest diagnostic confusion arises from the name of the disorder itself and begs the questions, what is the relationship between OCPD and obsessive-compulsive disorder (OCD). A future PBB article will be devoted to differentiating between them but for now it is sufficient to say that individuals with OCPD do not have the true obsessions and compulsions seen in OCD; however, there is a bit of symptoms overlap (e.g., hoarding) and a good amount of comorbidity between OCPD and OCD.  Other disorders that commonly co-occur with OCPD include anorexia nervosa, major depressive disorder, and the anxiety disorders (Lilenfeld et al., 2006; McGlashan et al., 2000).  And of course, OCPD is often comorbid with other personality disorders, not only within Cluster C but across clusters as well (Grant et al., 2005).

Treatment:  Currently, no empirically-supported treatment (EST) exists for OCPD.  Several researchers have suggested cognitive-behavioral techniques are effective for this disorder (and it makes conceptual sense, as such techniques would help in relaxing perfectionistic standards and softening cognitive inflexibility; e.g., Beck et al., 2003) but no randomized clinical trials have been conducted.  Some have suggested that dialectical behavior therapy (DBT), a specific type of cognitive-behavioral therapy originally designed for suicidal behavior and borderline personality disorder, may be beneficial in treating OCPD.  Two case studies discuss treatment (Lynch & Cheavens, 2008; Miller & Kraus, 2007) but again no randomized controlled trials exist.  It should be noted here, however, that an individual rarely presents with only OCPD, the norm is for OCPD to be comorbid with another mental health condition.   Several studies have suggested that a comorbid personality disorder attenuates treatment of an Axis I condition (e.g., depression, anxiety disorders, anorexia nervosa; Crane et al., 2007; Newton-Howes et al., 2006).   

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