Evaluation of a standardized posttraumatic stress disorder treatment framework in routine mental health care: Effectiveness and predictors of treatment outcome in a consecutive sample.

The primary aim of the present study was to evaluate the effectiveness of standardized care package (CP) treatment for posttraumatic stress disorder (PTSD) in a Danish sample of adult psychiatric outpatients (N = 948). Secondary aims were to identify baseline predictors of treatment outcomes and investigate between-group differences in outcomes with regard to sex and treatment modality (i.e., group vs. individual therapy). The naturalistic, nonrandomized study followed a pre-post design. Patient data from five psychiatric outpatient clinics were collected between March 2011 and November 2017. Data were drawn from self-report questionnaires (i.e., SCL-90-R, WHO-5, BHS) and therapist-reported measures (i.e., GAF-S, GAF-F) administered at baseline and posttreatment. Between-group effects for sex and therapy modality (group vs. individual) were analyzed using analyses of variance, and possible predictors of outcomes were selected through LASSO regression and analyzed via hierarchical regression. Pre-post effects were small to moderate, ds = 0.39-0.69. No differences emerged regarding treatment modality, but women had significantly better outcomes than men. Aside from sex, only baseline symptom severity predicted outcomes. The effectiveness of the CP treatment was generally limited, indicating the need to implement improved therapeutic practices, such as the use of evidence-based treatments, and to provide better training to mental health clinicians. The findings underscore the need for further comparisons of group and individual treatment modalities using evidence-based therapies as well as the need to investigate factors that may affect treatment outcome.

Mind the gap: In-session silences are associated with client attachment insecurity, therapeutic alliance, and treatment outcome.

OBJECTIVE: The association between in-session silences and client attachment, therapeutic alliance, and treatment outcome was investigated in two treatments for bulimia nervosa. METHOD: 69 women and one man were randomized to two years of psychoanalytic psychotherapy (PPT) or 20 sessions of cognitive behavioral therapy (CBT). Client attachment was assessed using the Adult Attachment Interview. Early, middle and late sessions (N = 175) were evaluated with the Vanderbilt Therapeutic Alliance Scales, and quality of in-session silences was coded with the Pausing Inventory Categorization System (PICS). Multilevel Poisson and linear regression analyses were performed. RESULTS: Coders identified 6236 pauses, which were more frequent in PPT than in CBT. Higher pausing frequency and higher relative frequency of obstructive pauses were associated with client insecure attachment as well as with poorer treatment alliance, and accounted for part of the relation between client attachment and therapeutic alliance. Good outcome clients had higher relative frequency of productive pauses, especially in mid-treatment, and lower relative frequency of obstructive pauses, especially in late treatment. CONCLUSION: The study further validates the PICS. Findings indicate that therapists may be able to use in-session silences as an indicator of client attachment insecurity and as a prognostic sign of eventual treatment outcome.

Personality disorders: patient characteristics and level of outpatient treatment service.

BACKGROUND: In this naturalistic study, patients with personality disorders (N = 388) treated at Stolpegaard Psychotherapy Center, Mental Health Services, Capital Region of Denmark were allocated to two different kinds of treatment: a standardized treatment package with a preset number of treatment hours (basic hospital service) and 2: a specialized treatment program for the most severely affected patients without a predetermined restricted number of treatment hours and significantly more individual psychotherapy (regional specialized hospital services). AIMS: To investigate patient characteristics associated with clinicians' allocation of patients to the two different personality disorder services. METHODS: Patient characteristics across eight domains were collected in order to study whether there were systematic differences between patients allocated to the two different treatments. Patient characteristics included measures of symptom severity, personality pathology, trauma and socio-demographic characteristics. Significance testing and binary regression analysis were applied to identify important predictors. RESULTS: Patient characteristics on fifteen variables differed significantly, all in the expected direction, with patients in regional specialized hospital services showing more pathology and psychosocial problems. In the regression model, only age and two variables capturing psychosocial functioning remained significant predictors of allocation. DISCUSSION: The finding that younger age was the most significant predictor of longer treatment replicates an earlier finding of allocation to treatment for personality disorder. Overall, this study therefore lends further support to the importance of demographic and social contextual factors in clinicians' allocation of patients to different treatment services for personality disorder.

Client attachment security predicts alliance in a randomized controlled trial of two psychotherapies for bulimia nervosa.

OBJECTIVE: This study investigated the relation between clients' attachment patterns and the therapeutic alliance in two psychotherapies for bulimia nervosa. METHOD: Data derive from a randomized clinical trial comparing cognitive-behavioral therapy (CBT) and psychoanalytic psychotherapy (PPT) for bulimia nervosa. Client attachment patterns were assessed with the Adult Attachment Interview. Independent raters scored audiotapes of early, middle, and late therapy sessions for 68 clients (175 sessions) using the Vanderbilt Therapeutic Alliance Scale. RESULTS: Client attachment security was found to be a significant (p = .007) predictor of alliance levels at the three measured time points, with clients higher on attachment security developing stronger alliances with their therapists in both treatments as compared to clients higher on attachment insecurity. No evidence was found to support a hypothesized interaction whereby dismissing clients would develop weaker alliances in PPT and preoccupied clients would develop weaker alliances in CBT. CONCLUSIONS: As the first study to examine client attachment and therapeutic alliance using observer-based instruments, this study supports the theoretical assumption that clients with secure attachment patterns are likely to develop stronger alliances with their therapist across different treatment settings.

Therapist adherence is associated with outcome in cognitive-behavioral therapy for bulimia nervosa.

Studies of therapist adherence in relation to treatment outcome have produced mixed results. The aim of the present study was to investigate change in therapist adherence to cognitive-behavioral therapy (CBT) for bulimia nervosa over time, and to investigate the relationship between adherence and client outcome in early, middle, and late phases of treatment. Thirty-six clients received the focused form of "enhanced" CBT (CBT-E) for bulimia nervosa. Trained observers rated audiotapes of 92 full-length therapy sessions from early (Session 3), middle (Session 11), and late phases (Session 20) of treatment using the Cognitive-Behavioral Therapy Treatment Protocol Adherence Scale. Change in adherence across the 3 treatment phases was examined using multilevel analysis. The relationship between early, middle, and late adherence levels and end-of-treatment binging frequency was examined using multilevel Poisson regression analysis. Adherence decreased significantly over the course of treatment. Higher levels of therapist adherence in early and middle phases of treatment were associated with reduced binging frequency, whereas higher levels of adherence measured late in treatment was not. Results indicate that therapists' adherence to the CBT-E treatment protocol decreases over time and that high levels of protocol adherence in early and middle phases of treatment are more important for positive client outcomes than high levels of adherence in the end of treatment. (PsycINFO Database Record

A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa.

OBJECTIVE: The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. METHOD: A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. RESULTS: Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. CONCLUSIONS: Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.