Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating.

OBJECTIVE: This study examines childhood and clinical factors theorized to impact therapeutic alliance development over the course of psychotherapy. METHOD: Raters assessed the therapeutic alliance of 212 client-therapist dyads, participating in two randomized controlled trials of schema therapy and cognitive behavioural therapy for binge eating or major depression, at three time points. Linear mixed models were used to characterize therapeutic alliance development over time and assess the influence of childhood trauma, perceived parental bonding, diagnosis and therapy type on scores. RESULTS: Participants differed in initial alliance ratings for all subscales but had similar growth trajectories in all but the patient hostility subscale. A diagnosis of bulimia nervosa or binge eating disorder predicted greater initial levels of client distress, client dependency and overall client contribution to a strong therapeutic alliance, compared with a diagnosis of depression. Therapy type, childhood trauma and perceived parental bonds did not predict alliance scores. CONCLUSION: Findings highlight the potential influence of clinical and personal characteristics on alliance strength and development, with implications for maximizing treatment outcomes through anticipating and responding to these challenges.

Specialist supportive clinical management for anorexia nervosa: Analysis of therapy content and relation to outcome.

OBJECTIVE: Psychotherapy for anorexia nervosa (AN) is complex and multifaceted, with little known about likely effective components of treatments. The current study explored the spoken content of specialist supportive clinical management (SSCM) for AN, a treatment with evidence of effectiveness in several randomized clinical trials. METHOD: One hundred seventy-eight therapy sessions constituting all ten therapist-patient dyads of those who completed SSCM treatment in the original clinical trial of SSCM, were transcribed verbatim. Themes were developed and content analyzed using qualitative content analysis of complete therapy sessions by four analysts, with 10% of sessions cocoded for interrater agreement. RESULTS: Over three quarters of session content was within the clinical management theme, the largest subtheme relating to normalizing eating, followed by weight, mechanics of SSCM, and encouragement of self-care. Approximately 20% of total content was in the supportive psychotherapy theme, half about relationships. The relative proportion of clinical management content remained high, decreasing during the last five sessions. Those achieving good outcome did not have a lower ratio of clinical management to supportive psychotherapy content. DISCUSSION: The current study revealed strong clinical management focus on core symptoms of AN-normalization of eating and weight gain-throughout SSCM for AN. PUBLIC SIGNIFICANCE: Six clinical trials have found SSCM to be effective in treating AN. Content of SSCM sessions in the original trial was classified using qualitative content analysis. Study findings revealed strong clinical management focus on core AN symptoms-normalization of eating and weight gain-throughout SSCM, with the ratio of clinical management to supportive psychotherapy greater for those with a good outcome.

Specialist Supportive Clinical Management for anorexia nervosa: what it is (and what it is not).

OBJECTIVE: Specialist Supportive Clinical Management (SSCM) is a psychotherapy comprising a clinical management focus addressing anorexia nervosa (AN) symptoms and a supportive therapy component. SSCM has been an active control therapy in randomised controlled trials for AN, but has proven to be an effective therapy in its own right. There has been speculation about how this relatively straightforward therapy works. Some of the commentaries and descriptors used for SSCM, however, do not reflect the content or principles of SSCM. This paper clarifies areas of misunderstanding by describing what SSCM is and what it is not, particularly in relation to commentary about its constituent characteristics. CONCLUSIONS: SSCM utilises well established clinical management for AN (with a sustained focus on normalised eating and weight restoration) coupled with supportive therapy principles and strategies. Common factors across both arms include core counselling skills and a positive therapeutic alliance to promote adherence and retention in treatment for AN. Compared to other comparator therapies to date, SSCM is a simpler therapy without unique or novel theoretically derived strategies. Comparable outcomes with more complex psychotherapies raise the question of whether the combined core components of SSCM may be sufficient for many people with AN.

Activation therapy for the treatment of inpatients with depression - protocol for a randomised control trial compared to treatment as usual.

BACKGROUND: Inpatients with depression have a poor long term outcome with high rates of suicide, high levels of morbidity and frequent re-admission. Current treatment often relies on pharmacological intervention and focuses on observation to maintain safety. There is significant neurocognitive deficit which is linked to poor functional outcomes. As a consequence, there is a need for novel psychotherapeutic interventions that seek to address these concerns. METHODS: We combined cognitive activation and behavioural activation to create activation therapy (AT) for the treatment of inpatient depression and conducted a small open label study which demonstrated acceptability and feasibility. We propose a randomised controlled trial which will compare treatment as usual (TAU) with TAU plus activation therapy for adult inpatients with a major depressive episode. The behavioural activation component involves therapist guided re-engagement with previously or potentially rewarding activities. The cognitive activation aspect utilises computer based exercises which have been shown to improve cognitive function. DISCUSSION: The proposed randomised controlled trial will examine whether or not the addition of this therapy to TAU will result in a reduced re-hospitalisation rate at 12 weeks post discharge. Subjective change in activation and objectively measured change in activity levels will be rated, and the extent of change to neurocognition will be assessed. TRIAL REGISTRATION: Unique trial number: U1111-1190-9517. Australian New Zealand Clinical Trials Registry (ANZCTR) number: ACTRN12617000024347p .

Predictors of premature termination from psychotherapy for anorexia nervosa: Low treatment credibility, early therapy alliance, and self-transcendence.

OBJECTIVE: Failure to complete treatment for anorexia nervosa (AN) is- common, clinically concerning but difficult to predict. This study examines whether therapy-related factors (patient-rated pretreatment credibility and early therapeutic alliance) predict subsequent premature termination of treatment (PTT) alongside self-transcendence (a previously identified clinical predictor) in women with AN. METHODS: 56 women aged 17-40 years participating in a randomized outpatient psychotherapy trial for AN. Treatment completion was defined as attending 15/20 planned sessions. Measures were the Treatment Credibility, Temperament and Character Inventory, Vanderbilt Therapeutic Alliance Scale and the Vanderbilt Psychotherapy Process Scale. Statistics were univariate tests, correlations, and logistic regression. RESULTS: Treatment credibility and certain early patient and therapist alliance/process subscales predicted PTT. Lower self-transcendence and lower early process accounted for 33% of the variance in predicting PTT. DISCUSSION: Routine assessment of treatment credibility and early process (comprehensively assessed from multiple perspectives) may help clinicians reduce PTT thereby enhancing treatment outcomes.

Qualitative meta-synthesis: the experience of chronic pain across conditions.

AIM: To synthesize qualitative descriptions of the experience of chronic pain across conditions. BACKGROUND: Chronic pain is a transdiagnostic symptom in that while somatic pathology plays a role in activating pain pathways, psychological and social factors contribute to the experience of pain over time. The treatment of the underlying condition may require both biomedical intervention and biopsychosocial approaches. DESIGN: Qualitative meta-synthesis using Confidence in the Evidence from Reviews of Qualitative Research (CERQual) developed by Grading of Recommendations Assessment Development and Evaluation (GRADE) working group to evaluate the strength of the evidence. DATA SOURCES: PubMed and Ovid Medline from 2000-2015. REVIEW METHODS: Following a systematic search strategy all papers were assessed in relation to inclusion criteria and quality. Themes were extracted from each study and a meta-synthesis conducted before completing an evaluation of confidence in the findings. RESULTS: Forty-one papers exploring the experience of chronic pain were included in the review. Five meta-themes were identified across the studies: 1) the body as obstacle; 2) invisible but real; 3) disrupted sense of self; 4) unpredictability; and 5) keeping going. There was high confidence in the evidence for three themes: 'the body as obstacle'; 'disrupted sense of self' and 'keeping going'; and moderate confidence in the evidence for 'invisible but real' and 'unpredictability'. CONCLUSIONS: The findings in this review suggest there are similarities in the experience of chronic pain across a range of conditions that have implications for the development of transdiagnostic pain management strategies and interventions.

Assessing the distinctiveness of psychotherapies and examining change over treatment for anorexia nervosa with cognitive-behavior therapy, interpersonal psychotherapy, and specialist supportive clinical management.

OBJECTIVE: Therapist adherence to cognitive-behavior therapy (CBT), interpersonal psychotherapy (IPT), and specialist supportive clinical management (SSCM) for anorexia nervosa (AN), was examined across three phases of therapy in a randomized clinical trial. METHOD: Adherence in early, middle, and late phase therapy sessions from 53 of 56 participants in the trial was assessed using the CSPRS-AN by independent raters after listening to complete therapy sessions. RESULTS: The three forms of psychotherapy were distinguishable by blind raters. Subscale scores were higher for the corresponding therapy than the other therapy modalities. In CBT and SSCM, a phase-by-therapy effect was found, with the CBT subscale highest for CBT, intermediate for SSCM, lowest for IPT, and elevated in the middle phase of CBT and SSCM. The SSCM subscale was highest for SSCM, intermediate for CBT, lowest for IPT, and elevated in the middle phase of SSCM. Adherence to activities around normalizing eating, weight gain, and education about anorexia nervosa was higher in SSCM than in either CBT or IPT. DISCUSSION: Ensuring the distinctiveness of therapies in existing clinical trials with differential treatment outcome is essential. Research on adherence to therapy modalities has the potential to help understanding of the effective components of new and existing treatments for AN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:958-962).

Clinical effectiveness of transdiagnostic health management interventions for older people with multimorbidity: a quantitative systematic review.

AIM: The aim of this study was to evaluate the clinical effectiveness (improvement in health status and/or functioning and use of health services) of transdiagnostic health management interventions for people aged 65 years and older. BACKGROUND: The care of older people with multimorbidity is of increasing concern for nurses. A transdiagnostic approach to health management interventions (promote self-management or lifestyle) may be apposite for providing older people with the skills to manage symptoms that may or may not be disease-specific. DESIGN: Quantitative systematic review. REVIEW METHODS: Cochrane methods using Cochrane's Effective Practice and Organization of Care Methods (EPOC) for assessing risk of bias and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) for assessing the weight of evidence. DATA SOURCES: Medline, CINAHL, PubMed and PsycINFO 1999-2014. RESULTS: Twelve studies were included in the review (n = 10,393). All 12 studies provided results for health outcomes (health status and functioning) and six provided results for health outcomes and health service utilization. Ten studies reported statistically significant improvements in health outcomes but of these studies only two were of low risk of bias. Three studies identified some statistically significant reductions in health service utilization. The weight of evidence for the health management interventions included in the review, were low/moderate for improvements in health status and low for improvements in health service utilization. CONCLUSION: While there is some very preliminary evidence suggesting that structured transdiagnostic health management interventions may be clinically effective for older people with multimorbidity the effect sizes are small and the quality of this evidence is generally low.

Cognitive remediation as a treatment for major depression: A rationale, review of evidence and recommendations for future research.

OBJECTIVE: There is considerable literature regarding the effectiveness of cognitive remediation (CR) in schizophrenia and in conditions such as stroke and traumatic brain injury. Patients with major depressive disorder (MDD) present with significant cognitive impairment which in many cases may not resolve with treatment. Neurobiological data suggest that this may relate to underlying dysfunction of pre-frontal cortical areas of the brain and their connections with limbic structures. There has been limited research into specific CR to activate these areas and target impaired cognitive function in MDD. We therefore review current evidence, examine the theoretical basis for and present a rationale for research into CR in MDD. In addition, we will examine important methodological issues in developing such an approach. METHOD: Based on preliminary studies using CR-based techniques, data from CR in schizophrenia, data regarding baseline and residual cognitive impairment in depression, and knowledge of the neurobiology of MDD, we examine the possible utility of CR strategies in the treatment of MDD and make recommendations for research in this area. RESULTS: A small number of previous studies have examined specific CR in MDD. The studies are small and inconclusive. However, data on the neuropsychological function and neurobiology of MDD suggest that this is an approach that deserves further attention and research. CONCLUSIONS: Further research is required in carefully selected populations, using well-defined CR techniques and some form of comparator treatment.

Reimagining eating disorder spaces: a qualitative study exploring Maori experiences of accessing treatment for eating disorders in Aotearoa New Zealand.

BACKGROUND: Health, illness, and the body are conceptualized within the cultural context of a society. The values and belief systems of a society, including media portrayals, shape how health and illness present. Traditionally, Western portrayals of eating disorders have been prioritized over and above Indigenous realities. This paper explores the lived experiences of Maori with eating disorders and their whanau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand. METHOD: Kaupapa Maori research methodology was used to ensure the research supported Maori health advancement. Fifteen semi-structured interviews were completed with Maori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whanau. Structural, descriptive, and pattern coding was undertaken within the thematic analysis. Low's spatializing culture framework was used to interpret the findings. RESULTS: Two overarching themes identified systemic and social barriers to accessing treatment for Maori with eating disorders. The first theme, was space, that described the material culture within eating disorder settings. This theme critiqued eating disorder services, including idiosyncratic use of assessment methods, inaccessible service locations, and the limited number of beds available in specialist mental health services. The second theme, place, referred to the meaning given to social interactions created within space. Participants critiqued the privileging of non-Maori experiences, and how this makes a place and space of exclusion for Maori and their whanau in eating disorder services in New Zealand. Other barriers included shame and stigma, while enablers included family support and self-advocacy. CONCLUSION: More education is needed for those working in the space of primary health settings about the diversity of those with eating disorders to enable them to look beyond the stereotype of what an eating disorder looks like, and to take seriously the concerns of whaiora and whanau who present with disordered eating concerns. There is also a need for thorough assessment and early referral for eating disorder treatment to ensure the benefits of early intervention are enabled for Maori. Attention given to these findings will ensure a place for Maori in specialist eating disorder services in New Zealand.

Eating disorders are at least as common in Maori (Indigenous people of New Zealand) when compared to their non-Maori counterparts, however, a recent study investigating specialist service use data identified lower-than-expected service use for Maori. This paper explores the lived experiences of Maori with eating disorders and their whanau (family/support network) to understand the barriers and enablers to accessing treatment. Participants in this study identified both systemic and social barriers to accessing treatment for eating disorders; Systemic barriers included the idiosyncratic use of assessment methods by health practitioners, and inaccessible service locations, including the number of available inpatient beds. While social barriers included the stereotype of what an eating disorder looks like, shame, stigma, and discrimination; support networks were described as both an enabler and barrier to accessing specialist treatment for eating disorders. The findings from this study suggest thorough assessment and early referrals are needed for Maori presenting with disordered eating concerns. Moreover, more education is needed for those working in primary healthcare settings about the diversity of eating disorders to ensure they move beyond the stereotype of what an eating disorder looks like.

Patients' experiences of cognitive functioning in recurrent depression: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Recurrent depressive episodes involve significant morbidity, suicide risk and recurrent hospitalizations. In both major depressive disorder and bipolar disorder, there are significant impairments in functioning following resolution of acute symptoms. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides an in-depth qualitative understanding of the subjective experience of cognitive impairment following a depressive episode in a recurrent mood disorder. It identifies descriptions of two types of experience (being stuck and being preoccupied with one's thoughts) that led to impairments in concentration, memory, organization and decision-making. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses need to develop an awareness of the impact of cognitive difficulties in the process of recovery from recurrent mood disorders. Mental health nurses need to provide knowledgeable reassurance, information and interventions to people who experience cognitive difficulties to provide a framework of understanding that promotes recovery. ABSTRACT: Introduction People who experience recurrent depressive episodes often have ongoing cognitive problems that impact on their functional recovery. These cognitive difficulties have been identified as impacting on social, interpersonal and occupational functioning and can result in vulnerability to relapse. Aim The aim of this qualitative study was to explore participants' subjective experiences of cognitive impairment after discharge from mental health services following treatment for recurrent depression. Methods The study was designed as a qualitative study in order to best capture participants' subjective experiences. Data were collected by semi-structured interviews and were analysed using a process of thematic analysis. Results Twenty participants took part in this study. All participants described experiences of either 1) "being stuck"; or 2) "being preoccupied with own thoughts"; however, all participants described the experiences in the third theme: "it stops you living to your potential." Implications for practice In order to promote recovery in a meaningful way, mental health nurses need to provide information about and strategies for managing cognitive difficulties associated with recurrent mood disorders.

Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy.

Cognitive-behavioural therapy (CBT) is the recommended treatment for binge eating, yet many individuals do not recover, and innovative new treatments have been called for. The current study compares traditional CBT with two augmented versions of CBT; schema therapy, which focuses on early life experiences as pivotal in the history of the eating disorder; and appetite-focused CBT, which emphasises the role of recognising and responding to appetite in binge eating. 112 women with transdiagnostic DSM-IV binge eating were randomized to the three therapies. Therapy consisted of weekly sessions for six months, followed by monthly sessions for six months. Primary outcome was the frequency of binge eating. Secondary and tertiary outcomes were other behavioural and psychological aspects of the eating disorder, and other areas of functioning. No differences among the three therapy groups were found on primary or other outcomes. Across groups, large effect sizes were found for improvement in binge eating, other eating disorder symptoms and overall functioning. Schema therapy and appetite-focused CBT are likely to be suitable alternative treatments to traditional CBT for binge eating.

Three psychotherapies for anorexia nervosa: a randomized, controlled trial.

OBJECTIVE: Few randomized, controlled trials have examined the efficacy of treatments for anorexia nervosa. Cognitive behavior therapy and interpersonal psychotherapy are effective in a related disorder, bulimia nervosa. There are theoretical and treatment indications for these therapies in anorexia nervosa. METHOD: Fifty-six women with anorexia nervosa diagnosed by using strict and lenient weight criteria were randomly assigned to three treatments. Two were specialized psychotherapies (cognitive behavior therapy and interpersonal psychotherapy), and one was a control treatment combining clinical management and supportive psychotherapy (nonspecific supportive clinical management). Therapy consisted of 20 sessions over a minimum of 20 weeks. RESULTS: For the total study group (intent-to-treat group), there were significant differences among therapies in the primary global outcome measure. Nonspecific supportive clinical management was superior to interpersonal psychotherapy, while cognitive behavior therapy was intermediate, neither worse than nonspecific supportive clinical management nor better than interpersonal psychotherapy. For the women completing therapy, nonspecific supportive clinical management was superior to the two specialized therapies. CONCLUSIONS: The finding that nonspecific supportive clinical management was superior to more specialized psychotherapies was opposite to the primary hypothesis and challenges assumptions about the effective ingredients of successful treatments for anorexia nervosa.

Psychotherapy for depression: a randomized clinical trial comparing schema therapy and cognitive behavior therapy.

BACKGROUND: The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported, however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective therapy for depression. METHODS: In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined. 100 participants with major depression received weekly cognitive behavioral therapy or schema therapy sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses examined outcome for those with chronic depression and comorbid personality disorders. RESULTS: ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with chronic depression or comorbid personality disorders. LIMITATIONS: This study needs replication. CONCLUSIONS: This preliminary research indicates that ST may provide an effective alternative therapy for depression.