A cohort study of engagement in telehealth psychotherapy versus in-person services.

OBJECTIVE: Although telehealth psychotherapies have been studied for over 20 years, mental health services remained largely delivered in person until the COVID-19 pandemic forced clinics to reconsider the utility of telehealth psychotherapy. This study aims to compare patient engagement in in-person versus telehealth services in outpatient psychotherapy for mood and anxiety disorders. METHOD: A cohort investigation was conducted, using a propensity score matched sample, extracted from an electronic health record (EHR) to compare engagement in psychotherapy for 762 patients who used in-person services before the pandemic to a cohort of 762 patients who used telehealth psychotherapy after the onset of COVID-19. The authors compared cohorts on initial engagement in psychotherapy services following an initial intake, number of psychotherapy sessions attended, and the rate of missed sessions. RESULTS: There was a 26% increase in the total number of individual psychotherapy sessions attended when the clinics transitioned to telehealth services (p < .001). In addition, patients who received telehealth psychotherapy were five times more likely to not cancel or miss any scheduled sessions (p < .001). CONCLUSION: These results indicate that telehealth services may result in improved treatment engagement for outpatient centers focused on brief evidence-based psychotherapies for mood and anxiety disorders.

Change over time in brain serotonin transporter binding in major depression: effects of therapy measured with [(123) I]-ADAM SPECT.

Several studies have reported low brain serotonin transporter (SERT) binding in individuals with major depression. We hypothesized that the SERT standardized uptake ratio (SUR) values using [(123) I]-ADAM single photon emission computed tomography would increase in depressed subjects who responded to cognitive behavior therapy (CBT) compared to CBT nonresponders. [(123) I]-ADAM scans were acquired before and after 12 weeks of CBT from 20 depressed subjects and on two occasions 12 weeks apart from 10 nondepressed, healthy volunteers. The primary outcome measure was change over time in SUR values in the midbrain, medial temporal lobe, and basal ganglia regions. Depressed subjects demonstrated low pretreatment mean SUR values that significantly increased over time in the midbrain (P = .011), right medial temporal lobe (P = .008), and left medial temporal lobe (P = .000) regions. Treatment responders showed a significant increase over time in SUR values in left medial temporal lobe (P = .029) and right medial temporal lobe (P = .007) regions. Partial and nonresponder subjects also showed a significant increase over time in SUR values in the left medial temporal region (P = .040) (vs. healthy volunteers), but to a lesser degree. The findings suggest that low pretreatment SERT binding may increase over time in some depressed individuals who experience symptom improvement.

Research setting versus clinic setting: Which produces better outcomes in cognitive therapy for depression?

OBJECTIVE: To compare the outcomes of cognitive therapy for depression under controlled and clinically representative conditions, while holding several therapist and clinical assessment factors constant. METHOD: Treatment outcomes for a sample of 23 adults with a primary diagnosis of Major Depressive Disorder who received cognitive therapy in an outpatient clinic were compared with outcomes of 18 clients who were treated in the cognitive therapy condition of a large, multi-site randomized clinical trial of treatments for depression. All participants had been treated by one of two therapists who served as clinicians in both settings. Individuals in the two samples were diagnostically and demographically similar (approximately 50% Female, 83% White). A variety of client characteristics, assessed prior to treatment, as well as the outcomes of treatment, were examined. RESULTS: Significantly superior treatment outcomes were observed in the individuals treated in the research study, relative to clients in the outpatient clinic, and the difference was not accounted for by intake characteristics. Individuals treated by the therapists in the RCT experienced almost three times as much improvement in depressive symptoms as clients seen in the outpatient setting. CONCLUSIONS: If replicated, the findings suggest that differences exist between treatment outcomes in research and outpatient settings and that these differences may not simply be due to therapist experience and training, or differences in patient populations. Future research should further examine the impact of fidelity monitoring, treatment expectation and motivation, and the duration and timing of treatment protocols on clinical outcomes.

Training Cognitive Behavioral Therapy Supervisors: Didactics, Simulated Practice, and "Meta-Supervision".

The delivery of competent clinical supervision is vital to the successful training of new cognitive behavioral therapists, and-in the case of peer supervision and consultation-a boon to the maintenance of therapists' high professional standards throughout their careers. However, it is only recently that the field of psychotherapy in general and cognitive behavioral therapy (CBT) in particular has implemented formal methods of training clinicians to be competent supervisors. Drawing on recent findings from evidence-based programs of CBT supervision, this article highlights the contents and processes of a graduate training course in CBT supervision involving didactics, readings, and experiential exercises. The 6 major modules of this seminar are explicated, including such topics as the supervisory relationship, enhancing CBT competencies in supervisors and supervisees alike, promulgating ethical practices, and successfully managing the administrative aspects of supervision. In addition, the concept of "meta-supervision" is described and illustrated in the form of a transcript from a long-distance, computer-assisted meeting between a senior consulting supervisor and his junior "supervisor-evaluee." The transcript highlights the key features of meta-supervision, including the cross-cultural considerations that must be addressed when doing international training.

The Dynamics of Self-Esteem in Cognitive Therapy for Avoidant and Obsessive-Compulsive Personality Disorders: An Adaptive Role of Self-Esteem Variability?

Self-esteem variability is often associated with poor functioning. However, in disorders with entrenched negative views of self and in a context designed to challenge those views, variable self-esteem might represent a marker of change. We examined self-esteem variability in a sample of 27 patients with Avoidant and Obsessive-Compulsive Personality Disorders who received Cognitive Therapy (CT). A therapy coding system was used to rate patients' positive and negative views of self expressed in the first ten sessions of a 52-week treatment. Ratings of negative (reverse scored) and positive view of self were summed to create a composite score for each session. Self-esteem variability was calculated as the standard deviation of self-esteem scores across sessions. More self-esteem variability predicted more improvement in personality disorder and depression symptoms at the end of treatment, beyond baseline and average self-esteem. Early variability in self-esteem, in this population and context, appeared to be a marker of therapeutic change.

Medial prefrontal cortex hyperactivation during social exclusion in borderline personality disorder.

Frontal systems dysfunction and abandonment fears represent central features of borderline personality disorder (BPD). BPD subjects (n=10) and matched non-psychiatric comparison subjects (n=10) completed a social-cognitive task with two confederates instructed to either include or exclude subjects from a circumscribed interaction. Evoked cerebral blood oxygenation in frontal cortex was measured using 16-channel functional near infrared spectroscopy. BPD subjects showed left medial prefrontal cortex hyperactivation during social exclusion suggesting potential dysfunction of frontolimbic circuitry.

Competency in conducting cognitive-behavioral therapy: foundational, functional, and supervisory aspects.

The delivery of cognitive-behavioral therapy (CBT) is described in terms of foundational and functional competencies, with additional attention paid to how these skills are applied in clinical supervision. Foundational competencies include such qualities as ethical behavior, good interpersonal relational skills, a healthy capacity for self-awareness and self-correction, cross-cultural sensitivity, and an appreciation for the empirical basis of clinical procedures. Functional competencies include the ability to think like an empiricist and to teach clients to do the same, to conceptualize cases in terms of maladaptive beliefs and behavioral patterns, to structure sessions in an organized and time-effective manner, and to assign and review homework assignments. CBT supervisors have the multiple responsibilities of serving as professional role models for their supervisees, nurturing the latter's professional development (although also being ready to identify and remediate problems in the supervisee's performance), and engaging in ongoing self-improvement and education to function most effectively as clinical mentors. A brief, descriptive supervisory vignette is presented.

Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders.

Participants were 30 adult outpatients diagnosed with avoidant personality disorder or obsessive-compulsive personality disorder who enrolled in an open trial of cognitive therapy for personality disorders. Treatment consisted of up to 52 weekly sessions. Symptom evaluations were conducted at intake, at Sessions 17 and 34, and at the last session. Alliance variables were patients' first alliance rating and "rupture-repair" episodes, which are disruptions in the therapeutic relationship that can provide corrective experiences and facilitate change. Stronger early alliances and rupture-repair episodes predicted more improvement in symptoms of personality disorder and depression. This work points to potentially important areas to target in treatment development for these personality disorders.

Hypothesized mechanisms of change in cognitive therapy for borderline personality disorder.

Preliminary evidence suggests that cognitive therapy (CT) is effective in treating borderline personality disorder (BPD). According to cognitive theory, BPD patients are characterized by dysfunctional beliefs that are relatively enduring and inflexible and that lead to cognitive distortions such as dichotomous thinking. When these beliefs are activated, they lead to extreme emotional and behavioral reactions, which provide additional confirmation for the beliefs. It is hypothesized that a change in dysfunctional beliefs is the primary mechanism of change associated with CT. However, additional mechanisms of change are likely also at work in CT, including enhancement of skills, reduction in hopelessness, and improvement in attitude toward treatment. Each of these mechanisms is discussed in light of cognitive theory, data from an open clinical CT trial, relevant literature, and therapeutic interventions. Findings from the CT trial support the role of cognitive change during therapy and its continuation after termination.

After the attempt: maintaining the therapeutic alliance following a patient's suicide attempt.

The risk of a patient's suicide is a prominent occupational hazard for psychotherapists. The precise number of patients who attempt suicide while in treatment and then resume therapy with the same therapist is not known, but this situation is a relatively common occurrence in clinical practice. Such scenarios can pose significant challenges to the reestablishment of the therapeutic trust and a workable treatment alliance. The aim of this paper is to identify the challenges facing a clinician treating a patient who resumes therapy following a serious suicide attempt, and to offer guidelines for maintaining the viability of the therapeutic alliance.

An open clinical trial of cognitive therapy for borderline personality disorder.

Although borderline personality disorder (BPD) is a major public health concern, psychotherapeutic trials have been limited. The present uncontrolled clinical trial examines whether cognitive therapy for BPD is associated with significant improvement on measures of psychopathology. A total of 32 patients with BPD, who also reported suicide ideation or who engaged in self-injury behavior, received weekly cognitive therapy sessions over a 1-year period as described by Layden et al. (1993). The results revealed significant and clinically important decreases on measures of suicide ideation, hopelessness, depression, number of borderline symptoms and dysfunctional beliefs at termination and 18-month assessment interviews. Implications for further research with this difficult-to-treat patient population are discussed.

Cognitive therapy for chronic depression.

Recent literature indicates that there are important clinical differences between chronic and non-chronic depression. This article considers the implications of these differences when conducting cognitive therapy (CT) with chronically depressed patients. CT with chronic patients requires a greater emphasis on combating hopelessness, helplessness, and perfectionism, addressing early life-adverse experiences, and modifying maladaptive schemas. In addition, the effectiveness of CT may be enhanced by focusing on patients' poor social skills, ineffective reasoning skills, and their depressive identity. The case example presented illustrates CT with a chronically depressed patient.

A case illustration of resistance from a cognitive perspective.

Brian, a 36-year-old, single, white male, entered cognitive therapy in response to a depressive episode precipitated by the loss of a job. In addition to his Major Depression, the client met diagnostic criteria for Dysthymia and Personality Disorder Not Otherwise Specified. The first three sessions focused on Brian's unemployment crisis and related dysphoria, as well as his passive-avoidant approach to life. Brian collaborated with the therapist in formulating a treatment plan and quickly found a new job, whereupon he abruptly withdrew from therapy. Shortly thereafter, Brian contacted the therapist in a renewed state of "crisis" and returned for a fourth session. The therapist attempted to draw a link between Brian's passive-avoidant style and his vulnerability to problems such as those he currently was experiencing. The client had difficulty understanding the therapist's thread of logic, became somewhat defensive and combative, and did not return for further sessions.

A cognitive perspective on resistance in psychotherapy.

The phenomena that comprise resistance in therapy are described and discussed from a cognitive viewpoint. The cases of Brian, Julie, and Victoria are reviewed to illustrate similar and contrasting manifestations of resistance, and suggestions for further individualized conceptualization and intervention are presented. Emphasis is placed on gaining an accurate, empathic understanding of the client's difficulties in changing. This is coupled with methods that allow the client some autonomy in charting the course of therapy, at the same time reinforcing the importance of the therapist's active involvement in educating and stimulating the client toward greater awareness and adaptability. In order to be maximally effective in encouraging such changes, therapists must be aware of their own tendencies to react adversely to client resistance. It is vital that therapists maintain their professionalism and confidence in persevering toward a better understanding of what will be helpful to their clients.