[Effects of Dialectical Behavior Therapy (DBT) Skills Training on Depression and Anxiety Disorders - A Pilot Study under Routine Care Conditions]. / Effekte des Skills-Trainings der Dialektisch-Behavioralen Therapie (DBT) bei Depressionen und Angststörungen ­ Eine praxisorientierte Pilotstudie.

OBJECTIVE: Skills training as an integral part of dialectical behavioral therapy (DBT) is highly effective in the treatment of borderline personality disorder. Research interest is increasingly focused on the transdiagnostic effects of the skills training on depression and anxiety disorders. The present study examined the extent to which the findings of high-quality randomized controlled studies can be transferred to everyday treatment under routine care conditions. METHODS: N=26 patients without personality disorders were treated in a day clinic over a period of eight weeks. In the control group, 11 patients received routine care treatment and in the experimental group 15 patients additionally received weekly skills training. Symptom distress, as well as emotion regulation and mindfulness were assessed longitudinally at three time points. Multilevel analyzes were used to examine whether there was an additive effect of the skills training. RESULTS: The experimental group was superior to the control group in all endpoints. The effect sizes were comparable to those from experimental research. Improvements in mindfulness were significantly correlated with reductions in symptom distress. DISCUSSION: The findings fit into previous research efforts and complement them with a naturalistic research perspective. The advantages and disadvantages of an experimental and naturalistic research perspective are discussed, and relevant limitations of the present study are highlighted. CONCLUSION: Skills training is an established, flexible, modular therapy program that is ideal for improving the adaptability of patients with different psychological diagnoses.

Towards a taxonomy of mechanisms of change? Findings from an expert survey on the association between common factors and specific techniques in psychotherapy.

OBJECTIVE: In the present study, we used structural equation modeling (SEM) to investigate the complex relationship between common factors, i.e., mechanisms of change, and specific factors, i.e., therapeutic techniques. METHOD: N = 256 psychotherapy experts were asked to rate the appropriateness of 14 techniques commonly used in psychotherapy to facilitate five different common factors - resource activation, motivational clarification, self-management & emotion regulation, social competence, and therapeutic relationship. Using SEM, we defined techniques as indicators and common factors as latent variables. Data were split randomly into two subsets. Indicators were selected if three a priori defined criteria were met based on training data (n = 128). Subsequently, the goodness of model fit was assessed in the test data (n = 128). RESULTS: The proposed model revealed adequate fit. All factor loadings were theoretically sound and significant in magnitude. Findings suggest that psychotherapy experts discriminate between common factors by their various associations with therapeutic techniques. CONCLUSION: Suggestions are made, how therapeutic techniques are to be used to facilitate desirable change in the patient. Our model is a step towards a taxonomy of mechanisms of change that may help to improve research-informed decision-making.

What sticks? Patients' perspectives on treatment three years after psychotherapy: A mixed-methods approach.

Objective: In the present study, a patient-focused, mixed-methods approach was applied to relate patients' personal experiences of change processes during therapy to their long-term psychometric treatment outcomes. Method: Comprehensive follow-up quantitative assessments and qualitative interviews were conducted with n = 30 patients who had completed an integrative CBT treatment three years prior. Qualitative content analysis by two independent coders was used to categorize patients' subjective explanations of therapeutic change. Correlations were applied to relate the frequency and diversity of change factors to clinically significant change of symptom distress at post-treatment and 36-month follow-up. Cluster analysis was performed to identify clusters of patients with similar patterns of change factors. Results: Qualitative content analysis with good interrater reliability revealed five main categories: (1) Therapeutic relationship (2) Activating resources (3) Motivational clarification and insight (4) Action-oriented coping strategies (5) Healing therapeutic setting. Higher levels of change factors were associated with greater relief of symptoms at post-treatment and 36-month follow-up. Cluster analysis revealed three different groups of patients. Conclusions: The analysis provides insight into therapeutic change factors from the patient's perspective. Some categories are consistent with theoretically driven models of common factors. Results may help tailor psychotherapy to patients' individual needs.

Processes of change after a sudden gain and relation to treatment outcome-Evidence for an upward spiral.

OBJECTIVE: Sudden gains are sudden symptom improvements from 1 psychotherapy session to the next. This study investigates the processes that may facilitate treatment outcome after a sudden gain occurred. METHOD: A sample of 211 depressed patients who underwent cognitive-behavioral therapy was analyzed. Sudden gains were identified using a session-by-session self-report symptom measure. Patient ratings of general change factors (therapeutic alliance; coping skills) in the sessions before and after a sudden gain were investigated as predictors of outcome. Propensity score matching was used to compare sudden gain patients with similar patients who did not experience a sudden gain. RESULTS: Therapeutic alliance and coping skills increased in the postgain sessions. There were no comparable processes of change among patients without sudden gains. The therapeutic alliance was found to moderate the association between sudden gains and treatment outcome. CONCLUSION: Results suggest that sudden gains trigger change factors that facilitate the association between gains and treatment outcome. Patient-therapist dyads should work with sudden gains to consolidate symptom relief. (PsycINFO Database Record

Sudden gains in routine care cognitive behavioral therapy for depression: A replication with extensions.

BACKGROUND: Over the last decade, a substantial amount of findings have been reported on the association between sudden gains (large symptom improvements in a between-session interval) and treatment outcome. Accurate replications of previous findings are needed to tackle inconsistencies and to shed light on the clinical implications of sudden gains. This study investigates whether similar effects of sudden gains can be expected under routine care conditions, when the patients are comparable to those examined in the original study by Tang and DeRubeis (1999). METHOD: Using propensity score matching (PSM), 462 patients treated with cognitive behavioral therapy (CBT) under routine conditions were matched stepwise to patients of the original study on sudden gains, a randomized controlled CBT trial (RCT). RESULTS: After the application of PSM, the effects of sudden gains on treatment outcome were similar to those found by Tang and DeRubeis (1999). The closer the match between the RCT and the naturalistic sample, the more similar the association between sudden gains and treatment outcome. CONCLUSION: Sudden gains seem to have a significant impact on recovery rates, even in treatments under routine care. Results suggest that one important aspect of replication success is to control for confounding baseline covariates.

Clinical effectiveness of cognitive behavioral therapy for depression in routine care: A propensity score based comparison between randomized controlled trials and clinical practice.

BACKGROUND: The efficacy of cognitive behavioral therapy (CBT) for the treatment of depressive disorders has been demonstrated in many randomized controlled trials (RCTs). This study investigated whether for CBT similar effects can be expected under routine care conditions when the patients are comparable to those examined in RCTs. METHOD: N=574 CBT patients from an outpatient clinic were stepwise matched to the patients undergoing CBT in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). First, the exclusion criteria of the RCT were applied to the naturalistic sample of the outpatient clinic. Second, propensity score matching (PSM) was used to adjust the remaining naturalistic sample on the basis of baseline covariate distributions. Matched samples were then compared regarding treatment effects using effect sizes, average treatment effect on the treated (ATT) and recovery rates. RESULTS: CBT in the adjusted naturalistic subsample was as effective as in the RCT. However, treatments lasted significantly longer under routine care conditions. LIMITATIONS: The samples included only a limited amount of common predictor variables and stemmed from different countries. There might be additional covariates, which could potentially further improve the matching between the samples. CONCLUSIONS: CBT for depression in clinical practice might be equally effective as manual-based treatments in RCTs when they are applied to comparable patients. The fact that similar effects under routine conditions were reached with more sessions, however, points to the potential to optimize treatments in clinical practice with respect to their efficiency.