Psychotherapy for the treatment of depression: a comprehensive review of controlled outcome research.

Previous quantitative reviews of research on the efficacy of psychotherapy for depression have included only a subset of the available research or limited their focus to a single outcome measure. The present review offers a more comprehensive quantitative integration of this literature. Using studies that compared psychotherapy with either no treatment or another form of treatment, this article assesses (a) the overall effectiveness of psychotherapy for depressed clients, (b) its effectiveness relative to pharmacotherapy, and (c) the clinical significance of treatment outcomes. Findings from the review confirm that depressed clients benefit substantially from psychotherapy, and these gains appear comparable to those observed with pharmacotherapy. Initial analysis suggested some differences in the efficacy of various types of treatment; however, once the influence of investigator allegiance was removed, there remained no evidence for the relative superiority of any 1 approach. In view of these results, the focus of future research should be less on differentiating among psychotherapies for depression than on identifying the factors responsible for improvement.

An appraisal of constructivist psychotherapies.

Predicated on a postmodern epistemology, constructivist theories emphasize the proactive, self-organizing features of human knowing and their implications for psychotherapy. This article outlines the potential contributions of 4 clinical lineages sharing a constructivist philosophy--personal construct theory, structural--developmental cognitive therapy, narrative reconstruction, and constructivist family therapy--and briefly reviews emerging trends in psychotherapy research compatible with this perspective. Although current constructivist approaches confront problems as well as prospects, they represent a growing force within psychotherapy, contributing to the sophistication of psychological theory, the diversification of clinical research, and the extension of therapeutic technique.

Psychopathology associated with sexual abuse: the importance of complementary designs and common ground.

In their recent longitudinal study of youth victimization and consequent traumatization, S. Boney-McCoy and D. Finkelhor (1996) contrast their position with previous retrospective research (S. Harter, P. Alexander, & R. A. Neimeyer, 1988; M. R. Nash, T. C. Hulsey, M. C. Sexton, T. L. Harralson, & W. Lambert, 1993a), arguing that their data support the impact of victimization per se, independent of the moderating effect of family environment. Because Boney-McCoy and Finkelhor's argument may misrepresent the results of such studies, this article (a) clarifies the actual findings of previous retrospective studies of abuse, (b) suggests methodological limitations both in Boney-McCoy and Finkelhor's research and in that of S. Harter et al., 1998, and M. R. Nash et al., 1993a, that should be remedied by future investigators, and (c) argues that both retrospective clinical research and prospective community surveys converge on a common ground, namely, that specific abuse experiences can best be understood and investigated in the context of the prior, contemporaneous, and subsequent family environments in which they occur.

Professional and paraprofessional group treatments for depression: a comparison of cognitive-behavioral and mutual support interventions.

The relative efficacy of professional and paraprofessional therapists in providing group cognitive-behavioral therapy (CBT) and mutual support group therapy (MSG) was examined. Depressed outpatients (N = 98) were randomly assigned to CBT or MSG led by either 2 professional or 2 paraprofessional therapists. Results suggest that nonprofessionals were as effective as professionals in reducing depressive symptoms and that clients in the CBT and MSG conditions improved equally. Clinically significant improvement was demonstrated for both conditions. However, following treatment, more patients in the professionally led CBT groups were classified as nondepressed and alleviated than in the paraprofessionally led CBT groups. Additionally, therapist adherence to manual-based treatments was associated with greater improvement in clinician-rated depressive symptoms in both conditions and skills in cognitive restructuring were associated with greater improvement among clients in CBT.

A comparison of group treatments of women sexually abused as children.

We randomly assigned 65 women who had been sexually abused by a father, stepfather, or other close relative to 1 of 3 treatment conditions: a 10-week interpersonal transaction (IT) group, a 10-week process group, or a wait list condition. Subjects were evaluated at pretreatment, posttreatment, and (if assigned to a group) a 6-month follow-up on measures of social adjustment, depression, fearfulness, and general distress. Results suggested that both the IT and process group formats were more effective than the wait list condition in reducing depression and in alleviating distress; changes were maintained at follow-up. Subjects in the process group format exhibited improvement in social adjustment, whereas subjects in the wait list condition actually deteriorated.

Effects of running or weight lifting on self-concept in clinically depressed women.

Forty clinically depressed women were randomized to a running, weight lifting, or delayed treatment condition. Self-concept was assessed at baseline, pre-, mid-, and posttreatment for all subjects and at 1, 7, and 12 months for exercise groups. Significant improvements in self-concept were found for exercise groups relative to control groups. No significant differences between exercise groups were found, and improvements were reasonably well-maintained over time. Differential changes on dimensions of self-concept were not demonstrated. These results suggest that both running and weight lifting exercise programs improve self-concept in clinically depressed women.

Cognitive predictors of depression and suicide ideation.

A total of 136 adult subjects who met the Research Diagnostic Criteria for major (unipolar) depression were assessed for intensity of depressive symptomatology (using the Hamilton Rating Scale for Depression and the Beck Depression Inventory) and for lethality of current suicide ideation (using the Scale for Suicide Ideation). In addition, they were administered a variety of questionnaires assessing cognitive variables presumed to mediate depression and suicidality. Multiple regression analyses indicated that depressive symptomatology was best predicted by Beck's Hopelessness Scale in combination with the Detachment factor of the Crandell Cognitions Inventory. In addition, suicidality was significantly predicted by the Selective Abstraction and Overgeneralization factors of Lefebvre's Cognitive Error Questionnaire, when the effects of the Beck Depression Inventory were partialed out. The practical implications of these findings for discriminating suicidal from nonsuicidal depressives are discussed.

Death anxiety and counseling skill in the suicide interventionist.

In light of recent evidence that suicide intervention workers may experience greater fear of death than the general population, the present study examined the death anxiety of interventionists and its relation to skill in responding to suicidal clients. A sample of 109 suicide prevention workers from three independent crisis centers were administered the Death Anxiety Scale (Templer, 1970) and the Suicide Intervention Response Inventory (Neimeyer & MacInnes, 1981). Compared to 109 matched controls, the interventionists were found to have significantly lower death anxiety, thereby reversing the earlier finding. Moreover, no linear or curvilinear relationship between death anxiety and suicide counseling skill could be identified. Together, these results give some justification to the traditional neglect of death concern as a factor in screening or training crisis intervention personnel.

Factorial structure of the suicide intervention response inventory.

Previous research has reported the development and validation of the Suicide Intervention Response Inventory (SIRI), a self-report instrument assessing a counselor's ability to select an appropriate response to the life-threatening client. The present study examined whether the response skill measured by the instrument might be multidimensional, rather than unitary as previously assumed. Inventories completed by 457 paraprofessional counselors from five suicide and crisis intervention services throughout the United States were factor-analyzed to yield their simple structure. Results suggested that the instrument is indeed multifactorial, with four component factors identified as Elaboration of the Complaint, Exploration of Suicidality, Involvement, and Reflection of Negative Feelings. The implications of these findings for training in crisis counseling and for the further psychometric development of the instrument are noted.

Personal and professional factors and suicide intervention skills.

This research investigated the relationship of professional and personal factors to the ability of counselors to respond appropriately to suicidal verbalizations using the Suicide Intervention Response Inventory (SIRI). Level of training, experience with suicidal clients, and death acceptance were positively related to suicide intervention competencies. A personal history of suicidality and a belief that suicide is a personal right were negatively related to such skills. Regression analysis revealed that personal history of suicidality and attitude toward suicide as a personal right accounted for a modest, but significant, percentage of the variance in SIRI scores, beyond that accounted for by professional factors. Post hoc analysis indicated that the negative relationship between personal history of suicidal behaviors and suicide counseling skills was significant in the professionally trained participants. These results highlight the importance of attitudes toward suicide and personal history of suicidality, as well as training and experience, in effectively counseling potentially suicidal clients.

Unfounded trust: a constructivist meditation.

From a postmodern standpoint, all trust is ultimately unfounded, in the sense that no authoritative theoretical, empirical or practical foundation exists to ground a unified, explicit, and justified framework for psychotherapeutic practice. Following a constructivist meditation on these themes, I offer five playful prescriptions for addressing this predicament that suggest a provisional way forward in a terrain that offers no firm footholds having bedrock certainty.

Patterns of symptomatic change in depressed patients in a private inpatient mood disorders program.

This naturalistic study of 352 depressed patients admitted to a mood disorders program in a private psychiatric hospital demonstrated that, for the majority of patients, combining cognitive group therapy with ongoing supportive individual, psychoeducational, milieu, and pharmacological interventions resulted in rapid overall improvement and discharge within a few weeks. Improvement was manifested across cognitive and vegetative factor scores of the Beck Depression Inventory. However, patterns of symptom remission differed for subgroups defined by different lengths of stay. For example, patients hospitalized for 4 weeks showed good initial response, followed by a plateau in improvement, and, finally, continued response. These patients eventually reached the same level of functioning at discharge as did more rapidly responding patients with briefer stays. In contrast, a subset of patients (10% of the sample) hospitalized 5 weeks or more showed less overall improvement (especially in vegetative symptoms), plateauing at a moderately symptomatic level. These data suggest that in a minority of depressed individuals, continuing physiological disturbances may underlie dysthymia or residual depression. However, in contrast to the high rates (20-30%) of chronicity reported from tertiary care settings, these data indicate the relatively good initial treatment response of depressed patients admitted to a private psychiatric hospital.

A personal construct approach to perception of disclosure targets.

Investigating the perception of targets for self-disclosure from the perspective of the psychology of personal constructs, it was predicted that respondents from a mixed-nationality group would (a) characterize friends more than acquaintances in terms of 'superordinate' personality-descriptive dimensions, (b) 'differentiate' friends more than acquaintances by extensive application of constructs to them, and (c) 'polarize' targets for high disclosure by construing them sharply and meaningfully in terms of personally significant dimensions of meaning. All predictions received significant support for 34 college students (Mdnage 22 yr.) who responded in writing to a questionnaire. The results suggest the fruitfulness of further examining self-disclosure and friendship formation from a vantage point which emphasizes the perceptual and interpretive framework of an adult person.

Reauthoring life narratives: grief therapy as meaning reconstruction.

New conceptualizations of bereavement have begun to highlight the process of meaning reconstruction in the aftermath of loss, and the important role this plays in adaptation. This article summarizes theoretical and empirical contributions to this emerging perspective, and discusses several specific implications these carry for the practice of grief therapy.

Searching for the meaning of meaning: grief therapy and the process of reconstruction.

A comprehensive quantitative review of published randomized controlled outcome studies of grief counseling and therapy suggests that such interventions are typically ineffective, and perhaps even deleterious, at least for persons experiencing a normal bereavement. On the other hand, there is some evidence that grief therapy is more beneficial and safer for those who have been traumatically bereaved. Beginning with this sobering appraisal, this article considers the findings of C.G. Davis, C.B. Wortman, D.R. Lehman, and R.C. Silver (this issue) and their implications for a meaning reconstruction approach to grief therapy, arguing that an expanded conception of meaning is necessary to provide a stronger basis for clinical intervention.

Grief therapy and research as essential tensions: prescriptions for a progressive partnership.

Although the articles in this Special Series take an important step toward fostering mutually respectful dialogue between thanatological research and practice, many impediments still stand in the way of the continuation of the conversation. This closing coda therefore offers several prescriptions for sustaining a constructive exchange between the two domains, in the hope that a more artful and empirically informed grief therapy might yet take shape that embodies the unique strengths of each perspective.

Evaluation of suicide intervention effectiveness.

Considering the prevalence of suicide and other forms of self-injurious behavior, it is ironic that relatively little attention has been paid to the training of mental health workers in suicide intervention. Still less effort has been spent in evaluating the effectiveness of such workers or the agencies in which they serve. We review the evaluation strategies that have been used to assess the process and outcome of suicide intervention, ranging from macroanalyses of the impact of crisis services on suicide rates in the community to microanalyses of the competence of individual suicide interventionists. Particular attention is paid to the Suicide Intervention Response Inventory, a self-administered test of suicide counseling skills whose validity, reliability, and practical utility suggest the benefit of its use in a broader range of research and applied settings. The advantages and disadvantages of each evaluation strategy are discussed, and guidelines are offered for the sophistication of future research and program evaluation efforts.