Dynamic interpersonal therapy for moderate to severe depression: a pilot randomized controlled and feasibility trial.

BACKGROUND: Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated. METHODS: 147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion. RESULTS: The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes. CONCLUSIONS: DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.

Judging clinical competence using structured observation tools: A cautionary tale.

BACKGROUND: One method for appraising the competence with which psychological therapy is delivered is to use a structured assessment tool that rates audio or video recordings of therapist performance against a standard set of criteria. AIMS: The present study examines the inter-rater reliability of a well-established instrument (the Cognitive Therapy Scale - Revised) and a newly developed scale for assessing competence in CBT. METHOD: Six experienced raters working independently and blind to each other's ratings rated 25 video recordings of therapy being undertaken by CBT therapists in training. RESULTS: Inter-rater reliability was found to be low on both instruments. CONCLUSIONS: It is argued that the results represent a realistic appraisal of the accuracy of rating scales, and that the figures often cited for inter-rater reliability are unlikely to be generalizable outside the specific context in which they were achieved. The findings raise concerns about the use of these scales for making summative judgements of clinical competence in both educational and research contexts.

A New Scale for the Assessment of Competences in Cognitive and Behavioural Therapy.

BACKGROUND: Scales for assessing competence in CBT make an important contribution to research and practice. AIMS: To develop a novel scale. METHOD: A new structured assessment tool is described, which draws on a widely-used CBT competence framework to identify relevant areas of clinical practice. RESULTS: Scale content was clarified through piloting and review by a range of stakeholders. CONCLUSION: Pending formal testing of the psychometric properties, the scale is ready for use to assess competences in cognitive and behavioural therapy.

Are competence frameworks fit for practice? Examining the validity of competence frameworks for CBT, psychodynamic, and humanistic therapies.

Practitioners transporting psychological therapies from a research context to clinical settings need to know what competences they should demonstrate to maintain congruence with the evidence base. This study explores the validity of a suite of competence frameworks for cognitive behavior therapy (CBT), humanistic, and psychodynamic therapies developed to aid the transportation process. Experienced psychological therapists (N = 111) undertook a Q-sort of 100 items, drawn from frameworks representing each of the modalities and including a set of pantheoretical generic competences, rating items as characteristic or uncharacteristic of their orientation. There were significant differences in the way competences were assigned, with practitioners strongly favoring items from their own modality framework and eschewing items from the others. These results confirm the validity of the items within the frameworks; their utility and application is discussed.

Developing a competence framework for cognitive analytic therapy.

OBJECTIVE: This paper describes the development and summarizes the content of a competence framework for delivery of cognitive analytic therapy (CAT). DESIGN: The framework was developed using the evidence-based method developed by Roth and Pilling (2008, Behavioural and Cognitive Psychotherapy, 36, 129). METHODS: A review of the CAT outcome literature identified where CAT interventions had evidence of efficacy. Standard texts on CAT were primary sources for details of theory and practice. This process was supported by an expert reference group (ERG). The role of the ERG was to provide professional advice on areas where the evidence base was lacking, but where CAT interventions were commonly used by therapists trained in the model. RESULTS: A framework was produced and structured in terms of core knowledge, core skills, and meta-competences (which require therapeutic judgement rather than simple adherence to a treatment protocol). CONCLUSIONS: The framework enables trainees, service users, service managers, and commissioners to better understand a) the core features of CAT and b) what competences need to be in place for CAT to be skilfully delivered in practice. PRACTITIONER POINTS: It is possible to define the core competences of CAT. Whilst generic competences are important, there are five CAT-specific domains of competence. The CAT-specific competences reflect the three-phase structure of the therapy: reformulation, recognition, and revision.

Therapist training and supervision in clinical trials: implications for clinical practice.

BACKGROUND: Researchers in clinical trials usually pay close attention to therapist selection, training, supervision and monitoring, but the extent of this input has not been systematically documented. AIMS: To describe the extent of training and supervision activity within clinical trials, and to consider any implications for transporting therapies from research to routine clinical contexts. METHOD: Twenty-seven randomized studies examining the efficacy of CBT interventions for people with depression or anxiety disorders were selected on the basis of their quality and impact on the field. Published and unpublished sources were used to gather information about therapist selection, training and supervision within these trials. RESULTS: The review identified the extent of investment by researchers in assuring therapist expertise, adherence and competence. It also indicated inconsistencies in the clarity with which this input was reported. CONCLUSIONS: The ubiquity of intervention-specific training in research contexts risks being overlooked when commissioning evidence-based therapies in routine practice. This has clear implications for the likely effectiveness of interventions. Greater consistency in the reporting of training in clinical trials may help to draw attention to the role of training and supervision in maximizing clinical outcomes.

Developing a competence framework for psychological interventions in a multidisciplinary paediatric context.

This paper describes the development and content of a competence framework for psychological interventions, intended to apply to healthcare workers of all disciplines working in a paediatric context. To achieve this, a review of the literature was used to indicate where current interventions had evidence for efficacy; this scoping exercise was complemented by an expert reference group (ERG) whose role was to offer professional advice on areas where the evidence base is not strong but where the field commonly employs interventions. Iterative peer review of the emerging framework was undertaken both by the ERG and external peer reviewers selected for their expertise in the field. The characteristics of the completed framework are presented, along a discussion of the uses to which it can be put. The framework is best seen as a practitioner support tool, providing a basis for training and practice in paediatric contexts.

Psychodynamic psychotherapies: evidence-based practice and clinical wisdom.

This article is based on an exhaustive review of the psychotherapy outcomes literature, undertaken originally at the instigation of the UK Department of Health by Roth and Fonagy (Department of Health, 1995). We have recently updated this review (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Roth & Fonagy, 2004) and extended it to identify all studies of psychoanalytic psychotherapy. The usual methods for identifying studies were employed (Fonagy, Target, et al., 2002; Roth & Fonagy, in press). The key questions that should be asked of this literature given the current state of research in this area (also see Westen, Morrison, & Thompson-Brenner, 2004) are: Are there any disorders for which short-term psychodynamic psychotherapy (STPP) can be considered evidence-based, Are there any disorders for which STPP is uniquely effective as either the only evidence-based treatment or as a treatment that is more effective than alternatives, and Is there any evidence base for long-term psychodynamic psychotherapy (LTPP) either in terms of achieving effects not normally associated with short-term treatment or addressing problems that have not been addressed by STPP? In this context, short-term therapy is conceived of as a treatment of around 20 sessions delivered usually once weekly.

Is it mere distraction? Peri-traumatic verbal tasks can increase analogue flashbacks but reduce voluntary memory performance.

Several experiments have shown that we can reduce the frequency of analogue flashbacks with competing tasks presented during a trauma film (i.e. peri-traumatically). A "distraction" hypothesis suggests that any competing task may reduce flashbacks due to distraction and/or a load on executive control. Alternatively, a "modality" hypothesis based on clinical models of PTSD suggests that certain tasks will not protect against intrusions (Experiment 1) and could actually increase them (Experiment 2). Experiment 1 contrasted two concurrent tasks, Verbal Interference (counting backwards in threes) and Visuospatial tapping, against a no-task Control condition during trauma film viewing. The Visuospatial group had significantly fewer intrusions of the film over 1-week than the Control group. Contrary to a distraction account, the Verbal Interference group did not show this effect. Using a larger sample, Experiment 2 showed that the Verbal Interference group (counting backwards in sevens) had more intrusions (and inferior voluntary memory) than no-task Controls. We propose that this is in line with a modality hypothesis concerning trauma flashbacks. Disrupting verbal/conceptual processing during trauma could be harmful for later flashbacks.