Exploring therapist characteristics as potential moderators of the effects of client feedback on treatment outcome.

Although studies have shown that client feedback can improve treatment outcome, little is known about which factors might possibly moderate the effects of such feedback. The present study investigated potential therapist variables that might influence whether frequent client feedback is effective, including the Big Five personality traits, internal/external feedback propensity and self-efficacy. Data from two previous studies, a quasi-experimental study and a randomized controlled trial, were combined. The sample consisted of 38 therapists and 843 clients (55.4% females, mean age = 42.05 years, SD = 11.75) from an outpatient mental health institution. The control condition consisted of cognitive-behavioural therapies combined with low frequency monitoring of clients' symptoms. In the experimental condition, high-intensity (i.e., frequent) client feedback as an add-on to treatment as usual was provided. Outcomes were measured as adjusted post-treatment symptom severity on the Symptom Checklist-90 and drop out from treatment. The final model of the multilevel analyses showed that therapists with higher levels of self-efficacy had poorer treatment outcomes, but when high-intensity client feedback was provided, their effectiveness improved. Furthermore, higher self-efficacy was associated with a higher estimation of therapists' own effectiveness, but therapists' self-assessment of effectiveness was not correlated with their actual effectiveness. The results of this study might indicate that therapists with high levels of self-efficacy benefit from client feedback because it can correct their biases. However, for therapists with low self-efficacy, client feedback might be less beneficial, possibly because it can make them more insecure. These hypotheses need to be investigated in future research.

Characteristics and stability of hallucinations and delusions in patients with borderline personality disorder.

BACKGROUND: Psychotic features have been part of the description of the borderline personality disorder (BPD) ever since the concept "borderline" was introduced. However, there is still much to learn about the presence and characteristics of delusions and about the stability of both hallucinations and delusions in patients with BPD. METHODS: A follow-up study was conducted in 326 BPD outpatients (median time between baseline and follow-up = 3.16 years). Data were collected via telephone (n = 267) and face-to-face interviews (n = 60) including the Comprehensive Assessment of Symptoms and History interview, Positive And Negative Syndrome Scale and the Psychotic Symptom Rating Scale. RESULTS: The point prevalence of delusions was 26%, with a median strong delusion conviction. For the group as a whole, the presence and severity of both hallucinations and delusions was found to be stable at follow-up. Participants with persistent hallucinations experienced more comorbid psychiatric disorders, and they differed from those with intermittent or sporadic hallucinations with their hallucinations being characterized by a higher frequency, causing a higher intensity of distress and more disruption in daytime or social activities. CONCLUSIONS: Delusions in patients with BPD occur frequently and cause distress. Contrary to tenacious beliefs, hallucinations and delusions in participants with BPD are often present in an intermittent or persistent pattern. Persistent hallucinations can be severe, causing disruption of life. Overall, we advise to refrain from terms such as "pseudo", or assume transience when encountering psychotic phenomena in patients with BPD, but rather to carefully assess these experiences and initiate a tailor-made treatment plan.

The effect of shorter exposure versus prolonged exposure on treatment outcome in Tourette syndrome and chronic tic disorders - an open trial.

Background: Exposure and response prevention has shown to be an effective strategy and is considered a first-line intervention in the behavioural treatment of tic disorders. Prior research demonstrated significant tic reduction after 12 two hour sessions. Objective: In this open trial, the question is addressed whether, relative to these prolonged sessions, exposure sessions of shorter duration yield differential outcome for patients with tic disorders. Methods: A total of 29 patients diagnosed with Tourette syndrome (TS) or chronic tic disorder were treated with shorter exposure sessions (1 h), and these data were compared to the data from a study about prolonged exposure (2 h, n = 21). Outcome was measured by the Yale Global Tic Severity Scale (YGTSS). Results: Results suggest that after taking the difference in illness duration between the two groups into account, the effectiveness of shorter exposure sessions is not inferior to that of prolonged exposure. Conclusions: Results suggest that treatment with shorter exposure might be more efficient and more patients can be reached. Future research is needed to gain more insight into the mechanisms underlying the efficacy of behavioural treatments for tics.

Improving the efficiency of cognitive-behavioural therapy by using formal client feedback.

OBJECTIVE: Feedback from clients on their view of progress and the therapeutic relationship can improve effectiveness and efficiency of psychological treatments in general. However, what the added value is of client feedback specifically within cognitive-behavioural therapy (CBT), is not known. Therefore, the extent to which the outcome of CBT can be improved is investigated by providing feedback from clients to therapists using the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). METHOD: Outpatients (n = 1006) of a Dutch mental health organization either participated in the "treatment as usual" (TAU) condition, or in Feedback condition of the study. Clients were invited to fill in the ORS and SRS and in the Feedback condition therapists were asked to frequently discuss client feedback. RESULTS: Outcome on the SCL-90 was only improved specifically with mood disorders in the Feedback condition. Also, in the Feedback condition, in terms of process, the total number of required treatment sessions was on average two sessions fewer. CONCLUSION: Frequently asking feedback from clients using the ORS/SRS does not necessarily result in a better treatment outcome in CBT. However, for an equal treatment outcome significantly fewer sessions are needed within the Feedback condition, thus improving efficiency of CBT.

Level and appraisal of fatigue are not specific in burnout.

Fatigue is a main feature of the burnout syndrome but also very common in other psychiatric disorders such as major depression and anxiety disorders. This raises the question of whether the level and appraisal of fatigue is experienced differently by individuals suffering from burnout than by those exhibiting anxiety disorders and major depression. If fatigue is experienced differently in burnout compared with other disorders, this may clarify why fatigue is the main feature of the burnout syndrome. This knowledge may lead to the application of specific therapeutic interventions aimed at the experience of fatigue in burnout. In the present study, we investigated whether fatigue is experienced differently in burnout patients than in patients suffering from anxiety disorders or major depression. We presented 73 burnout patients, 67 depressed patients, 57 patients with an anxiety disorder and 127 healthy participants with a rating scale containing statements about the fatigue-performance relationship, and we assessed the level of fatigue, depression and anxiety. The level of fatigue reported by burnout patients was high but did not differ from that of the other patient groups. The appraisal of fatigue also did not differ among the patient groups. The burnout patients did not appraise their fatigue as a result of unrewarding activities nor did they catastrophize fatigue in an exceptional way. Thus, the level of fatigue and the appraisal of fatigue may be less relevant to the understanding of the specific pathological processes associated with burnout than is often presumed.

Cognitive performance in both clinical and non-clinical burnout.

Relatively little is known about cognitive performance in burnout. The aim of the present study was to further our knowledge on this topic by examining, in one study, cognitive performance in both clinical and non-clinical burnout while focusing on three interrelated aspects of cognitive performance, namely, self-reported cognitive problems, cognitive test performance, and subjective costs associated with cognitive test performance. To this aim, a clinical burnout patient group (n = 33), a non-clinical burnout group (n = 29), and a healthy control group (n = 30) were compared on self-reported cognitive problems, assessed by a questionnaire, as well as on cognitive test performance, assessed with a cognitive test battery measuring both executive functioning and more general cognitive processing. Self-reported fatigue, motivation, effort and demands were assessed to compare the different groups on subjective costs associated with cognitive test performance. The results indicated that the clinical burnout patients reported more cognitive problems than the individuals with non-clinical burnout, who in turn reported more cognitive problems relative to the healthy controls. Evidence for impaired cognitive test performance was only found in the clinical burnout patients. Relative to the healthy controls, these patients displayed some evidence of impaired general cognitive processing, reflected in slower reaction times, but no impaired executive functioning. However, cognitive test performance of the clinical burnout patients was related to larger reported subjective costs. In conclusion, although both the clinical and the non-clinical burnout group reported cognitive problems, evidence for a relatively mild impaired cognitive test performance and larger reported subjective cost associated with cognitive test performance was only found for the clinical burnout group.

Fear-related associations in children of parents with an anxiety disorder.

BACKGROUND AND OBJECTIVES: Children of parents with an anxiety disorder are at elevated risk for developing an anxiety disorder themselves. According to cognitive theories, a possible risk factor is the development of schema-related associations. This study is the first to investigate whether children of anxious parents display fear-related associations and whether these associations relate to parental anxiety. METHODS: 44 children of parents with panic disorder, 27 children of parents with social anxiety disorder, and 84 children of parents without an anxiety disorder filled out the SCARED-71, and the children performed an Affective Priming Task. RESULTS: We found partial evidence for disorder-specificity: When the primes were related to their parent's disorder and the targets were negative, the children of parents with panic disorder and children of parents with social anxiety disorder showed the lowest error rates related to their parents' disorder, but they did not have faster responses. We did not find any evidence for the expected specificity in the relationship between the parents' or the children's self-reported anxiety and the children's fear-related associations, as measured with the APT. LIMITATIONS: Reliability of the Affective Priming Task was moderate, and power was low for finding small interaction effects. CONCLUSIONS: Whereas clearly more research is needed, our results suggest that negative associations may qualify as a possible vulnerability factor for children of parents with an anxiety disorder.

Collaborative stepped care v. care as usual for common mental disorders: 8-month, cluster randomised controlled trial.

BACKGROUND: Thus far collaborative stepped care (CSC) studies have not incorporated self-help as a first step. AIMS: To evaluate the effectiveness of CSC in the treatment of common mental disorders. METHOD: An 8-month cluster randomised controlled trial comparing CSC to care as usual (CAU) (Dutch Trial Register identifier NTR1224). The CSC consisted of a stepped care approach guided by a psychiatric nurse in primary care with the addition of antidepressants dependent on the severity of the disorder, followed by cognitive-behavioural therapy in mental healthcare. RESULTS: Twenty general practitioners (GPs) and 8 psychiatric nurses were randomised to provide CSC or CAU. The GPs recruited 163 patients of whom 85% completed the post-test measurements. At 4-month mid-test CSC was superior to CAU: 74.7% (n = 68) v. 50.8% (n = 31) responders (P = 0.003). At 8-month post-test and 12-month follow-up no significant differences were found as the patients in the CAU group improved as well. CONCLUSIONS: Treatment within a CSC model resulted in an earlier treatment response compared with CAU.

Working Mechanisms of Exposure and Response Prevention in the Treatment of Tourette Syndrome and Tic Disorders Revisited: No Evidence for within-Session Habituation to Premonitory Urges.

BACKGROUND: Exposure and response prevention (ERP) has been shown to be an effective treatment for Tourette syndrome (TS) and chronic tic disorders (CTD). ERP is based on voluntary tic suppression in combination with prolonged exposure to premonitory urges preceding tics. A prevailing hypothesis of the working mechanism underlying ERP in tics is habituation to the premonitory urges as a result of prolonged exposure. However, results so far are equivocal. This study aims to further explore the relation between urges and ERP in tics, by investigating the course of premonitory urges during ERP sessions. METHODS: Using a data-driven approach, within-session habituation to premonitory urge intensity was investigated. In total, 29 TS patients rated urge intensity at seven timepoints during ten 1 h ERP sessions. RESULTS/CONCLUSIONS: Latent growth modeling showed an increase in urge intensity during the first 15 min of each session followed by a plateau in the remaining 45 min of the session. This does not support the idea of within-session habituation to premonitory urges as a working mechanism of ERP. Other potential underlying working mechanisms are discussed and should be tested in future research.

Predictors for treatment outcome of binge eating with obesity: a naturalistic study.

This study examines predictors of short-term treatment outcome for obese individuals with binge eating disorder (BED). A battery of assessment questionnaires was given to 212 patients on admission of a CBT day-treatment program for BED. Treatment outcome assessed by changes in eating disorder symptomatology was measured in 182 completers. Linear regression analyses indicated that a combination of variables at baseline predicted 26% of the variance in treatment outcome. High social embedding and higher scores on openness (NEO-PI-R) were significantly related to more improvement after treatment. Higher scores on depressive symptoms (BDI), agoraphobia (SCL-90) and extraversion (NEO-PI-R) were significantly related to less improvement. The analyses show that the level of social embedding and psychopathological comorbidity (state and trait) are predictors for treatment outcome. This study confirms the notion that social context and comorbidity need to be taken into account as described in treatment guidelines of NICE and APA for BED.

Effectiveness of Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality problems in a 'real-world' sample: moderation by diagnosis or severity?

BACKGROUND: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment for borderline personality disorder (BPD). Two prior randomized controlled trials (RCTs) have shown the efficacy of this training. In both RCTs, patients with borderline features who did not meet the DSM-IV criteria for BPD were excluded, which were many. We investigated the effectiveness of STEPPS in a sample representative of routine clinical practice and examined whether DSM-IV diagnosis and/or baseline severity were related to differential effectiveness. METHODS: Patients whom their practicing clinician diagnosed with BPD were randomized to STEPPS plus adjunctive individual therapy (STEPPS, n = 84) or to treatment as usual (TAU, n = 84). RESULTS: STEPPS recipients showed more improvement on measures of general and BPD-specific psychopathology as well as quality of life than TAU recipients, both at the end of treatment and at a 6-month follow-up. Presence of DSM-IV-diagnosed BPD was not related to differential treatment effectiveness, but dimensional measures of symptom severity were; STEPPS was superior to TAU particularly in patients with higher baseline severity scores. CONCLUSIONS: The findings show the effectiveness of STEPPS in a 'real-world' sample, and underscore the importance of dimensional versus categorical measures of personality disturbance.

EEG findings in burnout patients.

The concept of burnout remains enigmatic since it is only determined by behavioral characteristics. Moreover, the differential diagnosis with depression and chronic fatigue syndrome is difficult. EEG-related variables in 13 patients diagnosed with burnout syndrome were compared with 13 healthy comparison subjects in order to explore the existence of neurobiological markers for burnout. Burnout patients showed reduced P300 amplitude, a lower alpha peak frequency and reduced beta power. These EEG-related differences in burnout patients differ from those described in the literature in depression and chronic fatigue patients. Our preliminary findings suggest that burnout might be considered as a separate clinical syndrome.

A randomized controlled trial of a Dutch version of systems training for emotional predictability and problem solving for borderline personality disorder.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment for persons with borderline personality disorder (BPD) that is relatively easy to implement. We investigated the efficacy of a Dutch version of this treatment (VERS). Seventy-nine DSM-IV BPD patients were randomly assigned to STEPPS plus an adjunctive individual therapy, or to treatment as usual. Assessments took place before and after the intervention, and at a 6-month follow-up. STEPPS recipients showed a significantly greater reduction in general psychiatric and BPD-specific symptomatology than subjects assigned to treatment as usual; these differences remained significant at follow-up. STEPPS also led to greater improvement in quality of life, especially at follow-up. No differences in impulsive or parasuicidal behavior were observed. Effect sizes for the differences between the treatments were moderate to large. The results suggest that the brief STEPPS program combined with limited individual therapy can improve BPD-treatment in a number of ways.

Stepped-care versus treatment as usual in panic disorder: A randomized controlled trial.

Stepped-care (SC) models for anxiety disorders are implemented on a large scale and are assumed to be as effective for the greater majority of patients as more intensive treatment schemes. To compare the outcomes of SC and international guideline-based treatment (Treatment as Usual: TAU) for panic disorder, a total of 128 patients were randomized to either SC or TAU (ratio 2: 1, respectively) using a computer generated algorithm. They were treated in four mental health care centres in the Netherlands after therapists had been trained in SC by a senior expert therapist. SC comprised 10-week guided self-help (pen-and-paper version) followed, if indicated, by 13-week manualized face-to-face cognitive behavioural therapy (CBT), with medication- if prescribed- kept constant. TAU consisted of 23-week regular face-to-face CBT (RCBT) with medication -when prescribed- also kept constant. The means of the attended sessions in the SC condition was 5.9 (SD = 4.8) for ITT and 9.6 (SD = 9.6) for the RCBT condition. The difference in the number of attended sessions between the conditions was significant (t(126) = -3.87, p < .001). Remission rates between treatment conditions did not differ significantly (SC: 44.5%; RCBT: 53.3%) and symptom reduction was similar. Stepping up SC treatment to face-to-face CBT showed a minimal additional effect. Importantly, drop-out rates differed significantly for the two conditions (SC: 48.2%; RCBT: 26.7%). SC was effective in the treatment of panic disorder in terms of symptom reduction and remission rate, but dropout rates were twice as high as those seen in RCBT, with the second phase of SC not substantially improving treatment response. However, SC required significantly less therapist contact time compared to RCBT, and more research is needed to explore predictors of success for guided self-help interventions to allow treatment intensity to be tailored to patients' needs and preferences.

The effect of feedback-informed cognitive behavioral therapy on treatment outcome: A randomized controlled trial.

OBJECTIVE: Previous studies have shown that feedback-informed treatment can improve outcomes of psychological treatments. This randomized controlled effectiveness trial evaluated the effect of progress feedback on treatment duration, symptom reduction, and dropout in individual cognitive behavioral therapies (CBTs). A control condition where CBT was combined with low-intensive monitoring of progress was compared to an experimental condition where CBT was combined with a high-intensive form of feedback. METHOD: Data of 368 outpatients (57.9% female, mean age 41.4 years, SD = 12.2) in secondary care were analyzed using multilevel analyses. Treatment duration was assessed with the number of sessions clients received. Symptom reduction was measured with the Symptom Checklist Revised. Possible moderators of the effect of intensive progress feedback on outcome were explored. RESULTS: Clients achieved the same amount of symptom reduction in significantly fewer sessions in the high-intensive feedback condition. Additionally, dropout was significantly lower in the high-intensive feedback condition. Post hoc analyses assessing clients' diagnoses as a possible moderator showed that clients with personality disorders (mainly Cluster C) achieved more symptom reduction in fewer sessions when high-intensity feedback was provided. Also, a high degree of implementation within the experimental condition was associated with fewer treatment sessions. CONCLUSION: In sum, the use of high-intensive client feedback reduced treatment duration and reduced dropout of CBT. Thus, feedback-informed CBTs seem to be a promising adaptation of conventional CBT. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Influence of sleep on symptom improvement and return to work in clinical burnout.

OBJECTIVES: The current study examined the extent to which symptom improvement and full return to work occurs among clinically burnt-out employees and what the influence of concurring sleep problems is with respect to health recovery. METHODS: Fifty-nine burnt-out employees on extended sick leave assessed their symptoms for 2 weeks using an electronic diary. After 6 months, the measurements were repeated. Symptom levels were compared with those of a healthy reference group that was assessed only once. RESULTS: After 6 months, all burnout symptoms had decreased significantly, and full return to work was achieved by 37% of the burnt-out individuals. The symptom levels at 6 months of follow-up among those who had fully returned to work were similar to healthy levels and significantly lower than the levels of those still on sick leave. The persons who benefited poorly from sleep at baseline had higher exhaustion levels at follow-up than those who benefited from sleep. Trouble falling asleep and less refreshing sleep at baseline hampered eventual full work resumption. CONCLUSIONS: The results show that a significant number of clinically burnt-out employees is able to recover in a 6-month period and that sleep plays an important role both in symptom improvement and in return to work.

Clinical burnout is not reflected in the cortisol awakening response, the day-curve or the response to a low-dose dexamethasone suppression test.

Burnout is presumed to be the result of chronic stress, and chronic stress is known to affect the HPA-axis. To date, studies on HPA-axis functioning in burnout have showed inconsistent results. In the present study, a large sample (n=74) of clinically diagnosed burnout individuals, mostly on sick-leave, were included and compared with 35 healthy controls. Salivary cortisol was sampled on 2 days to determine the cortisol awakening response (CAR) and the day-curve. In addition, the dexamethasone suppression test (DST) was applied to assess the feedback efficacy of the HPA-axis. There were no differences observed in the CAR, day-curve or CAR after DST in the burnout group as compared to a healthy control group. Burnout shows overlap in symptoms with chronic fatigue syndrome (CFS) and depression. Therefore, differential changes in HPA-axis functioning that resemble the hypo-functioning of the HPA-axis in CFS, or rather the hyper-functioning of the HPA-axis in depression, might have obscured the findings. However, no effect of fatigue or depressive mood on HPA-axis functioning was found in the burnout group. We concluded that HPA-axis functioning in clinically diagnosed burnout participants as tested in the present study, seems to be normal.

A longitudinal study on cortisol and complaint reduction in burnout.

Several studies have investigated the association between burnout and HPA-axis functioning, but the results are far from consistent. This does not preclude the possibility that within a group of burnout patients a recovery of symptoms in a longitudinal course corresponds to (changes in) cortisol parameters. The latter possibility is tested in the present study before and after treatment, and at follow-up. HPA-axis functioning and burnout complaints were assessed in burned-out participants at baseline (n=74), post-treatment (n=62) and at follow-up (n=53). Multilevel regression analysis was used to test the hypothesis. Burnout complaints were significantly reduced at 8.5 months post-treatment, but there was no further reduction in complaints at follow-up 6.3 months later. Cortisol after awakening, and after dexamethasone intake showed no changes from baseline to post-treatment and follow-up. There was a small decline in cortisol during the day over the longitudinal course. The cortisol level after awakening in the longitudinal course showed significant positive association with the initial exhaustion level, a negative association with the change in the burnout exhaustion score, and a positive association with the change in depression. Although these associations are statistically significant, they only explain a small fraction of the variance in cortisol after awakening between and within persons. This implies that changes at symptom level are hardly related to changes in cortisol functioning, therefore the clinical implications of this finding are limited.

Cortisol deviations in people with burnout before and after psychotherapy: a pilot study.

Burnout is characterized by exhaustion, cynicism, and feelings of reduced competence. These complaints may be reflected in disturbances in the main stress regulatory endocrine system: the hypothalamus pituitary adrenal (HPA) axis. In this study, the HPA-axis hormone cortisol was sampled after awakening and during the day in 22 participants with clinical burnout and in 21 healthy controls. The cortisol level after awakening was shown to be significantly lower in the burnout group as compared with the control group. Cortisol levels during the day did not differ. The same sampling procedure was repeated after 14 sessions of psychotherapeutic intervention. The intervention led to a significant reduction in complaints and to an increase of the initially lowered morning cortisol levels. No consistent correlations, however, between the changes in subjective complaints and the change in cortisol parameters were found.

The effectiveness of a convergence dialogue meeting with the employer in promoting return to work as part of the cognitive-behavioural treatment of common mental disorders: A randomized controlled trial.

BACKGROUND: Dialogue between supervisor and employee is of great importance for occupational rehabilitation. OBJECTIVE: To evaluate the effectiveness of a convergence dialogue meeting (CDM) of employee, therapist and supervisor aimed at facilitating return to work (RTW) as part of cognitive-behavioural treatment. METHODS: Randomized controlled trial including 60 employees sick-listed with common mental disorders and referred for specialized mental healthcare. Employees were randomly allocated either to an intervention group (n = 31) receiving work-focused cognitive-behavioural therapy plus CDM or a control group (n = 29) receiving work-focused cognitive-behavioural therapy without CDM. RESULTS: The time to first RTW was 12 days shorter (p = 0.334) in the intervention group, although full (i.e., at equal earnings as before reporting sick) RTW took 41 days longer (p = 0.122) than the control group. The odds of full RTW at the end of treatment were only 7% higher (p = 0.910) in the intervention group as compared to the control group. CONCLUSIONS: CDM did not significantly reduce the time to RTW. We recommend that therapists who are trained on CDM focus on barriers and solutions for RTW.