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James Pretzer May 23rd, 2005 09:35 PM

Long-term follow-up of CT/CBT with Panic/Agoraphobia
I recently stumbled across a study with truly long-term follow-up. Fava and his colleagues (2001) collected follow-up data on a sample of 132 patients treated for panic disorder and agoraphobia. The subjects were panic-free following 12 sessions of exposure therapy and were re-assessed 2 to 14 years following treatment (mean 8 years). According to the summary I came across, 23% had a relapse during the follow-up period while 62.1% remained in remission after 10 years. Relapse rates were higher for subjects who were younger, were more depressed, had residual agoraphobic avoidance at the close of treatment, or who were using medication concurrently with CBT.

For details see:
Fava, G. A., Rafanelli, C. Grandi, S., Conti, s., Ruini, C., Magelli, L., & Belluardo, P. (2001). Long-term outcome of panic disorder with agoraphobia treated by exposure. Psychological Medicine, 31, 891-898.

Palamino May 30th, 2005 12:55 AM

Re: What uncertainties do we face in CT/CBT?
Read Gordon Bower, particularly his associative network is so clear and includes the important role of cognition and behavior.

Doug William September 15th, 2005 06:24 PM

Re: What uncertainties do we face in CT/CBT?
I probably should have started a new thread for this, but.........And I hope this will generate responses from other people as well as Dr. Pretzer.

In the training of therapists, is supervision still primarily conducted in the third person? That is, where the therapist reports to a supervisor in a separate office about the content of a session? Throughout my training this often seemed so odd, because in most every other trade the apprentice both has the opportunity to observe his teacher or mentor, and the mentor has the opportunity to directly observe and guide the student or apprentice. In a profession where so much communication takes place outside the literal utterance of words on both the therapist's part and the patient's part, I have always been puzzled by the supervisors distance from the actual treatment and the assumption that progress can adequate determined in this way. Since it it clear from all the postings here that CBT is not simply a technology to be followed or a checklist to be followed, is anything happening to improve the training of therapists. I am sure I am not the only one to have wondered about this, but I rarely read about other training models. Of course, I understand that the typical supervisory model is the most time effective and I guess cost effective system to follow--- has a combination of supervisory methods been tried?? And I'm talking about a sustained supervision where the supervisor is always in the therapy room? Psychodynamic training programs always had their reasons for not doing this- although for training purposes these reasons never made sense to me.



James Pretzer September 23rd, 2005 10:06 PM

Supervision in CT/CBT?
There are real drawbacks to basing supervision on the supervisee's description of a therapy session. The supervisor only hears about the things the supervisee noticed, remembered, and is willing to report. Obviously, this could mean that the supervisor misses out on important information. The supervisor also has limited opportunity to independently evaluate the supervisee's conceptualization, treatment plan, and interventions because all the data is filtered through the supervisee.

An apprenticeship model where the supervisee sits in and observes sessions the supervisor is conducting and where the supervisor sits in on sessions the supervisee is conducting, is not a bad concept (I think Dave Burns wrote a chapter on supervision based on this model). Unfortunately, in real life this would take a lot of time (and thus be expensive) and would be a real scheduling headache in most settings. Also, having a third party sitting in the room can really distort the therapist-client interaction.

There are other solutions that are more practical. Often the easiest way for the supervisor to model the desired behavior and to observe the supervisee's behavior is to review recordings of sessions. Supervisor and supervisee can review and discuss videos (or audio recordings) of the supervisor or other experienced therapists doing CT and can review recordings of the supervisee's sessions. This provides more detailed (and less biased) data that the supervisee's description of the session.

One can also observe live sessions through one-way mirrors or closed-circuit TV but this ends up being more time-consuming and more of a scheduling problem that reviewing tapes. An advantage of observing live sessions is that the supervisor can potentially coach the supervisee during the session. I've seen this done through the use of a "bug-in-the-ear" (i.e. an earpiece that relays the supervisor's instructions) or by phoning the supervisee during the session. I've also seen it done by having the therapist stop half-way through the session to step out of the room and consult with the supervisor. From what I've seen, each of these methods seems somewhat disruptive and I'm not sure they add much.

I do find that reviewing videos adds a lot.

Doug William September 27th, 2005 10:14 PM

Supervision: The Student's Point of View
Students Out There!!!

Please read the last two posts in this thread. This is a topic that should be close to all of your hearts!!!

What do you think about this subject-- especially for those of you going through supervision now?


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