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  #1  
Unread June 6th, 2005, 09:42 PM
James Pretzer James Pretzer is offline
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Default Improving Outcomes in CBT

Antony, Ledley, and Heimberg have a new book coming out in the Fall of 2005 Improving Outcomes and Preventing Relapse in Cognitive-Behavioral Therapy which I recommend highly. Each chapter takes a major Axis I problem and summarizes empirically-supported treatment approaches. The authors then provide clear, practical suggestions for overcoming problems encountered when treating that disorder, getting better results, and
reducing the risk of relapse. It will be an excellent resource both for therapists working to master CBT and for seasoned practitioners who want to increase their effectiveness.

Antony et al's book got me thinking about additional options for increasing the effectiveness of CBT. I'll post some ideas here and I'd encourage you to post ideas and questions as well.
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  #2  
Unread June 6th, 2005, 09:46 PM
James Pretzer James Pretzer is offline
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Default Improving Outcomes in CBT with SMI

CBT has made major advances in treating serious mental illness effectively in recent years but there is room for considerable improvement. A "Training Grid" outlining best practices for improved outcomes for people with serious mental illness has been developed by the CAPP Task Force on Serious Mental Illness. It is intended to assist providers in identifying interventions appropriate for their settings and those they serve, identifying need for advanced clinical training, and finding out how to access clinicians and researchers who have developed, implemented, and/or studied the outcomes of the interventions and instruments described.

It can be found at http://www.apa.org/practice/grid.html
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  #3  
Unread June 9th, 2005, 09:17 PM
James Pretzer James Pretzer is offline
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Default Improving Outcomes in CBT with "Recalcitrant Populations"

The Winter, 2005 edition of Cognitive and Behavioral Practice includes a special series "Adapting CBT for Recalcitrant Populations." The series includes articles on CBASP for Chronic depression, Sensation-focused Intensive Treatment for Panic with Agoraphobia, Treatment of Refractory OCD, Treatment for PTSD Related to Childhood Abuse, and a Broad Spectrum Treatment for Alcohol Dependence.

The series on "Recalcitrant Populations" is followed by a special series on CT with Bipolar Disorder, an article on enhancing couple therapy, and three articles on CBT with children. All in all, very promising.
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  #4  
Unread June 16th, 2005, 09:25 PM
James Pretzer James Pretzer is offline
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Default Feedback improves performance

While not specific to CBT, a number of authors argue that feedback about clients' response to therapy (or lack thereof) improves therapists' performance (see summaries in Brickman, 1999 and Gray & Lambert, 2001). Some studies show that when therapists are systematically provided with feedback about how each client's degree of improvement compares with the amount of improvement that would normally be expected, experienced therapists end up being more efficient and effective.

Why is it important to have a system in place for systematically assessing the client's degree of improvement and providing feedback? Because clinicians' unsystematic impressions regarding clients' degree of improvement turn out not to be very accurate. Research shows that we're subject to a variety of biases and often aren't very good at realizing when our judgements are biased.

The idea of developing systematic ways of monitoring clients' progress and providing therapists with useful feedback seems quite reasonable and I think is has considerable potential. However, the way in which this process is implemented can make a big difference in whether it ends up being effective (and cost-effective) or not. Thus far, most of the attempts at monitoring outcomes and providing feedback which I've seen have meant extra paperwork for therapists and clients without doing anything to improve outcomes.
Brickman, L. (1999). Practice makes perfect and other myths about mental health services. American Psychologist, 965-978.

Gray, G. V. & Lambert, M. J. (2001). Feedback: A key to improving therapy outcomes. Behavioral Healthcare Tomorrow, 25 - 26, 45.
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  #5  
Unread September 3rd, 2005, 09:26 PM
James Pretzer James Pretzer is offline
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Default Improving Outcomes in CBT by reducing premature termination

Surveys show that nearly half of people who begin psychotherapy, individual, group, or couples, quit, dissatisfied, against the therapist's recommendation. An article in the Harvard Review of Psychiatry, discusses why this happens so often and suggests some ways to prevent it. Here's my summary of a summary of the article which I received [My comments are italicized and in brackets. Note that the article is about psychotherapy in general, not CBT].

The authors note some reasons why patients drop out: they are unwilling to open up about themselves, they cannot agree with the therapist about what the problem is,they just don't get along with or feel confidence in the therapist, they believe they are not improving quickly enough, or they have unrealistic expectations.

The result, often, is that the patient feels like a failure. His or her problems are likely to get worse, and the symptoms are more likely to become chronic. When a patient drops out of group therapy, other group members may feel abandoned and group cohesion may be damaged. Psychotherapists may be demoralized because they feel rejected, and this feeling may interfere with the treatment of other patients.

What can be done about it? The authors base their recommendations on several dozen research studies and clinical descriptions they found.

Patient selection: Before starting therapy, it may help to screen patients for a good match to the therapist and the therapy. There's some evidence that screening questionnaires for psychodynamic and cognitive behavioral therapy can help to distinguish patients who will complete therapy from those who won¹t. With reliable screening, patients at high risk for dropping out might be offered a different treatment, or specific preparation for treatment.

Preparation: Before beginning psychotherapy, some patients need to be educated about the process. They can be given an explanation of the rationale, the roles and obligations of patient and therapist, expected difficulties and realistic hopes. This can be done with audiotaped or videotaped instructions, [or by the therapist discussing this with them].

Short-term or time-limited therapy: When the treatment is brief or has a fixed end point, dropout rates tend to be lower, in some studies, as much as 50% lower. As the authors note, that is partly because the less time a patient spends in therapy, the less opportunity there is for premature termination. But knowing when it will end may provide a sense of urgency and purpose that prevents patients from becoming discouraged.

Negotiation. Therapist and patient should agree in advance on the means and ends of therapy, what this person needs to accomplish and how it is to be accomplished. Negotiation is especially important in group therapy because otherwise, patients referred to groups may think that the unique features of their own situation are being ignored.

Case management: This is sometimes necessary to solve problems that make psychotherapy difficult, such as lack of adequate housing or employment or a disastrous family situation. Case management today is used mainly for people suffering from severe mental illness, especially those with low income and little education. One study found that case management for severelydepressed patients in group therapy reduced the rate of quitting by 50%. [Note: this is totally different from the "case management" offered by many MCOs and insurance companies.]

Motivational enhancement: Sometimes the problem is that the patient is not yet sufficiently willing or ready to change. Motivational enhancement aims to promote confidence in the ability to change and create a climate in which commitment to change becomes possible. It is already common in the treatment of alcoholism, drug addiction, and eating disorders. [see Miller & Rolnick's book on Motivational Interviewing.]

Establishing the therapeutic alliance: Many studies have shown that the critical feature of all successful psychotherapy is a strong working relationship between the patient and the therapist. There is no formula for achieving it, although warmth, empathy, respect, and interest are always important. The alliance should be formed quickly; some believe that if it does not develop within the first three sessions, it never will.

Appointment reminders: Reminding patients of their appointments is routine for many health care professionals but sometimes avoided by psychotherapists because they want to promote responsibility in patients, or because they believe it¹s better to explore the meanings behind cancellations. The authors suggest that encouraging consistent attendance is more important.

Facilitating expression of feelings: The therapist must create an atmosphere in which a patient can safely discuss uncomfortable feelings, doubts, and questions about the therapy and the therapist. Otherwise, the patient may become uneasy and abandon the therapeutic project.

The authors note that there has been far too little research on this subject. They point out that no single strategy will work for all patients and in all situations, and they recommend that clinicians try several approaches. But only more research will make it possible to compare ways of preventing dropouts and to suggest more specific recommendations.

References

Ogrodniczuk JS, et al. (2005). Strategies for Reducing Patient-Initiated Premature Termination of Psychotherapy, Harvard Review of Psychiatry, 13, No. 2, pp. 57& 70
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  #6  
Unread October 7th, 2005, 09:40 PM
James Pretzer James Pretzer is offline
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Default Getting Better Results from Homework Assignments

Detweiler-Bedell & Whisman (2005) have published a study that examines whether the way in which homework is assigned and reviewed influences the outcome of CT for depression. They found that outcomes were better when the therapist set concrete homework goals (e.g. specified the amount of homework to do, how often to do the homework, or how much time to spend on it) and/or provided written reminders of the assignment for the client to take home. Client involvement in homework assignment and homework review were also associated with better outcomes.
Detweiler-Bedell, J. B. & Whisman, M. A. (2005). A lesson in assigning homework: Therapist, client, and task characteristics in cognitive therapy for depression. Professional Psychology: Theory, Research, and Practice, 36, 219-223.
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