Cognitive-behavioral therapy for bulimia nervosa: Time course and mechanisms of change.

Cognitive-behavioral therapy (CBT) is an effective treatment of bulimia nervosa, but its mechanisms of action have not been established. In this study the authors analyzed the results of a randomized control trial comparing CBT with Interpersonal Psychotherapy (IPT) to identify possible mediators of change of CBT for BN and its time course of action. Reduction in dietary restraint as early as Week 4 mediated posttreatment improvement in both binge eating and vomiting. Measures of self-efficacy concerning eating behavior, negative affect, and body shape and weight at midtreatment were also significantly associated with posttreatment outcome at 20 wks. No evidence was found that the therapeutic alliance mediated treatment outcome. CBT had a significantly more rapid treatment effect than IPT, with 62% of posttreatment improvement evident by Week 6. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic Alliance and Treatment Adherence in Two Interventions for Bulimia Nervosa: A Study of Process and Outcome.

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist × Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluating alliance-focused intervention for potential treatment failures: A feasibility study and descriptive analysis.

This article describes a pilot study evaluating the feasibility of an approach developed to test the efficacy of a therapeutic intervention (brief relational therapy) for patients with whom it is difficult to establish a therapeutic alliance. In the first phase of the study, 60 patients were randomly assigned to either short-term dynamic therapy (STDP) or short-term cognitive therapy (CBT), and their progress in the first eight sessions of treatment was monitored. On the basis of a number of empirically derived criteria, 18 potential treatment failures were identified. In the second phase of the study, these identified patients were offered the option of being reassigned to another treatment. The 10 patients who agreed to switch treatments were reassigned either to the alliance-focused treatment, referred to as brief relational therapy (BRT), or a control condition. For patients coming from CBT, the control condition was STDP. For patients coming from STDP, the control condition was CBT. The results provide preliminary evidence supporting the potential value of BRT as an intervention that is useful in the context of alliance ruptures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reflective-functioning during the process in brief psychotherapies.

Reflective-functioning (RF) is the ability to recognize the existence and nature of mental processes taking place in the self and in others (e.g., intentions and wishes). RF was investigated here as a patient variable during the process in two studies of brief psychotherapy. The first study investigated cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) in the TDCRP sample. The second study investigated psychodynamic psychotherapy (BPDT). The Psychotherapy Process Q-set (PQS) was implemented to identify process correlates associated with high and low RF in order to distinguish which specific components in the psychotherapeutic process are related to RF. Process correlates defining high RF had good outcome, and process correlates defining low RF had poor outcome. RF remained stable or decreased during treatments and was linked with personality characteristics in the patients. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Therapeutic alliance and clinical outcome in the NIMH Treatment of Depression Collaborative Research Program: Preliminary findings.

Investigated the effect of the therapeutic alliance on clinical outcome in the 7 most improved and 7 least improved cases in the 4 treatments investigated in a study (I. Elkin et al; see PA, Vols 72:20648 and 77:10249) of treatment of depression. The treatments were interpersonal therapy (IPT), cognitive-behavior therapy, imipramine plus clinical management, and placebo plus clinical management. Clinical observer ratings of alliance, using Vanderbilt Therapeutic Alliance Total Scale scores, were compared across and within treatment groups and were related to clinical status at termination. Despite selective, significant relationships between alliance and outcome across treatments, the alliance–outcome relationship was significant only for IPT within treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents.

This study evaluated the efficacy of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) with depressed adolescents in Puerto Rico. Seventy-one adolescents meeting Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) criteria for a diagnosis of depression were randomly assigned to 1 of 3 conditions: CBT, IFT, or wait list (WL). Pretreatment, posttreatment, and 3-month follow-up measures of depression symptoms, self-esteem, social adjustment, family emotional involvement and criticism, and behavioral problems were completed. Results suggest that IPT and CBT significantly reduced depressive symptoms when compared with the WL condition. IPT was superior to the WL condition in increasing self-esteem and social adaptation. Clinical significance tests suggested that 82% of adolescents in IPT and 59% of those in CBT were functional after treatment. The results suggest that both IPT and CBT are efficacious treatments for depressed Puerto Rican adolescents. IPT's impact in other levels of outcome is discussed in terms of its consonance with Puerto Rican cultural values. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of coping-oriented couples therapy on depression: A randomized clinical trial.

The aim of this study was to evaluate the effectiveness of treating depression with coping-oriented couples therapy (COCT) as compared with cognitive-behavioral therapy (CBT; A. T. Beck, C. Ward, & M. Mendelson, 1961) and interpersonal psychotherapy (IPT; M. M. Weissman, J. C. Markowitz, & G. L. Klerman, 2000). Sixty couples, including 1 clinically depressed partner, completed pre- and posttest questionnaires as well as follow-up assessments at 6-month intervals over the subsequent 1.5 years. Effects of the 3 treatments on depressive symptomatology assessed by the Beck Depression Inventory (A. T. Beck, A. J. Rush, B. L. Shaw, & G. Emery, 1979) and Hamilton Rating Scale for Depression (M. Hamilton, 1960); recovery rates; and relapse rates were examined. Additionally, changes in relationship quality were evaluated. Results suggest that the COCT is as effective in improving depressive symptomatology as are the well-established, evidenced-based CBT and IPT approaches. The COCT did not demonstrate a significantly better outcome with regard to self-reported relationship satisfaction or dyadic coping; however, it did produce significant improvements in partners' expressed emotion, changes that were not seen in other treatment conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient interpersonal impacts and the early therapeutic alliance in interpersonal therapy for depression.

The therapeutic alliance consistently predicts positive psychotherapy outcomes. Thus, it is important to uncover factors that relate to alliance development. The goal of this study was to examine the association between patient interpersonal characteristics and alliance quality in interpersonal therapy for depression. Data derive from a subsample (n = 74) of a larger naturalistic database of outpatients treated at a mood disorders clinic of a university-affiliated psychiatric hospital. Following Session 3 of treatment, therapists completed the Impact Message Inventory (Kiesler & Schmidt, 1993) to assess patients' interpersonal impacts on them. Also following Session 3, patients completed the Working Alliance Inventory (Horvath & Greenberg, 1989) to assess alliance quality. As predicted, patients' affiliative interpersonal impacts, as perceived by their therapists, were positively associated with alliance quality, controlling for baseline depression severity. Although unrelated to the initial hypotheses, patients concurrently taking psychotropic medications reported better alliances than patients receiving psychotherapy only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attachment as moderator of treatment outcome in major depression: A randomized control trial of interpersonal psychotherapy versus cognitive behavior therapy.

Anxiety and avoidance dimensions of adult attachment insecurity were tested as moderators of treatment outcome for interpersonal psychotherapy (IPT) and cognitive- behavioral therapy (CBT). Fifty-six participants with major depression were randomly assigned to these treatment conditions. Beck Depression Inventory-II, Six-Item Hamilton Rating Scale for Depression scores, and remission status served as outcome measures. Patients higher on attachment avoidance showed significantly greater reduction in depression severity and greater likelihood of symptom remission with CBT as compared with IPT, even after controlling for obsessive-compulsive and avoidant personality disorder symptoms. Results were replicated across treatment completers and intent-to-treat samples. These results suggest that it is important to consider the interaction between attachment insecurity and treatment type when comparing efficacy of treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems.

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The potential value of integral membrane proteins in the vaccination of lambs against Haemonchus contortus

Cognitive-behavioral therapy (CBT) is applicable to all eating disorders but has been most intensively studied in the treatment of bulimia nervosa (BN). CBT is designed to alter abnormal attitudes about body shape and weight, replace dysfunctional dieting with normal eating habits, and develop coping skills for resisting binge eating and purging. CBT is effective in reducing all core features of BN and shows good maintenance of therapeutic improvement. Although superior to therapy with antidepressant drugs, CBT has not been shown to be consistently superior to alternative psychological treatments. Different hypotheses about CBT's mechanisms of action are discussed.     

How effective and acceptable is a self-treatment manual with concomitant brief therapy in bulimia nervosa

We compared 8 fortnightly sessions plus a self-care manual (guided self change, GSC) with 16 weekly individual sessions of cognitive behaviour therapy (CBT). There were 31 sufferers of DSM-III-R-bulimia nervosa (BN) in each group. Both treatments resulted in significant improvements regarding self and interviewer based measures of bulimia nervosa as well as depression, self-esteem, quality of life and knowledge about nutrition, weight and shape. There were no significant differences between therapies regarding drop-out rate, compliance with follow-up, and the number of patients receiving additional treatment. At none of the assessments was there a significant difference between GSC and CBT regarding severity of BN, Beck Depression Inventory-score, self-esteem, and quality of life. A significantly higher percentage of CBT-patients were abstinent from bingeing for at least one week at the end of treatment. Three months later, the GSC-group had caught up in this respect and knew more about nutition, weight and shape. Only the sum-scores on a BN self-rating scale were worse for GSC than CBT at the end of therapy and at follow-up. There were no significant differences between the two groups in general treatment satisfaction and judgement about the usefulness of the therapies. Thus, guided self change with a selfcare manual can save therapist time without impinging significantly on treatment satisfaction and effectiveness.     

Does interpersonal therapy help patients with binge eating disorder who fail to respond to cognitive-behavioral therapy?

The aim of this quasi-experimental study was to examine the effectiveness of group interpersonal therapy (IPT) in treating overweight patients with binge eating disorder who did not stop binge eating after 12 weeks of group cognitive-behavioral therapy (CBT). Participants in this study were randomly allocated to either group CBT or to an assessment-only control group. After 12 weeks of treatment with CBT, 55% of participants met criteria for improvement and began 12 weeks of weight loss therapy, whereas the nonresponders began 12 weeks of group IPT. Over the 24-week period, participants who received treatment reduced binge eating and weight significantly more than the waiting-list control group. However, IPT led to no further improvement for those who did not improve with CBT. Predictors of poor outcome were early onset of, and more severe, binge eating. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive treatments for eating disorders.

Cognitive-behavioral therapy (CBT) is applicable to all eating disorders but has been most intensively studied in the treatment of bulimia nervosa (BN). CBT is designed to alter abnormal attitudes about body shape and weight, replace dysfunctional dieting with normal eating habits, and develop coping skills for resisting binge eating and purging. CBT is effective in reducing all core features of BN and shows good maintenance of therapeutic improvement. Although superior to therapy with antidepressant drugs, CBT has not been shown to be consistently superior to alternative psychological treatments. Different hypotheses about CBT's mechanisms of action are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Group cognitive-behavioral therapy and group interpersonal psychotherapy for the nonpurging bulimic individual: A controlled comparison.

Evaluated the effectiveness of group cognitive-behavioral treatment (CBT) and group interpersonal psychotherapy (IPT) for binge eating. 56 women with nonpurging bulimia were randomly assigned to 1 of 3 groups: CBT, IPT, or a wait-list control (WLC). Treatment was administered in small groups that met for 16 weekly sessions. At posttreatment, both group CBT and group IPT treatment conditions showed significant improvement in reducing binge eating, whereas the WLC condition did not. Binge eating remained significantly below baseline levels for both treatment conditions at 6-mo and 1-yr follow-ups. These data support the central role of both eating behavior and interpersonal factors in the understanding and treatment of bulimia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological versus pharmacological treatments of bulimia nervosa: Predictors and processes of change.

This article extends the acute outcome findings from a study comparing psychological and pharmacological interventions for bulimia nervosa (B. T. Walsh et al., 1997) by examining 3 additional domains: predictive factors, therapeutic alliance, and time course of change. One hundred twenty women were randomized to cognitive-behavioral therapy (CBT), supportive psychotherapy (SPT) plus antidepressant medication or a placebo, or a medication-alone condition. Results indicate that high baseline frequencies of binge eating and vomiting, as well as a positive history of substance abuse or dependence, are negative prognostic indicators. Although a greater overall therapeutic alliance may increase the likelihood of remission, symptom change over the course of treatment may have as much of an impact on patient ratings of alliance as the reverse. CBT was significantly more rapid than SPT in reducing binge eating and vomiting frequencies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Internal validity of Project MATCH treatments: discriminability and integrity

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.     

Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

The authors examined the relation between therapeutic alliance, retention, and outcome for 308 cocaine-dependent outpatients participating in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. High levels of alliance were observed in supportive–expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC), and alliance levels increased slightly but significantly from Session 2 to Session 5 in all groups. In contrast to other studies, alliance was not a significant predictor of drug outcome. However, alliance did predict patient retention differentially across the 3 treatments. In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)