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)     

Self-monitoring in the assessment of eating disorders.

Self-monitoring is a key feature of cognitive behavioral therapy (CBT) for eating disorders. It provides a detailed measure of eating problems and the circumstances under which they occur, but it does not yield precise estimates of amount of caloric intake. It indexes the progress of treatment and helps guide the focus of each therapy session. Adherence to self-monitoring is good provided that therapists implement it skillfully within a collaborative therapeutic alliance. Anorexia nervosa patients may pose a particular challenge in this respect. Self-monitoring may play an important role in the rapid effects of CBT for bulimia nervosa. Preliminary data indicate that self-monitoring of binge eating and purging may provide a valid measure of treatment outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Association Between Patient Characteristics and the Therapeutic Alliance in Cognitive-Behavioral and Interpersonal Therapy for Bulimia Nervosa.

The therapeutic alliance is an established predictor of psychotherapy outcome. However, alliance research in the treatment of eating disorders has been scant, with even less attention paid to correlates of alliance development. The goal of this study was to examine the relation between specific patient characteristics and the development of the alliance in 2 different treatments for bulimia nervosa (BN). Data derive from a large, randomized clinical trial comparing cognitive- behavioral therapy (CBT) and interpersonal therapy (IPT) for BN. Across both treatments, patient expectation of improvement was positively associated with early- and middle-treatment alliance quality. In CBT, baseline symptom severity was negatively related to middle alliance. In IPT, more baseline interpersonal problems were associated with poorer alliance quality at midtreatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Potential Mediators of Cognitive-Behavioral Therapy for Adolescents With Comorbid Major Depression and Conduct Disorder.

Several possible mediators of a group cognitive-behavioral therapy (CBT) for depressed adolescents were examined. Six measures specific to CBT (e.g., negative cognitions, engagement in pleasurable activities) and 2 nonspecific measures (therapeutic alliance, group cohesion) were examined in 93 adolescents with comorbid major depressive disorder and conduct disorder who were randomly assigned to the Adolescent Coping With Depression (CWD-A) course or a life skills control condition. Change on the Automatic Thoughts Questionnaire (S. D. Hollon & P. C. Kendall, 1980) appeared to mediate treatment effects on depressive symptoms. Therapeutic alliance by the 3rd session was higher among the CWD-A participants but did not predict reductions in depressive symptoms. Findings suggest that reducing negative thinking may be the primary mechanism through which the CWD-A intervention reduces depression. (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)     

CBT With Older People: Alterations and the Value of the Therapeutic Alliance.

Cognitive-behavioral therapy (CBT) is empirically supported for use with older people. Reasons for its efficacy are not fully understood--i.e., whether theory-driven techniques or nonspecific "common factors" (such as the therapeutic alliance) are responsible. In this article, the authors discuss age-related psychotherapy components. They address the difficulties of using CBT with older populations and the importance of the TA in therapy with the elderly. Finally, they identify 4 areas where the application of the TA may enhance CBT among older adults: philosophy or socialization, cognitive restructuring, resource building in the context of aging, and affect tolerance. The authors argue that a strong TA can facilitate each of these processes in the application of CBT to current cohorts of older people. (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)     

Review of Roadblocks in Cognitive-Behavioral Therapy: Transforming Challenges Into Opportunities for Change.

This article provides a review of "Roadblocks in Cognitive-Behavioral Therapy: Transforming Challenges Into Opportunities for Change" (see record 2004-00137-000). In the nearly 50 years since cognitive-behavioral treatment (CBT) models were pioneered by Albert Ellis and Aaron Beck, CBT approaches have enjoyed a wide range of applications and considerable empirical and clinical success. A frequent criticism of the CBT model has been that its approaches favor technique and behavioral change over the "substance" of psychotherapy (e.g., therapeutic alliance, resistance, engagement). Designed primarily for clinicians, "Roadblocks in Cognitive-Behavioral Therapy" is well-written and easy to read. In keeping with the tradition of CBT, the authors rely on empirical research to support their tenets, while keeping the emphasis of each chapter on clinical utility. (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.     

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)     

Cognitive therapy of anxiety disorders.

A review of studies of cognitive-behavioral therapy (CBT) for generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia indicates that CBT is consistently more effective than waiting-list and placebo control groups. In general, CBT has proved more beneficial than supportive therapy as well. Comparisons with active behavioral treatments provide more variable results. Converging evidence suggests that cognitive change may be a strong predictor of treatment outcome, but that such change may be produced by a number of therapeutic approaches. Pretest–posttest change with CBT is depicted in meta-analytic summary form for each disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship and techniques in cognitive-behavioral therapy--A motivational approach.

Motivational attunement is presented here as a set of guiding principles that can be used to foster the therapeutic alliance in cognitive-behavioral therapy (CBT). The overarching goal of motivational attunement is to provide the client with need-satisfying experiences. In order to do so, the therapist must attune his or her interventions to the client's motivational goals. The authors attempt to demonstrate how therapists can assess motivational goals and use this information to foster the central components of the alliance. The authors also outline how motivational attunement can be used to prevent and resolve alliance ruptures. Finally, empirical support for the effects of motivational attunement is briefly described. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic alliance and outcome: Impact of treatment length and pretreatment symptomatology.

Studied data collected in 1978–1982 in a research project at a university psychological clinic that provides low-cost services to families in the community. Data consisted of pre- and posttherapy written measures and audiotapes from selected sessions with 40 patients (aged 20–57 yrs). Findings indicate that (1) strength of therapeutic alliance was established within the 1st 3 sessions of therapy with little change over the course of therapy, (2) short length therapy cases had lower levels of therapist positive alliance, (3) therapeutic alliance was predictive of outcome, and (4) therapeutic alliance was adversely affected by pretreatment symptomatology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive behavioral guided self-help for the treatment of recurrent binge eating.

Objective: Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy–effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). Method: In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. Results: At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. Conclusions: CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder.

This study investigated the quality and development of the therapeutic alliance as a mediator of change in schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder. Seventy-eight patients were randomly allocated to 3 years of biweekly SFT or TFP. Scores of both therapists and patients for the therapeutic alliance were higher in SFT than in TFP. Negative ratings of therapists and patients at early treatment were predictive of dropout, whereas increasingly positive ratings of patients in the 1st half of treatment predicted subsequent clinical improvement. Dissimilarity between therapist and patients in pathological personality characteristics had a direct effect on growth of the therapeutic alliance but showed no relationship with clinical improvement. The authors conclude that the therapeutic alliance and specific techniques interact with and influence one another and may serve to facilitate change processes underlying clinical improvement in patients with borderline personality disorder. (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.     

Cost-effectiveness of guided self-help treatment for recurrent binge eating.

Objective: Adoption of effective treatments for recurrent binge-eating disorders depends on the balance of costs and benefits. Using data from a recent randomized controlled trial, we conducted an incremental cost-effectiveness analysis (CEA) of a cognitive–behavioral therapy guided self-help intervention (CBT–GSH) to treat recurrent binge eating compared to treatment as usual (TAU). Method: Participants were 123 adult members of an HMO (mean age = 37.2 years, 91.9% female, 96.7% non-Hispanic White) who met criteria for eating disorders involving binge eating as measured by the Eating Disorder Examination (C. G. Fairburn & Z. Cooper, 1993). Participants were randomized either to treatment as usual (TAU) or to TAU plus CBT–GSH. The clinical outcomes were binge-free days and quality-adjusted life years (QALYs); total societal cost was estimated using costs to patients and the health plan and related costs. Results: Compared to those receiving TAU only, those who received TAU plus CBT–GSH experienced 25.2 more binge-free days and had lower total societal costs of $427 over 12 months following the intervention (incremental CEA ratio of ?$20.23 per binge-free day or ?$26,847 per QALY). Lower costs in the TAU plus CBT–GSH group were due to reduced use of TAU services in that group, resulting in lower net costs for the TAU plus CBT group despite the additional cost of CBT–GSH. Conclusions: Findings support CBT–GSH dissemination for recurrent binge-eating treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Therapeutic Alliance in Cognitive-Behavioral Treatment of Children Referred for Oppositional, Aggressive, and Antisocial Behavior.

The authors examined the therapeutic alliance in evidence-based treatment for children (N = 185, 47 girls, 138 boys; ages 3-14 years) referred clinically for oppositional, aggressive, and antisocial behavior. Different alliances (child-therapist, parent-therapist) were assessed from each participant's perspective at 2 points over the course of treatment. As predicted, both child-therapist and parent-therapist alliances related to therapeutic change, family experience of barriers to participation in treatment, and treatment acceptability. Greater alliance was associated with greater therapeutic change, fewer perceived barriers, and greater treatment acceptability. The findings could not be attributed to the influence of socioeconomic disadvantage, parent psychopathology and stress, and child dysfunction or to rater effects (common rater variance in the predictors and criteria). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing readiness for change in adolescents with eating disorders.

The Readiness and Motivation Interview (RMI) is a semistructured interview measure of readiness and motivation to change that can be used for all eating disorder diagnoses. The RMI has demonstrated excellent psychometric properties and has both clinical and predictive utility in adult samples. This study examined the psychometric properties of the RMI in a younger population, namely, 12- to 18-year-old girls with eating disorders. Study participants (N = 65) completed the RMI and measures of convergent, discriminant, and criterion validity. Adolescents with eating disorders were able to conceptualize and articulate their readiness for change and to report the extent to which change efforts were for themselves versus for others. RMI readiness profiles across eating disorder symptom domains in adolescents were comparable to those in adults, with higher reported readiness to change binge eating than to change dietary restriction or compensatory strategies. Differences in internal consistency between adult and adolescent samples are discussed. Interviewing adolescents early in treatment about readiness may assist clinicians in forming an alliance with this difficult-to-engage population, while also providing valuable information for treatment planning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)