Are results of randomized controlled trials useful to psychotherapists?

Two clinicians provided opposite answers to the title question: Persons argued that information from randomized controlled trials (RCTs) is vital to clinicians, and Silberschatz argued that information from RCTs is irrelevant to clinicians. Persons argued that clinicians cannot provide top quality care to their patients without attending to findings of RCTs and that clinicians have an ethical responsibility to inform patients about, recommend, and provide treatments supported by RCTs before informing patients about, recommending, and providing treatments shown to be inferior in RCTs or not evaluated in RCTs. Silberschatz argued that RCTs do not and cannot answer questions that concern practicing clinicians. He advocates alternative research approaches (effectiveness studies, quasi-experimental methods, case-specific research) for studying psychotherapy.

The role of psychotherapy in the treatment of depression: review of two practice guidelines.

We review two recent practice guidelines' assessments of the role of psychotherapy in the treatment of major depression in adults. We examine the practice guideline published by the American Psychiatric Association (APA) and that published by the Depression Guideline Panel of the Agency for Health Care Policy and Research. We focus on the guidelines' evaluations of psychotherapies, their statements about the role of psychotherapy in first-line treatment of depression, and the procedures they recommend for choosing among psychotherapies. We argue that the APA guideline understates the value of cognitive, behavioral, brief psychodynamic, and group therapies. Both guidelines understate the value of psychotherapy alone in the treatment of more severely depressed outpatients. The APA guideline overvalues the role of combined psychotherapy-pharmacotherapy regimens, particularly in view of the greater cost of this strategy. The APA guideline also makes recommendations about choosing among psychotherapies that are not well supported by empirical evidence. We conclude with some guidelines for guideline development.

Psychodynamic therapists' reservations about cognitive-behavioral therapy : implications for training and practice.

This article offers suggestions for psychodynamic therapists who encounter obstacles while learning cognitive-behavioral therapy (CBT) or working in settings where CBT is used. The authors discuss three types of questions commonly raised by psychodynamic therapists about CBT. These concern 1) the therapeutic relationship, 2) the focus of therapeutic interventions, and 3) the depth of change. To help psychodynamic therapists overcome obstacles to learning CBT, the authors focus on similarities between psychodynamic and cognitive-behavioral models in these three areas. They also examine differences between the models, including differences dependent on value judgments, and offer suggestions for making productive use of differences between the models in the training process.

Relationships between symptoms of depression and anxiety and dysfunctional beliefs about achievement and attachment.

Psychiatric outpatients (N = 293) provided data to test the symptom specificity and final common pathway hypotheses about symptoms of depression and anxiety. The symptom specificity hypothesis predicts that the symptoms reported by a depressed or anxious patient depend on the dysfunctional beliefs he or she endorses. In contrast, the final common pathway hypothesis predicts that symptoms are unrelated to the types of beliefs the patient endorses. These hypotheses were tested in the context of theories that emphasize the importance of dysfunctional beliefs about achievement and attachment. Only limited support for the symptom specificity hypothesis was obtained; support was strongest for the link between attachment beliefs and anxiety symptoms. Relationships between symptoms and dysfunctional beliefs did not depend on psychiatric diagnosis.

Psychotherapy outcome studies do not accurately represent current models of psychotherapy. A proposed remedy.

It is argued that the design of contemporary psychotherapy outcome studies is conceptually incompatible with the models of psychotherapy evaluated in those studies. Contemporary outcome studies are incompatible with psychotherapy models because the outcome studies treat patients with standardized treatments that are assigned on the basis of psychiatric diagnosis rather than with individualized treatments based on a theory-driven psychological assessment of the individual's difficulties. One possible remedy, idiographic outcome studies using a case formulation model of assessment and treatment, is proposed here. It is suggested that this research strategy may narrow the scientist-practitioner gap and make it easier to demonstrate differential outcomes of different treatments.

Endorsement of dysfunctional beliefs depends on current mood state.

In two studies we tested the hypothesis that endorsement of dysfunctional beliefs depends on current mood state for persons who are vulnerable to depression. The first study showed that reports of dysfunctional beliefs vary with spontaneous diurnal mood fluctuations in 47 depressed psychiatric patients. The effect of mood state was highly significant (p less than .01); dysfunctional thinking increased when mood was worst and decreased when mood was best. The second study conceptually replicated this finding in a population of asymptomatic subjects. As predicted, reports of dysfunctional beliefs varied as a function of mood state in 14 persons who had experienced a depressive episode but not in 27 who had never been depressed. These findings support the cognitive theory of depression, which proposes that dysfunctional beliefs are vulnerability factors for depression but also that reporting of dysfunctional beliefs depends on current mood state.

The effect of patients' beliefs about their illnesses on compliance in psychotherapy.

Sixty patients treated in the outpatient psychiatric clinic of a large urban teaching hospital were surveyed regarding their beliefs about the causes of their illness. Patients' beliefs were found to be related to two measures of compliance: number of visits and manner of termination from therapy. Subjects endorsing more medical and fewer nonmedical explanations for their illness made more visits to the clinic and ended treatment in a more compliant manner than did patients who endorsed more nonmedical beliefs about the causes of their illness. Results also showed that, except for age, demographic and diagnostic variables were not related to compliance.

Processes underlying formal thought disorder in psychiatric inpatients.

Three theories about the cognitive processes underlying symptoms of formal thought disorder in psychiatric inpatients were tested. Chapman and Chapman's "excessive yielding to normal bias" theory and a response competition theory were tested by using two ambiguity tasks. Chapman and Chapman's bias theory predicts a smaller ambiguity effect for thought-disordered patients; a response competition hypothesis predicts a larger ambiguity effect. Results showed no difference between thought-disordered and non-thought-disordered patients. To test a distractibility theory of thought disorder, subjects performed a Stroop-type task in which they counted the number of digits (e.g., 3333) or symbols (####) in a set. Thought-disordered patients did show an increased effect of the presence of the digits, and this finding was replicated in a second inpatient sample. Thus, results were consistent with the distractibility theory and with a reformulation of the bias theory, in which the bias shown by thought-disordered patients is not a tendency toward a particular response, but rather toward a particular rule, or set, for responding.