Patients' and therapists' experiences of general change mechanisms during bug-in-the-eye and delayed video-based supervised cognitive-behavioral therapy. A randomized controlled trial.

OBJECTIVE: This secondary analysis of a randomized controlled trial investigated whether bug-in-the-eye (BITE) supervision (live computer-based supervision during a psychotherapy session) affects the manner in which patients and therapists experience general change mechanisms (GCMs) during cognitive-behavioral therapy (CBT). METHOD: A total of 23 therapists were randomized either to the BITE condition or the control condition (delayed video-based [DVB] supervision). After each session, both patients (BITE: n = 19; DVB: n = 23) and therapists (BITE: n = 11; DVB: n = 12) completed the Helping Alliance Questionnaire (HAQ) and the Bernese Post Session Report (BPSR). The HAQ total score and the 3 secondary factors of the BPSR (interpersonal experiences, intrapersonal experiences, problem actuation) functioned as GCMs. Multilevel models were performed. RESULTS: For patients, GCMs did not develop differently between BITE and DVB during CBT. Therapists rated the alliance as well as interpersonal and intrapersonal experiences not significantly different between BITE and DVB during CBT, but they perceived problem actuation to increase significantly more in BITE than in DVB (p < .05). CONCLUSION: BITE supervision might be helpful in encouraging CBT therapists to apply interventions, which focus on the activation of relevant problems and related emotions.

Patient Characteristics and Patient Behavior as Predictors of Outcome in Cognitive Therapy and Exposure Therapy for Hypochondriasis.

OBJECTIVE: Psychotherapy for hypochondriasis has greatly improved over the last decades and cognitive-behavioral treatments are most promising. However, research on predictors of treatment outcome for hypochondriasis is rare. Possible predictors of treatment outcome in cognitive therapy (CT) and exposure therapy (ET) for hypochondriasis were investigated. METHOD: Characteristics and behaviors of 75 patients were considered as possible predictors: sociodemographic variables (sex, age, and cohabitation); psychopathology (pretreatment hypochondriacal symptoms, comorbid mental disorders, and levels of depression, anxiety, and somatic symptoms); and patient in-session interpersonal behavior. RESULTS: Severity of pretreatment hypochondriacal symptoms, comorbid mental disorders, and patient in-session interpersonal behavior were significant predictors in multiple hierarchical regression analyses. Interactions between the predictors and the treatment (CT or ET) were not found. CONCLUSIONS: In-session interpersonal behavior is an important predictor of outcome. Furthermore, there are no specific contraindications to treating hypochondriasis with CT or ET.

Assessment of patient interpersonal behavior: Development and validation of a rating scale.

OBJECTIVE: Patient in-session interpersonal behavior, as part of the therapeutic alliance, is an important aspect of the psychotherapy process and impacts treatment outcome. In the present study, the development and validation of a rating scale of patient in-session interpersonal behavior is described. METHOD: A 10-item rating scale, the Assessment Form of Patient Interpersonal Behavior (AFPIB), was developed using an inductive procedure. The AFPIB was then validated in a sample of patients with hypochondriasis (N = 30), by having two independent raters assess patients' interpersonal behaviors shown in videotaped psychotherapy sessions (N = 60). RESULTS: The AFPIB demonstrated good reliability and validity. CONCLUSIONS: Thus, the AFPIB seems to be a promising rating scale for the assessment of patient interpersonal behavior shown in psychotherapy sessions.

The Effects of Bug-in-the-Eye Supervision on Therapeutic Alliance and Therapist Competence in Cognitive-Behavioural Therapy: A Randomized Controlled Trial.

Live supervision enables a supervisor to have direct insight into the psychotherapeutic process and allows him or her to provide immediate feedback to the trainee. Therefore, live supervision might be superior to traditional supervisory formats that only allow for the provision of delayed feedback. When considering the different live supervision formats, bug-in-the-eye (BITE) supervision is particularly promising because of its improved and less invasive procedure. The current study compared the efficacy of BITE supervision with that of delayed video-based (DVB) supervision. In the present study, 23 therapists were randomly assigned to either the BITE supervision or DVB supervision groups. The participants were psychotherapy trainees who treated 42 patients (19 under BITE supervision and 23 under DVB supervision) over 25 sessions of cognitive-behavioural therapy. Two independent raters blind to the treatment conditions evaluated therapeutic alliance and therapist competence based on 195 videotapes. Therapeutic alliance was significantly stronger among the treatments conducted under BITE supervision than those conducted under DVB supervision. Moreover, a higher level of therapeutic competence was found in the BITE condition than in the DVB condition. However, no differences between supervision conditions were found when the results were controlled for the level of therapeutic alliance and therapist competence demonstrated in the first session. No differences were observed between the supervision conditions with respect to patient outcomes. There is evidence that BITE supervision is able to improve therapeutic alliance and therapist competence. However, these findings should be interpreted with caution because possible pre-treatment differences between therapists might explain the superiority of BITE supervision. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: BITE supervision positively influences the therapeutic alliance and therapeutic competencies during cognitive-behavioural therapy. A supervision format that more directly addresses therapeutic processes is more effective in improving those processes than an indirect supervision format. Pre-treatment differences between therapists might explain the superiority of BITE supervision. BITE supervision can be considered a safe intervention.

Therapist competence and therapeutic alliance are important in the treatment of health anxiety (hypochondriasis).

The role of treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) is rarely investigated in psychotherapeutic treatment for health anxiety. This study aimed to investigate the role of the assessment perspective for the evaluation of treatment delivery factors and their relevance for treatment outcome. Therapist adherence, therapist competence, and therapeutic alliance were evaluated by independent raters, therapists, patients, and supervisors in 68 treatments. Patients with severe health anxiety (hypochondriasis) were treated with cognitive therapy or exposure therapy. Treatment outcome was assessed with a standardized interview by independent diagnosticians. A multitrait-multimethod analysis revealed a large effect for the assessment perspective of therapist adherence, therapist competence, and therapeutic alliance. The rater perspective was the most important for the prediction of treatment outcome. Therapeutic alliance and therapist competence accounted for 6% of the variance of treatment outcome while therapist adherence was not associated with treatment outcome. Therapist competence was only indirectly associated with treatment outcome, mediated by therapeutic alliance. Both therapeutic alliance and therapist competence demonstrated to be important treatment delivery factors in psychotherapy for health anxiety. A stronger consideration of those processes during psychotherapy for health anxiety might be able to improve psychotherapy outcome.

Treatment failure in cognitive-behavioural therapy: therapeutic alliance as a precondition for an adherent and competent implementation of techniques.

OBJECTIVES: Treatment failure is a common phenomenon, but little is known about the reasons. Therapeutic alliance, therapist adherence, and therapist competence are considered important aspects of treatment success and formed the focus of the current investigation. DESIGN: Three randomized controlled trials for the treatment of depression, social phobia, and hypochondriasis were the basis of the current study. METHODS: The role of therapeutic alliance, as well as therapist adherence and competence, were investigated in 61 patients, which were classified either as treatment failure or as treatment success. Process variables were evaluated by independent raters on the basis of videotapes of the first three treatment sessions. RESULTS: Therapists' adherence and therapeutic alliance differed significantly between successful treatments and those classified as failures, whereas therapists' competence did not. In cross-sectional analysis, we found a moderating effect of adherence with alliance on treatment outcome, indicating that the better the therapeutic alliance, the stronger the effect of adherence on treatment outcome. Moreover, higher therapists' competence was found to affect treatment outcome positively, only mediated by therapeutic alliance. Higher therapists' adherence affected treatment outcome positively, only mediated by the competence-alliance relationship. In additional longitudinal analyses, we found evidence that the therapeutic alliance within one session influences therapists' adherence and competence in the subsequent session, but not the other way around. CONCLUSIONS: Therapeutic alliance proved to be an important variable for the prediction of treatment failure. Furthermore, in our longitudinal analyses, we found evidence that the therapeutic alliance is a precondition for the adherent and competent implementation of therapeutic techniques, which questions the results of our cross-sectional analysis and of previous research. PRACTITIONER POINTS: Clinical implications Treatment failure is associated with a lower therapeutic alliance in cognitive-behavioural treatment. Therapeutic alliance seems to be an important precondition for the adherent and competent implementation of therapeutic techniques. Therapeutic alliance should be monitored during psychotherapeutic treatment. Cautions or limitations Results are limited to cognitive-behavioural therapy and may not be representative for other treatment approaches. Process analyses are based on highly standardized randomized controlled trials and may not be generalizable to routine care.

Cognitive therapy versus exposure therapy for hypochondriasis (health anxiety): A randomized controlled trial.

OBJECTIVE: Cognitive-behavioral therapy has proven to be highly effective in the treatment of hypochondriasis and health anxiety. However, little is known about which therapeutic interventions are most promising. The aim of the present study was to compare the efficacy of cognitive therapy (CT) with exposure therapy (ET). METHOD: Eighty-four patients with a diagnosis of hypochondriasis were randomly allocated to CT, ET, or a waiting list (WL) control group. The primary outcome measure was a standardized interview that evaluated hypochondriacal cognitions as well as behaviors conducted by independent diagnosticians. Several self-report questionnaires were evaluated as secondary outcome measures. Treatment success was evaluated at posttreatment and at 1-year follow-up. RESULTS: Both CT (Hedges's g = 1.01-1.11) and ET (Hedges's g = 1.21-1.24) demonstrated their efficacy in comparison with the WL in the primary outcome measure. Moreover, a significant reduction in depressive symptoms and bodily complaints was found in the secondary outcome measures for both treatments in comparison with the WL, but anxiety symptoms were only significantly reduced by ET. In a direct comparison, no significant differences were found between CT and ET in the primary or the secondary outcome measures. Regarding safety behaviors, we found a significantly larger improvement with ET than with CT in the completer analyses. CONCLUSIONS: The results suggest high efficacy of CT as well as ET in the treatment of hypochondriasis. Cognitive interventions were not a necessary condition for the change of dysfunctional cognitions. These findings are relevant to the conceptualization and psychotherapeutic treatment of hypochondriasis and health anxiety.

Nondisclosure during psychotherapy supervision: validation of the German version of the supervisory questionnaire (SQ).

Nondisclosure is considered to be a central obstacle to effective psychotherapy supervision. The aim of the current study was the validation of the German version of the Supervisory Questionnaire (SQ; Yourman & Farber, 1996), a short measure for the assessment of supervisee nondisclosure. The investigation was based on a sample of 589 supervisees. Confirmatory factor analyses suggested a two-factor model of the SQ which included one factor describing nondisclosure regarding the patient (α=.74) and another describing nondisclosure regarding the supervisor (α=.71). The SQ demonstrated satisfactory convergent and discriminant validity. Additionally assessed supervisee characteristics accounted for 16% of the variance in nondisclosure. These results provide general support for the reliability and validity of the SQ in a large sample of supervisees.

Cognitive intervention response is related to habitual physical activity in older adults.

BACKGROUND AND AIMS: This study analysed the associations between physical activity and the effects of cognitive training on perceived cognitive functioning and life satisfaction in older adults. METHODS: A sample of 114 intervention group participants (65-89 yrs) received weekly group sessions of cognitive stimulation for two months. This sample was stratified into groups according to habitual physical activity (PA) and matched with 45 controls. Participants completed the Memory Complaint Questionnaire (MAC-Q), Nuremberg Self-Rating List (NSL) and Alzheimer Disease Assessment Scale - Cognitive Subscale (ADAS-Cog) at three time-points (baseline, 2 months, and 6-month follow-up). RESULTS: At baseline, groups did not differ in absolute MAC-Q, NSL or ADAS-Cog scores. NSL difference scores (follow-up score minus baseline NSL score) of the three cognitive intervention groups (>6.95h MVPA/ wk; 3.64-6.95h MVPA/wk; <3.64h MVPA/wk) and controls were -3.8±7.3, -2.5±11.0, +0.3±12.0 and +0.1±9.1 over 2 months, and -4.2±7.6, -4.0±14.0, -1.8±7.7 and +0.5±9.7 over 6 months, respectively. MAC-Q difference scores were -1.1±2.9, -1.1±3.4, -0.3±3.9 and +0.3±2.7 over 2 months, and -1.5±3.2, -0.8±2.9, -0.3±2.9 and +0.3±2.2 over 6 months. The groups significantly (p<0.05) differed on NSL and MAC-Q difference scores. Specifically, the more active groups differed from controls, and in some cases from the least active group. Groups did not differ on ADAS-Cog difference scores. CONCLUSIONS: Our findings indicate a relation between amount of physical activity and the effects of a cognitive stimulation intervention on perceived cognitive functioning and life satisfaction. Physically more active persons may gain more benefit from cognitive stimulation than the physically less active.