psychotherapy exam 4

Murphy Journal Club 3: Background

• Metaanalyses demonstrate small but significant association between alliance and symptom reduction in CBT for depression

• 20% rate of dropout in psychotherapy for depression

• Dropout associated with alliance

  • 1 study in CBT for depression+meds

• No studies of client expectations of alliance

• How does the therapeutic alliance affect other areas of therapy like dropout?

  • No studies looking at high expectations of alliance (what client predicts/imagines what the relationship between client and therapist is going to be like)

Study aims

• Compare change in symptoms prior to dropout between those who did/didn’t drop out

  • Examine client and therapist reported early alliance as predictors of dropout

Methods: participants

• n=126 clients CBT for depression

  • 60% female

  • 83% white

  • 85% completed some college

  • Mean age ~32

  • Primary major depressive disorder; stable med dose (34%) - could not have serious disorder like bipolar, substance dependence

• N = 5 therapists

  • Advanced graduate students

    • 2 women, 3 men

Methods: treatment

• Up to 16 weeks

• CBT for depression

• Dropout

  • Stated intent to discontinue

  • No show 4 weeks

Methods: measures

• Working alliance inventory-short

  • Therapist and I collaborate on setting goals for my therapy, etc.

• Beck depression inventory

Results: dropout

• 17% dropout (robust)

• Mean dropout session ~6

• Lower symptom reduction predicted dropout risk

• Those who dropped out had higher depression symptoms at last session than those who did not dropout

Results: Alliance

• Client rated alliance predicted dropout risk over and above baseline depression and medication status

• No significant prediction by therapist reported or client predicted alliance

• No significant association between dropout and demographic factors, or medication status

Transtheoretical model of change: 5 core constructs

Decisional balance

Self-efficacy

Temptation

Stages of change

Processes of change

Decisional balance

individual's relative weight of pros vs. cons of changing

Self-efficacy

situation-specific confidence in ability to cope with high-risk situations without relapsing

Temptation

intensity of urge to engage in the behavior

Transtheoretical model of change

How someone progresses through stages of change

Stages

pre-contemplation

contemplation

preparation

action

maintenance

relapse

termination

Pre-contemplation

Not intending to take action in the foreseeable future (usually measured: at least next 6 months)

May be uninformed or underinformed about consequences of behavior

Or may have tried to change in the past and be demoralized

Avoid reading, thinking, talking about problematic behavior

Not ready for action-based therapy

Contemplation

Intending to change in next 6 months (some time in the foreseeable future)

Increased awareness of benefits of change

But also very aware of costs of change

Decisional balance -> ambivalence

Can get stuck in this stage

Not ready for action-oriented therapy

Preparation

Intending to take action in immediate future (the next month)

Typically have made some meaningful step towards change in the past year

Have a plan of action, but not acting yet

Ideal targets for action-oriented therapy

Action

Have made specific, overt change in past 6 months

Must meet criterion agreed upon by physicians/scientists to be sufficient to reduce health risks

Criterion depends on the behavior

Maintenance

Working to prevent relapse

Need to apply change processes less

Less temptation, more self-efficacy

Relapse

Regress to an earlier stage

Relapse is common

Typically return to contemplation or preparation

Not necessarily back to pre-contemplation

Termination

Not temptation, total self-efficacy

As if the unhealthy behavior never happened

Will not relapse regardless of context

<20% of smokers reach termination

More realistic goal may be sustained maintenance

Distributions of smokers by stage

Looking at current smokers (not in action/maintenance/termination)

Most people remain stuck in the early stages & not ready for action

- Most are in precontemplation and contemplation, fewer are in preparation

Treatments are going to be more effective if matched with stages people are actually in

Processes of change

overt and covert behaviors that people use to progress through the stages of change

Processes of change - 4 ways

Consciousness raising: increased awareness of causes, consequences, cures

- precontemplation stage

Self re-evaluation: assess self-image with and without the behavior

- contemplation

Stimulus control: remove cues for behavior, add prompts for healthy alternatives

- action

Contingency management: reinforce positive health behaviors

- action

Motivational interviewing - goal

Goal: reduce or eliminate substance use or other health-risk behaviors through expressing empathy and eliciting clients’ reasons for and commitment to changing

Informed by humanism, Carl Rogers person-centered therapy

Suited for clients in the precontemplation and contemplation stages

Four core assumptions of motivational interviewing

1. Ambivalence about substance use and change is normal and is an important motivational barrier to substance use behavior change

2. Ambivalence can be resolved by exploring the client's intrinsic motivations and values

3. Your alliance with the client is a collaborative partnership to which you each bring important expertise

4. An empathic, supportive counseling style provides conditions under which change can occur

Core skills in MI: OARS

Asking open questions

Affirming

Reflective listening

Summarizing

Asking open questions

Open questions are questions that invite clients to reflect before answering and encourage them to elaborate

Encourage clients to tell their story

Help therapist understand client's point of view

Facilitate dialogue

form: "Tell me about..."

Affirming

Therapist expresses genuine positive regard for client

Promotes client self-efficacy

Convey message of “I see you, what you say matters, and I want to understand what you think and feel”

Emphasize client strengths, successes, and efforts to change

You vs. I framing

Reflective listening

Key component to expressing empathy

Make a mental hypothesis about the underlying meaning or feeling of client statements and then reflect that back your best guess

Establishes trust and invites clients to explore their own perceptions, values, and feelings

Encourages a nonjudgmental, collaborative relationship

Follow open questions with at least one or more reflective listening response before asking another question

Summarizing

Form of reflective listening that distills the essence of several client statements and reflects them back

Select statements that have meaning for the client and present them in summary the gives a fuller picture of client’s experience

Ways of summarizing

Collecting: create a narrative of a series of related client statements

Linking: link back to an earlier client statement

Transitional: wraps up a conversation or task to propel the change process

Ambivalence: summarize sustain and change talk during 1 session

Recapitulation: summarize change talk from many sessions

Sustain talk and change talk

Sustain talk: client statements that support not changing

Change talk: client statements that support changing

Goal: evoke change talk and minimize evoking or reinforcing sustain talk

Change talk: DARN-CAT

Desire to change

Ability to change

Reasons to change

Need to change

Commitment

Activation

Taking steps

Evoking change talk

Eliciting importance of change

Exploring extremes

Looking back

Looking forward

Minimizing sustain talk

Simple reflections

Amplified reflections

Double-sided reflections

Agreements with a twist

Reframing

Emphasis on autonomy

Developing discrepancy

Identify how behavior conflicts with client's values and goals

Recognition of discrepancy -> increased motivation to change

Therapist must convey acceptance, compassion, affirmation

The Columbo approach

MI Efficacy

Meta-analysis on adolescents with substance-use

Small effect size for post-treatment & follow-up

Most have only 1 session of MI

With larger doses of MI, we might have more substantial effect sizes

Summary

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

acute vs. chronic

Acute pain vs. Chronic pain

Acute

Less than three months

Is a symptom

Identified cause; body’s response to injury

Diminishes with healing and responds to treatment

Chronic

More than three months

Is a condition

May develop after incident; may have known or unknown cause

Persists beyond expected healing time and/or despite treatment

Pain categories

Nociceptive pain

Musculoskeletal

Described as aching or deep

Neuropathic pain

Peripheral or central nerves

Described as burning, shooting, electric

Headache pain

Felt in forehead, eyes, neck

Describe as a tight band, pounding, throbbing, dull

Development of pain theories

René Descartes (17th century): mind cannot influence the body

Specificity Theory of Pain (1894): sensory receptors are directly responsible for pain

Gate Control Theory (1965): pain signals project from pain location and are gated by the brain

Neuromatrix Model of Pain (1976): pain is an interaction between initial pattern of nerve impulses (neuromatrix) and sensory experiences and learning (neuroplasticity)

Biopsychosocial Model

Build on the Gate Control Theory and the Neuromatrix Model of Pain

The individual experience of pain is influenced by physiological, psychological and social factors

Pain is physical signals sent by the nervous system; Suffering and pain behaviors are affected by individual differences

Psychological factors

Pain cognitions

Catastrophizing

Subcategory of pain cognition

Hurt vs. harm

Negative affect

Answer-seeking

Pain self-efficacy

Behavioral factors

Passive coping

Guarding

resting/underactivity

Active coping

Exercise

Overactivity

Social factors

Solicitous others

Punishing others

Chronic pain cycle

Experience of chronic pain

Decreased activity/deconditioning

Negative emotions

Avoidance/withdrawal

Distress/disability

Experience of chronic pain

CBT-CP model

Goals of CBT-CP

Reduce negative impact of pain on daily life

Improve physical and emotional functioning

Increase effective coping skills for pain management

Reduce pain intensity

Components of CBT-CP

Exercise & pacing

Relaxation training

Behavioral activation

Cognitive restructuring

Sleep health

Exercise

Goal: increase activity levels to increase physical health

“Motion is lotion”: the more you move, the easier to move

PCP (medical provider)-approved walking program or other low impact exercise

Difficult for clients to accept that movement will make pain better

Emphasize movement is foundation for healthy body, walking is safe, and plan will be gradual

Set goal to walk 5 days/week with increasing duration

Cannot be accomplished through existing activities

Pacing

Engage in moderate, safe level of activity regularly

Time is guide

Break activity into segments with rest between

Helps to maintain a consistent activity level, improve mood through effectively accomplishing tasks

Relaxation training

Chronic pain is a physical and psychological stressor

Creates additional wear and tear on the body

Physical tension and emotional distress increase pain-related stress

Use relaxation skills to activate parasympathetic nervous system to counter stress response

Repeated practice -> skill to manage stress

Relaxation training techniques

Deep breathing

Guided imagery

Progressive muscle relaxation

Behavioral activation

Those with chronic pain tend to have decreased their engagement in pleasurable, meaningful activities

Decreases quality of life, increases negative mood

Benefits of engaging in pleasurable activities

- Positive distraction from pain

- Improved mood and self-esteem

- Increased socialization

- Enhanced attention, concentration ability

- Enhanced sense of purpose and direction

Cognitive restructuring

Catastrophizing

Should statements

All or none thinking

Overgeneralization

Jumping to conclusions

Emotional reasoning

Disqualifying the positive

Sleep

Sleep -> pain

Not getting enough sleep: can increase the feeling of pain & disrupt the restorative process

Negative consequences in mood & attention that also modulates sleep

Pain -> sleep

Pain can impact sleep

Pain-related factors that influence sleep

Pain medications

bedding/pillows

Daytime bed use

Substance use

Low daytime activity

Stimulus control

Only go to bed when sleepy

Use bed only for sleep and sex

If unable to sleep after 20 minutes, get out of bed and return only when sleepy

Wake up at the same time every day

Do not nap

Efficacy of CBT-CP

For lower-back pain, evaluate pain & disability

Immediately after treatment: small-medium effect size on disability & pain

Pain follow-up: effect size becomes smaller over time

Disability follow-up: also drops over time, rebound at 12 months

The effects tend to be statistically significant but small

Summary

Sleep continuity: sleep metric

Sleep duration: total amount of time from sleep onset to sleep offset

Sleep onset latency (SOL): amount of time to fall asleep

Wake after sleep onset (WASO): amount of time spent awake from sleep onset to sleep offset

Sleep quality: subjective perception of quality of sleep

Sleep efficiency: sleep duration/time in bed (%)

Healthy: 85%-90% or higher

Sleep stages

Non-rapid eye movement (NREM)

3 stages: stage 1, 2, 3

Progress from lighter to deeper sleep

Rapid eye movement (REM)

Characterized by rapid eye movements, muscle paralysis, and mixed frequency EEG activity

- Prevent us from acting out on our dreams

- EEG activity: similar to an awake brain

Two process model of sleep regulation

The homeostatic sleep drive

As you stay awake, the drive accumulates

The accumulating pressure for sleep drives for sleepiness

During sleep, the pressure decreases

The circadian drive for arousal

24-hour clock in our body, one of the output is circadian wakefulness

Sending the highest alerting signals during mid-day, dropping off at biological night

Most likely to fall asleep when pressure for sleep is high and circadian alerting signal is low

Most likely to wake up when pressure for sleep is low and circadian alerting signal goes up

Circadian rhythms

Describe 24-hour rhythms and multiple processes that keep us in sync with the light/dark cycle

Allow us to anticipate changes in our environment rather than respond passively

the circadian rhythm of melatonin: Low during daytime, have a peak over night

To measure circadian rhythm: measure the time we see the steep rise of melatonin levels

Cognitive Behavior Therapy for Insomnia (CBTI)

Behavioral treatment designed to treat chronic insomnia (unable to fall asleep, stay asleep, wake up too early)

Behavioral model of insomnia

Y-axis: insomnia severity

Threshold: when insomnia symptoms become clinically significant

Premorbid: no insomnia symptoms

Acute: meaningful insomnia symptoms

Early: engage in perpetuating factors

Chronic: precipitating factor goes away, perpetuating behaviors maintaining the insomnia in the long-run

3P model of insomnia

Predisposing: risk factors, things make you more vulnerable to insomnia but don’t cause insomnia on their own

- Genetic risk, medical conditions, mental disorders

Precipitating: stressor in the short-run

- Stressful life event (positive or negative)

- Most people experience in their lives

Perpetuating: behaviors that maintain insomnia over time

- Try to compensate for the sleep loss or to get more sleep

- Spending excessive time awake in bed, going to bed earlier, doing things in bed other than sleep or sex (try to catch sleep)

The problem with perpetuating factors

Mismatch between time in bed and sleep duration

Stimulus dyscontrol

Conditioned arousal

3 core components of CBTI

Stimulus control

Sleep restriction

Sleep hygiene

Stimulus control: playing the odds

Odds 1 in 2: sleep/sex

Odds 1 in 6: sleep/sex/read/eat/worry/work

Complex conditioning history: stimulus paired with many responses

Low probability the stimulus will yield a single given response (sleep)

Stimulus control

Aims to limit amount of time spent in bed/bedroom awake

Instructions:

- Go to bed only when sleepy

- Avoid any behavior in the bed or bedroom other than sleep and sexual activity

- Leave the bedroom if awake more than 15 minutes

- Return to bed only when sleepy

Goal: reduce stimulus dyscontrol; create new conditioning history (bed-sleep instead of bed-awake)

Sleep restriction

Limit sleep opportunity to current sleep duration

Sleep prescription

- Set fixed wake time based on patients weekday needs

- Set bedtime based on average sleep duration

Goals

- Reduced mismatch between time in bed and time asleep

- Increase sleep pressure -> more consolidated sleep

Weekly upward titration by 15 minutes if >90% sleep efficiency

Sleep hygiene

good habits related to sleep

Aims to address problematic sleep-related behaviors/environment

Not effective monotherapy

Example sleep hygiene instructions

- Exercise regularly

- Make sure you bedroom is at a comfortable temperature

- Don’t watch the clock

Optional components

Cognitive therapy

Reduce preoccupation with or anxiety about insomnia

Relaxation/mindfulness

Reduce physiological arousal in the pre-sleep period

Light therapy

Reduce circadian phase delay/advance

CBTI efficacy

Recommended as first-line treatment for insomnia by American College of Physicians

Reduces sleep onset latency and wake after sleep onset by ~50%

60-80% have a therapeutic response to treatment

Improvements stable up to 24 months

Small acute increases in sleep duration but ~1hr increase over long-term follow up

CBTI vs. hypnotics: efficacy

Similarly effective in short-term

CBTI treatment responses maintained up to 24 months

- Long-term: more enduring benefits

Gains from medications diminish after medication cessation

- Hypnotics: more side-effects, tolerance problems

CBTI + hypnotics

adults with insomnia randomly assigned to CBTI alone or CBTI + hypnotics

Conclusion: the combined group has a faster response to treatment compared to CBTI alone, but both groups end up in the same place

Light Therapy

Light has multiple effects: circadian and training effects (directs our circadian clock), but also non-circadian regions of the brain (arousal effect), and mood-related areas of the brain (mood-promoting effect independent of the circadian effect)

time of light exposure

The time at which we receive light exposure affects its impact on circadian clock

Bright light in the morning + dim light in the evening: shift circadian clock earlier

Dim light in the morning + bright light in the evening: shift circadian clock later

The same principle used in light therapy: increase in bright light morning exposure

Light therapy delivery options

Historically: delivered through light boxes: high-intensity lighting

10,000 lux = outdoor natural daylight, 30min-1hr each morning after wake up to receive treatment

Limitation: have to sit in front of the box: burdensome

Recent alternative: wearable light therapy glasses

Benefits: less burden, can continue morning routine

Downsides: much dimmer intensity of light compared to the box (400-500 lux, bright indoor lighting)

Light therapy in seasonal depression

Compared patients with seasonal depression to healthy controls

Baseline: one week of fixed sleep schedule

Two light therapy conditions: bright light 6-8am or 7-9pm

Measure depression symptoms & circadian rhythm using melatonin onset

Compared to baseline week, depression symptoms decreased in both conditions, largest in morning condition compared to evening condition

Patients with seasonal depression have a significant delay pre baseline

In baseline: an advance just by stabilizing the sleep schedule

Morning light condition: further circadian phase advance

Evening light condition: circadian phase moved later

Conclusion: two effects of lights (circadian + mood impact)

Interpersonal and social rhythm therapy (IPSRT)

Developed for bipolar disorders

What are the intervening mechanisms of stressful life events precipitating mood episodes?

Social time cues: interacting with people, eating, etc.

Stressful life events disrupt social time cues (context about time), which impact circadian rhythms, and result in disruption in biological rhythms, which in turn precipitate a mood episode

Interpersonal and social rhythm therapy (IPSRT) component

Interpersonal psychotherapy +

Social rhythm therapy: stabilize social time cues, which in turn stabilizes biological rhythms

Have clients track their social rhythm through social rhythm measure (SRM-5)

Help them construct a daily schedule to stabilize social time cues

IPSRT Efficacy

Efficacious for improving bipolar disorders

BP vs. TAU

T0: baseline; T1: 3-month into treatment; T2: 3-month follow up

A significant reduction in manic symptoms for IPSRT compared to TAU

Increase the amount of time into the next mood episode

Improved regularity of social rhythms

Association between increase social rhythm regularity & reduced likelihood of mood episode recurrence

The role of sleep and circadian medicine in traditional psychotherapy

Sleep disturbance and mental health

Across disorders, medium to large effects for decreased sleep continuity, small to medium to decreased sleep depth, small to medium to increased REM pressure compared to healthy controls

Takeaway: broad association between worse sleep and mental health conditions

Delayed sleep timing associated with blunted response to psychotherapy for OCD

Worse sleep reduces treatment responses for psychotherapies

Later sleep timing (suggesting rhythm delay) is associated to lower response to ERP for OCD

Bedtime at baseline: divided into non-delayed and delayed group

delayed: less reduction in symptoms, more non-responders

Consistent lighting schedules associated with treatment response in residential OCD treatment facilities

Residential facilities for OCD categorize by the average symptom scores of their patients at discharge

Responder facility: the average patient responds to treatment

Non-responder facility: the average patient doesn't respond to treatment

A fixed lighting schedule can have impact on treatment outcomes

Multiple symptoms of psychopathology decrease following CBTI in adolescents

Adolescents with insomnia treated with CBTI (GT)/CBTI over Internet (IT)/waitlist

Both GT and IT significantly decreased mood symptoms that are maintained after 12-month follow-up

Both GT and IT significantly improvements in sleep efficiency

Only treated for insomnia but have improvement on other symptoms

Depression and anxiety decrease following CBTI in pregnant women

Pregnant women with insomnia treated with digital CBTI or TAU

Depression and anxiety decrease from pre to post insomnia treatment and were maintained after 12-month post-treatment follow-up

Suicide ideation decreases following CBTI

Treated with CBTI or control

CBTI reported lower rate of SI at post-treatment and 1-yr follow-up

CBTI enhances PTSD treatment

Treated with CBTI first and then CPT (treatment for PTSD) or control first + CBT

After CBTI/control & after CPT, CBTI has significantly lower depression and PTSD symptoms

Only targeting sleep has significant positive benefits for individual depression and PTSD symptoms

Adding CBTI onto psychotherapy for PTSD improves treatment outcomes

CBTI prevents incidence of depression

Patients treated with CBTI followed over time

Those who were treated with CBTI were less likely to be depressed in the future compared to control

Can leverage CBTI to prevent new depression onset in the future

Summary