A randomized controlled trial of a brief family intervention to reduce accommodation in obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is associated with substantial impairment across a number of life domains. Recently increased interest has been focused on the bi-directional relationship between OCD and family processes, particularly a subset of family reactions to OCD symptoms that are termed "accommodation." Accommodation consists of any changes in family members' behavior aimed at preventing or reducing the patient's rituals or their distress related to OCD symptoms. For example, family members may provide patients with supplies they need to ritualize (e.g., extra soap), or may engage in rituals themselves (e.g., excessive washing). Previous research has indicated high levels of accommodation are associated with more severe OCD symptoms and functional impairment on the part of patients, and may interfere with the first line psychosocial treatment for OCD, a form of cognitive behavior therapy (CBT) consisting of exposure (to cues provoking obsessions) and ritual prevention (ERP). Thus, the aims of this research project were to develop and test a brief intervention focused on reducing accommodation in the family members of adult OCD patients with the aim of facilitating the implementation of ERP. Eighteen patient and family member dyads participated in the study. All patients received a course of standard individual ERP for OCD. Family members were randomized to either the intervention group or a control group that did not receive any intervention. The goals of the two-session intervention were to identify current accommodation behaviors and provide alternative ways of responding to OCD symptoms. Patients and family members were assessed at baseline and regularly throughout the 25-week study. Results revealed that the intervention successfully reduced accommodation with a large effect size. Patients whose family members received the intervention showed greater levels of symptom reduction than patients whose family members had not. Hierarchical regression analyses revealed that change in family accommodation from baseline accounted for a significant amount of variance in later OCD symptoms. These results suggest that this intervention successfully enhanced the outcomes of standard CBT including ERP for adults with OCD. The findings support further exploration of this intervention in larger samples and in other diagnostic groups where accommodation is likely to occur

Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: an investigation of mediation

Patients’ outcome expectancies and the working alliance are two psychotherapy process variables that researchers have found to be associated with treatment outcome, irrespective of treatment approach and problem area. Despite this, little is known about the mechanisms accounting for this association, and whether contextual factors (e.g., psychotherapy type) impact the strength of these relationships. The primary aim of this study was to examine whether patient-rated working alliance quality mediates the relationship between outcome expectancies and pre- to post-treatment change in anxiety symptoms using data from a recent randomized clinical trial comparing a transdiagnostic treatment (the Unified Protocol [UP]; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Client workbook, Oxford University Press, New York, 2011a; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Patient workbook. New York: Oxford University Press, 2017b) to single diagnosis protocols (SDPs) for patients with a principal heterogeneous anxiety disorder (n = 179). The second aim was to explore whether cognitive-behavioral treatment condition (UP vs. SDP) moderated this indirect relationship. Results from mediation and moderated mediation models indicated that, when collapsing across the two treatment conditions, the relationship between expectancies and outcome was partially mediated by the working alliance [B = 0.037, SE = 0.05, 95% CI (.005, 0.096)]. Interestingly, within-condition analyses showed that this conditional indirect effect was only present for SDP patients, whereas in the UP condition, working alliance did not account for the association between expectancies and outcome. These findings suggest that outcome expectancies and working alliance quality may interact to influence treatment outcomes, and that the nature and strength of the relationships among these constructs may differ as a function of the specific cognitive-behavioral treatment approach utilized.This study was funded by grant R01 MH090053 from the National Institutes of Health. (R01 MH090053 - National Institutes of Health)First author draf

The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders a randomized clinical trial

IMPORTANCE: Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments. OBJECTIVE: To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders. DESIGN, SETTING, AND PARTICIPANTS: From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat. INTERVENTIONS: The UP or SDPs. MAIN OUTCOMES AND MEASURES: Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs. RESULTS: Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d, −0.93; 95% CI, −1.29 to −0.57) and SDPs (Cohen d, −1.08; 95% CI, −1.43 to −0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (β, 0.25; 95% CI, −0.26 to 0.75) and from baseline to the 6-month follow-up (β, 0.16; 95% CI, −0.39 to 0.70) indicated statistical equivalence between the UP and SDPs. CONCLUSIONS AND RELEVANCE: The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders.This study was funded by grant R01 MH090053 from the National Institute of Mental Health. (R01 MH090053 - National Institute of Mental Health)First author draf

Alliance across group treatment for veterans with posttraumatic stress disorder: The role of interpersonal trauma and treatment type

The authors examined initial levels and pattern of change of alliance in group treatment for posttraumatic stress disorder (PTSD) for veterans. One hundred and 78 male veterans with PTSD were recruited for this study. Participants were randomly assigned to either group cognitive-behavioral therapy (GCBT) or to group present-centered therapy (GPCT). Alliance with fellow group members was assessed every other session throughout the group (total of seven assessments). Hierarchical linear modeling was used to determine whether treatment condition or index trauma type (interpersonal or noninterpersonal) impacted initial levels of alliance or change in alliance over time. Alliance increased significantly throughout treatment in both conditions. The presence of an interpersonal index event, compared to a noninterpersonal index event, did not significantly impact either initial levels of alliance or change in alliance over time. Participants in the GCBT condition experienced significantly greater growth in alliance over time compared to those in the GPCT condition (p ± .05) but did not have significantly different initial alliance ratings. The components and focus of the GCBT treatment may have facilitated more rapid bonding among members. Interpersonal traumatic experience did not negatively impact group alliance

Latent Factor Structure and Construct Validity of the Cognitive Emotion Regulation Questionnaire–Short Form Among Two PTSD Samples

The Cognitive Emotion Regulation Questionnaire–Short form (CERQ-Short; Garnefski & Kraaij, 2006) was developed to assess nine theoretically derived factors of emotion regulation. However, the psychometric properties of this measure have never been studied in a clinical sample. The present study examined the latent factor structure and construct validity of the CERQ-Short in two samples presenting for posttraumatic stress disorder treatment (N = 480). Results indicated that a six-factor solution, rather than the proposed nine factors, was the best-fitting measurement model. The original CERQ-Short factors of acceptance, positive refocusing, other-blame, and self-blame were retained. A novel perseveration factor incorporated both the original rumination and catastrophizing factors and a novel reappraisal factor incorporated items from the original positive reappraisal and putting into perspective factors. The revised six-factor measurement model provided good fit and demonstrated strong construct validity in a second clinical sample. Results support a more parsimonious six-factor CERQ-Short measurement model

The significant others’ responses to trauma scale (SORTS): applying factor analysis and item response theory to a measure of PTSD symptom accommodation

Background: Symptom accommodation by family members (FMs) of individuals with posttraumatic stress disorder (PTSD) includes FMs’ participation in patients’ avoidance/safety behaviours and constraining self-expression to minimise conflict, potentially maintaining patients’ symptoms. The Significant Others’ Responses to Trauma Scale (SORTS) is the only existing measure of accommodation in PTSD but has not been rigorously psychometrically tested.Objective: We aimed to conduct further psychometric analyses to determine the factor structure and overall performance of the SORTS. Method: We conducted exploratory and confirmatory factor analyses using a sample of N = 715 FMs (85.7% female, 62.1% White, 86.7% romantic partners of individuals with elevated PTSD symptoms).Results: After dropping cross-loading items, results indicated good fit for a higher-order model of accommodation with two factors: an anger-related accommodation factor encompassed items related largely to minimising conflict, and an anxiety-related accommodation factor encompassed items related primarily to changes to the FM’s activities. Accommodation was positively related to PTSD severity and negatively related to relationship satisfaction, although the factors showed somewhat distinct associations. Item Response Theory analyses indicated that the scale provided good information and robust coverage of different accommodation levels.Conclusions: SORTS data should be analysed as both a single score as well as two factors to explore the factors’ potential differential performance across treatment and relationship outcomes