The impact of executive function on response to cognitive behavioral therapy in late-life depression

New Study (1)Abstract:
Objective: Late-life depression (LLD) is a common and debilitating condition among older adults. Cognitive behavioral therapy (CBT) has strong empirical support for the treatment of depression in all ages, including in LLD. In teaching patients to identify, monitor, and challenge negative patterns in their thinking, CBT for LLD relies heavily on cognitive processes and, in particular, executive functioning, such as planning, sequencing, organizing, and selectively inhibiting information. It may be that the effectiveness of CBT lies in its ability to train these cognitive areas.
Methods: Participants with LLD completed a comprehensive neuropsychological battery before enrolling in CBT. The current study examined the relationship between neuropsychological function prior to treatment and response to CBT.
Results:When using three baseline measures of executive functioning that quantify set shifting, cognitive flexibility, and response inhibition to predict treatment response, only baseline Wisconsin Card Sort Task performance was associated with a significant drop in depression symptoms after CBT. Specifically, worse performance on the Wisconsin Card Sort Task was associated with better treatment response.
Conclusions: These results suggest that CBT, which teaches cognitive techniques for improving psychiatric symptoms, may be especially beneficial in LLD if relative weaknesses in specific areas of executive functioning are present.

Goodkind M.S., Gallagher-Thompson D., Thompson L.W, Kesler S.R., Anker L. Flournoy J., Berman M. P., Holland J.M., & O’Hara R.M. (2015) The impact of executive function on response to cognitive behavioral therapy in late-life depression. Int J Geriatr Psychiatry. 2015 Jul 30. doi: 10.1002/gps.4325.

Internet versus face-to-face group cognitive-behavioral therapy for fibromyalgia: A randomized control trial

New Study (1)Abstract:

Background:The aim of this study was to explore the effectiveness of Internet-delivered cognitive-behavioral therapy (iCBT) in treating fibromyalgia (FM) compared with an identical protocol using conventional group face-to-face CBT.
Methods:Sixty participants were assigned to either (a) the waiting list group, (b) the CBT group, or (c) the iCBT group. The groups were assessed at baseline, after 10 weeks of treatment, and at 3-, 6-, and 12-month follow-ups. The primary outcome measured was the impact of FM on daily functioning, as measured by the Fibromyalgia Impact Questionnaire (FIQ). The secondary outcomes were psychological distress, depression, and cognitive variables, including self-efficacy, catastrophizing, and coping strategies.
Results: In post-treatment, only the CBT group showed improvement in the primary outcome. The CBT and iCBT groups both demonstrated improvement in psychological distress, depression, catastrophizing, and utilizing relaxation as a coping strategy. The iCBT group showed an improvement in self-efficacy that was not obtained in the CBT group. CBT and iCBT were dissimilar in efficacy at follow-up. The iCBT group members improved their post-treatment scores at their 6- and 12-month follow-ups. At the 12-month follow-up, the iCBT group showed improvement over their primary outcome and catastrophizing post-treatment scores. A similar effect of CBT was expected, but the positive results observed at the post-treatment assessment were not maintained at follow-up.
Conclusions: The results suggest that some factors, such as self-efficacy or catastrophizing, could be enhanced by iCBT. Specific characteristics of iCBT may potentiate the social support needed to improve treatment adherence.

Vallejo M. A., Ortega J., Rivera J., Comeche M.I. & Vallejo-Slocker L.(2015). Internet versus face-to-face group cognitive-behavioral therapy for fibromyalgia: A randomized control trial. J Psychiatr Res. 2015 Sep;68:106-13. doi: 10.1016/j.jpsychires.2015.06.006. Epub 2015 Jun 20.

Grant Porteous, LMSW and Kevin DeBruyn, LMSW – Workshop Participant Spotlights

TKevin and Grant November, 2015raveling from Traverse City, Michigan, Kevin and Grant attended the 2-day CBT for Weight Loss and Maintenance workshop taught by Deborah Beck Busis, LMSW.

Kevin DeBruyn, LMSW, is the founder and owner of Adaptive Counseling and Case Management, which helps chronically ill patients manage their health care and achieve a healthy lifestyle. Grant works as a clinician at Adaptive Counseling and Case Management.

Many chronically ill patients have issues with weight loss and maintenance, which made this workshop a perfect fit. Both use evidence-based treatments in their practice and were interested in training in CBT. Synthesizing CBT with health care made this workshop a unique fit and had the benefit of being, as Grant stated, ” straight from the horses mouth.”

Their best take aways?

Grant: The framework and process demonstrations through roleplays and case examples

Kevin: “I learned many new ways to structure what I’m already doing” to engage the client and move through treatment

Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial

New Study (1)Abstract:

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking). Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n=17) or to a 12-week waitlist (n=19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory-II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ?30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p=0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d=2.1, p<0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD=12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.

Wilhelm S, Phillips K. A., Didie E., Buhlmann U., Greenberg J.L., Fama J.M., Keshaviah A., & Steketee G. (2013) Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behav Ther. 2014 May;45(3):314-27. doi: 10.1016/j.beth.2013.12.007. Epub 2013 Dec 29.

How to Know if Therapy is Working

In many cases, it’s difficult for clients to know whether they’re making progress because therapists do not necessarily state the goals and desired outcomes of therapy sessions. Clients may need to rely on their own global impressions. When clients are treated by cognitive behavior therapy (CBT) clinicians, though, they know how well therapy is working, because CBT therapists monitor progress each week by:

  1. evaluating clients’ symptoms
  2. measuring the occurrence of specific target behaviors
  3. assessing progress toward specific goals

In fact, research shows that when both therapists and clients receive feedback on progress, clients tend to have better outcomes (Lambert, et al., 2002).

Judith S. Beck, Ph.D.

Judith S. Beck, Ph.D.

For example, CBT clinicians ask clients to fill out symptom checklists before each session, such as those for depression and anxiety. If applicable, clients may track and report the occurrence of panic attacks, angry outbursts, or incidents of self-harm behavior. They may also track the frequency and amount of alcohol, drugs, nicotine, or food they ingested in the previous week—or the number of minutes they engaged in compulsive rituals. The type of monitoring and assessment varies from client to client, based on the goals they’ve decided they want to work toward. CBT therapists discuss these assessments with clients. When clients do not make expected progress, they conceptualize the difficulty and modify treatment accordingly.

How long can it take before clients’ symptoms decrease? Sometimes clients notice improvements almost immediately, especially when they have three kinds of experiences:

  • They realize that the treatment plan their therapist describes makes sense to them. They understand how it is that they’ll overcome their difficulties. And they have confidence that their particular therapist will be competent and helpful.
  • They change their unhelpful thinking in session and feel better.
  • They enact an “action plan,” at home and notice an improvement in their mood. The action plan, collaboratively designed with their therapist, usually includes (1) reading “therapy notes” of the most important things they learned in session and (2) engaging in specific activities that are linked to the accomplishment of their goals. For example, a depressed client might make plans with friends; an anxious client might expose himself to a feared situation to find out to what degree a negative outcome occurs.

These three kinds of experience increase hope and clients are able not only to arrest their downward negative spiral but also to reverse direction. They then find themselves on an upward positive spiral.

So how can clients tell if therapy is working? They can ask themselves:

  • How is my mood throughout the week (not just at the end of sessions)? Is it at least gradually improving (albeit with ups and downs)?
  • Are my specific symptoms or problematic behaviors improving?
  • Am I solving problems and working toward my goals?

If the answers are yes, then therapy is working.


Lambert, M., Whipple, J., Vermeersch, D., Smart, D., Hawkins, E., Nielsen, S., & Goates, M. (n.d.). Enhancing psychotherapy outcomes via providing feedback on client progress: A replication. Clinical Psychology & Psychotherapy Clin. Psychol. Psychother., 91-103.

Workshop Participant Spotlight – Pablo Alonso

As a therapist in Madrid, Pablo knew he wanted to improve his skills and, after reading many of both Drs. Beck’s books, he decided to come to Philadelphia for our Core 2: CBT for Anxiety course. “Part of being a great therapist is constantly working to improve your skills, and the best way is to go directly to the source.”

DSC_0138Pablo works in a clinic at the University of Madrid where he is a therapist, researcher, and supervisor of final-year students. He also works at the Deyre Medical Clinic, where he provides therapy to trauma patients. His clients are mainly adults and adolescents with depression, anxiety, and substance use disorders.

“When I grow up as a therapist I want to be just like Amy,” referring to Dr. Wenzel, who instructed the 3 day course on CBT for Anxiety. Roleplays were his favorite part of the workshop, because that’s when he got to see Dr. Wenzel “in action.”

On having the opportunity to meet Dr. Aaron Beck, “I have seen so many videos on YouTube, it was like I met him a long time ago.” 

His favorite lesson from the workshop was that “CBT is eclectic, it’s not a rigid therapy where you have to do A, B, then C. It’s fluid.”

No trip to Philadelphia is complete without a history tour and a cheese steak, which Pablo enjoyed and said,”I’m going to have to repeat that!”

Cognitive–behavioral therapy for late-life anxiety: Similarities and differences between veteran and community participants

New Study (1)Abstract:

Cognitive–behavioral therapy (CBT) is an evidence-based treatment for anxiety; however, a growing body of research suggests that CBT effect sizes are smaller in Veteran samples. The aim of this study was to perform secondary data analyses of a randomized controlled trial of CBT for late-life generalized anxiety disorder compared with treatment as usual (TAU) in a Veteran (n = 101) and community-based (n = 122) sample. Veterans had lower income and less education than community participants, greater severity on baseline measures of anxiety and depression, poorer physical health, and higher rates of psychiatric comorbidity. Treatment effects were statistically significant in the community sample (all ps < 0.01), but not in Veterans (all ps > 0.05). Further analyses in Veterans revealed that poorer perceived social support significantly predicted poorer outcomes (all ps < 0.05). Our results underscore the complexity of treating Veterans with anxiety, and suggest that additional work is needed to improve the efficacy of CBT for Veterans, with particular attention to social support.

Barrera, T. L., Cully, A. J., Amspoker B. A., Wilson, L. N., Kraus-Schuman, C., Wagener, D. P., Calleo, S. J., Teng, E. J., Rhoades, H. M. & Mosozera, N. (2015)9. Cognitive–behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants  Journal of Anxiety Disorders, Volume 33, Issue null, Pages 72-80

Developing and using a case formulation to guide cognitive-behavior therapy

New Study (1)Abstract:

This article describes a case formulation-driven approach to cognitive-behavior therapy (CBT) that draws on the formulations and interventions in the ESTs while helping the therapist make many of the clinical decisions that are not directly addressed in the ESTs. We begin the article with an overview of case formulation-driven CBT. Then we describe each of the steps of case formulation-driven CBT, giving special attention to the step of developing a case formulation. We conclude with a brief discussion of alternate approaches to case formulation in CBT, and a brief review of evidence supporting the use of a case formulation approach to CBT.

Persons, B. J., & Lisa, S. T. (2015). Developing and Using a Case Formulation to Guide Cognitive-Behavior Therapy. Journal of Psychology & Psychotherapy 5(2)