Just as there were research papers on depression that stood out and got me thinking last month, so too there were particular papers on psychotherapy that I found more interesting than others. 

David Clark and colleagues have developed a very successful CBT treatment programme for social anxiety disorder.  When clients have made good progress, Clark talks about "broadening the bandwidth" - encouraging them to take on social challenges that are beyond any that they are likely to face routinely in day to day life.  For example for somebody who is anxious about spilling things and creating a scene where they fear they will feel humiliated, Clark might first model and then encourage the client to deliberately spill their drink in a bar to test out whether their fear of humiliation is realistic or not.  The paper by Wolitzky & Telch below takes a somewhat similar over the top approach.  The authors describe getting people suffering from a fear of heights to progressively climb a multi-storey car park and look out over the railings at each level.  The augmented exposure condition also asked participants to (a) put their feet at the edge of the landing with their hands behind their backs, leaning over the railing, and looking down; (b) move their heads in all directions while standing at the railing without holding it; (c) stand at the edge while shaking their heads from left to right in order to induce dizziness, and staying at the edge while dizzy without holding the railing; (d) run towards the edge and leaning over it as they approach, with their hands behind their backs; (e) run backwards towards the railing with their hands in front of them to prevent touching the railing and their heads facing front to avoid turning back to look at the edge (therapists put their arms out to catch the participants at the railing for safety); and (f) run towards the railing, facing forward, with their eyes closed and hands behind their backs (again, therapists held hands out to ensure safety). Of these six actions, a different action was performed each minute. If the participant refused to engage in the action for more than half of the minute because of anxiety, that action was repeated for the next minute. If the participant performed the action as instructed, the next action in the list was performed for the following minute, and so on. The actions were cycled throughout the entire 36 min of treatment. Treatment was stopped after the participant had completed six, 6-min trials, regardless of how high the participant was able to ascend. Thus, the highest landing participants reached depended on their individual fear ratings. Therapists were instructed to give statements of encouragement and coaching.  Challenging stuff!  And the clients randomized to this augmented exposure group did considerably better than those randomized only to more standard exposure.  It makes me wonder about augmenting desensitisation for almost any anxiety disorder.

I've said before that if there was one thing I would change about my one-to-one work with clients over the last decade or so, high on the list would be to have started taping sessions sooner.  However there is surprisingly little hard data to support or contradict this clinical impression.  As Shepherd et al state in their paper on this subject "Audio recording of cognitive behavioural therapy (CBT) sessions has been recommended but not yet widely adopted. It is believed to have positive effects on later recall and reflection by the patient and on supervisory quality and accuracy for therapists."  They go on to conclude from questions to both therapists and clients that  "The use of audio recording of sessions as an adjunct to therapy (where patients listen to recordings between sessions) and for therapist supervision is rated as both highly acceptable and useful by both therapists and patients."  Sadly this isn't the quantitative evidence of improved outcomes through adding tape recording/reviewing to CBT that I'm hoping for.  Maybe though this "softer" research will encourage more important studies to follow.  Taping could very well be a straightforward way of helping clients more effectively with little extra cost involved.

As a CBT therapist I am fairly cynical about the evidence supporting the value of "Swatting the NATS (negative automatic thoughts)".  So, for example in the treatment of depression, adding in such cognitive elements doesn't seem to add to the effectiveness of a more purely behavioural approach.  There is however separate data suggesting that working with more emotionally charged material may at times be worthwhile rather than simply staying at a more cool intellectual level of discussion - see for example the Experiencing scale.  Lombardo & colleagues paper extends this suggestion from therapy to supervision, arguing that "the CBT supervision model provides a relatively "heartless" account of professional development, which may undermine its effectiveness."  They go on to write "A theoretical review of emotions in supervision and learning is provided, to summarize relevant theoretical and empirical literature. The objectives are to clarify the role of emotions in CBT supervision, and to use this understanding to outline an emotionally-attuned mode ... ".  Interesting stuff and worth looking at by CBT therapists and supervisors generally.

Wolitzky, K. B. and M. J. Telch (2009). "Augmenting In Vivo Exposure With Fear Antagonistic Actions: A Preliminary Test." Behavior Therapy 40(1): 57-71.  [Abstract/Full Text]
The current study investigated the efficacy of an exposure augmentation strategy in which the phobic individual is encouraged to enact actions that are in direct opposition to the fear action tendencies associated with acrophobia (fear of heights). Participants (N = 88) meeting DSM-IV criteria for specific phobia (acrophobia) were randomized to (a) exposure with oppositional actions (E + OA), (b) exposure only (EO), (c) a credible placebo consisting of pulsed audio-photic stimulation (APS), or (d) a waitlist control (WLC). Treatment consisted of six, 6-min exposure trials. Participants were assessed with questionnaire, behavioral, and physiologic measures at pre- and posttreatment, and at a 1-month follow-up session. Participants receiving E + OA showed significantly greater improvement on behavioral and questionnaire measures than those in the other 3 conditions at both posttreatment and follow-up. Further, whereas treatment improvement generalized to an untrained context for those receiving E + OA, such was not the case for EO- and APS-treated participants. Findings suggest augmenting exposure with oppositional actions may enhance treatment outcome and thus warrant additional investigation with clinical samples.

Shepherd, L., P. M. Salkovskis, et al. (2009). "Recording Therapy Sessions: An Evaluation of Patient and Therapist Reported Behaviours, Attitudes and Preferences." Behavioural and Cognitive Psychotherapy 37(02): 141-150.  [Abstract/Full Text] 
Background: Audio recording of cognitive behavioural therapy (CBT) sessions has been recommended but not yet widely adopted. It is believed to have positive effects on later recall and reflection by the patient and on supervisory quality and accuracy for therapists. Aims: To evaluate self-reported attitudes and behaviour regarding audio recording of therapy sessions in both patients and therapists in a setting where such recording is routinely carried out. Method: In a centre specializing in CBT for anxiety disorders, 72 patients completed a questionnaire at the start of therapy and 31 patients completed a questionnaire at the end of therapy. Fifteen therapists also completed a similar questionnaire. Results: Ninety percent of patients reported listening to recordings between therapy sessions to some extent. The majority reported discussing the recordings with their therapist. Patients typically planned to keep the recordings after therapy ended. Most patients and therapists endorsed positive attitudes towards the use of recordings. Similar advantages (e.g. improving memory for sessions) and disadvantages (e.g. practical issues and feeling self-conscious) of recordings were generated by patients and therapists. Therapists were more likely than patients to express concern about recordings being distressing for patients to listen to. Both patients and therapists regarded the use of recordings for therapist peer supervision purposes favourably. Conclusion: The use of audio recording of sessions as an adjunct to therapy (where patients listen to recordings between sessions) and for therapist supervision is rated as both highly acceptable and useful by both therapists and patients.

Lombardo, C., D. Milne, et al. (2009). "Getting to the Heart of Clinical Supervision: A Theoretical Review of the Role of Emotions in Professional Development." Behavioural and Cognitive Psychotherapy 37(02): 207-219.  [Abstract/Full Text] 
Background: The importance of supervision is increasingly recognized, yet it remains little understood, impairing research and practice. Specifically, the CBT supervision model provides a relatively "heartless" account of professional development, which may undermine its effectiveness. Method: A theoretical review of emotions in supervision and learning is provided, to summarize relevant theoretical and empirical literature. The objectives are to clarify the role of emotions in CBT supervision, and to use this understanding to outline an emotionally-attuned model, illustrating its application to two critical aspects of CBT supervision (the development of a learning alliance and enhancing professional competence). Conclusion: The reviewed literature (theory and research evidence) supports the explicit and systematic incorporation of emotions into CBT supervision. Conceptually, this can be achieved by integrating Lazarus's (1991) general theory of emotion with the CBT model. The illustrations of this augmented model indicate its value in understanding and managing both the "rupture-repair" cycle that can affect the supervisory alliance, and the "deskilling-development" pattern that appears to be necessary for the acquisition of competence. We propose that CBT supervision might usefully be guided by our expanded model, as this affords greater internal consistency and may be more effective educationally.