Evidence-based Psychological Interventions FOURTH EDITION
1Evidence-based Psychological InterventionsFOURTH EDITION
ACKNOWLEDGEMENTSDISCLAIMER AND COPYRIGHTThis review has been produced by the Australian PsychologicalSociety (APS) with funding from the Australian GovernmentDepartment of Health. The APS project team comprised:This publication was produced by The AustralianPsychological Society Limited (APS) as a resource to guidethe provision of services to people with mental disorders.The information provided does not and cannot replaceclinical judgment and decision making. Although everyreasonable effort has been made to ensure the accuracy ofthe information, no guarantee can be given that theinformation is free from error or omission. The APS, itsofficers, employees, and agents will accept no liability forany act or omission occurring from reliance on theinformation provided, or for the consequences of any suchact or omission. The APS does not accept any liability forany injury, loss, or damage incurred by use of or reliance oninformation in this document. Such damages include,without limitation, damages that might be regarded as direct,indirect, special, incidental, or consequential.Mr Harry LovelockMs Marguerite HoneDr Rebecca MathewsMr Adam VujicDr Louise RoufeilMs Laura SciacchitanoMr Fletcher CurnowMs Selena MeneghiniList of reviewersAssoc Prof Rocco CrinoMr Tony McHughDr Mandy DeeksProf Greg MurrayDr John FarhallDr Lyn O’GradyMr Stephen HirnethAssoc Prof Amanda RichdaleDr Catherine HynesDr Susette SowdenDr Moira JungeDr Caroline StevensonAssoc Prof Nikolaos KazantzisProf John ToumbourouAssoc Prof Chris LeeProf Tracey WadeMs Tracy MacFarlaneDr Simon WilkschProf Marita McCabeDr Hollie WilsonProf Peter McEvoyAny reproduction of this material must acknowledge theAPS as the source of selected passage(s), extract(s), orother information or material reproduced. For reproductionor publication beyond that permitted by the Copyright Act1968 (Cth), permission should be sought in writing.Input was also sought from the following key stakeholders: Australian Association of Social Workers (AASW) Occupational Therapy Australia (OTA) Royal Australian College of General Practitioners (RACGP) Royal Australian and New Zealand College of Psychiatrists(RANZCP)Copyright 2018 The Australian Psychological Society Ltd.
Table of ContentsABBREVIATIONS4REVIEW OF THE RESEARCH LITERATURE5ESTABLISHING AN EVIDENCE BASE11METHODOLOGY13PRESENTATION OF THE LITERATURE15SUMMARY TABLE: ADULTS16SUMMARY TABLE: CHILDREN AND ADOLESCENTS17MENTAL DISORDERS: ADULTS19MENTAL DISORDERS: CHILDREN & ADOLESCENTS1253
AbbreviationsABBTAcceptance-based behaviour therapyACTAcceptance and commitment therapyADHDAttention deficit hyperactivity disorderMANTRA Maudsley Anorexia Nervosa Treatment forAdultsBDDBody dysmorphic disorderMBCTMindfulness-based cognitive therapyBEDBinge eating disorderMBRPMindfulness-based relapse preventionBMIBody mass indexMBSRMindfulness-based stress reductionBPDBorderline personality disorderMCTMetacognitive therapyCATCognitive analytic therapyMDFTMultidimensional family therapyCBGTCognitive behavioural group therapyMETMotivational enhancement therapyCBTCognitive behaviour therapyMFGPMultifamily group psychoeducationCRTCognitive remediation therapyMIMotivational interviewingDBTDialectical behaviour therapyMSTMultisystemic family-focused therapyDDPDynamic deconstructive psychotherapyNOSNot otherwise specifiedDSMDiagnostic and Statistical Manual of MentalDisordersOCDObsessive compulsive disorderPCT-APanic control treatment for adolescentsEDNOSEating disorder not otherwise specifiedPHNPrimary Health NetworksEFTEmotion-focused therapyPSTProblem-solving therapyEMDREye movement desensitisation andreprocessingPTSDPosttraumatic stress disorderERPExposure response preventionRCTRandomised controlled/clinical trialFIFamily interventionSADSocial anxiety disorderFPTFocal psychodynamic therapySFBTSolution-focused brief therapyGADGeneralised anxiety disorderSFTSolution-focused therapyICDInternational Classification of DiseasesSSRISelective serotonin reuptake inhibitorsIPSRTInterpersonal and social rhythm therapyTAUTreatment as usualIPTInterpersonal therapyIUTIntolerance of uncertainty therapy4Evidence-based Psychological InterventionsMAGTMindfulness and acceptance based grouptherapyFOURTH EDITION
Review of the Research LiteratureBACKGROUNDThis document is a systematic review undertaken toupdate the APS document Evidence-BasedPsychological Interventions in the Treatment of MentalDisorders: A Literature Review (3rd edition). This reviewwas first conducted in 2003 in the context of theAustralian government’s Better Outcomes in MentalHealth Care initiative. It was updated in 2006 and againin 2010 with consideration of the introduction of primaryhealthcare services through the Access to AlliedPsychological Services (ATAPS) and Better Outcomes toMental Health Care initiative.The current update takes into account the 2016Australian government changes to the delivery ofprimary mental health care services in Australia that aimto make mental health services more accessible and totarget groups in the community that are most in need.The latest changes have included major developmentsthat impact on the structure and approaches used in theprovision of mental health services, including theestablishment of primary health networks (PHNs),replacing Medicare locals as the local coordinatinghealthcare organisations, along with a suite of mentalhealth reforms. These reforms include undertakingregional needs assessment and tailoring services tolocal needs, delivering services within a stepped careapproach, making optimal use of digital mental healthservices, and targeting priority groups such as Aboriginaland Torres Strait Islander people, children and youth,and clinical care coordination for severe and complexmental illness.1This review is intended to provide the latest evidenceabout a range of psychological interventions for thetreatment of mental disorders to assist in decisionmaking about optimal mental health treatment. Thisshould support the work of the PHNs as well as mentalhealth professionals providing psychologicalinterventions under Better Access and other governmentfunded mental health initiatives.Information is provided as part of a narrative review withan expert synthesis of the research findings andconclusions, including identification of key limitations.The review does not contain a comprehensive critique ofthe research undertaken, and readers seeking a detailedunderstanding of the research methodology and findingsshould access the source articles.DISORDERS INCLUDED IN REVIEW3Mood disorders Depression Bipolar disorderAnxiety disorders Generalised anxiety disorder Panic disorder Specific phobia Social anxiety disorder Obsessive compulsive disorder Posttraumatic stress disorderSubstance use disordersPURPOSE AND LIMITATIONS OF THE REVIEWThere is now sufficient evidence to demonstrate thatpsychological interventions are both effective andcost-effective in the treatment of mental disorders andthat these interventions contribute more broadly to thecommunity and the economy through a reduction inneed for access to health services generally andincreased functioning and employability.2Eating disorders Anorexia nervosa Bulimia nervosa Binge eating disorderAdjustment disorderDissociative disorders1For information about the Australian government reforms and guidance on the priority areas,see nsf/Content/PHN-Mental Tools2Levin, C., & Chisholm, D. (2016). Cost-effectiveness and affordability of interventions, policies, and platforms for the prevention and treatment of mental, neurological, andsubstance use disorders. In V. Patel, D. Chisholm, T. Dua, R. Laxminarayan, & M. E. Medina-Mora (Eds.), Mental, neurological, and substance use disorders: Disease controlpriorities (3rd ed., Vol. 4, pp. 219–236). Washington DC: World Bank.3As directed by the Australian Government, disorders included are based on the International Statistical Classification of Diseases and Related Health Problems - 10th Revision Chapter V Primary Care Version, excluding dementia, delirium, tobacco use disorder, and mental retardation, with the addition of borderline personality disorder.5
Sleep disordersSexual disordersSomatoform disorders Pain disorderThe following psychological interventions are included inthe current review: Acceptance and commitment therapy (ACT) Cognitive behaviour therapy (CBT) Somatisation disorder Dialectical behaviour therapy (DBT) Hypochondriasis Emotion-focused therapy (EFT) Body dysmorphic disorder Eye movement desensitisation and reprocessing (EMDR)Psychotic disorders Family therapy and family-based interventionsBorderline personality disorderAttention deficit hyperactivity disorderConduct disorder (child)Enuresis (child) Hypnotherapy Interpersonal psychotherapy (IPT) Mindfulness-based cognitive therapy (MBCT) andmindfulness-based stress reduction (MBSR) Narrative therapy Play therapy (children) Psychodynamic psychotherapyINTERVENTIONS INCLUDED IN THE REVIEW PsychoeducationHealth professionals have an obligation to provideservices that have an evidence base. Further, mostgovernment-funded initiatives demand thatpsychologists and other mental health professionalsworking in the primary sector deliver effective, shortterm therapies as the most cost-effective approach topsychological intervention. On this basis, this reviewincluded a broad range of psychological interventionsselected through direction from government andidentification of interventions with a large or increasingevidence base. This has led to the inclusion of twointerventions not previously reviewed: eye movementdesensitisation and reprocessing, and play therapy. Inaddition, in line with the government’s mental healthreforms, there was a focus on interventions that usedigital approaches. Schema-focused therapy Self-help Solution-focused brief therapy (SFBT)It should be noted that although the review includes abroad range of interventions, these are not all approvedfor use in government programs. For example, theMedicare Benefits Schedule specifies that only cognitivebehaviour therapy and interpersonal therapy (andnarrative therapy for Aboriginal and Torres Strait Islanderpeople) are eligible interventions under the BetterAccess to Mental Health Care initiative. Healthprofessionals providing services under specificgovernment-funded programs should ensure that theintervention selected meets the requirements for serviceprovision under the program.6Evidence-based Psychological InterventionsFOURTH EDITION
DESCRIPTION OF INTERVENTIONSAcceptance and commitment therapyDialectical behaviour therapyAcceptance and commitment therapy (ACT) is based ona contextual theory of language and cognition known asrelational frame theory. It makes use of a number oftherapeutic strategies, many of which are borrowed fromother approaches, including CBT. However, ACT focuseson the context and function of psychological experiences(e.g., thoughts, feelings, and sensations) as the target ofinterventions, rather than on the actual form or frequencyof particular symptoms. In ACT, individuals increase theiracceptance of the full range of subjective experiences,including distressing thoughts, beliefs, sensations, andfeelings in an effort to promote desired behaviour changethat will lead to improved quality of life. A key principle isthat attempts to control unwanted subjective experiences(e.g., anxiety) are often not only ineffective but evencounterproductive in that they can result in a net increasein distress, result in significant psychological costs, orboth. Consequently, individuals are encouraged toconnect with their experiences fully and without defencewhile moving toward valued goals. ACT also helpsindividuals to identify their values and translate them into4specific behavioural goals.Dialectical behaviour therapy (DBT) is designed to servefive functions: enhance capabilities, increase motivation,enhance generalisation to the natural environment,structure the environment, and improve cliniciancapabilities and motivation to treat effectively. The overallgoal is the reduction of ineffective action tendencieslinked with deregulated emotions. It is delivered in fourmodes of therapy. The first mode involves a traditionaldidactic relationship with the clinician. The second modeis skills training which involves teaching the four basicDBT skills of mindfulness, distress tolerance, emotionregulation, and interpersonal effectiveness. Skillsgeneralisation is the third mode of therapy in which thefocus is on helping the individual to integrate the skillslearnt into real-life situations. The fourth mode of therapyis team consultation, which is designed to support6clinicians working with difficult clients.Cognitive behaviour therapyCognitive behaviour therapy (CBT) is a focused approachbased on the premise that cognitions influence feelingsand behaviours, and that subsequent behaviours andemotions can influence cognitions. The clinician workswith individuals to identify unhelpful thoughts, emotions,and behaviours. CBT has two aspects: behaviour therapyand cognitive therapy. Behaviour therapy is based on thetheory that behaviour is learned and therefore can bechanged. Examples of behavioural techniques includeexposure, activity scheduling, relaxation, and behaviourmodification. Cognitive therapy is based on the theorythat distressing emotions and maladaptive behavioursare the result of faulty patterns of thinking. Therefore,therapeutic interventions such as cognitive restructuringand self-instructional training are aimed at replacingdysfunctional thoughts with more helpful cognitions,which leads to an alleviation of problem thoughts,emotions, and behaviour. In this review, metacognitivetherapy has been included as part of CBT. Skills training(e.g., stress management, social skills training, parenttraining, and anger management) is another important5component of CBT.Emotion-focused therapyEmotion-focused therapy (EFT) combines a clientcentred therapeutic approach with process-directive,marker-guided interventions derived from experientialand Gestalt therapies applied at in-session intrapsychicand/or interpersonal targets. These targets are thought toplay prominent roles in the development andexacerbation of disorders such as depression. The majorinterventions used in EFT (e.g., empty-chair and twochair dialogues, focusing on an unclear bodily-felt sense)facilitate creation of new meaning from bodily feltreferents, letting go of anger and hurt in relation toanother person, increased acceptance and compassionfor oneself, and development of a new view and7understanding of oneself.4Ruiz, F. J. (2012). Acceptance and commitment therapy versus traditional cognitive behavioral therapy: A systematic review and meta analysis of current empirical evidence.International Journal of Psychology & Psychological Therapy, 12, 333–357.5Hofmann, S. G., Asu Asnaani, M. A., Imke, J. J., Vonk, M. A., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. CognitiveTherapy Research, 36, 427–440.6Yeomans, F. E., Levy, K. N., & Meehan, K. B. (April, 2012). Treatment approaches for borderline personality disorder. Psychiatric Times, 29, 42–46.7Johnson, S. M., Burgess Moser, M., Beckes, L., Smith, A., Dalgleish, T., Halchuk, R., Coan, J. A. (2013). Soothing the threatened brain: Leveraging contact comfort with emotionallyfocused therapy. PLoS ONE, 8(11), e79314. https://doi.org/10.1371/journal.pone.00793147
Eye movement desensitisation and reprocessingEye movement desensitisation and reprocessing(EMDR) is a treatment developed by Francine Shapiroto assist clients exposed to traumatic events. Thetechnique uses bilateral stimulation, right/left eyemovement, or tactile stimulation, that is said to activatecognitive processes to release emotional experiencesthat are “trapped” or buried. Although EMDR may beused for different mental health problems, it has beenprimarily used in trauma therapy. During an EMDRsession the clinician helps the client to revisit thetraumatic event(s) and connect with the associatedthoughts, feelings, and sensations. While doing this theclinician holds a finger about 45 centimetres from theclient’s face and moves the finger back and forth askingthe client to track the movement with his or her eyes.While the client is tracking the movement and recallingthe specific traumatic event the clinician works to movethe client to more positive thoughts, hence helping himor her to resolve the negative and distressing feelings8associated with the event.Family interventionsIn this review, family interventions (including behaviouralparent-training interventions) are defined asinterventions that explicitly focus on altering interactionsbetween or among family members in order to improvethe functioning of the family as a unit, its subsystems,and/or the functioning of the individual members of thefamily. This framework includes formal family therapywork such as systemic family therapy that views thepresenting problem(s) as patterns or systems that needchanging and adjusting, rather than viewing problems9as residing in a particular person.HypnotherapyHypnotherapy involves the use of hypnosis, aprocedure during which the clinician suggests that theindividual experiences changes in sensations,perceptions, thoughts, or behaviour. The hypnoticcontext is generally established by an inductionprocedure. Traditionally, hypnotherapy involves educationabout hypnosis and discussion of commonmisconceptions, an induction procedure such as eyefixation, deepening techniques such as progressivemuscle relaxation, therapeutic suggestion such as guidedimagery, anchoring techniques and ego-strengthening,and an alerting phase that involves orienting the10individual to the surroundings.Interpersonal psychotherapyInterpersonal psychotherapy (IPT) is a brief, structuredapproach that addresses interpersonal issues. Theunderlying assumption of IPT is that mental healthproblems and interpersonal problems are interrelated.The goal of IPT is to help clients understand how theseproblems, operating in their current life situation, leadthem to become distressed and put them at risk ofmental health problems. Specific interpersonal problems,as conceptualised in IPT, include interpersonal disputes,role transitions, grief, and interpersonal deficits. IPTexplores individuals’ perceptions and expectations ofrelationships, and aims to improve communication and11interpersonal skills.Mindfulness-based cognitive therapy andmindfulness-based stress reductionMindfulness-based cognitive therapy (MBCT) andmindfulness-based stress reduction (MBSR) aretreatments that emphasise mindfulness meditation as theprimary therapeutic technique. MBCT and MBSR areused to interrupt patterns of ruminative cognitiveaffective processing that can lead to depressive relapse.In MBCT and MBSR, the emphasis is on changing therelationship to thoughts, rather than challenging them.The aim is to raise awareness at a metacognitive level sothat an individual can fully experience cognitions andemotions that pass through the mind that may or maynot be based on reality. The goal is not to change thedysfunctional thoughts but to experience them as being12real in the present time and separate from the self.8Shapiro, F. (2014). The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: Addressing the psychological and physical symptoms stemming fromadverse life experiences. The Permanente Journal, 18(1), 71–77.9Hontoria Tuerk, E., McCart, M. R., & Henggeler, S. W. (2012). Collaboration in family therapy. Journal of Clinical Psychology, 68, 168–178.10Izquierdo de Santiago, A. & Khan, M. (2009). Hypnosis for schizophrenia. Cochrane Database of Systematic Reviews 2007(4). CD004160.pub3. doi:10.1002/1465185811Jako
Interpersonal psychotherapy (IPT) Mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) Narrative therapy Play therapy (children) Psychodynamic psychotherapy Psychoeducation Schema-focused therapy Self-help Solution-focused brief therapy (SFBT)
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EXECUTIVE SUMMARY VII design, then classified interventions based on the overall evidence and a set of predetermined criteria. Each intervention was classified as evidence-based, evidence-informed, promising, emerging, or of interest. Finally, we grouped interventions in three categories: prevention, reunification, or reconnection.Each
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