Beyond Efficacy and Effectiveness: Clinical Efficiency Is Necessary for Dissemination

Nearly all patients interact with critical gatekeepers—insurance companies or centralized healthcare systems. For mental health dissemination efforts to be successful, these gatekeepers must refer patients to evidence-based care. To make these referral decisions, they require evidence about the amount of resources expended to achieve therapeutic gains. Without this information, a bottleneck to widespread dissemination of evidence-based care will remain. To address this need for information, we introduce a new perspective, clinical efficiency. This approach directly ties resource usage to clinical outcomes. We highlight how cost-effectiveness approaches and other strategies can address clinical efficiency, and we also introduce a related new metric, the incremental time efficiency ratio (ITER). The ITER is particularly useful for quantifying the benefits of low-intensity and concentrated interventions, as well as stepped-care approaches. Given that stakeholders are increasingly requiring information on resource utilization, the ITER is a metric that can be estimated for past and future clinical trials. As a result, the ITER can allow researchers to better communicate desirable aspects of treatment, and an increased focus on clinical efficiency can improve our ability to deliver high-quality treatment to more patients in need.

Exposure Therapy for Misophonia: Concepts and Procedures

Misophonia, a condition marked by extreme intolerance to certain classes of sounds (e.g., respiratory or gustatory noises), has recently attracted increased research attention. As yet there are no evidence-based treatments, although some promising options are under empirical consideration. This paper presents a stress management and exposure therapy-based treatment protocol for adults with misophonia. The protocol details considerations specific to exposure therapy for misophonia, including unique considerations for developing hierarchies and example misophonia exposure exercises and exposure homework. Stress management approaches employed to facilitate engagement with exposure are also described. Two case examples are included, which illustrate the application of the misophonia treatment protocol. The first case describes treatment for a client whose misophonia symptoms are the primary focus and the second case describes treatment for a client whose misophonia symptoms are secondary to relationship difficulties. This protocol can be used to stimulate further treatment research for misophonia and guide treatment for individuals with misophonia.

An Examination of the Relationship Between Perfectionism and Neurological Functioning

Clinical perfectionism is the rigid pursuit of high standards, interfering with functioning. Little research has explored neural patterns in clinical perfectionism. The present study explores neural correlates of clinical perfectionism, before and after receiving ten 50-minute, weekly sessions of acceptance and commitment therapy (ACT), as compared to low-perfectionist controls, in specific cortical structures: the dorsolateral prefrontal cortex (DLPFC), medial prefrontal cortex (MPFC), right inferior parietal lobule (IPL). Participants in the perfectionist condition (n = 43) were from a randomized controlled trial evaluating ACT for clinical perfectionism and low-perfectionist controls were undergraduate students (n = 12). Participants completed three tasks (editing a passage, mirror image tracing, circle tracing) using functional near-infrared spectroscopy (fNIRS) to measure neural activation. Results indicate that ḥin the DLPFC and MPFC of the perfectionists whereas activation in the other tasks were relatively similar. There were no differences were observed in the right DLPFC, MPFC, and right IPL between the posttreatment perfectionist and nonperfectionist control groups. Our findings suggest an unclear relationship between neural activation and perfectionism.

A Review of Motivational Interviewing in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder

Although cognitive behavioral therapy (CBT) is a highly effective treatment for individuals with obsessive-compulsive disorder (OCD), a portion people with OCD do not benefit fully from CBT due to ambivalence about participating in treatment, nonadherence to exposure exercises, and dropout. This paper reviews the promising evidence for motivational interviewing (MI) as a therapeutic approach that is well suited to address these issues and potentially improve treatment outcomes. It will also provide a discussion of MI processes that may enhance CBT for OCD which can foster a collaborative relationship that integrates a patient's own goals and values into exposure planning, helps resolve ambivalence or reluctance to engage in exposure exercises and builds and supports patients' intrinsic motivation to participate in treatment. The review will conclude with a case report describing the use of pre-CBT MI for an individual with OCD.

Motivational Interviewing as a Therapeutic Strategy for Trafficked Persons

It is estimated that 40 million people worldwide have experienced human trafficking (UN, International Labour Organization & Walk-Free Foundation, 2019), with 313,000 trafficked persons in the state of Texas alone (Busch-Armendariz et al., 2016). These staggering numbers are indicative of human trafficking as a growing public health concern. To date researchers have neither studied nor proposed a specific psychotherapeutic modality in the treatment of trafficked persons. Given the unique concerns of this populations, including mistrust of authority, emotional coercion, and abuse by traffickers, often co-occurring substance use concerns, and difficulty with standard treatment adherence, we propose a therapeutic strategy that might assist providers in addressing a broad range of concerns, particularly assisting trafficked persons in the effort to leave their situation. This strategy is motivational interviewing (MI; Miller et al., 2009) and has shown substantial efficacy to enhance motivation to change as applied within in a broad range of healthcare settings. We briefly review the broad tenants of MI and illustrate its application within two hypothetical cases of trafficking. Future research that examines the potential benefits of MI within trafficking populations is warranted.

Introduction to the Special Issue on Exploring the Versatility of Motivational Interviewing

Evidence indicates that motivation early in treatment is critical to treatment outcome, and motivational interviewing (MI) has addressed this finding by helping individuals work through ambivalence about change. Not only has it demonstrated improvements in treatment outcome across treatment populations and settings, it has been adapted with success into brief motivational interventions. This special issue explores the use of MI with populations at great risk for ambivalence in therapy, including college students violating campus policy, individuals who have been trafficked, and individuals in exposure therapy. The papers further highlight the versatility of MI-based interventions, as well as their limitations, that may help inform future directions for adapting MI as we move toward digital and web-based interventions.

Motivational Interviewing Enhances Group Cognitive Behavioral Therapy for Anxiety Disorders

This pilot study tested whether the addition of motivational interviewing (MI) prior to group cognitive behavioral therapy (CBT) for anxiety may improve the effectiveness of the treatment. Prior to group CBT, 40 individuals with a principal diagnosis of an anxiety disorder (40% panic disorder, 25% generalized anxiety disorder, 22.5% social phobia, and 12.5% others) were randomly assigned to receive either three individual sessions of MI or were assigned to a control group that did not receive MI. The pretreatment MI group, compared to the control group, experienced significantly greater reduction in anxiety symptoms post-CBT. These results suggest that brief MI pretreatment enhances the efficacy of CBT on anxiety. A combination of MI and CBT may be particularly promising for the treatment of anxiety, with MI directed at increasing motivation and commitment to change, and CBT directed at helping the client achieve the desired changes.

Brief Motivation-Based Interventions for Students Sanctioned for Violating Campus Cannabis Use Policies

College cannabis use continues to rise, yet few students voluntarily seek treatment for cannabis use, despite use-related problems. Thus, the campus judicial system may be one way to identify high-risk cannabis users and intervene with them. Despite research indicating that brief motivational interventions (BMIs) decrease risky alcohol use among students sanctioned for psychological services following campus alcohol policies violations, extant data do not support BMI for students who violate cannabis polices. Thus, the aims of this review paper are to (a) review the extant literature of BMI for cannabis use among sanctioned students, (b) discuss some unique issues concerning BMI for cannabis use, and (c) provide case examples of promising novel ways BMI may be used to address unique needs of these students. Given the wide range of cannabis use and related problems experienced by these students, personalized approaches to BMI-based interventions may improve outcomes for these students.