BMJ Open Effectiveness of metacognitive interventions for mental disorders in adults: a systematic review protocol (METACOG)
Franziska Kuhne,1,2 Ramona Meister,1 Alessa Jansen,1,3 Martin Harter,1 Steffen Moritz,4 Levente Kriston1
Introduction Whereas the efficacy of cognitive- behavioural therapy has been demonstrated for a variety of mental disorders, there is still need for improvement, especially regarding less prevalent or more severe disorders. Recently, metacognitive interventions have been developed and are now available for a variety of diagnoses. Still, a systematic review investigating the effectiveness of different metacognitive interventions for various mental disorders is missing.
Methods and analysis Randomised controlled trials (RCTs), cross-over and cluster RCTs and non-randomised controlled trials on metacognitive interventions (ie, metacognitive therapy, metacognitive training, others) in adults with any mental disorder will be included. As comparators, another psychological or pharmacological treatment, a combined psychological and pharmacological treatment, treatment as usual or no active treatment are eligible. Outcomes refer to efficacy and acceptability of metacognitive interventions.
Ethics and dissemination In light of the popularity of metacognitive interventions, the systematic review will provide researchers, clinicians and patients with substantial information on the intervention’s effectiveness across different mental disorders. Results will be published in peer-reviewed journals and disseminated through a patient workshop.
Cognitive-behavioural therapy and recent developments
Mental disorders are highly prevalent and often accompanied by comorbidity as well as severe role, functional and health-related quality of life impairments.1 2 A number of mental disorders share a rather chronic course associated with poor health-related quality of life, poor somatic health and disability.3 4 Mental disorders are often treated inadequately or not at all.2 5 An evidence-based psychotherapy for the treatment of most disorders is cognitive-behavioural therapy (CBT)–a scientific and empirical treatment that stems from classical and instrumental conditioning as well as from cognitive approaches.6 As a family of interventions, it involves different general and disorder-specific interventions and techniques.7 Evidence supports the use of CBT in the treatment of a variety of mental disorders.8 9 Limitations refer to insufficient benefits as well as non-response and adverse effects in some patient groups.10-12 Meta-analyses illustrate methodological shortcomings in psychotherapy studies on less prevalent or more severe mental disorders.13-15 Due to these limitations, further developments in psychological and specifically psychotherapeutic techniques were achieved including the development of metacognitive interventions.16
During the last 20 years, metacognitive interventions have been developed and disseminated for a variety of mental disorders. They became increasingly popular, and their evidence base has advanced. Nevertheless, quite different psychotherapeutic approaches refer to ‘metacognitive’ changes, which is why a thorough definition is both warranted and not easy to accomplish.17
Metacognitions as described by Flavell18 refer to ‘knowledge and cognitions about cognitive phenomena’ (p 906). As a distinction from other therapies, metacognitive interventions specifically focus on distorted and central metacognitive processes underlying mental disorders. Their primary aim is not to change the cognitive contents, but to apply rather indirect treatment approaches to alter specific metacognitions or their functions.19-21 In this sense, metacognitions reference thoughts about thoughts, or thinking about one’s thinking.22 Since the above-mentioned definition by Flavell18 was a major starting point for research on metacognitions also into psychotherapy, we will include metacognitive interventions related to this definition into our systematic review.
Currently, two main approaches of therapy and research on metacognitions in mental disorders are prominent: (1) The transdiagnostic ‘metacognitive therapy’ focuses on core cognitive processes and dysfunctional beliefs in mental disorders in general.19 23 Metacognitive therapy as developed by Wells mainly addresses dysfunctional beliefs about thinking.23 It describes cognitive processes like worrying, rumination, dysfunctional threat monitoring or thought suppression as well as dysfunctional beliefs about these processes (like ‘rumination is helpful to avoid threat’) as key in mental disorders.19 24 These cognitive processes and beliefs are addressed via interventions like the attention training technique or behavioural experiments.19 Although metacognitive therapy is rooted in CBT, it differs from traditional CBT in several aspects like its focus on inflexible cognitive processes (instead of cognitive contents), or on how metacognitions influence thoughts and emotions.23 (2) The more disorder-specific ‘metacognitive training’ as developed by Moritz and colleagues25 focuses on the alteration of specific cognitive biases (eg, jumping to conclusions or externalising attributions in schizophrenia) in the development, maintenance and treatment of specific disorders such as psychosis or borderline personality disorder.20 21 In experimental psychology, confidence is regarded a central aspect of metacognition, which is picked up by metacognitive training aiming to ‘sow the seeds of doubt’, that is to decrease overconfidence by challenging cognitive biases.26 It challenges symptoms rather indirectly by treating cognitive biases instead of challenging the core symptoms of mental disorders directly (‘backdoor approach’).20 Unlike metacognitive therapy, metacognitive training can be administered either as an adjunct to traditional CBT or as a stand-alone intervention.21 25 Both approaches may be conducted in an individual or group format.
Due to ongoing development, further interventions involving metacognitions become available, especially for patients with schizophrenia.17 27 Therefore, we will only include psychotherapeutic interventions focusing on metacognitive change (as defined by Flavell18) as the central mechanism.
Evaluation studies on metacognitive interventions have been conducted in patients with generalised anxiety, obsessive-compulsive and social anxiety disorder, post-traumatic stress disorder, depression and schizophrenia,19 25 and applications to new populations, like chronic fatigue syndrome, body dysmorphic disorder, emotional instability or alcohol abuse are under way.19 The evidence update of the British National Institute for Health and Clinical Excellence incorporates Wells’ metacognitive therapy already as step-three intervention into the treatment guideline for adults with generalised anxiety disorders.28
Existing evidence and rationale for the present review
As there was an increase in evaluation studies on metacognitive interventions during the last years, it is one aim of the current review to summarise the empirical evidence on metacognitive interventions.
Some previous reviews on metacognitive interventions were done narratively, rather than systematically, and conclude encouraging positive effects.11 19 25 Methodological shortcomings of these reviews are in limited search strategies, the mix of high-quality and low-quality primary studies, no exploration of heterogeneity between primary studies and no comparison of types of metacognitive interventions. One systematic review on ‘third wave’ therapies explicitly excluded metacognitive interventions.29 Two consecutive Cochrane reviews on ‘third wave’ therapies for the acute phase treatment of depressive disorders focused on randomised controlled trials (RCTs) and included only outpatients, and thus were not able to include all metacognitive interventions.30 31
Furthermore, meta-analyses on metacognitive interventions have demonstrated inconsistent findings. A meta-analysis on metacognitive therapy including uncontrolled trials yielded large significant effects.32 Since the literature search of this review was conducted 3 years ago and was limited to anxiety and depression, we will cover current studies by an update that also includes other mental disorders. Regarding metacognitive training, by using different inclusion criteria, outcomes and assessment methods, meta-analyses reached very different results, from non-significant,33 over mixed34 to significant small to moderate effects.35 The latter set of meta-analyses focused exclusively on patients with schizophrenia, as metacognitive training for depression and borderline personality disorder has so far only been addressed by single studies.36 37 Moreover, current studies are available on a self-help version of metacognitive training for OCD.38 39
Therefore, a comprehensive and methodologically sound systematic review on metacognitive interventions is needed. Separate meta-analyses will be conducted to estimate the effects of the different approaches including ‘metacognitive therapy’ and ‘metacognitive training’. If trials on other ‘metacognitive’ interventions fulfil our inclusion criteria, their conceptual background will be analysed carefully. Following this, they will either be allocated to one of the above-mentioned approaches or to a new category. Additional subgroup analyses shall reveal if there are differential effects in groups of mental disorders. Information on randomised and non-randomised controlled trials will be incorporated to gain a more comprehensive picture of the evidence base. By this systematic review, clinicians may be supported in the assessment of newly developed psychological treatments.
The objective of the systematic review is to assess the effects of metacognitive interventions for adult patients with mental disorders. In detail, the review aims (a) to investigate whether approaches of metacognitive interventions are effective, (b) to investigate whether effectiveness within these approaches varies across mental disorders and (c) to explore the acceptability of different approaches of metacognitive interventions.
METHODS AND ANALYSIS
Criteria for selecting studies for this review
Types of studies
Randomised controlled trials (RCTs), including crossover and cluster RCTs, and non-RCTs will be included. For non-RCTs, we require that at least two groups of independent participants are compared. No restrictions regarding other design characteristics will be applied.
Types of participants
As metacognitive interventions target diverse and several less frequent mental disorders, studies conducted in adults (>18 years) with mental disorders (including substance-induced disorders, schizophrenia and other psychotic disorders, affective disorders, anxiety disorders, somatoform disorders, dissociative disorders, sexual disorders, eating disorders, sleep disorders or personality disorders) will be considered. The diagnosis either needs to rely on a formal classification system, that is the International Classification of Diseases40 or the Diagnostic and Statistical Manual of Mental Disorders 41 or on reliable and validated (patient-reported or observer-reported) scales. Differences in deriving the diagnosis (formal diagnostic criteria vs validated questionnaires) will be documented and considered in analyses of between- study heterogeneity. We will allow for any comorbidity and setting (inpatient and outpatient). Studies in which patients with physical disorders are included will only be considered if patients received a formal diagnosis of a mental disorder via one of the before-mentioned classification systems.
Types of interventions
As a distinction from other psychotherapies, metacognitive interventions specifically focus on ‘knowledge and cognitions about cognitive phenomena’.18 They highlight the role of maladaptive cognitive processes, as opposed to cognitive contents, in the development, maintenance and treatment of mental disorders. They mainly involve psychological interventions focusing on cognitive processes and related dysfunctional beliefs (eg, thought suppression and beliefs about its effect in ‘metacognitive therapy’) or specific cognitive biases (eg, jumping to conclusions in ‘metacognitive training’ for psychosis). Included metacognitive interventions have to fulfil the following criteria:
► administered in individual or group format,
► lead by a therapist or as a self-help-programme,
► administered face-to-face or electronically,
► delivered as stand-alone intervention, as an adjunctive treatment or in combination with a psychological or pharmacological treatment.
Types of comparators
The comparators may be another psychological or pharmacological treatment, a combined psychological and pharmacological treatment, treatment as usual (a thorough description will be recorded) or no specific active treatment (eg, no treatment, wait-list control (WL), placebo).
Types of outcome measures
The primary efficacy outcome will refer to changes in metric outcomes on disorder-specific, comprehensive and validated symptom rating scales (eg, Psychotic Symptom Rating Scales (PSYRATS) delusion score for schizophrenia or other psychotic disorders42 or Hamilton Rating Scale for Depression (HRSD) for depressive disorders43) at the end of treatment. If necessary, subscales relating to relevant symptom domains rather than global symptom burden will be considered. If several symptom rating scales are available for one disorder, they will be ordered and included according to psychometric criteria and frequency of their application. If the original authors report patient-reported and observer-reported outcomes, we will give preference to observer-rating scales as they may be blinded.
The primary acceptability outcome will be treatment dropout, defined as the number of participants who dropped out of the allocated treatment for any reason.
Secondary efficacy outcomes will include treatment response as defined by the study authors (often as a minimum decrease in a symptom scale score from baseline to post-treatment/follow-up), improvement in overall symptomatology (measured for example by the Clinical Global Impressions (CGI) scale44), changes in metacognitive processes (measured for example by the Metacognitions Questionnaire (MCQ-30)45), satisfaction with treatment (measured for example by the Patient Satisfaction Questionnaire(PSQ)46) and quality of life (measured for example by the WHO-QoL-BREF47).
Beyond, applicability of metacognitive interventions (ie, applicability and transfer in everyday life or in crises; measured for example by single items) and autonomy (as measured for example by the subscale level of independence of the WHO-QoL48) will be included. These secondary outcomes have been identified as clinically relevant outcomes by means of a patient involvement workshop and focus group with seven adult patients with different mental disorders, which was held in December 2015 at the Department of Medical Psychology at the University Medical Center Hamburg-Eppendorf.
Secondary acceptability outcomes will refer to adverse events and adverse effects (like suicide attempts or worsening of symptoms).
Outcomes will be evaluated at the end of treatment for the main outcomes. Additionally if follow-up assessments are reported, they will be analysed with their timing categorised as short term (up to 6 months post-treatment), medium term (7 to 12 months post-treatment) or long term (longer than 12 months).
Search methods for identification of studies
Several methods will be used to retrieve potentially relevant articles. In addition to standard electronic medical databases clinical trial registers and sources of grey literature will be searched. The ‘ancestry approach’ (forward and backward reference search) will be applied by examining reference lists and performing citation searches. In addition, relevant experts will be contacted.
Bibliographic database search
The following databases will be searched: Cochrane Central Register of Controlled Trials, Medline, ISI Web of Science, Biological Abstracts/Previews Archive (BIOSIS), PsycINFO and Cumulative Index to Nursing and Allied Health Literature. All databases will be searched using both relevant subject headings (controlled vocabularies) and keywords (free text). For searches, an intervention-component will be combined (AND) with a design component.
We will restrict the search date to 1994 onwards (unless otherwise stated), which is the year when the metacognitive model of psychological disorders was first presented by Wells and Matthews.49 There will be no restrictions on language or publication status applied to the searches.
Search in clinical trial registers
We will search International trial registries via the WHO’s trials portal International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov to identify additional unpublished or ongoing studies.
Search in sources of grey literature
We will search two sources of grey literature for metacognitive interventions (1994 onwards): the ProQuest Dissertations and theses database (http://www.proquest. com/libraries/academic/dissertation-theses/), and Open Grey (http://www.opengrey.eu/).
We will check the reference lists of all included studies and relevant systematic reviews to identify additional studies potentially missed from the original electronic searches (for example unpublished or in-press citations). We will also conduct a cited reference search of reports of included studies, including existing reviews on the topic.
Further, we will contact the first author of all included studies for information on unpublished or ongoing studies.
Key author search
As in some circumstances, publications on metacognitive interventions were not termed as such, we will search for further publications of the key authors of all metacognitive interventions.
Study selection and data extraction
At first, we will screen titles and abstracts for inclusion and code studies as ‘retrieve’ (eligible or potentially eligible/ unclear) or ‘do not retrieve’ (ineligible). We will then retrieve the full texts (study reports respective publications), and two review authors will independently screen the full texts and determine studies for inclusion. Reasons for exclusion of ineligible studies will be recorded. We will resolve any disagreement through discussion or, if required, consult a third reviewer. Multiple reports that relate to the same study will be collated so that each study rather than each report is the unit of interest of the review. We will record the selection process in sufficient detail to complete a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.50 Literature records will be managed using EndNote software.51
To extract study characteristics and outcome data, we will use a structured data collection form, which will be piloted on at least three studies in the review. Two review authors will independently extract study characteristics and outcome data from the included studies. Data on the following study characteristics will be collected:
- Methods: study design, total duration of study, location, date of study (year).
- Participants: number of participants (N), diagnosis, age range, % female.
- Interventions: metacognitive approach (eg, metacognitive therapy, metacognitive training), extent (eg, stand-alone intervention, active ingredient of a larger intervention), intensity of contact (eg, therapist led, self help), intervention dose (eg, frequency or duration of sessions).
- Outcomes: scale for measurement of primary outcome.
We will note in the ‘Characteristics of included studies’ table if outcome data were not reported in a usable way. We will resolve disagreements by consensus or by involving a third reviewer.
Assessment of methodological quality
Two review authors will independently assess risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.52 Risk of bias will be assessed according to the following domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting and other bias.
The Risk Of Bias in Non-randomized Studies – of Interventions (ROBINS-I)53 for assessing the quality of non-randomised studies in meta-analyses will be used to assess the quality of non-randomised controlled trials.52 We will assess recruitment bias, baseline imbalance, loss of clusters, incorrect analysis and comparability with individually randomised trials in cluster-randomised trials. Any disagreements will be resolved by discussion or by involving a third reviewer. We will judge each potential source of bias according to the grading of the relevant risk of bias tool (eg, high, low or unclear risk).
Planned treatment comparisons
Separate meta-analyses will be calculated for the different conceptual backgrounds, like for the ‘metacognitive therapy’ or the ‘metacognitive training’ approaches. For each mental disorder, the following main comparisons are planned based on clinical importance and expected frequency of the comparisons in clinical trials:
► metacognitive intervention versus other psychological treatment.
► metacognitive intervention versus pharmacological treatment.
► metacognitive intervention versus no specific active treatment (no treatment, WL, treatment as usual (TAU)).
► metacognitive intervention versus placebo.
► metacognitive intervention in combination with another psychological treatment, with pharmacological treatment or with no specific active treatment versus another psychological treatment, another pharmacological treatment, another unspecific active treatment or placebo.
Effectiveness measures for dichotomous outcomes will be pooled as ORs. We will analyse continuous data as mean differences (MD). If different rating scales were used to assess the same outcome in the included studies, standardised MD will be calculated.
Meta-analyses will be undertaken only if it is meaningful, that is if treatments, participants and the underlying clinical question are similar enough for pooling.54 We will narratively describe skewed data reported as medians and interquartile ranges.
To broaden the evidence base of the planned review, data from non-randomised controlled trials, cluster-randomised trials and cross-over trials will be included in addition to individually randomised parallel trials. Cluster-randomised trials will be included if proper adjustment for the intracluster correlation can be calculated. Regarding cross-over trials, we will include data from the first active treatment phase. Concerning studies with multiple treatment groups, for each of the main objectives addressed in our review, only data from the comparison of interest will be considered. If the study provides more than one comparison of interest for one of the main objectives, we will divide the number of participants in the arm used several times by the number of arms for all analyses to avoid including participants more than once in the analysis.
In case of missing or unclear data, we will contact the first/corresponding author respective study funder to obtain key study characteristics and outcome data (eg, when a study is identified as abstract only). All requests and correspondences will be documented.
Substitution of missing data will follow current guidelines, for example, calculating standard errors from exactly reported t-values or estimating dichotomous from metric outcomes.52 55 56 For all studies, effect sizes will be calculated using the intention-to-treat principle, that is, analysing all subjects allocated to a study arm. For all outcomes, the definition of the intention-to-treat sample provided by the authors will be followed.
Statistical heterogeneity between study results will be tested for significance using Cochran’s Q-test and quantified using the P-statistic.52 P-values will be interpreted as follows: 0%-40%: might not be important; 30%-60%: may represent moderate heterogeneity; 50%-90%: may represent substantial heterogeneity; 75%-100%: considerable heterogeneity. Substantial and considerable statistical heterogeneity needs further exploration, but magnitude and direction of effects and the strength of evidence for heterogeneity will be taken into account as well.
Possible reporting bias and small-study effects will be tested using visual examination of funnel plots and by performing Egger’s test if a minimum of 10 studies is to be included in the meta-analysis.
All analyses will be performed using a random effects model, assuming that included studies will not be functionally equivalent and will show some clinical (concerning population, intervention) and methodological heteroge- neity.54 Results will be displayed as forest plots. If it will not be possible to combine studies via meta-analysis, a narrative summary will be provided.52 57
Subgroup analysis and investigation of heterogeneity
To identify possible treatment effect moderators, a priori defined subgroup analyses (in case of categorical predictors) or metaregression analyses (in case of metric predictors) will be performed. These analyses will relate to the primary effectiveness and acceptability outcomes and consider diagnosis subtype, intervention extent (stand-alone intervention or active ingredient of a larger psychological treatment), intensity of contact (eg, therapist-led or self-help intervention) or intervention dose (eg, frequency or duration of sessions). Differences between subgroups will be tested formally.58 59
Metaregression analysis will be performed using the restricted maximum likelihood estimate method, a recommended random effects approach accounting for residual between-trial heterogeneity.60
In case of considerable heterogeneity between study results that cannot be explained by the a priori defined subgroup and metaregression analyses, a series of a posteriori (explorative) metaregression analyses will be performed to identify sources of heterogeneity. A priori and a posteriori analyses will be clearly labelled as such.
We will conduct sensitivity analyses regarding the primary effectiveness and acceptability outcomes. Sensitivity analyses will be performed excluding studies with a high or unclear risk of bias (separately for each of the seven domains according to the risk of bias tool of the Cochrane Handbook52) and/or with outlying findings. Additional sensitivity analyses will be performed excluding non-randomised trials to control for possible design effects. Further, differences in making the diagnosis will be addressed in sensitivity analyses by excluding those studies that did not use formal diagnostic criteria.
Ethics and dissemination
The systematic review aims to synthesise the current available evidence according efficacy and acceptability of metacognitive interventions for mental disorders. Our work intends to contributing to minimise a research gap and thereby enabling patients, physicians, guideline developers and policy-makers to make evidence-based decisions regarding treatment selection. The protocol of this review has been registered with the International Prospective Register of Systematic Reviews (PROS- PERO), Protocol No. CRD42016051006. The review’s start date was 15 November 2016, and it is expected to be completed by the end of 2017. The set of extracted data will be published as online supplementary material or will be available from the corresponding author.
We will ensure the dissemination of our results using multiple strategies including peer-reviewed open-access journal publications, conference presentations and executive summaries. Further, dissemination of results will be discussed in a second workshop with patients with mental disorders. The planned publication will be prepared according to the PRISMA statement.50 Changes to this study protocol along with the rationale will be reported, if necessary.
Comparative Analysis of the Social Concepts Role in Adapting to the Situation of Severe Disabling Somatic Disease
Perceptions of health and illness are basic to human consciousness, as in health situation and in situation of the disease. Identifying specificity concepts of healthy and sick person in a situation of severe stigmatizing disease is to aid understanding and clarify the mechanism of selecting adaptation strategies. The study found that for patients with tuberculosis express ideas about health related to health as the lost value. Representation of the sick are in the nature of adaptation to change their social role, which emphasizes the dissatisfaction with themselves, trying to find excuses to their position among other people, the fear of negative perspectives and attempts to resolve the crisis of identity. The article analyzes adaptive strategies of patients with pulmonary tuberculosis in terms of the author’s «disease situation» concept. The identified strategies are considered as an aspect of the subjective element of the «disease situation». The results can be used in rehabilitation practice.
Predictors of psychological security in patients of depressive spectrum
Increase in the number of patients with depressive disorders and protracted course of the disease induce the search for new form of psychological assistance. The paper considers possibilities of the metacognitive schema therapy by J. Young in the group work with patients suffering from disorders of depressive spectrum.
The aim of psychological work is development of psychological security in patients with depressive disorders. Psychological security is studied as a result of the interaction of the person and the environment, dynamic process mediated by cognitive, affective, behavioral characteristics. Within cognitive-behavioral approach a pilot study was performed which was directed at detection of the level of psychological security in patients suffering from disorders of depressive spectrum. The interrelationships of indices of psychological security, their correlation with psychological, therapeutic and clinical-dynamic traits of patients were studied. Methods of psychodiagnosis included: Beck Depression Inventory, Beck Hopelessness Scale, the scale of selfassessment of level of anxiety by Spielberger–Khanin; World Assumptions Scale by R. Janoff- Bulman (O. Kravtsova’s adaptation), the questionnaire Early Maladaptive Schemas by J. Young in P.M. Kas’yanik’s, E.V. Romanova’s adaptation and Life Style Index by Plutchik-Kellerman in L.I. Wasserman’s, E.B. Klubova’ s adaptation. The study enrolled 40 patients with depressive spectrum disorders of non-psychotic level, mainly female, under treatment and under group psychotherapy at the wards of Mental Health Research Institute, Tomsk National Research Medical Center.
Study results. In patients with depressive disorders early maladaptive schemas, emotional deprivation, inhibition, unrelenting standards were revealed. It was established that severity of depressive disorder determined degree of psychological security. The more severe the depression was, the more severe the distortion of the image of «Self» was, including experience of hopelessness, reduction of belief in one’s one forces, loss of control over events of one’s own life. Level of tension of defensive mechanisms differed in patients of different nosological groups.
Recovery of psychological security of patients was contributed by method of schema therapy applied in group form and directed at cognitive restructuring by the way of satisfaction of disordered needs. In the psychocorrective work the techniques were used which were directed at training in acceptance of the problem situation as a part of life experience, re-estimation of one’s own role with acceptance of responsibility and formation of active attitude in overcoming the emerged circumstances.
The results of the performed study allowed to claim that method of the integrative schema therapy by J. Young was an efficient method of psychological correction of cognitive distortions which reduced psychological security in patients of depressive spectrum.
Stoyanova I.Ya., Smirnova N.S. Predictors of psychological security in patients of depressive spectrum. Med. psihol. Ross., 2018, vol. 10, no. 1, p. 6. doi: 10.24411/2219-8245-2018-11061 [in Russian, in English].
Received: December 12, 2017 Accepted: December 29, 2017 Publisher: February 5, 2018
Mental health is one of most acutely discussed problems in psychiatry, medical psychology, psychotherapy, and other scientific disciplines. Within the framework of a psychological model the content of this category is steadily expanded. In the contemporary scientific research mental health is considered as a complex phenomenon including psychological characteristics of mental balance, plasticity during interaction of different domains of the personality.
Harmony and self-control are considered as significant criteria of mental health which determine maintenance of dynamic balance between the person and the environment in the situations, requiring mobilization of resources for adequate adaptation to favorable and negative influences .
The concept of «psychological security” is closely associated with mentioned above psychological characteristics. Its purposeful studies within the framework of a psychological model are dated the middle of the XXth century. In A. Maslow’s views, need for security and protection is one of human bottom-level needs .
- Janoff-Bulman considers security as a significant feeling for mentally healthy person. It includes three categories of world assumptions, making the core of subjective world of the person, attitude towards the surrounding world: assumption that in the world there is more good than evil, assumption that the world is full of sense as well as assumption of worth of his/her own «Self». R. Janoff-Bulman notes that feeling of psychological security, protectability is born at childhood, has subjective content filling, contributing to human mental stability and one’s success in the life and also is an important condition of one’s personality development. A high level of psychological security contributes to personality growth, enhances ambitions of the person .
Currently, in the scientific literature an extensive material on different aspects of the security is accumulated [7; 9; 16; 19; 20; 21; 24; 28]. Thereby the problem of psychological security remains insufficiently developed in relation to clinical trials directed at study of correlation of psychological security and mental health, at formation of psychological security in patients in the process of psychological rehabilitation .
The body of studies expands where psychological security is studied in the context of external conditions where the person is an object of influence [8; 19; 24; 32]. Researchers, working in this direction, focus their attention on study of external factors provoking psychological insecurity, susceptibility of the individual to psychotraumatic circumstances. Under such interpretation the «external threat» distinguished on the basis of the source of origin becomes the central phenomenon: natural cataclysms, epidemics, technogenic accidents, social adversity [3; 9; 16; 19; 21; 24; 25].
Another cluster of studies of this phenomenon is devoted to study of the interrelationship of the person with the reality surrounding him/her, consideration of his/her features under perception of threat, and also the coping with it [5; 17; 23; 26; 31; 33]. The principle of feedback in the form of opportunities of the self-control providing resistance to environmental influences allowed to study psychological security as a result of interaction of the person and the environment, as a dynamic process of transition of system from condition of danger to condition of security, mediated by cognitive, personal, behavioral characteristics. In these studies individual-psychological traits are considered as resources of adaptation identified with overcoming of difficult situations. Thus, responsibility of the person for his/her psychological security is emphasized, and its formation is connected with development and self-development [14; 15; 36].
Relevance of research of psychological security of patients suffering from depressive disorders is caused by high prevalence of these disturbances, need of maintenance of mental health and rendering effective psychological assistance with support on personality resources [24; 27; 30; 31; 33].
Being guided by the principles of system approach [14; 36] and the analysis of references, in relation to studies within medical psychology, psychological security can be considered as an integrative and multidimensional phenomenon:
1) a process, i.e. a dynamic component of psychological security which is possible to be formed in the course of psychocorrectional work;
2) a state providing basic need of the personality;
3) a personality trait.
The system-dynamic model of psychological security is represented by the following components:
- sense of purpose of life (existence of the sense bearing goals and possibility of use of various ways for their achievement);
- readiness for overcoming the life difficulties and possibility of self-development;
- responsibility and constructiveness of thought, high level of differentiation;
- openness in relation to the world, people, oneself; flexibility as openness to the novelty.
The relations between these psychological components are mobile also synergic ones [17; 28; 31].
In our research and practical work we rely on definition of psychological security as a dynamic system where the center is the person as an integral, active, reflexive, responsible nature, capable to solve life contradictions. Psychological security is considered as a condition having dynamic character both in inner space of the subject, and in the system «person – environment». This definition includes understanding of psychological security not only in the context of survival and adaptation, but also opens possibilities of self-realization and self-development.
Because psychological security contains three main components in the structure: affective, cognitive, and behavioral, so the most suitable method for its formation in patients with depressive spectrum disorders, in our views, is cognitive-behavioral approach.
Studies of depression within the cognitive-behavioral approach were carried out with support of the concept of cognitive vulnerability by A. Beck  which considers two levels of thought processes – superficial and deep. The first level is responsible for the way of processing of information. Thus, selective focusing of attention on negative aspects blocks adequate processing of positive events in life of depressive patients.
The second level – a deep one, testifies to presence of complex system of the affectively loaded dysfunctional assumptions to which patients adhere. Dysfunctional assumptions or schemas represent life philosophy of the patient, «system of deep attitudes towards oneself, the world, people, the setting basis for processing the current information and strategy of the solution of problems». In this system the entire life experience of the person is fixed, and the special role is played by childhood impressions and features of his/her family .
Important feature of depressogenic cognitive schemas is the lack of differentiation of their contents that indicates their infantile nature. The reasons of development of basic premises of depression are introduced as follows:
1) loss of one of the parents in the childhood therefore psychological losses can be interpreted as irreversible and intolerable traumas;
2) presence of the parent, whose system of assumptions actualizes his/her deficiency or system of constructs consisting of rigid, unrelenting rules;
3) deficiency of social skills, negative experience of communication, lack of empirical testing of negative experience;
4) the physical defect contributing to formation of the image of «Self» as different from the others, avoiding of the contacts hindering the testing.
The Cognitive-Behavioural Therapy (CBT) as a system of psychotherapeutic approaches exists more than 45 years. Its basis is a carefully developed theoretical base which was formulated in the course of long work with a large number of patients. Today in the world the results of hundreds of studies evidencing efficiency of this method in therapy of affective disorders are accumulated.
The CBT method was created for individual work with patients. However in 1979 in the classical handbook of therapy for depression A. Beck et al. have mentioned possibility of its use in group work.
In 2009 the medical protocol of group CBT of depressions was developed and approved. Authors came to a conclusion that realization of this method in a format of group represents unique therapeutic opportunity, the effect from which comes not only from development of cognitive techniques, but also amplifies as a result of group therapeutic process [38; 39; 40; 41].
Describing features of group therapy in formation of psychological security in cognitive-behavioural paradigm, difficulties of carrying out the group in the conditions of a psychiatric hospital should be noted .
Goal-setting, conformable to above-mentioned conditions, differs from traditional group cognitive-behavioral therapy. It can be formulated as an acquaintance with psychotherapy, involvement of the depressive patient in the process of psychotherapy, secondly, mitigation of problem behavior of the depressive patient so that he/she again could carry out activity out of walls of the clinic.
In psychiatric wards there are some effective ways of the help to depressive patients: psychopharmacology, milieu therapy, somatic therapy, individual psychotherapy, etc. However, formation of psychological security is more effective in group work, than in other ways of psychological assistance. Many patients with depressive disorders need study of difficulties which in them arise during communication with other people. Thus, the group creates the unique therapeutic environment, and in focus of group work there is still a transformation of the distorted cognitions. Positive changes are achievable in the different ways: by means of behavioral experiments, study of cases, solution of tasks, playing the roles, mental restructuring .
Metacognitive therapy or schema therapy by J. Young is among modern approaches from the so-called «third wave» of CBT. Emergence of this direction (metacognitive therapy)
– MCT – is connected with names of the Oxford scientists – David Clark and Adrian Wells who created basic model which was developed for patients suffering from generalized anxiety disorder, and later – was adjusted for treatment of a wide range of mental diseases, including depressions [6; 40; 42; 45; 46].
Unlike traditional cognitive models, metacognitive therapy focuses its attention not on the contents and sense of automatic thoughts, but on the process of thought, on the metacognitions, on «thought concerning thought» .
In views of founders of MCT, patients suffering from excess anxiety or depression often complain of impossibility to control their thought, of the persuasive, repeating thoughts
– rumination which can be connected with the negative anticipation of events, with experiences of own failures, excessive fixing on body symptoms. The complex of the templates of thought associated with persuasive fixing of attention on negative aspects is called Cognitive-Attentional Syndrome (CAS) which is the main target of the metacognitive therapy. MCT-therapists help patients to free from this syndrome by means of identification and change of metacognitive assumptions, training in ways of control of the direction of their thought.
Schema therapy (ST) or the schema-focused model is developed by the American doctor Jeffrey Young and is an integrative psychotherapeutic approach which combines in itself ideas of CBT, theory of attachment, Gestalt-therapy and psychodynamic approaches. This integrative approach is focused, first of all, on work with patients with chronic depressions, post-traumatic personality disorders, and also personality disorders [2; 13; 37; 47; 48].
In his approach J. Young continued development of the concept of cognitive «schemas» begun by A. Beck, considerably having expanded and having modified it. By means of clinical observations he identified 18 early maladaptive schemas in five domains.
In total in ST five bottom-level needs are distinguished, to each of which there corresponds a number of early maladaptive schemas :
- Need for secure attachment (including security, understanding, and acceptance);
- Need for autonomy, competence and feeling of Self;
- Need for freedom to express one’s one true needs and emotions;
- Need for spontaneity and game;
- Need for realistic restrictions and self-control.
- Young defines mental health as an ability to manifest and satisfy one’s own basic psychological needs. The early maladaptive schemas created in early experience as ways of presentation of this experience, determine emotions, behavior and nature of processing of information [47; 48]. It contributes to understanding of why patients with depressive spectrum disorders fix on negative, morbid ideas contrary to obvious presence of positive factors in vital activity. According to ST, negative ideas arise when bottom-level needs of the child were not satisfied. According to this the main task is to help the adult to meet his/her needs which were not satisfied at childhood, and to contribute to their satisfaction.
Specifics of the schema therapy in comparison with traditional CBT include the following features:
- Focus on processing of memories of traumatic early experience;
- An intensive use of techniques of imagination for change of negative emotions;
- Conceptualization of the psychotherapeutic relations as limited re-parenting for creation of conditions of experience of positive experience of interaction in the secure environment;
- A support of the model of schema modes which helps the therapist and the patient to understand his/her relevant problems and to create a set of therapeutic techniques.
In addition to early maladaptive schemas the main conceptual apparatus of ST includes concept of schema modes, meaning a certain stable moment-to-moment emotional states, intended to explain change of mood or existence of conflict desires and ideas at the same time, thus, the modes describe the states caused by activation of the schema.
Modes of schemas («schema modes») are described by four main categories:
- Mode «The dysfunctional child».
- Mode «The dysfunctional parent».
- Mode «The dysfunctional coping modes».
Two modes are connected with mental health: 1) «Mode of happy child» and 2) «Mode of healthy adult».
For a chronic depression the model of schema modes including a mode «vulnerable child» is typical. Especially strong negative emotions of grief, melancholy, abandonment and loneliness are associated with it. The specialist’s task is to overcome a defensive mode of avoiding the pain and hard feelings in which most frequently the patient is, and to help to meet this part, directing process in three aspects: 1) to divide estimates of oneself which are little differentiated, for example, frequently «bad» and «sad» are merged among themselves; 2) to teach to express his/her needs; 3) partially to satisfy needs of the patient in the course of psychotherapy.
The schema therapy is directed at reorganization of the relevant cognitive structures by satisfaction of disordered needs, including needs for security in the course of psychotherapy [2; 47; 48].
Chronification of depressive states, recurrent course induces the use of new integrative forms of psychotherapy, on the basis of clinical-psychological and individual- personality characteristics of patients for the purpose of increase of efficiency of the given help. In this foreshortening the pilot study directed at the identification of level of psychological security in patients suffering from disorders of depressive spectrum was carried out. In addition, interrelationships of the main indicators of psychological security, their correlation with psychological, therapeutic and clinical-dynamic features were studied.
Research problems included selection of tools for identification of correlation between the level of psychological security and clinical-dynamic indicators, assessment of psychological security of patients with depressive disorders depending on their nosology, severity of the disease, and identification of targets for differentiated psychotherapy.
Main criteria of inclusion of patients in study sample were as follows: existence of depressive symptoms classified in the sections of ICD-10 (F32.0, F32.1, F33.01, F33.11, F43.21, F43.22), the informed patient’s consent to participation in the study, hospitalization. Criteria of exclusion from sample: CNS organic impairment, substance dependence, somatic or neurologic disorders associated with high risk of development of depression as well as refusal of the patient of participation in the study.
Proceeding from the methodological reasons of study of psychological security, the program of psychodiagnostics included the following methods: Beck Depression Inventory (BDI) , Beck Hopelessness Scale [Ibid.], scale of self-assessment of level of anxiety by Spielberger–Khanin ); World Assumptions Scale by R. Janoff-Bulman (in O. Kravtsova’s adaptation) , revealing eight categories of beliefs as well as the questionnaire Early Maladaptive Schemas by J. Young (YSQ S3R) in P.M. Kas’yanik’s, E.V. Romanova’s adaptation  and Life Style Index by Plutchik-Kellerman in L.I. Wasserman’s, E.B. Klubova’s adaptation etc. .
The original version of the technique by R. Janoff-Bulman does not assume calculation of an index of psychological security. Possibility of calculation of the total index «Psychological security» as an arithmetic mean from addition of indices of all eight subscales is established by S.A. Bogomaz, A.G. Gladkikh .
The questionnaire «Early Maladaptive Schemas» includes 18 early maladaptive schemas in five domains:
DISCONNECTION AND REJECTION
- Emotional deprivation
- Social isolation/Alienation
IMPAIRED AUTONOMY AND PERFORMANCE
- Vulnerability to harm or illness
- Enmeshment/Undeveloped Self
- Failure to achieve
- Insufficient self-control/Self-discipline
- Search for approval/recognition
OVERVIGILANCE AND INHIBITION
- Emotional inhibition
- Unrelenting standards/Hypercriticalness
By means of Life Style Index the level of tension of 8 main psychological defenses as well as their total index was investigated.
Statistical data processing was carried out with application of the package of the standard programs Statistica for Windows (V.10.0). Statistical methods were as follows: descriptive statistics, Spearman’s correlation analysis, Mann–Whitney’s criterion.
40 patients with disorders of depressive spectrum of non-psychotic level who were receiving therapy and taking part in group psychotherapy at wards of Mental Health Research Institute of Tomsk National Research Medical Center participated in the study. In the examined group women (n = 32) predominated (p<0.01) – 80%. Value of mean age of male patients was 46 years, female – 44.5 years.
The analysis of marital status of patients with disorders of depressive spectrum in the examined group indicated the considerable specific weights (55%) of lonely patients. 18 patients (45%) were married. In the examined sample patients with the higher education predominated (p<0.01) – 70% (n = 28).
As a pharmacotherapy all patients received antidepressants of various pharmacological groups.
At the first stage after carrying out the psychodiagnosis the assessment of interrelationships of the level of psychological security (as a total index «Psychological security») and nosological belonging of depressive disorder, degree of its severity and indices of clinical scales was carried out.
Results of study
The findings testify to absence of significant correlations between the level of psychological security and nosological belonging of disorders of depressive spectrum (p>0.05). Thus, interrelationships between severity of disorders and indicators of psychological security both in general (r = -0.69; p<0.05) and according to separate scales were found: «worth of own Self» (r = -0.51; p<0.05), «degree of self-control» (r = -0.55; p<0.05). On the basis of the findings it is possible to claim that, the more severe the depression is, the more severe the distortion of the image of «Self» is, including hopelessness experience, decrease in belief in one’s own forces, loss of control over events of the life.
Correlation between the level of hopelessness and psychological security according to scales «controllability of events in the world» (r = -0.39; p<0.05), «sense of purpose of the world» (r = -0.64; p<0.05) was established. Interpretation of these indices testifies to conviction of patients with the low level of security that the world around has no sense, events occur incidentally and do not subordinate to laws of justice, one should not trust anybody since it is not secure. They do not trust in possibility of change of life to the best, feel their own helplessness.
The analysis of data according to J. Young’s questionnaire showed that in all patients the maximum characteristics in domains «disconnection and rejection», and also «overvigilance and inhibition» are revealed. Thus, severity of the following early maladaptive schemas is noted (severity degree more than 50%):
1) «emotional deprivation» (the schema assuming impossibility of close emotional relationship with others (needs for security, stability, protection will never be satisfied));
2) «emotional inhibition» (that is manifested in attempt to control feelings and emotions, to avoid feelings of shame and guilt);
3) «unrelenting standards» (at the heart of the schema – belief what has to conform to high internalized standards of behavior and performance, usually in order to avoid criticism, leading to feeling of tension, impossibility to stop).
These data coincide with D.V. Truyevtsev’s study on identification and analysis of early maladaptive schemas at different levels of depression severity. As a result of this study it was established that irrespective of severity level, in depression «emotional inhibition» and «unrelenting standards» are actualized. In further studies by O.A. Sagalakova, D.V. Truyevtsev et al. on investigation of rumination the cognitive patterns of helplessness including uncertainty, negative self-estimation, presentation strict requirements to oneself [22; 23; 30; 34] are described.
Research of features of psychological defense by means of Life Style Index (LSI) in patients with depressive spectrum disorders of different nosological representation allowed designating psychotherapy «targets».
It is established that in patients with short-term depressive reaction the highest level of tension of the defensive mechanism «denial» in comparison with other clinical groups is noted (p<0.05). High level of this defensive mechanism indicates a lack of other defensive mechanisms. Respectively, it is necessary to include in psychotherapeutic actions the techniques directed at training in acceptance of a problem situation as a part of life experience, revaluation of one’s own role in the psychotraumatic situation, with taking responsibility and formation of an active position in overcoming of the developed circumstances.
In patients with prolonged depressive reactions the most severe defensive mechanisms (p<0.05), in comparison with other nosological groups, were as follows: «regression» – return to earlier stages of mental development, «compensation» – emphasizing the socially approved behavior, «rationalization» – removal of tension by means of logical ideas. Also in group of patients with prolonged depressive reactions the highest level of trait anxiety according to scale of level of anxiety by Spielberger–Khanin was revealed when comparing with other nosological groups. Increase of anxiety as an integrative indicator of level of security and actualization of the complex of defensive mechanisms, assumes complex psychological work.
In patients with depressive episodes (within a single episode and Recurrent Depressive Disorder (RDD)) according to Life Style Index a higher (p<0.05) level of tension of two defensive mechanisms, in comparison with other nosological groups, was revealed: «replacement» – shift of aggression from a stronger and more significant onto a weaker object or onto itself as well as «projection» – a locus of unacceptable thoughts and feelings outwards. These mechanisms strengthen idea of the world as hostile and insecure. Also in patients of this group a higher (p<0.05) hopelessness level was determined (Beck Hopelessness Scale), than in patients with depressive reactions. This can testify to the severe pessimism concerning the future. Therefore creation of the most secure empathic environment becomes an important psychotherapeutic task.
Thus, the work with early maladaptive schemas, image of «Self», psychological defensive mechanisms becomes predictor of formation of psychological security in the course of group work with patients suffering from depressive spectrum disorders. During detection of psychological characteristics contributing to disturbance of psychological security in the course of group work its participants acquire understanding of their own schemas as not constructive ways of coping with reality. There is a need for development of a new experience which gives the chance to make independently necessary cognitive, affective, interpersonal and behavioral changes for prevention of recurrence in the future.
- In patients with depressive disorders, irrespective of nosological belonging the early maladaptive schemas including emotional deprivation, inhibition, unrelenting standards are revealed.
- Severity of depressive disorder determines degree of psychological security.
- In the course of psychological work it is necessary to consider that the level of tension of defensive mechanisms differs in patients of depressive spectrum of various nosological groups.
- The analysis of references and results of the carried out study allow to claim that the method of integrative schema therapy by J. Young is an effective method of psychological correction of cognitive distortions which reduce psychological security in patients with depressive spectrum disorders.