Identifying patient profiles suitable for cognitive behavior Therapy: The role of psychological mindedness

Sir,

Psychological interventions, such as cognitive behavior therapy (CBT), have robust evidence for efficacy in many psychiatric and even some nonpsychiatric disorders.[1] Notwithstanding this considerable evidence base, cultural variations in receptiveness and efficacy of psychotherapeutic techniques have gained a lot of clinical and research attention.

CBT differs from the other major form of therapy, namely pharmacotherapy, in many aspects. First, the former is more active, collaborative and requires the patient and therapist to jointly invest more time and effort. Second, CBT usually involves a variety of homework assignments, and often, the family members are also called upon to play the role of a cotherapist. Factoring in these differences, it is clear that CBT or similar directive psychotherapies may not be everyone's cup of tea. Further, in the Indian culture, introspection and talking about one's emotional troubles are often frowned upon.[2] It, therefore, becomes incumbent upon clinicians to identify patient profiles suitable for CBT to optimize chances of response. One of the important factors that have been posited to play a role in acceptability and treatment outcomes with CBT is the concept of psychological mindedness.

Psychological mindedness is defined as person's capacity for self-examination, self-reflection, introspection, and personal insight.[3] It includes an ability to recognize meanings that underlie overt words and actions, to identify and appreciate emotional nuance and complexity, to analyze what underlies overt words and actions to recognize the links between past and present, and to insight into one's own and others’ motives and intentions. Psychologically minded people tend to have higher insight into their illness.

There is some evidence linking higher psychological mindedness and favorable outcomes in both short-term supportive and interpretive psychotherapies.[4] However, trials which have investigated psychological mindedness as a moderator for treatment outcomes in CBT did not find clear evidence of effect modification,[5] though the authors of this trial point out that sample sizes were inadequate for testing interactions between psychological mindedness and therapy outcomes. Lower dysfunctional attitudes have been found to mediate outcomes with both pharmacotherapy and psychotherapy in chronic depression.[6] However, there is a dearth of studies that have directly examined the utility of metacognitive constructs such as psychological mindedness in moderating response to CBT.

To facilitate such studies yielding valid results, we need to further operationalize the construct of psychological mindedness in observational and interventional studies of CBT. The effect of psychological mindedness on the acceptability of CBT-based psychotherapeutic interventions in diverse cultural contexts may be looked into. We suggest that future studies should examine the moderating role of psychological mindedness by checking the interaction between psychological mindedness and CBT versus one or two comparator treatments, in the context of a robust randomized controlled design. This will help us conclude the role of psychological mindedness in moderating CBT-related outcomes. This will also pave the way for personalizing CBT approaches and optimize treatment outcomes.