Therapeutic Pyramid Research Articles

Erratum

Journal of Marital and Family TherapyVolume 47, Issue 4 p. 1013-1013 ERRATUMFree Access Erratum This article corrects the following: Way of being and the therapeutic pyramid: Expanding the application of a common factors meta-model Sean D. Davis PhD, Stephen T. Fife PhD, Jason B. Whiting PhD, Kay P. Bradford PhD, Volume 47Issue 1Journal of Marital and Family Therapy pages: 69-84 First Published online: November 8, 2020 First published: 20 October 2021 https://doi.org/10.1111/jmft.12545AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL The article by Davis et al., (2020) was published with following error. The term “(Fife et al., The case management of family violen2014)” under the last paragraph of the section “INTRODUCTION” should be read as “(Fife et al., 2014).” REFERENCE Davis, S.D., Fife, S.T., Whiting, J.B., & Bradford, K.P. (2020). Way of being and the therapeutic pyramid: Expanding the application of a common factors meta-model. Journal of Marital and Family Therapy, 47(1), 69– 84. https://doi.org/10.1111/jmft.12466 Volume47, Issue4October 2021Pages 1013-1013 ReferencesRelatedInformation

Way of being and the therapeutic pyramid: Expanding the application of a common factors meta-model.

Common factors proponents have suggested the need for principle-based meta-models to explain how various factors interact with each other to produce change. The therapeutic pyramid is a common factors meta-model that outlines how therapeutic skills and techniques, the therapeutic alliance, and a therapist's way of being interactive to produce therapeutic change. Skills and techniques occupy the smallest top portion of the pyramid, with the therapeutic alliance in the middle and a therapist's way of being forming the foundation of the pyramid. The success of any layer rests on the quality of the immediately underlying layer. This study illustrates the broad applicability of common factors meta-models by applying the therapeutic pyramid to couples therapy, family therapy, training and supervision, and professional ethics.

The Supervision Pyramid: A Commonalities-Based Synthesis of Intervention, Relationship, and Person/Personhood.

Adapting the therapeutic pyramid to the supervision of psychotherapy, the author presents and describes the supervision pyramid-a simple meta-model of the broad conceptual organizers of the supervisor's contribution to the experience and outcomes of supervision. The supervision pyramid consists of three commonalities: supervisor skills and interventions, the supervisory relationship, and the supervisor's person and personhood. Those three commonalities converge to stimulate supervisee learning and relearning and client improvement and symptom reduction. The implications of this meta-model for supervision conceptualization and conduct and for supervisor training are briefly described.

Is top-down therapy a more effective alternative to conventional step-up therapy for Crohn's disease?

The management of Crohn’s disease involves immunosuppressive protocols in a step-up approach that progresses through a therapeutic pyramid with several tiers of medication. Medications at the top are considered more potent but present greater risk. A new top-down approach to therapy inverts this procedure, using top-tier drugs for initial treatment. A critical appraisal of the current literature relating to top-down therapy was performed to evaluate its merit. A literature search was conducted on PubMed, Ovid, and PubMed Central to identify studies of the efficacy of top-down therapy. Papers were appraised critically using the Scottish Intercollegiate Guidelines Network score to evaluate current evidence for the use of top-down therapy. Nineteen studies were identified, including six randomized controlled trials, thirteen cohort studies, and two cost-benefit studies. Early combined therapy involving both biologics and immunomodulators was found to be effective at improving patient outcomes; however, early biologics alone were not shown to have a clear benefit over step-up therapy. Likewise, the early use of immunomodulators alone showed inconsistent results with respect to efficacy in terms of both remission and surgical outcomes. Evidence for application in pediatric populations was also inconclusive. The cost-benefit analyses found that top-down therapy merits investigation, as it proved to be economical given current data. Top-down therapy has the potential of being a viable alternative to step-up therapy, but further studies are needed to determine the most appropriate patients to receive this treatment.

Prevalence and Risk Factors for Therapy Escalation in Ulcerative Colitis in the Swiss IBD Cohort Study.

Physicians traditionally treat ulcerative colitis (UC) using a step-up approach. Given the paucity of data, we aimed to assess the cumulative probability of UC-related need for step-up therapy and to identify escalation-associated risk factors. Patients with UC enrolled into the Swiss IBD Cohort Study were analyzed. The following steps from the bottom to the top of the therapeutic pyramid were examined: (1) 5-aminosalicylic acid and/or rectal corticosteroids, (2) systemic corticosteroids, (3) immunomodulators (IM) (azathioprine, 6-mercaptopurine, methotrexate), (4) TNF antagonists, (5) calcineurin inhibitors, and (6) colectomy. Data on 996 patients with UC with a median disease duration of 9 years were examined. The point estimates of cumulative use of different treatments at years 1, 5, 10, and 20 after UC diagnosis were 91%, 96%, 96%, and 97%, respectively, for 5-ASA and/or rectal corticosteroids, 63%, 69%, 72%, and 79%, respectively, for systemic corticosteroids, 43%, 57%, 59%, and 64%, respectively, for IM, 15%, 28%, and 35% (up to year 10 only), respectively, for TNF antagonists, 5%, 9%, 11%, and 12%, respectively, for calcineurin inhibitors, 1%, 5%, 9%, and 18%, respectively, for colectomy. The presence of extraintestinal manifestations and extended disease location (at least left-sided colitis) were identified as risk factors for step-up in therapy with systemic corticosteroids, IM, TNF antagonists, calcineurin inhibitors, and surgery. Cigarette smoking at diagnosis was protective against surgery. The presence of extraintestinal manifestations, left-sided colitis, and extensive colitis/pancolitis at the time of diagnosis were associated with use of systemic corticosteroids, IM, TNF antagonists, calcineurin inhibitors, and colectomy during the disease course.

The therapeutic pyramid: a common factors synthesis of techniques, alliance, and way of being.

Common factors in therapy such as the therapeutic alliance and client motivation have been found to account for more change than therapy models. But common factors have been critiqued as only lists of variables that provide little practical guidance. Some researchers have demonstrated that certain common elements (e.g., the therapeutic alliance) account for more variance than others (e.g., techniques), suggesting that some factors should be emphasized over others. Such findings suggest the need for alternatives to model-based therapy, with one alternative being meta-models, or "models of models," that focus on how therapeutic factors interact with each other to produce change. The purpose of this article is to propose a meta-model describing the relationship between two specific common factors-the therapeutic alliance and interventions. We also propose a new factor-a therapist's way of being-that we believe is foundational to effective therapy. The model is proposed in pyramid format, with techniques on top, the therapeutic alliance in the middle, and therapist way of being as the foundation. The hierarchical relationships between these three concepts are discussed, along with implications for training, research, and therapy.

A short history of anti-rheumatic therapy - VI. Rheumatoid arthritis drugs

The treatment of rheumatoid arthritis traditionally includes symptomatic drugs, showing a prompt action on pain and inflammation, but without any influence on disease progression, and other drugs that could modify the disease course and occasionally induce clinical remission (DMARDs or disease modifying anti-rheumatic drugs). This review describes the historical steps that led to the use of the main DMARDs in rheumatoid arthritis, such as gold salts, sulphasalazine, chloroquine and hydroxychloroquine, D-penicillamine, and other immunoactive drugs, including methotrexate, azathioprine, cyclosporin and leflunomide. The historical evolution of use of these drugs is then discussed, including the strategy of progressive ("therapeutic pyramid") or of more aggressive treatment, through the simultaneous use of two or more DMARDs ("combination therapy").

Prescribed drugs and neurological complications

Over the last 2 decades, assessment of patient health status has undergone a dramatic paradigm shift, evolving from a predominant reliance on biochemical and physical measurements to an emphasis upon...

The Stanford Health Assessment Questionnaire: Dimensions and Practical Applications

The ability to effectively measure health-related quality-of-life longitudinally is central to describing the impacts of disease, treatment, or other insults, including normal aging, upon the patient. Over the last two decades, assessment of patient health status has undergone a dramatic paradigm shift, evolving from a predominant reliance on biochemical and physical measurements, such as erythrocyte sedimentation rate, lipid profiles, or radiographs, to an emphasis upon health outcomes based on the patient's personal appreciation of their illness. The Health Assessment Questionnaire (HAQ), published in 1980, was among the first instruments based on generic, patient-centered dimensions. The HAQ was designed to represent a model of patient-oriented outcome assessment and has played a major role in many diverse areas such as prediction of successful aging, inversion of the therapeutic pyramid in rheumatoid arthritis (RA), quantification of NSAID gastropathy, development of risk factor models for osteoarthrosis, and examination of mortality risks in RA.Evidenced by its use over the past two decades in diverse settings, the HAQ has established itself as a valuable, effective, and sensitive tool for measurement of health status. It is available in more than 60 languages and is supported by a bibliography of more than 500 references. It has increased the credibility and use of validated self-report measurement techniques as a quantifiable set of hard data endpoints and has contributed to a new appreciation of outcome assessment. In this article, information regarding the HAQ's development, content, dissemination and reference sources for its uses, translations, and validations are provided.

¿Por qué un tratamiento precoz en la artritis reumatoide?

Rheumatoid arthritis is an autoimmune disease characterized by chronic inflammation of diarthrodial joints, which may also cause involment of other organs. Today, most authors agree that nearly 80% of the patients will present with some degreee of disability after 10 years evolution. Prognosis of rheumatoid arthritis is uncertain, and lesions, that are produced in the first years of the disease, may progress despite clinical improvement, since pathogenesis of these lesions may differ from simple acute joint inflammation. Early diagnosis is therefore essential in order to start treatment before structural joint damage develops, since there is evidence that patients treated during the first year from the beginning of symptoms present better functional capacity outcome than those treated later. Classic treatment for this disease had been based, until recently, on the traditional therapeutic pyramid which consisted in sequential introduction of drugs. Poor results of this strategy and awareness of the bad prognosis of the disease has demanded a reevaluation of its therapeutic approach. In this sense, introduction of remission induction agents early in the course of the disease seems appropiate, with the aim of reducing morbidity and functional disability.

Rheumatoid arthritis and primary care: the case for early diagnosis and treatment.

Rheumatoid arthritis is a chronic inflammatory disease that can cause severe pain and disability. Disease management historically was based on a "therapeutic pyramid" in which treatment escalated as symptoms worsened. However, the demonstration of early joint damage in patients with rheumatoid arthritis has emphasized the importance of early identification and treatment. Key features in establishing a diagnosis include joint examinations, assessments of extra-articular manifestations, laboratory tests, and radiologic examinations. Care must be taken to rule out other disorders with symptoms that overlap those of rheumatoid arthritis. Treatment of rheumatoid arthritis typically involves disease-modifying antirheumatic drugs, nonsteroidal anti-inflammatory drugs, and low-dose corticosteroids--often used in combination. A new class of therapeutic agents designed to neutralize inflammatory cytokines has added a new dimension to the therapeutic armamentarium against rheumatoid arthritis. Etanercept, a bioengineered soluble receptor fusion protein that blocks tumor necrosis factor activity, is the first compound in this class to be approved for treatment of patients with refractory rheumatoid arthritis. Therapeutic trials indicate that etanercept can reduce disease activity with relatively few drug-related adverse effects, thus helping persons with rheumatoid arthritis return to more normal, healthy lives.

Remodeling the therapeutic pyramid: evolving therapeutic strategies for rheumatoid arthritis

The approach to treatment of rheumatoid arthritis (RA) is undergoing dramatic change, With a prevalence of 1% of the general population. RA is the most common cause of disability that is potentially reversible if correct management of the disease is begun in the early phases. While the traditional therapeutic pyramid model has been in place for the past 25 years, evolving therapeutic strategies suggest that it is appropriate primarily for patients with benign synovitis, and an inverted pyramid is necessary to treat aggressive synovitis, control inflammation early and to prevent rapid joint destruction, disability and early death. Important principals underlying the remodeling of the therapeutic pyramid and evolving therapeutic strategies include: identifying patients with benign and aggressive synovitis: early control of inflammation to stabilize functional status at near normality; need for combination therapy in aggressive synovitis until a major breakthrough or ‘magic’ bullet becomes available; awareness that drugs that control inflammation in a more fundamental manner, such as disease-modifying anti-rheumatic drugs, are more effective in pain control and disability than non-steroidal anti-inflammatory drugs; and, most importantly, education of patients, primary and managing care physicians, health maintenance organizations, insurance companies, and government officials that two-thirds of the cost of RA lies in the complications of the disease and that providing resources for early aggressive therapy is a good investment for all. Successful treatment of rheumatoid arthritis is best accomplished by a coordinated team of a consultant rheumatologist and a managing primary care physician. Much like an early consultation with an oncologist when cancer is suspected, an early consultation with a rheumatologist can help separate benign and aggressive synovitis. If the latter, the rheumatologist can help identify important co-morbid conditions and recommend appropriate therapy. Follow-up programs can then be outlined to maintain control of inflammation at all times, utilize appropriate pharmacologic and non-pharmacologic physical and occupational therapy modalities for mechanical pain, and highlight potential toxicities to be monitored. This program, initiated early, will help prevent administration of toxic drugs to patients with benign synovitis. And, just as important for patients with aggressive synovitis, this strategy is designed to reduce the high incidence of morbidity and mortality and the costly episodes of hospitalizations and salvage surgery that can be so devastating to patients and their families.

Remodeling the therapeutic pyramid: evolving therapeutic strategies for rheumatoid arthritis

The approach to treatment of rheumatoid arthritis (RA) is undergoing dramatic change, With a prevalence of 1% of the general population. RA is the most common cause of disability that is potentially reversible if correct management of the disease is begun in the early phases. While the traditional therapeutic pyramid model has been in place for the past 25 years, evolving therapeutic strategies suggest that it is appropriate primarily for patients with benign synovitis, and an inverted pyramid is necessary to treat aggressive synovitis, control inflammation early and to prevent rapid joint destruction, disability and early death. Important principals underlying the remodeling of the therapeutic pyramid and evolving therapeutic strategies include: identifying patients with benign and aggressive synovitis: early control of inflammation to stabilize functional status at near normality; need for combination therapy in aggressive synovitis until a major breakthrough or ‘magic’ bullet becomes available; awareness that drugs that control inflammation in a more fundamental manner, such as disease-modifying anti-rheumatic drugs, are more effective in pain control and disability than non-steroidal anti-inflammatory drugs; and, most importantly, education of patients, primary and managing care physicians, health maintenance organizations, insurance companies, and government officials that two-thirds of the cost of RA lies in the complications of the disease and that providing resources for early aggressive therapy is a good investment for all. Successful treatment of rheumatoid arthritis is best accomplished by a coordinated team of a consultant rheumatologist and a managing primary care physician. Much like an early consultation with an oncologist when cancer is suspected, an early consultation with a rheumatologist can help separate benign and aggressive synovitis. If the latter, the rheumatologist can help identify important co-morbid conditions and recommend appropriate therapy. Follow-up programs can then be outlined to maintain control of inflammation at all times, utilize appropriate pharmacologic and non-pharmacologic physical and occupational therapy modalities for mechanical pain, and highlight potential toxicities to be monitored. This program, initiated early, will help prevent administration of toxic drugs to patients with benign synovitis. And, just as important for patients with aggressive synovitis, this strategy is designed to reduce the high incidence of morbidity and mortality and the costly episodes of hospitalizations and salvage surgery that can be so devastating to patients and their families.

Early, aggressive therapy for rheumatoid arthritis: Concerns, descriptions, and estimate of outcome

The past few years have witnessed changing perceptions about rheumatoid arthritis (RA); it is now considered a serious systemic disease that confers not only physical and social morbidity but also earlier mortality. The long-term outcome of sequential monotherapy based on the therapeutic pyramid has been disappointing. A review of prognostic factors, acute disease activity measures, functional measures, and the results of preliminary trials with combination therapy suggests that specific goals of treatment can be established and that logical, aggressive treatment in early disease can be accomplished. These goals should include prompt control and continuous reduction of the active joint count to < or = 4 and normalization of acute-phase reactants. The "graduated-step paradigm" of treatment designed with these goals in mind is described, and a retrospective series that gives an estimate of outcome with its use is reported.

Inverting the therapeutic pyramid: Observations and recommendations on new directions in rheumatoid arthritis therapy based on the author's experience

In evaluating current therapy for rheumatoid arthritis (RA), it is increasingly being recognized that sequential single-drug treatment, as exemplified by the traditional therapeutic pyramid, is often too little, too late, and ineffective in preventing disease progression or joint damage in patients with "at-risk," aggressive synovitis or what might be called type 2 RA. Designation of drugs as either antiinflammatory or disease-modifying is not supported by the author's experience. Evidence exists that prevention of joint damage correlates best with control of clinical and laboratory measures of inflammation, regardless of the medication used. The earlier and more effective the control of the inflammation, the better the patient response. Until a major breakthrough occurs, the author recommends that patients with aggressive RA be treated with a combination of fast-acting and slow-acting medications to achieve early control and then "bridge down" to a simplified maintenance program. Retrospective observation by the author of 54 patients with early, intermediate, and late disease treated with combinations of prednisone, methotrexate, auranofin, hydroxychloroquine, and azathioprine showed maximum response in patients with disease duration of less than 2 years, minimal toxicity, and lack of erosions in patients with control of inflammation. Twelve patients with inflammation not initially suppressed by prednisone and methotrexate had improved control with additional drugs in combination, including auranofin, hydroxychloroquine, and azathioprine. After inflammation was controlled, reduction of prednisone and methotrexate doses was possible in 60% of patients, primarily those with early disease.(ABSTRACT TRUNCATED AT 250 WORDS)