Supervising Cognitive-Behavioral Psychotherapy: Pressing Needs,Impressing Possibilities

While accounts of the practice of cognitive behavioral therapy (CBT) supervision have been available over the past 15 years and have demonstrated consistency in terms of an overall model specifying the structure, process and content of supervision sessions, a number of gaps can be identified in the literature on the clinical supervision of CBT. Comprehensive consensus statements of the competencies underlying clinical supervision have been developed both in the United States (Falender et al., J Clin Psychol, 60, 771–785, 2004) and in the United Kingdom (Roth and Pilling, IAPT supervision competencies framework, University College London, 1992), but there has been a lack of attention to relevant theory and to procedural detail. As a consequence, the literature on CBT supervision has only recently begun to assimilate concepts from the wider supervision field (e.g. developmental models), and there is as yet no manual that would allow supervisors to make explicit determinations of competency. Furthermore, supervision in general continues to suffer both from the absence of compelling empirical support demonstrating its effectiveness in improving clinical outcomes, and there is a lack of explicitly-defined supervisory procedures that can be reliably observed and measured. Unfortunately, this combination of factors hampers the development of CBT supervision (e.g. it complicates efforts to provide a standardized framework for training in supervision). As an important starting point in ‘treating’ the underdeveloped state of CBT supervision, we outline a formulation of its current condition, then suggest some promising interventions.     

A Nonrandomized Effectiveness Comparison of Broad-Spectrum Group CBT to Individual CBT for Depressed Outpatients in a Community Mental Health Setting

Controlled trials have established the efficacy of cognitive-behavior therapy (CBT) for depression. However, the relative effectiveness of individual versus group treatment formats in real-world settings is less well established. The current study evaluated the effectiveness of group CBT (n = 157) compared to individual CBT (n = 77) for depressed outpatients in a naturalistic setting. Symptom improvements for depression, anxiety, and quality of life were compared between treatment formats in intent-to-treat and completer analyses. Effect sizes and rates of recovery were examined. Results showed that both individual and group CBT were effective, even in the presence of high levels of comorbidity. Whereas individual CBT was associated with larger effect sizes and significantly higher rates of recovery, group CBT compared favorably to outcomes established by past research. A broad-spectrum group CBT program may be a viable treatment option when depression symptoms are less severe and when this format of treatment delivery is desirable.     

An evaluation of the effectiveness of Diploma-level training in cognitive behaviour therapy

Background

As part of the UK government’s initiative to Increase Access to Psychological Therapies (see http://www.iapt.nhs.uk/for full details of the IAPT programme) there has been an expansion in the provision of post-graduate Diploma training in cognitive behaviour therapy (CBT). Previous evaluations of such training programmes have yielded mixed results but have been limited by small sample sizes and/or limited assessment measures.

Aims

To evaluate the impact of a long-standing Diploma in CBT training programme on a variety of measures of CBT competence.

Method

Trainees’ levels of CBT skill are compared at the beginning and end of CBT training. The effect of therapist factors such as age, professional background and gender on the development of CBT competence is also examined.

Results

Results show that trainees demonstrate higher levels of CBT skills after completing the training than they did before, with the majority achieving pre-determined criteria for competence. Trainees’ gender was not related to their performance but trainees’ age showed a negative association with CBT skill (older trainees performed worse). Trainees’ professional background also had an impact on their level of CBT competence, with trainees who were clinical psychologists demonstrating the highest levels of competence across a range of measures.

Conclusions

CBT Diploma training leads to increases in the level of trainees’ CBT competence, with the majority achieving the levels demonstrated in research trials by the end of training. Thus, this training is likely to lead to improved outcomes for patients. Further research is needed to determine the most efficient ways of enhancing CBT skills.     

Randomized,placebo-controlled trial of cognitive-behavioral therapy alone or combined with sertraline in the treatment of pediatric obsessive–compulsive disorder

Background

To examine the efficacy of sequential sertraline and cognitive-behavioral therapy (CBT) treatment relative to CBT with pill placebo over 18 weeks in children and adolescents with obsessive–compulsive disorder (OCD).

Methods

Forty-seven children and adolescents with OCD (Range = 7–17 years) were randomized to 18-weeks of treatment in one of three arms: 1) sertraline at standard dosing + CBT (RegSert + CBT); 2) sertraline titrated slowly but achieving at least 8 weeks on the maximally tolerated daily dose + CBT (SloSert + CBT); or 3) pill placebo + CBT (PBO + CBT). Assessments were conducted at screening, baseline, weeks 1–9, 13, and 17, and post-treatment. Raters and clinicians were blinded to sertraline (but not CBT) randomization status. Primary outcomes included the Children's Yale-Brown Obsessive–Compulsive Scale, and response and remission status. Secondary outcomes included the Child Obsessive Compulsive Impact Scale–Parent/Child, Children's Depression Rating Scale-Revised, Multidimensional Anxiety Scale for Children, and Clinical-Global Impressions-Severity.

Results

All groups exhibited large within-group effects across outcomes. There was no group by time interaction across all outcomes suggesting that group changes over time were comparable.

Conclusions

Among youth with OCD, there was no evidence that sequentially provided sertraline with CBT differed from those receiving placebo with CBT.

ClinicalTrials.gov Identifier

NCT00382291.     

Predictors of outcome in Internet-based cognitive behavior therapy for severe health anxiety

Internet-based cognitive behavior therapy (CBT) for severe health anxiety can be effective, but not all patients achieve full remission. Under these circumstances, knowledge about predictors is essential for the clinician in order to make reliable treatment recommendations. The primary aim of this study was to investigate clinical, demographic, and therapy process-related predictors of Internet-based CBT for severe health anxiety. We performed three types of analyses on data from a sample comprising participants (N = 81) who had received Internet-based CBT in a randomized controlled trial. Outcomes were a) end state health anxiety, b) improvement in health anxiety (continuous change scores), and c) clinically significant improvement. Outcomes were assessed at six-month follow-up. The results showed that the most stable predictors of both end state health anxiety and improvement were baseline health anxiety and depressive symptoms. Treatment adherence, i.e. the number of completed treatment modules, also significantly predicted outcome. Notably, health anxiety at baseline was positively associated with symptom improvement while depressive symptoms was negatively related to improvement. Demographic factors were largely without significant impact on end state symptoms or improvement. We conclude that baseline symptom burden and adherence to treatment have strong predictive effects in Internet-based CBT for severe health anxiety.     

Evidence-based treatment and therapist drift

Cognitive-behavioural therapy (CBT) has a wide-ranging empirical base, supporting its place as the evidence-based treatment of choice for the majority of psychological disorders. However, many clinicians feel that it is not appropriate for their patients, and that it is not effective in real life-settings (despite evidence to the contrary). This paper addresses the contribution that we as clinicians make to CBT going wrong. It considers the evidence that we are poor at implementing the full range of tasks that are necessary for CBT to be effective - particularly behavioural change. Therapist drift is a common phenomenon, and usually involves a shift from ‘doing therapies’ to ‘talking therapies’. It is argued that the reason for this drift away from key tasks centres on our cognitive distortions, emotional reactions, and use of safety behaviours. A series of cases is outlined in order to identify common errors in clinical practice that impede CBT (and that can make the patient worse, rather than better). The principles behind each case are considered, along with potential solutions that can get us re-focused on the key tasks of CBT.     

The clinical effectiveness of cognitive behaviour therapy: outcome for a large sample of adults treated in routine practice

There is increasing interest in questions about how far the demonstrated efficacy of psychological therapies in research trials can be translated into clinical effectiveness in routine practice. This paper summarises outcome data from several hundred patients treated with CBT in routine clinical practice in a National Health Service psychology service, and compares their outcomes with some of the published research. Although the data have flaws common in ordinary clinical practice (no untreated controls, missing data, uncontrolled pharmacotherapy, etc.), the analyses suggest that CBT in this context is an effective treatment, albeit with probably not quite such good results as it achieves in research trials. Using clinical significance statistics on standardised measures, about half of the sample reliably improved over a course of therapy, including about a third who recovered to normal range.     

"It's led me astray": How Cognitive Behavioural Therapists experience personal therapy in clinical practice

Personal therapy is considered to be an essential component of most psychotherapeutic training programmes. However, it remains peripheral to cognitive behavioural therapy (CBT) training courses. We present a subsection of results from a qualitative study that examines how CBT therapists use personal therapy in their clinical practice. Seven CBT therapists who have undergone personal therapy were interviewed. Participants were asked about how they used personal therapy in their clinical practice and their accounts were analysed using interpretative phenomenological analysis (IPA) to identify common themes. This article presents the results of the first master theme, “Personal therapy creates conflict”, which explores a paradox that arises between personal therapy and CBT clinical practice; participants suggest that personal therapy equips them with therapeutic tools that paradoxically hinder their capacity to practice a standardised protocol‐led CBT. Results show that participants found personal therapy created considerable internal conflict, where their use of technical evidence‐based treatment protocols as practitioners was experienced in tension with the relationally oriented therapy they had received as clients. We discuss results in the context of Gabriel Marcel's philosophical insights on the dehumanising effects of technology on human relationships. We conclude with a brief consideration of the current political climate that increasingly privileges short‐term technical solutions to psychological distress.     

Cognitive-Behavioral Therapy With Chinese Americans: Research, Theory, and Clinical Practice

In this article, we discuss how to conduct cognitive-behavioral therapy with Chinese Americans. We present an integration of theory, research, and clinical practice to help mental health practitioners understand how Chinese culture may potentially influence the CBT treatment process for Chinese immigrants. Several recommendations are provided as to how to adapt and modify CBT to better meet the therapeutic needs of Chinese American clients. A case example demonstrates how cultural modifications of CBT can lead to effective psychotherapy outcomes for Chinese American clients.     

Increased skills usage statistically mediates symptom reduction in self-guided internet-delivered cognitive–behavioural therapy for depression and anxiety: a randomised controlled trial

Cognitive–behavioural therapy (CBT) is an effective treatment for clinical and subclinical symptoms of depression and general anxiety, and increases life satisfaction. Patients’ usage of CBT skills is a core aspect of treatment but there is insufficient empirical evidence suggesting that skills usage behaviours are a mechanism of clinical change. This study investigated if an internet-delivered CBT (iCBT) intervention increased the frequency of CBT skills usage behaviours and if this statistically mediated reductions in symptoms and increased life satisfaction. A two-group randomised controlled trial was conducted comparing internet-delivered CBT (n = 65) with a waitlist control group (n = 75). Participants were individuals experiencing clinically significant symptoms of depression or general anxiety. Mixed-linear models analyses revealed that the treatment group reported a significantly higher frequency of skills usage, lower symptoms, and higher life satisfaction by the end of treatment compared with the control group. Results from bootstrapping mediation analyses revealed that the increased skills usage behaviours statistically mediated symptom reductions and increased life satisfaction. Although skills usage and symptom outcomes were assessed concurrently, these findings support the notion that iCBT increases the frequency of skills usage behaviours and suggest that this may be an important mechanism of change.     

Toward Cognitive-Behavioral Therapy for Sexual Minority Women: Voices From Stakeholders and Community Members

Sexual minority women (SMW) experience an elevated risk of mental health problems compared to heterosexual women. However, knowledge gaps remain regarding whether cognitive-behavioral therapy (CBT) interventions meet SMW’s mental health needs. Further, virtually no studies have integrated stakeholder (i.e., researchers with content expertise in SMW’s health and clinical providers who work with SMW) and community member (i.e., SMW) perspectives to identify CBT approaches that address SMW-specific issues. This study used qualitative data gathered from 39 SMW who reported depression, anxiety, suicidality, and heavy drinking in the past 3 months and 16 content experts and clinical providers to obtain information relevant to enhancing CBT for SMW. In addition, we used thematic analysis to identify themes related to the adaptation and delivery of CBT for SMW. Building on prior literature, this study’s findings revealed seven considerations for delivering mental health services to SMW: (1) attending to SMW’s diverse gender identities and expressions; (2) focusing on SMW’s nonbinary stressors; (3) formulating SMW’s gender-based stressors within a feminist framework; (4) applying intersectionality frameworks; (5) incorporating issues of diversity, multiculturalism, and social justice; (6) addressing the role of trauma exposure; and (7) addressing the role of alcohol use in SMW’s lives. These considerations are reviewed in terms of their implications for clinical practice, with a focus on enhancing applications of existing CBT interventions to best respond to the unique needs of this population.     

Cognitive Behavior Therapy for Older Adults: Practical Guidelines for Adapting Therapy Structure

Cognitive behavioral therapy (CBT) has been shown to be an effective approach for a wide range of problems affecting older adults. While a variety of empirical and clinical papers have examined modifications to the content and delivery of CBT to enhance its efficacy with older adults, changes to the structure of therapy with this population have not been as widely discussed. Issues around optimizing the structure of CBT with older adults are presented, along with suggestions for realizing these changes within a clinical context.     

Cognitive behaviour therapy for common mental disorders in people with Multiple Sclerosis: A bench marking study

Background

Mental health problems such as depression and anxiety are common in Multiple Sclerosis (MS) and are often under treated.

Aims

This paper reports on the clinical effectiveness of a cognitive behaviour therapy service for common mental disorders in people with MS and compares it to previous randomised controlled trials (RCTs) of cognitive behaviour therapy (CBT) in this population.

Methods

49 patients were deemed appropriate for CBT and 29 accepted treatment. Assessments were completed at baseline and end of treatment and included the Hospital Anxiety & Depression Scale. Results in the form of a standardized effect of treatment were compared with five previous RCTs.

Results

The results from this clinical service indicated statistically significant outcomes with reductions in depression and anxiety. The uncontrolled effect size was large but inferior to those found in published RCTs.

Conclusions

Cognitive behaviour therapy is effective for people with MS in routine clinical practice. Possible limits on effectiveness include more liberal patient selection, lack of specificity in rating scales and heterogeneity of target problems. Given the high rates of distress in this population, routine psychological interventions within neurology services are justifiable. Future research should aim to maximise CBT in such settings.     

Developing an Acceptance-Based Behavioral Treatment for Binge Eating Disorder: Rationale and Challenges

Binge eating disorder (BED), characterized by recurrent eating episodes in which individuals eat an objectively large amount of food within a short time period accompanied by a sense of loss of control, is the most common eating disorder. While existing treatments, such as cognitive behavioral therapy (CBT), produce remission in a large percentage of individuals with BED, room for improvement in outcomes remains. Two reasons some patients may continue to experience binge eating after a course of treatment are: (a) Difficulty complying with the prescribed behavioral components of CBT due to the discomfort of implementing such strategies; and (b) a lack of focus in current treatments on strategies for coping with high levels of negative affect that often drive binge eating. To optimize treatment outcomes, it is therefore crucial to provide patients with strategies to overcome these issues. A small but growing body of research suggests that acceptance-based treatment approaches may be effective for the treatment of binge eating. The goal of the current paper is to describe the development of an acceptance-based group treatment for BED, discuss the structure of the manual and the rationale and challenges associated with integrating acceptance-based strategies into a CBT protocol, and to discuss clinical strategies for successfully implementing the intervention.     

The Cognitive‐Behavioural Theory and Treatment of Bulimia Nervosa: An Examination of Treatment Mechanisms and Future Directions

Enhanced cognitive‐behavioural therapy (CBT‐E) is the current treatment of choice for bulimia nervosa. While the cognitive‐behavioural theory and treatment of bulimia nervosa have made a substantial contribution to our understanding of the disorder, approximately half of patients treated with CBT‐E fail to achieve remission of binge eating and purging. There is evidence showing that mechanisms proposed by the CBT‐E model are associated with binge eating and purging symptoms, and therefore likely important targets for treatment. To identify future directions in improving the efficacy of this treatment, and informed by a model of the client change process, we review the evidence for the hypothesised treatment mechanisms of CBT‐E. We conclude that while the proposed treatment mechanisms of CBT‐E largely change over the course of treatment, there is limited evidence that the treatment manipulations of CBT‐E are responsible for the specific changes in the proposed treatment mechanisms. In addition, given a lack of research in this area, we could find no evidence that changes in the additional treatment mechanisms outlined in CBT‐E are associated with changes in the core symptomatology of binge eating and purging. Based on these findings, we recommend that future efforts are directed towards understanding the client change process in CBT‐E and outline three clear directions for research.     

Predicting Treatment Outcomes From Internet-Based Cognitive Behavior Therapy for Obsessive–Compulsive Disorder

Internet-based cognitive-behavioral therapy (ICBT) with therapist support shows promise as a treatment for obsessive-compulsive disorder (OCD). Yet, not all patients respond to ICBT. It is therefore important to identify predictors of ICBT outcomes to determine who is likely to benefit. Relative to the large literature on predictors of outcomes for in-person CBT for OCD, very few studies have investigated ICBT predictors. Therefore, we analyzed predictors of outcome in an open trial (n = 30) of ICBT for OCD using the OCD-NET platform, which consists of 10 online modules delivered with therapist support. The Yale-Brown Obsessive-Compulsive Scale (YBOCS) was administered by independent raters as the primary outcome measure at baseline and posttreatment. In this sample, greater baseline OCD severity and OCD-related avoidance behaviors were associated with higher end-state OCD symptoms (i.e., poorer outcome). Patients with a past history of face-to-face CBT for OCD also had worse outcomes. Although these results require replication, these factors may identify individuals at risk for poor ICBT outcomes.     

Exposure-based cognitive behavior therapy for anxiety related to asthma: A feasibility study with multivariate baseline design

In the presence of asthma, the risk of having an anxiety disorder is increased twofold. The few trials conducted on cognitive behavior therapy (CBT) for anxiety and asthma have mainly targeted panic disorder, and with mixed results. Experimental laboratory research indicates that increased anxiety may lead to hypervigilance toward asthma. Hence, fear and avoidance associated with increased anxiety due to asthma may be an important treatment target. A treatment that learn participants to differentiate between anxiety and asthma through gradual exposure to situations that risk triggering anxiety for asthma may be a possible avenue. As a first step to investigate this issue further, we developed a 10-week exposure-based CBT protocol for anxiety related to asthma and tested it in six participants using multivariate baseline design with repeated assessments throughout treatment. All participants reported satisfaction with treatment, as well as subjective overall improvement after treatment. Visual analysis, using graphs over each individual's trajectory, as well as potential efficacy on group level analyzing standardized mean change, indicated improvements in important outcomes. We conclude that exposure-based CBT is feasible and may improve anxiety related to asthma. Further investigation under randomized controlled trial conditions is warranted.     

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

Homework Compliance and Quality in Cognitive Behavioral Therapies for Anxiety Disorders and Obsessive-Compulsive Disorder

Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention.