An exploration of the therapeutic process while using computerised cognitive behaviour therapy

Background: Modern technologies that offer an alternative to face‐to‐face therapy have gained ground in the NHS. Critics have argued that some of the important elements of the therapeutic change process necessarily require a human therapist. Yet, the traditional understanding of the change process in psychotherapy is challenged by evidence that some computerised cognitive behaviour therapy (cCBT) programs may be as effective as face‐to‐face therapy, suggesting that in certain cases the interaction between user and a cCBT product satisfies sufficient criteria for personal change without the need for actual human contact. Aim: This study used the cCBT package Blues Begone as a means of investigating the process by which a computer‐mediated program helped adults with mild depression help themselves. Method: Seven qualitative interviews were conducted with mildly depressed users who had completed Blues Begone in their own homes without any additional human help or support. Findings: Interpretive phenomenological analysis (IPA) was performed with four main themes emerging. These were: the meaningful relationship; shape from confusion; stimulation and empowerment. This study illustrates some of the ways that some depressed users make use of cCBT self help.     

Ocular motility and cognitive process

This study investigates the amount of ocular motility occuring in response to questions varying the kind of cognitive process required for answer. Fewer eye movements occur in response to questions designed to elicit visuo-spatial as compared to verbal-conceptual processes, a finding consistent with our earlier observation of more ‘stares’ occuring with the former than with the latter questions. The results are inconsistent with the traditional hypothesis that visual imagery involves an increase in scanning eye movements. The findings are interpreted in terms of a model postulating an interaction of the form of visual information processing and the type of cognitive activity subjects engage in.     

The role of optimism in the process of schema-focused cognitive therapy of personality problems

The aim of this study was to examine the determinants and effects of optimism in the process of schema-focused cognitive therapy of personality problems. The sample consisted of 35 patients with panic disorder and/or agoraphobia and DSM-IV Cluster C personality traits who participated in an 11-week residential program with one symptom-focused and one personality-focused phase. This study examines the role played by optimism during the individual sessions of the second phase, using a time series approach. Decreased patient's belief in his/her primary Early Maladaptive Schema and increased patient-experienced empathy from the therapist in a session predicted increased patient-rated optimism before the subsequent session. Increased patient-rated optimism in turn predicted decreased schema belief and distress and increased insight, empathy, and therapist-rated optimism. The slope of optimism across sessions was related to change in most of the overall outcome measures. There appears to be a positive feedback in the process of schema-focused cognitive therapy between decreased schema belief and increased optimism. In addition, optimism appears to mediate the effects of schema belief and therapist empathy on overall improvement, and to serve as an antecedent to decreased distress and to increased empathy, insight, and therapist's optimism.     

Three applications of functional analysis with group dynamic cognitive behavioral group therapy

Case illustrations from group dynamic cognitive behavioral group therapy are presented to demonstrate three applications of functional analysis and the resulting cognitive behavioral interventions. The principles of group dynamic cognitive behavioral group therapy are explained. A functional analysis is applied first to the problem behavior of an individual group member. A clinical case illustrates how the group members help to change this individual group member's behavior from a learning theory perspective. Next, the circular interactional problem behavior between two group members is reduced to the individual functional analysis of each of the two member's problem behaviors. It is then illustrated how the two group member's problem behaviors, as well as feedback from others, contribute toward helping to change each others behavior. The paper concludes that functional analysis and ensuing behavioral interventions can be also applied to group as a whole behavior.     

Sudden gains and outcome: a broader temporal analysis of cognitive therapy for depression

Individual Beck Depression Inventory (BDI) time courses of 38 clients receiving cognitive therapy (CT) and a modified form of CT were studied in order to investigate temporal changes during CT for depression. The primary aim was to determine if alternative methods of defining and computing gains occurring early in CT would alter the conclusions drawn in the current literature. Three types of gains were studied: sudden gains (previously studied sudden, substantial, and stable improvements in depression during 1 between-session interval after Session 2), first-session gains (occurring after first sessions), and pretreatment gains (occurring after pretreatment assessments). Positive outcomes were predicted by first-session gains and by sudden gains occurring in the first half of treatment, highlighting the importance of early change in CT for depression.     

A daily process analysis of physical activity,sedentary behavior,and perceived cognitive abilities

ObjectivesThis study evaluated the role of both physical activity and sedentary behavior in daily perceptions of cognitive abilities and whether these relations exist within-person, between-person, or both.DesignNon-experimental, intensive longitudinal research using ecological momentary assessments.MethodCollege students wore accelerometers and provided end-of-day reports on physical activity, sedentary behavior, and perceived cognitive abilities for 14 days.ResultsAcross self-reports and objective measures of behavior, daily deviations in physical activity were positively associated with perceived cognitive abilities. Daily deviations in self-reported, but not objectively-assessed, sedentary behavior also were negatively associated with perceived cognitive abilities. Contrary to previous research, overall levels of physical activity and sedentary behaviors were not associated with perceived cognitive abilities.ConclusionsThese findings indicate that physical activity has a within- rather than between-person association with perceived cognitive abilities although between-person associations effects may require longer monitoring periods to manifest. Further research is needed to establish the direction of causality and resolve whether the nature (rather than quantity) of sedentary activities influences cognition.     

The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains

Although cognitive therapy for depression is an efficacious treatment, questions about the aspects of the therapy that are most critical to successful implementation remain. In a sample of 60 cognitive therapy patients with moderate to severe depression, we examined three aspects of therapists’ adherence to cognitive therapy techniques, the patients’ facilitation or inhibition of these techniques, and the therapeutic alliance as predictors of session-to-session symptom improvement across the first five therapy sessions. Two elements of therapist adherence (viz., cognitive methods and negotiating content/structuring sessions) emerged as the strongest predictors of symptom improvement. Patient facilitation or inhibition of therapist adherence also predicted subsequent symptom change. Neither adherence to behavioral methods/homework nor the therapeutic alliance was a significant predictor in parallel analyses. Although alliance scores did not predict subsequent symptom change, they were significantly predicted by prior symptom change. These findings support the model of change that motivates cognitive therapy for depression, and they highlight the potential role of patient facilitation of therapists’ adherence in treatment response.     

The process of cognitive therapy: The first dysfunctional thought changes less than the last one

An observant cognitive therapy patient reported that the first dysfunctional thought elicited and treated in homework sessions was more resistant to change than later distorted thoughts. To determine whether this was due to the fact that this thought was elicited first, or to the fact that it was treated first, systematic data were collected from 9 patients in 48 sessions of cognitive therapy. In half of these sessions, dysfunctional thoughts were treated in the order they were elicited; in half of the sessions, they were treated in the reverse order. Results showed that the first dysfunctional thought elicited changed least; there was no effect of order of treatment. Several possible explanations of this finding are offered.     

Differences in baseline and process variables between non-responders and responders in Internet-based cognitive behavior therapy for chronic tinnitus

Although Internet-based cognitive behavior therapy (iCBT) is an effective treatment for chronic tinnitus, several patients do not improve. In the current study, baseline and process variables were compared between non-responders and responders. Data from patients participating in two randomized controlled trials on iCBT for chronic tinnitus were re-analyzed. Based on the literature, a pre-post difference on the “Tinnitus Handicap Inventory” (THI) of less than seven points improvement was used to operationalize non-response. Associations between non-response and baseline variables (age, gender, and questionnaire scores), patient progress (THI), the process of the therapeutic alliance (“Working Alliance Inventory-Short Revised”; WAI-SR), as well as other process variables (number of logins, amount of messages sent from therapists to patients) were investigated. The results showed that non-responders had a less favorable change on the THI than responders already at mid-treatment (p < .05). The alliance (WAI-SR) during iCBT was not associated with non-response. Non-responders showed more severe sleep disturbances, logged in less in the iCBT platform, and received fewer messages from the therapists than responders, but these differences were mostly not significant anymore when correcting for multiple testing. To conclude, no symptom change in the first half of iCBT for chronic tinnitus patients is a risk factor of not benefiting from iCBT.     

Sequential analysis as a method of feedback for family therapy process

Abstract

The purpose of this study was to examine the relationship between therapist verbal behavior and family cooperation and resistance during the second session of family therapy with juvenile delinquents. Sequential analysis was used to investigate the impact of one therapist's behavior on family resistance and cooperation in a sample of 12 families. The results of the sequential analysis revealed that therapist “support” and “teach” behaviors were associated with significant increases in the likelihood of family cooperation. The study provides an example of how sequential analysis can be used to inform family therapists about the impact of their behavior on families.     

The spiritual dimension of cognitive therapy

There has been a quiet buildup of interest in spirituality within psychiatry. However, spirituality tends to be a vague and fuzzy concept to psychiatrists and probably to other psychotherapists. The field is surprisingly large, and there is space in this paper only to present a skeletal outline of the cognitive aspects of it. My observations come from spiritual issues discussion groups for inpatients and a religion and psychiatry clinic for outpatients at Butler Hospital.This paper is modified from one presented as part of a symposium in Spirituality and Psychotherapy at the Annual Convention of the American Psychiatric Association in New York City, May 14, 1990.     

Change mechanisms in cognitive therapy of a simple phobia: Logical analysis and empirical hypothesis testing

The effectiveness of two hypothesized change mechanisms in cognitive therapy was investigated: logical analysis and empirical hypothesis testing. Thirty-eight spider phobics, as determined by performance on a behavioral avoidance test, were randomly assigned to either one of these two conditions or to a no-treatment control condition. Subjects participated in three group sessions. Outcome phobia questionnaire data suggested that both mechanisms produced desirable changes in a short period of time, with stronger evidence that logical analysis was superior to the control. Outcome from the behavior avoidance test and self-efficacy ratings failed to reach statistical significance but the trends were in the direction of positive change. Results are discussed in terms of the tripartite response dessynchrony hypothesis. Suggestions for future process research in cognitive therapy are provided.William O'Donohue, Ph.D., is an assistant professor of psychology at Northern Illinois University.Jeff Szymanski is a graduate student in clinical psychology at Northern Illinois University.The authors would like to thank Christine Casselles, Melissa McKelvie, Thomas M. Brown, Jill C. Rudman, Bonnie Schrieber, Amy Ray, Anne Valle, Lisa Herold, Jacqueline Ryan, Heather Barta, and Angela Leek for their assistance in this project. Moreover, the authors are grateful to Sol Feldman and Jane Fisher for their comments on an earlier version of this paper.