(Emotion-centered) problem-solving therapy: An update

Problem-solving therapy (PST) is a psychosocial intervention, typically considered to be a member of the cognitive and behaviour therapies family, and is based on a biopsychosocial, diathesis-stress model of psychopathology. The overarching goal of this approach is to promote the successful adoption of adaptive problem-solving attitudes and the effective implementation of certain behaviours as a means of coping with life stressors in order to attenuate the negative effects of such events on physical and mental well-being. Over the past several decades, in addition to accumulating strong support for its efficacy as a clinical intervention, similar to many other forms of psychotherapy, PST has undergone various evolutionary changes. Developed primarily as a more cognitive-based approach, due to the large body of literature in the field of affective neuroscience that underscores the importance of the impact of affect on problem solving, PST has evolved into emotion-centered problem-solving therapy (EC-PST). This article provides for a brief excursion into the historical roots of PST and why it has evolved into EC-PST, as well as providing support for its characterisation as a transdiagnostic approach. In addition, several meta-analyses that underscore its efficacy are described, as well as the most recent clinical guidelines that comprise EC-PST.     

Understanding,respecting and integrating difference in therapeutic practice

The purpose of this paper is to promote thought and discussion around how and why we treat patients in chosen ways. In the present climate practitioners are required to treat patients following NICE guidelines in which cognitive behavioural therapy (CBT) is the treatment of choice in the majority of diagnoses. This paper raises concerns that this may lead to an homogenization of treatment, loss of invaluable skills and understanding from other treatment approaches, and loss to the patient who may be best cared for by a combination of treatments and approaches, most notably patients presenting with complex pathology. This paper aims to present this as a general principle, and by way of example, will focus on coupling two specific treatment orientations, cognitive behavioural therapy with psychodynamic psychotherapy, with the specific diagnosis of obsessive compulsive disorder (OCD).

Methods: Clinical material is drawn from case studies from practice in secondary adult mental health care services within the NHS. All patients were referred to the psychological services for treatment for OCD and provided with 1:1 therapy with UKCP‐registered therapists. Details have been anonymized by describing fictitious cases re‐constructed from clinical material. A theoretical understanding is included which provides both an overview for integrating treatment for the specific example of OCD and is intended by extension to other diagnoses.

Results: Working with the commonalities of therapeutic approaches, and integrating specific skills of CBT and psychodynamic psychotherapy, appears to offer a viable mode of treatment for cases resistant to single‐orientation therapies.

Conclusions: Coupling the skills of different therapies can be effective in treating complex patients that are referred to the secondary mental health services. Conversely, restricting practice to single orientation therapies can lead to an impoverished care for patients and diminution of invaluable therapeutic skills which may become underused, undervalued and lost in the practice of mental health care within the NHS. Acknowledgement of the skills of others, valuing these and learning from each other can help to avoid the defensive reactions of practitioners, where each may defensively retreat to their corners of specialism. Respecting and sharing skills from different orientations, and acknowledging this in the NICE guidelines, is good for both mental health services and patient care and addresses the concerns raised by practitioners exemplified by Bateman (2000 Bateman, A. 2000. Integration in psychotherapy: An evolving reality in personality disorder.. British Journal of Psychotherapy, 17(2): 147–156.  [Google Scholar], p. 147) that ‘psychotherapy continues to be bedeviled by ideological schisms with practitioners apparently ignoring alternative conceptualizations and potentially superior interventions’.     

Motivational Interviewing Versus Cognitive Behavioral Group Therapy in the Treatment of Problem and Pathological Gambling: A Randomized Controlled Trial

Pathological gambling is a widespread problem with major implications for society and the individual. There are effective treatments, but little is known about the relative effectiveness of different treatments. The aim of this study was to test the effectiveness of motivational interviewing, cognitive behavioral group therapy, and a no-treatment control (wait-list) in the treatment of pathological gambling. This was done in a randomized controlled trial at an outpatient dependency clinic at Karolinska Institute (Stockholm, Sweden). A total of 150 primarily self-recruited patients with current gambling problems or pathological gambling according to an NORC DSM-IV screen for gambling problems were randomized to four individual sessions of motivational interviewing (MI), eight sessions of cognitive behavioral group therapy (CBGT), or a no-treatment wait-list control. Gambling-related measures derived from timeline follow-back as well as general levels of anxiety and depression were administered at baseline, termination, and 6 and 12 months posttermination. Treatment showed superiority in some areas over the no-treatment control in the short term, including the primary outcome measure. No differences were found between MI and CBGT at any point in time. Instead, both MI and CBGT produced significant within-group decreases on most outcome measures up to the 12-month follow-up. Both forms of intervention are promising treatments, but there is room for improvement in terms of both outcome and compliance.     

It is never the right time: How to help a mother to separate from her young child

In this paper I have described a short-psychotherapy treatment with a mother, a 3-year-old girl, and occasionally a father, over the difficulty in separating and settling down at nursery. The mother's unresolved mourning for the early miscarriage of her second baby was one important factor. She held on to the company and comfort provided by the little girl, who had become the vessel of maternal projections. Filled with Poppy's projections, the mother had also felt unable to withstand and process them. Mr Green was a conflictual element in the family, rather than a supportive husband and father, and Poppy's care and problems were left with the mother. Nine sessions unblocked the situation and allowed Poppy to settle down at a private nursery.     

Changes in illness-related cognitions rather than distress mediate improvements in irritable bowel syndrome (IBS) symptoms and disability following a brief cognitive behavioural therapy intervention

Objective

A previous randomised controlled trial demonstrated that a cognitive behavioural therapy (CBT) self-management intervention significantly improved irritable bowel syndrome (IBS) symptoms and disability compared to treatment as usual (TAU). The current study analysed additional data to establish whether; 1) cognitive, behavioural and emotional factors hypothesized to perpetuate IBS symptoms and disability changed following CBT and, 2) ascertain if changes in these factors over the intervention period mediated treatment effects 6-months later.

Method

IBS patients (CBT = 31, TAU = 33) completed measures pre-and-post intervention including: Brief Illness Perception Questionnaire, Hospital Anxiety & Depression Scale and Cognitive and Behavioural Responses to Symptoms Questionnaire. Path models were evaluated to determine whether changes in cognitive and behavioural factors over the treatment period mediated treatment effects.

Results

Compared to TAU, CBT patients showed significant positive changes on several cognitive variables but not anxiety and depression following intervention. Positive change in illness perceptions following intervention mediated the treatment effect on improved IBS symptom severity and social adjustment six months later. Changes in damaging beliefs mediated the effect on social adjustment.

Conclusions

Change in cognition rather than mood mediated treatment related improvements. Changing negative perceptions of IBS appears to be a particularly important treatment mechanism.     

The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study

Low self esteem in individuals with a psychotic disorder is common and may be related to poorer clinical outcomes. However, there has been little research on devising treatment methods to improve self-esteem either generally or in psychotic patients in particular. The aims of this study were to evaluate the efficacy of a simple cognitive behavioural intervention to improve self esteem in psychotic patients who scored poorly on a self-esteem measure. This pilot study was a randomised control trial with a convenience sample of chronic psychotic inpatients. The cognitive behavioural self-esteem intervention, as an adjunct to treatment as usual (TAU), was compared to TAU alone in patients with psychosis. The individual self-esteem intervention as described by Tarrier (The use of coping strategies and self-regulation in the treatment of psychosis. (2001)) consisted of working with participants to elicit positive self-attributes and then identify specific behavioural examples to provide evidence of this attribute. Emphasis was given to any consequential change in the patient's belief that they had the attribute. The results indicated that this cognitive behavioural treatment for self-esteem used as an adjunct treatment in psychosis, resulted in clinical benefits in terms of increased self-esteem, decreased psychotic symptomatology and improved social functioning. These benefits were largely maintained at 3-month follow-up.     

The frequency of actions and thoughts scale: development and psychometric validation of a measure of adaptive behaviours and cognitions

This paper describes the development and preliminary psychometric evaluation of an instrument that measures the frequency of adaptive behaviours and cognitions related to therapeutic change during cognitive behavioural therapy (CBT), for symptoms of anxiety and depression. Two studies were conducted. In study one, 661 participants completed an online survey with 28 items targeting adaptive behaviours and cognitions. Exploratory factor analysis performed on part of the sample (n = 451) revealed that a four-factor solution ‘characterised’ the data. This led to the development of a 12-item instrument, the Frequency of Actions and Thoughts Scale (FATS). Confirmatory factor analysis was used to confirm the factor structure of the FATS using the remaining sample (n = 210), which revealed an acceptable model fit. In study two, 125 participants with clinically significant symptoms of anxiety, depression, or both were recruited to an Internet-delivered CBT (iCBT) treatment course. Participants completed the FATS and other measures throughout treatment, after treatment, and at three-month follow-up. Correlations and residual change scores of the FATS and its subscales with measures of anxiety, depression, behavioural activation, and CBT-related skills usage supported the construct validity of the FATS. A significant increase in FATS scores over treatment was also observed. The findings provide preliminary support for the psychometric properties of the FATS, which appears to have utility in research investigating mechanisms of change in CBT.     

Is cognitive behavioural therapy effective in reducing suicidal ideation and behaviour when delivered face-to-face or via e-health? A systematic review and meta-analysis

Cognitive Behavioural Therapy (CBT) is a widely used psychotherapeutic intervention for suicide prevention despite its efficacy for suicide prevention in adults remaining ambiguous. Reluctance or inability to access face-to-face help suggests that e-health delivery may be a valuable resource for suicidal people. The aim of this study was to systematically review and conduct meta-analysis on research assessing the efficacy of CBT delivered via face-to-face and e-health for suicidal ideation and behaviour. A comprehensive literature search of MEDLINE, PsycINFO, Scopus, PubMed and The Cochrane Central Register of Controlled Trials was conducted. From 764 identified articles, 26 met the inclusion criteria for investigating CBT for suicidal ideation and behaviours in adult populations. Data were extracted on study characteristics and meta-analysis was performed where possible. There was a statistically significant, small to medium effect for face-to-face delivered CBT in reducing suicidal ideation and behaviour although there was significant heterogeneity between the included studies. CBT delivered via e-health was not found to be efficacious for reducing suicidal ideation and behaviour in adults though the number of studies reviewed was small.     

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.     

Staff support in medical oncology: A problem-solving approach

Abstract

At a time of low morale the multidisciplinary staff working on a medical oncology rated the severity and frequency of problems arising in their working environment and their personal levels of stress and job satisfaction. An anonymous paper and pencil exercise was used to identify problems at work and possible solutions which staff then discussed as a group. Within four months some changes were implemented resulting in a significant reduction in problems on the unit and a commensurate improvement in morale. Interdisciplinary communication particularly benefited. This problem solving approach was useful in overcoming initial resistance to seeking a cooperative solution to shared problems at work.     

Cognitive errors,coping patterns,and the therapeutic alliance: A pilot study of in‐session process

Aim: This exploratory study examined the association between clients’ assessment of the therapeutic alliance and their cognitive errors (CE) and coping action patterns (CAP). Method: Selected therapy sessions of clients (N = 26) were rated for cognitive errors and coping action patterns using the CERS and CAPRS methods (Drapeau, Perry, & Dunkley, 2008; Perry, Drapeau, & Dunkley, 2005). The therapeutic alliance was assessed using the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). Results: Following Bonferroni corrections, no significant relationship was found between clients’ CEs and their ratings of the WAI. However, the ‘Negotiation’ CAP was associated with the total alliance score, and with the Task and Goal subscales. Implications: A better understanding of the cognitive processes presented by clients in session can enable clinicians to address these factors early on when the alliance is most critical.     

"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.     

Meta-analysis of the efficacy and acceptability of cognitive-behavioural therapy for Arab adult populations experiencing anxiety,depression or post-traumatic stress disorder

A meta-analysis of the literature of cognitive behaviour therapy (CBT) with Arab adult populations experiencing anxiety, depression or post-traumatic stress disorder (PTSD) was conducted. Nine studies (n = 536) met the eligibility criteria. Three of the nine studies (33%) were randomised control trials using waitlist control groups. All studies (100%) reported a statistically significant reduction in psychological symptoms at post-treatment with large effect sizes for anxiety (effect size, 95% confidence interval) (1.44 [1.29, 1.59]), depression (1.26 [1.16, 1.35]) and PTSD (2.08 [1.94, 2.23]). Six out of the nine studies (67%) collated follow-up data and reported that reductions of psychological symptoms were maintained at follow-up. An average dropout rate of 26% indicated good overall acceptability. Five out of nine (55%) of the trials reported diagnostic remission rates and of those trials the mean remission rate was 31%). Five of the nine eligible studies (55%) delivered remotely via Internet or telephone were found to have similar effect sizes as face-to-face CBT. The current meta-analysis indicates the potential of CBT, delivered either face-to-face or via internet, as efficacious and acceptable interventions for the treatment of anxiety, depression and PTSD for Arab adult populations.     

Clinical Experiences in Conducting Cognitive-Behavioral Therapy for Social Phobia

Several authors have identified a disconnect between psychotherapy research, including research on cognitive behavioral therapy (CBT), and real-world psychotherapy practice. This disconnect has several negative consequences, potentially including less-than-optimal practice standards as well as a lack of input from practicing psychotherapists on how research can be improved and made more relevant in their day-to-day clinical work. As part of an ongoing effort to engage practicing psychotherapists in a feedback loop with psychotherapy researchers, this study reports the results of a survey of CBT therapists who have used CBT in the treatment of social phobia (SP). The survey was designed primarily to document how often certain potential problems, identified by expert researchers and CBT manuals, actually act as barriers to successful treatment when CBT is employed in nonresearch environments. The participants were 276 psychotherapists responding to email, online, and print advertisements completing the online survey. Participants varied considerably in psychotherapy experience, work environment, experience in using CBT for SP, and in some ways varied in their usual CBT techniques when treating SP. Among the most prominent barriers identified by many of the participants were patient motivation, comorbidity, logistical problems (especially with exposures), patient resistance, and severity and chronicity of SP symptoms. These findings may be useful for psychotherapy researchers as areas for potential study. The results may also suggest topics requiring clinical guidelines, innovations within CBT, and dissemination of successful techniques to address the barriers identified here.     

A brief cognitive behavioural therapy psychoeducational group for Chinese people with chronic illnesses: an evaluation study

This pilot study attempted to examine the effectiveness of a brief cognitive behavioural therapy (CBT) psychoeducational group for Chinese people with chronic illness in Hong Kong. It adopted a single group design, and 52 participants joined the group. A questionnaire with three outcome measures, measuring general mental health, quality of life and dysfunctional attitudes and beliefs, was administered to participants at pre-test, post-test and six month follow-up. Repeated measures ANOVAs were employed and revealed positive changes in most of the outcome measures across the three time points. Cohen’s d showed a moderate to large effect size for most outcome measures. From a step care perspective, a culturally attuned brief CBT psychoeducational group may serve as an early intervention and a triage to attract suitable people with chronic illness to engage in the treatment process.     

Letting a little nonverbal air into the room: Insights from acceptance and commitment therapy Part 1: Philosophical and theoretical underpinnings

In recent years, a new “wave” of mindfulness based Cognitive Behavior Therapies (CBT) has become popular. Such approaches include Acceptance and Commitment Therapy (ACT; Acceptance and commitment therapy: An experiential approach to behaviour change. New York: Guilford Press, 1999), Mindfulness-based Cognitive Therapy for Depression (Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press, 2002), and Mindfulness-based Stress Management (Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell Publishing, 1990). In contrast to traditional CBT, these approaches often minimize attempts to change the form and frequency of dysfunctional thoughts. Is there any way to integrate traditional CBT with mindfulness based CBT? To answer this question, we discuss the philosophical and theoretical underpinnings of one form of traditional CBT (Rational-Emotive and Cognitive Behavioral Therapy) and one form of mindfulness based CBT (ACT). We argue that some aspects of each therapy can be integrated. However, in order to prevent techniques from being used haphazardly or inconsistently, we suggest that the different forms of CBT need to be driven by a common philosophical orientation (e.g., functional contextualism) and theoretical orientation (e.g., Relational Frame Theory).