Contextual Factors for Research on Psychological Therapies for Aboriginal Australians

This paper is to provide a commentary to Can cognitive behavioural therapy (CBT) be effective for Aboriginal Australians? Perspectives of Aboriginal practitioners trained in CBT. It is inspiring that this study has found that CBT can play a useful role in therapy for Aboriginal and Torres Strait Islander people but the outcomes need to be considered with caution. CBT can provide a useful tool when working with Aboriginal and Torres Strait Islander people, but in itself is not adequate for a number of reasons. Firstly, it is not culturally responsive but can be part of an approach that might be culturally appropriate. The authors are compelled at this point to give a history of mental health and Aboriginal and Torres Strait Islander people to provide a background context to the discussion and to illustrate why some psychological approaches such as CBT can only ever be part of the tools that might be used in a broader framework, that is required to address and strengthen Aboriginal and Torres Strait Islander people's well‐being.     

Evaluation of a Combined Cognitive Behavioural Therapy and Interpersonal Process Group in the Psychotherapy Training of Clinical Psychologists

It is now widely acknowledged that both content and process elements of psychotherapy play a part in client treatment outcomes. Despite this, there are pressures on Australian clinical psychology training programs to teach evidence‐based approaches in a relatively short time frame. Producing clinical psychology graduates who have an adequate level of competence in evidence‐based practice and meeting the demands of professional accreditation requirements can mean that less time is available to teach the process elements of psychotherapy. The aim of this study was to conduct a preliminary evaluation of a clinical psychology psychotherapy training program that combines an interpersonal process group with a cognitive behavioural therapy training model that incorporates self‐reflection and self‐practice. Eleven participants who participated in the training in 2008 completed the Counseling Self‐Estimate Inventory at pre‐ and post‐training. Significant improvements on the majority of the subscales of this inventory were found. A separate sample of nine trainees and clinical psychology registrars who also previously completed the program attended individual interviews in 2010 aimed at gaining their perspective regarding various aspects of the program. Self‐practice of cognitive behavioural therapy techniques was found to be important in the identification and management of trainees’ own core beliefs, and to their appreciation of how challenging this process may be for clients. The interpersonal process group was described by participants as enhancing their competency as psychotherapists. Common themes included the experience of anxiety and a high level of emotion, and understanding how this experience might be similar for clients; increased self‐awareness; and increased competence in process issues. Many participants believed the process and content components of training were equally important to their development as psychotherapists.     

Computerised Cognitive Behavioural Therapy in an Adult Mental Health Service: A Pilot Study of Outcomes and Alliance

This pilot study aimed to explore the clinical outcomes and therapeutic relationship for clients of an adult mental health service using Beating the Blues, a computerised cognitive behaviour therapy (CCBT) package. Sixteen participants completed the programme and reported a significant reduction in Beck Depression Inventory scores posttreatment. Participants' mean item ratings on the relationship measure were above the neutral midpoint, but no association was found between the therapeutic relationship and outcome. The results are discussed in terms of the utility of CCBT as part of a stepped-care model and how further research might usefully explore the nature of the relationship formed between clients and CCBT programmes.     

Disentangling the Impact of Resistance and Ambivalence on Therapy Outcomes in Cognitive Behavioural Therapy for Generalized Anxiety Disorder

Resistance and ambivalence about change are increasingly recognized as important determinants of treatment outcomes. Moreover, resistance and ambivalence are thought to be theoretically related in that clients who are more ambivalent about change are more likely to demonstrate resistance to the process and tasks of treatment. In the context of cognitive behavioural therapy (CBT) for generalized anxiety disorder, the present study simultaneously examined early resistance and ambivalence using two observer-based coding systems in order to determine their inter-relationship and, importantly, to investigate their relative contributions to outcome. Resistance was also coded during mid-treatment in order to investigate possible mediation pathways. Early ambivalence (clients’ arguments against change or counter-change talk) was found to be no longer related to outcomes when early resistance was taken into account, suggesting that disharmony in the therapeutic relationship is more important to outcomes than ambivalence per se. Moreover, mid-treatment resistance partially mediated the relationship between early resistance and post-treatment worry severity. That is, higher early opposition to therapist direction is related to poorer outcomes, in part because it is associated with greater resistance during the working phase of CBT. The findings underscore the critical need for therapists to be sensitive to identifying resistance early and throughout treatment.     

Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.     

The Acceptability of Computer-Aided Cognitive Behavioural Therapy: A Pragmatic Study

The clinical and cost-effectiveness of a computer-aided cognitive behavioural therapy (CCBT) programme, Beating the Blues, is indicated by a number of studies, but relatively little is known about its acceptability for patients with depression, anxiety, or both. This study investigated the acceptability of Beating the Blues offered on eight scheduled clinic visits with brief face-to-face support. Pre and posttreatment measures explored the relationship among programme acceptability, treatment continuation, and outcomes for people accessing the programme in routine care. Two hundred and nineteen patients with depression, anxiety, or both were offered Beating the Blues in 11 primary and secondary care practices. One hundred and ninety-one (87%) completed the pretreatment measures and 84 (38%) completed a treatment feedback questionnaire. Analysis of treatment acceptability for CCBT indicated a positive patient experience with the programme. Pretreatment expectancies predicted CCBT treatment completion but not outcomes. No differences were found between men and women on pretreatment measures. Posttreatment, women reported more favourable responses to the therapy, finding the programme more helpful and more satisfactory, than did men. No relationship between treatment acceptability and age was found. Study limitations, including research methods and attrition rates, and implications for future research are discussed. It is concluded that the Beating the Blues CCBT programme is an acceptable treatment for common mental health problems in routine care.     

The Establishment of Cognitive Behavioural Therapy in Argentina

Although Argentina is well known for the popularity of psychoanalysis, in recent years the field of psychotherapy has been expanded to include cognitive behavioural therapy. At present, cognitive behavioural therapy has become much more common in universities and postgraduate educational programmes in Argentina. This work aims to describe the development of cognitive behavioural therapy in Argentina. First, we will depict some general characteristics of psychology in Argentina. Then, we will refer to the first cognitive behavioural therapists in Argentina, highlighting the trajectories of the local main figures, and the events that paved the road for the development of this model in Argentina, such as the visit of Hans Eysenck to Buenos Aires, the impact of Aaron T. Beck's work, and the presence of Vittorio Guidano. Then, we will describe the various institutions that, in the 1990s, established the Argentinian Cognitive Therapies Association. Finally, we will describe the current development of cognitive behavioural therapy in Argentina, and analyse its characteristics and the challenges of local culture.     

Spontaneous Self‐Practice of Cognitive Behavioural Therapy (CBT) by Aboriginal Counsellors During and Following CBT Training: A Retrospective Analysis of Facilitating Conditions and Impact

Previous cognitive behavioural therapy (CBT) training studies have suggested that therapists who practice CBT strategies on themselves during training may experience professional and personal benefits. However, it has also been reported that some CBT trainees are reluctant to engage in self‐practice. The present study reports an incidental finding from a CBT training study with Aboriginal counsellors: all five counsellors reported that they practiced CBT techniques on themselves without specific encouragement by the trainers to do so. This paper therefore posed three questions: (a) Why—in contrast to some other trainees—did this group choose to apply CBT to themselves? (b) How did they apply it—with what purpose, in what contexts, and which skills? (c) What was the impact of CBT self‐practice? Data from the group's reflections were qualitatively analysed by two of the researchers, and “member checked” by the remainder. Results indicated that the counsellors were motivated to practice CBT on themselves for two principal reasons: the value they placed on CBT, and their personal need resulting from the high number of crises experienced while living and working in their communities. The counsellors reported practicing CBT in a wide variety of contexts as part of their learning. As in previous studies, the impact of CBT self‐practice was that it increased their confidence and competence as therapists. It also appeared to be a valuable burnout prevention strategy. If the results are generalisable, they suggest that self‐experiential training in CBT may be a culturally responsive and adaptive way for Aboriginal counsellors to enhance their learning of CBT skills.     

Reflections on the Theory-Practice Gap in Cognitive Behavior Therapy

The papers in this special series, edited by Pilecki and McKay (2013--this issue), are devoted to examining the theory-practice gap in cognitive-behavior therapy (CBT). A gap between theory and practice can occur at more than one level. First, there exists a substantial and concerning gap between the theories and interventions supported by research and those being offered to patients in the community (i.e., research-practice gap). There is also a growing concern in the field that the techniques and procedures that characterize cognitive-behavioral therapies are becoming increasingly divorced from underlying theories (i.e., theory-procedure gap). In the present commentary we hope to summarize and comment on some of the themes, issues, and future directions raised by our contributors.     

Behavioural and ERP Effects of Cognitive and Combined Cognitive and Physical Training on Working Memory and Executive Function in Healthy Older Adults

Cognitive and physical training have been shown to be effective in improving older adults’ cognition. However, it is not yet clear whether combined cognitive and physical training offers an advantage compared to cognitive training alone. Twenty-two older adults performed cognitive or combined cognitive and physical training in order to compare their effects on working memory event-related potentials (ERPs) and on working memory and executive function performance. Before and after eight weeks of training, performance in Plus Minus, Flanker, Updated Span, and Complex Span tasks was measured, and ERPs were registered during performance of an n-back task (0-back, 2-back, and 3-back). Post-training behavioural improvement was observed in Updated Span, Complex Span, and n-back tasks. During the n-back task, the N2/P3 complex was modulated by training, with a decrease in N2 amplitude and an increase in P3 amplitude in the posttraining session compared to the pretraining session. These changes in ERP components suggest that both types of training potentially reduce the need for attentional control to perform the tasks correctly and increase working memory capacity. Thus, based on our data, no conclusion can be reached on the direct advantage of combined training, either at behavioural or at neural level. However, the present study might suggest an indirect advantage of such a combined training, because the cognitive benefit was found to be highly similar in both types of training. Using combined cognitive and physical training may produce a potential improvement in general fitness and an increased appeal of training.     

Therapist Self-Efficacy in Delivering Cognitive Processing Therapy in a Randomized Controlled Implementation Trial

Efforts to improve the implementation of evidence-based treatments (EBT) have recently made important strides. One such example is understanding the vital role that weekly consultation plays as therapists learn to deliver an EBT. Because mechanism-based research can further support EBT implementation, the present study sought to examine the potential relationship between therapist self-efficacy in relation to treatment fidelity and outcomes.We examined therapist self-efficacy ratings from 80 therapists working with 188 patients. These data were collected as part of a randomized controlled implementation trial testing cognitive processing therapy (CPT). Across post-workshop training conditions, we ran multilevel models to assess (1) changes in therapist self-efficacy, (2) therapist self-efficacy in relation to treatment fidelity, and (3) therapist-self-efficacy in relation to patient PTSD symptom outcomes.We found that therapist self-efficacy significantly improved over the course of 6 months of CPT training. Baseline therapist self-efficacy was differentially associated with client outcomes based on post-workshop training condition. Specifically, therapists with low self-efficacy that did not receive post-workshop consultation tended to have poorer outcomes than therapists with low self-efficacy that received consultation. In the present sample, therapist self-efficacy was not related to treatment fidelity.As this was the first study to examine therapist self-efficacy in the implementation of an evidence-based treatment, our findings suggest that self-efficacy may be an important implementation factor in treatment outcomes and worthy of ongoing research.     

Online Cognitive Behavioural Therapy Training for Therapists: Outcomes,Acceptability, and Impact of Support

The objectives of the present study were to assess the effects of online cognitive behavioural therapy (CBT) training for therapists on measures of CBT knowledge, skills, confidence, and utilisation; to determine what differences might exist between a group supported by regular telephone contact and an independent group who undertook online training without additional support; and to determine the acceptability of CBT online training among rural and remote mental health professionals. Mental health practitioners were randomly allocated to a supported training group (six sessions of 15‐min support) or an independent group. They undertook a 12‐week online CBT training program. The two groups showed similar gains on an objective test of knowledge of CBT, and on self‐report measures of knowledge, skills, confidence levels, and utilisation of skills. However, the supported training group had a significantly higher program completion rate than the independent group. Participants evaluated the program favourably. The results suggest that online CBT training represents a promising and cost‐effective approach to training the mental health workforce, and may be particularly attractive for those who live in regional, rural, and remote communities. A challenge is to determine the most cost‐effective ways to enhance program completion rates and trainee skills.     

"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.     

Combined Individual Cognitive Behavior Therapy and Parent Training for Childhood Depression: 2- to 3-Year Follow-Up

Fourteen children with significant depressive symptoms from an open clinical trial of Primary and Secondary Control Enhancement Training augmented with Caregiver–Child Relationship Enhancement Training, participated in a 2- to 3-year follow-up assessment. The results suggested that the significant decreases in depressive symptoms observed at posttreatment were maintained at 2- to 3-year follow-up. Mothers' reports of significant improvement of child psychosocial functioning were also maintained, providing social validation of the effects. Pretreatment child-rated mother-child relations predicted depressive symptoms at 2- to 3-year follow-up. These long-term data support the use of the combined intervention and suggest the need for further research on caregiver involvement in treatment.     

An Open Trial of Web-Based Mindfulness-Based Cognitive Therapy for Perinatal Women at Risk for Depressive Relapse

Depression occurring during pregnancy and postpartum (i.e., the perinatal period) is common and associated with adverse outcomes for women and their offspring. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk for depressive relapse among at-risk individuals generally, and recent adaptations document the efficacy of MBCT among perinatal women specifically. In addition, MBCT, when delivered using a web-based format (Mindful Mood Balance [MMB] program), has demonstrated acceptability and feasibility for at-risk individuals generally. The aim of the present open trial study was to examine the feasibility, acceptability, and preliminary outcomes of MMB for use with pregnant women at risk for depressive relapse (N = 37). We predicted that MMB would be feasible and acceptable as assessed by session completion and participation in phone coaching calls, home practice completion, and self-reported satisfaction via questionnaire and interview. We also predicted that women would not demonstrate significant worsening of depression symptom severity during MMB, consistent with our focus on prevention. A brief case example based on a composite of participants is presented to illustrate the MMB structure and content and the phone coaching protocol. Participants demonstrated engagement with the program, reported perceiving benefits in the intended depression prevention targets of MMB, and sustained minimal to mild depressive symptom severity over the course of the program. Given these promising results and the potential benefits of averting depression for women and their families, further development and rigorous testing of MMB among at-risk pregnant women is warranted.     

Exploring Decision Making Around Therapist Self‐Disclosure in Cognitive Behavioural Therapy

Background

Therapist self‐disclosure (TSD) usage varies greatly among different psychotherapy orientations. Anecdotal evidence seems to suggest that there are reasons for its judicious use, and a small number of researchers have proposed guidelines for how TSD should be used to help therapists across psychotherapy models make decisions around disclosure. However, there is almost no literature specifically exploring how cognitive behaviour therapy (CBT) practitioners make decisions around employing TSD within the CBT framework.

Objective

This study aimed to explore how experienced CBT practitioners make decisions around TSD.

Method

In‐depth qualitative interviews were conducted with six clinical psychologists who were trained and experienced in CBT, and the interviews were analysed thematically.

Results

There were two overarching themes in terms of how they made decisions to self‐disclose: (A) the rules for TSD use, which included sub‐themes (a) it must have a clear purpose, (b) it must fit, (c) the therapist must maintain boundaries, and (d) the therapist must always reflect on his/her use of TSD; and (B) how they use TSD, which included subthemes of (a) using it as a tool for change and (b) using it to manage the therapeutic relationship.

Conclusion

Participants’ decisions on whether or not to self‐disclose were strongly influenced by the CBT model, and this process went beyond what is suggested in the transtheoretical literature. Understanding this process may lead to the development of CBT‐specific guidelines for making TSD‐related decisions.     

Changes in Decentering Across Cognitive Behavioral Group Therapy for Social Anxiety Disorder

To further improve treatments, we need to better understand potential common treatment mechanisms, such as decentering, or the ability to observe thoughts and feelings as objective events in the mind rather than personally identifying with them (Safran & Segal, 1990). Therefore, this study examined whether 12 sessions of Cognitive Behavioral Group Therapy (CBGT) for 63 clients (57.6% female, 50.8% White) diagnosed with social anxiety disorder led to increases in decentering and whether increased decentering was associated with improved outcome. Furthermore, this study examined whether decentering was associated with outcome over and above a competing mechanism—cognitive reappraisal. Overall, results indicated that CBGT in this study led to similar outcomes compared to previous studies and decentering increased over CBGT (d’s from 0.81 to 2.23). Change in decentering predicted improvement on most, but not all, measures of outcome and those who no longer met criteria for social anxiety disorder at posttreatment had significantly greater change in decentering across therapy and significantly higher decentering scores at post-treatment compared to those who retained a social anxiety disorder diagnosis at posttreatment. Finally, changes in decentering predicted outcome over and above changes in reappraisal on all outcome measures. These results largely support the role of decentering in CBGT for social anxiety; however, the implications of the inconsistencies in results based on which outcome measure was used are discussed.     

森田疗法与认知行为疗法的比较分析

阐述森田疗法和认知行为疗法的基本理论,在此基础上对两种疗法作比较分析。尽管这两种心理治疗方法在治疗程序和具体操作方法上迥然不同,但在发病机制的解释和治疗原理方面,它们又有很多相似之处,对存在这种现象的原因进行了探讨。