Extensions and Mechanisms of Mindfulness‐based Cognitive Therapy: A Review of the Evidence

Mindfulness‐based cognitive therapy (MBCT) was originally developed to prevent depressive relapse and recurrence and has also been widely extended to new patient populations and target problems over the last 14 years. We provide a comprehensive review of this literature, examining the strength of the evidence base for specific populations and target problems and identifying questions for future research to address. Specifically, we review studies addressing the use of MBCT for depressive disorders (prevention of depressive relapse and treatment of residual and current depressive symptoms), the use of MBCT in the treatment or management of other mental disorders (bipolar disorder, anxiety disorders, mixed anxiety and depression symptoms, disordered eating, personality disorders, and psychosis), and the use of MBCT in behavioural medicine contexts. Additionally, we discuss the extension of MBCT during specific developmental periods, like childhood, pregnancy and post‐partum, and adult caregiving, and, finally, we address the use of MBCT among clinical health‐care providers. In the second section, we review hypothesised mechanisms of change in MBCT and reflect on implications for theories of how MBCT works in the application to various patient populations and target problems. We also consider research addressing active ingredients and what is known about the “dosage” of meditation practice. We conclude with a summary of recommendations for future research.     

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.     

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.     

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.     

Predictors and consequences of sudden gains in transdiagnostic cognitive-behavioural therapy for anxiety disorders

Sudden gains—substantial stable symptom improvements between consecutive therapy sessions—are a common phenomenon. As condensed points of change, examination of sudden gains can provide insight into mechanisms of therapeutic change. This study investigated the association between sudden gains and cognitive change, therapeutic alliance, and/or client engagement in transdiagnostic group cognitive-behavioural therapy for anxiety disorders. Of 58 treatment initiators, 21% (n = 12) exhibited a sudden gain. Consistent with previous research, sudden gainers demonstrated significantly greater pre- to post-treatment symptom improvement than non-sudden gainers. Observational coding of therapy sessions found that sudden gains were associated with elevated levels of cognitive change and client engagement in the pre-gain session, and elevated levels of cognitive change and therapeutic alliance in the post-gain session. However, these results varied by use of within- and between-subject control comparisons, highlighting the value using a dual control methodology. In context of previous research, the results on cognitive change replicate previous findings in depressive populations, and clarify mixed findings in anxiety populations. The results on therapeutic alliance replicate previous findings for the first time in an anxiety sample, although the between-subject control comparisons revealed complexity previously undetected. This study was also the first to investigate and thus establish the relation between client engagement and sudden gains.     

The Nature,Timing, and Symptom Trajectories of Dropout From Transdiagnostic and Single-Diagnosis Cognitive-Behavioral Therapy for Anxiety Disorders

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.     

Mindfulness‐Based Interventions in Counseling

Mindfulness is a relatively new construct in counseling that is rapidly gaining interest as it is applied to people struggling with a myriad of problems. Research has consistently demonstrated that counseling interventions using mindfulness improve well‐being and reduce psychopathology. This article provides a detailed definition of mindfulness, including a discussion of the mechanisms underlying mindfulness practice; explores the implementation of mindfulness as a counseling intervention; and examines literature supporting its effectiveness.     

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.     

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.     

Enhanced Cognitive Behavior Therapy: A Single Treatment for All Eating Disorders

Eating disorders are serious mental illnesses affecting a significant proportion of women and a smaller number of men. Approximately half of those with an eating disorder (ED) will not meet the criteria for anorexia or bulimia nervosa, and will be diagnosed with an eating disorder not otherwise specified (EDNOS). Until recently, there were no recommended treatments for EDNOS. This article provides an overview of enhanced cognitive behavior therapy, a validated treatment for all forms of EDs.     

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.     

Training Aboriginal Practitioners in Cognitive Behavioural Therapy

Comments on an article by Bennett‐Levy and colleagues. This commentary reviews a dissemination of cognitive behavioral therapy (CBT) for Aboriginal Australians, with regard to the strengths of the dissemination effort and areas for future efforts. As an initial step in bringing CBT to a population that has been severely limited in access to evidence based practice, despite a notable need, this study was an important step forward. Feedback from the participatory action research group (n = 5 Aboriginal Australian counsellors) identified CBT elements and adaptations perceived to be particularly effective with Aboriginal Australian clients. Case conceptualization was identified as a potential avenue for further tailoring CBT to the individual needs of clients. Several factor including the success of the dissemination effort, reports that clients shared CBT techniques with their communities, and the skill‐building nature of CBT raised the possibility of future community‐based dissemination.     

Commentary on Three Articles on Self‐practice/Self‐reflection in Cognitive‐Behavioural Therapy

The commentary embraces three valuable contributions to the development of professional practice: (a) engagement with self‐practice/self‐reflection as a professional self‐development: the role of therapist beliefs; (b) spontaneous self‐practice of cognitive‐behavioural therapy (CBT) by aboriginal counsellors during and following CBT training: a retrospective analysis of the facilitating conditions and impact; (c) developing metacompetence in low intensity CBT interventions: evaluating a self‐practice/self‐reflection programme for experienced low intensity CBT practitioners. Each article provides different perspectives of the self‐practice and self‐reflection benefits for efficient therapy and their use as powerful resources in therapeutic training skills in general and CBT in particular. Conclusions of their contributions close the commentary.     

认知疗法的整合性发展

认知疗法于20世纪60-70年代在美国产生,在数十年的发展过程中其理论与治疗技术不断得以丰富和发展,目前已成为心理治疗的主要流派之一。本文主要对今年来认知疗法的整合性发展,及其在应用中存在的一些问题进行了概述。     

Toward an Integration of Interpersonal Risk Models of Depression and Cognitive‐Behaviour Therapy

Empirical research has increasingly focused on interpersonal variables associated with the development and maintenance of depression. This article outlines some key interpersonal risk factors for depression, including anxious attachment, sociotropy, excessive reassurance seeking, interpersonal stress generation, reduced social support, social skills deficits, and social avoidance. Recommendations are made for how cognitive‐behavioural therapy may be adapted to address such factors. Specifically, suggestions are offered for how cognitive and behavioural interventions, such as cognitive restructuring, behavioural activation, behavioural experiments, and skills training, may be used with depressed clients to promote positive relationships and reduce maladaptive interpersonal behaviours.     

Unified Protocol vs Trauma-Focused Cognitive Behavioral Therapy Among Adolescents With PTSD

Harmful consequences of COVID-19, such as prolonged quarantine, lack of social contact, and especially loss of parents or friends, can negatively impact children and adolescents’ mental health in diverse ways, including engendering posttraumatic stress symptoms. Our study is the first to compare the transdiagnostic Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich et al., 2009; Ehrenreich-May et al., 2017) with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in terms of outcomes related to PTSD symptoms (COVID-19-related vs. COVID-19 unrelated PTSD) and comorbid symptoms (i.e., anxiety, depression) and other measures (i.e., emotion regulation, self-injury, anger). Individuals diagnosed with PTSD were randomly assigned to the UP-A (n = 46) or TF-CBT group (n = 47), administered the SCID-5 and a battery of measures and followed up posttreatment and then after 3, 6, and 9 months. Ninety-three adolescents with PTSD were enrolled, 45% boys and 61% COVID-19-related PTSD. We adopted an intention-to-treat approach. At the initial post-intervention assessment, except for emotion regulation and unexpressed angry feelings, in which UP-A participants reported greater reductions, no significant differences in other variables were secured between the UP-A and TF-CBT. However, at follow-up assessments, the UP-A evidenced significantly better outcomes than TF-CBT. We found support for the UP-A compared with TF-CBT in treating adolescents with PTSD, regardless of COVID-19-related PTSD status, in maintaining treatment effectiveness over time.     

Cognitive Behavioral Therapy for Attention-Deficit/Hyperactivity Disorder in College Students: A Review of the Literature

The current review presents a theory-guided review of the existing cognitive behavioral therapy (CBT) interventions for attention-deficit/hyperactivity disorder (ADHD) in college students. Across the eight studies that investigated this topic, moderate reductions were shown in inattentive symptoms but little to no change was reported in hyperactive/impulsive symptoms. Results indicated a moderate treatment effect on self-reported quality of life and school/work functioning, yet less of an impact on GPA, response inhibition, social functioning, and executive functioning. Methodological and statistical problems and inconsistencies were noted. Since college students are emerging adults, it is likely that the optimum CBT intervention for college students with ADHD lies somewhere in between the existing clinic-based adult ADHD CBT interventions as well as the school-based adolescent ADHD psychosocial interventions. Directions for future research and recommendations for clinicians in university settings are provided in an attempt to further develop the existing college students CBT clinical research evidence base.