Cognitive Behavior Therapy for Obsessions and Compulsions: New Applications and Emerging Trends

This paper describes recent developments in the cognitive behavioral treatment (CBT) of obsessive compulsive disorder (OCD). Although behavioral treatment of OCD consisting of exposure and response prevention (ERP) has been shown to be clinically effective, certain limitations with ERP have led clinical researchers to propose that treatment should be augmented with direct cognitive interventions. Modification of dysfunctional beliefs and faulty appraisals or interpretations of the obsession are now considered a crucial component of CBT for obsessions and compulsions. This paper discusses the conceptual basis of the new CBT for OCD and reviews its limited empirical status. A case example is provided in which CBT is used to treat obsessional ruminations of becoming sick. The article concludes with a discussion of the challenges and pitfalls involved in offering CBT for obsessions and compulsions.     

Durability of Cognitive Behavioral Therapy Effects for Youth and Adolescents With Anxiety,Depression, or Traumatic Stress:A Meta-Analysis on Long-Term Follow-Ups

Cognitive behavioral therapies (CBT) for youth with anxiety, traumatic stress, and depression have demonstrated strong effects in individual studies and meta-analyses. Relatively more attention has been given to posttreatment effects, though, and assessment of follow-up effects has been limited at the meta-analytic level. The current meta-analysis aimed to (a) examine the effects of youth CBT at posttreatment, 1-month, 3-month, 6-month, 1-year, and long-term (2 + years) follow-up as well as (b) identify research-related variables (e.g., measure respondent type) that relate to effects. Using a random effects model across 110 child and adolescent CBT groups, within-group effect sizes were large at posttreatment (g = 1.24) and from 1-month through long-term follow-up (g = 1.23–1.82), and effect sizes did not significantly differ by treatment target (i.e., anxiety, traumatic stress, depression). However, availability of outcome data for effect sizes diminished across later follow-up assessments. Moreover, effect sizes were significantly associated with outcome respondent type across assessment timing, with outcome measures from caregiver and youth respondents associated with smaller effect sizes (B = -0.97, p < 0.001) relative to outcome measures that were evaluator-reported. Results provide initial support for the durability of treatment effects for youth CBTs and highlight the importance of some confounding variables. Implications for improving treatment research standards and prioritizing assessment of long-term follow-up assessment are discussed.     

Cognitive Factors that Maintain Social Anxiety Disorder: a Comprehensive Model and its Treatment Implications

Social anxiety disorder (SAD) is a common, distressing and persistent mental illness. Recent studies have identified a number of psychological factors that could explain the maintenance of the disorder. These factors are presented here as part of a comprehensive psychological maintenance model of SAD. This model assumes that social apprehension is associated with unrealistic social standards and a deficiency in selecting attainable social goals. When confronted with challenging social situations, individuals with SAD shift their attention toward their anxiety, view themselves negatively as a social object, overestimate the negative consequences of a social encounter, believe that they have little control over their emotional response, and view their social skills as inadequate to effectively cope with the social situation. In order to avoid social mishaps, individuals with SAD revert to maladaptive coping strategies, including avoidance and safety behaviors, followed by post‐event rumination, which leads to further social apprehension in the future. Possible disorder‐specific intervention strategies are discussed.     

Cognitive Barriers to Successful Weight Management: 7 Stymie Beasts

This paper focuses on one of the most significant barriers, especially for teenagers and their families, to the effectiveness of cognitive behavioral therapy (CBT) for weight management: high rates of attrition. Cognitive barriers contribute to attrition and to decreasing commitment to full engagement in the process (deliberate practice). Excuses capture the essence of one type of those cognitive barriers. Excuses are defined as shifts in attribution from self-focused causes of struggles to achieve goals to more externally-focused causes—resulting in decreasing full engagement. Those excuses (shifts in attribution) do not just happen. People make decisions to implement those shifts away from personal responsibility. Ten cognitive biases lie at the heart of such problematic delusional decision making. This paper identifies seven excuses created by that biased decision making as anthropomorphisms called Stymie Beasts. Such unique simply worded visually distinctive creatures may help improve recall and focus on these powerful antagonists to successful weight control. Then, the use of two CBT techniques, Therapeutic Understanding of Science (TUS) and Rational Emotive Therapy (RET), illustrated with examples for all seven Stymie Beasts, shows how CBT may prevent and dismantle those Beasts (excuses). Ideas for future research using randomized controlled trials to test these notions are also presented.     

An Investigation of the Rate and Predictors of Initiating and Attending Group Cognitive Behavioral Therapy for Insomnia After Referral

Although group Cognitive Behavioral Therapy for Insomnia (CBT-I) is an efficacious and well-studied treatment, relatively less is known about its clinical effectiveness in community outpatient settings. Prior research has suggested that dropout from CBT-I may be high in treatment settings vs. clinical trials. The current study therefore investigated the rates and predictors of initiating and attending CBT-I group within an outpatient psychiatry clinic. Participants were 75 consecutive outpatients presenting for treatment at a specialty sleep and anxiety clinic who completed an evaluation and were referred to CBT-I group. Participants completed self-report measures at initial evaluation, and their attendance throughout treatment was tracked. The majority of patients attended ≥1 session, with a mean of 3/5 sessions completed for initiators. Those with poorer global sleep quality and longer sleep onset latency were less likely to attend group and attended fewer sessions. Those with more severe anxiety and depression were less likely to initiate attendance and attended fewer sessions. The majority of patients referred to CBT-I initiated group and attended at least half of the sessions. Further, demographics do not seem to impact these rates. Unfortunately, those with the most severe symptoms, and thus in most need for treatment, are least likely to initiate and attend. This may be due to comorbid anxiety or depression symptoms. Future research should replicate these findings, as well as explore how to encourage those most in need of treatment to initiate and attend CBT-I.     

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.     

The Development and Initial Validation of the Cognitive Fusion Questionnaire

Acceptance and Commitment Therapy (ACT) emphasizes the relationship a person has with their thoughts and beliefs as potentially more relevant than belief content in predicting the emotional and behavioral consequences of cognition. In ACT, “defusion” interventions aim to “unhook” thoughts from actions and to create psychological distance between a person and their thoughts, beliefs, memories, and self-stories. A number of similar concepts have been described in the psychology literature (e.g., decentering, metacognition, mentalization, and mindfulness) suggesting converging evidence that how we relate to mental events may be of critical importance. While there are some good measures of these related processes, none of them provides an adequate operationalization of cognitive fusion. Despite the centrality of cognitive fusion in the ACT model, there is as yet no agreed-upon measure of cognitive fusion. This paper presents the construction and development of a brief, self-report measure of cognitive fusion: The Cognitive Fusion Questionnaire (CFQ). The results of a series of studies involving over 1,800 people across diverse samples show good preliminary evidence of the CFQ’s factor structure, reliability, temporal stability, validity, discriminant validity, and sensitivity to treatment effects. The potential uses of the CFQ in research and clinical practice are outlined.     

Dissemination and Implementation of Cognitive Behavioral Therapy for Depression in the Kaiser Permanente Health Care System: Evaluation of Initial Training and Clinical Outcomes

Notwithstanding its empirical status and strong recommendation in clinical practice guidelines, cognitive behavioral therapy (CBT) continues to be delivered infrequently and with low fidelity on the clinical front lines. Recently, organized efforts and policies within the public sector to disseminate and implement CBT and other evidence-based psychotherapies have yielded encouraging results and provided optimism for bridging the research-to-practice-gap. Following from these efforts, the current article examines the initial impact and experience of the implementation of an individualized approach to CBT training and treatment within the Kaiser Permanente health care system. Initial training outcomes, including changes in general and specific competencies, were assessed using divergent assessment methods within the initial cohort of therapists undergoing training. Initial patient outcomes, including changes in depression and anxiety, were assessed among patients receiving treatment from therapists in training. Results revealed training in and implementation of CBT-D was associated with overall large improvements in therapist competencies and in clinically significant improvements in both depression and anxiety among patients. Findings from the initial phase of dissemination and implementation within a large private system provide support for, and extend recent findings related to, the feasibility and effectiveness of training in and implementation of CBT-D in a real-world context.     

抑郁症认知治疗理论及实践进展

认知治疗分化为认知行为与认知分析治疗两个流派。抑郁的贝克认知模型、归因模型、自我价值关联模型以及抑郁的注意过程等认知理论为认知治疗奠定了基础。认知行为治疗、认知行为分析系统心理治疗以及基于冥想的认知治疗等已经在实践中被较有力的临床证据检验。认知治疗在抑郁症的治疗中已显示出广泛的应用前景。     

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.     

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.     

The Importance of Theory in Cognitive Behavior Therapy: A Perspective of Contextual Behavioral Science

For the past 30 years, generations of scholars of cognitive behavior therapy (CBT) have expressed concern that clinical practice has abandoned the close links with theory that characterized the earliest days of the field. There is also a widespread assumption that a greater working knowledge of theory will lead to better clinical outcomes, although there is currently very little hard evidence to support this claim. We suggest that the rise of so-called “third generation” models of CBT over the past decade, along with the dissemination of statistical innovations among psychotherapy researchers, have given new life to this old issue. We argue that theory likely does matter to clinical outcomes, and we outline the future research that would be needed to address this conjecture.     

A case study of behavioral assessment and treatment of insect phobia

We assessed the academic performance of a 14-year-old boy with insect phobia in the context of feared stimuli. The dependent measure was math calculation rate across three conditions that varied therapist statements about the presence of crickets and the actual presence of live crickets. Subsequent treatment consisted of graduated exposure and contingent rewards for math problem completion. Assessment results indicated that the boy's performance was consistently low in the presence of live crickets but not when he was spuriously informed that crickets were present (the primary referral concern). Treatment results indicated no effect from exposure alone and a dramatic effect when exposure was combined with contingent rewards.     

焦虑障碍的虚拟现实暴露疗法研究述评

虚拟现实暴露疗法(VRET)是传统的行为疗法的一种转换形式, 也是经典的现实情境暴露疗法的替代性治疗形式。虚拟现实整合了即时计算机图形学、身体感觉传感、视觉成像技术, 给来访者提供近似真实的、可以沉浸(immersion)和交互作用的虚拟环境。研究者采用虚拟现实暴露疗法治疗幽闭恐怖症、恐高症、飞行恐怖症、创伤后应激障碍、惊恐障碍等焦虑障碍, 并且关注虚拟现实暴露疗法的认知机制以及心理生理机制。实验研究表明, 虚拟现实暴露疗法在治疗焦虑障碍时是有效的。被试经过治疗之后, 对情境的控制感和自我效能感提升, 消极自我评价降低, 对创伤事件的容忍力提高, 重新获得对情境的控制感。与心率指标相比, 皮肤电是预测虚拟现实暴露疗法治疗效果更好的指标。虚拟现实暴露疗法还处于实验验证阶段, 并没有应用到实际临床中, 需要更加规范的实验设计验证该疗法的认知机制以及心理生理机制。虚拟现实暴露疗法结合功能磁共振成像(FMRI)用于心理治疗, 会是未来发展的新方向。     

Cognitive specificity and affective confounding in social anxiety and dysphoria in children

Cognitive features of social anxiety and dysphoria were examined with a design that allowed for evaluation of each state alone and in combination. From a community sample of 211 8 to 12 year olds, four groups of children were defined based on previous researcher's criteria: mixed (high socially anxious-dysphoric;n= 14), socially anxious (high socially anxiousnondysphoric;n= 14), dysphoric (non-socially anxious-dysphoric;n= 13), and control (non-socially anxious-nondysphoric;n= 14). The negative cognitive triad and negative cognitions pertaining to the self were associated with both dysphoria and social anxiety. Both dysphoric and socially anxious groups reported significantly more cognitive distortions than the control group, yet cognitive distortions of overgeneralizing and personalizing were specific to social anxiety and not dysphoria. Both dysphoric and socially anxious groups reported significantly more depressive cognitions than the control group, and evidence of cognitive content-specificity emerged only for anxiety, although there was some evidence for depressive content-specificity in the mother's ratings. The mixed group was the most dysfunctional on all of the cognitive measures. This study provided some evidence of cognitive-specificity as well as the confounding between the affective states of dysphoria and social anxiety. Methodological, theoretical, and treatment implications are highlighted.     

Homework Completion,Patient Characteristics,and Symptom Change in Cognitive Processing Therapy for PTSD

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.     

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.     

Strategies included in cognitive behavioral therapy programs to treat internalized disorders: a systematic review

This review aimed to identify the strategies used in programs based on cognitive behavioral therapy (CBT) to prevent and treat symptoms of anxiety, depression, and internalized behaviors of children and adolescents. Based on an online search (ERIC, PsycInfo, Virtuose UQAM, and Google Scholar), 61 studies describing different cognitive behavioral programs were selected. Results showed that 40 strategies were implemented in at least one program. However, none of the strategies were systematically present in all programs, and only few were reported in more than 50% of the studies. Cognitive restructuring and problem-solving were the most popular strategies to treat depressive symptoms, whereas anxiety programs also generally included relaxation and exposure. Furthermore, six strategies were identified in a single anxiety program, whereas nine strategies were implemented in only one depression program. These results suggest that in anxiety and depression programs designed for children and adolescents, the label “CBT” encompasses a wide variety of programs with only few similar strategies. Such findings highlight the need to define a common basis for CBT programs, in order to better reflect CBT theory and to identify the effectiveness of the strategies included in these programs.     

Depression and Anxiety: Integrating the Tripartite and Cognitive Content-Specificity Assessment Models

The cognitive content-specificity hypothesis proposes that depression and anxiety can be discriminated on the basis of unique cognitive profiles. Alternatively, the Tripartite model suggests that, although depression and anxiety share a general distress factor, anhedonia is a characteristic of depression with anxious arousal a characteristic of anxiety. Past research devoted to integrating these two models has been limited in a number of ways. To remedy these limitations, this study attempted to assess the complete Tripartite model and used a multidimensional cognitive assessment tool to handle the heterogeneity of anxious cognitive content. Results on data collected from 411 clients seeking services at a university counseling center suggested that a one-to-one mapping between Tripartite dimensions and cognitive content was possible. Further, variables from each model simultaneously explained unique variance in depression and anxiety ratings.     

Psychological Factors Behind Truancy,School Phobia,and School Refusal: A Literature Study

Truancy is a problem that normally leads to treatment interventions within different organizations. Within these organizations different perspectives on the causes and consequences of the above problem can be found. The purpose of this literature study is to map out and describe the current state of research within the fields of school refusal, truancy, and school phobia. The investigation was carried out in the form of a systematic review of the relevant research literature. Research shows that approximately 90% of all young people who refuse to go to school have some form of psychiatric diagnosis.