Cognitive-Behavioral Therapy for Individuals Recovering from a First Episode of Psychosis

Schizophrenia is one of the most devastating psychiatric illnesses. There has been a tremendous worldwide research and clinical effort into early intervention for psychosis. However, despite significant improvement in symptoms after a first episode, there is no corresponding quality improvement in function for many individuals. Thus, increased attention has been given to psychological intervention in particular cognitive behavioral therapy (CBT) with the hope of enhancing functional recovery. Outcome trials of CBT for schizophrenia are promising and other work in CBT suggests this may be a viable psychological intervention for this population. This paper will review the need for a CBT approach after a first episode of psychosis and describe a modular CBT approach for this population. This approach addresses adaptation as well as both functional and symptomatic outcome, an approach which parallels the theoretical shift in CBT that occurred in the last decade.     

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.     

Group cognitive-behavioral therapy for hoarding disorder: an open trial

Although cognitive-behavioral therapy (CBT) appears to be a promising treatment approach for hoarding disorder, treatment to date has been quite labor intensive. The goal of this study, therefore, was to assess the potential effectiveness of group CBT for hoarding, without home visits by the clinician. Forty-five individuals with hoarding disorder enrolled in either a 16 or 20 session program of group CBT; 30 (67%) completed treatment. Using mixed-effects models to account for missing data, we report data from 35 (78%) participants who provided enough data for analysis. Participants demonstrated significant improvements in hoarding symptoms, as well as symptoms of depression and anxiety, and quality of life. Improvements in hoarding symptoms were comparable to two published clinical trials on individual CBT for hoarding disorder. Results of this study suggest that group CBT for hoarding, without home discarding sessions by the clinician, may be an effective treatment option with the potential advantage of increasing treatment access by reducing clinician burden and cost of treatment.     

Telephone-Administered Cognitive Behavioral Therapy: A Case Study of Anxiety and Depression in Parkinson’s Disease

Parkinson’s disease (PD) is a chronic medical illness with a high incidence of psychiatric comorbidity, specifically depression and anxiety. Research on treatment of such psychiatric complications is scarce. Non-pharmaceutical treatment options are especially attractive. Cognitive behavioral therapy (CBT) is a psychotherapeutic treatment option that has been successful in other chronically medically ill populations with comorbid depression and anxiety. The current research had two aims. The first was to pilot the feasibility of screening and identifying PD patients with symptoms of anxiety and depression in a specialized outpatient clinic. The second aim was to pilot the feasibility of telephone-administered CBT for the treatment of depression and anxiety in persons with PD, which was done through a case series comparing telephone-administered CBT to a Support strategy. A fairly large portion (67.5%) of patients screened in the outpatient clinic were identified as having symptoms of anxiety and/or depression. Results also indicated that CBT delivered via the telephone is a useful approach for targeting psychiatric symptoms in this population. A case example is given to illustrate the clinical considerations associated with delivering therapy via telephone to persons with PD. This study was conducted at the Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. The first author was previously affiliated with the Houston Center for Quality of Care and Utilization Studies.     

Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis

During the last two decades, Internet-delivered cognitive behavior therapy (ICBT) has been tested in hundreds of randomized controlled trials, often with promising results. However, the control groups were often waitlisted, care-as-usual or attention control. Hence, little is known about the relative efficacy of ICBT as compared to face-to-face cognitive behavior therapy (CBT). In the present systematic review and meta-analysis, which included 1418 participants, guided ICBT for psychiatric and somatic conditions were directly compared to face-to-face CBT within the same trial. Out of the 2078 articles screened, a total of 20 studies met all inclusion criteria. Results showed a pooled effect size at post-treatment of Hedges g = .05 (95% CI, ?.09 to .20), indicating that ICBT and face-to-face treatment produced equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there have been few studies of the individual psychiatric and somatic conditions so far, and for the majority, guided ICBT has not been compared against face-to-face treatment. Thus, more research, preferably with larger sample sizes, is needed to establish the general equivalence of the two treatment formats.     

A randomized clinical trial of group and individual Cognitive-Behavioral Therapy approaches for Social Anxiety Disorder

To compare the effectiveness of two Cognitive-Behavioral Therapy (CBT) interventions—an individual and a group intervention—in Social Anxiety Disorder therapy. We compared the two treatment groups against a waitlist condition in a randomized clinical trial with 86 young adults. The individual CBT intervention was Trial-Based Cognitive Therapy (TBCT) developed by De-Oliveira, a novel technique in which the therapist engages the patient in a simulated judicial trial with the goal of identifying and changing core dysfunctional beliefs. The group intervention consisted of exposition therapy based on the Hofmann and Otto protocol (Group CBT) to restructure negative and dysfunctional cognitions regarding social situations. Both interventions reduced psychiatric symptoms from pre- to post-test and primary social anxiety and depression symptoms relative to waitlist controls. The interventions were recently introduced in Brazil, and this is the first randomized control trial to compare TBCT and this Group CBT, which were effective in assessing changes in social anxiety symptoms as well as co-occurring psychiatric symptoms.     

Cognitive-behaviour therapy for depersonalisation disorder: an open study

Depersonalisation (DP) and derealisation (DR) are subjective experiences of unreality in, respectively, one's sense of self and the outside world. These experiences occur on a continuum from transient episodes that are frequently reported in healthy individuals to a chronic psychiatric disorder that causes considerable distress (depersonalisation disorder: DPD). Despite the relatively high rates of reporting these symptoms, little research has been conducted into psychological treatments for this disorder. We report on an open study where 21 patients with DPD were treated individually with cognitive behavioural therapy (CBT). The therapy involved helping the patients re-interpret their symptoms in a non-threatening way as well as reducing avoidances, safety behaviours and symptom monitoring. Significant improvements in patient-defined measures of DP/DR severity as well as standardised measures of dissociation, depression, anxiety and general functioning were found at post-treatment and six-months follow-up. Moreover, there were significant reductions in clinician ratings on the Present State Examination (Wing, Cooper & Sartorius, 1974), and 29% of participants no longer met criteria for DPD at the end of therapy. These initial results suggest that a CBT approach to DPD may be effective, but further trials with larger sample sizes and more rigorous research methodology are needed to determine the specificity of this approach.     

Experimental and Behavioral Approaches to Alcoholism: Kongressrapport

Hypochondriasis is highly prevalent in medical settings, has detrimental effects for affected individuals, and is associated with high societal costs. Although cognitive behavior therapy (CBT) has been shown to be effective in the treatment of hypochondriasis, it is not widely available because of a lack of properly trained therapists. Therefore, it is essential to evaluate therapy forms that require less therapist time. The authors investigated the effect and economic impact of group CBT delivered in a psychiatric setting among 24 people with hypochondriasis. A within-group design with prolonged baseline was used, and all participants received 10 weeks of group-based treatment. The primary outcome measures were the Health Anxiety Inventory and the Illness Attitude Scales. Results indicate significant improvement on both measures at posttreatment and 6-month follow-up (Cohen's d = 1.03–1.72). Medical and nonmedical costs were substantially lowered. The authors conclude that group-based CBT delivered in a psychiatric setting is an effective and potentially highly cost-effective treatment for hypochondriasis.     

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。     

A Brief History of Metacognitive Therapy: From Cognitive Science to Clinical Practice

Metacognitive therapy (MCT) is proving to be an effective treatment for anxiety and depression with effects that may exceed CBT. It has been described as a paradigm shift in psychotherapy in its theory-driven cognitive science approach and systematic development and evaluation. MCT was developed by Adrian Wells based on an information processing theory, the Self-Regulatory Executive Function model by Wells and Matthews. MCT theory formulates psychological disorders as sharing common causal factors under the influence of metacognition, representing a particular top-down model of biases in cognitive regulation. A key clinical implication was that a core set of interventions could be developed to impact a wide range of symptoms and disorders. In this paper, we trace the historical development of MCT and the major studies that informed theory and practice with the aim of introducing clinicians and researchers to this area and to understand why the metacognitive approach has developed into a treatment that is proving to be potentially more effective than current gold-standard treatments. In doing so, we will draw out the distinctive features of the approach and explore how this might offer a blueprint for scientific advancement in clinical psychology and psychotherapy.     

The Impact of Cumulative Minority Stress on Cognitive Behavioral Treatment With Gender Minority Individuals: Case Study and Clinical Recommendations

For sexual minority individuals (i.e., lesbian, gay, and bisexual [LGB] persons), minority stress includes experiences of discrimination, expectations of rejection, internalized negativity, and concealment of identity. Sexual minority stress has been linked to various negative mental health outcomes (e.g., depression, anxiety), and levels of psychiatric comorbidity are high among LGB people. However, little is known about the extension of minority stress models to gender minority individuals (i.e., transgender and gender nonconforming persons) and its impact on mental health in this particular group. Further, the influence of gender minority stress on the delivery and outcome of traditional cognitive behavioral therapy (CBT) approaches is unclear. A case study of CBT for chronic depression with a young, transgender individual is presented. This case study highlights potential barriers that may arise with gender minority clients when implementing evidence-based clinical interventions in the context of an individual’s minority stress history. Implications for cognitive-behavioral treatments with gender minority individuals and recommendations for clinicians and researchers are discussed.     

Cognitive behavioral therapy of violence-related posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) represents the most common psychiatric condition following exposure to violence. Although an increasing number of cognitive behavioral therapy (CBT) studies point to efficacy of this approach in ameliorating PTSD following violence, the methodological rigor of many studies has not been optimal. Further, a significant proportion of traumatized individuals does not benefit from CBT. This article reviews CBT outcome studies, discusses the methodological limitations of CBT studies for PTSD, and offers suggestions for future research. This review highlights the need for more systematic studies of components of CBT with a range of trauma populations to delineate the parameters of effective CBT for individuals with PTSD.     

Implementation of the Wolverine Mental Health Program,Part 2: Implementation Phase

To enhance mental health care for youth in a midwestern residential treatment facility, Wolverine Human Services partnered with the Beck Institute (an intermediary) and an implementation research team to implement cognitive-behavioral therapy (CBT). CBT has strong evidence supporting effectiveness for treating youth internalizing and externalizing problems, but it is a complex psychosocial intervention that demands a thoughtful implementation approach. This study outlines the implementation phase (2.5 years) of a 5-year collaborative effort. The implementation phase focused on (a) adapting CBT to fit the complex youth needs and the roles of the multidisciplinary team members resulting in a new comprehensive and coordinated care model, and (b) the strategies utilized to support its competent integration by all team members. Six blended implementation strategies were deployed in this phase: forging implementation teams, installing progress monitoring, adapting CBT, training, providing supervision and consultation, and training the trainers. A components-based approach to CBT yielded six core skills: active listening, problem solving, mood monitoring and intervention mapping, activity scheduling, distress tolerance, and cognitive restructuring. By the end of this phase, all staff had robust exposure to and experience with the adapted form of CBT. The work of our academic–community partnership has both research and clinical implications, with respect to integrating an adapted version of CBT for residential environments (CBT-RE).     

The cost effectiveness of cognitive behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face

Objective

A number of effective treatments for bulimia nervosa have been developed, but they are infrequently used, in part due to problems with dissemination. The goal of this study was to examine the cost effectiveness of telemedicine delivery of cognitive behavioral therapy for bulimia nervosa.

Method

A randomized controlled trial of face-to-face versus telemedicine cognitive behavioral therapy for bulimia nervosa. One hundred twenty eight women with DSM-IV bulimia nervosa or eating disorder, not otherwise specified subsyndromal variants of bulimia nervosa were randomized to 20 sessions of treatment over 16 weeks. A cost effectiveness analysis from a societal perspective was conducted.

Results

The total cost per recovered (abstinent) subject was $9324.68 for face-to-face CBT, and $7300.40 for telemedicine CBT. The cost differential was accounted for largely by therapist travel costs. Sensitivity analyses examining therapy session costs, gasoline costs and telemedicine connection costs yielded fundamentally similar results.

Discussion

In this study, CBT delivered face-to-face and via telemedicine were similarly effective, and telemedicine delivery cost substantially less. These findings underscore the potential applicability of telemedicine approaches to eating disorder treatment and psychiatric treatment in general.     

Cognitive behaviour therapy with adults with intractable epilepsy and psychiatric co-morbidity: preliminary observations on changes in psychological state and seizure frequency

Cognitive behaviour therapy (CBT) was undertaken with six adults with chronic, poorly controlled seizures and co-existing psychiatric and/or psychosocial difficulties. During 12 sessions of CBT from an experienced CBT Nurse Specialist, treatment focused concurrently on epilepsy-related problems, associated psychopathology and on the development of psychological strategies to reduce seizure occurrence. At the end of treatment participants rated their initial epilepsy-related problem as having less impact on their daily lives and at one-month follow-up reported less deleterious impact on everyday life in terms of their psychological difficulties. In addition participants demonstrated significant improvements in terms of their self-rated work and social adjustment, and in their decreased use of escape-avoidance coping strategies. These positive findings occurred despite the absence of a significant decrease in seizure frequency. Issues raised by the complexity and severity, both of these patients' psychological/psychosocial difficulties and their epilepsy, are discussed in relation to the optimal length of treatment that may be required when adopting a CBT model in this patient group.     

A pragmatic approach to measuring adherence in treatment delivery in psychotherapy

ABSTRACT

Measuring therapists’ adherence to treatment manuals is recommended for evaluating treatment integrity, yet ways to do this are poorly defined, time consuming, and costly. The aims of the study were to develop a Therapy Component Checklist (TCC) to measure adherence to manualised CBT; to test its application in research and clinical practice; to determine its validity; and consider its cost benefits. We conducted a randomised trial in 230 people with cancer evaluating effectiveness of CBT for depression. In this, therapists delivered manualised treatment. Experts agreed on key components of therapy and therapists were asked to record these after therapy sessions by ticking a TCC. Inter-rater reliability was tested using an independent rater. Therapists delivered 543 CBT sessions. TCCs were completed in 293, of which 39 were assessed by the independent rater. Self-reported TCC data suggested close adherence to the manual. Prevalence-adjusted and bias-adjusted kappa scores suggested substantial agreement, (>0.60) in 38 out of 46 items. Self-rating of adherence saved around £96 per rating. In conclusion the TCC provides a quick and cost effective way of evaluating the components of therapy delivered. This approach could be applied to other psychological treatments and may help with linking therapeutic interventions with outcome.     

Exposure therapy for social anxiety disorder in people who stutter: An exploratory multiple baseline design

Background & objectives: Social anxiety disorder (SAD) is a debilitating condition, and approximately half of adults who stutter have SAD. Cognitive-behavioral therapy (CBT) has shown promise in decreasing social anxiety symptoms among adults who stutter, but exposure, arguably the essential component for successful CBT for SAD, has been understudied and underemphasized. Aims of this study were to develop an exposure therapy protocol designed specifically for people who stutter and have SAD and evaluate its potential efficacy in reducing social anxiety and stuttering severity using a multiple baseline design.Methods: Six participants received ten sessions of exposure therapy. Participants reported daily social anxiety, and social distress and stuttering severity were evaluated at major assessment points.Results: There were substantial reductions in social anxiety and considerable improvements in affective, behavioral, and cognitive experiences of stuttering. No consistent change was observed for stuttering frequency. Gains were mostly maintained after six-months.Conclusions: Results suggest that the novel exposure approach may decrease social distress, but not necessarily influence speech fluency. These findings underscore the importance of the assessment and treatment of SAD among adults who stutter and suggest that the integration of care between clinical psychologists and speech-language pathologists may prove beneficial for this population.     

First‐line therapy for post‐traumatic stress disorder: A systematic review of cognitive behavioural therapy and psychodynamic approaches

Background

Despite evidence supporting cognitive behavioural therapy (CBT)‐based interventions as the most effective approach for treating post‐traumatic stress disorder (PTSD) in randomised control trials, alternative treatment interventions are often used in clinical practice. Psychodynamic (PDT)‐based interventions are one example of such preferred approaches, this is despite comparatively limited available evidence supporting their effectiveness for treating PTSD.

Aims

Existing research exploring effective therapeutic interventions for PTSD includes trauma‐focused CBT involving exposure techniques. The present review sought to establish the treatment efficacy of CBT and PDT approaches and considers the potential impact of selecting PDT‐based techniques over CBT‐based techniques for the treatment of PTSD.

Results

The evidence reviewed provided examples supporting PDT‐based therapy as an effective treatment for PTSD, but confirmed CBT as more effective in the treatment of this particular disorder. Comparable dropout rates were reported for both treatment approaches, suggesting that relative dropout rate should not be a pivotal factor in the selection of a PDT approach over CBT for treatment of PTSD.

Conclusion/Implications

The need to routinely observe evidence‐based recommendations for effective treatment of PTSD is highlighted and factors undermining practitioner engagement with CBT‐based interventions for the treatment of PTSD are identified.     

Cognitive behavioral therapy in practice: therapist perceptions of techniques,outcome measures,practitioner qualifications,and relation to research

Cognitive behavioral therapy (CBT) has a strong evidence base for several psychiatric disorders, however, it may be argued that currently there is no overall agreement on what counts as ‘CBT’. One reason is that CBT is commonly perceived as encompassing a broad range of treatments, from purely cognitive to purely behavioral, making it difficult to arrive at a clear definition. The purpose of the present study was to explore practicing therapists’ perceptions of CBT. Three hundred fifty members of two multi-disciplinary interest groups for CBT in Sweden participated. Mean age was 46 years, 68% were females, 63% psychologists and mean number of years of professional experience was 12 years. Participants completed a web-based survey including items covering various aspects of CBT practice. Overall, therapist perceptions of the extent to which different treatment techniques and procedures were consistent with CBT were in line with current evidence-based CBT protocols and practice guidelines, as were therapists’ application of the techniques and procedures in their own practice. A majority of participants (78%) agreed that quality of life or level of functioning were the most important outcome measures for evaluating treatment success. Eighty percent of therapists believed that training in CBT at a basic level was a requirement for practicing CBT. There was a medium size Spearman correlation of r_s=.46 between the perceived importance of research to practice and the extent to which participants kept themselves updated on research. Implications for training, quality assurance, and the effectiveness of CBT in clinical practice are discussed.