Effectiveness of Cognitive Behavioral Therapy for Anxiety and Depression Among Orthodox Jews

Several clinical papers have provided clinical recommendations for how to provide cognitive behavioral therapy (CBT) for obsessive-compulsive symptoms among Orthodox Jewish individuals. However, no published studies have described culturally adapted CBT for anxiety or depression in this population or quantified the effectiveness of such approaches. We evaluated the effectiveness of CBT for symptoms of generalized anxiety and depression in a sample of Orthodox Jews (n = 65) and a comparison sample (n = 42) presenting to the Center for Anxiety, a private outpatient clinic with three offices in the New York area (www.centerforanxiety.org). A chart review revealed that all patients received CBT-based interventions with appropriate religious-cultural adaptations of treatment, which we present in two case studies. We observed statistically and clinically significant treatment gains from pretreatment to midtreatment (anxiety: t = 8.56, p < .001; depression: t = 8.01, p < .001), and again from midtreatment through termination (anxiety: t = 3.68, p < .001; depression: t = 3.62, p < .001). No significant differences in anxiety or depression were observed between Orthodox Jewish patients and controls at any time point or for treatment effects (anxiety: Wilks’ Lambda = .950, F = 2.65, p = .076, η_p² = .050; depression: Wilks’ Lambda = .99, F = 2.00,p = .49, η_p² = .014). This paper offers clinical insight into delivery of CBT to Orthodox Jewish patients, as well as preliminary support for the effectiveness of CBT in treating symptoms of generalized anxiety and depression within this population.     

A Propensity Score Analysis of Homework Adherence-Outcome Relations in Cognitive Behavioral Therapy for Depression

Little is known about whether or not a consistently high level of homework adherence over the course of therapy benefits patients. This question was examined in two samples of patients who were receiving individual Cognitive Behavioral Therapy (CBT) for depression (Ns = 128 [Sequenced Treatment Alternatives to Relieve Depression: STAR-D] and 183 [Continuation Phase Cognitive Therapy Relapse Prevention: C-CT-RP]). Logistic and linear regression and propensity score models were used to identify whether or not clinician assessments of homework adherence differentiated symptom reduction and remission, as assessed by the Hamilton Depression Rating Scale-17 (HDRS-17), the Quick Inventory of Depressive Symptomatology–Self-Reported Scale (QIDS-SR), and the QIDS–Clinician Scale (QIDS-C). CBT-related response and remission were equally likely between both high and low homework adherers in both studies and in all models. But in propensity adjusted models that adjusted for session attendance, for both the STAR-D and C-CT-RP samples, greater homework adherence was significantly associated with greater response and remission from depression in the first and last 8 sessions of CBT. Our results suggest that homework adherence can account for response and remission early and late in treatment, with adequate session attendence.     

Cognitive Behavioral Therapy for Insomnia in Older Adults

Insomnia is associated with significant morbidity and is often a persistent problem, particularly in older adults. It is important to attend to this complaint and not assume that it will remit spontaneously. In many cases, unfortunately, insomnia remains unrecognized and untreated, often because it is presumed that insomnia is an inevitable consequence of aging. Although the sleep structure naturally changes with advancing age, these changes are not necessarily associated with complaints of poor sleep, distress, or daytime consequences, while chronic insomnia clearly is. There is increasing evidence that cognitive behavioral therapy (CBT) is effective for the management of chronic insomnia in the elderly and that it is of significant benefit for insomnia comorbid with medical and psychological conditions, also more prevalent in older age. The aim of this article is to familiarize clinicians working with older adults with the different components of CBT for insomnia and how to adapt the treatment to this population. A clinical case and session-by-session implementation of CBT for insomnia are described to illustrate information and guidelines provided in this article.     

认知行为疗法在儿童焦虑症治疗中的应用

焦虑症是一种最常见的儿童疾病.病理焦虑通常被定义为与年龄不适当的焦虑,导致功能障碍和严重痛苦.目前大量调查儿童焦虑的CBT治疗效果的研究显示,针对各种患有不同焦虑障碍的儿童CBT是有效的.典型的认知行为治疗包括四个主要方面:心理教育,应对技能,暴露和应急管理.Coping Cat治疗方案是在随机对照试验中针对儿童焦虑最常被实施的CBT治疗方案.目前认知行为疗法在治疗儿童焦虑症中也存在着局限,今后需要进行更深入的研究.     

Treating Young Adult Depression With Text-Delivered Cognitive Behavioral Therapy: A Pilot Randomized Clinical Trial

Young adults (ages 18 to 25) in the U.S. suffer from the highest rates of past-year major depressive episode and are the least likely to receive treatment compared to other age groups. As such, we examined the feasibility, acceptability, and efficacy of a text-message delivered cognitive behavioral therapy: CBT-txt with young adults. The study was a 2-month pilot RCT to test a 4-week intervention for depression that contained 197 text messages (average 12 texts every other day). The sample, recruited via Facebook and Instagram, was 102 U.S. young adults who presented with at least moderate depressive symptomatology. Assessments occurred at baseline prior to randomization and at 1 and 2 months post enrollment. The primary outcome, severity of depressive symptoms, was assessed using the Beck Depression Inventory II. Feasibility benchmarks were met and participants reported high levels of engagement with and acceptability of the intervention. Logistic regression indicated that treatment participants were three times as likely to have minimal or mild depression symptoms at 2 months compared to waitlist control participants. Latent change score modeling found that the strongest significant treatment effect appeared at the 1-month follow-up period, particularly for participants who began with severe depressive symptoms. Mediation analysis revealed significant indirect treatment effects of increases in behavioral activation on reducing depressive symptoms, suggesting a mechanism of change. Limitations were that the sample was relatively small and consisted of primarily women. These results provide initial evidence for the feasibility, acceptability, and efficacy of a text-delivered treatment for young adult depression.     

Tailoring Cognitive Behavioral Therapy for Individuals Diagnosed with Bulimia Nervosa

There is a wealth of data indicating the effectiveness of cognitive behavioral therapy in the treatment of bulimia nervosa. However, the best evidence indicates a treatment success rate of 50%. The purpose of this paper is to briefly describe cognitive behavioral treatment of bulimia nervosa and to offer suggestions on how this therapy approach may be tailored to best serve the needs of individual clients. Such tailoring should ultimately lead to even greater treatment success.     

Emotion Regulation Strategies in Cognitive Behavioral Therapy for Panic Disorder

Emotion regulation (ER) has been incorporated into many models of psychopathology, but it has not been examined directly in cognitive behavioral therapy (CBT) for panic disorder with agoraphobia (PD/A). In this study, a preliminary model of ER in CBT for PD/A is proposed based on existing theories, and several propositions of the model are tested. We hypothesized that increases in cognitive reappraisal would precede decreases in biased cognitions, decreases in expressive suppression would follow decreases in biased cognitions, and a reduction in symptom severity would follow decreases in expressive suppression. Twenty-nine patients who received CBT for PD/A completed weekly self-report measures of symptom severity, anxiety sensitivity, reappraisal and expressive suppression. In addition, patients were compared to a matched normal sample. Cross-lagged analyses partially supported the hypotheses. Reappraisal did not change until late stages of therapy and was generally not associated with treatment outcome. Suppression decreased significantly and exhibited a reciprocal relationship with biased cognitions. Symptom reduction followed decreases in suppression as hypothesized. However, patients did not differ in ER from matched controls at either pre- or posttreatment. Results suggest the important distinction between reappraisal and appraisal, and stress the role of session-by-session decreases in suppression as a predictor of symptom reduction.     

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.     

Implementing Cognitive Behavioral Therapy in Specialty Medical Settings

This article is an introduction to the second issue of a two-part special series on integrating cognitive behavioral therapy (CBT) into medical settings. The first issue focused on integrating CBT into primary care, and this issue focuses on implementing CBT in other specialty medical settings, including cancer treatment, HIV care, and specialized pediatric medical clinics. Models for treatment delivery to improve ease of implementation are also discussed, including telehealth and home-delivered treatment. The six articles in this series provide examples of how to transport CBT techniques that are largely designed for implementation in outpatient mental health settings to specialized medical settings, and discuss unique considerations and recommendations for implementation.     

Integrating Cognitive Behavioral Therapy Into Primary Care Settings

This article serves as an introduction to the first issue of the Cognitive and Behavioral Practice special series on cognitive-behavioral practice in medical settings. This first issue of our two-part series focuses on strategies and recommendations for integrating cognitive behavioral therapy (CBT) into primary care settings and the unique challenges primary care in particular presents. Our subsequent issue will focus on the implementation of CBT in other, more specialized forms of medical care, including cancer treatment and HIV care.     

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。     

Cognitive, Affective and Behavioral Correlates of Internalization of Regulations for Religious Activities

The main goal of this study was to examine the relationship between different types of extrinsic motivation for religious behaviors as conceptualised within self-determination theory (Ryan & Deci, 2000) and Wulff's (1991) framework of literal versus symbolic approaches of religious contents. Results from a Belgian sample of active believers (N=186) show that the internalization of one's reasons for performing religious behaviors was positively associated with an open, symbolic interpretation of religious belief contents and a stronger adherence to Christian beliefs. Moreover, internalization was also positively related to general well-being and frequency of prayer but unrelated to church attendance. It is concluded that individuals who engage in religious behaviors because of its perceived personal significance will show more cognitive flexibility and open-mindedness towards Christian belief contents, a stronger adherence to this message, higher well-being and more frequent engagement in specific religious behaviors.

The Effects of Cognitive Behavioral Therapy for Insomnia on Multidimensional Perfectionism

Perfectionism is related to insomnia and objective markers of disturbed sleep. This study examined whether multidimensional perfectionism is related to dysfunctional beliefs about sleep, sleep-effort, pre-sleep arousal, and polysomnography-determined markers of sleep among individuals with insomnia. The effects of cognitive behavioral therapy for insomnia (CBT-I) on perfectionism was also examined. This was a secondary analysis of a randomized controlled trial on CBT-I. Forty-three insomnia patients were randomized to treatment (receiving CBT-I) or waitlist control groups. Sleep was recorded using polysomnography at baseline. Participants completed measures of perfectionism, dysfunctional beliefs about sleep, sleep-effort and pre-sleep arousal at baseline and posttreatment. Total perfectionism scores and doubts about action, concern over mistakes and personal standards were each significantly related to increased sleep effort, pre-sleep arousal and dysfunctional beliefs about sleep at baseline. Patients receiving treatment displayed increased total perfectionism scores posttreatment d = .49. In those receiving treatment, levels of organization d = .49 and parental expectations d = .47 were significantly increased posttreatment, relative to baseline. In line with the literature, our results confirm that perfectionism is related to insomnia. Here, insomnia was related to increased sleep effort, pre-sleep arousal and dysfunctional beliefs about sleep. The propensity to maintain a high standard of order and organization may be elevated following CBT-I, considering the treatment protocol expects patients to strictly adhere to a set of clearly defined rules. Levels of parental expectations may be increased following CBT-I since the patient-therapist-relationship may trigger implicit expectations in patients which are reminiscent of their relationship to their parents.     

Ambivalence and Alliance Ruptures in Cognitive Behavioral Therapy for Generalized Anxiety

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.     

A Case Study Illustrating Therapist-Assisted Internet Cognitive Behavior Therapy for Depression

Randomized controlled trials show that therapist-assisted Internet cognitive behavior therapy (ICBT) is efficacious in the treatment of depression. Given that this is a novel way of delivering cognitive behavior therapy, however, clinical service providers may have questions about how to provide therapist-assisted ICBT in clinical practice, particularly with respect to therapist assistance. To exemplify this approach, we present a case study of an older adult male who received 12 modules of therapist-assisted ICBT for depression over the course of 5 months. Highlights of the therapeutic exchanges that occurred over email are provided to illustrate the type of information clients may share with therapists and the nature of therapist assistance. Treatment progress was assessed via self-report questionnaires measuring depression, anxiety, and adjustment. Consistent with the research evidence, significant improvement was observed on all symptom measures at posttreatment. Satisfaction with the therapist-assisted ICBT program and a strong therapeutic alliance was also reported. The case will expand clinician understanding of therapist-assisted ICBT and may serve to stimulate clinician interest in the provision of therapist-assisted ICBT. Future research directions stemming from this case are presented.     

Treatment of Maternal Depression With In-Home Cognitive Behavioral Therapy Augmented by a Parenting Enhancement: A Case Report

Depression is prevalent among mothers who participate in home visitation programs. This case study describes In-Home Cognitive Behavioral Therapy (IH-CBT), an empirically based treatment for depressed mothers that is strongly integrated with ongoing home visitation. The use of a Parenting Enhancement for Maternal Depression (PEMD) module was added to address parenting difficulties in a depressed mother. This case describes issues and challenges encountered in delivering treatment in the home with low-income, depressed mothers. Issues involving engagement, adaptation to the setting, responding to the unique needs of low-income mothers, and partnership with concurrent home visiting to optimize outcomes are considered. Long-term follow-up (18 months after the end of treatment) permits examination of sustainability of gains. Implications for treating this high-risk population are discussed.     

Metaphors and Stories in Cognitive Behavioral Therapy with Children

Despite the recent proliferation of material on cognitive behavioral approaches with children and adolescents and the call for these approaches to be more child-friendly, there is scant attention paid to the use of metaphors with youngsters. This paper emphasizes the value metaphors add to cognitive behavioral therapy with children and adolescents. The advantages which recommend metaphor use for cognitive behavioral therapy with children are delineated. Further, seven guidelines for clinical practice are outlined. Examples of both clinician-generated and patient-generated metaphors are also presented.