Evaluation of an Inference‐Based Approach to Treating Obsessive‐Compulsive Disorder

This study evaluated an inference‐based approach (IBA) to the treatment of obsessive‐compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. “Maybe the door is open”, “My hands could be dirty”) as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty‐four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale‐Brown Obsessive Compulsive Scale (Y‐BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y‐BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.     

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.     

Influence of Co‐Morbid Generalized Anxiety Disorder,Panic Disorder and Personality Disorders on the Outcome of Cognitive Behavioural Treatment of Obsessive‐Compulsive Disorder

This study examined co‐morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive‐compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co‐morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention‐to‐treat criteria, patients with generalized anxiety disorder and/or panic disorder co‐morbidity showed less treatment gains at post‐treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post‐treatment and the 12‐month follow‐up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co‐morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12‐month follow‐up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post‐treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

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.     

Coding Counsellor Behaviour in Motivational Interviewing Sessions: Inter‐Rater Reliability for the Swedish Motivational Interviewing Treatment Integrity Code (MITI)

The aim of this study was to evaluate inter‐rater reliability when using the Swedish version of the Motivational Interviewing Treatment Code (MITI) as an adjunct to MI training, clinical practice and research. Coders were trained to use the MITI for scoring taped sessions. The 4‐month basic training had a duration of 39 hours. Following training, 60 audio‐taped live interviews were randomly assigned for MITI coding. Mean intra‐class correlation (ICC) coefficients were calculated for 7 coders across all pairs of coders. Cronbach's alpha was calculated to estimate the covariance between each pair across their common interviews. Six months later, a second inter‐rater reliability test was performed, when 5 coders coded the same 15 randomly selected tapes. At the second reliability testing the mean ICC was 0.81 and the mean Cronbach's alpha was 0.96. However, the ICC varied for different sub‐variables of the MITI, ranging from 0.42 empathy to 0.79 for number of Closed questions. In conclusion, MITI shows promising potential to be a reliable tool to confirm and enhance MI training as well as practice in clinical settings and in evaluating MI integrity in clinical MI research. However, coder assessment of empathy and MI‐spirit, “global” variables, requires further refinement.     

Introducing Assertiveness Training in Hungary

Abstract

The preliminary results of an evaluation of a systematic assertiveness training programme (based on a cognitive-behavioural approach) in psychiatric care in Hungary are presented. The method adopted was specific to the Hungarian/Middle-European circumstances since people had difficulty in exercising their personal rights in the past. In groups of “neurotic” patients and comparison subjects three questionnaires (the Rathus-scale (R), the Assertiveness Inventory (AI) and the Uncertainty Questionnaire (UQ)) were administered at the beginning and at the end of the treatment. The training programme consisted of eight sessions with an emphasis on education about assertiveness and on the practice of skills such as saying “no” or standing up for oneself. A statistical analysis indicated significant improvement in the social skills of the participants, while an item analysis showed high internal consistency in all three questionnaires, and a concurrent validity analysis revealed a strong correlation between the Rathus-scale and the Assertiveness Inventory. The results indicate that assertiveness training can be used effectively in mental health care in Hungary.     

The effects of safety behavior availability versus utilization on inhibitory learning during exposure

ABSTRACT

This study re-analyzes data from Sy and colleagues (2011; Behaviour Research and Therapy, 49, 305–314) comparing safety behavior availability (SBA) to safety behavior utilization (SBU) during exposure therapy for claustrophobic concerns. The present investigation assessed differential rates of inhibitory learning (i.e. change in danger expectancy and coping self-efficacy) between SBA and SBU before, during, and after a single-session treatment. Thirty-nine participants with marked claustrophobic fear completed six consecutive 5-minute exposure trials in a claustrophobia chamber. Participants in the SBA condition exhibited more interference with inhibitory learning relative to the SBU condition. Danger expectancy was significantly higher in the SBA group and decreased at a markedly slower rate across exposure trials relative to SBU. Coping self-efficacy was also significantly lower among participants in the SBA condition, although groups demonstrated similar rates of change across trials. Limitations, clinical implications, and future directions are discussed.     

The Mediatory Role of Maladaptive Schema Modes Between Parental Care and Non-Suicidal Self-Injury

Non-suicidal self-injury (NSSI) is being increasingly recognised as a behaviour of significant clinical importance. Yet, there remains uncertainty regarding the underlying mechanisms of NSSI. This study aimed to explore the relationship between maladaptive schema modes, parental bonding, and NSSI. Seventy psychiatric outpatients with a history of NSSI completed the Deliberate Self-Harm Inventory, Schema Mode Inventory, and Parental Bonding Inventory. Results revealed that maladaptive schema modes were significantly associated with low parental care and with an earlier age of onset, longer duration, and higher number of methods of NSSI. Maladaptive schema modes also significantly mediated the relationship between parental care and age of onset of NSSI and between parental care and duration of NSSI. Two maladaptive schema modes (namely, Punitive Parent and Angry Child) were also found to be significant mediators in this relationship. The clinical implications of this research are discussed.     

Combining Pharmacotherapy with Cognitive‐Behavioral Interventions for Obsessive‐Compulsive Disorder

This paper reviews the evidence‐based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive‐compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin re‐uptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision‐making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.     

A Contemporary View of Applied Relaxation for Generalized Anxiety Disorder

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.