Evidence-based Practice in Cognitive-Behaviour Therapy

book review

A qualitative study exploring the perceived impact of supervision training on cognitive therapy supervisor practice

Although cognitive therapy (CT) has a large empirical base, research is lacking for CT supervision and supervision training, which presents an obstacle for evidence-based practice. A pilot CT supervision training programme, based on Milne’s (2007a, 2009) evidence-based supervision and Roth and Pilling (2008) supervision competences was developed by the Northern Ireland Centre for Trauma and Transformation (NICTT), an organisation specialising in CT therapy provision and training. This study qualitatively explores CT supervisors’ perceptions of the impact the training had on their practice. Semi-structured interviews were conducted with seven participants, transcribed verbatim and analysed using Burnard’s (1991) thematic content analysis.

Findings illustrated that experienced CT supervisors perceived benefit from training and that the majority of supervisors had implemented contracts, used specific supervision models and paid more attention to supervisee learning as a result of the training. Obstacles to ensuring good supervision included the lack of reliable user-friendly evaluation tools and supervisor consultancy structures.

Recommendations are also made for future research to establish the long-term effects of supervision training and its effect on patient outcomes. Implications for future training based on adult learning principles are discussed.

Habit reversal training as a treatment for refractory OCD - A case study

Nearly 4 million American men and women from all geographic, ethnic, or economic backgrounds are diagnosed with obsessive-compulsive disorder (OCD). While a combination of cognitive behaviour therapy (CBT) and psycho-pharmaca seems successful for 50% to 60% of patients, for intractable cases the typical recommendation is more medication or more CBT, however there is little evidence that the intensified treatment regimen is successful. In this paper, habit reversal training, including awareness training, competing/other response training, self-monitoring, social support, and generalisation, was implemented with a long-term treatment-refractory OCD patient. Treatment gains and long-term maintenance indicate the potential of habit reversal procedures with these patients.

Behavioural and cognitive behavioural training interventions for assisting foster carers in the management of difficult behaviour.

Background The provision of training for foster carers is now seen as an important factor contributing to the successful outcome of foster care placements. Since the late 1960s, foster carer training programs have proliferated, and few of the many published and unpublished training curricula have been systematically evaluated. The advent of cognitive-behavioural therapy (CBT) and the research evidence demonstrating its effectiveness as a psychotherapeutic treatment of choice for a range of emotional and behavioural problems, has prompted the development of CBT-based training programmes. CBT approaches to foster care training derive from a ’skill-based’ training format that also seeks to identify and correct problematic thinking patterns that are associated with dysfunctional behaviour by changing and/or challenging maladaptive thoughts and beliefs. Objectives To assess the effectiveness of cognitive-behavioural training interventions in improving a) looked-after children’s behavioural/relationship problems, b) foster carers’ psychological well-being and functioning, c) foster family functioning, d) foster agency outcomes. Search methods We searched databases including: CENTRAL (Cochrane Library Issue 3, 2006), MEDLINE (January 1966 to September 2006), EMBASE (January 1980 to September 2006), CINAHL (January 1982 to September 2006), PsycINFO (January 1872 to September 2006), ASSIA (January 1987 to September 2006), LILACS (up to September 2006), ERIC (January 1965 to September 2006), Sociological Abstracts (January 1963 to September 2006), and the National Research Register 2006 (Issue 3).We contacted experts in the field concerning current research. Selection criteria Random or quasi randomised studies comparing behavioural or cognitive-behavioural-base Data collection and analysis Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Main results Six trials involving 463 foster carers were included. Behavioural and cognitive-behavioural training interventions evaluated to date appear to have very little effect on outcomes relating to looked-after children, assessed in relation to psychological functioning, extent of behavioural problems and interpersonal functioning. Results relating to foster carer(s) outcomes also show no evidence of effectiveness in measures of behavioural management skills, attitudes and psychological functioning. Analysis pertaining to fostering agency outcomes did not show any significant results. However, caution is needed in interpreting these findings as their confidence intervals are wide. Authors’ conclusions There is currently little evidence about the efficacy of behavioural or cognitive-behavioural training intervention for foster carers. The need for further research in this area is highlighted.

Encouraging lifestyle behaviour change in mild cognitive impairment patients:development of appropriate educational material

Objectives: A healthy lifestyle may help maintain cognitive function and reduce the risk of developing dementia. This study employed a focus group approach in order to gain insight into opinions of mild cognitive impairment (MCI) patients, caregivers (CG) and health professionals (HP) regarding lifestyle and its relationship with cognition. The qualitative data were used to design, develop and pilot test educational material (EM) to help encourage lifestyle behaviour change. Method: Data gathering phase: structured interviews were conducted with HP (n = 10), and focus groups with MCI patients (n = 24) and CG (n = 12). EM was developed and pilot tested with a new group of MCI patients (n = 21) and CG (n = 6). Results: HP alluded to the lack of clinical trial evidence for a lifestyle and MCI risk link. Although they felt that lifestyle modifications should be recommended to MCI patients, they appeared hesitant in communicating this information and discussions were often patient-driven. MCI patients lacked awareness of the lifestyle cognition link. Participants preferred EM to be concise, eye-catching and in written format, with personal delivery of information favoured. Most pilot testers approved of the EM but were heterogeneous in terms of lifestyle, willingness to change and support needed to change. Conclusion: MCI patients need to be made more aware of the importance of lifestyle for cognition. EM such as those developed here, which are specifically tailored for this population would be valuable for HP who, currently, appear reticent in initiating lifestyle-related discussions. Following further evaluation, the EM could be used in health promotion activities targeting MCI patients.

The relationship between specific cognitive impairment and behaviour in Prader-Willi syndrome

Background

Individuals with Prader-Willi syndrome (PWS) have been shown to demonstrate a particular cognitive deficit in attention switching and high levels of preference for routine and temper outbursts. This study assesses whether a specific pathway between a cognitive deficit and behaviour via environmental interaction can exist in individuals with PWS.

Methods

Four individuals with PWS participated in a series of three single-case experiments including laboratory-based and natural environment designs. Cognitive (computer-based) challenges placed varying demands on attention switching or controlled for the cognitive demands of the tasks while placing no demands on switching. Unexpected changes to routines or expectations were presented in controlled games, or imposed on participants' natural environments and compared with control conditions during which no unexpected changes occurred. Behaviour was observed and heart rate was measured.

Results

Participants showed significantly increased temper outburst related behaviours during cognitive challenges that placed demands on attention switching, relative to the control cognitive challenges. Participants showed significantly increased temper outburst related behaviours when unexpected changes occurred in an experimental or the natural environment compared with when no changes occurred.

Conclusions

Difficult behaviours that could be triggered reliably in an individual by a specific cognitive demand could also be triggered via manipulation of the environment. Results suggest that a directional relationship between a specific cognitive deficit and behaviour, via environmental interaction, can exist in individuals with PWS.

A specific pathway can be identified between genetic characteristics and behaviour profiles in Prader-Willi syndrome via cognitive, environmental and physiological mechanisms

Behavioural phenotypes associated with genetic syndromes have been extensively investigated in order to generate rich descriptions of phenomenology, determine the degree of specificity of behaviours for a particular syndrome, and examine potential interactions between genetic predispositions for behaviour and environmental influences. However, relationships between different aspects of behavioural phenotypes have been less frequently researched and although recent interest in potential cognitive phenotypes or endophenotypes has increased, these are frequently studied independently of the behavioural phenotypes.

Taking Prader-Willi syndrome (PWS) as an example, we discuss evidence suggesting specific relationships between apparently distinct aspects of the PWS behavioural phenotype and relate these to specific endophenotypic characteristics.

The framework we describe progresses through biological, cognitive, physiological and behavioural levels to develop a pathway from genetic characteristics to behaviour with scope for interaction with the environment at any stage.

We propose this multilevel approach as useful in setting out hypotheses in order to structure research that can more rapidly advance theory.

Agility and search and rescue training differently affects pet dogs' behaviour in socio-cognitive tasks

Both genetic factors and life experiences appear to be important in shaping dogs' responses in a test situation. One potentially highly relevant life experience may be the dog's training history, however few studies have investigated this aspect so far. This paper briefly reviews studies focusing on the effects of training on dogs' performance in cognitive tasks, and presents new, preliminary evidence on trained and untrained pet dogs' performance in an 'unsolvable task'. Thirty-nine adult dogs: 13 trained for search and rescue activities (S&R group), 13 for agility competition (Agility group) and 13 untrained pets (Pet group) were tested. Three 'solvable' trials in which dogs could obtain the food by manipulating a plastic container were followed by an 'unsolvable' trial in which obtaining the food became impossible. The dogs' behaviours towards the apparatus and the people present (owner and researcher) were analysed. Both in the first 'solvable' and in the 'unsolvable' trial the groups were comparable on actions towards the apparatus, however differences emerged in their human-directed gazing behaviour. In fact, results in the 'solvable' trial, showed fewer S&R dogs looking back at a person compared to agility dogs, and the latter alternating their gaze between person and apparatus more frequently than pet dogs. In the unsolvable trial no difference between groups emerged in the latency to look at the person however agility dogs looked longer at the owner than both pet and S&R dogs; whereas S&R dogs exhibited significantly more barking (always occurring concurrently to looking at the person or the apparatus) than both other groups. Furthermore, S&R dogs alternated their gaze between person and apparatus more than untrained pet dogs, with agility dogs falling in between these two groups. Thus overall, it seems that the dogs' human-directed communicative behaviours are significantly influenced by their individual training experiences. © 2009 Elsevier B.V. All rights reserved.

Apolipoprotein E e4 allele influences aggressive behaviour in Alzheimer's disease

The rising number of people with cognitive impairment is placing health care budgets under significant strain. Dementia related behavioural change is a major independent risk factor for admission to expensive institutional care, and aggressive symptoms in particular are poorly tolerated by carers and frequently precipitate the collapse of home coping strategies. Aggressive change may result from known genetic risk factors for Alzheimer's disease (AD) and therefore accompany conventional markers such as apolipoprotein E (ApoE). We tested this hypothesis in 400 moderately to severely affected AD patients who were phenotyped for the presence of aggressive or agitated behaviour during the month prior to interview using the Neuropsychiatric Inventory with Caregiver Distress. The proportion of subjects with aggression/agitation in the month prior to interview was 51.8%. A significantly higher frequency of the e4 allele was found in individuals recording aggression/agitation in the month prior to interview (chi2 = 6.69, df = 2, p = 0.03). The additional risk for aggression/agitation conferred by e4 was also noted when e4 genotypes were compared against non-e4 genotypes (chi2 = 5.45, df = 1, p = 0.02, OR = 1.60, confidence interval (CI) 1.06 to 2.43). These results indicate that advanced Alzheimer's disease patients are at greater risk of aggressive symptoms because of a genetic weakness in apolipoprotein E.

Cognitive inhibition and interference in dissociative indentity disorder: the effects of anxiety on specific executive functions:The effects of anxiety on specific executive functions

Using an experimentally based, computer-presented task, this study assessed cognitive inhibition and interference in individuals from the dissociative identity disorder (DID; n=12), generalized anxiety disorder (GAD; n=12) and non-clinical (n=12) populations. Participants were assessed in a neutral and emotionally negative (anxiety provoking) context, manipulated by experimental instructions and word stimuli. The DID sample displayed effective cognitive inhibition in the neutral but not the anxious context. The GAD sample displayed the opposite findings. However, the interaction between group and context failed to reach significance. There was no indication of an attentional bias to non-schema specific negative words in any sample. Results are discussed in terms of the potential benefit of weakened cognitive inhibition during anxious arousal in dissociative individuals.

Comparison of elicitation methods for moral and affective beliefs in the theory of planned behaviour

Although the theory of planned behaviour (TPB) has been applied successfully in the area of food choice, it has been criticized for its pure utilitarian approach to the factors determining behaviour. Despite the increase in predictive power of the model with added components such as affective attitude and moral and ethical concerns, in most studies the elicitation process still only addresses people's utilitarian beliefs about the behaviour with little attention paid to other aspects. This study compares the traditional method of elicitation of advantages and disadvantages with two other methods (word association and open-ended) in the elicitations of beliefs, attitudes and moral concerns in relation to the consumption of organic foods. Results show the traditional method to be best for eliciting cognitive beliefs, open-ended emotion task for eliciting emotional beliefs and open-ended beliefs task best for moral concerns. The advantages and disadvantages of each method are discussed.

Prospective information for pass decisional behaviour in Rugby Union

Decision-making requires the perception of relevant information variables that emerge from the player–environment interaction. The purpose of the present article is to empirically assess whether players’ decisional behavior about which type of pass to make is influenced by the spatio-temporal variable tau. Time series positional data of rugby players were analyzed from video footage taken in real match scenarios. The tau of the distance motion gap between attacker and defender was calculated, along with the duration of the next pass. Results revealed that the initial tau value predicted 64% of the variance found in pass duration. A qualitative distinction of tau dynamics between two periods of the approach between the attacker and the defender was also observed. We argue that the time-to-contact between the attacker and the defender may yield information about future pass possibilities. Additionally, the informational fields constraining attacker–defender interaction may be viewed as a convergent channeling of possibilities towards a single pass solution.