Managing the therapeutic relationship in online cognitive behavioural therapy for depression: Therapists' treatment of clients' contributions

This article examines how therapists and clients manage the therapeutic relationship in online psychotherapy. Our study focuses on early sessions of therapy involving 22 therapist-client pairs participating in online Cognitive Behavioural Therapy (CBT) for depression. Using Conversation Analysis (CA), we examine how therapists can orient to clients’ contributions, while also retaining control of the therapeutic trajectory. We report two practices that therapists can use, at their discretion, following clients’ responses to requests for information. The first, thanking, accepts clients’ responses, orienting to the neutral affective valence of those responses. The second, commiseration, orients to the negative affective valence of clients’ responses. We argue that both practices are a means by which therapists can simultaneously manage developing rapport, while also retaining control of the therapeutic process.

Implementing cognitive remediation therapy : lessons from two public mental health services

Objective: Neurocognitive deficits are a core symptom domain of schizophrenia, occurring in 75 -90 % of people with this diagnosis and influencing long term functional outcomes. This article aims to describe the pilot implementation of cognitive remediation therapy (CRT) in two large public mental health services and detail changes made to the delivery of this therapy after this trial. Conclusions: CRT provides an evidence based approach to targeting cognitive deficits but the translation of this therapy from a research setting to clinical practice has not been well evaluated.

Impact of cognitive behaviour therapy via mail for cessation of benzodiazepine use : a series of case reports

Benzodiazepines are widely prescribed to manage sleep disorders, anxiety and muscular tension. While providing short-term relief, continued use induces tolerance and withdrawal, and in older users, increases the risk of falls. However, long-term prescription remains common, and effective interventions are not widely available. This study developed a self-managed cognitive behaviour therapy package for cessation of benzodiazepine use delivered to participants via mail (M-CBT) and trialled its effectiveness as an adjunct to a general practitioner (GP)-managed dose reduction schedule. In the pilot trial, participants were randomly assigned to GP management with immediate or delayed M-CBT. Significant recruitment and engagement problems were experienced, and only three participants were allocated to each condition. After immediate M-CBT, two participants ceased use, while none receiving delayed treatment reduced daily intake by more than 50%. Across the sample, doses at 12 months remained significantly lower than baseline, and qualitative feedback from participants was positive. While M-CBT may have promise, improved engagement of GPs and participants is needed for this approach to substantially impact on community-wide benzodiazepine use.

Relationship between expectation management and client retention in online Cognitive Behavioural Therapy

Background Engaging clients from the outset of psychotherapy is important for therapeutic success. However, there is little research evaluating therapists’ initial attempts to engage clients. This article reports retrospective analysis of data from a trial of online Cognitive Behavioural Therapy (CBT) for depression. Qualitative and quantitative methods were used to evaluate how therapists manage clients’ expectations at the outset of therapy and its relationship with client retention in the therapeutic intervention. Aims To develop a system to codify expectation management in initial sessions of online CBT and evaluate its relationship with retention. Method Initial qualitative research using conversation analysis identified three different communication practices used by therapists at the start of first sessions: no expectation management, some expectation management, and comprehensive expectation management. These findings were developed into a coding scheme that enabled substantial inter-rater agreement (weighted Kappa = 0.78; 95% CI: 0.52 to 0.94) and was applied to all trial data. Results Adjusting for a range of client variables, primary analysis of data from 147 clients found comprehensive expectation management was associated with clients remaining in therapy for 1.4 sessions longer than those who received no expectation management (95% CI: -0.2 to 3.0). This finding was supported by a sensitivity analysis including an additional 21 clients (1.6 sessions, 95% CI: 0.2 to 3.1). Conclusions Using a combination of qualitative and quantitative methods, this study suggests a relationship between expectation management and client retention in online CBT for depression, which has implications for professional practice. A larger prospective study would enable a more precise estimate of retention.

Managing clients’ expectations at the outset of online Cognitive Behavioural Therapy (CBT) for depression

Background Engaging clients in psychotherapy by managing their expectations is important for therapeutic success. Initial moments in first sessions of therapy are thought to afford an opportunity to establish a shared understanding of how therapy will proceed. However there is little evidence from analysis of actual sessions of therapy to support this. Objective This study utilised recordings to examine how therapists manage clients’ expectations during the first two sessions of online Cognitive Behavioural Therapy (CBT). Methods Expectation management was investigated through conversation analysis of sessions from 176 client-therapist dyads involved in online CBT. The primary focus of analysis was expectation management during the initial moments of first sessions, with a secondary focus on expectations at subsequent points. Analysis Clients’ expectations for therapy were most commonly managed during the initial moments of first sessions of therapy. At this point, most therapists either outlined the tasks of the first and subsequent sessions (n=36), or the first session only (n=108). On other occasions (n = 32), no attempt was made to manage clients’ expectations by outlining what would happen in therapy. Observations of the interactional consequences of such an absence suggest clients may struggle to engage with the therapeutic process in the absence of appropriate expectation management by therapists. Conclusion Clients may more readily engage from the outset of therapy when provided with an explanation that manages their expectation of what is involved. Therapists can accomplish this by projecting how therapy will proceed, particularly beyond the initial session.

The effectiveness of psychosocial interventions for cognitive dysfunction in cancer patients who have received chemotherapy : a systematic review

Background: Chemotherapy-related cognitive dysfunction (CRCD) refers to problems with memory,attention span, or concentration, experienced by patients with cancer who have had chemotherapy. CRCD can have a significant negative effect on a patient’s quality of life. The exact cause of CRCD is unknown but is presumed to be multifactorial. Objective: To conduct a systematic review of the effectiveness of psychosocial interventions designed to treat CRCD. Methods: Participants of interest to the review were over 18 years of age, diagnosed with cancer, and receiving chemotherapy or had received chemotherapy in the past. Interventions of interest were methods to improve cognitive function. Included study designs were randomized controlled trials, quasi-experimental trials, and quantitative observational studies. The primary outcome of interest was level of cognitive function. A three-step search strategy was utilized to identify studies published from 1985 to 2011 from a wide range of databases. Joanna Briggs Institute systematic review methods were used but findings were analyzed using the Cochrane Collaboration Review Manager 5.1 program.Weightedmean differences with 95% confidence intervals were calculated from the continuous data. Results: Searching identified 3,109 potentially relevant articles and 120 full-text articles were retrieved. Two further papers were sourced from reference lists of retrieved articles. From 122 papers, six were suitable for critical appraisal and six were included in the analysis. Meta-analysis was conducted on two cognitive behavioral therapy (CBT) trials for the outcome of inability to concentrate. Significant effect was seen for one CBT intervention at 20 weeks (p = .004). Significant effect from CBT on quality of life was seen at 6-month follow-up (p < .05). Conclusions: Despite some evidence of an effect, there is insufficient evidence at this stage to strongly recommend any of the interventions to assist in decreasing the effects of CRCD, except in terms of improving quality of life.

Is group more cost effective than individual cognitive behaviour therapy? The evidence is not solid yet

This paper critically evaluates the empirical evidence of 36 studies regarding the comparative cost-effectiveness of group and individual cognitive behaviour therapy (CBT) as a whole, and also for specific mental disorders (e.g. depression, anxiety, substance abuse) or populations (e.g. children). Methods of calculating costs, as well as methods of comparing treatment outcomes were appraised and criticized. Overall, the evidence that group CBT is more cost-effective than individual CBT is mixed, with group CBT appearing to be more cost effective in treating depression and children, but less cost effective in treating drugs and alcohol dependence, anxiety and social phobias. In addition, methodological weaknesses in the studies assessed are noted. There is a need to improve cost calculation methodology, as well as more solid and a greater number of empirical cost-effectiveness studies before a firm conclusion can be reached that group CBT is more cost effective then individual CBT.

Orienting to emotion in computer-mediated Cognitive Behavioural Therapy

Exploring emotions is a defining feature of psychotherapy. This study explores how therapists explore emotions when they cannot see or hear their clients. In analysing 1,279 sessions of online text-based Cognitive Behavioural Therapy (CBT) we focused on therapists’ commiserations (e.g., “I’m sorry to hear that”) and their affective inferences (e.g., “that sounds very scary for you”). Both practices routinely prefaced moves to pursue a range of therapeutic activities, many of which did not prioritise sustained focus on the emotion that had just been oriented to. By separating message composition from message transmission, the modality used for these therapy sessions enabled therapists to combine orientations to emotion with attempts to shift the focus of discussion. Our analysis finds that although physically co-present and computer-mediated psychotherapy share a common focus on emotional experience, the modality used for therapy can be relevant in the design and use of these orientations. Data are in British English.

Evidence-based Practice in Cognitive-Behaviour Therapy

book review

Group Trauma-Focused Cognitive-Behavioural Therapy with Former Child Soldiers and other War-affected Boys in the DR Congo: A Randomised Controlled Trial.

Background: The Democratic Republic of Congo (DRC) has been home to the world’s deadliest con?ict since World War II and is reported to have the largest number of child soldiers in the world. Despite evidence of the debilitating impact of war, no group-based mental health or psychosocial intervention has been evaluated in a randomised controlled trial for psychologically distressed former child soldiers.

Method: A randomised controlled trial involving 50 boys, aged 13–17, including former child soldiers (n = 39) and other war-affected boys (n = 11). They were randomly assigned to an intervention group, or wait-list control group. The intervention group received a 15-session, group-based, culturally adapted Trauma-Focused Cognitive–Behavioural Therapy (TF-CBT) intervention. Assessment interviews were completed at baseline, postintervention and 3-month follow-up (intervention group).

Results: Analysis of Covariance (ANCOVA) demonstrated that, in comparison to the wait-list control group, the TF-CBT intervention group had highly signi?cant reductions in posttraumatic stress symptoms, overall psychosocial distress, depression or anxiety-like symptoms, conduct problems and a signi?cant increase in prosocial behaviour (p < .001 for all). Effect sizes were higher when former child soldier scores were separated for sub-analysis. Three-month follow-up of the intervention group found that treatment gains were maintained.

Conclusions: A culturally modi?ed, group-based TF-CBT intervention was effective in reducing posttraumatic stress and psychosocial distress in former child soldiers and other war-affected boys.

Responding to mental health statutory drivers: experience of a low intensity cognitive behavioural therapy programme

Objectives Stress control (SC), a brief psycho-education course, was implemented to increase access to psychological therapies in line with Northern Irish mental health service statutory drivers. The first aim of this study was to gauge the efficacy of SC in a robust manner with clinical significance testing. The second aim was to assess whether demographics traditionally ‘hard-to-reach’ – males, younger adults and those from deprived areas – accessed SC. The third aim was to elucidate what prompted their access and the experiences of attendees at SC. Methods Attendees at SC were 170 adults over six iterations of the course. Pre- and post-questionnaires included the Depression Anxiety Stress Scales – 21, captured demographic details and qualitative feedback, which was subject to a mixed-methods analysis. Results SC attendees reported significant decreases on depression, anxiety and stress sub-scales post-intervention. Moreover, 38.71% ( n =36) of attendees who completed SC exhibited clinically significant improvement afterwards on one or more sub-scale. Attendance figures for males, younger adults and those classified as socioeconomically deprived were modest. Patterns within the data suggested prospective success for targeting these cohorts. Conclusions SC attracted people in need of mental healthcare input and affected quantifiable change within those people’s lives, while satisfying statutory demands for service delivery in an accessible community context. Recommendations to increase engagement with those traditionally ‘hard-to-reach’ for psychological services are provided, which, if implemented, have the potential to achieve further compliance with Northern Irish mental health statutory drivers.

Case-series Evaluating a Transdiagnostic Cognitive-behavioral Treatment For Co-occurring Anxiety Disorders.

Background. Patients with anxiety disorder diagnoses commonly have more than one anxiety diagnosis. While cognitive-behavioral interventions have proven efficacy in treating single anxiety disorder diagnoses, there has been little investigation of their efficacy in treating cooccurring anxiety disorders. Aims. To evaluate the efficacy of a transdiagnostic cognitive-behavioral intervention for treating co-occurring anxiety disorders. Methods. An A-B single case study design (N = 6) was used to evaluate the efficacy of a 12 to 13 session modular transdiagnostic cognitive-behavioral intervention for treating co-occurring anxiety disorders across patients with at least two of the following diagnoses: GAD, Social Phobia, Panic Disorder and/or OCD. Results. Five of the six participants completed treatment. At post-treatment assessment the five treatment completers achieved diagnostic and symptomatic change with three participants being diagnosis free. All participants who completed treatment no longer met criteria for any DSM-IV-TR Axis-I diagnosis at the three-month follow-up assessment, and demonstrated reliable and clinically-significant improvements in symptoms. Across the participants, statistically significant improvements from pre- to post-intervention were found on measures of anxiety, depression and general well-being, and all improvements were maintained at three-month follow-up. Conclusions. Results suggest that transdiagnostic cognitive behavioral interventions can be of benefit to patients with co-occurring anxiety disorders.

Dyad function-based cognitive behavioural therapy as a treatment for obsessive compulsive disorder in two school aged children with high functioning autism

Children with High-Functioning Autism (HF A) are more vulnerable to developing Obsessive Compulsive Disorder (OCD) than typically developing children and those with Low-Functioning Autism (Gadow et al., 2005). This study used a multiple baseline design across behaviours (Cooper, Heron, & Heward, 2007) to investigate if a two phase function-based Cognitive Behaviour Therapy (CBT) would decrease obsessive compulsive behaviours (OCBs) in two children ages 7 and 9 who met criteria for OCD and HF A. This multimodal treatment package consisted of treatment enhancements to meet the children's cognitive, linguistic, and social challenges associated with their HF A diagnosis, as well as a manual and accompanied children's workbook (Vause, Neil, & Feldman, in progress). In line with previous research conducted on CBT as a treatment for OCD in this population (e.g., Wood et at, 2009), the children in this study experienced clinically significant decreases in their OCBs as a result of receiving the CBT protocol.

Investigating Changes in Parent Knowledge about Obsessive Compulsive Behaviour Following Group Function-Based Cognitive Behavioural Therapy for Children with High Functioning Autism

This study investigated improvements in parent knowledge of effective intervention strategies following participation in a group function-based CBT treatment (GFbCBT) package for children with comorbid OCD and ASD. Nineteen parents of children ages 7-12 years with High Functioning Autism (HFA) participated in the 9-week treatment program. Key components of treatment included psychoeducation and mapping, cognitive-behavioural skills training, function-based interventions and exposure and response prevention (ERP). Treatment sessions also included direct parent education, which followed a behavioural skills training model (Miltenberger, 2008). Parent knowledge (N = 19) was measured pre and post treatment using a vignette about a child demonstrating obsessive-compulsive behaviour. Results of a one-tailed pairwise t-test indicated statistically significant changes (p=.036) in overall parent knowledge following participation in treatment. Statistically significant changes were also found in parents’ ability to generate ERP and function-based intervention strategies. These results provide preliminary evidence that parents benefit from active involvement in the GFbCBT treatment package.

Exploring the Therapeutic Alliance in Cognitive-Behavior Therapy with Children with Autism Spectrum Disorder: An Interpretative Phenomenological Approach

Abstract The therapeutic alliance (TA) is the most studied process of adult psychotherapeutic change (Zack et al., 2007) and has been found to have a moderate but robust relationship with therapeutic outcome regardless of treatment modality (Horvath, 2001). The TA is loosely described as the extent to which the therapist and the participant connect emotionally and work together towards goals. Conceptualizations of the TA with children have relied on adult models, even though it is widely acknowledged that the pediatric population will rarely willingly commit to therapy, nor readily admit to any challenges that they may be experiencing (Keeley, Geffken, McNamara & Storch, 2011). For children with Autism Spectrum Disorder (ASD) the therapeutic alliance may require an even greater retheorizing considering the communicative and social difficulties of this particular population. Despite this need, research on children with ASD and the therapeutic TA is almost non-existent. In this qualitative study, transcripts from semi-structured interviews with mothers of children with ASD were analyzed using Interpretative Phenomenological Analysis (IPA). IPA closely examines how individual people make sense of their life experiences using a theme-by-theme approach. The three interviewees were mothers whose children were participants in a nine-week Cognitive Behaviour Therapy (CBT) group for obsessive-compulsive behaviours (OCB). A total of four superordinate themes were identified: (i) Centralization and disremembering the TA, (ii) Qualities of the therapist, (iii) TA and the importance of time, and (iv) Signs of a healthy TA. The mothers’ perspectives on the TA suggest that, for them and their children, a strong TA was a required component of the therapy. Implications for clinicians and researchers are discussed.