Practice Article
Working with gender and sexual minorities in the context of Islamic culture: a queer Muslim behavioural approach
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- Khashayar Farhadi Langroudi, Matthew D. Skinta
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- 01 April 2019, e21
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There has been a large increase in the migration of Muslim populations towards the western world and the USA in the past decade. Many have migrated in the hope of finding a safe home away from war, persecution, or a better economic situation, with many coming from Afghanistan and Syria. Gender and sexual minorities (GSM), or individuals who are not heterosexual and do not identify with their sex assigned at birth, are disproportionately over-represented within migrating groups. While most of these individuals will not have received psychotherapy in their home countries, it is likely they would receive or be required to obtain psychological services as part of the asylum process or through psychoeducational services as a requirement to receive assistance. In exploring the specific needs of Muslim GSM individuals, we highlight the diverse impacts of minority stress, shame, and how these might be mitigated through the integration of acceptance and commitment therapy (ACT) and compassion-focused therapy (CFT). ACT and CFT may provide a helpful framework for a culturally adapted therapy that targets the needs of those experiencing intersectional Muslim and GSM identities, and can foster the cultivation of a meaningful life that can include all aspects of their identities.
Key learning aims(1) To understand the context within which Muslim GSM individuals experience shame.
(2) To learn to adapt an acceptance and compassion-based approach in working with GSM Muslim clients.
(3) To describe how culturally competent hypotheses might inform case conceptualization with GSM Muslim clients.
Service Models and Forms of Delivery
Addressing issues of race, ethnicity and culture in CBT to support therapists and service managers to deliver culturally competent therapy and reduce inequalities in mental health provision for BAME service users
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- Saiqa Naz, Romilly Gregory, Meera Bahu
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- 22 April 2019, e22
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Conversations around improving access to psychological therapies for BAME (Black, Asian and minority ethnic) service users have been ongoing for many years without any conclusion or resolution. BAME service users are often under-represented in primary care mental health services, and often have worse outcomes, leading to them being portrayed as ‘hard to reach’, and to deterioration in their mental health. They are over-represented in secondary care mental health services. The authors of this article argue that more resources are required in order to understand the barriers to accessing mental health services, and improve both access and recovery for BAME service users. This paper examines concepts such as race, ethnicity and culture. It aims to support service managers and therapists to develop their confidence to address these issues in order to deliver culturally competent psychological therapies to service users from BAME communities, with a focus on primary care. It is based on our experiences of working with BAME communities and the feedback from our training events on developing cultural competence for CBT therapists. The paper also discusses the current political climate and the impact it may have on service users and the need for therapists to take the wider political context into consideration when working with BAME service users. Finally, the paper stresses the importance of addressing structural inequalities at a service level, and developing stronger ethical guidelines in the area of working with diversity for CBT therapists in the UK.
Key learning aims(1) To examine concepts such as race, ethnicity and culture and to provide a shared understanding of these terms for CBT therapists.
(2) To assist CBT therapists and supervisors to develop their confidence in addressing issues of race, ethnicity and culture with BAME service users within the current political climate and to deliver culturally competent therapy.
(3) To assist service managers to promote equality of access and of outcomes for service users from BAME communities.
(4) To understand how unequal expectations of therapists in services impacts on CBT therapists from BAME communities.
(5) To widen understanding of some of the structural inequalities at service level which the CBT community needs to overcome, including recommending stronger ethical guidelines around working with diversity in the UK.
Case Study
Using the evidence base for social anxiety to understand and treat paranoia: a single case experimental design
- Stephanie Hicks
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- 15 April 2019, e23
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Research suggests that paranoia and social anxiety can be understood as part of the same continuum, having shared processes such as the anticipation of threat, cognitive biases, poor self-concept, worry and safety-seeking behaviours. There is limited research on whether evidence-based interventions for social anxiety could be used with individuals who experience paranoia; however, an existing brief intervention study using techniques taken from cognitive behavioural therapy (CBT) for social anxiety has had promising results.
This paper uses a single-case experimental design to explore whether using a clinical model of the maintenance of paranoia followed by CBT for social anxiety can be an effective formulation and intervention method in cases where social anxiety processes appear to be maintaining paranoid thoughts. This may be an effective formulation and intervention method, resulting in a reduction in anxiety and a reduction in the distress associated with paranoid thoughts. The clinical implications are discussed along with limitations and recommendations for further research.
Key learning aims(1) To describe shared processes in social anxiety and paranoia.
(2) To identify the benefits and limitations of using a clinical model of paranoia and CBT for social anxiety for formulation and intervention with individuals experiencing paranoia.
(3) To identify areas where further research is warranted in treatment for individuals experiencing paranoia.
Education and Supervision
Cognitive behavioural therapy training in Tanzania: a qualitative study of clinicians’ experiences
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- Lydia Stone, Megan A. Arroll
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- 15 April 2019, e24
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Cognitive behaviour therapy (CBT) in an effective technique used widely in Western countries. However, there is limited evidence as to the utility, perception and understanding of CBT in developing countries. This study describes and investigates the experience of CBT training and practice in a group of practitioners in Tanzania. A qualitative approach to the investigation was used, and seven participants from Tanzania’s only psychiatric hospital who had completed CBT training were interviewed. The resulting verbatim transcripts were analysed via interpretative phenomenological analysis. Five superordinate themes emerged from the analysis: ‘the medical model’, ‘novelty’, ‘practicalities’, ‘process’ and ‘therapist effects’. The two themes ‘therapist effects’ and ‘process’ are discussed in detail as these may be particularly relevant to the clinical application of the therapy in a new culture and context. The implications for future development of CBT in Tanzania are considered. In developing CBT for dissemination in Tanzania, specific cultural and clinical issues highlighted by indigenous clinicians need consideration.
Key learning aims(1) To identify what range of factors may influence clinicians’ perception of and learning about CBT when CBT training is delivered in a mental health setting in Tanzania, or to those with East African origins.
(2) To consider the use of qualitative research approaches to inform the early stages of adapting CBT for use in new settings and applications.
(3) To be able to apply knowledge about cultural differences to standard CBT in order to promote culturally sensitive practice.
Original Research
Culture and therapist self-disclosure
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- Peter Phiri, Shanaya Rathod, Mary Gobbi, Hannah Carr, David Kingdon
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- Published online by Cambridge University Press:
- 11 April 2019, e25
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Cognitive behaviour therapy (CBT) as a treatment for schizophrenia and psychotic-related disorders has been shown to have significantly greater drop-out rates in clients of black and minority ethnic (BME) groups. This has resulted in poor outcomes in treatments. Our recent qualitative study thus aimed to develop culturally sensitive CBT for BME clients. The study consisted of individual in-depth 1:1 interviews with patients with a diagnosis of schizophrenia, schizo-affective, delusional disorders or psychosis (n = 15) and focus groups with lay members (n = 52), CBT therapists (n = 22) and mental health practitioners (n = 25) on a data set of 114 participants. Several themes emerged relating to therapist awareness on culturally derived behaviours, beliefs and attitudes that can influence client response and participation in therapy. The current paper aims to explore one of these themes in greater detail, i.e. client-initiated therapist self-disclosure (TSD). Using thematic analysis, the paper highlights key elements of TSD and how this could impact on therapist’s reactions towards TSD, the therapeutic alliance and ultimately, the outcomes of therapy. The findings appear to show that TSD has significant relevance in psychological practice today. Some BME client groups appear to test therapists through initiating TSD. It is not the content of TSD they are testing per se, but how the therapist responds. Consequently, this requires therapists’ cognisance and sensitive responses in a manner that will nurture trust and promote rapport. Further investigation in this area is suggested with a recommendation for guidelines to be created for clinicians and training.
Key learning aims(1) To develop a dialogue and practice with confidence when addressing issues of self-disclosure with diverse populations.
(2) To appreciate the impact therapist self-disclosure has in early stages of engagement, in particular when working with patients from BME communities.
(3) To understand the impact and role of self-disclosure as initiated by patients.
(4) To increase therapist awareness on cultural differences in self-disclosure and develop ways to address this in therapy.
(5) To challenge therapists to adapt psychological therapies to diverse cultures and be cognisant that ‘one size does not fit all’.
Service Models and Forms of Delivery
Delivering a culturally adapted therapy for Muslim clients with depression
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- Ghazala Mir, Ruqayyah Ghani, Shaista Meer, Gul Hussain
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- 12 April 2019, e26
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Inequalities in mental health treatment access and outcomes for minority ethnic and religious groups in the UK have been recognized for more than a decade; however, work to address these at an operational level is still emerging. In recognition of the need for culturally adapted therapies, researchers at the University of Leeds developed and piloted an adapted therapy for Muslim clients, based on behavioural activation (BA), an existing evidence-based psychosocial treatment for depression. Therapists and supervisors at Touchstone, Leeds have been trained to deliver the culturally adapted approach, which supports Muslim clients who choose to use ‘positive religious coping’ as a resource for health. This paper describes the key elements of the intervention and how it is being delivered in practice to increase service uptake and recovery in Muslim communities.
Practice Article
A protocol for managing dissociative symptoms in refugee populations
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- Zoe J. Chessell, Francesca Brady, Sameena Akbar, Adele Stevens, Kerry Young
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- 22 April 2019, e27
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This article describes a clinical protocol for supporting those presenting with post-traumatic stress disorder (PTSD) and dissociative symptoms, particularly dissociative flashbacks, based on a cross-culturally applicable model. The protocol is discussed from the perspective of working with a refugee and asylum seeker population, although many of the principles will be applicable to clients from any background presenting with these dissociative symptoms. The protocol addresses the assessment and formulation of a client’s dissociative symptoms. It includes guidance on sharing psycho-education with clients regarding the evolutionary function of dissociation and developing practical strategies to monitor and manage dissociative symptoms. The strengths and limitations of this protocol are also discussed.
Key learning aimsAfter reading this article people will:
(1) Be able to understand a cross-culturally applicable model of dissociation and how it applies to clinical practice when working with clients presenting with dissociative symptoms, particularly dissociative flashbacks, in the context of a diagnosis of PTSD.
(2) Be able to assess and formulate dissociative symptoms as part of an overall PTSD formulation.
(3) Be able to develop practical strategies for assisting clients in monitoring and managing their dissociative symptoms.
(4) Be familiar with adaptations for using this approach with refugee and asylum seeker populations.
Education and Supervision
‘Courses for Horses’: designing, adapting and implementing self practice/self-reflection programmes
- Mark H. Freeston, Richard Thwaites, James Bennett-Levy
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- 29 April 2019, e28
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Self-Practice/Self-Reflection (SP/SR) has been proposed both as an adjunct to therapy training programmes, and also as a means for therapist development among experienced therapists. Research suggests it develops aspects of knowledge and skill that may not be addressed through other training methods. With increasing interest in SP/SR, a growing evidence base regarding both participant benefits and potential risks from SP/SR, and the development of SP/SR programmes across a range of therapeutic modalities, we argue it is timely to identify a set of principles that can guide the design, adaptation and implementation of SP/SR programmes. At this stage, there is little empirical evidence to guide trainers wishing to implement SP/SR in different contexts. Accordingly, these principles have been derived from reflection on developing, testing and implementing SP/SR programmes as well as on other training and supervisory experience. The first set of principles detailed in Section 1 draw on various theories of learning and development and frame the processes involved, the next principles speak to the content of SP/SR programmes, and the final principles address structure. Within Section 2, the principles are then considered for their practical implications. In Section 3, the sharing of what are initially private self-reflections is then considered together with some implications for SP/SR programmes, especially when there is assessment involved. We argue that SP/SR will continue to progress with well-designed standard programmes, careful implementation, thoughtful adaptation, ongoing innovation, and especially more evaluation.
Key learning aims(1) To understand the principles for designing, adapting and implementing SP/SR programmes that are drawn from theory and from the authors’ experience of developing and implementing SP/SR programmes over the last 20 years.
(2) To understand the possible factors that guide the processes, content and structure of SP/SR programmes.
(3) To understand how best to maximize effective engagement and learning (and limit harm) when planning or implementing an SP/SR programme.
Original Research
Impact of a brief worry-based cognitive therapy group in psychosis: a study of feasibility and acceptability
- Helen Courtney, Lucy White, Thomas Richardson, Ben Dasyam, Jo Tedbury, Jane Butt
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- 29 April 2019, e29
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Previous research suggests that CBT focusing on worry in those with persecutory delusions reduces paranoia, severity of delusions and associated distress. This preliminary case series aimed to see whether it is feasible and acceptable to deliver worry-focused CBT in a group setting to those with psychosis. A secondary aim was to examine possible clinical changes. Two groups totalling 11 participants were run for seven sessions using the Worry Intervention Trial manual. Qualitative and quantitative data about the experience of being in the group was also collected via questionnaires, as was data on number of sessions attended. Measures were delivered pre- and post-group and at 3-month follow-up. These included a worry scale, a measure of delusional belief and associated distress and quality of life measures. Of the 11 participants who started the group, nine completed the group. Qualitative and quantitative feedback indicated that most of the participants found it acceptable and helpful, and that discussing these issues in a group setting was not only tolerable but often beneficial. Reliable Change Index indicated that 6/7 of the group members showed reliable reductions in their levels of worry post-group and 5/7 at follow-up. There were positive changes on other measures, which appeared to be more pronounced at follow-up. Delivering a worry intervention in a group format appears to be acceptable and feasible. Further research with a larger sample and control group is indicated to test the clinical effectiveness of this intervention.
Key learning aims(1) To understand the role of worry in psychosis.
(2) To learn about the possible feasibility of working on worry in a group setting.
(3) To be aware of potential clinical changes from the group.
(4) To consider acceptability for participants of working on worries in a group setting.
Transdiagnostic CBT for adult emotional disorders: A feasibility open trial from Saudi Arabia
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- Yousra Alatiq, Omar Al Modayfer
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- 21 May 2019, e30
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Transdiagnostic cognitive behavioural therapy (T-CBT) provides potential for improving psychotherapy services in countries with limited resources. The primary aim of this study was to assess the feasibility and potential benefits of using T-CBT in Saudi Arabia to treat adult emotional disorders in a naturalistic open trial. A secondary aim was to measure the effect of this approach when delivered by junior psychologists as a low-intensity intervention. The overall sample consisted of 198 patients (160 in the low-intensity group). Only 33 (16.7%) patients had completed the treatment plan, 55 (27.3%) were still active in treatment, and 109 (55%) had disengaged from the treatment. The pre- and post-assessments for the clients who completed the treatment showed a significant decrease in all outcome measures. This result held true for the whole sample and the low-intensity group. This study provides initial evidence that T-CBT is suitable for clients with emotional disorders in Saudi Arabia. The study also provides support for the effect of T-CBT as a low-intensity intervention delivered by junior psychologists. However, one of the study limitations was the sample size for the group who completed the treatment and was properly discharged from service. Implications and recommendations are discussed.
Key learning aims(1) To examine the feasibility and potential benefits of using T-CBT in Saudi Arabia.
(2) To measure the effect of T-CBT as low-intensity interventions delivered by junior psychologists.
(3) To establish evidence-based practice for T-CBT in Saudi Arabia.
Case Study
Cognitive Behavioural Therapy Suicide Prevention (CBT-SP) imagery intervention: a case report
- Marie Carey, Catherine Wells
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- 17 June 2019, e31
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Very little clinical work or research to date has focused on the prioritization of suicidal imagery intervention in the stabilization of risk. Current Cognitive Behavioural Therapy Suicide Prevention (CBT-SP) does not specifically address suicidal imagery as a priority intervention. This paper prioritizes imagery modification as the central task of therapy with the suicidal client. This is a single subject case review describing specific imagery interventions used to destabilize the comforting component of suicidal images, de-glamourize the suicidal image as a problem-solving method and the reconstruction of new images to offset the emotional grasp of both ‘flash-forward’ violent suicidal images and suicidal ‘daydreaming’ rumination. It is hypothesized that when suicidal images become less emotionally charged, the desire to act upon suicide decreases. Focusing on imagery intervention as a priority aims to stabilize risk in a more clinically specific and targeted way. Rob is a 19-year-old depressed young man with chronic suicidal ideation/images with repeated suicide attempts. All GP referrals are of a crisis nature since the age of 16. He was referred to a CBT clinician with specific training and experience in CBT-SP who proposed the following brief imagery intervention. Socialization to treatment rationale was pivotal at the outset to help facilitate strong therapeutic alliance, ‘buy-in’ to the intended de-glamourization of suicide planning/daydreaming/rumination and the effects of intrusive ‘flash-forward’ images on emotional well-being. Therapy was facilitated weekly, supported by telephone contact, on an out-patient basis in the HSE (Health Service Executive) Irish Adult Mental Health service. The care plan and interventions were supported by access to the 24-hour acute Adult Mental Health services, as required. There was no requirement for direct client engagement with the acute services. Rob engaged with five treatments of CBT-SP imagery intervention and full stabilization of risk to self by suicide was achieved. At the time of writing, Rob is alive, has no engagement with the services and no further GP referral requests for intervention. Despite Rob leaving therapy before full completion, brief targeted suicidal imagery intervention was observed to stabilize the risk of suicidal behaviour. This young man has completed his schooling, engaged in ‘life’ planning rather than ‘death’ planning and has not required further intervention from this service. Further research is required to engage frontline clinicians on the merits of suicidal imagery assessment in routine clinical practice.
Key learning aims(1) To assess for imagery and violent day dreaming in suicidal patients.
(2) Conceptualizing suicidal rumination and daydreaming as being a maladaptive problem-solving technique in overcoming psychological pain.
(3) Use of suicide-specific assessment.
(4) Ask about the presence of suicidal imagery as part of routine mental health assessment with the suicidal client.
Who am I without anorexia? Identity exploration in the treatment of early stage anorexia nervosa during emerging adulthood: a case study
- A. Koskina, U. Schmidt
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- 13 June 2019, e32
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Emerging adulthood (age 18–25 years) is a distinct developmental phase, characterized by multiple life changes, transitions and uncertainties, associated with significant risk of mental ill health in vulnerable individuals. Identity exploration and development is key during this phase, and the development of an eating disorder during this time can significantly impact on this process. This single-case study details the treatment of an 18-year-old female outpatient with first episode, recent onset anorexia nervosa. Using the Maudsley Model of Anorexia Nervosa Treatment in Adults (MANTRA), focus was placed on identity exploration and development as a tool to reduce the dominance of anorexia nervosa and increase recovery focus. Outcome measures at end of treatment and 6-month follow-up showed significant sustained improvement in BMI and EDE-Q scores. The patient gave detailed positive feedback suggesting that this was a highly acceptable and effective intervention. The case study is discussed with reference to limitations and some reflections on the utility of incorporating identity work in the treatment of anorexia nervosa in emerging adulthood.
Key learning aims(1) This case study is thought to have important clinical implications for tailoring the treatment of early stage AN to the emerging adult population.
(2) Identity exploration is a key feature of this developmental stage, and incorporating this work into therapy allows for experimentation and formation of an alternative, healthy set of values, beliefs and behaviours.
(3) This case also highlights the value of using role models in the construction of a non-illness driven identity, to support with behavioural change.
Original Research
Psychotherapists’ reports of technique use when treating anxiety disorders: factors associated with specific technique use
- Zachary J. Parker, Glenn Waller
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- 27 June 2019, e33
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Cognitive behavioural therapy (CBT) is the most efficacious and effective psychological intervention for treating anxiety disorders. Behavioural techniques, in particular exposure-based techniques, are fundamental to positive outcomes. However, research suggests that these techniques are either not used or are under-used when treating anxiety disorders. This study assesses therapists’ reported use of CBT techniques in the treatment of anxiety disorders, and explores which therapist variables influence technique use. A total of 173 CBT therapists completed measures on their demographics, routine therapy practices in treating anxiety disorders, and internal states (e.g. self-esteem). These data were analysed to see how often therapists employed particular techniques and the correlates of the use of those techniques. Behavioural techniques (e.g. exposure) were the least utilized set of core CBT skills, being used less often than non-CBT techniques. The under-utilization of these key techniques was associated with greater levels of increased inhibitory anxiety amongst therapists. Supervision and therapists’ self-esteem were both positively associated with the use of non-CBT techniques. While this study established what CBT therapists purport to use in routine practice with anxious populations, further research is needed to assess the association between adherence (or lack thereof) and client outcomes, and the factors that drive non-adherence.
Key learning aimsAs a result of reading this paper, the reader should:
(1) Learn about what psychotherapists report as occurring in routine care for individuals with anxiety and related disorders.
(2) Know the potential therapist traits that influence the use of CBT techniques.
(3) Gain knowledge to help explain to clients why previous therapy may not have been effective.
(4) Develop a richer understanding of what factors may influence their own therapeutic practice.
A test of the feasibility of a visualization method to show the depth and duration of awareness during Method of Levels therapy
- Jakub Grzegrzolka, Warren Mansell
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- 27 June 2019, e34
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Many psychological therapies help clients to direct and sustain their awareness onto specific aspects of their problems to promote change. Yet, no theory-driven measure exists that can code moment-by-moment changes in awareness during a therapy session. It is known that awareness plays a crucial role in the process of change, but little is known about the underlying core processes. Perceptual Control Theory (PCT) offers a scientific explanation of psychological distress as loss of control and describes the role of awareness in processes responsible for restoring control by resolving any internal conflict. The Depth and Duration of Awareness Coding Scheme (D-DACS) was previously developed to capture the person’s current focus of awareness and its duration on the areas that from a PCT point of view are desirable in order to facilitate effective psychological change. The current research applies D-DACS to code three publicly available Method of Levels (MOL) therapy sessions delivered by an expert therapist and presents a visual representation of the client’s presumed attention in these sessions. The results showed that an average of 61.65% of the client’s attention was focused on the D-DACS areas, which is higher than the previous studies involving novel therapists. The produced visual representation of the clients’ presumed attention helps to examine the utility of this new coding scheme and further examine the validity of the underlying theory. Such work might help in examining effectiveness of therapy in meeting the underlying theoretical foundations of change. However, limitations and areas for improvement are also evident.
Key learning aims(1) To provide a rationale for the use of observer-rated measures of within-session processes involved in therapeutic change.
(2) To describe the desired focus of the client’s awareness in order to facilitate effective psychological change as described by Perceptual Control Theory.
(3) To use an earlier validated scheme to code the depth and duration of awareness of three clients in best practice videos of Method of Levels psychotherapy.
(4) To present and test the feasibility of a visual representation of moment-to-moment changes in a client’s awareness in a therapy session.
An evaluation of predictors of dropout from an Emotional Coping Skills programme in a community mental health service
- Shalini Raman, Thomas Richardson
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- 04 July 2019, e35
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Drop-out from mental health services is a significant problem, leading to inefficient use of resources and poorer outcomes for clients. Adapted dialectical behaviour therapy (DBT), often termed Emotional Coping Skills (ECS) programmes, show some of the highest rates of drop-out from therapy recorded in the literature. The present study aimed to add to the evidence base, by evaluating predictors of drop-out from an ECS programme in a UK-based Community Mental Health Team (CMHT). An existing data set of 49 clients, consisting of clients’ responses on a number of questionnaires, was evaluated for predictors of drop-out. Predictors of drop-out included symptom severity, substance use and client demographics. Independent-samples t-tests and chi-square cross tabs analyses revealed no significant differences between drop-outs and completers of therapy on any of the variables. This suggests that contrary to common assumptions and previous findings, clients using substances, who are highly anxious, or who experience a greater degree of emotion dysregulation, are not more likely to drop out from ECS programmes compared with other individuals. The clinical implications of these findings and future research are discussed within the wider context of the evidence base.
Key learning aims(1) To be familiar with common predictors of drop-out from psychological therapies, as indicated by the literature.
(2) To understand the theories underlying factors that impact drop-out and the associated consequences for mental health services.
(3) To understand the potential impact of staff assumptions of factors that affect drop-out on client retention.
(4) To have an understanding of initiatives and strategies that may improve client-retention and engagement in services.
Cognitive behavioural therapy for worry in young individuals with at-risk mental states: a preliminary investigation
- Andrea Pozza, Sandro Domenichetti, Davide Dèttore
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- Published online by Cambridge University Press:
- 16 July 2019, e36
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Cognitive behavioural therapy (CBT) is a first-line strategy in reducing or delaying risk of transition to psychosis among young individuals with at-risk mental states (ARMS). However, there is little knowledge about its effects on other outcomes associated with ARMS. No study on CBT for ARMS has assessed worry, an important process associated with this condition. The present study investigated changes in worry at immediate post-treatment and 14-month follow-up after CBT for young individuals with ARMS seeking psychiatric care in mental health services. Thirty-seven young individuals (mean age = 26 years, SD = 6.07; 22.20% female) seeking psychiatric care in mental health services and classified as reporting ARMS through the Comprehensive Assessment of At-Risk Mental States were included. The Positive And Negative Syndrome Scales (PANSS) and Penn State Worry Questionnaire (PSWQ) were administered at baseline, post-treatment, and follow-up. CBT consisted of 30 weekly individual 1-hour sessions based on a validated CBT for ARMS manual enriched with components targeting worry [psychoeducation, problem-solving, (meta)cognitive restructuring, behavioural experiments]. Seven participants (18.91%) at follow-up had cumulatively made transition to psychosis. Repeated measures ANOVA with post-hoc pairwise comparisons showed significant changes in PSWQ scores from baseline to post-treatment and from baseline to follow-up; PSWQ scores remained stable from post-treatment to follow-up. This is the first study investigating changes in worry after CBT for ARMS, which appears to be a promising strategy also for this outcome. Future research with a larger sample size and control group may determine whether changes in worry are also associated with reduced transition risk.
Key learning aims(1) To understand CBT evidence and procedures for young individuals with ARMS.
(2) To reflect on the current limitations in the literature on CBT for ARMS.
(3) To understand the importance and clinical implications of assessing worry in ARMS.
(4) To focus on changes in worry as an outcome after CBT for ARMS.
(5) To reflect on future research directions on the role of worry in CBT for ARMS.
Case Study
The unified protocol for anxiety and depression with comorbid borderline personality disorder: a single case design clinical series
- Michelle E. Lopez, Steven R. Thorp, Matthew Dekker, Andrew Noorollah, Giovanna Zerbi, Laura A. Payne, Emily Meier, Jill A. Stoddard
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- Published online by Cambridge University Press:
- 31 July 2019, e37
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This study used a single case experimental design to investigate the use of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) among a sample of individuals with depression and anxiety who also presented with borderline personality disorder (BPD). Eight women received individual treatment with the UP over the course of 14–16 treatment sessions, and were assessed for anxiety and depression severity on a weekly basis over a 2–6 week baseline period and throughout treatment. Three of the eight participants demonstrated reliable pre- to post-treatment clinical improvements on depression and stress scales, and one participant demonstrated a reliable reduction on an anxiety scale. Two participants demonstrated a reliable improvement in overall anxiety. The results indicate that the UP applied to individuals diagnosed with primary BPD may lead to clinical improvement in depression, stress and anxiety for some individuals. However, the majority of individuals with BPD in our sample did not show strong improvement, and this suggests the need for additional sessions of UP or an intervention that focuses on the symptoms of BPD specifically for some women.
Key learning aims(1) To describe the applicability of the Unified Protocol in the treatment of individuals with borderline personality and co-occurring anxiety or depression.
(2) To understand the value of utilizing a transdiagnostic approach as an alternative to diagnosis-specific approaches to treatment.
(3) To identify the four core modules of the Unified Protocol and describe the general format for individual treatment.
Original Research
Writing the ‘self’ into self-practice/self-reflection (SP/SR) in CBT: learning from autoethnography
- Craig Chigwedere
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- Published online by Cambridge University Press:
- 16 July 2019, e38
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Self-practice/self-reflection (SP/SR) allows cognitive behavioural therapists (CBT) to self-experience the techniques they use clinically. However, it is difficult to find published first-hand accounts of CBT therapists’ SP/SR experiences. This may be because CBT research is primarily positivist and objective, while SP/SR is intrinsically subjective. Borrowing from the principles of autoethnography may offer a subjectivist qualitative methodology, allowing CBT therapists to write up their SP/SR experiences as rich, first-hand research material, potentially impacting theory and practice. This novel personal case study of SP/SR borrows from autoethnography, adapting it to analyse the self-practice of the CBT model of worry, in order to understand my own experience of worry as well as the model itself.
Key learning aims(1) To develop an approach to the research that is applicable to first-hand SP/SR material.
(2) To demonstrate how therapists can continue SP/SR practice post-CBT training.
(3) To illustrate how, with the aid of autoethnographic principles, SP/SR practice can influence not only the practitioner’s personal and therapist-self, but also theory development.
Review Paper
A review of the relationship between intolerance of uncertainty and threat appraisal in anxiety
- S. Milne, C. Lomax, M. H. Freeston
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- Published online by Cambridge University Press:
- 09 August 2019, e38
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The development and conceptual relationship of the constructs of threat appraisal (TA) and intolerance of uncertainty (IU) are explored in the context of anxiety disorders. A narrative review tracking the development of these constructs and their relationship is undertaken. There is some evidence to suggest that the interaction between the components of threat appraisal (probability × cost) may partially account for or provide a theoretical framework which explains presenting levels of anxiety. Furthermore, research suggested that IU is a construct which contributes to a broad range of anxiety disorders. It was concluded that distinctive cognitive biases linked with IU – such as interpreting ambiguous and uncertain (both positive and negative) information as highly concerning – suggests that IU is interpreted negatively independent of threat appraisal. These findings mean a number of issues remain unclear, including whether IU in anxiety-provoking situations is sufficient in itself – independent of threat appraisal – in eliciting high levels of anxiety. Additionally, it is unclear whether threat appraisal and IU act as independent constructs, or more in an interactive manner in anxiety. To achieve further clarity on these issues, methodological recommendations for future research are made.
Key learning aims(1) To understand the conceptual foundations of TA and IU in the cognitive model of anxiety.
(2) To understand the empirical evidence supporting the role of both TA and IU in anxiety.
(3) To appreciate the potential relationship between these concepts in anxiety.
Service Models and Forms of Delivery
Real-world evaluation of digital CBT for insomnia in the primary care setting – many should not log on to doze off
- Zheyu Xu, Kirstie N. Anderson
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- Published online by Cambridge University Press:
- 05 August 2019, e39
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Cognitive behaviour therapy for insomnia (CBTi) has emerged as the first-line treatment for insomnia where available. Clinical trials of digital CBTi (dCBTi) have demonstrated similar efficacy and drop-out rates to face-to-face CBTi. Most patients entering clinical trials are carefully screened to exclude other sleep disorders. This is a case series review of all those referred to a dCBTi within an 18-month time period. Those initially screened, accepted after exclusion of other sleep disorders, commencing and completing therapy were assessed to understand patient population referred from general practice in the UK. 390 patient referrals were analysed. 135 were suitable for dCBTi with a high rate of other sleep disorders detected in screening. 78 completed therapy (20.0%) and 44.9% had significant improvement in sleep outcomes, achieving ≥20% improvement in final sleep efficiency. dCBTi can be used within the UK NHS with good benefit for those who are selected as having insomnia and who then complete therapy. Many referrals are made with those likely to have distinct primary sleep disorders highlighting the need for education regarding sleep and sleep disorders prior to dCBTi therapy.
Key learning aims(1) The use of unsupported digital cognitive behavioural therapy for insomnia (dCBTi) requires proper patient selection.
(2) There are many insomnia mimics and also previously unrecognized sleep and psychiatric disturbances that are under-diagnosed in the primary care setting that are contraindications for unsupported dCBTi.
(3) The use of a stepped care approach similar to the UK’s Improving Access to Psychological Therapies (IAPT) model using dCBTi could be feasible in the public health setting.