the Cognitive Behaviour Therapist - Latest volume

Although cognitive behavioural therapy (CBT) is recommended for the treatment of a number of mental disorders among the general population, the ability of individuals with learning disabilities (LD) to understand CBT concepts and engage in CBT has been questioned. Aims: To examine whether specific prerequisite skills for CBT can be taught to people with LD using a newly developed training intervention and to investigate the acceptability of the intervention. Method: The study adopted a within-subjects case series research design. Quantitative assessment methods were used to evaluate the CBT skills of six adults with mild to moderate LD pre-intervention, following intervention and at 1-week follow-up. Participants were also asked to provide some qualitative feedback about how they had experienced the intervention. Results: The cognitive mediation skills and the ability of most participants to link activating events to emotions increased following intervention training and this improvement was maintained for four of them at follow-up. The feedback of participants regarding the process and content of the task demands was positive. Conclusions: The findings suggest that people with LD can learn some of the skills considered necessary to participate in CBT, such as cognitive mediation. However, further and more robust research is required to substantiate these findings.

Research in the field of cognitive behavioural therapy (CBT) has primarily focused on the acquisition and development of skills and competence. Little is known regarding the experience of training from trainees’ perspectives. This systematic review aimed to review and critique the research conducted on the experience of CBT training. Four electronic databases were searched for published studies reporting on the experience of CBT training. Thirteen articles were selected based on pre-determined inclusion and exclusion criteria and were assessed for quality using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD; Sirriyeh et al., 2012). Due to the lack of consistency in the study designs and outcome measures used, a narrative synthesis of the findings was conducted. Findings were categorized within three themes for synthesis: ‘experience of benefit’, ‘internal processes of engagement’ and ‘external influences on engagement’. Overall, this review was able to draw conclusions regarding the experiences of aspects of CBT training from relatively good quality research. However, the review also highlights the lack of studies exploring specific hypotheses regarding the experience of training.

Within IAPT (Improving Access to Psychological Therapies), cognitive behavioural therapy (CBT) is offered to all clients regardless of gender, religion, culture and language. Hence, the demand for working with interpreters to facilitate communication during therapy in IAPT has increased. This study explored the experience of therapists working with interpreters to facilitate communication in psychological therapies with clients with mild to moderate anxiety and depression including those with co-morbid physical health problems. Thirteen participants, including six CBT therapists and seven Psychological Wellbeing Practitioners (PWPs) working in an NHS IAPT service, were interviewed. A qualitative approach, using semi-structured interviews and thematic analysis (Braun and Clarke, 2006), was implemented. The following four major themes were identified from the participants’ accounts: negotiating a three-way communication, difficulties in expressing empathy, a lack of shared understanding and working creatively with interpreters. During this collaborative working new understandings of engaging emerged leading participants to view this work as possible.

Imagery rescripting (ImRs) is a psychological intervention designed to change the meaning of images and associated memories and reduce emotional distress. Recent studies have shown that ImRs can be successfully applied to many psychological problems and disorders; however, little has been reported on the application of ImRs for panic disorder (PD). Consequently, we explored the therapeutic effects of ImRs on patients with PD. Fifteen patients with PD received 16 individual cognitive behavioural therapy (CBT) sessions weekly, including one ImRs session. Early traumatic memories associated with recurrent images in panic situations were identified and rescripted to alleviate maladaptive encapsulated beliefs. ImRs ratings (vividness and distress of the images and memories and conviction degree of encapsulated beliefs) were measured prior to and after ImRs. Self-negative contents not directly related to symptoms of panic attack were observed as common themes in the worst meaning of the image, the memory, and in the encapsulated belief. Whilst five (33%) patients had anticipatory anxiety, 10 (67%) patients had other self-negative beliefs. ImRs significantly reduced distress from images, memories and encapsulated beliefs; however, it did not change the vividness of images and memories. There was no significant correlation between the reduction in PD severity over the CBT program and the change in each ImRs rating. The results of this study are promising for certain aspects of panic disorder. However, further research is needed to overcome the limitations of this study.

Evidence exists that the effectiveness of psychotherapy depends more on therapists’ variables than on their theoretical orientation or the techniques they use. Nevertheless, relatively little is known regarding the process of cognitive behavioural psychotherapists’ development. The purpose of the study was to explore how beginning cognitive behavioural therapy (CBT) practitioners develop, considering various professional and personal influences. Eight in-depth interviews with beginning therapists were conducted, and the Grounded Theory Method was used for data analysis. The developmental process was conceptualized as Gaining Professional Confidence, and three phases of this process were identified: (1) Externally Based Confidence in CBT Methods, (2) Internalized Confidence in CBT Methods, and (3) Therapists’ Self-Confidence. The results indicate that trainees’ self-reflection on their personal qualities, values, attitudes and preferences should be given more attention in CBT training, as this plays a crucial role in their overall professional development.

Cognitive behavioural therapy (CBT) is a highly effective treatment for obsessive compulsive disorder (OCD). Identifying, challenging and monitoring interpretations of intrusions is considered a key element of CBT for OCD but preliminary research suggests that treatment does not always include identification and modification of misinterpretations. The present investigation explored ‘OCD-expert’ and ‘non-OCD-expert’ clinicians’ views on key elements of CBT for OCD to determine whether identifying and modifying key interpretations were considered important in therapy and whether clinicians who do not have specific expertise in OCD found working with interpretations difficult. Study 1 used a qualitative approach to investigate OCD-expert and non-OCD-expert clinician's views on key elements of CBT for OCD. Study 2 used a questionnaire to investigate what non-OCD-expert clinicians viewed as important and difficult aspects of CBT for OCD. Study 1 results showed that OCD-expert and non-OCD-expert clinicians reported working with interpretations was a key element of CBT for OCD. However, OCD-expert clinicians linked interpretations more closely to a formulation and intervention plan and reported using more techniques and questionnaires when working with interpretations compared with non-OCD-expert clinicians. Study 2 results showed that non-OCD-expert clinicians rated interpretations as both important and difficult to work with but no more important or difficult than other key elements of CBT for OCD. OCD-expert and non-OCD-expert clinicians identify working with interpretations as a key element of CBT for OCD. Non-OCD-expert clinicians may benefit from additional training on formulation tools that help identify, monitor and challenge interpretations of intrusions.

Recent developments have led the UK government to deem clinical supervision ‘essential’ to a safe and effective national health service. Cognitive behavioural therapy (CBT) supervision has been increasingly operationalized and manualized, but there are few psychometrically sound observational instruments with which to measure CBT supervision. This paper reports the factor analysis of a promising 23-item instrument for observing competence in CBT supervision (Supervision: Adherence and Guidance Evaluation: SAGE). N =115 qualified mental health practitioners (supervisors and their supervisees) rated the same supervision session by completing SAGE. A principal components analysis indicated that a two-factor solution, identified as the ‘Supervision Cycle’ and the ‘Supervisee Cycle’ components, accounted for 52.8% of the scale variance and also demonstrated high internal reliability (α = .91 and α = .81, respectively). These findings provide the basis for a shorter, 14-item version of SAGE, clarify the factor structure of SAGE, ease implementation, and afford more succinct feedback. Short-SAGE also improves implementation yield, taking half the time to complete as the original 23-item scale. These conceptual and practical improvements strengthen the role of SAGE as a promising observational instrument for evaluating CBT supervision, complementing self-report assessments of competent CBT supervision with an instrument that can fulfil the distinctive functions that are provided through direct observation.

Over the last decade, there has been increasing interest in the use of metaphor in cognitive behaviour therapy. However, to date, there has been only very limited research on the use of metaphor in CBT sessions, and no studies which have examined how to train therapists in this skill. The present study is the first in the literature to explore how we might train therapists in metaphor-enhanced CBT. Twelve therapists attended two half-day training workshops, 2 weeks apart. Details of the content of the training workshop are provided. The therapists rated the workshop quality and provided structured self-report ratings and reflections on their ongoing application of learning over a 3-month period which were compared with pre-training ratings. Therapists reported significantly increased awareness of metaphors, with increased confidence in responding intentionally to client metaphors and bringing them into shared conceptualizations. In addition, there were significant increases in reported time spent elaborating on client metaphors, and use of metaphors when conceptualizing with clients. Barriers and solutions to application of learning are discussed.

Currently recommended psychotherapies for depression are not always delivered in a consistent manner. There is an assumption that the use of clinical supervision will ensure reliable treatment and patient recovery. However, there is limited research supporting this assumption. This study explored the role of supervision in the treatment of depression. In particular, it examined how supervisors’ own characteristics and those of patients can influence the focus of supervision sessions. Clinical supervisors who worked with cognitive behavioural therapy (CBT) therapists treating depression cases were asked to indicate their supervision focus for three different patient vignettes. These vignettes varied in clinical complexity. Participants’ intolerance to uncertainty and their self-esteem were also assessed. Supervisors tended to focus their supervisees on the use of evidence-based therapeutic techniques for both straightforward and complex cases. However, their approach was less evidence-based for diffuse cases. Three supervisory types emerged: an ‘Alliance- and Technique-Focused’ group, a ‘Case Management-Focused’ group, and an ‘Unfocused’ group. Personal characteristics of the supervisors varied across the groups. The content of supervision sessions is influenced by factors from outside the therapy process. These factors might cause supervisors to avoid focusing on evidence-based aspects of therapy, thus feeding therapist drift. Suggestions are made for new supervision protocols that consider the supervisor's personal characteristics.

The use of virtual reality (VR) interventions for psychosis is on the rise. As information-processing biases such as overconfidence in memory are likely to be involved in the formation and maintenance of delusions, VR could also be used to correct cognitive distortions and in turn ameliorate delusions. The present study illustrates two case studies in which a VR intervention was employed to reduce delusions by means of correcting experiences. Participants navigated four virtual environments via a head-mounted display (HMD) and computer and were asked to recollect previously seen faces and objects and to rate their response confidence. The scenarios were created to elicit false memories. Immediately after each response, they received feedback to correct possible overconfidence in false memories. We present two case studies to illustrate individual differences. Both participants benefited from the intervention: delusions were reduced from pre- to post-assessment (after 3 weeks) as measured with the Positive and Negative Syndrome Scale and Psychotic Symptom Scale. This was corroborated by results on the Paranoia Checklist and the Community Assessment of Psychic Experiences collected immediately after the session. Immediate effects also showed a reduction in delusion conviction rate. The present study provides preliminary evidence that delusions may be ameliorated by a VR paradigm designed to correct memory overconfidence. Cybersickness emerged as a problem in one of the patients.

Despite an emerging evidence base for the efficacy of supported computerized cognitive behavioural therapy (eCBT), uptake in services has been slow. Therapists’ beliefs about eCBT may constitute a barrier to offering eCBT to clients, but little research has investigated this topic. The aim of this study was to investigate therapist attitudes towards eCBT in one inner-city Improving Access to Psychological Therapies (IAPT) service using a survey design. Data were analysed using descriptive statistics. Thirty-three therapists took part in the study. Although 97% of participants reported that they knew ‘what eCBT involves’, and 62% reported that they were ‘confident to offer eCBT to clients’, only 10% endorsed that ‘there is a strong evidence-base to support the use of eCBT’. Two-thirds of the sample believed that eCBT ‘could be effective for mild and moderate mental health difficulties’, but most participants believed that eCBT would perform ‘worse’ or ‘much worse’ than face-to-face interventions for a range of disorders. Barriers to offering eCBT related predominantly to assumptions about client expectations of therapy, and perceived lack of a therapeutic relationship. Participants identified the provision of training on eCBT for those recommending treatment options to clients as a potential solution. Results from this study highlight therapists’ attitudes to eCBT that might contribute to low uptake rates of eCBT. Particularly, misperceptions about the evidence base for eCBT may be prevalent. Appropriate training and ongoing supervision for therapists are considered as interventions that may increase acceptance of eCBT as a valid treatment option.

Self-esteem refers to how an individual appraises themselves and is associated with good mental health. A number of studies have identified the efficacy of cognitive behavioural therapy (CBT) in the treatment of low self-esteem based on the formulation and treatment trajectory developed by Fennell (1999). However, there has been little empirical enquiry into the efficacy of the programme delivered in primary care. The current study investigated the effectiveness of a CBT programme for low self-esteem delivered within primary care. Fifty-four participants attended a 9-week ‘Boost Your Mood’ group programme. Paired sample t-tests were conducted on pre- and post-group scores on measures of depression, anxiety and self-esteem. Results indicated that there were statistically significant improvements in levels of depression, anxiety and self-esteem post-treatment. Findings are consistent with the suggestion that group CBT may be effective at increasing levels of self-esteem and reducing levels of depression and anxiety when delivered in a primary care setting.

This paper describes three case examples from a recent trial of family intervention specifically designed for people of African-Caribbean descent. These examples, told from the therapists’ perspectives, highlight key components of the intervention and issues that arose in working with this client group. Findings from the study suggest that it is possible to engage this client-group in family therapy similar to traditional evidenced-based family interventions, although as illustrated in the paper, it is important that therapists pay attention to themes that are likely to be particularly pertinent for this group, including experiences of discrimination and mistrust of services. The use of Family Support Members, consisting of members of the person's care team or volunteers recruited from the community, may also help support people to engage in therapy in the absence of biological relatives.

Family accommodation in obsessive-compulsive disorder (OCD) refers to a condition in which a family member assists or facilitates the patient with OCD in performing the compulsion, or provides assurance to minimize or reduce the anxiety level. This condition can be significantly disabling to the individual as well as to the family dynamic. In this case report, a mother of a 14-year-old female patient carried out almost all the compulsive behaviours and rituals for her child. Family-based cognitive behavioural therapy was offered to this case over a 4-month period with a successful treatment outcome. This result provides initial evidence that this type of intervention is suitable for patients from Saudi Arabia, a non-Western culture.