'It's not always textbook social anxiety': A survey-based study investigating the nature of social anxiety and experiences of therapy in autistic people

LAY ABSTRACT

The nature of social anxiety has been widely researched in non-autistic people. This existing research has allowed therapists to develop effective therapy for social anxiety in non-autistic people. Meanwhile, some research suggests that autistic people may have different experiences of anxiety compared to non-autistic people. In addition, there is some evidence that modified therapy may help autistic people with social anxiety, although we also know that many autistic people feel failed by existing mental health services.This article provides a detailed picture of social anxiety in autistic people. This includes similarities and differences compared to non-autistic people. In terms of similarities, people often described feeling afraid that others would judge them, and this would have negative consequences. In terms of differences, autistic people commonly reported a clash between their traits and their social environment, which caused them distress and discomfort. This included factors only rarely reported by non-autistic people (such as struggling with too much sensory stimulation or inaccessible forms of communication and encountering discrimination for these problems). Based on this, we propose a 'distinct' model of social anxiety with particular relevance to autistic people. In addition, many participants reported negative experiences in therapy for social anxiety. They thought therapists wrongly viewed their fears of social situations as irrational and ungrounded. They thought therapists did not adapt the therapy process in an individualised way and did not understand neurodiversity or recognise neurodivergence.Standard approaches for social anxiety may not always suit autistic people, so this needs further exploration. We highlight several practical recommendations for therapists offering therapy for social anxiety to autistic people.

Protocol for the STEADY intervention for type 1 diabetes and disordered eating: Safe management of people with Type 1 diabetes and EAting Disorders studY

This paper describes the protocol to test the feasibility of the Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY) intervention. STEADY is a novel complex intervention for people with type 1 diabetes and disordered eating (T1DE) of mild to moderate severity. The STEADY intervention integrates cognitive behavioural therapy (CBT) with diabetes education, and was developed using Experience-Based Co-Design. METHODS: The feasibility of STEADY will be tested using a randomised controlled feasibility trial. Forty adults with T1DE will be recruited and randomised into the STEADY intervention or treatment as usual control group. We will collect demographic, biomedical and psychometric data, routine glucose metrics and conduct the Structured Clinical Interview for DSM-5. Participants randomised to the STEADY intervention will receive 12 STEADY therapy sessions with a diabetes specialist nurse trained in CBT, delivered via videoconference and an optional smartphone app. The main outcome at 6 months will be the feasibility of STEADY (recruitment, dropout rates, feasibility of delivery). The secondary outcomes are biomedical (HbA1c and glucose time in range) and psychological (person-reported outcome measures in disordered eating, diabetes distress, depression and anxiety). A process evaluation will evaluate the fidelity, feasibility, acceptability and appropriateness of STEADY, and participant experiences. ETHICS AND DISSEMINATION: The protocol was approved by the East of England-Essex Research Ethics Committee (21/EE/0235). Study findings will be shared with study participants and disseminated through peer-reviewed publications and conference presentations.

Satisfaction, engagement, and outcomes in internet-delivered cognitive behaviour therapy adapted for people of diverse ethnocultural groups: an observational trial with benchmarking

Introduction

Depression and anxiety are the most common mental health disorders worldwide. Internet-Delivered Cognitive Behaviour Therapy (ICBT) can reduce barriers to care to broad cross sections of the population. However, People of Diverse Ethnocultural Backgrounds (PDEGs) other than White/Caucasian underutilize mental health services and are under represented in clinical trials of psychological interventions.

Methods

To address this research gap we adapted an evidence-based ICBT program for PDEGs. The current pilot study explores the engagement, satisfaction, and effectiveness in the adapted ICBT program by PDEGs (N=41) when benchmarked against a sample of PDEGs (N=134) who previously completed a non-adapted version of the ICBT program.

Results

An intent-to-treat analyses showed that the adapted ICBT program is effective in reducing anxiety and depression symptoms among PDEGs. Large within-group pre-to post-treatment Cohen's effect sizes of d = 1.23, 95% CI [0.68, 1.77] and d = 1.24, 95% CI [0.69, 1.79] were found for depression and anxiety, respectively. Further, 81.8% of the PDEGs who received the adapted ICBT reported overall satisfaction, 90.9% reported increased confidence in managing symptoms, and 70.7% completed majority of the psychoeducational lessons in the ICBT program.

Conclusion

No statistically significant differences in the clinical outcomes, engagement, and satisfaction were found between the pilot study and benchmark sample. Future directions for ICBT research with PDEGs are described.

Clinical trial registration

https://beta.clinicaltrials.gov/study/NCT05523492, identifier NCT05523492.

Understanding the relationship between social camouflaging in autism and safety behaviours in social anxiety in autistic and non-autistic adolescents

BACKGROUND

Social camouflaging (hereafter camouflaging) in autism includes factors such as masking and compensating for one's neurodevelopmental differences, and to assimilate or 'fit in' with non-autistic peers. Efforts to hide one's authentic self and autism traits (masking) resemble impression management (IM) in safety behaviours identified in Clark and Wells' (1995) cognitive model of social anxiety (SA). This study explores the relationship between camouflaging in autism and safety behaviours in SA among autistic and non-autistic adolescents.

METHODS

One hundred fifteen adolescents (14-19 years) with (n = 61; 36 female) and without (n = 54; 37 female) a clinical diagnosis of autism matched on age and SA symptom severity were recruited from clinics, schools and online. Adolescents completed online measures including autism traits, SA symptoms, camouflaging behaviours, SA-related safety behaviours and SA-related negative cognitions. Partial and bivariate Pearson's correlations and structural equation modelling were used to understand the relationship between camouflaging, safety behaviours, autism traits and SA in both groups. Exploratory factor analysis assessed item-level factor cross-loadings between camouflaging and safety behaviours.

RESULTS

Across both groups, masking and IM were significantly associated with SA symptom severity, not autism traits, via SA-related social cognitions. Exploratory factor analysis indicated construct overlap across masking, assimilation, IM and avoidance behaviours and identified factors analogous to self-focused attention, social avoidance and mental rehearsal identified in the Clark and Wells' (1995) model of SA.

CONCLUSIONS

This is the first study using group-matched design to identify that masking (factor in social camouflaging) and IM both relate to SA in autistic and non-autistic adolescents. Assessment and formulation of construct overlap between masking and IM may inform psychoeducation and adaptation of SA treatment for autistic adolescents.

Trauma therapies for psychosis: A state-of-the-art review

BACKGROUND

Traumatic events, particularly childhood interpersonal victimisation, have been found to play a causal role in the occurrence of psychosis and shape the phenomenology of psychotic experiences. Higher rates of post-traumatic stress disorder (PTSD) and other trauma-related mental health problems are also found in people with psychosis diagnoses compared to the general population. It is, therefore, imperative that therapists are willing and able to address trauma and its consequences when supporting recovery from distressing psychosis.

METHOD

This paper will support this need by providing a state-of-the-art overview of the safety, acceptability and effects of trauma therapies for psychosis.

RESULTS

We will first introduce how seminal cognitive-behavioural models of psychosis shed light on the mechanisms by which trauma may give rise to psychotic experiences, including a putative role for trauma-related emotions, beliefs and episodic memories. The initial application of prolonged exposure and eye movement and desensitation and reprocessing therapy (EMDR) for treating PTSD in psychosis will be described, followed by consideration of integrative approaches. These integrative approaches aim to address the impact of trauma on both post-traumatic stress symptoms and trauma-related psychosis. Integrative approaches include EMDR for psychosis (EMDRp) and trauma-focused Cognitive-Behavioural Therapy for psychosis (tf-CBTp). Finally, emerging dialogic approaches for targeting trauma-related voice-hearing will be considered, demonstrating the potential value of adopting co-produced (Talking with Voices) and digitally augmented (AVATAR) therapies.

CONCLUSION

We will conclude by reflecting on current issues in the area, and implications for research and clinical practice.

Internet-based cognitive behaviour therapy for the prevention, treatment and relapse prevention of eating disorders: A systematic review and meta-analysis

Eating disorders (EDs) are undertreated worldwide. In the UK the lag between recognition of symptoms and treatment ranges from about 15 months to in excess of 2 years. Internet-based cognitive behaviour therapy (ICBT) could be a viable alternative to face-to-face cognitive behaviour therapy (CBT) that avoids the negative impacts of delayed interventions. Based on evidence from randomised controlled trials (RCTs), this systematic review investigated the efficacy of minimally guided self-help ICBT, without face-to-face therapy, for the prevention, treatment and relapse prevention of all types of EDs in adults. The electronic databases MEDLINE, PsychINFO, CENTRAL, Scopus, and Web of Science were searched between 1991 and 2021. Inclusion criteria specified RCTs with ICBT versus inactive comparison groups. The Cochrane Risk of Bias Tool-2 was used for quality assessments. Qualitative synthesis and meta-analyses were conducted. Findings typically showed medium significant beneficial effect sizes for prevention studies ranging from (-0.31 [95% CI: -0.57, -0.06] to -0.47 [95% CI: -0.82, -0.11]) and generally large effect sizes for the treatment studies ranging from (-0.30 [95% CI: -0.57, -0.03] to -1.11 [95% CI: -1.47, -0.75]). Relapse prevention studies yielded mainly small non-significant beneficial effects with significant effect sizes of (-0.29 [95% CI: -0.56, -0.03] and -0.43 [95% CI: -0.70, -0.16]). Only the treatment studies reached clinical significance and cognitive symptoms improved more than behavioural symptoms. ICBT appears to be efficacious for the prevention, treatment and relapse prevention of eating disorders with treatment interventions being the most beneficial. However, the evidence base is very small, particularly for treatment and relapse prevention, indicating the need for more high-quality RCTs.

Stimulus control for insomnia: A systematic review and meta-analysis

Stimulus control (SC) is commonly viewed as an evidence-based treatment for insomnia, but it has not been evaluated comprehensively with modern review and meta-analytic techniques. The aim of the current study was thus to perform a systematic review and meta-analysis of trials that examine the efficacy of stimulus control for insomnia. A systematic search for eligible articles and dissertations was conducted in six online bibliographic databases. The 11 included studies, with the majority published between 1978 and 1998, were randomised controlled and experimental studies in adults, comparing stimulus control for insomnia with passive and active comparators and assessing insomnia symptoms as outcomes. A random effects model was used to determine the standardised mean difference Hedge's g at post-treatment and follow-up for three sleep diary measures: the number of awakenings, sleep onset latency, and total sleep time. A test for heterogeneity was conducted, forest plots were produced, the risk of publication bias was estimated, and the study quality was assessed. In the trials identified, stimulus control resulted in small to large improvements on sleep onset latency and total sleep time, relative to passive comparators (g = 0.38-0.85). Compared with active comparators, the improvements following stimulus control were negligible (g = 0.06-0.30). Although methodological uncertainties were observed in the included trials, stimulus control appears to be an efficacious treatment for insomnia when compared with passive comparators and with similar effects to active comparators. More robust studies are, however, warranted before stronger conclusions are possible to infer.

Assessing clinician competence in the delivery of cognitive-behavioural therapy for eating disorders: development of the Cognitive-Behavioural Therapy Scale for Eating Disorders (CBTS-ED)

Evidence-based cognitive-behaviour therapy for eating disorders (CBT-ED) differs from other forms of CBT for psychological disorders, making existing generic CBT measures of therapist competence inadequate for evaluating CBT-ED. This study developed and piloted the reliability of a novel measure of therapist competence in this domain-the Cognitive Behaviour Therapy Scale for Eating Disorders (CBTS-ED). Initially, a team of CBT-ED experts developed a 26-item measure, with general (i.e. present in every session) and specific (context- or case-dependent) items. To determine statistical properties of the measure, nine CBT-ED experts and eight non-experts independently observed six role-played mock CBT-ED therapy sessions, rating the therapists' performance using the CBTS-ED. The inter-item consistency (Cronbach's alpha and McDonald's omega) and inter-rater reliability (ICC) were assessed, as appropriate to the clustering of the items. The CBTS-ED demonstrated good internal consistency and moderate/good inter-rater reliability for the general items, at least comparable to existing generic CBT scales in other domains. An updated version is proposed, where five of the 16 "specific" items are reallocated to the general group. These preliminary results suggest that the CBTS-ED can be used effectively across both expert and non-expert raters, though less experienced raters might benefit from additional training in its use.

"The early bird catches the worm"-Prediction of early response and its importance for treatment outcome in a naturalistic setting of cognitive behaviour therapy

OBJECTIVE

Knowledge about predictors of early response (ER) remains limited. This study examined patient, process, and therapist variables to predict ER in a naturalistic setting.

RESEARCH DESIGN AND METHODS

Data from 493 psychotherapy outpatients were analysed. ER was defined by a ≥25% reduction in general psychological distress (ER percent) and by the reliable change index (ER RCI) within the first 10 sessions measured by the Brief Symptom Inventory-18. ER prediction was determined using logistic regression. General psychological distress (GSI) throughout treatment in patients with and without ER was modelled using a multilevel linear model. This model aimed to predict GSI over treatment using repeated measurements, considering group affiliation (ER percent vs. no ER percent), controlled for other predictors.

RESULTS

The prevalence of ER percent and ER RCI were 63.6% and 47.5%, respectively. GSI and therapeutic relationship significantly predicted ER (ER percent: χ2 (6) 70.32, p < .001, Nagelkerkes R2  = .19; ER RCI: χ2 (6) 134.71, p < .001, Nagelkerkes R2  = .35). Patients who rated the therapeutic relationship more positively were more likely to achieve ER (OR = 1.10). Difference in outcomes between patients with and without ER during treatment was influenced by factors such as therapeutic relationship, GSI, therapist experience, and mental comorbidities. Including these variables improved the predictive model from AIC = 17,042.98 to AIC = 16,730.24.

CONCLUSION

The therapeutic relationship is a crucial predictor of ER. Patients achieving ER tend to have better outcome than those without ER. The early phase of therapy warrants particular attention to enhance psychotherapy outcomes.

Predictors of homework engagement in group CBT for social anxiety: client beliefs about homework, its consequences, group cohesion, and working alliance

OBJECTIVE

Group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) is effective, but little data exist on generic relational components of the therapeutic process, such as group cohesion and therapy alliance, and central CBT-specific components such as homework engagement, beliefs, and perceived consequences. The aim of this study was to investigate the relationships between homework, group cohesion, and working alliance during group CBT for social anxiety disorder.

METHOD

Participants (N = 105) with SAD engaged in 12 sessions of group CBT. Measures of homework, working alliance, and group cohesion were completed at multiple points throughout treatment. Random-intercept cross-lagged panel models were used to evaluate the prospective relationships between measures.

RESULTS

Prospective relationships between the homework outcomes did not vary throughout the treatment period, with the only significant relationships seen between the random intercepts ("trait" levels). Homework beliefs were a significant negative predictor of future group cohesion, but only in mid- to late-treatment. Homework consequences and working alliance were significantly and positively predictive of each other throughout therapy.

CONCLUSION

Early homework engagement is associated with higher engagement throughout therapy. Working alliance and homework engagement are important to bolster early in group CBT.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12616000579493..

The relationships among working alliance, group cohesion and homework engagement in group cognitive behaviour therapy for social anxiety disorder

OBJECTIVE

Few studies have investigated the role of generic relational factors, such as group cohesion and working alliance, in group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD). The aim of this study was to examine the temporal associations among working alliance, group cohesion, and an index of a CBT-specific factor, homework engagement, as correlates of fear of negative evaluation and symptoms of social anxiety in group CBT for SAD.

METHOD

There were 105 participants with a diagnosis of social anxiety disorder who were randomly assigned to 12 sessions of group imagery-enhanced or standard CBT. Participants completed measures at various time points during the 12-session interventions, and the relationship among variables was examined through random-intercept cross-lagged panel models.

RESULTS

Group cohesion was significantly associated with social anxiety symptoms at the end of treatment, however there was no significant relationship with working alliance. Greater homework engagement predicted lower social interaction anxiety, but only during mid-treatment.

CONCLUSION

The results highlight the importance of supporting group cohesion and maximising homework engagement during core components of social anxiety treatment such as behavioural experiments.

Cognitive factors and processes in models of insomnia: A systematic review

Cognition is central to the experience of insomnia. Although unhelpful thoughts about and around insomnia are a primary treatment target of cognitive behaviour therapy for insomnia, cognitive constructs are termed and conceptualised differently in different theories of insomnia proposed over the past decades. In search of consensus in thinking, the current systematic review identified cognitive factors and processes featured in theoretical models of insomnia and mapped any commonality between models. We systematically searched PsycINFO and PubMed for published theoretical articles on the development, maintenance and remission of insomnia, from inception of databases to February, 2023. A total of 2458 records were identified for title and abstract screening. Of these, 34 were selected for full-text assessment and 12 included for analysis and data synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified nine distinguishable models of insomnia published between 1982 and 2023 and extracted 20 cognitive factors and processes featured in these models; 39 if sub-factors were counted. After assigning similarity ratings, we observed a high degree of overlap between constructs despite apparent differences in terminologies and measurement methods. As a result, we highlight shifts in thinking around cognitions associated with insomnia and discuss future directions.

Guided versus self-guided internet delivered cognitive behavioural therapy for diagnosed anxiety and related disorders: a preliminary meta-analysis

Guided and self-guided internet-delivered cognitive-behavioural therapy (ICBT) has been demonstrated to be efficacious in the treatment of anxiety and related disorders (ARDs). The aim of the current study was to examine the efficacy of guided and self-guided ICBT for adults diagnosed with ARDs using a meta-analytic synthesis of randomised controlled trials directly comparing the two treatment approaches. Eleven studies (n = 1414) were included. There was a small, but significantly pooled between-group effect size at post-treatment (g = 0.16; 95% CI: 0.03-0.28) favouring guided ICBT. At follow-up, the between-group effect size was small and non-significant (g = 0.13; 95% CI: -0.04-0.30). Gender distribution moderated outcome at post-treatment (higher proportions of females resulted in a smaller between-group effect size). Type of support provided in the guided-treatment arm moderated treatment outcome at follow-up (those receiving synchronous support had a larger between-group effect size). Amount of guidance in the guided-treatment arm moderated effect sizes at post-treatment and follow-up (more guidance leading to larger between-group effect sizes). Automated reminders, disorder type, and treatment length did not moderate outcomes. The results suggest that guided and self-guided ICBT interventions result in similar outcomes, however guided interventions may be marginally more effective in the short term.

What if we have too many models of worry and GAD? - ADDENDUM

BACKGROUND AND AIMS

It is almost 40 years since Borkovec et al. (1983) provided the definition of worry that has guided theory, research and treatment of Generalized Anxiety Disorder (GAD). This review first considers the relative paucity of research but the proliferation of models. It then considers nine models from 1994 to 2021 with the aim of understanding why so many models have been developed.

METHODS AND RESULTS

By extracting and coding the components of the models, it is possible to identify similarities and differences between them. While there are a number of unique features, the results indicate a high degree of similarity or overlap between models. The question of why we have so many models is considered in relation to the nature of GAD. Next, the treatment outcome literature is considered based on recent meta-analyses. This leads to the conclusion that while efficacy is established, the outcomes for the field as a whole leave room for improvement. While there may be scope to improve outcomes with existing treatments, it is argued that rather than continue in the same direction, an alternative is to simplify models and so simplify treatments.

DISCUSSION

Several approaches are considered that could lead to simplification of models resulting in simpler or single-strand treatments targeting specific processes. A requirement for these approaches is the development of brief assessments of key processes from different models. Finally, it is suggested that better outcomes at the group level may eventually be achieved by narrower treatments that target specific processes relevant to the individual.

Toward a synthesis of cognitive behaviour therapy via component analysis of self-regulation

The cognitive behavioural therapies (CBTs) are the choice psychotherapies for many clinicians treating a wide range of adult psychological disorders including various anxieties, mood, substance use, eating, schizophrenia and personality-related. Empirical research in the CBTs is ever increasing, and the accumulating evidence supporting efficacious treatments is substantial and well documented. However, with prolific research comes a seemingly accelerating and worrying trend of purportedly different therapies, and numerous hybrids and combinations of therapies and techniques. For many clinicians this is increasingly confusing and not helpful in clinical practice. This article is a critique of current trends and directions in clinical research, which show signs of limited effectiveness, fragmentation, and obfuscation. An alternative strategy is proposed-examining transdiagnostic therapeutic effects, which appear related to treating pervasive dysregulated emotions, with component analyses of four principal self-regulation components (viz., self-monitoring; functional analysis; identifying values, goals and treatment-plans; and feedback). Such a strategy is likely to lead to a more coherently synthesized and effective CBT.

Online versus in-person delivery of cognitive behaviour therapy for obsessive compulsive disorder: An examination of effectiveness

Cognitive behavioural therapy (CBT) including exposure and response prevention is the first-line psychological treatment for obsessive compulsive disorder (OCD). Given changes in the clinical landscape, there are increasing efforts to evaluate its effectiveness in online contexts. Mirroring the traditional in-person delivery, few studies have assessed the role of therapist-guided, manual-based CBT for OCD delivered in real-time via videoconferencing methods. The present study sought to fill this gap by comparing in-person and online delivery of group-based CBT for the treatment of OCD. A convenience sample of participants with moderate to severe OCD (n = 144) were recruited from a naturalistic database from two large OCD specialty assessment and treatment centres. Patients received group-based CBT that was provided in-person (pre-COVID-19 pandemic; March 2018 to March 2020) or online via videoconferencing (during the COVID-19 pandemic; March 2020 to April 2021). In both delivery methods, treatment consisted of 2-h weekly sessions led by trained clinicians. Analyses revealed that, regardless of treatment modality, both in-person and online groups demonstrated significant, reliable, and statistically equivalent improvements in OCD symptoms post-treatment. Videoconferenced, clinician-led CBT may be a promising alternative to in-person delivery for those with moderate to severe OCD symptoms.

Trait and symptom change in group cognitive behaviour therapy for anxiety and depression

Personality traits underlying both anxiety disorders and depression are more malleable than previously presumed. This study examined associations between changes in personality traits (i.e. negative affectivity and detachment) and alleviation of anxiety and depression symptoms following cognitive behaviour therapy (CBT). We hypothesized that decreases in negative affectivity would predict alleviation of depression and anxiety symptoms and decreases in detachment would predict decreases in depression and, to a lesser degree, anxiety symptoms. Data (N = 156) were collected in a randomized controlled trial comparing transdiagnostic and diagnosis-specific group CBT for patients with major depressive disorder, social anxiety disorder, panic disorder or agoraphobia. We assessed personality traits using the Personality Inventory for DSM-5 (PID-5) and symptoms with the Hopkins Symptom Checklist 25-item scale (SCL). Prediction was based on regression analyses. We found that decreases in negative affectivity predicted lower levels of depression and anxiety symptoms while decreases in detachment only predicted lower levels of depression symptoms. The findings substantiate current efforts to explicate the dynamic interplay between personality traits and symptoms and support the existing focus on targeting negative affectivity and detachment in therapy for anxiety disorders and depression. The trial is registered at clinicaltrials.gov (ID NCT02954731).

Effectiveness of primary care interventions in conjointly treating comorbid chronic pain and depression: a systematic review and meta-analysis

BACKGROUND

Chronic pain and depression are highly comorbid, but the lack of consensus on the best treatment strategies puts patients at high risk of suboptimal care-coordination as well as health and social complications. Therefore, this study aims to quantitatively assesses how effective different primary care interventions have been in treating the comorbid state of chronic pain and depression. In particular, this study evaluates both short-term outcomes-based specifically on measures of chronic pain and depression during an intervention itself-and long-term outcomes or measures of pain and depression in the months after conclusion of the formal study intervention.

METHODS

This study is a systematic review and meta-analysis of randomised-controlled trials (RCTs) enrolling patients with concurrent chronic pain and depression. Intensity and severity of pain and depression symptoms were the primary outcomes. The main inclusion criteria were RCTs that: (i) enrolled patients diagnosed with depression and chronic pain, (ii) occurred in primary care settings, (iii) reported baseline and post-intervention outcomes for chronic pain and depression, (iv) lasted at least 8 weeks, and (v) used clinically validated outcome measures. Risk of bias was appraised with the Risk of Bias 2 tool, and GRADE guidelines were used to evaluate the quality of evidence.

RESULTS

Of 692 screened citations, 7 multicomponent primary care interventions tested across 891 patients were included. Meta-analyses revealed significant improvements in depression at post-intervention (SMD = 0.44, 95% CI [0.17, 0.71], P = 0.0014) and follow-up (SMD = 0.41, 95% CI [0.01, 0.81], P = 0.0448). Non-significant effects were observed for chronic pain at post-intervention (SMD = 0.27, 95% CI [-0.08, 0.61], P = 0.1287) and follow-up (SMD = 0.13, 95% CI [-0.3, 0.56], P = 0.5432).

CONCLUSIONS

Based on the results of the meta-analysis, primary care interventions largely yielded small to moderate positive effects for depressive symptoms and no significant effects on pain. In one study, stepped-care to be more effective in treatment of comorbid chronic pain and depression than other interventions both during the intervention and upon post-intervention follow-up. As such, depression appears more amenable to treatment than pain, but the number of published RCTs assessing both conditions is limited. More research is needed to further develop optimal treatment strategies.

Development of a Brief Psychological Trauma Intervention for Child Sexual Abuse in India

Despite the alarming increase in incidences of child sexual abuse (CSA) in India, intervention research remains preliminary and generic. Although Cognitive Behavior Therapy (CBT) has been found to be consistently effective in addressing the adverse consequences of CSA, none of the cultural adaptations of CBT have been evidenced in India so far. Hence, the present study was conceived to develop a CSA-focused brief CBT intervention for children between 7 and 13 years of age. Intervention development progressed through four steps: 1) a systematic review of literature; 2) a qualitative study, including focused group discussions, conducted with 19 mental health professionals; 3) development of the intervention; 4) expert evaluation and finalization. We developed the intervention with three key elements: restoring the child's functioning, assisting the child in processing, and managing trauma effectively and initiating the process of growth. The intervention predominantly followed the CBT framework while integrating culturally specified techniques. The intervention contains 8 modules and 18 sub-modules structured around three phases of intervention. The intervention is spread across a minimum of 6 required sessions and a maximum of 12 session held twice weekly for approximately 90-120 min duration. A list of 35 activities corresponding to each phase and sub-module of the present intervention has been designed as an intervention workbook. In conclusion, the newly developed intervention is a manualised, culturally competent, psychological intervention developed within the CBT framework for children aged 7-13 years with experience of CSA. The next phases include piloting intervention for feasibility.

Defining work-focused cognitive behavioural therapy (W-CBT) and whether it is effective at facilitating return to work for people experiencing mental health conditions: A systematic review and narrative synthesis

It is unclear what constitutes Work Focused Cognitive Behaviour Therapy (W-CBT). This review sought to define W-CBT and ascertain its effectiveness at facilitating return to work (RTW) for people experiencing mental health conditions. A systematic review and narrative synthesis were undertaken. Five databases were searched (Medline, ProQuest, PsychInfo, Scopus, and Web of Science). English publications with an intervention combining CBT with RTW were selected. Quality checklists from the Joanna Briggs Institute were applied. Searching yielded 16,863 results. 23 moderate-to-high quality studies from 25 articles were included (13 experimentally designed studies, 3 pilots/case studies and 7 reviews). Results indicated W-CBT is effective at facilitating RTW for mild-to-moderate mental health conditions. For a program to be labelled W-CBT it is recommended it is (1) a stand-alone intervention; (2) delivered with an understanding RTW is the goal; and, (3) the CBT components are always framed by matters, subjects and contexts related to work.

Exploring the role of CBT in the self-management of type 2 diabetes: A rapid review

Background

Type 2 diabetes has been recognised as a global health concern: one that requires intervention to lessen the incumbrance caused by the chronic illness. This rapid review was conducted to determine the scientific evidence available on how Cognitive Behaviour Therapy (CBT) interventions improved the self-management of individuals with type 2 diabetes.

Aim

The aim of the review was to synthesise current scientific evidence regarding CBT-based interventions and self-management practices.

Method

The rapid review served as a framework to appraise current national and international literature. The researchers used Google Scholar, Journal Storage (JSTOR), PsycINFO, APA PsycArticles, SAGE journals and EBSCO Discovery Services to search for relevant studies. This was performed by employing keywords. Nine relevant studies were identified. The studies were heterogenous in methodology. Seven of the nine studies were conducted in developing countries.

Results

The study found that the context of developmental countries plays a significant role in the development of type 2 diabetes and requires tailored intervention because of socio-economic variabilities. The main themes identified in relation to improving self-management included: the characteristics of the CBT-based interventions, namely the format, duration, and outcomes, and identifying the techniques and components used in the CBT-based interventions.

Conclusion

The review emphasised the need to further investigate the role of CBT in improving self-management of type 2 diabetes, especially in a South African context.

Contribution

The review summarised the techniques that have proven to be effective for the self-management of type 2 diabetes.

Overcoming death anxiety: a phase I trial of an online CBT program in a clinical sample

BACKGROUND

Growing research indicates that death anxiety is implicated in many mental health conditions. This increasing evidence highlights a need for scalable, accessible and cost-effective psychological interventions to reduce death anxiety.

AIMS

The present study outlines the results of a phase I trial for one such treatment: Overcome Death Anxiety (ODA). ODA is the first CBT-based online intervention for fears of death, and is an individualised program requiring no therapist guidance.

METHOD

A sample of 20 individuals with various mental health diagnoses commenced the ODA program. Death anxiety was assessed at baseline and at post-intervention. Depression, anxiety and stress were also measured.

RESULTS

In total, 50% (10/20) reached the end of the program and completed post-treatment questionnaires. Of these, 60% (6/10) showed a clinically reliable reduction in their overall death anxiety, and 90% (9/10) showed a reduction on at least one facet of death anxiety. There were no adverse events noted.

CONCLUSIONS

ODA appears to be a safe and potentially effective treatment for death anxiety. The findings have provided initial evidence to support a randomised controlled trial using a larger sample, to further examine the efficacy of ODA.

Internet-delivered cognitive behavioural therapy for chronic fatigue among adolescents with a chronic medical condition: a single case study

BACKGROUND

Severe fatigue is a prominent symptom among adolescents with a chronic medical condition, with major impact on their well-being and daily functioning. Internet-based cognitive behavioural therapy (I-CBT) is a promising treatment for severe fatigue among adolescents with a chronic medical condition, but its effectiveness has not been studied.

AIMS

We developed an I-CBT intervention for disabling fatigue in a chronic medical condition and tested its feasibility and effectiveness in an adolescent with an immune dysregulation disorder (IDD), namely juvenile idiopathic arthritis (JIA).

METHOD

The application of I-CBT is illustrated through a clinical case study of a 15-year-old girl with JIA and chronic severe fatigue. An A-B single case experimental design was used with randomization of the waiting period prior to start of the intervention. Outcomes were weekly measures of fatigue severity, physical functioning, school absence and pain severity.

RESULTS

Fatigue severity significantly decreased following I-CBT. Improvements were observed towards increased school attendance and improved physical functioning following the intervention, but these effects were too small to become significant.

CONCLUSIONS

The study provides preliminary support for the feasibility and effectiveness of the application of I-CBT for severe fatigue in adolescents with a long-term medical condition.

Three ways to change your mind: an epistemic framework for cognitive interventions

Belief change is an important element of much CBT, yet very little consideration has been given to the theories of knowledge, the epistemology, which underlie this process. This article argues that understanding the epistemic basis of the techniques therapists use can help guide their choice of interventions. The empirical evidence for cognitive restructuring is considered, the importance of distancing and decentring noted, and three epistemic styles are identified: the rational-empiricist, pragmatist and 'constructivist' approaches. Different schools of CBT emphasise one or more of these. The article describes how these epistemes can be used to make decisions about which cognitive interventions to use, particularly when clients may be sceptical about reality testing because of entrenched beliefs or real-life adversity.

Cost-effectiveness of transdiagnostic group cognitive behavioural therapy for anxiety disorders v. treatment as usual: economic evaluation of a pragmatic randomized controlled trial over an 8-month time horizon using self-reported data

BACKGROUND

This economic evaluation supplements a pragmatic randomized controlled trial conducted in community care settings, which showed superior improvement in the symptoms of adults with anxiety disorders who received 12 sessions of transdiagnostic cognitive-behavioural group therapy in addition to treatment as usual (tCBT + TAU) compared to TAU alone.

METHODS

This study evaluates the cost-utility and cost-effectiveness of tCBT + TAU over an 8-month time horizon. For the reference case, quality-adjusted life years (QALYs) obtained using the EQ-5D-5L, and the health system perspective were chosen. Alternatively, anxiety-free days (AFDs), derived from the Beck Anxiety Inventory, and the limited societal perspective were considered. Unadjusted incremental cost-effectiveness/utility ratios were calculated. Net-benefit regressions were done for a willingness-to-pay (WTP) thresholds range to build cost-effectiveness acceptability curves (CEAC). Sensitivity analyses were included.

RESULTS

Compared to TAU (n = 114), tCBT + TAU (n = 117) generated additional QALYs, AFDs, and higher mental health care costs from the health system perspective. From the health system and the limited societal perspectives, at a WTP of Can$ 50 000/QALY, the CEACs showed that the probability of tCBT + TAU v. TAU being cost-effective was 97 and 89%. Promising cost-effectiveness results using AFDs are also presented. The participation of therapists from the public health sector could increase cost-effectiveness.

CONCLUSIONS

From the limited societal and health system perspectives, this first economic evaluation of tCBT shows favourable cost-effectiveness results at a WTP threshold of Can$ 50 000/QALY. Future research is needed to replicate findings in longer follow-up studies and different health system contexts to better inform decision-makers for a full-scale implementation.

Development of competence in cognitive behavioural therapy and the role of metacognition among clinical psychology and psychotherapy students

BACKGROUND

There is a paucity of research on therapist competence development following extensive training in cognitive behavioural therapy (CBT). In addition, metacognitive ability (the knowledge and regulation of one's cognitive processes) has been associated with learning in various domains but its role in learning CBT is unknown.

AIMS

To investigate to what extent psychology and psychotherapy students acquired competence in CBT following extensive training, and the role of metacognition.

METHOD

CBT competence and metacognitive activity were assessed in 73 psychology and psychotherapy students before and after 1.5 years of CBT training, using role-plays with a standardised patient.

RESULTS

Using linear mixed modelling, we found large improvements of CBT competence from pre- to post-assessment. At post-assessment, 72% performed above the competence threshold (36 points on the Cognitive Therapy Scale-Revised). Higher competence was correlated with lower accuracy in self-assessment, a measure of metacognitive ability. The more competent therapists tended to under-estimate their performance, while less competent therapists made more accurate self-assessments. Metacognitive activity did not predict CBT competence development. Participant characteristics (e.g. age, clinical experience) did not moderate competence development.

CONCLUSIONS

Competence improved over time and most students performed over the threshold post-assessment. The more competent therapists tended to under-rate their competence. In contrast to what has been found in other learning domains, metacognitive ability was not associated with competence development in our study. Hence, metacognition and competence may be unrelated in CBT or perhaps other methods are required to measure metacognition.

Is schema therapy effective for adults with eating disorders? A systematic review into the evidence

Commonly developing in adolescence and following a chronic course, eating disorders are life-threatening psychological disorders and typically very difficult to treat despite the body of research exploring treatment options. Due to the high levels of severity and the enduring nature of eating disorders, schema therapy has been proposed as a more effective treatment than cognitive behaviour therapy. To assess the effectiveness of schema therapy in adults with eating disorders, the present systematic review was designed in accordance with PRISMA guidelines. A structured search of electronic databases and grey literature was conducted, and the Mixed Methods Assessment Tool was used to assess the quality of each article. Four articles including 151 participants were found which demonstrated that schema therapy is effective at reducing eating disorder symptoms and behaviour and general psychopathology. Despite the limitations of this study, including the scarcity of research available and varying methodologies used, the present systematic review found evidence supporting the use of schema therapy in patients with eating disorders, particularly those experiencing severe and enduring forms.

Accessibility of Psychological Treatments for Bulimia Nervosa: A Review of Efficacy and Engagement in Online Self-Help Treatments

Bulimia nervosa is an eating disorder characterised by marked impairment to one's physical health and social functioning, as well as high rates of chronicity and comorbidity. This literature review aims to summarise existing academic research related to the symptom profile of BN, the costs and burden imposed by the illness, barriers to the receipt of care, and the evidence base for available psychological treatments. As a consequence of well-documented difficulties in accessing evidence-based treatments for eating disorders, efforts have been made towards developing innovative, diverse channels to deliver treatment, with several of these attempting to harness the potential of digital platforms. In response to the increasing number of trials investigating the utility of online treatments, this paper provides a critical review of previous attempts to examine digital interventions in the treatment of eating disorders. The results of a focused literature review are presented, including a detailed synthesis of a knowledgeable selection of high-quality articles with the aim of providing an update on the current state of research in the field. The results of the review highlight the potential for online self-help treatments to produce moderately sized reductions in core behavioural and cognitive symptoms of eating disorders. However, concern is raised regarding the methodological limitations of previous research in the field, as well as the high rates of dropout and poor adherence reported across most studies. The review suggests directions for future research, including the need to replicate previous findings using rigorous study design and methodology, as well as further investigation regarding the utility of clinician support and interactive digital features as potential mechanisms for offsetting low rates of engagement with online treatments.

The moderating and mediating role of telepresence and cognitive change in cognitive behaviour therapy delivered via videoconference

In this study, we combined the results of two controlled trials and examined the relationships between working alliance, telepresence, cognitive change and treatment outcome. Sixty-five participants with a primary diagnosis of generalized anxiety disorder (GAD) or panic disorder with agoraphobia (PDA) received cognitive behaviour therapy delivered via videoconference. Participants completed measures of working alliance and telepresence after three psychotherapy sessions. They also completed measures of treatment outcome and dysfunctional beliefs (cognitive change) specific to PDA and GAD at pretreatment and posttreatment. Results revealed that telepresence at the fifth session moderated the relationship between the working alliance at the first and fifth sessions. As telepresence increased, its impact on the working alliance diminished. Cognitive change mediated the relationship between the working alliance at the fifth session and treatment outcome.

Smartphone-based behaviour analysis for challenging behaviour in intellectual and developmental disabilities and autism spectrum disorder - Study protocol for the ProVIA trial

Background

Challenging behaviour (CB) comprises various forms of aggressive and problematic behaviours frequently occurring in children with intellectual and developmental disability (IDD) or autism spectrum disorder (ASD). CB often arises from impaired communication or problem solving skills. It is often met with coercive measure due to a lack of alternative strategies on the part of the caregiver, while it also impacts on the caregivers due to the exposure to physical harm and high levels of stress. Within the ProVIA project we developed a smartphone-based tool for caregivers of children with IDD and/or ASD to prevent and modify CB. The ProVIA app systematically helps caregivers to identify specific causes of CB and provides individualised practical guidance to prevent CB and consecutive coercive measures, thus aiming to improve the health and well-being of the children and caregivers.

Methods

In this uncontrolled open trial we will enrol N = 25 caregivers of children aged 3-11 years with a diagnosis of IDD and/or ASD. Participants will use the ProVIA-Kids app for 8 weeks. During the intervention phase, participants will conduct behaviour analyses after each instance of CB. The app will summarise the identified putative causes for the CB in each situation, and provide recommendations regarding the handling and prevention of CB. Furthermore, the app will aggregate data from all available behaviour analyses and identify the most relevant (i.e., most frequently reported) risk factors. Measurement points are at baseline (T0), after the intervention (T1) and 12 weeks after the end of the intervention (follow-up; T2). The primary outcome is the absolute change in parental stress (EBI total scale) between T0 and T1. Further aspects of interest are changes in CB severity and frequency, caregiver mood, satisfaction with the parenting role (EFB-K total scale) and experienced parenting competence (FKE total scale). Pre-post comparisons will be analysed with paired sample t-tests.

Discussion

ProVIA is pioneering structured behaviour analysis via smartphone, assessing predefined causes of CB and providing feedback and recommendations. If this approach proves successful, the ProVIA-Kids app will be a valuable tool for caregivers to prevent CB and improve their own as well as the children's quality of life.

Trial registration

The study is registered at https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_IDDRKS00029039 (registered May 31, 2022).

The service user experience of SlowMo therapy: A co-produced thematic analysis of service users' subjective experience

OBJECTIVES

SlowMo is the first blended digital therapy for paranoia, showing significant small-moderate reductions in paranoia in a recent large-scale randomized controlled trial (RCT). This study explored the subjective service-user experience of the SlowMo therapy content and design; the experience of the blended therapy approach, including the triangle of the therapeutic alliance; and the experience of the digital aspects of the intervention.

DESIGN

Qualitative co-produced sub-study of an RCT.

METHODS

Participants were 22 adult service users with schizophrenia-spectrum psychosis and persistent distressing paranoia, who completed at least one SlowMo therapy session and a 24-week follow-up, at one of 3 sites in Oxford, London, and Sussex, UK. They were interviewed by peer researchers, using a topic guide co-produced by the Patient and Public Involvement (PPI) team. The transcribed data were analysed thematically. Multiple coding and triangulation, and lay peer researcher validation were used to reach a consensus on the final theme structure.

RESULTS

Six core themes were identified: (i) starting the SlowMo journey; (ii) the central role of the supportive therapist; (iii) slowing things down; (iv) value and learning from social connections; (v) approaches and challenges of technology; and (vi) improvements in paranoia and well-being.

CONCLUSIONS

For these service users, slowing down for a moment was helpful, and integrated into thinking over time. Learning from social connections reflected reduced isolation, and enhanced learning through videos, vignettes, and peers. The central role of the supportive therapist and the triangle of alliance between service user, therapist, and digital platform were effective in promoting positive therapeutic outcomes.

Group intervention for sexual minority adults with common mental health problems: preliminary evaluation

BACKGROUND

Stigma against lesbian, gay, bisexual or queer (LGBQ) people may increase their risk of mental illness and reduce their access to and/or benefit from evidence-based psychological treatments. Little is known about the feasibility, acceptability and effectiveness of adapted psychological interventions for sexual minority individuals in the UK.

AIMS

To describe and evaluate a novel LGBQ Wellbeing group therapy for sexual minority adults experiencing common mental health problems, provided in a UK Improving Access to Psychological Therapies (IAPT) service.

METHOD

An eight-session LGBQ Wellbeing group intervention was developed drawing on CBT and LGBQ affirmative principles. We compare the socio-demographic and clinical characteristics of patients who completed and dropped out of the groups, and explore changes in self-reported symptoms of depression, anxiety and functional impairment.

RESULTS

Over eight courses provided, 78 service-users attended at least one session, of whom 78.2% completed the intervention (drop-out rate 21.8%). Older participants were more likely to drop out. There was a lower proportion of female and bisexual or ethnic/racial minority individuals than would be expected. There were significant reductions in severity of depression, anxiety and functional impairment following the group, and more than half of those who completed the intervention needed no further treatment.

CONCLUSIONS

There was preliminary evidence of the feasibility of, and potential clinical benefit in, a group therapy intervention for sexual minority adults experiencing common mental health problems. Future research should investigate access and outcomes for participants with additional social disadvantage, e.g. those who are female, older, bisexual or ethnic/racial minority.

Internet-delivered cognitive behaviour therapy for post-traumatic stress disorder: a randomised controlled trial and outcomes in routine care

BACKGROUND

Despite its potential scalability, little is known about the outcomes of internet-based cognitive behaviour therapy (iCBT) for post-traumatic stress disorder (PTSD) when it is provided with minimal guidance from a clinician.

AIM

To evaluate the outcomes of minimally guided iCBT for PTSD in a randomised control trial (RCT, Study 1) and in an open trial in routine community care (Study 2).

METHOD

A RCT compared the iCBT course (n=21) to a waitlist control (WLC, n=19) among participants diagnosed with PTSD. The iCBT group was followed up 3 months post-treatment. In Study 2, treatment outcomes were evaluated among 117 adults in routine community care. PTSD symptom severity was the primary outcome in both studies, with psychological distress and co-morbid anxiety and depressive symptoms providing secondary outcomes.

RESULTS

iCBT participants in both studies experienced significant reductions in PTSD symptom severity from pre- to post-treatment treatment (within-group Hedges' g=.72-1.02), with RCT findings showing maintenance of gains at 3-month follow-up. The WLC group in the RCT also significantly improved, but Study 1 was under-powered and the medium between-group effect favouring iCBT did not reach significance (g=0.64; 95% CI, -0.10-1.38).

CONCLUSIONS

This research provides preliminary support for the utility of iCBT for PTSD when provided with minimal clinician guidance. Future studies are needed to clarify the effect of differing levels of clinician support on PTSD iCBT outcomes, as well as exploring how best to integrate iCBT into large-scale, routine clinical care of PTSD.

Cognitive behaviour therapy in adults with spinal cord injury: A scoping review

AIM

The aim of this study is to report on the extent and range of the research evaluating cognitive behaviour therapy (CBT) in adults with spinal cord injury.

BACKGROUND

Spinal cord injury is a devastating event that can lead to permanent neurologic deficit. Compared with the average person, spinal cord injury (SCI) patients are at twice the risk of developing mood disorders, highlighting vulnerability of SCI patients' mental states which can be easily hurt. CBT is the most commonly used psychosocial intervention.

DESIGN

This was a scoping review.

REVIEW METHOD

Five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and Airiti Library) were searched for articles published between 1990 and 2021. Google Scholar was utilized to search additional articles listed in the reference lists of included articles.

RESULTS

Overall, 16 articles met the inclusion criteria, with the majority reporting on CBT, that focused on psychological distress and neuropathic pain. The core concept of intervention included disease identification, cognitive distortion/modification and coping strategies.

CONCLUSIONS

There were significant knowledge gaps on the interventions' content and effectiveness for psychological distress of persons with SCI. Development of multifaceted cognitive behaviour interventions, especially to strengthen self-identity and to inspire patients' hope, is needed. Further research is required to investigate the long-term effectiveness of CBT.

Evaluating a Novel Treatment Adapting a Cognitive Behaviour Therapy Approach for Sexuality Problems after Traumatic Brain Injury: A Single Case Design with Nonconcurrent Multiple Baselines

There has been little progress in development of evidence-based interventions to improve sexuality outcomes for individuals with traumatic brain injury (TBI). This study aimed to evaluate the preliminary efficacy of an individualised intervention using a cognitive behaviour therapy (CBT) framework to treat sexuality problems after TBI. A nonconcurrent multiple baseline single-case design with 8-week follow-up and randomisation to multiple baseline lengths (3, 4, or 6 weeks) was repeated across nine participants (five female) with complicated mild–severe TBI (mean age = 46.44 years (SD = 12.67), mean post-traumatic amnesia = 29.14 days (SD = 29.76), mean time post-injury = 6.56 years (median = 2.50 years, SD = 10.11)). Treatment comprised eight weekly, individual sessions, combining behavioural, cognitive, and educational strategies to address diverse sexuality problems. Clinical psychologists adopted a flexible, patient-centred, and goal-orientated approach whilst following a treatment guide and accommodating TBI-related impairments. Target behaviour was subjective ratings of satisfaction with sexuality, measured three times weekly. Secondary outcomes included measures of sexuality, mood, self-esteem, and participation. Goal attainment scaling (GAS) was used to measure personally meaningful goals. Preliminary support was shown for intervention effectiveness, with most cases demonstrating sustained improvements in subjective sexuality satisfaction and GAS goal attainment. Based on the current findings, larger clinical trials are warranted.

Treatment experiences during a cognitive behaviour therapy group intervention targeting repetitive negative thinking: A qualitative study

OBJECTIVES

Treatment of repetitive negative thinking (RNT) focuses rather on individual than group cognitive behaviour therapy (CBT) treatment. Additionally, little is known on how clients experienced these interventions. This study investigates clients' experiences on participating in a CBT group intervention targeting RNT (RNT-G).

DESIGN

Of the 80 participants, 11 were randomly selected for an in-depth, semi-structured interview after treatment. Interviews focused on what participants experienced as important on group aspects, offered interventions, homework tasks, and possible changes.

METHODS

All participants were adults, diagnosed with major depressive disorder and/or generalized anxiety disorder and being currently in mental health care treatment. After transcribing the interviews, analyses were performed according to the guidelines of thematic analysis.

RESULTS

Four major themes were identified. First, the group format itself was experienced as an important factor of change. The experiences about the different offered interventions during the group formed a second theme. A third theme related to changes in family or professional life and dealing with RNT as a result of the intervention. Finally, group participation, social interactions, and mental health care treatment were experienced as mutually influencing during the intervention.

CONCLUSIONS

The results of this study shed some light on which treatment interventions were perceived as beneficial during the RNT-G and should therefore be emphasized in treatment. Further, they indicate that the treatment in a group format was experienced as helpful by the participants. Finally, a positive mutual influence between the group intervention and the ongoing individual treatment was experienced.

South African youth's understanding of feelings, thoughts and behaviours: Implications for the development of CBT-based mental health interventions

BACKGROUND

Mental health problems are common in youth in low- and middle-income countries (LMICs), including South Africa. Preventative interventions, based on cognitive behaviour therapy (CBT), delivered in schools, have been found to alleviate symptoms of depression and anxiety in high income countries (HICs). However, less is known about whether youth in LMICs are able to engage with the core concepts of CBT.

AIMS

To explore how young people in the Western Cape, South Africa, understand key CBT concepts, such as feelings, thoughts and behaviours.

METHOD

We interviewed 22 young people (10-15 years of age; mean age 11.6 years; SD = 1.0) recruited from two public primary schools in the Western Cape, South Africa. Interviews were audio-recorded, transcribed verbatim, translated from Afrikaans into English where necessary and analysed thematically using a deductive approach.

RESULTS

Young people described feelings as internal, private, and should only be shared with trusted others. They also described how feelings varied, depending on the situation. They found the concept of thoughts more challenging to describe. Youth were able to say what they do when they experience unpleasant feelings, and they linked their behaviours to their feelings and thoughts.

CONCLUSIONS

In this cultural context, our qualitative investigation found evidence that young people were able to engage with abstract concepts including feelings and to some degree, thoughts. To ensure that CBT-based interventions are developmentally appropriate and accessible, psychoeducation may help youth distinguish between thoughts, feelings and behaviours, and a focus on identifying and naming feelings may be beneficial.

Which, who and when? Therapeutic processes in group cognitive behaviour therapy for anxiety disorders

The evidence for the effect of therapeutic alliance in group cognitive behaviour therapy (CBT) for anxiety disorders is unclear. Identifying whether the alliance-outcome relationship depends on (1) which components are assessed, (2) who is measuring the alliance and (3) when the alliance is measured will help to clarify the role of the client-therapist relationship in therapy. The present study explored the effects of alliance component (agreement vs. bond), rater perspective (client vs. therapist) and timing (early vs. late therapy) on the alliance-outcome relationship. Individuals with an anxiety disorder enrolled into transdiagnostic group CBT were studied, with n = 78 at early therapy and n = 57 at late therapy. Results showed that greater client-rated agreement significantly predicted improved post-treatment outcomes throughout the course of therapy, while stronger client-rated bond in late therapy predicted reduced treatment gains. In contrast, therapist perceptions of agreement and bond were not associated with post-treatment outcomes at any point in therapy. Client-reported group cohesion also was not associated with additional variance in outcome after accounting for client-rated alliance. Overall, the findings highlight the importance of prioritizing the client's perception of the client-therapist relationship in CBT for anxiety disorders, as well as distinguishing the effects of component, rater and timing in future process-outcome studies.

Developing a novel intervention for type 1 diabetes and disordered eating using a participatory action design process: Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY)

AIMS

To develop a cognitive behavioural therapy-based intervention for people with type 1 diabetes and disordered eating using Experience-Based Co-Design as part of the Safe management of people with Type 1 diabetes and EAting Disorders studY (STEADY).

METHODS

Fifteen people with type 1 diabetes and experience of disordered eating (33 ± 11 years old, 22 ± 12 years diabetes duration) and 25 healthcare professionals working in type 1 diabetes or eating disorders (44 ± 9 years old; 14 ± 10 years of professional experience) attended six Experience-Based Co-Design workshops from July 2019 to March 2020 to collaboratively develop intervention content.

RESULTS

We developed a cognitive behaviour therapy intervention 'toolkit' that can be tailored for individual patient needs. Participants designed and revised toolkit materials to ensure acceptability and relevance for people with diabetes and disordered eating by engaging in guided discussion, brainstorming, and rapid testing to review toolkit prototypes in an iterative process. Workshop themes were 'Insulin titration'; 'Hypoglycaemia'; 'Coming to terms with diabetes'; 'Fear of weight gain'; 'Toolkit revision'; and 'Practical elements of STEADY therapy'. The intervention is focussed on improving diabetes self-care and embedded in a multidisciplinary healthcare approach. The intervention will be delivered in 12 sessions by a diabetes specialist nurse trained in cognitive behavioural therapy.

CONCLUSIONS

Through an iterative co-design process, people with type 1 diabetes and healthcare professionals collaboratively developed a novel intervention toolkit that can be used with a wide range of disordered eating presentations. The intervention will be tested in the STEADY feasibility randomised controlled trial.

Utilization, Patient Characteristics, and Longitudinal Improvements among Patients from a Provincially Funded Transdiagnostic Internet-delivered Cognitive Behavioural Therapy Program: Observational Study of Trends over 6 Years

OBJECTIVE

There is strong evidence supporting internet-delivered cognitive behaviour therapy (iCBT) and consequently growing demand for iCBT in Canada. Transdiagnostic iCBT that addresses both depression and anxiety is particularly promising as it represents an efficient method of delivering iCBT in routine care. The Online Therapy Unit, funded by the Saskatchewan government, has been offering transdiagnostic iCBT for depression and anxiety since 2013. In this article, to broadly inform implementation efforts, we examined trends in utilization, patient characteristics, and longitudinal improvements for patients receiving transdiagnostic iCBT over 6 years.

METHODS

Patients who completed telephone screening between November 2013 and December 2019 were included in this observational study. Patients provided demographics and mental health history at screening and completed measures at pre-treatment, post-treatment and at 3- to 4-month follow-up. Treatment engagement and satisfaction were assessed.

RESULTS

A total of 5,321 telephone screenings were completed and 4,283 of patients were accepted for treatment over the 6-year period (80.5% acceptance). The most common reason for referral to another service was high suicide risk/severe symptoms (47.1%). Examination of trends showed growing use of transdiagnostic iCBT over time (37% increase per year). There was remarkable stability in patient characteristics across years. Most patients were concurrently using medication (57.3%) with 11.9% reporting using iCBT while on a waiting list for face-to-face treatment highlighting the importance of integrating iCBT with other services. Consistent across years, large improvements in depression and anxiety symptoms were found and maintained at 3- to 4-month follow-up. There was strong patient engagement with iCBT and positive ratings of treatment experiences.

CONCLUSIONS

As there is growing interest in iCBT in Canada, this large observational study provides valuable information for those implementing iCBT in terms of likely user characteristics, patterns of use, and improvements. This information has potential to assist with resource allocation and planning in Canada and elsewhere.

Adapting cognitive behavioural therapy for adolescents with psychosis: insights from the Managing Adolescent first episode in psychosis study (MAPS)

Background

Onset of psychosis commonly occurs in adolescence, and long-term prognosis can be poor. There is growing evidence, largely from adult cohorts, that Cognitive Behavioural Therapy for Psychosis (CBTp) and Family Interventions (FI) can play a role in managing symptoms and difficulties associated with psychosis. However, adolescents have distinct developmental needs that likely impact their engagement and response to talking therapy. There is limited guidance on adapting CBTp to meet the clinical needs of under-eighteens experiencing psychosis.

Method

This educational clinical practice article details learnings from therapists and supervisors working with young people (aged 14-18 years) with psychosis during the Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS) randomised clinical treatment trial, supplemented by findings from nested qualitative interviews with young people receiving CBTp.

Results

Suggested are given for tailoring CBTp assessment, formulation and interventions to meet the developmental and clinical needs of adolescents with psychosis. Developmentally appropriate techniques and resources described.

Conclusions

Early indications from MAPS study indicate this developmentally tailored approach is an acceptable, safe and helpful treatment for young people with psychosis. Further research is needed to develop empirically grounded and evaluated CBTp for adolescents.

Getting "Back on Track" After a Cardiac Event: Protocol for a Randomized Controlled Trial of a Web-Based Self-management Program

Background

After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management.

Objective

The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone.

Methods

People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either “self-directed” completion of the Back on Track program (without assistance) or “supported” completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only.

Results

Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study.

Conclusions

The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/34534

Treatment of Dental Anxiety and Phobia-Diagnostic Criteria and Conceptual Model of Behavioural Treatment

Dental anxiety and dental phobia are still prevalent among adult individuals and should be considered a dental public health issue. Dental anxiety/phobia is often described as a vicious cycle where avoidance of dental care, poor oral health, and psychosocial effects are common features, often escalating over time. Treatment should include therapy for dental anxiety/phobia and oral diseases. This paper discusses aetiology, prevalence, and diagnosis of dental anxiety/phobia and, in detail, presents a conceptual treatment model at the Dental Fears Research and Treatment Center in Gothenburg, Sweden. In addition, based on systematic reviews, evidence-based treatment for dental anxiety is revealed including the interdisciplinary approach between psychology and dentistry.

Yoga complements cognitive behaviour therapy as an adjunct treatment for anxiety and depression: Qualitative findings from a mixed-methods study

OBJECTIVES

Cognitive behaviour therapy (CBT) is recommended for treating anxiety and depression, demonstrating good efficacy and moderate rates of engagement. To further improve outcomes and access to evidence-based treatments, researchers have sought to enhance CBT protocols with mindfulness-based approaches, such as yoga. This study aimed to examine whether yoga is an acceptable and complementary adjunct to CBT through exploring the lived experiences of adults with anxiety and depression who engaged in an adjunct therapeutic yoga programme alongside group CBT.

DESIGN

Single-group qualitative design with post-intervention and follow-up timepoints.

METHODS

Thirty-six adults with anxiety and depression self-selected into a therapeutic yoga programme as an adjunct to group CBT. Qualitative interviews were conducted with 27 participants immediately after the eight-week programme and again three months later. Thematic analysis was used to identify common themes from the lived experiences.

RESULTS

Three primary themes, with nine subthemes, were identified which reflect the experiences of the combined therapies, the complementary elements, and process of engagement over time. The adjunct yoga programme was highly acceptable to adults with anxiety and depression, enhancing engagement and perceived outcomes. Yoga was identified as providing a unique combination of elements that complemented processes of CBT, such as behavioural activation and thought disputation. Yoga practices represented mental health self-management tools that are accessible and available as relapse prevention strategies.

CONCLUSIONS

Therapeutic yoga warrants consideration as an adjunct treatment for anxiety and depression as it offers unique and complementary elements to CBT and can enhance engagement and perceived clinical outcomes.

PRACTITIONER POINTS

Adults with anxiety and depression experienced a therapeutic yoga programme as a suitable and appealing adjunct that enhanced engagement with psychological treatment. Yoga offers a unique combination of elements, including a values system, body-based mindfulness practices, and breathing techniques, that complement CBT processes, such as behavioural activation, awareness of maladaptive patterns, and thought disputation. A therapeutic yoga programme provides adults with anxiety and depression with an accessible and sustainable mental health self-management tool. Therapeutic yoga can be considered for integration to models of mental health service provision to enhance engagement and clinical outcomes for adults with anxiety and depression.

Using 360-degree videos for virtual reality exposure in CBT for panic disorder with agoraphobia: a feasibility study

BACKGROUND

Cognitive behavioural therapy (CBT) is an effective treatment for panic disorder with agoraphobia (PDA). However, implementation of some of the procedures involved, particularly in vivo exposure, can be time consuming and taxing for routine health care services. CBT with exposure taking place in virtual reality (VR-CBT) is a more time-efficient option and has shown promising results in the treatment of PDA. However, VR-CBT requires expensive equipment and appropriate virtual environments, which historically has been costly and cumbersome to produce. Thus, access to VR-CBT has been sparse in regular care environments.

AIMS

The aim of this study was to investigate whether VR-CBT using filmed virtual environments produced with a low-cost 360-degree film camera can be a feasible and acceptable treatment for PDA when implemented in a primary care context.

METHOD

This was an open feasibility trial with a within-group design, with assessments conducted at pre-test, post-test, and 6-month follow-up. Participants (n = 12) received a 10-12 week treatment programme of VR-CBT and PDA-related symptoms were assessed by the primary outcome measure The Mobility Inventory for Agoraphobia (MIA) and the Panic-Disorder Severity Scale-Self Rated (PDSS-SR).

RESULTS

The results showed that treatment satisfaction was high and participants were significantly improved on PDA-related measures at post-treatment and at 6-month follow-up with large effect sizes (Cohen's d range = 1.46-2.82). All 12 participants completed the treatment.

CONCLUSIONS

These findings suggest that VR-CBT with 360-degree video virtual environments delivered to primary care patients with PDA is feasible, acceptable, and potentially efficacious.

Does treatment preference affect outcome in a randomized trial of a mindfulness intervention versus cognitive behaviour therapy for social anxiety disorder?

Research suggests that treatment preference may affect outcome of randomized clinical trials, but few studies have assessed treatment preference in trials comparing different types of psychosocial interventions. This study used secondary data analysis to evaluate the impact of treatment preference in a randomized trial of a mindfulness-based intervention adapted for social anxiety disorder (MBI-SAD) versus cognitive behaviour group therapy (CBGT). Ninety-seven participants who met DSM-5 criteria for SAD were randomized. Prior to randomization, twice as many participants expressed a preference for the MBI-SAD over CBGT. However, being allocated or not to one's preferred treatment had no impact on treatment response. Additionally, with the exception of perception of treatment credibility, treatment matching had no impact on treatment-related variables, including treatment initiation, session attendance, homework compliance, satisfaction with treatment and perception that treatment met expectations. In sum, despite the greater preference for the mindfulness intervention in this sample of participants with SAD, we found little evidence of preference effects on our study outcomes. Findings should be viewed as preliminary and require replication.

A cross-sectional study of auditory verbal hallucinations experienced by people with a diagnosis of borderline personality disorder

BACKGROUND

The presence of auditory verbal hallucinations (AVHs) does not currently feature in the main diagnostic criteria for borderline personality disorder (BPD). However, there is accumulating evidence that a high proportion of BPD patients report longstanding and frequent AVHs which constitute a significant risk factor for suicide plans and attempts, and hospitalization.

AIM

This study addressed questions about the validity and phenomenology of AVHs in the context of BPD. The longer-term aim is to facilitate the development and translation of treatment approaches to address the unmet need of this population.

METHOD

This was a cross-sectional study, combining phenomenological and psychological assessments administered in person and online. We explored the experiences of 48 patients with a diagnosis of BPD who were hearing AVHs.

RESULTS

Participants gave 'consistent' reports on the measure of AVH phenomenology, suggesting that these experiences were legitimate. Similar to AVHs in a psychosis context, AVHs were experienced as distressing and appraised as persecutory. AVHs were found to be weakly associated with BPD symptoms. AVHs were also rated highly as a treatment priority by the majority of participants.

CONCLUSION

The findings suggest that AVH is a legitimate and distressing symptom of BPD and a treatment priority for some patients. The relative independence of AVHs from other BPD symptoms and emotional states suggests that psychological treatment may need to be targeted specifically at the symptom of AVHs. This treatment could be adapted from cognitive behaviour therapy, the psychological intervention that is recommended for the treatment of AVHs in the context of psychosis.

Implementing evidence-based individual psychotherapies for adults with eating disorders in a real world clinical setting

OBJECTIVE

This study aimed to evaluate the effectiveness of evidenced-based psychological treatments (specifically, Cognitive-Behaviour Therapy for Eating Disorders [CBT-ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology.

METHOD

Three hundred and seventy-nine participants meeting criteria for DSM-5 anorexia nervosa, bulimia nervosa, binge-eating disorder or other specified feeding or eating disorder completed pre- and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging.

RESULTS

Ninety seven percent of participants received treatment in line with evidence-based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m² over treatment, with similar outcomes for MANTRA and CBT-ED.

DISCUSSION

These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence-based psychotherapies to real-world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders.

Cost-effectiveness analysis of telephone-based cognitive behaviour therapy compared to treatment as usual CBT for cancer patients: Evidence from a small, randomised controlled trial

OBJECTIVE

A previous equivalence randomised trial indicated that Telephone-based Cognitive Behaviour Therapy (T-CBT) was not inferior to Treatment as Usual CBT (TAU-CBT) delivered face to face in terms of psychological benefit with both groups showing post-therapy improvements compared to pre-therapy baseline. The aim here is to clarify costs and benefits through an economic evaluation of the two therapy models.

METHOD

The cost-effectiveness analysis (cost per quality-adjusted life year [QALY]) was derived from a single-centre (UK-based), two-arm randomised control trial. Data from 78 patients were available for the main analysis, which includes both an NHS cost perspective and a societal perspective which includes the cost of time off work and any additional private care. Sensitivity analyses were undertaken, which included patients only completing the four core therapy sessions (46 patients) and considering only patients taking both core and the additional therapy sessions which were optional (32 patients).

RESULTS

The base-case analysis, adopting an NHS perspective, showed that T-CBT was associated with an incremental cost of £50 (95% CI: -£759 to £989) and a 0.03 QALY (95% CI: -0.09 to 0.03) decrement per patient when compared to TAU-CBT. The analysis adopting a societal perspective yielded similar results, with T-CBT providing an incremental cost of £171 (95% CI: -£769 to £1112) and a 0.03 QALY (95% CI: -0.08 to 0.03) decrement per patient in comparison to TAU-CBT. The first sensitivity analysis, considering patients only taking the core therapy sessions, showed that T-CBT provided an incremental cost of £100 (95% CI: -£945 to £1247) and yielded a decrement of 0.01 QALY (95% CI: -0.03 to 0.01) per patient compared to TAU-CBT. The second sensitivity analysis, which focused solely on patients who also underwent optional sessions, showed that T-CBT was associated with an incremental cost of £17 (95% CI: -£1307 to £1454) and a 0.04 QALY (95% CI: -0.11 to 0.03) decrement per patient when compared to TAU-CBT.

CONCLUSIONS

Based on this single trial, T-CBT is not cost-effective as a therapy option for cancer patients with high psychological needs when compared to TAU-CBT.

Following up internet-delivered cognitive behaviour therapy (CBT): A longitudinal qualitative investigation of clients' usage of CBT skills

BACKGROUND

While the acquisition and application of Cognitive Behaviour Therapy (CBT) skills is a core component and likely mechanism of effect maintenance in all CBT-based treatments, the extent of post-therapeutic CBT skills usage among internet-delivered CBT (iCBT) clients remains under-researched.

METHOD

Nested within a pragmatic randomized controlled trial, 241 participants received an 8-week supported iCBT intervention for anxiety and/or depression and answered open-ended questions about their use and experience of CBT skills at 3-, 6-, 9-, and 12-month follow-up. Recurrent, cross-sectional qualitative analysis following the descriptive and interpretive approach was used to create a taxonomy, through which all qualitative data was coded.

RESULTS

In total, 479 qualitative responses across 181 participants were analysed. Participants reported using a wide range of CBT skills and associated helpful and hindering experiences and impacts. The reasons for discontinued CBT skills usage were diverse, ranging from rare adverse effects to healthy adaptation.

CONCLUSION

The study shows how clients receiving iCBT in routine care learn CBT skills during treatment and utilize them in productive ways post-treatment. Findings coincide with similar research in face-to-face CBT and may inform future research to drive innovation and iCBT intervention development.