Cognitive Behavioral Therapy Training Research Articles

Embedding Cognitive Behavioural Therapy training in practice: facilitators and barriers for trainee educational psychologists (TEPs)

At the national level there has been a call for more therapeutic interventions and Cognitive Behavioural Therapy (CBT) has been identified as one approach that can be used. The training of educational psychologists (EPs) has been extended to three years and this provides an opportunity to increase the depth of knowledge of particular therapeutic models and their use in educational settings. This paper reports developments within two UK educational psychology initial professional training programmes, involving the design of units with a specific emphasis on the development of CBT competencies with children and young people. It details an evaluation of trainee educational psychologists’ (TEPs’) experiences of undertaking CBT case‐work during their placements within educational psychology services. Focus groups were run on each programme using a common script, transcribed and then responses coded using ATLAS.ti. This led to the development of a conceptual framework that gives an understanding of the main barriers and facilitators to implementing CBT interventions within schools. There are implications for educational psychology services, trainers and service users as well as the TEPs themselves.

P03-149 - Cognitive behavioral psychotherapy supervision - what works?

IntroductionSubstantial empirical support for cognitive behavioral therapy (CBT) effectiveness in the treatment of various psychiatric disorders has been demonstrated. Adequate training in CBT results in improved therapist competence and patient outcomes. Essential part of the training in CBT is a clinical supervision. A review of theoretical perspectives on CBT supervision is provided. Commonly encountered obstacles in CBT supervision are illuminated with case examples.ObjectivesAt the end of the presentation participants will be able to describe a theoretical approach to CBT supervision, list common obstacles encountered in CBT supervision and describe strategies to effectively address these obstacles.AimsThe aim of the presentation is to encourage CBT psychotherapy supervisors to reflect on the supervisory methods they use and increase their ability to provide effective CBT supervision.MethodsThe literature on successful CBT supervision is reviewed. This case based presentation will illustrate strategies for addressing commonly encountered roadblocks in supervision.ResultsHaving a theoretical framework for CBT supervision enhances supervisors’ ability to provide successful supervision.ConclusionsReview of theoretical approaches to CBT supervision, the description of commonly encountered obstacles and strategies to manage them during the supervision creates platform for reflection on the supervisory methods used by the participants.

Alternative Headache Treatments: Nutraceuticals, Behavioral and Physical Treatments

There is a growing body of evidence supporting the efficacy of various complementary and alternative medicine approaches in the management of headache disorders. These treatment modalities include nutraceutical, physical and behavioral therapies. Nutraceutical options comprise vitamins and supplements (magnesium, riboflavin, coenzyme Q(10), and alpha lipoic acid) and herbal preparations (feverfew, and butterbur). Although controversial, there are some reports demonstrating the benefit of recreational drugs such as marijuana, lysergic acid diethylamide and psilocybin in headache treatment. Behavioral treatments generally refer to cognitive behavioral therapy and biobehavioral training (biofeedback, relaxation training). Physical treatments in headache management are not as well defined but usually include acupuncture, oxygen therapy, transcutaneous electrical nerve stimulation, occlusal adjustment, cervical manipulation, physical therapy, massage, chiropractic therapy, and osteopathic manipulation. In this review, the available evidence for all these treatments will be discussed.

Reliability and validity of the Japanese version of the Cognitive Therapy Awareness Scale: A scale to measure competencies in cognitive therapy

This study aimed to test reliability and validity of the Japanese-version Cognitive Therapy Awareness Scale, a self-rating scale that measures basic knowledge of cognitive behavioral therapy (CBT) concepts and methodology. Furthermore, we explored optimal cutoff score to demonstrate required standard of CBT competency. The reliability and validity of the scale was tested among 252 mental health professionals. The participants' number of readings relevant to CBT, as well as their experience in training and practice in CBT were used as external standards of competency. The scale has good internal consistency (the Kuder-Richardson formula 20=0.76). The total score of the scale was significantly correlated with experience in training and practice in cognitive behavioral therapy, and the number of relevant readings (Spearman's rho =0.27, 0.28 and 0.44, respectively, P<0.001). No significant correlation was found between the total score of the scale and experience in general psychosocial care (Spearman's rho = -0.02, P=0.76). The receiver operating characteristics curve analysis produced the area under curve (AUC) of 0.77 (SD=0.05, P<0.001), and a cutoff score of 31/32 produced sensitivity of 0.81 and specificity of 0.64 to discriminate trainees who have experience of 40 h or more of CBT training and five or more of relevant readings, from those who do not meet this standard. The Japanese-version Cognitive Therapy Awareness Scale was successfully validated. It has been demonstrated that the scale specifically assess knowledge in cognitive behavioral therapy. This scale would serve as a rough guide to assess competencies among beginner cognitive behavior therapists.

Mechanisms of symptom reduction in treatment for obsessions.

We explored the dynamic relationship between cognition and obsession severity during 2 different treatments for primary obsessions, examining evidence for the hypothesis that symptom reduction would be mediated by appraisals about the meaning of unwanted intrusive thoughts. Data from a recent randomized controlled trial were analyzed with traditional mediation analyses and latent difference scores. The trial had compared cognitive behavioral therapy and stress management training among 73 patients with primary obsessions. Mediation analyses were conducted with pre-, post-, and follow-up scores on the Obsessions subscale of the Yale-Brown Obsessive Compulsive Scale and 2 self-report measures of cognitions related to obsessive-compulsive disorder. Bivariate dual change score (BDCS) analyses were conducted with weekly assessments of obsession severity and appraisals of personal significance. Change in most cognitions related to obsessive-compulsive disorder accounted for reduction in obsession severity during the course of treatment and follow-up. BDCS analyses of the longitudinal data, however, indicated prior obsession severity is a leading indicator of subsequent change in appraisals, rather than the reverse. Analyses also suggested cognitive behavioral therapy is more effective than stress management training when symptoms are severe and that stress management training is more advantageous in the context of mild-to-moderate obsessions. The traditional mediation analysis indicated that appraisal change is a tenable mediator of obsession reduction, but the BDCS results raise doubts about the causal direction. The results highlight the importance of examining the dynamic relationship between putative mediators and outcome variables, and they suggest interesting hypotheses about mechanisms in treatment of obsessions.

A randomised controlled trial of cognitive-behavioural therapy for women with problematic menopausal hot flushes: MENOS 2 trial protocol

ObjectivesHot flushes and night sweats (HF/NS) are experienced by 60–70% of menopausal women and are problematic for approximately 20–25%. Potential health risks associated with hormone-replacement therapy (HT) have led to...

Cognitive Function and Treatment Response in a Randomized Clinical Trial of Computer-Based Training in Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT), because of its comparatively high level of cognitive demand, is likely to be challenging for substance users with limitations in cognitive function. However, it is not known whether computer-assisted versions of CBT will be particularly helpful (e.g., allowing individualized pace and repetition) or difficult (e.g., via complexity of computerized delivery) for such patients. In this secondary analysis of data collected from a randomized clinical trial evaluating computer-assisted CBT, four aspects of cognitive functioning were evaluated among 77 participants. Those with higher levels of risk taking completed fewer sessions and homework assignments and had poorer substance use outcomes.

Breaking the cycle: Cognitive behavioral therapy and biofeedback training in a case of cyclic vomiting syndrome

The present article presents a case of cognitive behavioral therapy (CBT) along with heart rate variability (HRV) biofeedback training for the treatment of a medication unresponsive 13-year-old boy with cyclic vomiting syndrome (CVS). CVS is characterized by recurring stereotypic episodes of vomiting, interspersed with asymptomatic periods. Triggers for vomiting include anticipatory anxiety related to school examinations, family conflicts, and birthday parties as well as infectious diseases, and certain foods. Current treatment design addressed two pivotal etiological factors: autonomic dysregulation and anticipatory anxiety. Treatment outcome suggests that vomiting episodes may be successfully prevented by aiding the patient to identify and manage precipitant psychological stressors, to regulate HRV patterns, and gain a renewed sense of bodily control and self-efficacy. Further research is suggested using a controlled study with pre- and post-behavioral and stress measures to evaluate the effectiveness of CBT and biofeedback training compared to pharmacotherapy and placebo.

Sudden gains versus gradual gains in a psychotherapy training clinic

Sudden gains are abrupt and substantial improvements in symptoms. This study used the Outcome Questionnaire-45 (OQ-45; Lambert et al., 1996) to characterize sudden gains occurring in a cognitive-behavioral therapy training clinic. Also, gradual gainers were identified and used as a comparison group. Sudden gains were identified in 23% of patients and in 29% of those who entered treatment in the clinical range on the OQ, within the range of prevalence established by previous sudden gain studies in the context of randomized controlled trials (RCT's). As in earlier research, sudden gains tended to occur early in therapy. However, sudden gains were more likely to be reversed than in RCT's. Gradual gains occurred for 54% of nonsudden gainers; they were of similar magnitude to sudden gains but occurred later in therapy. Sudden gainers showed significantly better outcomes at the end of treatment than did gradual gainers. Sudden gains have clear prognostic significance, but more research is needed to determine why they may be more transient in naturalistic studies or studies involving less experienced therapists than they are in RCT's.

Computers and psychosocial treatment for child anxiety: recent advances and ongoing efforts

Building on the empirical data supporting the efficacy of cognitive-behavioral therapy (CBT) for child anxiety, researchers are working on the development and evaluation of cost-effective and transportable CBT approaches. Related to this, a widely endorsed goal is to disseminate evidence-based treatments from research settings to community settings. Computer-assisted treatments have emerged as a means to provide cost-effective and efficient service to an increased number of anxious youth for whom a CBT treatment would be otherwise unavailable. We offer a rationale for the development and evaluation of computer-assisted psychosocial treatments for anxiety in youth, offer illustrative advances made in this area, and describe our efforts in using computers to enhance dissemination of CBT for child anxiety. Specifically, our illustrations include a description of (a) Camp-Cope-A-Lot (CCAL), a computer-assisted CBT for the treatment of anxiety disorders in youth ages 7-12, and (b) CBT4CBT: Computer-based training in CBT for anxious youth. Findings from evaluations of these programs are summarized, and further advances are proposed and discussed.

Employing external facilitation to implement cognitive behavioral therapy in VA clinics: a pilot study

BackgroundAlthough for more than a decade healthcare systems have attempted to provide evidence-based mental health treatments, the availability and use of psychotherapies remains low. A significant need exists to identify simple but effective implementation strategies to adopt complex practices within complex systems of care. Emerging evidence suggests that facilitation may be an effective integrative implementation strategy for adoption of complex practices. The current pilot examined the use of external facilitation for adoption of cognitive behavioral therapy (CBT) in 20 Department of Veteran Affairs (VA) clinics.MethodsThe 20 clinics were paired on facility characteristics, and 23 clinicians from these were trained in CBT. A clinic in each pair was randomly selected to receive external facilitation. Quantitative methods were used to examine the extent of CBT implementation in 10 clinics that received external facilitation compared with 10 clinics that did not, and to better understand the relationship between individual providers' characteristics and attitudes and their CBT use. Costs of external facilitation were assessed by tracking the time spent by the facilitator and therapists in activities related to implementing CBT. Qualitative methods were used to explore contextual and other factors thought to influence implementation.ResultsExamination of change scores showed that facilitated therapists averaged an increase of 19% [95% CI: (2, 36)] in self-reported CBT use from baseline, while control therapists averaged a 4% [95% CI: (-14, 21)] increase. Therapists in the facilitated condition who were not providing CBT at baseline showed the greatest increase (35%) compared to a control therapist who was not providing CBT at baseline (10%) or to therapists in either condition who were providing CBT at baseline (average 3%). Increased CBT use was unrelated to prior CBT training. Barriers to CBT implementation were therapists' lack of control over their clinic schedule and poor communication with clinical leaders.ConclusionsThese findings suggest that facilitation may help clinicians make complex practice changes such as implementing an evidence-based psychotherapy. Furthermore, the substantial increase in CBT usage among the facilitation group was achieved at a modest cost.

Personality traits in early psychosis: relationship with symptom and coping treatment outcomes

This study aimed to determine personality profiles of individuals with early psychosis based on the Five Factor Model of personality and assess the predictive value of personality traits or profiles on therapeutic outcomes of two group treatments for recent onset psychosis: cognitive behaviour therapy or skills training for symptom management. One hundred and twenty-nine individuals with early psychosis were recruited to participate in a randomized controlled trial. The participants were randomized to one of two group treatments or to a wait-list control group. Measures included a personality inventory (NEO Five Factor Inventory) and outcome measures of symptomatology (Brief Psychiatric Rating Scale-Expanded) and coping strategies (Cybernetic Coping Scale). Cluster analyses revealed three different personality profiles (based on the Five Factor Model) - none specifically linked to psychotic symptoms. No links were revealed between personality traits and symptom change scores. Personality traits were linked to therapeutic improvements in active coping strategies, with extraversion accounting for 17% of the variance. Neuroticism was linked to increased use of passive coping strategies. Active coping strategies were also predicted by profile 1 (holding the highest openness score) with 26% of the variance explained and by profile 3 (the highest extraversion score), with 14% of the variance explained. Individuals with early psychosis can present with distinct personality profiles as would be expected in a non-clinical population. Personality traits do not appear to influence symptomatic treatment outcomes but are linked to behavioural changes, such as the use of coping strategies.

An evaluation of the effectiveness of Diploma-level training in cognitive behaviour therapy

BackgroundAs part of the UK government’s initiative to Increase Access to Psychological Therapies (see http://www.iapt.nhs.uk/for full details of the IAPT programme) there has been an expansion in the provision of post-graduate Diploma training in cognitive behaviour therapy (CBT). Previous evaluations of such training programmes have yielded mixed results but have been limited by small sample sizes and/or limited assessment measures. AimsTo evaluate the impact of a long-standing Diploma in CBT training programme on a variety of measures of CBT competence. MethodTrainees’ levels of CBT skill are compared at the beginning and end of CBT training. The effect of therapist factors such as age, professional background and gender on the development of CBT competence is also examined. ResultsResults show that trainees demonstrate higher levels of CBT skills after completing the training than they did before, with the majority achieving pre-determined criteria for competence. Trainees’ gender was not related to their performance but trainees’ age showed a negative association with CBT skill (older trainees performed worse). Trainees’ professional background also had an impact on their level of CBT competence, with trainees who were clinical psychologists demonstrating the highest levels of competence across a range of measures. ConclusionsCBT Diploma training leads to increases in the level of trainees’ CBT competence, with the majority achieving the levels demonstrated in research trials by the end of training. Thus, this training is likely to lead to improved outcomes for patients. Further research is needed to determine the most efficient ways of enhancing CBT skills.

P.8.a.012 25-hydroxyvitamin D blood levels in recently admitted psychiatric inpatients

The principles of cognitive-behavioural therapy (CBT) have been applied successfully through individual psychotherapy to several psychiatric disorders. We adapted these principles to create a group-training programme for a non-psychiatric group—long-term (>12 months) unemployed people. The aim was to investigate the effects of the programme on measures of mental health, job-seeking, and job-finding.289 volunteers (of standard occupational classification professional groups) were randomly assigned to a CBT or control programme, matched for all variables other than specific content, that emphasised social support. 244 (134 CBT, 110 control) people started the programmes and 199 (109 CBT, 90 control) completed the whole 7 weeks of weekly 3 h sessions (including three CBT, seven control participants who withdrew because they obtained employment or full-time training). Questionnaires completed before training, on completion, and 3–4 months later (follow-up data available for 94 CBT, 89 control) assessed mental health, job-seeking activities, and success in job-finding. Analyses were based on those who completed the programmes. Participants were not aware that two interventions were being used. Investigators were aware of group allocation, but were accompanied in all programmes by co-trainers who were non-investigators.Before training, 80 (59%) CBT-group participants and 59 (54%) controls scored 5 or more on the general health questionnaire (GHQ; taken to define psychiatric caseness). After training, 29 (21%) and 25 (23%), respectively, scored 5 or more (p<0·001 for both decreases). Improvements in mean scores with training on the GHQ (between-group difference 3·91, p=0·05) and in other measures of mental health were significantly greater in the CBT group than in the control group. There were no significant differences between the groups in job-seeking activity during or after training, but significantly more of the CBT group than of the control group had been successful in finding full-time work (38 [34%] vs 13 [13%], p<0·001), by 4 months after completion of training.These results suggest that group CBT training can improve mental health and produce tangible benefits in job-finding. Application of CBT among the unemployed is likely to benefit both individuals and society in general.

Short cognitive behavioral therapy and cognitive training for adults with ADHD &amp;ndash; a randomized controlled pilot study

In clinical practice, a growing need exists for effective non-pharmacological treatments of adult attention-deficit/hyperactivity disorder (ADHD). Here, we present the results of a pilot study of 10 adults with ADHD participating in short-term individual cognitive- behavioral therapy (CBT), 9 adults participating in cognitive training (CT), and 10 controls. Self-report questionnaires, independent evaluations, and computerized neurocognitive testing were collected before and after the treatments to evaluate change. There were distinctive pre-hypotheses regarding the treatments, and therefore the statistical comparisons were conducted in pairs: CBT vs control, CT vs control, and CBT vs CT. In a combined ADHD symptom score based on self-reports, 6 participants in CBT, 2 in CT and 2 controls improved. Using independent evaluations, improvement was found in 7 of the CBT participants, 2 of CT participants and 3 controls. There was no treatment-related improvement in cognitive performance. Thus, in the CBT group, some encouraging improvement was seen, although not as clearly as in previous research with longer interventions. In the CT group, there was improvement in the trained tasks but no generalization of the improvement to the tasks of the neurocognitive testing, the self- report questionnaires, or the independent evaluations. These preliminary results warrant further studies with more participants and with more elaborate cognitive testing.

Multidisciplinary Cognitive-Behavioral Therapy Training for the Veterans Affairs Primary Care Setting

Current research highlights the need to embed evidence-based psychotherapies such as cognitive-behavioral therapy (CBT) within primary care settings. Few studies have examined CBT training procedures, and no studies have examined the impact of CBT training in the primary care setting. The current study sought to describe and assess the feasibility and effectiveness of a focused CBT training program for a diverse sample of primary care mental health providers in the Department of Veterans Affairs (VA). A multidisciplinary group of 28 mental health clinicians from 6 VA medical centers and 15 community-based outpatient clinics received an intensive 1½-day CBT workshop, held in Houston, Texas, in May 2008, including didactic presentations, expert modeling, and small-group role plays. CBT experts also provided biweekly follow-up group telephone consultation calls for participants over 12 weeks to aid in development of CBT skills. Participant program evaluation surveys and self-reported CBT knowledge, ability, and utilization were measured preworkshop, postworkshop, and 3 months postworkshop. Analyses compared mean change scores at baseline to those at 3-month follow-up. Wilcoxon signed rank tests were completed, and Cohen d effect-size calculations were also computed. Statistical analyses found that participant self-reported CBT knowledge (P < .01, effect size [ES] = 0.49) was significantly improved postworkshop and maintained at 3-month follow-up. Self-reported abilities were also improved (P = .07, ES = 0.40). The potency of the training experience appeared to be enhanced by the multimodal nature of the program. Although challenges exist, focused and intensive training in CBT appears feasible for multidisciplinary mental health practitioners in the primary care setting.

The dilemmas of identity faced by psychodynamic counsellors training in cognitive behavioural therapy

AbstractAim: A qualitative study was carried out to explore the dilemmas of identity experienced by qualified psychodynamic counsellors studying cognitive behavioural therapy (CBT). Method: Participants were students on a BA ‘top‐up’ programme that included an introductory module in CBT. Thematic analyses were carried out on participants' learning journals, and on the transcripts of focus groups convened a year after module completion. Findings: As they first engaged with the module, participants held highly negative views of CBT. Many were also resistant to engaging with module content. Over time, they were increasingly able to appraise CBT as an effective and ethical modality and find ways of integrating their new learning with their core theory. Conclusions: The study illustrates the ways in which macro‐political interventions, such as the Improving Access to Psychological Therapies initiative, can impact on the student experience. Training strategies are proposed for supporting counsellors' engagement with unfamiliar modalities.

Tailored cognitive–behavioral therapy and exercise training for high‐risk patients with fibromyalgia

The treatment of patients with fibromyalgia (FM), a high-prevalence chronic pain condition with a high impact on both patients and society, poses a great challenge to clinicians due to a lack of effective treatments. In view of the large individual variability in outcome, selecting patients at risk of long-term dysfunction and offering tailored treatment may be promising for beneficial treatment effects. High-risk patients were selected and classified into 2 groups (pain-persistence and pain-avoidance groups) and subsequently randomized in groups to either a treatment condition (TC) or a waiting list control condition (WLC). Treatment consisted of 16 sessions of cognitive-behavioral therapy (CBT) and exercise training in groups, tailored to the patient's specific cognitive-behavioral pattern, delivered within 10 weeks. Physical and psychological functioning and impact of FM were assessed at baseline, posttreatment, and 6-month followup. Treatment effects were evaluated using a linear mixed model. The treatment effects were significant for all primary outcomes, showing significant differences in physical (pain, fatigue, and functional disability) and psychological (negative mood and anxiety) functioning, and impact of FM for the TC in comparison with the WLC. Effect sizes in the TC were overall large, and reliable change indices indicated a clinically relevant improvement among the TC. The presented results demonstrate for the first time that tailored CBT and exercise training for high-risk patients with FM is effective in improving short- and long-term physical and psychological functioning, indicating that tailoring treatment is likely to promote beneficial outcomes in FM and reduce the burden for patients and society.

Cognitive-behavioural skills training for medical students: development and evaluation

Aims and methodThe effective management of patients with anxiety, depression or somatisation, who commonly present across all medical disciplines, requires an understanding of both pharmacological and psychological approaches such as cognitive-behavioural therapy (CBT). However, there is little research addressing effective ways of delivering CBT training that is relevant for doctors. We provided CBT skills training that included supervised casework to medical students at Oxford University and assessed participants' experiences.ResultsThe training was feasible, sustainable and highly valued. Students reported marked improvements in knowledge and skills related to CBT and felt more convinced of its effectiveness for patients and its relevance for doctors. They also gained generic medical skills and an increased understanding of mental health problems.Clinical implicationsSupervised casework appears to be an effective format for learning. It allowed students enhanced responsibility for patient care and an opportunity to practise using cognitive-behavioural strategies, some of which would be transferable to medical consultations.

The relationship of social function to depressive and negative symptoms in individuals at clinical high risk for psychosis

Social dysfunction is a hallmark symptom of schizophrenia which commonly precedes the onset of psychosis. It is unclear if social symptoms in clinical high-risk patients reflect depressive symptoms or are a manifestation of negative symptoms. We compared social function scores on the Social Adjustment Scale-Self Report between 56 young people (aged 13-27 years) at clinical high risk for psychosis and 22 healthy controls. The cases were also assessed for depressive and 'prodromal' symptoms (subthreshold positive, negative, disorganized and general symptoms). Poor social function was related to both depressive and negative symptoms, as well as to disorganized and general symptoms. The symptoms were highly intercorrelated but linear regression analysis demonstrated that poor social function was primarily explained by negative symptoms within this cohort, particularly in ethnic minority patients. Although this study demonstrated a relationship between social dysfunction and depressive symptoms in clinical high-risk cases, this association was primarily explained by the relationship of each of these to negative symptoms. In individuals at heightened risk for psychosis, affective changes may be related to a progressive decrease in social interaction and loss of reinforcement of social behaviors. These findings have relevance for potential treatment strategies for social dysfunction in schizophrenia and its risk states and predict that antidepressant drugs, cognitive behavioral therapy and/or social skills training may be effective.