Discussion

It is apparent that there is no strong evidence base as yet to decide which interventions would be most beneficial to individuals who request help. The factors that have been assumed to increase risk of complicated grief are also questioned by Stroebe & Schut (2001) who argue that these factors are subject to mediating variables such as social support and are complicated further because some risk factors are not static, for example, self-care. It is beyond the scope of this chapter to...

Cognitive Therapy in Health Psychology Settings

A cognitive model of stress examines the role of beliefs in illness and proposes that aperson's beliefs about illness determine both emotional reactions to illness health and to health behaviours (Beck, 1984 Pretzer, Beck & Newman, 1989). This formed the basis for forms of cognitive therapy for a range of problems in health psychology and behavioural medicine, including pain, HIV AIDS, cancer, heart disease and health-related behaviours like exercise and smoking. For example, a link has been...

Depressed HIVPositive Patients IPTHIV

Recognizing that medical illness is the kind of serious life event that might lend itself to IPT treatment, Markowitz etal. (1992) modified IPT for depressed HIV patients (IPT-HIV), emphasizing common issues among this population including concerns about illness and death, grief and role transitions. A pilot open trial found that 21 of the 24 depressed patients responded. In a 16-week controlled study, 101 subjects were randomized to IPT-HIV, CBT, supportive psychotherapy (SP), or IMI plus SP...

Binge Eating Disorder

The DSM IV provides research criteria for BED in Appendix B. The clinical picture is similar to BN, with the important absence of compensatory purging. CBT and IPT are at least as effective in treating BED as BN, and group treatment with either therapy is well accepted (Wilfley et al., 1993). However, BED is extremely common and could easily overwhelm eating disorder services. Many BED patients are overweight. Psychological approaches emphasise the benefits of stability, at whatever weight, and...

Behaviour Therapies

The behaviour therapies have relied on sophisticated individual experimental case designs applied to therapies for intractable personal problems. The literature is replete with outstanding examples although, as an extensive and successful series of treatment approaches, they have not been without criticism. The main criticisms have been that many behavioural treatments tend to focus on reducing single-target problems whereas, in reality, clients are likely to have multiple difficulties related...

Introduction

Cognitive therapy is a system of psychotherapy that (1) is based on a cognitive theory of personality and psychopathology with solid empirical foundations for its basic tenets, (2) sets out principles and strategies of practice that emerge from practice, theory and research and (3) has been subjected to outcome studies that attest to its efficacy and effectiveness with a broad range of disorders and populations (Figure 2.1). There are several main forms of cognitive-behavioural therapy. Those...

Relapse Prevention

During the final stages of the treatment much time was spent planning for emergencies and coping with future (re)lapses. Dianne and Mick designed their own personal (re)lapse-prevention manual using problem-solving techniques. Different alternatives were discussed like Dianne talking about her craving with Mick, Mick being allowed to confront Dianne with high-risk behaviours (for example, not getting out of bed in the morning) and expressing his concern about the matter, and reintroducing the...

References

Beach, S.R.H. & O'Leary, K.D. (1992). Treating depression in the context of marital discord Outcome and predictors of response of marital therapy versus cognitive therapy. Behavior Therapy, 23,507528. Beck, A.T. Steer, A. & Brown, G.K. (1996). Manual for Beck Depression Inventory-II. San Antonio, TX Psychological Corporation. Chambless, D.L., Ollendick, T.H. (2001) Empirically supported psychological interventions Controversies and evidence. Annual Review of Psychology, 52, 685-716....

Info

This phase of research into EMDR in its first decade was stimulated by the Shapiro (1989) publication outlining the procedure and its successful use with a mixed group of PTSD clients. Its merit lies in its originality, but few conclusions may be drawn from it because of design flaws including no blind assessors, unclear sample definition, and diagnostic assessment, limited use of standardised measures and a control treatment that was not the equivalent of a properly conducted flooding...

Which Therapy Should Be Offered

There is no definitive evidence about which therapy a clinician might preferentially recommend in BP. However, there are a number of shared characteristics in the therapies reported to be effective. Scott & Gutierrez (2004) identify that the 12- to 20-session courses of therapy all include four key interventions psychoeducation, medication adherence, lifestyle regularity (including reduction in substance misuse) and relapse prevention. Furthermore, each of these interventions assumes that...

What Is Counselling

Historically, counselling and psychotherapy have been largely similar forms of practice in terms of the underlying theoretical rationale on which they are based, the training of Handbook of Evidence-based Psychotherapies A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright 2007 John Wiley & Sons, Ltd. therapists and the types of clients that are seen. Any approach to psychological therapy, whether labelled as counselling, as psychotherapy, or in other terms,...

Aetiology

A growing body of research supports a multifactorial model of personality disorder, incorporating both biological and environmental factors. A recent review found that about half the variance in personality trait scores is attributable to the genetic differences between individuals (Bouchard, 1997), but investigators have not yet managed to identify the genes responsible for specific personality traits or disorders. Lang & Vernon (2001) observe that the controversies about definitions and...

Psychodynamic Therapy

Psychodynamic therapy has had a historical role in emphasising a psychological perspective of psychosis. Concepts of psychodynamic therapy may inform understanding of psychotic experiences. Clinicians working with psychosis will frequently sense the avoidant defensive attitude some patients have when confronted with reality. Moreover a sense of dissolution of ego boundaries is distinct in acute psychotic episodes. However, psychodynamic therapy for schizophrenia is not a viable approach (Mueser...

Conclusions

This chapter highlights the fact that psychological factors may be associated with the onset and the outcome of BP episodes and that the instability model of relapse allows clinicians to recognize the potential mechanisms by which psychological therapies may improve the prognosis of those at risk of persistent symptoms or frequent relapse. The three core brief manualized therapies (IPSRT, CT and FFT) have all developed specific models for use in BP. As such, the choice between the three...

Group Treatment With Bt And

One RCT found group and individual behaviour therapy were equally efficacious but with a faster response rate for individual therapy (Fals-Stewart et al., 1993). However the individuals were not typical of the OCD population as they were OCD treatment naive and did not have any co-morbid psychiatric conditions. McLean etal. (2001) compared CBT and ERP in a group treatment. Both treatments were superior to a waiting list control, with ERP being slightly more effective than CBT at the end of...

Section Ii Evidence Research And Practice Psychotherapeutic Evidence

In scoping the activity defined by either evidence-based practice or practice-based evidence, a central component is the concept of evidence itself. Evidence-based healthcare derives primarily from the twin disciplines of clinical epidemiology and general internal medicine from which it has been transported to other disciplines. The literature on evidence-based practice in general is considerable (for example, Sackett et al., 1996) and there are texts specifically addressing the evidence-base...

Definitions

Most fundamentally, there is continuing controversy about how to define personality disorder. The International Classification of Mental and Behavioural Disorders (ICD-10) (World Health Organisation, 1992) defines personality disorder as 'a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption.' ICD-10 lists eight...

Consensus Panels

Rush & Frances (2000) developed the expert consensus guidelines for psychiatric and behavioural problems. Fifty-six behavioural and 51 pharmacological experts were invited to participate 86 and 88 replied respectively. They asked the raters to rate a series of statements concerning a variety of psychosocial treatments. When asked to rate appropriate assessment methods, direct observation and functional assessment were identified as first-line choices in the assessment of psychiatric and...

Psychotherapy With Older People Basic Issues

The following outlines some basic issues to be considered when working with older adults. For a fuller consideration of the basic issues in psychotherapy with older adults, there are a number of alternative resources to consult - see Knight, 2004 Laidlaw et al., 2003, 2004 Miller, et al., 1998 Nordhus & Neilson, 1999 Steuer & Hammen, 1983 Zeiss & Steffen, 1996). It is important to make sure that these are thought out in advance - for instance, is there a specific room set aside for the...

Dynamic Psychotherapy

To date, this is the most extensively investigated psychotherapeutic approach to personality disorder. Karterud et al. (1992) completed a prospective study of 97 patients in a psychodynamically orientated day hospital in Oslo 76 had an Axis II disorder. The treatment programme in the unit consisted of two daily community meetings, plus group and individual psychotherapy sessions. After a mean stay of six months treatment results were very good for patients with Axis I disorders only, good for...

John McLeod

Counselling has become established as a widely available source of help for people who are troubled by a range of different problems in living. It is available from a variety of different agencies in the statutory, voluntary and private sectors. In addition, many doctors, nurses, social workers and teachers have been trained in the use of counselling skills. Counselling represents a form of help and support that is well received by members of the public, who generally recognise the wisdom of...

Impact On Health Services

In the health service, individuals with difficulties encompassed by the DSM-IV Cluster B categories make the heaviest demands on services - often presenting in crisis. A few recent studies have attempted to quantify these demands (Seivewright et al., 1991 Saarento et al., 1997). Smith et al. (1995) calculated that the cost to the NHS of treating individuals with personality disorders was 61.3 million in 1986. Much of the discussion about the cost of treating personality disorder has focussed,...

Summary

Social anxiety is a problem of high prevalence, great chronicity, and substantial personal cost. It benefits most from exposure treatments, although there is some evidence that the use of cognitive restructuring techniques may enhance exposure outcomes. Treatment for clients with the generalized subtype of social anxiety disorder may be associated with poorer outcomes, despite a rate of improvement similar to that of clients with less pervasive fears, and these clients may require a longer...

Evidence And Psychotherapies

One of the classic and most destructive uses of evidence was in Eysenck's (1952) claim that psychodynamic psychotherapy was no more effective than leaving people to recover spontaneously. Apart from the controversy that Eysenck sparked, he also led to a generation of psychotherapy researchers determined to improve the science of psychotherapy outcome research, subsequent summaries of which argued that Eysenck had considerably overestimated rates of spontaneous recovery and under-estimated...

Bulimia Nervosa

Bulimia nervosa appears to be a 'modern' disorder, reaching psychiatric awareness in the 1970s. It has been treated as a 'depressive equivalent' with antidepressant medication and therapies modified from antidepressant strategies. High-dose antidepressant medication (such as fluoxetine 60 mg daily) offers proven but often short-lived anti-bulimic benefit (Walsh et al, 1991) and benefits are inferior to the best psychological therapies (Agras et al., 1992). Extensive evidence supports cognitive...

Enhancing Capabilities

The first function of comprehensive DBT is to enhance the capabilities (called skills in DBT) of the clients. This is the function of the skills training mode. Clients often do not engage in skilful behaviours because such behaviours are not in their repertoires In order to engender behavioural change, clients must learn new, functional behaviours while as increasing the generalization of existing functional behaviours. The Skills Training Manual for Treating Borderline Personality Disorder...

Cognitive Therapy is Structured

Cognitive therapy has evolved a structured format that enables the therapist and client to work in the most efficient and effective way. The structure remains constant throughout therapy making therapy more transparent and understandable for both therapist and client. Having outlined what distinguishes cognitive therapy, we aim to convey a sense of how cognitive therapy proceeds in practice. We will outline a typical therapy session, as well as a typical progression for therapy as a whole. We...

Course of Treatment and Assessment of Progress

Initially, Dianne and Mick's treatment followed a BCT manual (Emmelkamp & Vedel, 2006). The first two sessions were used for psycho-education, explaining the treatment rationale and introducing the sobriety trust contract. We agreed upon abstinence rather than moderation as the treatment goal. As for the sobriety trust contract each day at a specific time, in order to prevent the couple arguing about her drinking behaviour throughout the day, Dianne was to initiate a brief discussion with...

Effective Treatment Modalities

In this section, we shall consider some of the modalities that can be considered effective, as shown by high CESs in the Mesa Grande. Again, the idea is not to describe every single effective treatment for alcohol problems but merely to focus on a few general approaches that are supported by research evidence and can easily be implemented in practice. The highest CES in Table 15.1 is for brief interventions however, there are a number of important considerations to bear in mind here. First, the...

Increasing Positive Interactions

From session two onwards we also tried to increase positive interaction between the couple. We wanted to shift Dianne and Mick's attention from recording only one another's negative behaviours (attentional bias), to also being able to recognize positive behaviours. As a Figure 4.3 Microanalysis of Dianne's drinking. Figure 4.3 Microanalysis of Dianne's drinking. homework assignment we asked both of them to write down pleasant or positive behaviours that they had observed in each other (for...

Level BBasic Training as IPT Therapist

Trainees should have read the IPT manual and have attended a recognized training course of 2-4 days. Supervision is offered at the discretion of the supervisor. Supervisees should have previous clinical training with a good knowledge of mood disorders. The first case using IPT should be in the treatment of major depression and the second case should be depression, dysthymia, adolescent depression or bulimia binge eating disorder. Each trainee should be supervised for a minimum of two cases on...

Emotional Problems

The effectiveness of psychological interventions for anxiety disorders, depression and anorexia nervosa will be considered in this section. While all children have developmentally appropriate fears, some are referred for treatment of anxiety problems when their fears prevent them from completing developmentally appropriate tasks such as going to school or socializing with friends. The overall prevalence for clinically significant fears and anxiety problems in children and adolescents is...

Are Eye Movements Necessary

Rosen et al. (1998) cite Lohr, Tolin & Kleinknecht (1998) that eye movements add nothing to treatment outcome. However, three out of five studies drawn on by Lohr et al. for their conclusions actually provide some support for the role of eye movements in EMDR in the reduction of reports of symptoms (Lohr, Kleinknecht & Tolin, 1995 Lohr, Tolin & Kleinknecht, 1996 Montgomery & Ayllon, 1994). For example, Lohr, Kleinknecht & Tolin (1995) 'Only when the eye movement was added, was...

Demographic Changes Older People In Society

When working with older people, knowledge about normal ageing and the experience of ageing is useful in order to understand the realities of growing older in society today. A fuller account for therapists is beyond the scope of this chapter but interested readers should see Laidlaw et al. (2003). It is important to take time to understand the individual's own experience and attitude towards ageing (Knight, 2004). Chronological age is, at best, a poor guide especially as attitudes appear to be...

Level D Recommendations for Becoming IPT Supervisor Trainer

To have achieved a level A, B and continue level C. To have a minimum of 10 supervised cases, preferably with two cases in each focal area. This supervision may be an individual or group, and includes the two or three cases in level B. Supervisors would be required to be a member of a network of supervisors. It is proposed that regional groups be established and meet at least twice a year. Supervisors must attend an introductory supervisor's workshop before providing supervision. It is...

Evidencebased Therapy Some Warnings

There are a number of points and warnings about the evidence-based approach that we would like to flag up, whilst mindful of the fact that these points (and others) will also be considered in many of the subsequent chapters. Any EBT can be done ineffectively. Just because a practitioner claims to be doing an EBT this does not guarantee that the therapy is being carried out effectively. Ineffectiveness can, of course, arise for a variety of reasons that may relate to therapist factors, client...

General Considerations

It is commonly asserted that, as a subject of academic interest and clinical consideration, anger has not enjoyed the attention that it manifestly deserves (Siegman & Smith, 1994). This is apparent not only within the psychological literature but also psycho-biological literature (Anderson & Silver, 1998). This despite the fact that, experienced as a transient emotion (Novaco, 1975), it is woven into the fabric of our daily circumstances in just the same fashion as any of the other...

Asthma

Asthma is a disease characterised by chronic or recurrent airways obstruction. It affects around 5 million adults and children in the UK and is a significant cause of mortality and morbidity. There has always been an awareness of the importance of psychological factors in asthma both in triggering acute attacks and in affecting adherence with medical treatment. The role of emotional factors in asthma has been well reviewed by Lehrer et al. (1993). More recently the British Thoracic Society, in...

Conclusion

Research findings thus far suggest that EMDR is an effective psychotherapy, a conclusion in accordance with a number of regulatory bodies such as the American Psychological Association (APA), the International Society for the Study of Trauma and Stress (ISTSS), and the National Institute for Clinical Excellence (NICE, 2005) for the British Department of Health. Results in randomised controlled comparison studies overwhelmingly show an effect for EMDR with a trend towards greater efficiency when...

About the Editors

Chris Freeman is a consultant psychiatrist and psychotherapist based at the Cullen Centre in the Royal Edinburgh Hospital and is also a senior lecturer in the Department of Psychiatry at the University of Edinburgh. He established the South of Scotland Training Programme in Cognitive Behaviour Therapy and has published widely in the areas of eating disorders and psychological therapies. Mick Power is Professor of Clinical Psychology at the University of Edinburgh and an honorary consultant...

Claustrophobia

There have been only a few studies, most by Rachman and his colleagues (Rachman, 1997) who found that the responses to the items in a claustrophobia questionnaire could be characterised by two factors describing fears of restriction or of suffocation. The former was most evident, for example, in response to the situation 'lying in a tight sleeping bag enclosing legs and arms, tied at the neck'. The latter was apparent in answers to 'swimming with a nose plug'. Rachman (1997) notes the...

Future Directions

We predict that the period to 2030 will see a range of exciting developments in cognitive therapy research and practice. In the area of outcome research, the most obvious area for advancement is where promising initial research suggests that cognitive therapy may prove to be an evidence-based approach personality disorders, anorexia nervosa and substance misuse. Here efficacy and effectiveness research is urgently needed to establish whether people with these complex mental health problems can...

Depressed Primary Care Patients

Many depressed individuals are willing to accept medical treatment but not mental health treatment. Schulberg and colleagues compared IPT to nortriptyline for depressed ambulatory medical patients in a primary care setting (Schulberg etal., 1993 Schulberg & Scott, 1991). Interpersonal therapy was integrated into the routine of the primary care centre. For example, nurses took vital signs before each session and if patients were medically hospitalized, IPT was continued in the hospital when...

Metaanalyses

Van Etten & Taylor (1998) was a meta-analysis of all treatments for PTSD, which indicated that behaviour therapy, SSRIs, and EMDR were the most effective forms of treatment. They also specified that EMDR appeared to be the 'more efficient' form of therapy, given that EMDR necessitated one third the amount of time to achieve its effects compared to outcomes reported in behaviour therapy research. Davidson & Parker (2001) in a meta-analysis covering a smaller number of studies, examined...

Antepartum Postpartum Depression

Pregnancy and the postpartum period are times of heightened depressive risk for patients who may wish to avoid pharmacotherapy. Spinelli & Endicott (2003) compared 16 weeks of IPT to a weekly parenting education control programme in a group of 38 antepartum women with major depression. Pregnancy is deemed a role transition that involves the depressed pregnant woman's self-evaluation as a parent, physiological changes of pregnancy, and altered relationships with the spouse or significant...

Case Example

Thomas was a 68-year-old married man, diagnosed with Parkinson's disease four years previously. As a consequence of the disease he had become uncertain and fearful of others' reactions to him in professional and social situations and had increasingly avoided such situations. This had profoundly affected his self-concept he was experiencing many features of depression. A cognitive formulation of Thomas's presenting problems suggested that, at a core level, central to his sense of self, Thomas...

Conclusions And Summary

Psychological treatments constitute a much-needed effective treatment alternative to physical treatments for late-life anxiety and depression because many older adults are unable to tolerate antidepressants or there may contra-indications to their use with older people with cardiac problems (Orrell et al., 1995) and in the case of anxiety disorders there may be a number of concerns about the prescription of benzodiazepines (Gerson et al., 1999). Future research is required into the...

Cognitive Therapy Focusses on Current Problems and is Goal Oriented

Cognitive therapists work with clients to identify and prioritise problems that the client is currently experiencing and to identify mutually agreed goals. The primary therapeutic work is then working with the client on these problems towards these goals, reviewing the problem and goal list on a regular basis. Cognitive therapists work strategically, planning several steps ahead, anticipating the stages of change that will enable a client to achieve his or her goals and the likely obstacles....

Behaviour Therapy

With Freud's conceptualisation of psychosis as a narcissistic process, there was very little effort at developing face-to-face interventions in sufferers of schizophrenia. Behaviour therapy, with its origins in empirical psychology, took up the challenge and used principles of differential reinforcement with problem behaviours in schizophrenia. As medication treatment brought promise to the treatment of positive symptoms, behaviour therapy found its applications mainly in the deficit symptoms...

Examples Of The Evidence Base

The subsequent chapters in this book will provide numerous specific examples of studies that provide evidence one way or another for the use of particular therapies with particular disorders, but it is worth considering one or two such studies briefly, then considering one or two of the meta-analyses and mega-analyses in order to illustrate some of the more general points that we wish to make about the evidence base. One of the most famous and most expensive therapy outcome studies was the...

Cognitive Therapy for Personality Disorders

The 1990s saw several developments of cognitive therapy for personality disorders. Beck, Freeman & Davis (2003) adapted traditional cognitive therapy for each of the DSM-IV personality disorders. Layden et al. (1993) developed a more in depth adaptation for borderline personality disorder, and Linehan (1993) developed a more integrative behavioural-cognitive Zen Buddhist approach for this client group. Meanwhile, Young developed a schema-focussed cognitive therapy for personality disorders,...

Evidence For Drug Treatments

There is evidence that serotonin reuptake inhibitors (SRIs) are more effective than placebo (Abramowitz, 1997 Goodman et al., 1990 Kobak et al., 1998 Piccinelli et al., 1995) and more effective than other kinds of antidepressants (Hoehn-Saric et al., 2000 Picinelli et al., 1995) in reducing OCD symptoms in clinical trials. The evidence suggests that different serotonin reuptake inhibitors have similar efficacy (Kobak et al., 1998 Picinelli et al., 1995) but clomipramine has a higher rate of...

Interpersonal Group Psychotherapy

Monroe-Blum & Marziali (1995) compared time-limited (35 weeks) group therapy focussing on interpersonal transactions with open-ended individual psychodynamic therapy for treatment of BPD. Participants were recruited from inpatient and outpatient psychiatric units linked with the University of Toronto 79 of the 110 patients who were randomly allocated to the two conditions accepted treatment. The investigators found that both approaches produced significant improvement and were equally...

Maintenance Treatment

Interpersonal therapy was first developed and tested in an eight-month, six-cell study (Klerman et al., 1974 Paykel et al., 1975). In today's parlance this study would be considered a 'continuation' treatment, as the concept of maintenance antidepressant treatment has lengthened. One-hundred-and-fifty acutely depressed women outpatients who responded (with > 50 symptom reduction) to between four and six weeks of AMI were randomly assigned to receive eight months of weekly IPT alone, AMI...

Identifying Highrisk Situations

Using Dianne's diary we identified the most important high-risk situations staying at home alone and feeling sad or worrying about household chores. We introduced different ways of coping with craving, the two most important being getting involved in some distracting activity and talking about it with someone who can support you. During these first weeks Dianne was relatively successful in remaining abstinent. Sometimes she would lapse into a one-day drinking episode but the next day she would...

Personal Therapy

Hogarty's 'personal therapy' (Hogarty et al., 1997a, 1997b) deserves a mention, as it is an effort to combine various approaches to devise an individually tailored integrated treatment for patients with schizophrenia. Personal therapy is a multimodal approach, which includes pharmacotherapy, family work, individual work and any other required support. This can be delivered over months to years and is paced according to the patient's needs. Relapse rates decreased with personal therapy but only...

Prediction Of Outcome With Behaviour Therapy

Studies by Buchanan, Meng & Marks (1996), Castle et al. (1994), De Araujo, Ito & Marks (1996) and Keijsers, Hoogduin & Schaap (1994) have looked at variables predicting outcome. They found poor outcome was associated with depression, longer duration of illness, poorer motivation and dissatisfaction with the therapeutic relationship. De Araujo, Ito & Marks (1996) found that initial severity did not predict outcome, whereas the other studies found higher initial severity was...

Stroke

The psychological sequelae of stroke, particularly post-stroke depression, have been extensively detailed in the research literature. Up to 40 of patients will suffer a depressive or anxiety disorder after stroke, with an associated negative impact on rehabilitation and increased mortality. Borrowing from the cancer literature, Lewis et al. (2001) found that fatalism and helplessness hopelessness were associated with reduced survival after stroke. Lincoln's group has contributed most of the...

Therapeutic Community Treatment

Bateman & Tyrer (2002) define a therapeutic community as 'an intensive form of treatment in which the environmental setting becomes the core therapy in which behaviour can be challenged and modified, essentially through peer pressure'. Dolan, Warren & Norton (1997) compared 70 patients admitted to the Henderson Hospital, a national specialist inpatient unit for severe personality disorder, with 67 non-admitted patients at assessment and then 12 months later. On average subjects met...

Assessment And Intervention

There have been many attempts to categorise grief but little consensus beyond a general view that for most people there is a reduction and change in the nature of distress over time. What is an appropriate time interval or the nature of the distress is less easy to determine. Many studies have used general assessment measures such as the Beck Depression Inventory or the General Health Questionnaire, which were not designed to measure the changes specific to the distress of bereavement. Efforts...

Behaviour Therapy Rationale

Behaviour therapies for depression are underpinned by learning theory as a means of explaining the decline into and resolution of the depressive state and are primarily aimed at engaging or re-engaging the patient in pleasurable and consequently positively reinforcing behaviours. Relative to psychotherapy, behaviour therapy concentrates more on behaviour itself and less on a presumed underlying cause. The basic premise of behavioural treatments is that depression is a learned response in light...

Aversion Therapy

Aversion therapy includes a variety of specific techniques based on both classical and operant conditioning paradigms. Aversion therapy used to be widely employed in the treatment of alcohol abuse dependence, but is currently more of historical interest. With aversive conditioning in alcohol-dependent subjects a noxious stimulus (UCS) is paired with actual drinking (CS) or with visual or olfactory cues related to drinking, with the aim of establishing a conditioned aversion for drinking. A...

Bloodinjury And Injection Phobia

People who require frequent administration of medication by injection, such as diabetics or those with chronic psychosis, are in danger if they are not able to tolerate injections. In a sample of over 1 200 people with insulin-dependent diabetes (Mollema et al., 2001) around Table 20.1 Outcome studies for treatment of dental phobia Design (including repeated measures) Five Groups graded video-aided exposure, video-presented models, participant modelling (in vivo exposure), attention-placebo,...

Cognitive And Behavioural Therapies

Over the past decade, a number of studies have examined the efficacy of psychological (mostly cognitive-behavioural) treatments for social anxiety disorder. The most commonly investigated treatments have been in vivo exposure (with or without the addition of cognitive restructuring techniques), social skills training, and relaxation training. The International Consensus Group on Depression and Anxiety's 'Consensus Statement on Social Anxiety Disorder' concluded that there is good evidence for...

Cognitive Therapy Aims to Enable Clients to Identify Evaluate and Respond to Maladaptive Thoughts Beliefs and Behaviours

The change process in cognitive therapy involves clients learning to recognise how their thoughts, feelings and behaviours are related to one another and how they are implicated in the presenting difficulties. Clients then go on to learn how to actively evaluate and respond to maladaptive thoughts and behaviours. Early phases of cognitive therapy involve the therapist in an active and educative role middle phases involve much more of a joint problem-solving stance with later stages involving...

Cognitive Therapy Areas Of Application

The last few decades have seen cognitive therapy adapted for mood, anxiety, personality, eating and substance misuse disorders. As well as these formal psychiatric disorders, cognitive therapy has been adapted for relationship problems and the psychological aspects of a range of medical disorders. Most recently cognitive therapy has been applied to the problem of anger generally and its manifestations in conflict specifically, while colleagues, mainly in England, have applied cognitive therapy...

Cognitive Therapy Draws on a Wide Range of Cognitive and Behavioural Techniques to Change Thinking Beliefs Emotions and

The development of cognitive therapy over several decades has drawn on other therapeutic modalities, the extensive accumulated clinical expertise of cognitive therapists, increasingly sophisticated and fine-tuned theory and a large body of research. This has led to the development of a wide range of cognitive and behavioural therapeutic strategies on which a cognitive therapist can potentially draw. The main cognitive approaches involve teaching clients to be able to identify, evaluate and...

Cognitive Therapy for Anxiety Disorders

Cognitive therapy has been adapted for the full range of anxiety disorders generalised anxiety disorder (Beck & Emery with Greenberg, 1985) panic disorder (Clark, 1986 Craske & Barlow, 2001) social phobia (Heimberg & Becker, 2002) and obsessive-compulsive disorder (Frost & Steketee, 2002 Salkovskis, 1985). For generalised anxiety disorder, Chambless & Gillis (1993) computed effect sizes across five studies in which cognitive therapy was compared with one of several control...

Cognitive Therapy for Eating Disorders

Only more recently has cognitive therapy been adapted for eating disorders (Vitousek, 1996). In their review of eight outcome studies, Compas et al. (1998) concluded that cognitive therapy for bulimia nervosa meets criteria for an efficacious approach, although effectiveness research suggests that on average only 55 are in full remission at follow up. A recent multi-site study has broadly replicated these findings (Agras et al., 2000). It is premature to comment on cognitive therapy for...

Cognitive Therapy for Psychosis

The last decade has seen an exciting development in cognitive therapy approaches for psychosis (Chadwick, Birchwood, & Trower, 1996 Fowler, Garety, & Kuipers, 1995 Morrison, 2002). While outcome research in this area is limited, a range of efficacy and effectiveness studies suggests that cognitive therapy is efficacious in the treatment of positive symptoms and that changes are maintained at follow-up (Garety et al., 1994 Kuipers et al., 1998 Rector & Beck, 2001 Tarrier et al., 1993).

Cognitive Therapy for Substance Misuse

There is a large body of research on psychosocial interventions for substance misuse, but cognitive therapy for substance abuse disorders is a more recent development (Beck et al., 1993 Marlatt & Gordon, 1985 Thase, 1997) and to date the evidence base for cognitive therapy as a preferred treatment choice is weak. The largest study in this area assigned 1 726 people with alcohol-abuse problems to cognitive therapy, a facilitated 12-step programme or motivational interviewing. Improvements...

Communication Training

Communication training was introduced from session nine onwards. During this training both partners' personalities became more salient, this may be due to the fact the drinking and depressive symptoms had lessened. In addition, we addressed assertiveness, not only because of Dianne's social anxiety but also because both partners found it difficult to express disapproval and make a request. During these sessions it became clear that Mick had great difficulty handling Dianne's preoccupation with...

Comparison Of Psychological And Drug Treatments And Combinations Of Treatment

A meta-analysis by Cox et al. (1993) found that serotonin reuptake inhibitors and exposure-based behaviour therapy treatments were equally and significantly effective for reducing OCD symptoms. Another review found no significant difference between the effect sizes of serotonin reuptake inhibitors and behavioural therapy (Kobak et al. 1998). One study showed a significantly greater improvement in obsessions with behavioural therapy plus the selective serotonin reuptake inhibitor drug...

Comparisons And Combinations Of Cbt And Medication

The few studies that have compared the efficacy of CBT to that of medication treatments have been difficult to interpret because of a variety of methodological problems. One study indicated that CBT was more effective than buspirone for socially anxious musicians (Clark & Agras, 1991) and another reported that combined imaginal and in vivo exposure was more effective than the beta-adrenergic blocker atenolol (Turner, et al., 1994a). However, neither atenolol nor buspirone has surpassed...

Conjoint IPT for Depressed Patients with Marital Disputes IPTCM

It is well established that marital conflict, separation and divorce can precipitate or complicate depressive episodes (Rounsaville et al., 1979). Some clinicians have feared that individual psychotherapy for depressed patients in marital disputes can lead to premature rupture of marriages (Gurman & Kniskern, 1978). To test and address these concerns, Klerman and Weissman developed an IPT manual for conjoint therapy of depressed patients with marital disputes (Klerman & Weissman, 1993)....

Counselling

There is along tradition of the use of counselling with people with intellectual disabilities, especially with adults with mild and moderate intellectual disabilities. Prout & Novak-Drabik (2003) conducted a meta-analysis of counselling outcome studies with people with intellectual disabilities. They cast their net broadly and reviewed articles published between 1968 and 1998 from multiple databases, used a variety of synonyms and related terms for intellectual disabilities and counselling...

Criteria For Evaluating The Outcome Of Treatment

Comprehensive surveys of treatment (Nathan & Gorman, 2002 Roth & Fonagy, 2005) have outlined the minimum criteria against which the efficacy of psychological treatment should be judged. As outlined by Nathan & Gorman (2002) these are as follows. Treatments should be tested by studies that examine groups of patients the treatment must be more effective than a pharmacological or psychological placebo or similar in effect to an established treatment. Many single cases may suffice. Studies...

Dental Phobia

Of the phobias in this review, fear of routine dentistry has probably received the greatest attention from theories of cognitive processing. Many people are unable to tolerate routine treatment that might save them from ill-health requiring even more alarming treatment such as extractions. Around a third of adults in an early survey were so afraid of dental treatment they would prefer to have it conducted while they were in a state of oblivion (Lindsay, Humphris & Barnby, 1987). It is...

Definitions Of Bereavement Grief Mourning

The term 'bereavement' is derived from the Anglo-Saxon word bereafian, which means to be robbed. The sense of a love and life taken resonate through literature and the narratives of bereaved people. The sense of emptiness is a common experience. A study day on perinatal loss was entitled 'The Aching Void'. The term 'grief' is often used to describe the emotional experience of loss but it is understood more widely as being not only the affective experience but also the cognitive, physical and...

Description Of The Disorder

Social anxiety disorder, also referred to as social phobia (Liebowitz et al., 2000), has as its essential feature an extreme fear of appearing anxious or doing or saying something embarrassing in social or performance situations, accompanied by a fear of negative evaluation by others (American Psychiatric Association, 1994). For a diagnosis to be made in adults, the individual must recognize that the fear is excessive. Frequently feared situations include public speaking, going to parties,...

Evidencebased Psychotherapy With Older People

The following section reviews the empirical evidence for psychological treatments for depression and anxiety, including cognitive behaviour therapy, interpersonal therapy, and psychodynamic psychotherapy. Powers et al. (2002) and Blazer (2002) have provided comprehensive reviews of both psychological and physical treatments for late-life depression. Perhaps the most noteworthy feature of research in this area is that there is simply not enough of it to draw firm conclusions about the...

Exposure

Exposure is a general term for various procedures that have in common that patients are exposed to situations that elicit tension and anxiety and that they are inclined to avoid or flee the situation (Van Hout & Emmelkamp, 2002). Traditionally there were two principal ways in which exposure might take place in vitro, or in imagination, in which the patient imagines himself in the anxiety-eliciting situation (also referred to as imaginal exposure) in vivo, or in reality, in which the patient...

From 1999 Onward

This second phase of research into EMDR was characterised by direct comparisons of EMDR with other treatments, mainly exposure therapies. Rogers et al. (1999) was a well controlled study comparing EMDR and exposure, paying particular attention to process issues such as speed, ease of application, comfort for the client, and safety. Twelve Vietnam veterans were given EMDR or exposure over one extended session with both groups showing improvements, but with EMDR showing greater positive changes...

Geriatric Depressed Patients

Interpersonal therapy was initially used as an addition to a pharmacotherapy trial of geriatric patients with major depression to enhance compliance and to provide some treatment for the placebo control group (Rothblum et al., 1982 Sholomskas et al., 1983). Investigators noted that grief and role transition specific to life changes were the prime interpersonal treatment foci. These researchers suggested modifying IPT to include more flexible duration of sessions, more use of practical advice...

Gaps In The Evidence Base

An important issue in treatment outcome is that many clients do not achieve as much change as would be desirable, either in terms of symptoms or in terms of the impact of symptom change in other areas of life. Previous research on the clinical significance of symptom change immediately following a course of CBGT for social anxiety demonstrated a significant improvement in clients' self-perceived quality of life (Safren et al., 1997). Further, improvements from CBGT were shown to be maintained...

Interpersonal Psychotherapy

A review of the literature suggests that a small number of non-cognitive or behavioural treatment alternatives exist for the treatment of social anxiety (for a review see Lipsitz & Marshall, 2001). These studies show promising results but are limited by a lack of rigorous methodology, such as incorporation of control groups or larger sample sizes. Promising results come from a recent uncontrolled trial applying interpersonal psychotherapy (IPT) to nine individuals with social anxiety...

Management of Depressed Mood

Although Dianne's sleeping and eating improved to some extent, her worrying lessened and her panic attack disappeared, Dianne kept on feeling sad and low on energy. Thus, the probable diagnosis of general anxiety disorder was not confirmed however, the diagnosis of depressive disorder was reaffirmed. Therefore after seven sessions of alcohol treatment, the manual Spouse-aided Therapy with Depressive Disorders (Emanuels-Zuurveen & Emmelkamp, 1997) was incorporated into Dianne and Mick's...

Operant Techniques

The basic underlying principle of operant techniques is quite simple their aim is to reinforce desired behaviour while undesired behaviour is extinguished or punished. A prime example of a (usually inpatient) treatment based on operant principles is the token economy. In a token economy, the therapist distributes so-called tokens for occurrences of desired behaviour (like for example brushing teeth, being timely, conducting a conversation, cleaning the room) with the aim to reinforce this...

Outcome Research In Emdr

There are currently, at the time of writing, 20 randomised controlled (RCTs) in EMDR and PTSD, (not including follow-up RCTs) and also four meta-analyses. This is a considerable outcome research base in a relatively short period of 17 years since the seminal paper on EMDR and represents a considerably greater research interest in this area than in any other single approach to PTSD, whether psychological or pharmacological. Although some of the earlier studies were criticised for lacking...

Phases of Treatment

Acute IPT treatment has three phases. The first phase, usually lasting one to three sessions, involves diagnostic evaluation, obtaining a thorough psychiatric history, and setting the treatment framework. The therapist reviews symptoms, gives the patient a diagnosis the patient as depressed by standard criteria (such as ICD-10), and gives the patient the sick role. ('You have an illness called major depression which is treatable it is not your fault.') The psychiatric history includes the...

Prevalence

Epidemiological surveys using a variety of diagnostic criteria estimate a prevalence of 10 to 15 of at least one personality disorder within the general population (Mattia & Zimmerman, 2001). The diagnosis is more commonly made in younger people (25 to 44 years). The sex ratio varies according to the specific disorder for example, women are more likely to be diagnosed with borderline personality disorder (BPD) whereas most individuals diagnosed with antisocial personality disorder are men....

Problemsolving Skills Training

Problem-solving skills training (D'Zurilla, 1986) has a heavy psycho-educational emphasis executed according to a fixed number of steps and applicable across a wide array of problems. 1. Problem orientation, during which patients explore their personal attitude towards problems. The most important aspects are that the patients learn to recognize their negative feelings as signals of problems and learn to distinguish between problems over which one can exert personal control (such as arguments)...

Problem Analysis

Before starting treatment, it is imperative to conduct a thorough analysis of the problems. This is not identical to arriving at a formal diagnosis. Two patients may satisfy the criteria of a particular DSM-IV diagnosis, but a careful analysis might reveal that patient A would benefit more from method X whereas patient B would likely benefit more from method Y. Problem analysis is indispensable for constructing a treatment plan. In this context, it is useful to distinguish a micro-analysis from...

Questionnaires Selfmonitoring and Observation of Behaviour

Questionnaires are often useful to generate a first impression of the problem behaviour. Depending on the problem behaviour (for example, anxiety, depression, substance abuse) the therapist can select from a number of questionnaires that collect domain-specific information. When the domain is depression, the therapist can administer the Beck Depression Inventory (Beck et al., 1996), which is developed to assess the behavioural manifestations of depression, as well as for example the Pleasant...

Structuring The Treatment In

Dialectical behaviour therapy consists of four primary treatment stages with pre-commitment occurring prior to beginning each stage. Currently, the main body of research on DBT is on what is called Stage 1 DBT. The first stage of DBT is usually one year of treatment designed to get the client's behaviours under control. Clients in Stage 1 are usually engaging in severely out of control behaviours. They are suicidal, engaging or having the urges to engage in non-suicidal self-injurious...

The Evidence Base For Cognitive Therapy Ct And The Comparison Of Behaviour Therapy And Cognitive Therapy

James & Blackburn (1995) examined the evidence base for the use of CT in OCD. They found few controlled studies and that multiple forms of treatment were often used. They concluded that there was little evidence of improved outcome when CT was added to medication and behavioural techniques. A systematic review by Abramowitz (1997) found no significant difference between behaviour therapy and cognitive therapy. In a further RCT Cottraux (2001) found a similar response rate following...

The Rationale For Adjunctive Psychological Treatments

Bipolar disorder has a median age of onset in the mid-20s, but most individuals report that they experienced symptoms or problems up to 10 years before diagnosis. Thus, the early evolution of BP may impair the process of normal personality development or may mean that the person starts to employ maladaptive behaviours from adolescence onwards. Co-morbid anxiety disorders, including panic and post-traumatic stress disorder (PTSD) and other mental health problems are common accompaniments of BP...

The Therapeutic Relationship

There are some common misconceptions regarding the nature of the therapeutic relationship in behaviour therapy. It is often thought of as distant, one sided and somewhat authoritarian. Arguably, behaviour therapists themselves are partly responsible for this prejudice as they - in contrast to psychodynamic therapists and experientially oriented therapists, for example - pay scarce attention to the therapeutic relationship in their published work. However, most behaviour therapists recognize the...

Treatment Comparisons

This research in EMDR can be viewed as having two phases. The first phase from Shapiro's seminal 1989 paper up until 1998 was characterised by research examining whether EMDR was an effective psychotherapeutic procedure for post traumatic stress disorder, and the contribution of its various elements, especially eye movements. The second phase from 1999 largely accepted EMDR as an effective treatment for PTSD (Foa, 2000) and now focused on research comparing the effectiveness and efficiency of...

Treatment

The patient should first have a diagnostic interview to establish the diagnosis of OCD and any other co-morbid diagnoses. The symptom severity should be evaluated using the Y-BOCS and the CAC. Such scales also list a wide range of obsessional thoughts and compulsions, thus opening the way for patients to disclose thoughts and behaviours they find embarrassing. The history of the course of OCD symptoms, engagement with and response to previous treatments, patient's treatment goals, social...