Cognitive behavioral therapy in practice: treatment delivered by trainees at an outpatient clinic is clinically effective

A roadmap to address stress in graduate students: How to develop and disseminate a student-led single-session evidence based intervention

Objective: This manuscript describes an evidence-based, student-led, single-session group intervention to support emotional wellbeing among graduate students. The present objective is to provide a roadmap for other universities. Participants: Key participants include clinical psychology graduate students (leader and workshop facilitators), faculty supervisor, representatives from receiving departments or schools, and institutional advocates. Methods: The two-hour workshop was based on four core transdiagnostic cognitive behavioral skills, including psychoeducation about emotions, mindful emotional awareness, cognitive flexibility, and behavior change. The workshop was designed and continues to be led by trained graduate students. Results: Key steps and lessons learned are presented for the exploration, preparation, implementation, and sustainment phases. Conclusions: This program has the potential to be flexibly replicated at other universities to assist with graduate student mental health. It provides unique supports for recipients and unique training opportunities for student facilitators.

Cognitive behavioural anger treatment for adults with intellectual disabilities: effects of therapist experience on outcome

BACKGROUND

Anger has been shown to be associated with aggression and violence in adults with intellectual disabilities in both community and secure settings. Emerging evidence has indicated that cognitive behavioural anger treatment can be effective in reducing assessed levels of anger and violent behaviour in these patient populations. However, it has been suggested that the effectiveness of these types of interventions is influenced by the experience and training of the therapists.

METHOD

In this service evaluation study, the pre- and post-treatment and 12-month follow-up assessment scores of 88 detained in-patient adults with intellectual disabilities and forensic histories who received cognitive behavioural anger treatment were examined in order to investigate whether participants' responsiveness to treatment was associated with treatment being delivered by qualified versus unqualified therapists.

RESULTS

Overall significant reductions in self-reported measures of anger disposition and anger reactivity were found with no significant time × therapist experience interaction effects. However, the patients treated by qualified therapists improved significantly on measures of anger control compared with those allocated to unqualified therapists.

CONCLUSIONS

Male and female detained patients with intellectual disabilities and forensic histories can benefit from an individual cognitive behavioural anger treatment intervention delivered by qualified and unqualified therapists, but therapist experience may be important in supporting patients to develop more complex anger control coping skills.

Outcomes of student trainee-delivered cognitive-behavioral therapy (CBT) on internalizing symptoms, CBT skills, and life satisfaction

Increased quality of life (QoL) is rated by patients as a primary factor in determining recovery from psychopathology. Cognitive-behavioral therapies (CBTs) are the most well-researched psychotherapies for internalizing disorders and appear effective at reducing symptoms even when delivered by trainees. Existing research suggests that the effects of CBTs on QoL are more modest than their effects on symptoms. However, little is known about the effects of trainee-delivered CBT on life satisfaction, a subjective measure of QoL. We analyzed data from 93 clients treated by students (n=23) in a graduate-level training clinic using an intent-to-treat approach, completers case analyses, and random forest imputation. Across methods of handling missing data, improvements in anxiety, depression, and CBT skills were more marked than improvements in QoL. Exploratory analyses suggested baseline life satisfaction was the strongest predictor of end-of-treatment life satisfaction. Future research should explore alternatives to "standard" CBT for clients with low life satisfaction.

A qualitative examination of trainee perspectives on cognitive behavioural supervision

Clinical supervision is the main method by which mental health professionals acquire the competence to deliver safe and effective therapy. The cognitive behavioural supervision (CBS) approach to supervision parallels CBT in structure and form, which may facilitate learning. Although supervision is integral to trainee development, little is known about what CBS interventions trainees consider helpful. Using a qualitative content analysis methodology, we aimed to identify the specific CBS interventions that trainees find most helpful. Eight trainees completing a CBT rotation in an out-patient hospital setting received weekly individual supervision by staff psychiatrists and psychologists. Following each supervision meeting, trainees completed open-ended responses describing what they found most and least helpful. Responses from 127 meetings were coded using a CBS framework. Overall, trainees found many aspects of supervision helpful. The interventions most frequently noted as valuable were teaching, planning, formulating, training/experimenting, and evaluation of their work. When trainees mentioned unhelpful events, insufficient collaboration and a desire for more or less supervision structure were most frequently noted. These results suggest that the perceived helpfulness of supervision may be tied to the use of CBS interventions that provide trainees with concrete skills that facilitate learning. Further suggestions and implications for supervisors are discussed.

Key learning aims

(1)

The Influence of Chronic Pain and Catastrophizing on Patient Outcomes in an Athletic Therapy Setting

CONTEXT

Chronic pain is a challenge for Athletic Trainers and Athletic Therapists working in a clinical or university setting. The fear avoidance model, including catastrophizing, is well established in other health professions but is not established in Athletic Training and Athletic Therapy and may affect rehabilitation outcomes.

OBJECTIVE

To measure the influence of catastrophizing on rehabilitation outcomes of patients being treated in an Athletic Therapy setting.

DESIGN

Prospective single group pre-post design.

SETTING

Student Athletic Therapy clinic.

PATIENTS

A total of 92 patients were evaluated at initial assessment, and 49 were evaluated at follow-up.

INTERVENTION

All participants completed self-reported function questionnaires to assess level of injury and then received individualized treatments for a variety of musculoskeletal injuries. All measures were completed at initial assessment and at follow-up approximately 6 weeks later.

MAIN OUTCOME MEASURES

The authors measured function using a variety of patient self-reported functional questionnaires: the Disability of the Arm, Shoulder, and Hand; Lower Extremity Functional Scale; the Neck Disability Index; and the Oswestry Disability Index depending on injury site. Catastrophizing was measured using the Pain Catastrophizing Scale.

RESULTS

Function significantly improved from the initial assessment to the follow-up (P > .001). Patients with acute pain experienced a significantly greater improvement in function between the initial assessment and follow-up compared with participants with chronic pain (P = .050). Those with high catastrophizing presented with lower levels of function at initial assessment (66.8%) and follow-up (72.1%) compared with those with low catastrophizing (80.8% and 87.0%, respectively).

CONCLUSION

Similar to other studies in other professions, the function of patients with chronic pain does not improve as much compared with patients recovering from acute pain in an Athletic Therapy setting. It is important to measure patient-reported outcomes to evaluate patient rehabilitation progress. Rehabilitating patients with chronic pain is a challenge, and pain catastrophizing should be evaluated at the initial assessment since catastrophizing is associated with worse function.

Benchmarking Community-Based Couple Therapy: Considering Measurement Reactivity

Couple therapy has been shown to be effective in randomized clinical trials; however, results from naturalistic couple therapy have been less consistent. This study utilized a benchmarking approach to compare the effectiveness of couple therapy in a community-based setting with findings from efficacy treatments, such as treatment within randomized clinical trials. The current study is the largest couple therapy sample published to date (N = 3,347 couples). Clients in couple therapy were asked to provide initial and weekly ratings of symptomology on the Outcome Questionnaire (OQ-45.2). We found that treatment effect sizes found at community clinics were smaller than efficacy studies (i.e., the benchmark). However, when taking into account measurement reactivity, the effect sizes were comparable. This is the first benchmarking study for community-based couple therapy, allowing for meaningful comparisons and understanding of outcomes in real-world couple therapy. Implications for the field are offered in terms of evaluating community-based psychotherapy studies with benchmarking for couple therapy. Results of this study provide clinicians and researchers a way to meaningfully compare couple therapy outcomes, accounting for differences in community-based practices and randomized clinical trials. This benchmark also underscores the impact of measurement sensitivity, an issue commonly overlooked in psychotherapy research and practice.

An examination of dysfunctional attitudes and extreme response styles as predictors of relapse in guided internet-based cognitive behavioral therapy for depression

OBJECTIVES

Internet-based cognitive behavioral therapy (iCBT) is an effective treatment option for depression, but its long-term effects are not well understood. We investigate for whom iCBT may have more enduring effects by evaluating dysfunctional attitudes as predictors of relapse.

METHODS

The sample consists of 31 iCBT responders (20 women, average age 31.6) who were followed for 1 year.

RESULTS

Higher Dysfunctional Attitudes Scale scores predicted higher risk of relapse (hazard ratio = 1.98). This relation remained significant when controlling for high style (dysfunctional) or content (functional) responses. Having relatively more positive extreme responses on style rather than content items did not predict risk of relapse.

CONCLUSIONS

Our results were consistent with the value of differentiating an extreme style of responding from otherwise endorsing belief in dysfunctional attitudes. Research that refines our understanding of patients' individual risk for relapse has the potential to inform how treatment might be individually tailored.

Outcomes, skill acquisition, and the alliance: Similarities and differences between clinical trial and student therapists

Considerable evidence from clinical trials supports the efficacy of cognitive therapy (CT) of depression. Less is known about outcomes when provided in other contexts, such as when provided by student therapists. We conducted a non-randomized comparison of student therapists vs. clinical trial therapists on change in depressive symptoms, dropout, change in CT skills, and therapeutic alliance among 100 clients with moderate to severe depression. Treatment manual and duration were the same. Clients treated by student therapists had largely comparable outcomes on depressive symptom change, therapeutic alliance, and CT skills. Results supported non-inferiority of student therapists on change in depressive symptoms, but non-inferiority was not supported when using an interviewer evaluated measure of depression. Evidence of non-inferiority was also obtained for client CT skills and therapeutic alliance. In fact, conventional superiority analyses indicated student therapists outperformed clinical trial therapists on alliance and CT skills. The rate of dropout among student therapists (30%) was numerically higher than among clinical trial therapists (17%) and our results did not support non-inferiority on dropout. CT provided by student therapists can achieve outcomes similar to those in a clinical trial, but more research about dropout is needed.

Multi-professional IAPT CBT training: clinical competence and patient outcomes

Background:

There is international interest in the training of psychological therapists to deliver evidence-based treatment for common mental health problems. The UK Improving Access to Psychological Therapies (IAPT) programme, one of the largest training initiatives, relies on competent therapists to successfully deliver cognitive behaviour therapy (CBT) and promote good patient outcome.

Aims:

To evaluate an IAPT CBT training course by assessing if trainees’ clinical skills improve during training and reach competency standards, and to report patient outcome for submitted training cases. To investigate a possible relationship between trainee competence and patient outcome. To explore professional differences during training.

Method:

CBT trainee (n = 252) competence was assessed via audio recordings of therapy sessions at the beginning, middle and end of training. Patient pre- to post-treatment outcomes were extracted from submitted training cases (n = 1927). Differences in professional background were examined across competence, academic final grade and tutorial support.

Results:

CBT trainees attained competence by the end of the course with 77% (anxiety recordings) and 72% (depression recordings) improving reliably. Training cases reported pre- to post-treatment effect sizes of 1.08–2.26 across disorders. CBT competence predicted a small variance in clinical outcome for depression cases. Differences in professional background emerged, with clinical psychologists demonstrating greater competence and higher academic grades. Trainees without a core professional background required more additional support to achieve competence.

Conclusions:

Part of a new CBT therapist workforce was successfully trained to deliver relatively brief treatment effectively. Trainees without a core profession can be successfully trained to competence, but may need additional support. This has implications for workforce training.

Effectiveness of routine psychotherapy: Method matters

OBJECTIVE

Though many studies have shown that psychotherapy can be effective, psychotherapy available in routine practice may not be adequate. Several methods have been proposed to evaluate routine psychological treatments. The aim of this paper is to demonstrate the combined utility of complementary methods, change-based benchmarking, and end-state normative comparisons, across a range of self-reported psychological symptoms.

METHOD

Benchmarks derived from randomized controlled trials (RCTs) and normative comparisons were used to evaluate the effectiveness of psychotherapy in a large (N = 9895) sample of clients in university counseling centers (UCCs).

RESULTS

Overall, routine psychotherapy was associated with significant improvement across all symptoms examined. For clients whose initial severity was similar to RCT participants, the observed pre-post effect sizes were equivalent to those in RCTs. However, treatment tended to lead to normative end-state functioning only for those clients who were moderately, but not severely, distressed at the start of psychotherapy.

CONCLUSIONS

This suggests that although psychotherapy is associated with an effective magnitude of symptom improvement in routine practice, additional services for highly distressed individuals may be necessary. The methods described here comprise a comprehensive analysis of the quality of routine care, and we recommend using both methods in concert. Clinical or methodological significance of this article: This study examines the effectiveness of routine psychotherapy provided in a large network of counseling centers. By comparing multiple established methods to define outcomes in this sample we provide a detailed understanding of typical outcomes. The findings show that, across several different problem areas, routine psychotherapy provided substantial benefit, particularly to clients in the most distress. However, there is room to improve, especially by increasing the number of clients who return to normal functioning by the end of treatment. Using distinct methods provides complementary answers to the question: How effective is routine psychotherapy?

Predictors of Dropout in Internet-Based Cognitive Behavioral Therapy for Depression

Internet-based cognitive behavioral therapy (iCBT), provided with guidance, has been shown to outperform wait-list control conditions and appears to perform on par with face-to-face psychotherapy. However, dropout remains an important problem. Dropout rates for iCBT programs for depression have ranged from 0% to 75%, with a mean of 32%. Drawing from a recent study in which 117 people participated in iCBT with support, we examined participant characteristics, participants' use of iCBT skills, and their experience of technical difficulties with iCBT as predictors of dropout risk. Educational level, extraversion, and participant skill use predicted lower risk of dropout; technical difficulties and openness predicted higher dropout risk. We encourage future research on predictors of dropout in the hope that greater understanding of dropout risk will inform efforts to promote program engagement and retention.

Cognitive behavioural therapy for eating disorders: how do clinician characteristics impact on treatment fidelity?

BACKGROUND

Clinicians routinely report not practising evidence-based treatments with eating disorders. There has been limited research investigating the impact of adaptable clinician characteristics such as self-efficacy and therapeutic optimism in this area. This study evaluated if there is a relationship between clinician therapeutic optimism, self-efficacy and the provision of evidence-based practice in the treatment of bulimia nervosa and binge eating disorder.

METHOD

A survey developed for this study was administered to 100 psychologists who were recruited online via a range of organisations affiliated with psychology and/or eating disorders. The survey measured demographic factors, eating disorder treatment knowledge, treatment fidelity, the use of individual treatment components and a range of clinician characteristics including self-efficacy and therapeutic optimism.

RESULTS

Results demonstrated that clinician self-efficacy was positively associated with and predicted treatment fidelity. Therapeutic optimism had significant low correlations with treatment fidelity but did not predict treatment fidelity.

CONCLUSION

These findings would suggest that strengthening clinician self-efficacy is useful in improving evidence-based practice in the treatment of binge eating disorder and bulimia nervosa and may also have implications in the training of clinicians. The study also demonstrated that the use of a range of knowledge translation strategies are valuable in enhancing clinician adherence to evidence-based practice. Further research with direct measures of treatment fidelity is needed to clarify these findings.

Effectiveness of cognitive behavioral therapy on health-related quality of life: An evaluation of therapies provided by trainee therapists

The present study was carried out to examine the treatment effect of cognitive behavioral therapy provided by trainee therapists at a university clinic, focusing on health-related quality of life (HRQOL) optimism and symptoms. The study was conducted through a repeated measures design and included a treatment group (n = 21), which received cognitive behavioral therapy for an average of 10.7 therapy sessions and a control group (n = 14), that was put on a wait list for 8.6 weeks on average. After treatment, the treatment group improved significantly concerning general health (p = 0.028) and optimism (p = 0.027). In addition, clients improved in several areas within mental health and displayed some reduction in anxiety symptoms. Concurrently, the results also indicated some improvement within the control group, which may have been caused by the initial therapeutic contact, expectancy effects or spontaneous remission. The study concluded that cognitive behavioral therapy provided by trainee therapists may have a positive effect on areas within HRQOL and optimism.

Comparing systemic therapy and cognitive behavioral therapy for social anxiety disorders: study protocol for a randomized controlled pilot trial

BACKGROUND

Social anxiety disorders are among the most prevalent anxiety disorders in the general population. The efficacy of cognitive behavioral therapy (CBT) for social anxiety disorders is well demonstrated. However, only three studies point to the efficacy of systemic therapy (ST) in anxiety disorders, and only two of them especially focus on social anxiety disorders. These ST studies either do not use a good comparator but minimal supportive therapy, they do not use a multi-person ST but a combined therapy, or they do not especially focus on social anxiety disorders but mood and anxiety disorders in general. Though ST was approved as evidence based in Germany for a variety of disorders in 2008, evidence did not include anxiety disorders. This is the first pilot study that will investigate multi-person ST, integrating a broad range of systemic methods, specifically for social anxiety disorders and that will compare ST to the "gold standard" CBT.

DESIGN

This article describes the rationale and protocol of a prospective, open, interventive, balanced, bi-centric, pilot randomized controlled trial (RCT). A total of 32 patients with a primary SCID diagnosis of social anxiety disorder will be randomized to either CBT or ST. Both treatments will be manualized. The primary outcome will include social anxiety symptoms at the end of therapy. Therapy will be restricted to no more than 26 hours (primary endpoint). Secondary outcomes will include psychological, social systems and interpersonal functioning, symptom adjustment, and caregiver burden, in addition to change measures, therapist variables and treatment adherence. At the secondary endpoints, 9 and 12 months after the beginning of therapy, we will again assess all outcomes.

DISCUSSION

The study is expected to pilot test a RCT which will be the first to directly compare CBT and multi-person ST, integrating a broad range of systemic methods, for social anxiety disorders, and it will provide empirical evidence for the calculation of the number of patients needed for a confirmatory RCT.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02360033 ; date of registration: 21 January 2015.

Early assessment of implementing evidence-based brief therapy interventions among secondary service psychiatric therapists

This implementation study was part of the Ostrobothnia Depression Study, in Finland, which covered implementation of motivational interviewing (MI) and behavioral activation (BA) within regional public psychiatric secondary care. It aimed to evaluate the mid-term progress of implementation and related factors. Altogether, 80 therapists had been educated through the implementation program by the point of the mid-term evaluation. Eligible information for evaluation was gathered using two questionnaires (q1, q2) with a one-year interval. A total of 45 of the 80 therapists completed q1, 30 completed q2, and 24 completed both questionnaires. Professional education was the only background factor associated with adopting the interventions (q1: p=0.059, q2: p=0.023), with higher education indicating greater activity. On the basis of trends such as changes in overall usefulness score from q1 to q2, the most involved therapists were slightly more likely to adopt MI/BA. Our experience so far suggests that encouraging staff to begin using new interventions during education is very important. The Consolidated Framework for Implementation Research was found to be a useful tool for constructing the evaluation.

The role of brief CBT in the treatment of anxiety and depression for young adults at a UK university: a pilot prospective audit study

Cognitive behaviour therapy (CBT) has rarely been offered to students seeking professional psychological help at universities in the UK. Here, we aimed to investigate whether a brief course of CBT would improve anxious and depressive symptoms. Forty-eight student patients received a brief course of CBT at a university National Health Service, Student Health Centre in England. Patients completed weekly self-report measures of anxiety and depression at the commencement of each CBT session. Student patients receiving CBT showed significant decreases in anxiety and depression. These effects remained after controlling for a range of potential covariates (e.g. primary problem, total time in treatment, therapist qualifications). Findings suggest CBT is effective in reducing anxiety and depressive symptoms in a ‘real-world’ university clinic.

Cognitive-behavioural therapy by psychiatric trainees: can a little knowledge be a good thing?

Aims and method To establish the competency of psychiatric trainees in delivering cognitive-behavioural therapy (CBT) to selected cases, following introductory lectures and supervision. Supervisor reports of trainees rotating through a national psychiatric hospital over 8.5 years were reviewed along with revised Cognitive Therapy Scale (CTS-R) ratings where available. Independent t-test was used to compare variables. Results Structured supervision reports were available for 52 of 55 (95%) trainees. The mean result (4.6, s.d. = 0.9) was at or above the accepted level for competency (≥3) for participating trainees. Available CTS-R ratings (n = 22) supported the supervisor report findings for those particular trainees. Clinical implications This study indicates that trainees under supervision can provide meaningful clinical interventions when delivering CBT to selected cases. The costs of supervision need to be judged against these clinical gains.

A four-session acceptance and commitment therapy based intervention for depressive symptoms delivered by masters degree level psychology students: a preliminary study

BACKGROUND

Depressive symptoms are one of the main reasons for seeking psychological help. Shorter interventions using briefly trained therapists could offer a solution to the ever-rising need for early and easily applicable psychological treatments.

AIMS

The current study examines the effectiveness of a four-session Acceptance and Commitment Therapy (ACT) based treatment for self-reported depressive symptoms administered by Masters level psychology students.

METHOD

This paper reports the effectiveness of a brief intervention compared to a waiting list control (WLC) group. Participants were randomized into two groups: ACT (n = 28) and waiting list (n = 29). Long-term effects were examined using a 6-month follow-up.

RESULTS

The treatment group's level of depressive symptoms (Beck Depression Inventory) decreased by an average of 47%, compared to an average decrease of 4% in the WLC group. Changes in psychological well-being in the ACT group were better throughout, and treatment outcomes were maintained after 6 months. The posttreatment "between-group" and follow-up "with-in group" effect sizes (Cohen's d) were large to medium for depressive symptoms and psychological flexibility.

CONCLUSIONS

The results support the brief ACT-based intervention for sub-clinical depressive symptoms when treatment was conducted by briefly trained psychology students. It also contributes to the growing body of evidence on brief ACT-based treatments and inexperienced therapists.