A enurese é uma condição caracterizada pela perda de urina durante o sono, em crianças com mais de cinco anos sem outra condição clínica que explique os episódios. A enurese pode ser primária, no caso das crianças que nunca obtiveram controle prévio, ou secundária, em que a enurese cessou por pelo menos seis meses. Também é classificada como monossintomática, na ausência de sintomas diurnos do trato urinário inferior ou não-monossintomática, quando está associada a tais sintomas, como a urgência miccional. A enurese, cujas causas apresentam componentes hereditários ainda pouco claros, tem sua etiologia baseada na combinação de três fatores: a poliúria noturna ou a hiperatividade detrusora ligada á incapacidade de despertar em resposta aos sinais da bexiga cheia. Há tratamentos medicamentosos e psicológicos, sendo que a desmopressina, análogo sintético da vasopressina, que atua na poliúria noturna e o alarme, que atua na incapacidade de despertar, apresentam os níveis mais altos de recomendação e evidência. Embora tais tratamentos estejam consolidados, ainda não há total clareza sobre seus mecanismos de funcionamento e o porquê de não alcançarem todos os casos. Este trabalho teve como objetivo verificar se um conjunto de variáveis atuaria como moderador do resultado do tratamento com alarme, ou seja, em que medida influenciava, positiva ou negativamente, o desempenho dos participantes atendidos. As variáveis avaliadas foram: tipo de acompanhamento (presencial e à distância), frequência inicial de episódios, nível de problemas de comportamento, escolaridade dos pais, sexo e idade. Foram incluídos na amostra 61 crianças e adolescentes de 6 a 17 anos que receberam tratamento com alarme, sendo que 34 foram acompanhados à distância e 27 presencialmente. No total, 37 participantes obtiveram sucesso, caracterizado por 14 noites consecutivas sem episódios, num período de 28 semanas. Doze participantes não obtiveram sucesso e outros 12 desistiram. Caracterizaram-se como moderadoras do resultado do tratamento as seguintes variáveis: tipo de acompanhamento (grupo acompanhado à distância obteve mais sucessos), frequência inicial de episódios (participantes que obtiveram sucesso tinham menos episódios, em média, no início do tratamento) e nível de problemas de comportamento (participantes que não obtiveram sucesso tinham escores maiores de problemas de comportamento externalizantes). Os resultados indicam a efetividade do alarme e apontam para os aspectos que devem receber atenção do clínico ao administrar esse tipo de tratamento / Enuresis is a condition in which children of at least five years of age lose urine during sleep, without another clinical condition that could explain the wetting episodes. Enuresis may be primary, when the child has not obtained previous bladder control, or secondary, when such control was achieved for at least six months. It is also classified as monosymptomatic, when it is not associated with other lower urinary tract symptoms or non monosymptomatic, when these symptoms, such as urgency, are present. Enuresis etiology has unclear hereditary aspects. Its physiology is based on a combination of at least two of three malfunctioning systems: incapacity to wake in response to the full bladder signals plus nocturnal polyuria or detrusor hyperactivity. There are evidence based pharmacological and psychological treatments. Desmopressin, a synthetic version of hormone vasopressin that reduces nocturnal polyuria is the first line pharmacological treatment, whereas the alarm, which acts in the incapacity to wake is the first line psychological treatment. Both have the higher levels of evidence and recommendation by the specialized literature. However, the mechanisms underlying these treatments results and the reasons they are not successful with every enuretic children are not entirely clear. The objective of this work was to verify to what stand a series of variables are moderators of alarm treatment outcome. These variables were: type of support (face-to-face versus long distance), initial bedwetting frequency, behavior problems scores, level of parents education, gender and age. Sixty-one children with ages from 6 to 17 were included. All received full spectrum home training. Thirty-four received long distance support during treatment and 27 received face-to-face support. Success was defined by 14 consecutive dry nights within a 28 weeks treatment period. Success was obtained by 37 children, while 12 did not succeed and other 12 dropped out. Three variables were observed as moderators of treatment outcome: type of support (long distance had better results), initial bedwetting frequency (participants who succeeded had fewer initial wet nights) and behavior problem scores (participants who did not succeed had higher externalizing problems scores). Results indicate alarm effectiveness and aspects that should be focuses of attention when this kind of treatment is administered

Objetivo: Avaliar a eficácia da Terapia Cognitiva Processual na melhora de pacientes com Transtorno de Estresse Pós-traumático. Desenho do estudo - Estudo randomizado, com dois grupos paralelos. Intervenções - Dois modelos de Terapia Comportamental Cognitiva - Terapia Cognitiva Processual e Exposição (os pacientes receberam tratamento farmacológico). Duração e frequência: Após a avaliação inicial (semana 00), as sessões de psicoterapia tiveram frequência semanal, durante onze semanas, e quinzenais nas quatro últimas semanas, totalizando 13 (treze) sessões. As sessões de psicoterapia duraram 1 (uma) hora. Os pacientes foram reavaliados após três meses. Número de participantes: Amostra de conveniência envolvendo 86 pacientes; 42 no grupo de Exposição e 44 no grupo de Terapia Cognitiva Processual. Resultados e Conclusão: Os dois grupos melhoraram, porém melhoras nos sintomas de TEPT não foram estatisticamente significantes entre os grupos (p > 0,1), assim como para sintomas depressivos e ansiosos (p > 0,2). Estes resultados sugerem que a Terapia Cognitiva Processual é tão eficaz quanto a Terapia de Exposição padrão-ouro / Objective: To evaluate the efficacy of Trial-Based Cognitive Therapy in the improvement of patients with posttraumatic stress disorder. Study design - Randomized study with two parallel groups. Interventions - Two Models of Cognitive Behavioral Therapy - Trial-Based Cognitive Therapy (TBCT) and Exposure (patients received pharmacological treatment). Duration and frequency: After the initial assessment (week 0), psychotherapy sessions were held weekly for eleven weeks and twice a week for four weeks, a total of thirteen (13) sessions. Psychotherapy sessions were one (1) hour long. Patients were reassessed after three months. Total Duration: 13 sessions of treatment and three months follow-up. Number of Participants: Convenience sample involveing 86 patients, 42 in the exposure group and 44 in the TrialBased Therapy group. Results and Conclusion: Both groups improved, but improvements in the symptoms of PTSD depression and anxiety were not statistically significant among the two treatment groups (p > 0.1; p > 0.2). These results suggest that Trial-Based Cognitive Therapy is as effective as the gold standard Exposure

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Clientes com Transtorno de Personalidade Borderline apresentam um alto índice de abandono de terapia. Entender o que ocorre durante as sessões entre terapeuta e cliente com este tipo de transtorno de personalidade pode contribuir para evitar futuros equívocos ou falhas na relação terapêutica, aumentando as chances de continuidade do processo terapêutico e diminuindo a probabilidade de abandono da terapia. O presente estudo teve como objetivo identificar as variáveis que estão relacionadas ao abandono de um caso de Transtorno de Personalidade Borderline. Participou do estudo uma terapeuta de orientação analítico-comportamental, com 12 anos de experiência clínica e uma cliente com 30 anos de idade, casada, sem filhos e com escolaridade superior completo. Um total de 13 sessões foi gravado em áudio, transcrito e categorizado segundo o Sistema Multidimensional para Categorização de Comportamentos da Interação Terapêutica. Foi feita análise sequencial de atraso (Lag sequential analysis). As sessões que compuseram os dados deste estudo foram entre a 9ª e a 22ª sessões, embora a 14ª sessão tenha sido excluída da análise de dados por ter sido uma sessão de casal. Os resultados mostraram que as categorias da terapeuta de maior porcentagem de ocorrência foram Facilitação, Solicitação de Relato e Empatia e as menos frequentes foram, Solicitação de Reflexão\", Aprovação e Recomendação. Reprovação foi a categoria que teve a menor frequência entre as demais categorias da terapeuta. Embora a categoria Interpretação tenha ocorrido em baixa frequência, sua duração foi grande. As categorias de maior porcentagem da cliente foram Relato e Estabelecimento de Relações entre Eventos. E as de menor porcentagem de ocorrência foram: Solicitação, Concordância, Oposição e Melhora. A categoria Metas não ocorreu nenhuma vez. Ao longo das sessões, foi observado um declínio na porcentagem de Estabelecimento de Relações entre Eventos e um aumento em Relato, no que se refere às categorias da cliente. Ao mesmo tempo, foi observada uma diminuição das categorias Empatia, Solicitação de Reflexão e Interpretação da terapeuta. As sequências que mais ocorreram foram Relato\" seguido por Facilitação\" e Facilitação\" seguida por Relato\". O abandono da terapia pareceu estar relacionado a diversos fatores: a) perda de oportunidades de aprovar e solicitar reflexão e interpretar, b) não dar atenção a relatos sobre queixas de doenças, exercendo função de invalidação, c) férias prolongadas da terapeuta e d) não flexibilidade da terapeuta em fazer mais uma sessão domiciliar em um momento de crise, repetindo assim, um comportamento de invalidação / Clients suffering from Borderline Personality Disorder show a high dropout rate in psychotherapy. The understanding of what occurs during the sessions between therapist and client suffering from this type of personality disorder may contribute to prevent future errors and failures, increasing chances of completing the therapeutic process and reducing drop-out probability. The current study had the objective of identifying the variables related to the drop-out in a case of Borderline Personality Disorder. Participated a female behavior-analytic therapist, with 12 years of clinical experience and a female client, 30 years old, married, no children, with a college degree. 13 complete sessions were recorded in video, transcribed and categorized according to the Multidimensional System for Categorization of Behaviors in Therapeutic Interaction. A lag sequential analysis was carried out. Data of this study refer to the 9th through the 22nd sessions, although the 14th session was excluded, since it was a couple session. Outcomes showed that the therapists categories in higher percentages were `Facilitation`, `Request of Report` and `Empathy` and the less frequent percentages were `Request of Reflection`, `Approval` and `Recommendation`. `Disapproval` was the therapists category appearing with lower frequency. Although `Interpretation` occurred in low frequency, it had a long duration. The clients categories with higher percentages were `Report` and `Establishment of Relationship between Events`. The lower percentages of occurrences were: `Request`, `Agreement`, `Opposition` and `Improvement`. The category `Aims` did not occur at any time. Throughout the sessions a decrease in percentage of the client\'s categories `Establishment of Relationship between Events` and an increase in \'Report\' were observed. At the same time a decrease in the therapists categories `Empathy`, `Request for Reflection` and `Interpretation` was noted. Sequences which occurred more frequently were `Report` followed by `Facilitation` and `Facilitation` followed by `Report`. The therapy drop-out seemed to be related to several factors: a) loss of opportunities by the therapist to approve, to request reflection and to interpret; b) lack of attention to reports on complaints of diseases, having an invalidation effect; c) therapists extended vacation and d) therapists refusal to attend an additional home session, in a critical moment, thus repeating the invalidation

The problem of this study was the reduction of a hypothesized fear of intimate interpersonal interaction among counselor trainees. This study had three purposes: 1. To determine whether implosive therapy is effective in reducing conditioned fear of close interpersonal interaction. 2. To determine whether the use of implosive therapy is effective in enhancing the counseling effectiveness of counselor trainees. 3. To provide information that may be beneficial for future research involving the use of implosive techniques in counselor training. Six hypotheses were formulated for the study. The .10 level of significance was chosen as the level at which the hypotheses would be accepted or rejected. Hypotheses I, II, and III were not supported. Hypotheses IV, V, and VI were accepted; however, no conclusions could be drawn without prior acceptance of at least one of the three hypotheses: I, II, or III. It was concluded that: 1. Group implosive therapy, as utilized in this study, was not effective in reducing conditioned fear of close interpersonal interaction. 2. The underlying assumption of the present study that the counselor trainees are as likely as clients to have developed a fear of close interpersonal interaction is seriously questioned. 3. Group implosive therapy as applied in this study is not effective in increasing the counseling effectiveness of counselor trainees.

Hearing distressing voices (also known as auditory verbal hallucinations) is a common symptom associated with a number of mental health problems. Psychological therapies, specifically cognitive behaviour therapy (CBT) can be an effective intervention for this patient group. The aim of CBT for voices (CBTv) is to reduce the distress associated with the experience, by encouraging the patient to re-evaluate their beliefs about the voice's omnipotence, omniscience, and malevolence. Despite the evidence for CBTv, very few patients are offered this therapy; largely due to a lack of resources. The aim of this thesis was to develop and begin to evaluate a CBT-based intervention for voices that was resource-light; in the hope that it could be more easily be implemented into clinical services, and therefore increase access. This thesis begins with an introduction to the research area, and is followed by a review and evaluation of the methods used in this thesis. Chapter 6 is a systematic review and meta-analysis of the current literature on brief (< 16 NICE recommended sessions) CBT for psychosis (CBTp). Chapters 7 and 8 describe the process of developing a brief CBT intervention for voices, based on the CBT self-help book ‘Overcoming Distressing Voices'. Both people who hear voices, and mental health clinicians were consulted on the intervention concept and design. The outcome of these studies was guided self-help CBTv, and an accompanying therapy workbook to guide the intervention. Chapters 9 and 10 detail the design and findings of a randomised controlled trial of guided self-help CBTv delivered by Clinical Psychologists, versus a wait-list control group. Data was collected at baseline (pre-randomisation) and 12 weeks post-randomisation. The primary outcome was voice-related distress. The findings across all of the studies are then summarised and reflected upon within the Discussion chapter – including consideration of the extent to which the overall aim of this thesis (increasing access) has been achieved.

Objetivo: Avaliar a eficácia da Terapia Cognitiva Processual na melhora de pacientes com Transtorno de Estresse Pós-traumático. Desenho do estudo - Estudo randomizado, com dois grupos paralelos. Intervenções - Dois modelos de Terapia Comportamental Cognitiva - Terapia Cognitiva Processual e Exposição (os pacientes receberam tratamento farmacológico). Duração e frequência: Após a avaliação inicial (semana 00), as sessões de psicoterapia tiveram frequência semanal, durante onze semanas, e quinzenais nas quatro últimas semanas, totalizando 13 (treze) sessões. As sessões de psicoterapia duraram 1 (uma) hora. Os pacientes foram reavaliados após três meses. Número de participantes: Amostra de conveniência envolvendo 86 pacientes; 42 no grupo de Exposição e 44 no grupo de Terapia Cognitiva Processual. Resultados e Conclusão: Os dois grupos melhoraram, porém melhoras nos sintomas de TEPT não foram estatisticamente significantes entre os grupos (p > 0,1), assim como para sintomas depressivos e ansiosos (p > 0,2). Estes resultados sugerem que a Terapia Cognitiva Processual é tão eficaz quanto a Terapia de Exposição padrão-ouro / Objective: To evaluate the efficacy of Trial-Based Cognitive Therapy in the improvement of patients with posttraumatic stress disorder. Study design - Randomized study with two parallel groups. Interventions - Two Models of Cognitive Behavioral Therapy - Trial-Based Cognitive Therapy (TBCT) and Exposure (patients received pharmacological treatment). Duration and frequency: After the initial assessment (week 0), psychotherapy sessions were held weekly for eleven weeks and twice a week for four weeks, a total of thirteen (13) sessions. Psychotherapy sessions were one (1) hour long. Patients were reassessed after three months. Total Duration: 13 sessions of treatment and three months follow-up. Number of Participants: Convenience sample involveing 86 patients, 42 in the exposure group and 44 in the TrialBased Therapy group. Results and Conclusion: Both groups improved, but improvements in the symptoms of PTSD depression and anxiety were not statistically significant among the two treatment groups (p > 0.1; p > 0.2). These results suggest that Trial-Based Cognitive Therapy is as effective as the gold standard Exposure

This thesis follows the research portfolio format and is carried out in part fulfilment of the academic component of the Doctorate in Clinical Psychology at the University of Edinburgh. An abstract provides an overview of the entire portfolio thesis. Chapter One contains a systematic review of published research exploring staff attitudes towards computerized cognitive behavior therapy (cCBT). Chapter Two is an empirical study examining a range of potential predictor variables on well-being outcomes from cCBT. Chapter one is prepared for Behavioural and Cognitive Psychotherapy, whereas chapter two is prepared for submission to the journal, Behaviour Research and Therapy. Both chapters follow the relevant author guidelines. Background: Evidence suggests that computerised cognitive behavioural therapy (cCBT) is both effective and efficacious in treating depression and anxiety. Numerous barriers to its implementation and uptake have been identified, however, including attitudinal variables and high patient attrition rates. Research examining predictors of response from cCBT have tended to adopt the pathological model of distress, focussing on symptom reduction rather than the promotion of well-being. Furthermore, exploration of possible predictors has tended to focus on a narrow range of factors (e.g. age, gender), neglecting key psychosocial variables (e.g. social identification, baseline distress) that could be exerting an effect. Aims: A systematic review examined staff attitudes towards cCBT for depression, anxiety, and comorbid depression and anxiety, focussing on three attitudinal domains: Perceived acceptability of cCBT; staff's self-reported intention to use cCBT in the future, and perceived advantages and disadvantages of cCBT for depression and/or anxiety. An experimental study was subsequently conducted, examining a range of potential predictors on well-being outcomes from a cCBT intervention utilising Beating the Blues. Method: A systematic search across five databases was conducted, followed by manual searches. Strict search criteria were applied, resulting in the identification of 15 studies. These were subjected to quality assessment, data extraction and synthesis. For the empirical study, data from 1354 participants was collected, with subgroup-analyses conducted on those completing measures of life and mental health satisfaction, functioning and well-being. Key potential predictors of interest were level of group identification, baseline distress, and socioeconomic deprivation. Results: Findings from the systematic review indicated that staff held relatively positive attitudes towards cCBT, with some ambivalence emerging in relation to perceived advantages and disadvantages of the intervention. The empirical study obtained significant effects of group identification on life and mental health satisfaction. A mediating impact of group identity on baseline distress emerged, whereas a moderating effect of baseline distress on deprivation was obtained for the functioning model. Discussion: The current findings demonstrated both positive and negative aspects of staff attitudes towards cCBT for depression and/or anxiety, whereas the empirical project established a clear link between social identification, baseline distress, and well-being. Results from both studies are discussed in terms of clinical implications relating to the uptake of cCBT.

The objective of the current research was to test the initial feasibility and potential efficacy of a group-based Acceptance and Commitment Therapy (ACT) intervention for partner aggression, compared to a support and discussion control group, in a clinical sample of adults. Specifically, the study was intended to provide preliminary evidence of the impact of an ACT group on psychological and physical aggression, and to examine the processes responsible for any treatment effects. One hundred and one participants (mean age = 31; 68% female) were randomly assigned to receive ACT or the support and discussion control group. Both interventions consisted of 12 weekly 2-hour sessions and participants were assessed with self-report measures at pre-treatment, twice during treatment, at post-treatment, and at 3- and 6-month follow-up. Results of growth curve modeling analyses demonstrated that participants in the ACT group had significantly greater decreases in psychological and physical aggression at post-treatment and follow-up, and also showed improvements in depressive symptoms, interpersonal problems, and social functioning. Finally, the effect of the ACT group on psychological and physical aggression was mediated by experiential avoidance, suggesting that the intervention had its effects, at least in part, through increasing emotional acceptance. These results demonstrate that an ACT approach to aggression may be a viable alternative to traditional treatments.

The pivotal role of inflated responsibility beliefs in the maintenance and treatment of obsessive-compulsive disorder (OCD) has been clearly demonstrated (Rachman, 1993; Salkovskis, 1998; Shafran, 1997; van Oppen & Arntz, 1994). Yet little is known about the origins of these beliefs, their contribution to a sense of inflated responsibility or the symptoms of OCD, or the contribution of personality to inflated responsibility and to OCD, The aims of this thesis were to investigate a model of the inter-relationships among the personality dimensions of neuroticism and psychoticism, inflated responsibility and OCD, and the origins of inflated responsibility to inflated responsibility and to OCD. In order to achieve these aims, a scale was developed to assess the origins of inflated responsibility based upon the five pathways proposed by Salkovskis, Shafran, Rachman, and Freeston (1999) and the additional domains of guilt, vigilance and thought-action fusion (Shafran, Thordarson, & Rachman, 1996; Shafran, Watkins & Charman, 1996; Tallis, 1994). Eighty-four participants with OCD (age M = 43.36) and 74 control participants (age M =37.14) volunteered to participate in the two studies of this thesis. The aim of Study 1 was to develop and validate a measure of the Origins of Inflated Responsibility (OIR). The results of the first study yielded a 25-ttem scale, the Origins of Inflated Responsibility Questionnaire (OIRQ) with five independent factors: responsibility, strictness, protection from responsibility, critical incidents, and peer blame which demonstrated both internal reliability and temporal stability over a 2-week period. In Study 2, participants also completed the Responsibility Attitudes Scale (Salkovskis, Wroe, Gledhill, Morrison, Forrester, Richards, ct al. (2000) (a measure of inflated responsibility), the Padua Inventory (Sanavio, 1988) (to measure of the symptoms of OCD)y and the Eysenck Personality Inventory-Revised (Eysenck & Eysenck, 1991). Multivariatc Analysis of Variance revealed that the OCD group scored higher on all variables than the control group except for strictness where the groups were not different, and psychoticism where the OCD group scored lower. A series of Multiple Regression analyses revealed that both group and the OIR contributed to inflated responsibility (R2 = .56). When all variables, OIR, inflated responsibility and neuroticism were entered as predictors of OCD, 60% of the variance in OCD was explained however, 49% of the variance was shared by the independent variables suggesting the presence of some underlying construct. Structural Equation Modelling, where all the constructs in the model were examined simultaneously, revealed that neuroticism contributed to the OIR, inflated responsibility and OCD. The OIR were also significant predictors of inflated responsibility and indirectly through inflated responsibility predictive of OCD. The OIR also directly predicted OCD and when the total effects are considered, their contribution was greater than the total effect for inflated responsibility alone. The results of these studies provide good support for the origins of inflated responsibility proposed by Salkovskis et al. (1999), as measured by the OIRQ developed for use in the current thesis. The results also support the contribution of inflated responsibility and neuroticism, as well as the OIR, to OCD, The large amount of variance shared by the OIR, inflated responsibility and neuroticism suggest that there might be some underlying construct, perhaps of a biopsychosocial nature, that requires further investigation for its role in the onset and maintenance of OCD. The clinical relevance of these findings is discussed in terms of early prevention strategies and interventions.