Cognitive behaviour therapy (CBT) is a therapeutic modality which is commonly argued to be oriented to a medical model, and so to diverge significantly in theory and practice from the traditional relational and humanistic roots of counselling psychology. A large body of literature and research exists which examines counselling psychologists’ professional identity in medical settings, but there appears to be a significant gap in the extant literature relating to how counselling psychologists experience professional identity specifically in the practice of CBT, a therapeutic modality which presently provides a considerable amount of employment for counselling psychologists. To address this gap, the present study sought to explore qualitatively whether counselling psychologists’ experience of their professional identity is affected by the inclusion of CBT in their practice. A sample of eight counselling psychologists who worked with CBT and had been qualified for at least five years were interviewed. Data gathered from the semistructured interviews were transcribed and analysed using interpretative phenomenological analysis (IPA), a method selected because it is concerned with the detailed examination of personal lived experience and the meaning of experience to participants. The methodology was approached within the contextual constructionist epistemological framework. Three superordinate themes, each containing four subordinate themes, emerged from participants’ accounts: (i) components of professional identity; (ii) the contribution of CBT to the professional self; and (iii) how CBT compromises the professional self. The findings are discussed in relation to the relevant literature, and lines of enquiry that have emerged have been located in current postmodern literature, arguments and debates. One main conclusion of the present study is that feeling comfortable with CBT can CBT, Counselling Psychology and Professional Identity 3 depend upon practitioners’ initial training, personal experience, cultural background, personal characteristics and personal beliefs – that is, the professional self as emerging from the personal self. Clinical implications, methodological limitations, directions for future research and reflections upon the researcher’s reflexivity are presented.

The aim of the present research was threefold: to investigate the fears of parents of children with chronic conditions; to evaluate the effectiveness of their treatment with either mindfulness-based therapy or cognitive behavioural therapy (CBT); and to assess treatment outcome in terms of health-related quality of life (HRQoL). Long-term stress can lead to some form of chronic stress reaction. In study one, fears of future cancer recurrence and of late effects of treatment were most prominent among parents of CNS tumour patients. Study two investigated the effectiveness of two group-based interventions on stress and burnout among parents of children with chronic conditions. Parents were offered either a CBT or a mindfulness programme. Both interventions significantly decreased stress and burnout. Study three focused on the HRQoL and life satisfaction of the parents in study two. The results indicate improvements for participants in both treatment groups regarding certain areas of HRQoL and life satisfaction. To conclude, fears concerning future cancer recurrence and late effects of treatment are most prominent among parents of children with cancer. Another conclusion is that CBT and mindfulness decrease stress and burnout and may have a positive effect on areas of HRQoL and life satisfaction. / The aim of the present research was threefold: to investigate the fears of parents of children with chronic conditions who suffer from fears, stress and burnout; to evaluate the effectiveness of their treatment with either mindfulness-based therapy or cognitive behavioural therapy (CBT); and to assess treatment outcome in terms of health-related quality of life (HRQoL). Research on parents of children with chronic conditions has shown that this parent group frequently suffers from psychological problems. Long-term stress can lead to some form of chronic stress reaction. In study one, parents of children with brain tumours were asked to rate the extent to which they experienced a set of specific fears related to their child’s brain tumour and its treatment. Fears of future cancer recurrence and of late effects of treatment were most prominent among parents of CNS tumour patients. Study two investigated the effectiveness of two group-based interventions on stress and burnout among parents of children with chronic conditions. After a waiting list control period, parents were offered either a CBT or a mindfulness programme. After eight group therapy sessions, both interventions significantly decreased stress and burnout. Study three focused on the HRQoL and life satisfaction of the parents in study two. The results indicate improvements for participants in both treatment groups regarding certain areas of HRQoL and life satisfaction. To conclude, many parents of children with chronic conditions suffer from stress-related mental illness and need targeted interventions for their own problems. The present research concludes that fears concerning future cancer recurrence and concerning late effects of treatment are most prominent among parents of children with cancer. Another conclusion is that CBT and mindfulness decrease stress and burnout and may have a positive effect on areas of HRQoL and life satisfaction in parents of children with chronic conditions.

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Stress and sleep problems are common in the working population and cause considerable costs for society. Sleep is the most important part of recovery, and poor sleep has a negative impact on overall functioning, which might have important consequences for both the employee, the employer and society. In order to find strategies to alleviate this contemporary public health concern of stress and poor sleep in the working population, this thesis evaluated interventions performed at the workplace to target these issues. The first intervention is a randomized controlled trial of a 25% work time reduction for full-time workers within the public sector in Sweden. Study I evaluated the impact of work time reduction on subjective sleep quality, sleep duration, sleepiness, perceived stress, and bedtime worries. Assessments included diary data from one week at three occasions over 18 months. Study II investigated time-use patterns through activity reporting sheets used during the work time reduction by evaluating the amount of total workload, paid work, non-paid work and recovery activities. Both studies investigated workdays and days off separately as well as the importance of gender, family status and work situation (only Study II). The second randomized controlled intervention of the thesis is a group cognitive behavioral therapy (CBT) intervention at the workplace targeting sleep disturbances among employees within the retail sector in Sweden (Study III). Data were collected through questionnaires, diaries and objective sleep measurement (actigraphy) over a period of ten days before and after the intervention, as well as at a three-month follow up. The study evaluated the effects of the intervention on sleep and explored the moderating effect of burnout-levels at baseline. In our studies, an economically fully compensated reduction of work hours for full-time workers lead to long-term positive effects on sleep duration and sleep quality, sleepiness and levels of perceived stress. During this work time reduction, the total workload of both paid and non-paid work was reduced and time spent in recovery activities increased. The results indicate that a more balanced relation between effort and recovery was established. The second intervention, which targets the individual through a group CBT-intervention for insomnia at the workplace, was shown to improve insomnia symptoms in daytime workers who did not suffer from concurrent burnout. Such an intervention could support the individual in handling sleep problems and preventing the development of more severe and chronic sleep disorders, as opposed to interventions aimed at making environmental changes at the workplace. However, the CBT-intervention evaluated within this thesis will need to be further developed in order to be beneficial for more groups of employees. The positive effects of these interventions might be beneficial for public health and help improve employee’s life satisfaction, daily functioning and health development.​ / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 2: Manuscript. Paper 3: Manuscript.</p>

Insomnia is a common health complaint that often becomes a persistent problem. The theoretical frameworks for understanding and treating insomnia have mostly been behavioural, yet the importance of cognitive processes has received greater attention over the years. The overall aim of this dissertation was to expand the knowledge on the processes from the Cognitive Model of Insomnia by investigating them in novel contexts. Study I examined the outcomes from cognitive therapy for insomnia on adolescents. Study II explored the relationship between cognitive processes and the association with remission and persistence of insomnia in the general population. Lastly, Study III investigated if cognitive processes mediated between cognitive behavioural therapy for insomnia (CBT-I) and outcomes of insomnia and depressive severity in a sample of people with insomnia comorbid with depressive problems. The findings show that cognitive therapy for insomnia affected sleep for adolescents, thus this is a promising treatment option for this age group. Further, it was found that cognitive processes distinguished between adults with normal sleep and persistent insomnia. For people with insomnia, elevated sleep-related worry at baseline increased the risk of reporting persistent insomnia later on, whereas a lowering of selective attention and monitoring, and safety behaviours over time increased the likelihood of remission from insomnia. This has clinical implications for insomnia assessment and treatment, as well as theoretical implications, and warrants further research. CBT-I was associated with greater reductions in dysfunctional beliefs and sleep-related safety behaviours compared to control treatment. Dysfunctional beliefs mediated between CBT-I and insomnia severity and depressive severity respectively. This supports the importance of negative thought content in both insomnia and depression.

Purpose: The relation between the causal attributions of individuals with panic disorder (PD) and their health outcomes remains relatively unexplored. Therefore we examined 1) the relationship between participants’ etiological beliefs about PD and baseline demographic and clinical characteristics and 2) whether participants’ etiological beliefs about PD predicted compliance, clinical response, and side effect profiles with the treatments they were assigned. Method: The study included 251 participants. A series of multiple linear regressions were used to evaluate the relationship between participants’ causal attributions, measured by the Etiological Model Questionnaire, and their baseline characteristics. To determine whether these beliefs predicted treatment outcome, logistic and linear regressions were conducted. Results: Our results revealed that participants with a family history of psychiatric illnesses were more likely to endorse biological etiological beliefs whereas those with a younger age, comorbid psychiatric disorders, and a history of suicide attempts were more likely to attribute their illness to psychological causes. Participants experiencing impairment in family life endorsed both psychological and environmental causal beliefs, while those reporting higher fear of body sensations and agoraphobic cognitions were more likely to attribute their illness to biological and psychological causes. With regards to treatment outcome, results indicated that participants who endorsed psychological and environmental etiological beliefs experienced more severe symptoms 12 weeks following treatment; irrespective of the type of treatment they received. Implications: The consideration of individuals’ causal attributions might help health-care professionals better assist clients by communicating a more balanced perspective of the causes of PD and deliver interventions that are in line with clients’ individual beliefs.

This thesis has been prepared in the paper based format and includes a systematic review, a novel empirical piece of research and a critical reflection. The thesis focuses on the implementation of the National Institute for Health and Clinical Excellence’s (NICE) guidance recommendations for the psychological interventions for those people suffering from schizophrenia. Papers 1 and 2 have been prepared for submission in ‘Psychology and Psychotherapy: Theory, Research and Practice’ and the ‘Journal of Mental Health’ respectively. Paper 1 includes a systematic literature search and narrative synthesis exploring if the recommendations for psychological interventions for schizophrenia were being met. Rates of implementation for Cognitive Behavioural Therapy (CBT) and Family Intervention (FI) were compared. The barriers against implementation and the strategies aimed at improving implementation were reviewed. Rates of implementation varied from 4% to 100% for CBT and 0% to 53% for FI. Previously reported barriers to implementation were found, with organisational barriers being most common. Implementation strategies discovered included training packages for CBT and FI. Rates of implementation are below recommended levels suggesting inequalities in the provision of psychological interventions for schizophrenia are present. Strategies to improve implementation that are comprehensive and supported from all levels of the NHS are considered to be most effective. Paper 2 reports a quantitative piece of research exploring if behaviourally specific and plain English language guidance can improve healthcare professional intentions to perform actions in line with recommendations for schizophrenia. An independent measure, single blind, randomised controlled design was used to disseminate guidance in two formats; the ‘original’ and ‘alternative’. Self-report measures revealed no significant results when comparing the original guidance to the alternative for the cognitive determinants of behaviour, actual behaviour change, or comprehension and satisfaction with the guidance. Behaviourally specific and plain English language does not affect intentions or behaviour to implement recommended guidance for the provision of psychological interventions for schizophrenia. A more multi-factorial approach including organisational culture may be required. Paper 3 is a critical reflection of the submitted papers and research process as a whole. Strengths and limitations of the included studies, the findings in the context of wider research, implications for clinical practice and future research are discussed.

There is a great deal of empirical evidence to support the efficacy and effectiveness of cognitive therapeutic approaches such as cognitive behaviour therapy (CBT) and motivational interviewing (MI). In addition to this, research has identified several mechanisms of change thought to underlie these approaches. However, there has been little exploration of the specific cognitive and emotional processes that may underlie change in CBT and MI, or indeed their interactions. This thesis specifically explored the role of reasoning and emotion in relation to MI and CBT.In the first paper, the initial sections provided a narrative review whereby the roles of reasoning and emotion in CBT and MI were critically evaluated in context of existing empirical evidence. Further to this, the literature examining the effects of emotion on deductive reasoning was systematically reviewed. A total of 19 papers were identified and the implications of the studies’ findings discussed in relation to the clinical practice of CBT and MI. The studies varied noticeably in terms of the quality of the methodologies employed. Overall the studies considered, suggested that the effects of emotion on reasoning were complex, and yet to be well understood. However, through extrapolating the findings from the experimental study of cognition and emotion to the clinical practice of CBT and MI, the review demonstrated the potential relevance of such findings, and indicated the need for research exploring the role of reasoning and emotion in these approaches.The second, empirical paper examined the extent to which statements reflecting informal reasoning and the emotional state of the client affected the generation of positive behaviour change statements and positive behaviour change in the context of MI with individuals with psychosis and alcohol use disorders. Participants (n=26) were clients selected from a large randomised controlled trial of integrated MI and CBT for psychosis and substance use. One audio recorded therapy session was selected for each participant. Reasoning and emotion statements were subsequently identified and categorised for each therapy session. It was found that the total number of reasoning statements generated positively predicted the total number of positive behaviour change statements generated. It was also found that negative emotional statements relating to the present, positively predicted the total number of reasoning statements generated. The results suggested that informal reasoning may be a specific cognitive process underpinning the production of behaviour change statements in MI with individuals with psychosis and alcohol use disorders, and provided support for the central role of discrepancy in producing change in MI. The final section provided a critical reflection of the research process. This included a rationale for the development of the literature review and the empirical paper, followed by a critical reflection on the study context and its’ implication to the study methodology. Finally the theoretical and future implications for research in this area were discussed along with the implications to clinical practice.

Bakgrund: Psykisk ohälsa är vanligt förekommande världen över och i Sverige är det den vanligaste orsaken till sjukskrivning. Vid ångestsyndrom rekommenderas behandling med Kognitiv beteendeterapi i kombination med farmakologisk behandling. KBT kan utföras av legitimerad terapeut men även i det egna hemmet via webben. Syfte: Syftet var att undersöka patienters upplevelse av behandling med KBT vid ångestsyndrom.Metod: En litteraturstudie med induktiv ansats. Resultat: Resultatet visar både för och nackdelar med behandlingen. Patienter har till stor del goda upplevelser av KBT då de lärt sig nya strategier att hantera sin ångest på. De negativa upplevelser som patienter har av behandlingen är bland annat att de upplever svårigheter att förstå konceptet, samt att den egna insatsen som krävs för en lyckad behandling är för stor. Resultatet visar även att de förväntningar som patienten har inför behandlingen påverkar utfallet, samt att KBT fungerar bättre hos vuxna än hos barn och ungdomar. Webbaserad KBT har visat sig ha positiv inverkan på ångest och upplevs mer flexibelt, men anses svårare eftersom det utförs på egen hand och många patienter upplever att det är lätt att tappa fokus. Konklusion:Även om resultatet av studien visar både positiva och negativa upplevelser av behandlingen så är majoriteten av de upplevelser som framkommit i studien positiva. / Background: Mental illness is a common problem worldwide and in Sweden it is the most common cause of sick leave. For people who suffer from anxiety syndrome, treatment with Cognitive Behavioral Therapy in combination with pharmacological treatment is recommended. CBT can be performed by a licensed therapist but can also be done via internet, in your own home. Purpose: The purpose of the study was to examine patients experience of CBT treatment against anxiety disorder.Method: A litterature review with an inductive approach. Results: The results show both advantages and disadvantages of the treatment. Patients have good experiences of CBT and have learned new strategies to manage their anxiety. The negative experiences that patients have from the treatment are, among other things, that they experience difficulties in understanding the concept, and that the own effort required for a successful treatment is too big for them to handle. The results also show that the patient's expectations prior to treatment affect the outcome, and that CBT works better in adults than in children and adolescents. Webbased CBT has been shown to have positive effect on anxiety and is experienced as more flexible treatment, but is also considered more difficult because the patients perform it on their own and many patients find it easy to lose focus. Conclusion: Although the results of the study show both positive and negative experiences of the treatment, the majority of the experiences that emerged in the study are positive.

Bakgrund: Sedan 2002 har inte bara rubrikerna om sömnstörningar och sömnsvårigheter ökat i de stora medierna. Antalet unga med sömnstörningar ökar varje år, där unga kvinnor är den grupp som ökat mest. Enligt folkhälsomyndighetens rapport 2019 upplever mer än var tredje svensk, 39 %, sömnbesvär i någon grad. Distriktssköterskan arbetar redan med att främja god kost, motion, sunda alkoholvanor, minskad rökning, stress och våld; faktorer som påverkar hälsan i allra högsta grad. Syfte: Att undersöka vilken effekt KBT har på symptomen av sömnproblem, och om metoden applicerbar att utföras av distriktssköterskor. Metod: Systematisk litteraturöversikt där 14 studier valdes ur databaserna Cinahl, Psycinfo och Pubmed. Artiklarna bearbetades gemensamt och de kategorier som framkom återfinns nedan, under respektive rubrik. Resultat: KBT-I både i grupp och i digital form visade på signifikanta förbättringar av sömnen och dess effekt på det dagliga livet. / Background: Since 2002 not only have the headliners about sleep difficulties and sleep disturbances multiplied in the big media. The number of young people with insomnia increases each year, and young women are the group that increases the most. Last year more than every third swede, 39 percent suffered from various grades of insomnia. District nurses already play a big part in preventing disease and promoting health by giving support and knowledge to patients about healthy foods, exercising, drinking habits, smoking, violence at home and stress; all of those very much the key to individual’s health. Aim: of the study to explore how CBT-I might affect the symptoms of insomnia and if this treatment can be performed by nurses. Method: Systematic review by synthesizing 14 studies from the databases Chinal, Psycinfo and Pubmed. The studies were processed individually and thereby mutually to find emerging themes which are to be presented under each heading. Result: CBT-I both in group and in digital form showed significant improvements in sleep and its effect on daily life. / <p>Godkännandedatum: 2020-11-04</p>