Evidence-Based Alternative Therapy to Reduce Anxiety in Ambulatory Mental Health Patients by Renee Denobrega MS, Widener University, 2013 BS, Alvernia University, 2007 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University January 2016

Although it is suggested that a dysfunctional stress response system may be associated with posttraumatic stress disorder (PTSD) the neurobiological underpinnings are not well established, especially in children. There is also limited research on how treatment for PTSD may impact associated physiology. Respiratory sinus arrhythmia (RSA) is a reliable measure of parasympathetic stress reactivity, and both resting RSA and RSA reactivity are physiological indicators related to children’s emotion functioning and regulation. The present study examined if pretreatment resting RSA levels predicted RSA reactivity at pretreatment and the trajectory of resting RSA, RSA reactivity, resting heart period (HP) and HP reactivity after Cognitive Behavioral Therapy (CBT). Forty-nine children who experienced at least 1 traumatic event and presented with PTSD symptoms were assessed for psychological measures, RSA and HP at pretreatment, post treatment and a 3-month follow up. At pretreatment, lower resting RSA was associated with increased RSA withdrawal. Analysis with repeated measures mixed models indicated that lower resting pretreatment RSA and lower RSA withdrawal increased during CBT, and individuals with higher resting RSA and RSA withdrawal decreased during CBT, so that those at the extreme ends of higher and lower indices converged in the middle by the end of treatment. These data suggest an optimal moderate range for resting RSA and RSA reactivity. There were also significant gender differences on RSA reactivity after CBT. Lower pretreatment resting RSA predicted lower resting heart period (higher heart rate) across all time points but did not change with CBT. Pretreatment resting RSA did not predict HP reactivity. Post hoc analysis also revealed that PTSD symptoms were significantly reduced after CBT but this change was not associated with pretreatment resting RSA levels. Overall, these results suggest that children may change physiologically after CBT and the direction of the changes may depend on initial resting RSA levels. / acase@tulane.edu

This paper reviews literature on the topic of death anxiety and therapy. The author conducted a study examining potential clients' perceptions of two different therapeutic approaches for working with terminally ill clients with death anxiety. A review of literature relevant to this topic indicates that death anxiety is correlated with many psychological problems; however, there are no clinical studies focused primarily on the treatment of death anxiety among clients with a terminal illness. In this study, potential clients were randomly assigned to watched either a short video of a cognitive behavioral therapy session or a short video of an acceptance and commitment therapy session focused on treating a terminal ill person's death anxiety. After watching the video, potential clients rated the session impact of the therapy approach using the Session Evaluation Questionnaire. In addition, participant's views of seeking psychotherapy were assessed with the Attitudes Toward Seeking Professional Psychology Help measure. No differences in ratings of session impact were found between participants who viewed the cognitive behavioral therapy session and the acceptance and commitment therapy session. However, participants' attitudes toward seeking therapy were positively associated with their views of the therapist and session depth. Consistent with past literature, women reported more death anxiety than men. In regards to potential clients' views of session impact variables, their view of postsession positivity was positively related to their view of session smoothness. Additionally, a positive correlation was found between potential clients' views of the therapist and session depth. Implications and conclusions are discussed.

The purpose of this study was to determine if there was a functional relation between the Cognitive-Behavioral Therapy-Based intervention curriculum, Tools for Getting Along (Smith & Daunic, 2012), and Externalizing Behaviors exhibited by students with EBD served in special education. Four students, nominated by their teacher and principal and receiving services in special education for behavioral goals addressing Externalizing Behaviors, participated in this single-subject, multiple-baseline study. Data collected to answer the research question were Systematic Direct Observations, Direct Behavior Ratings, The Strengths and Difficulties Questionnaire (Goodman, 1997), and the Social Problem-Solving Inventory-Revised (D’Zurilla et al. 2002). Participants began receiving Tools for Getting Along instruction in staggered intervals based on their baseline SDO, DBR, and consulting with their special education teacher. The SDQ and SPSI-R:S were administered pre- and post-intervention. Data indicated that although two students showed some improvements on DBR, there was not a functional relation between TFGA and Externalizing Behaviors. However, SDQ and SPSI-R:S sub-scale data did indicate some individual improvements. In addition to individual participant improvements, a number of implications for future research were noted from social validity data completed by the special education teacher, treatment fidelity observations, and in order to address the limitations of the study.

This study examined the level of satisfaction reported by participants of a technologically assisted intervention study (TAI). TAI is a type of teletherapy done through online, live video conferencing. Satisfaction was examined at three different time points, post therapy, 3-months post therapy, and 6-months post therapy. Analyses examined if there were any changes in reported satisfaction over the three time periods. Participants received cognitive behavioral therapy (CBT) targeted at reducing symptoms of mild to moderately severe depression. A satisfaction measure was developed for this study, and included quantitative and qualitative items which were analyzed to determine participants' level of satisfaction. Seventeen women residing in the Vernal and Roosevelt, Uintah Basin areas, volunteered to participate in the study that was funded by a CURI and AES grant. This study found that the women experienced a high level of satisfaction with TAI across the various dimension measured. This high level of satisfaction remained consistent across the three time periods examined. Qualitative data offered a depth of understanding regarding what particularly participants were and weren't satisfied with. (106 pages)

Group delivered empirically supported therapies have been reported to have beneficial effects for cancer patients. However, little is known about the relationship between group cohesion and outcomes of these interventions. This study tested the hypothesis that group cohesion relates to the effects of a group intervention. Participants included 56 women with Stage I to II breast cancer who had completed a 10-week CBSM intervention 3 to 12 months after undergoing surgery and adjuvant therapy. Groups of 3 - 5 participants met weekly for sessions of approximately 1 hour and 45 minutes duration. All participants were assessed at baseline (2 weeks prior to beginning the intervention) and at follow-up (12 weeks after enrollment in the study). Cohesion was measured at the end of each intervention session by External Comfort (EC), a factor of the relatedness scale of the Stuttgarter Bogen instrument (1976). EC denotes an aspect of the sense of comfort of an individual within the group that is dependent on how the group participant relates to other members. EC score for session 9 (EC9), and change in EC from session 2 to session 9 (calculated as a change score, i.e., session 9 score minus session 2 score), were used for analyses as independent variables in simple linear regression models. Dependent variables were also calculated as a change score (i.e., follow-up minus baseline) and included benefit finding (Post Traumatic Growth Inventory PTGI, total score and its 5 factors), depression (CESD), urinary cortisol, and natural killer cell function (total percent, number and cytotoxicity). Results yielded a positive change in EC from session 2 to session 9 (M = 2.29, S.D. = 2.67). Regression analyses indicated a significant negative relationship between change in EC9 and change in total PTGI scores (beta= -.450, p= .011), and change in Factor 1 Relating to Others (beta=-.414, p=.021). A marginally significant negative relationship was observed between change in EC from session 2 to session 9 and the New Possibilities Factor of the PTGI (beta=-.323, p=.077). A median split, by change in EC, indicated that participants with high EC scores throughout the intervention showed an increase in total PTGI scores, and in two of the five PTGI factors at follow-up. In contrast, participants who initially scored lower values in EC showed no change in these variables. These results suggest that the longer it takes an individual to feel comfortable in the group, the less the individual would be able to find benefit from their cancer experience after the intervention.

Syftet med studien var att utvärdera vad tidigare klienter på Lenagården HVB, ett behandlingshem för vuxna med psykiska problem, upplevde som värdefullt, respektive vad de upplevde som negativt eller saknade i sin behandling. Utvärderingsfrågorna utgick från Lenagårdens programteori samt aspekter som tidigare forskning kring institutionsbehandling pekat ut som viktiga för framgångsrik behandling. Data samlades in via kvalitativa intervjuer med fyra tidigare klienter. Systemteorin har använts som utgångspunkt för resultaatanalysen. Utvärderingen visar bland annat att gott bemötande i termer av vänlighet och respekt samt personalens kompetens ansågs vara värdefulla faktorer i behandlingen. Själva terapin och behandlingsmetoden ansågs av samtliga intervjupersoner vara givande. Individanpassade lösningar, delaktighet och en förtroendefull relation till terapeuten eller behandlaren var i sin tur avgörande faktorer för en positiv upplevelse av terapin och behandlingen. Andra faktorer som värdesattes var meningsfulla aktiviteter, att bo med andra klienter samt fortsatt kontakt med Lenagården efter avslutad behandling. Några negativa aspekter i behandlingen beskrevs som för lite personaltid, för kort vistelse samt brist på gemensamma aktiviteter. / The aim of this evaluation was to find out what former clients at Lenagården HVB, an institution for treatment of adults with psychological problems, experienced as important in their treatment and what they experienced as negative or missing. The questions answered by the former clients were based on the program theory of Lenagården as well as earlier research about residential treatment. Data was gathered by qualitative interviews with 4 former clients.System theory was used as a theoretical framework for the analysis of the results. The evaluation points out that the experience of being treated in a friendly and respectful manner, the staffs level of professional training and the treatment method in itself were considered important. A trustful relation to the therapist and participation in the treatment were essential for a positive experience of the treatment. Other important aspects of treatment were activities, living with other clients and continued relations with Lenagården after completed treatment. Some negative aspects that were mentioned were not enough time with the staff, too short stay and lack of organized activities.

Exposure therapy has received a great deal of support as an effective treatment for social anxiety. However, not all those who undergo exposure therapy improve, and some of those who do respond continue to report significant levels of symptoms. A theorized mechanism of change for exposure therapy is extinction learning. Extinction learning is believed to occur across exposure sessions during which new associations are formed and stored in memory. Individuals with social anxiety are prone to engage in post event processing (PEP), or rumination, after social experiences, which may interfere with extinction learning, and thus attenuate response to treatment. The current study examined whether PEP limits treatment response to two different exposure based treatments, a group based cognitive behavioral intervention and an individually based virtual reality exposure therapy among participants (n = 75) diagnosed with social anxiety disorder. The findings suggested that PEP decreased as a result of treatment and that social anxiety symptoms for those with greater amounts of PEP improved at a slower rate of change than those with lower levels of PEP. Implications for the role of PEP on treatment response are discussed.

This study is exploratory in nature and focuses on the relation between the individual and macrosystems by investigating the link between African Americans’ fear of confirming stereotypes and their experience with symptoms and treatments for social anxiety. This study hypothesizes that 1) among a sample of African Americans diagnosed with social anxiety, there will be a significant, positive relationship between African-Americans’ self-reported concerns over confirming stereotypes relevant to both social anxiety and their own self-reported levels of social anxiety, 2) significantly more African Americans will drop-out of therapy than Caucasians, 3) amongst African Americans, significantly more will drop out of group therapy than individual therapy, 4) the racial composition of the group will matter, such that more African Americans will drop out of groups where they are the only African American participant, compared to if there are other African Americans in the group, and 5) the presence of an African American co-therapist will impact attrition from group treatment, with higher attrition rates in groups without an African American co-therapist, compared to if there is one. Thirty-four participants, 23 females and 11 males, who self-identified as African Americans and forty-four participants, 23 females and 21 males, who self-identified as Caucasian took part in this study. Results did not show a relation between stereotype confirmation concern and social anxiety. Regarding attrition, results showed that significantly more African Americans dropped out of therapy than Caucasians. Additionally, more African Americans dropped out of group therapy than individual therapy. There was no impact of therapist ethnicity or the presence of other African Americans on attrition rates, though these tests were underpowered.

Advances in cancer treatment have led to a significant increase in the number of pediatric oncology survivors. These survivors often have late effects in their cognitive, academic, executive, and psychological functioning subsequent to their chemotherapy and radiation treatment. In particular, executive functioning (EF), which is crucial for cognitive and academic functioning, has been recognized as an area that is impacted by treatment. Several studies have described cognitive remediation programs that seek to improve EF skills in pediatric oncology survivors. Although these programs have led to improvements in EF skills, they are often difficult to replicate due to the extensive time requirement. Many survivors also experience distress and anxiety and would likely benefit from cognitive behavioral therapy, which has been shown to be an effective intervention for children with internalizing disorders. Thus, a brief intervention that combines treatment for executive functioning and psychological distress is warranted. A mixed methods study was conducted to evaluate the impact of a nine-week blended cognitive remediation and cognitive behavior therapy group for pediatric oncology survivors and their parents. Participants were pediatric cancer survivors, age 9-14, and their parents who were referred through a local children's hospital that specialized in oncology treatment. Pre and post measures of EF, psychological functioning, and parental stress were examined. Semi-structured interviews with participants and their parents were completed and analyzed to learn more about the function of short-term group therapy for pediatric oncology survivors. Content analysis of the parent support group sessions was also conducted. Significant changes were found for youth internalizing symptoms, youth adaptive skills, youth executive functioning, and parental stress. There was also a positive correlation between parental stress and parent-rated youth internalizing problems as well as parent-rated youth behavioral symptoms and a negative correlation between parental stress and parent-rated youth adaptive behavior. Qualitative interviews indicated that participants felt that the intervention was helpful. Themes from the parent group included the challenge of managing late effects, balancing multiple roles, and coping with distress. Implications, limitations, and recommendations for further areas of research are presented. / text