Abstract Co-morbid emotional disturbances are not uncommon in individuals with Asperger syndrome (AS) especially during the tumultuous period of adolescence. The few empirical studies that exist have only examined treatment outcomes for anxiety and anger in individuals with AS during childhood but there are no available treatment studies for adolescents or adults. Therefore, this research project aimed to examine the efficacy of a modified cognitive-behaviour therapy (CBT) program for emotional disturbance in young people with a diagnosis of AS. Firstly, it was important to establish the need for treatment by examining the prevalence and presentation of emotional disturbance in this population. Secondly, an investigation of the role of pessimistic attributional style, negative problem orientation and social competence as risk factors for emotional disturbance helped to determine the suitability of CBT. It was also essential that an existing CBT program was modified to suit the cognitive profile of young people with AS. Finally, the efficacy of a modified CBT program was evaluated in a pilot study and randomised controlled trial. In the first study, 68 young people with existing diagnosis of AS between the ages of 11 and 23 years completed a battery of measures that assessed for AS characteristics, emotional disturbances, risk factors, and cognitive ability. The results of this study indicated that approximately 21%, 20% and 40% of young people reported elevated levels of depression, anxiety, and anger symptoms respectively. Furthermore, approximately 60% of young people reported elevated levels on at least one of the emotional disturbance measures (i.e., depression, anxiety or anger symptoms), while 40% of adolescents reported elevated levels on at least two. Therefore, the study suggests that there is a need to develop evidence-based treatment for young people with AS. In addition, significant associations were found between pessimistic attributional style, negative problem orientation and social competence, and emotional disturbance. Multiple regressions suggested that these risk factors account for approximately 54%, 39% and 25% of variance in depression, anxiety and anger respectively. These results are consistent with the literature for typically developing young people, and thus, cognitive-behaviour therapy typically used to treat mood and anxiety disorders in the general population should be efficacious for the AS population. Furthermore, CBT has been shown to be efficacious in treating anxiety and anger problems in children with AS. Although there are no existing CBT programs targeting depression in young people with AS, there are numerous CBT programs for typically developing young people. One example is the Aussie Optimism Program (AOP), an Australian adaptation of the Penn Prevention program which has a strong evidence-base for treating depression. Based on the AS literature, the program was modified to suit the cognitive profile of young people with AS. These modifications include providing affective education, using visual materials, small groups with high therapist to adolescent ratio, and other modifications to assist learning. Study Two piloted the modified program with three young people with AS. The pilot study provided some evidence that the modified Aussie Optimism reduced symptoms of emotional disturbance, but the sample size was too small to obtain clear results. In addition, observations from the pilot study were used to further modify the CBT program, which enhanced the structure and delivery of the program. The final modified CBT program consisted of six 2-hour sessions teaching young people to identify emotions and discriminate between different levels of emotional intensity; to cope with emotions; to identify and challenge negative thoughts; and to solve problems. Finally, a randomised controlled trial was used in Study Three to examine the efficacy of the modified CBT in treating depression in young people with AS. Given the high co-morbidity of emotional disturbance, the study also tested the efficacy of CBT program in reducing symptoms of anxiety and anger. Forty-four young people with AS were randomly allocated to the intervention (n = 21) or the waitlist control (n = 23). The results of Study Three demonstrated that young people with high levels of depression and anger symptoms initially showed a significant reduction after the intervention, compared with the waitlist control group. Although anxiety levels reduced from time 1 to time 2 for the intervention group, the pattern of results was not statistically significant. Reliable change index (RCI) indicated that young people with high levels of symptoms at Time 1 showed meaningful clinical changes across measures of depression, anxiety and anger (parent and adolescent report) only in the intervention group (42-83%), but not in the waitlist control group (8-12%). Results in Study Three suggest that CBT modified to suit the cognitive profile of AS is efficacious in reducing depression and anger symptoms. Some of the methodological limitations of this study include a small sample size, attrition, participant variability, and a lack of longer-term follow-up. Despite these methodological limitations, these three studies provided strong evidence for the efficacy of CBT in treating emotional disturbance in young people with AS by establishing the need for an intervention, identifying the importance of the risk factors targeted by CBT, and demonstrating the efficacy of a modified CBT in reducing symptoms of emotional disturbance, specifically depression and anger, using a randomised controlled trial.

Doctor of Philosophy (PhD) / The purpose of this thesis was to investigate relationships between treatment knowledge, beliefs and outcome in Panic Disorder and/or Agoraphobia (Panic-Ag). Research from the psychotherapy and medical literature indicates patients’ treatment knowledge and beliefs, specifically acceptance of the treatment rationale (ATR), expectancies of treatment outcome (ETO) and treatment self-efficacy (TSE), are associated with clinical outcomes for a range of disorders. However, methodological limitations surrounding measurement of these constructs have undermined conclusions and/or such relationships have not been investigated in the field of Panic-Ag. Relationships between treatment knowledge, beliefs and outcome in Panic-Ag were examined using a 2 phase procedure. Phase 1 involved developing measures of treatment knowledge, ATR, ETO and TSE using patient and clinician samples. The psychometric properties of these measures were found to be satisfactory. Phase 2 investigated associations between treatment knowledge, beliefs and outcome following cognitive behaviour therapy (CBT) among 41 Panic-Ag participants. Measures were administered at pretreatment and 6-months posttreatment. It was hypothesised that treatment knowledge, ATR, ETO and TSE would be related to outcome, with associations mediated by belief in catastrophic cognitions. Of 4 Panic- Ag outcome measures (panic attack frequency, panic sensation severity, frequency of catastrophic cognitions and agoraphobic avoidance), results indicated improved treatment knowledge was significantly associated with frequency of catastrophic cognitions and agoraphobic avoidance. Posttreatment TSE was significantly associated with panic attack sensation severity, frequency of catastrophic cognitions and agoraphobic avoidance. Contrary to the hypothesis, ATR was not related to outcome. Similar findings concerning TSE and ATR were obtained in an independent sample of 34 Panic-Ag participants. Exploratory analyses found that pretreatment beliefs including outcome expectancies were unrelated to outcome. Mediational analyses revealed relationships between TSE and outcome were partially mediated by belief in catastrophic cognitions while relationships between treatment knowledge and outcome were not. Results are discussed in light of previous research, methodological limitations, clinical implications and future research directions.

The current research project has addressed the issue of the stress and anxiety experienced by Australian senior high school students as they prepare to undertake their final year examinations. Two studies were conducted. The first study looked at the feelings experienced by senior high school students, resources available to them to assist with exam preparation, resources actually accessed, and the strategies used to cope with examinations and associated feelings. Focus group interviews were conducted with 14 Year 11 and 13 Year 12 students from a public senior high school in Perth, Western Australia. Results indicated that students tend to most frequently report using avoidance strategies to cope with preparing and undertaking examinations, supporting previous research findings (e.g., Zeidner, 1996). The second study examined the effectiveness of a group based, cognitive behavioural program purposely designed to teach students strategies for coping specifically with test anxiety and also generalized anxiety symptoms. The program involved seven one-hour weekly sessions implemented with 31 Year 12 students who were undertaking their final year examinations. The program covered education about the nature and causes of stress and anxiety, relaxation training, cognitive restructuring, imaginal exposure and study skills training. The pre- and post-intervention scores on the TAI and RCMAS were analyzed using 2 (group) x 2 (gender) x 3 (symptom severity level) full factorial repeated measures ANOVAS. At pre-intervention, there were no significant differences between the treatment (N=31) and control (N=6), except for RCMAS Worry and Over Sensitivity, whereby the treatment group had a higher mean score, consistent with the greater ratio of female to male participants in the treatment group compared to the control group. At post intervention, the treatment group had reduced scores from preintervention levels for TAI Worry and Emotionality, RCMAS Total Anxiety, Physiological, Worry and Over Sensitivity and the Social Issues and Concentration subscales. In contrast, the post-intervention scores for the control group for these measures had increased from pre-intervention levels. However, there was no significant main effect for Group. Anecdotal program evaluation results from the treatment group students revealed that relaxation training was considered the most helpful aspect of the program. In contrast, at-home practice activities were considered the least helpful. A majority of participating students also reported that they believed the program would help them to manage stress and anxiety associated with examinations and other life stressors. Despite the lack of significant differences between the treatment and control groups in the current study, the pattern of results obtained generally followed that of previous research on the treatment of symptoms for test anxiety (e.g., Wessel & Mersch, 1994) and generalized anxiety (e.g., Kendall, 1994) employing a CBT approach. While the results of the current study may have been limited by the relatively small sample sizes of the treatment and control groups, the short- and longterm benefits of providing training in appropriate coping strategies for test anxiety, such as those involved in cognitive behavioural intervention, are further highlighted.

Despite the growing need for depression prevention programming for university students, few programs exist and those that do are too resource-intensive for broad dissemination. Furthermore, limited research has been conducted on mechanisms of change in CBT-based prevention programs and similar research conducted on CBT for depression demonstrates mixed findings. Therefore, there is a need to incorporate a formal model of health-behaviour change in prevention (and intervention) programs to clarify mechanisms of change and improve outcomes, such as the theory of planned behaviour (TPB). This series of studies developed and tested a formal CBT-TPB “hybrid” model to predict intention to change thinking patterns and a brief depression prevention program for university students and to examine the program’s potential to change the hypothesized constructs in the hybrid model. Results indicated support for the hybrid model, in that TPB factors predict intention to change thinking patterns. In addition, across an open and randomized control trial, my “Start Making a Change” intervention promotes change in TPB factors, as well as improvement in relevant CBT and well-being outcomes. The implication of this work is that brief, easy-to-disseminate, programs, based on a formal model of change, can effectively, at least in the short term, target and change important risk factors for depression onset in university students.

Cognitive behaviour therapy (CBT) is an effective treatment for depression but access is limited. One way of increasing access is to offer CBT via the Internet. In Study I, guided Internet-based CBT was found to have a large effect on depressive symptoms compared to taking part in an online discussion group. Approximately two hours were spent on guiding each patient and the large effect found differs from previous studies that showed smaller effects, probably due to lack of guidance. The intervention had no effect on the participants’ quality of life but significantly decreased their level of anxiety. Internet-based versions of self-report measures can be more practical and efficient than paper versions. However, before implementation, evidence of psychometrical equivalence to the paper versions should be available. This was tested in Studies II and III for the Montgomery-Åsberg Depression Rating Scale – Self-rated (MADRS-S) and the Beck Depression Inventory – Second Edition (BDI-II). When the full scales were investigated, equivalent psychometric properties were found in the two versions of the MADRS-S and BDI-II. However, in the Internet-version of the BDI-II, a lower score was found for the question about suicidality and the difference was statistically significant. Although the difference was small, this indicates that suicidality might be underestimated when using the Internet-based BDI-II. As the long-term prognosis after treatment for depression is poor, in Study IV we investigated the possibility of delivering CBT-based relapse prevention via the Internet. The results revealed that fewer participants in the intervention group experienced a relapse compared to the control group and that the time spent on guiding each participant was approximately 2.5 hours. A trend towards a higher remission rate was found in the CBT group at the six-month follow-up and a reduction of depressive symptoms was associated with a lowered risk of relapse. CBT-based relapse prevention via the Internet can potentially be made available to large numbers of patients, thus improving their prognosis. The Internet increases the possibilities for health care providers in the management of depression.

There is limited research into the impact of non-specific factors on the outcome of Cognitive Behaviour Therapy (CBT). This current study aimed to investigate the relationship between client and therapist attachment styles and client interpersonal problems to the therapeutic relationship and symptom reduction over eight sessions of CBT. Seventeen therapist-client dyads were asked to complete measures of interpersonal problems, attachment style and report on the therapeutic relationship. Results showed that in this small sample there was a relationship between core alliance, as rated by clients, to reduction in symptoms of depression over the course of eight sessions of CBT (TB=0.423, p<0.05) but not anxiety. Client level of confidence in relationships was negatively correlated with the reduction in anxiety symptoms over time (TB =-.320; p<0.05). The level of difference in scores on a measure of ‘confidence in relationships’ between therapists and clients was found to be positively correlated to the level of reduction in anxiety scores over eight sessions (TB = .0428; p<0.05) and negatively correlated to the therapist rated core alliance (TB=-.428, p<0.05). These results indicate that the role of attachment styles in CBT warrants further investigation and both clinical and theoretical implications of these findings are discussed. Key words: Cognitive Behaviour Therapy, therapeutic relationship, treatment outcomes, attachment, interpersonal problems Service Improvement Project Title: What is helpful about attending an Alzheimer’s café: does it do what it says on the tin? Abstract: Alzheimer’s Cafes were developed in 1997 in the Netherlands and have since been set up all over the world. They are a post-diagnostic support group for people with dementia and their families with an aim to reduce stigma around having dementia. As yet there have been very few evaluations of these cafes. This project aimed to find out what family carers of people with dementia found helpful about attending one of two Alzheimer’s cafes. Seven carers took part in a focus group and two were interviewed individually about what they found helpful about attending an Alzheimer’s Café and what they thought could be improved on in the future. Results showed that people found the opportunities to socialise with others ‘in the same boat’ the most helpful aspect as well as meeting professionals outside of the clinic. The results of this study will enable the development of a questionnaire that can be used to continue to evaluate the café and the feedback provided used to guide future service development. Key words: Alzheimer’s Café, social support, dementia, service evaluation Critical Literature Review Title: Risk and protective factors for psychological adjustment of children born with a cleft lip and/or palate and their families: A review of the literature Abstract: Research suggests that around 30-40% of children born with a cleft lip and /or palate will develop psychological difficulties. Services supporting these individuals need to be able to identify those that might be vulnerable as early as possible so that preventative support can be offered. This review summarises findings from research studies looking at within-group differences in samples of children with a cleft and their families. Risk factors found included being male, experiencing bullying or having additional difficulties. Protective factors included satisfaction with appearance and social support. The methodological strengths and weaknesses of these studies are discussed along with implications of the findings for theory and clinical practice.

Doctor of Health Science / The public mental health setting wherein clinicians work with clients diagnosed with borderline personality disorder (BPD) provides a continual challenge for clinicians. For many decades a pervasive therapeutic pessimism has surrounded any discussions of attempts to work with clients with BPD with this population being viewed as ‘too difficult’ and ‘impossible to work with’. This pessimism and the ensuing counter therapeutic responses have been well documented in the psychiatric literature. The development of treatments such as dialectical behaviour therapy (DBT), a cognitive-behavioural therapy, for BPD has provided a basis for therapy for which there is increasing evidence of successful outcomes. Despite this evidence, the pervasive pessimism has been slow to lift. A limited literature explores attempts to positively influence clinician responses to this clientele. Within the public mental health service in which this research is based, DBT is well-established as a therapeutic modality. In the course of providing training, consultation and supervision for parts of this service, anecdotal evidence emerged suggesting that the impact of practising as a DBT therapist was greater than anticipated and DBT may provide a tool for facilitating a positive change in clinician responses. Given that this perception is not described in the literature it was appropriate to begin research in this area employing a qualitative methodology. This research explored the experience and impact upon mental health clinicians in a public mental health service undertaking training in DBT and practicing as DBT therapists. In-depth, semi structured interviews were conducted in July 2005 with clinicians practising as DBT therapists. Data analysis revealed a marked shift in perspective from ‘management to treatment’. Participants described positive professional and personal impacts of training and practising as DBT therapists. An enhanced capacity for self-awareness and ‘living life to the full’ was described by a number of participants. This initial research suggests that the practice of DBT by clinicians can generate a positive shift in both personal and professional identities that translates into a more optimistic and humanistic approach to clients diagnosed with BPD. Such a change may represent a significant challenge to the prevailing mental health discourse and practice

Abstract Background: Cognitive Behaviour Therapy, (CBT) is well established as an effective treatment for depression. Its applicability in routine public mental health practice is however unknown, as most published studies excluded participants with suicide risk or if co-morbid with other disorders such as schizophrenia or bipolar affective disorder. Clients of public mental health services are characterised by symptom severity, chronic course of illness, treatment resistance and / or co-morbidity. In order to determine whether CBT has utility in routine public mental health practice, it is important to find out whether symptoms of depression (and anxiety) in this client population will respond to a course of CBT provided as part of standard care. Aims and Hypotheses: This effectiveness study aimed to ascertain if CBT is effective in treating depressed and/or anxious symptoms when such symptoms exist within the clinically more complex population found within Community Mental Health Services / Settings, (CMHSs). It was hypothesised that clients receiving CBT would show reliable and clinically significant improvement in symptoms of depression and anxiety but that the amount of improvement would be less than that reported in efficacy studies with less complex client groups. Method: This was a repeated measures, uncontrolled intervention study with results benchmarked against published data. Forty six adult clients of the Inner North Brisbane Mental Health Service (INBMHS) with diagnoses of Depression and / or Anxiety, in isolation or in conjunction with Schizophrenia, Bipolar affective disorder, or a Personality Disorder were treated with an eight (8) session manualised CBT program as part of routine clinical care. Standardised measures of depression, anxiety and stress were taken at time of referral, time of the commencement of treatment, time of treatment completion and at six-month post completion of treatment. Results: Participants showed reliable and statistically significant improvement in self reported symptoms from commencement to completion of treatment. Gains were retained at follow-up. Effect sizes were in the moderate to large range and improvements were clinically significant for approximately one third of the participants. Conclusions: CBT seems to be an effective treatment for depression and anxiety where such symptoms exist within a mental health population. Further research addressing the limitations of this study would add strength to the argument that the mental health population could benefit from the broad availability of such treatment.

Objectives: To demonstrate that at 6-months post-cessation of cognitive behaviour therapy (CBT) adapted for acquired brain injury (ABI), (1) patients maintain psychological benefits, (2) coping strategy selection improves, (3) community integration is enhanced, and (4) benefits are observed in both face-to-face and telephone administrations. Methods: Participants. Seventeen ABI patients with elevated psychological distress. Outcome Measures. Pre-treatment, post-treatment and 6-month follow-up performance on the Symptom Checklist-90-revised (SCL-90-R), Depression, Anxiety Stress Scales (DASS-21), Community Integration Questionnaire (CIQ) and the Ways of Coping-Revised Questionnaire (WOC-R). Procedures. Eleven CBT sessions provided in group, face-to-face format or individually by telephone. Results: For face-to-face and telephone groups, psychological distress was significantly reduced from pre-treatment to 6-months follow-up: DASS-21 (t16= 7.32, p <.000); SCL-90-R (t16= 6.22, p <.000). Community integration (t16= -6.15 p<.000) and problem-focused coping (t16= -3.67, p<.01) were also significantly enhanced. Conclusion: CBT adapted for patients with ABI carries robust benefits even 6-months after treatment.

Objectives: To demonstrate that at 6-months post-cessation of cognitive behaviour therapy (CBT) adapted for acquired brain injury (ABI), (1) patients maintain psychological benefits, (2) coping strategy selection improves, (3) community integration is enhanced, and (4) benefits are observed in both face-to-face and telephone administrations. Methods: Participants. Seventeen ABI patients with elevated psychological distress. Outcome Measures. Pre-treatment, post-treatment and 6-month follow-up performance on the Symptom Checklist-90-revised (SCL-90-R), Depression, Anxiety Stress Scales (DASS-21), Community Integration Questionnaire (CIQ) and the Ways of Coping-Revised Questionnaire (WOC-R). Procedures. Eleven CBT sessions provided in group, face-to-face format or individually by telephone. Results: For face-to-face and telephone groups, psychological distress was significantly reduced from pre-treatment to 6-months follow-up: DASS-21 (t16= 7.32, p <.000); SCL-90-R (t16= 6.22, p <.000). Community integration (t16= -6.15 p<.000) and problem-focused coping (t16= -3.67, p<.01) were also significantly enhanced. Conclusion: CBT adapted for patients with ABI carries robust benefits even 6-months after treatment.