Background: Although giving birth is a positive experience for many, some 10% of pregnant Swedish women suffer from severe fear of childbirth (FOC), which impairs their daily functioning and poses a risk for a negative delivery experience. This thesis focuses on the mental and health-economic effects of severe FOC, and explores new treatment options for childbirth-related anxiety. Aims: (i) to investigate the prevalence of and variables associated with severe FOC, (ii) to estimate the cost of illness of severe FOC and (iii) to explore whether Internetbased cognitive behaviour therapy (ICBT) is feasible for treating pregnant women with severe FOC and those with childbirth-related symptoms of posttraumatic stress disorder (PTSD). Design and Results: Study 1: In a cross-sectional study 1635 pregnant women were asked about their FOC via the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), and provided socio-demographic data and information of their preferred mode of delivery. It was found that 15.6% of the participants had a severe FOC, which also strongly correlated with the preference of a caesarean section. Study 2: In a prospective case-control cohort study we mapped all visits, in-patient care, sick leave and delivery variables from medical records and estimated the societal costs in two groups of women; one group with severe FOC and one with low FOC. The costs for the group with severe FOC were 38% higher than for the low FOC group. Study 3: Twenty-eight nulliparous women with severe FOC were self-recruited to an eight weeks ICBT program for severe FOC. Fifteen women followed the entire program. Their FOC decreased significantly after treatment (Cohen’s d=0.95, p<0.0001), which means that ICBT is feasible and an option for treating women with severe FOC. Study 4: Fifteen participants in Study 3 wrote narratives of the imminent delivery before as well as after therapy. After treatment, the women had a more realistic attitude towards childbirth, more self-confidence and more active coping strategies. Partners and staff were perceived as more helpful, and the women were more aware of the child they were bearing. Study 5: Fifty-six women with a traumatic delivery experience were included in a randomized wait-list controlled study (RCT) of the effects of an eight week long ICBT program for childbirth-related PTSD symptoms. These symptoms decreased in both groups during active therapy, while the between-group effect size varied depending on measurements. Psychiatric comorbidity decreased in both groups after active treatment. Conclusion: Severe FOC is prevalent among Swedish pregnant women, and the cost of illness of this marker of peripartum psychological vulnerability is considerable when treated using standard care. A new treatment option for this group with ICBT seems feasible and is associated with more realistic attitudes towards the imminent delivery. An RCT with eight weeks of ICBT for parous women with PTSD symptoms also had promising results. As severe FOC is prevalent and associated with mental and economic burdens for the individual and the society, there is an urgent need to expand the research field. It is important to find feasible and effective treatments that can be applied on a large scale. / Denna avhandling undersöker (i) hur vanligt det är att svenska gravida kvinnor lider av rädsla för förlossningen, och (ii) hur detta påverkar kvinnornas sjukvårdskonsumtion under denna period samt vilka kostnader detta innebär för samhället; testar och utvärderar (iii) nya behandlingsmetoder för rädsla för förlossningen och för posttraumatiska stressymptom efter en traumatisk förlossning. Avhandlingen består av fem delstudier: Studie 1 var en studie bland 1635 gravida kvinnor och visade att mer än var tionde gravid kvinna har svår förlossningsrädsla. Denna hade samband med kvinnornas önskemål om planerat snitt som förlossningssätt, och hos omföderskor, med tidigare negativa upplevelser av förlossningen. Studie 2 jämförde sjukvårdskonsumtion och sjukskrivning under graviditet och den första tiden efter förlossningen hos förstföderskor med svår respektive lindrig förlossningsrädsla, vilka omhändertagits i den ordinarie förlossningsvården. Gruppen med svår förlossningsrädsla visade sig ha avsevärt högre kostnader orsakade av att de i genomsnitt hade högre sjukskrivningstal under graviditet och fler besök på grund av psykiska besvär, samt oftare förlöstes med kejsarsnitt och hade komplicerade förlossningar. I Studie 3 testade 28 förstföderskor med svår förlossningsrädsla en ny behandlingsmetod med kognitiv beteendeterapi (KBT) via internet. Behandlingen medförde att kvinnornas rädsla kraftigt minskade från företill efter behandling. I Studie 4 skickade 15 av kvinnorna i Studie 3 in berättelser via nätet om hur de föreställde sig att deras förlossning skulle bli, såväl innan terapin startade som när den var avslutad. Efter genomförd terapi hade kvinnorna en mer realistisk attityd till förlossningen än före terapin och visade tecken på att ha ett bättre självförtroende och mer aktiva strategier att hantera den kommande förlossningen. Studie 5 utforskade om kvinnor, som upplevt en traumatisk förlossning, kan bli hjälpta av behandling med KBT via internet. Traumatiserade kvinnor slumpades till att antingen få behandling direkt eller få behandlingen efter en väntetid (kontrollgruppen). I båda grupperna minskade kvinnornas posttraumatiska stressymtom, liksom förekomsten av depression och andra ångestproblem. Sammanfattning: Avhandlingen visar att svår förlossningsrädsla är vanligt förekommande och medför lidande för kvinnor och ökade kostnader för samhället i samband med graviditet och förlossning, när detta problem hanteras i den vanliga vården. Två internetbaserade studier testar kognitiv beteendeterapi som behandling för svår förlossningsrädsla och för problem efter en traumatisk förlossning och visar att dessa behandlingsformer tycks fungera väl och i framtiden skulle kunna utgöra ett alternativ som medför att vård görs tillgänglig också för kvinnor som inte har tillgång till kvalificerade hjälpinsatser på andra sätt. Svår förlossningsrädsla och ångestproblem efter en traumatisk förlossning föreligger ofta tillsammans med annan psykisk sjuklighet varför diagnostik och behandling behöver utföras av personer med tillräcklig kompetens för dessa uppgifter. Otillräckligt behandlad/icke behandlad svår förlossningsrädsla ökar riskerna för att kvinnan upplever en kommande förlossning som traumatisk. Avhandlingens slutsatser behöver undersökas i fler och större studier, och, avseende behandlingsstudierna, i undersökningar som har tillräckligt stora kontrollgrupper. Om sådana studier bekräftar dessa preliminära fynd, blir frågan om screening för svår förlossningsrädsla aktuell eftersom det då finns såväl bra screeninginstrument som behandling som skulle kunna göras tillgänglig för stora grupper. Kommer samhället i denna situation att ha råd att inte försöka förebygga individuellt lidande och stora merkostnader för kvinnor med svår förlossningsrädsla? / Tämän tutkimuksen tavoitteena on tutkia (i) kuinka yleinen synnytyspelko on ruotsalaisten raskaana olevien naisten keskuudessa ja (ii) kuinka se vaikuttaa heidän terveyden‐ ja sairaanhoitopalveluiden kulutukseen raskauden aikana ja sen jälkeen, sekä selvittää miten synnytyspelko vaikuttaa yhteiskunnan kustannuksiin; kehittää, testata ja arvioida (iii) uusia hoitomuotoja synnytyspelon sekä synnytyksestä johtuvien psykologisen trau man (posttraumaattinen stressi, PTSD) hoitoon.' Tämä väitöskirja koostuu viidestä osatyöstä: 1. Ensimmäinen osatyö tutki synnystyspelon yleisyyttä 1635 raskaana olevan naisen keskuudessa. Tutkimus osoitti että joka seitsemäs raskaana oleva nainen Ruotsissa kärsii vakavasta synnytyspelosta. Keisarinleikkaus toiveen takana on usein vakava synnystyspelko. Uudelleen synnyttäjillä synnytyspelkoon vaikuttaa myös aiempi traumaattinen synnytyskokemus. 2. Toisessa osatyössa verrattiin ensisynnyttäjien terveyden- ja sairaanhoitokustannuksia sekä sairaslomapäiviä raskauden aikana, synnyksen yhteydessä sekä sitä seuraavan kolmen ensimmäisen kuukauden aikana. Vertailuryhmät seurasivat tavallista äitiysneuvolaohjelmaa, ryhmistä toisella oli vakava ja toisella lievä synnytyspelko. Vakavasta synnytyspelosta kärsivien naisten terveyden ja sairaanhoitopalvelujen käyttö osoittautui huomattavasti korkeammaksi kuin vertailuryhmässä. 3. Kolmannessa osatyössa 28 vakavasta synnytyspelosta kärsivää ensisynnyttäjää, testasi uutta ratkaisukeskeiseen terapiaan (KBT) pohjautuvaa Internetin kautta ohjattua psykologista hoito-ohjelmaa. Hoito lievensi huomattavasti osallistujien synnytyspelkoa. 4. Neljännessä osatyössä 15 naista (edellisestä osatyöstä 3) kirjoittivat osana terapiaansa kertomuksen tulevan synnytyksensä odotuksista. Sama tehtävä kertautui ennen terapian alkua sekä sen jälkeen. Kertomusten yhtäläiset teemat tunnistettiin minkä jälkeen ennen ja jälkeen hoitoohjelmaa kirjoitettujen kertomusten teemoja vertailtiin. Hoidon jälkeen naisten odotukset pohjautuivat suuremmassa määrin tietoon, he kuvailivat itsensä varmemmiksi sekä paremmin  valmistautuneiksi tulevaa synnytystä ajatellen. 5. Viides osatyö tutki Internetin kautta ohjatun ratkaisukeskeisen terapian (KBT) vaikutusta naisiin jotka kärsivät synnytyksen jälkeisestä henkisestä traumasta. Naiset satunnaistettiin tutkimuksessa joko välittömän hoidon ryhmään tai odotuslista ryhmään, joka sai saman hoidon myöhemmin. Hoidon jälkeen PTSD oireet vähenivät sekä hoitoettä kontrolliryhmässä. Myös masentuneisuus ja ahdistusoireet väheniväthoidon myötä. Yhteenvetona voidaan oheisista tutkimuksista todeta että synnytyspelko on yleinen ruotsalaisten raskaana olevien naisten keskuudessa. Synnytyspelko aiheuttaa kärsimystä sekä raskaana olevalle naiselle mutta myös lisäkustannuksia yhteiskunnalle. Kahdessa Internetin kautta ohjatussa ratkaisukeskeisessä hoito-ohjelmassa testattiin uusia hoitomuotoja raskaana oleville ensisynnyttäjille sekä synnytyksen jälkeisistä traumaoireista kärsiville naisille. Tulokset osoittavat, että Internetin kautta ohjattu hoito toimii näissä ryhmissä hyvin ja saattaisi tulevaisuudessa olla vaihtoehto kohderyhmille, joille sopivaa terapeuttista hoitoa nykytilanteessa ei voida tarjota. Koska vaikea synnytyspelko ja synnytystä seuraavat PTSD oireet esiintyvät usein muiden mielialahäiriöiden rinnalla, on tärkeää, että näitä naisia hoitavalla henkilökunnalla on tarpeellinen pätevyys hoitaa myös mielenterveysongelmia. Hoitamatta jätetty tai puutteelisesti hoidettu synnytyspelko lisää raskaana olevan naisen riskiä kokea synnytyksensä traumaattisena. Tulevissa tutkimuksissa tämän tutkimusprojektin tulokset ja johtopäätökset on syytä toistaa useammissa ja ennen kaikkea suuremmissa ryhmissä. Jos tutkimustemme alustaville tuloksille löytyy tukea, nousee kysymys synnystyspelon seulonnasta äitiysneuvoloissa ajankohtaiseksi; sekä seulontamenetelmä että tehokas hoitotapa ovat olemassa ja voitaisiin tarjota suuremmille kohderyhmille. Onko yhteiskunnalla sellaisessa tilanteessa varaa olla ennaltaehkäisemättä synnystyspelkoisten naisten kärsimystä?

Chronic pain is usually defined as pain of more than three months duration. The prevalence of chronic pain among the general population in Sweden is 18%. Compared with the general population, these patients report lower life satisfaction, decreased activity in daily life and higher levels of depression with decreased work ability, and increased sick leave. Research indicates that multimodal rehabilitation (MMR) programmes, including cognitive behavioural approaches for patients disabled by chronic pain, are effective for return to work. The primary aim of this thesis was to assess outcomes by a long-term follow-up of patients with chronic musculoskeletal pain. Furthermore, the aim was to evaluate two different rehabilitation strategies regarding impact on pain intensity, activity, depression, life satisfactions, and sick leave. Two groups, comprising 255 (between the years 1999-2002) and 296 (between 2007-2008) patients respectively, from the Pain Rehabilitation Clinic at Umeå University Hospital, Sweden, were all assessed by interdisciplinary teams. They completed questionnaires regarding pain intensity, disability, life satisfaction, anxiety and depression, and sick leave, before intervention, immediately after intervention (only the first group; n=255), and at one-year follow-up, after participating in a MMR programme in a specialist clinic, or after receiving a rehabilitation plan (RP) with follow-up in primary care. Allocation to either of the two groups was based on the initial interdisciplinary team assessment. Furthermore, a five-year follow-up of 158 patients with whiplash injury was conducted. Pain intensity decreased and life satisfaction increased significantly regarding somatic health in both groups, at follow-up. In addition, depression improved and disability decreased to a higher extent after participating in the MMR programme as compared to RP and subsequent follow-up in primary care. Patients’ positive beliefs about recovery, and positive expectations about work correlated with favourable rehabilitation outcomes. Sick leave at one year follow-up decreased in both groups. Regarding whiplash injury, patients who reported moderate or severe disability also reported significantly higher pain intensity, depression and post-traumatic stress scores and lower perception of general health compared with patients who reported mild or no disability. In conclusion, MMR programmes seem to be beneficial by decreasing pain intensity, depression, disability and sick leave among patients with chronic musculoskeletal pain. Furthermore, patients’ positive beliefs correlate with more favourable long-term outcomes. An interdisciplinary team assessment based on a biopsychosocial approach may be of value for selection of rehabilitation strategy.

Vaginismus is a sexual pain disorder, where spasm of musculature of the outer third of the vagina interferes with intercourse. Vaginismus exists in two forms: total vaginismus, where intercourse is impossible, and the more seldom described partial vaginismus, in which intercourse is possible but painful. The aim of the thesis was to develop a useful definition of partial vaginismus for both clinical and scientific purposes; to describe the prevalence of partial vaginismus among women with superficial coital pain; to report on symptoms and clinical findings in women with partial vaginismus; and to present treatment results for women with vaginismus. In a clinical sample of 224 women with superficial coital pain, we found a great overlap of the clinical diagnoses of partial vaginismus (PaV) and vulvar vestibulitis (VVS) (nowadays called provoked vestibulodynia); 102 women had both PaV and VVS. All women with VVS had vaginismus. Partial vaginismus was more common in all our samples than total vaginismus. sEMG of pelvic floor muscles was found to be of no value in distinguishing women with partial vaginismus with or without vulvar vestibulitis (PaV+/-VVS) (n=47) from each other or from an asymptomatic group (n=27). Women with PaV+/-VVS (n=53) reported not only burning pain but also itch during a standardized penetration situation (sEMG of pelvic floor muscles), while asymptomatic women (n=27) did not. In most cases, the appearance of burning pain preceded the appearance of itch. In a retrospective interview study, 24 women with PaV+/-VVS reported pain after intercourse more often than pain during penetration at the onset of the problem. When the women ceased having intercourse, both symptoms were equally common. Intensity of pain during penetration increased dramatically from very low at onset of the problem to very high when the women ceased having intercourse, while intensity of pain after intercourse was already high at onset of the problem and increased to very high when the women ceased having intercourse. Pain after intercourse in women with PaV+/-VVS was described as burning and/or smarting and lasted in mean for two hours, while pain during penetration was described with words like sharp/incisive/bursting and lasted for one minute. At long-term follow-up (more than three years) of a group of women treated with cognitive behaviour therapy for vaginismus (n=59, response rate 44/59 on a questionnaire), a majority were able to have and enjoy intercourse. The proportion of women with positive treatment outcome was, however, associated to the definition of treatment outcome. An ability to have intercourse at end of therapy was maintained at follow-up. Every tenth women with vaginismus healed spontaneously after thorough assessment. Conclusion: Partial vaginismus was more common in our studies than total vaginismus, and all women with vulvar vestibulitis had partial vaginismus. Women with PaV+/-VVS reported not only burning pain during standardized penetration but also itch. When the problem started in women with PaV+/-VVS, pain after intercourse was more common than pain during penetration. Pain after intercourse was described as longlasting and burning and/or smarting, while pain during penetration was described as short and sharp/incisive/bursting. Long-term follow-up results of a series of women treated with CBT for vaginismus show good treatment outcome.

Background People with psychiatric problems, despite efforts in recent decades still experience vulnerability. Patients with borderline personality disorder (BPD), where self-harm is common, often live in difficult and complex social relationships because of their illness. Additional knowledge and studies about mental illness, self-harm, dialectical behaviour therapy (DBT) and the therapeutic alliance are needed. Purpose and Method This study aims to examine how staff perceive and describe: DBT as a treatment method; the therapeutic alliance and the importance it has for treatment. The study utilises a qualitative approach with a qualitative content analysis method and presents earlier research on DBT and the therapeutic alliance. The empirical material consists of focus group interviews comprising three DBT - teams. The theoretical framework is based on attachment theory which addresses the dynamics of close relationships and how we act in them. Results Results show that DBT - teams describe patients with self-harm as vulnerable. Here, self-harm represents a way to reduce aggression and make life bearable. DBT is produced as a collaboration between therapist and patient, giving patients the opportunity for a new secure attachment to achieve self-respect and a meaningful life. The teams assess DBT as successful and effective. The therapeutic alliance is seen as an emotional and social interaction and is considered the most important tool in the treatment. Conclusions Patients who self-harm and have emotional difficulties may indicate insecure and lack of attachments. Through DBT, trust and confidence are trained and developed to enhance attachment patterns and move the process forward. New aspects emerge such as the significant role of relatives and the team and the importance of feeling hope in both the patient and the therapist. Furthermore, the health professional’s knowledge of the BPD diagnosis affects the care and the treatment of the patients and thus the patients’ possibility to live better lives. In a broader discussion of health determinants, health care, early intervention, cooperation and long-term measures are assessed to be important factors for promoting health and good living conditions for the patients.

A manualised cognitive behavioural therapy (CBT) programme was culturally adapted for use with adult Maori clients with depression who were receiving treatment from Te Whare Marie, a Maori Mental Health service that covers the greater Wellington region. The manual was developed in consultation with local and international literature pertaining to CBT with minority groups and the recommendations of an advisory team. The treatment programme integrated significant Maori concepts with the traditional strategies associated with CBT. The intervention was trialled with 16 Maori clients from Te Whare Marie with a primary diagnosis of depression. Case study and group analysis indicated that the adapted intervention was effective in reducing depressive symptomatology and negative cognition, and increasing general wellbeing in four culturally relevant dimensions. Differences between pre- and post- treatment scores were statistically significant in each of these areas. The intervention did not have a significant impact on the construct of cultural identity. Participants expressed high levels of satisfaction with the treatment, and in general the adaptations were positively received. Treatment was characterised by particularly low dropout rates with 15 of the 16 participants attending seven or more sessions. These results were discussed with reference to their implications for effective delivery of clinical service delivery to Maori consumers of mental health services in New Zealand.

Benzodiazepines have been widely prescribed since the 1960s for the management of adverse symptoms related to anxiety, depression, and sleep problems. They were regarded as an efficacious medication when compared with their predecessor, barbiturates. Within 10 years of their introduction, concerns began to be raised regarding their potential to produce dependence and withdrawal symptoms when ceased, including symptoms not present prior to their being prescribed. Subsequent research focussed on establishing effective strategies to ameliorate the adverse symptoms experienced even when the daily intake was slowly reduced. The aim of the work undertaken for this doctorate was to establish whether there was a role for cognitive behaviour therapy (CBT) in benzodiazepine cessation. The initial step in conducting the research for this doctorate was to obtain a detailed understanding of the current state of research on benzodiazepine cessation. Study 1 therefore focussed on establishing the effectiveness of treatment approaches used to assist individuals to cease benzodiazepine use. A Meta-analysis of treatment strategies undertaken in general practice and outpatient settings established that brief intervention resulted in superior cessation rates at post-treatment than routine care. Gradual dose reduction plus CBT was slightly superior to gradual dose reduction alone. However, substitutive pharmacotherapies in combination with gradual dose reduction did not result in a superior outcome to gradual dose reduction alone, and substitutive pharmacotherapy plus abrupt benzodiazepine cessation was less effective than gradual dose reduction. While, providing CBT in conjunction with gradual dose reduction offered a superior outcome than gradual dose reduction alone, current evidence does not identify the CBT strategies that contributed to the superior outcome. The next step in the development of the CBT intervention involved obtaining a deep appreciation of the issues relating to cessation from the perspective of General Practitioners (GPs) and Benzodiazepine Users (BzUs). Accordingly, Study 2 administered semi-structured interviews about benzodiazepine use and its cessation to 28 GPs and 23 BzUs. Responses were analysed using the Consensual Qualitative Research approach, as it enabled comparisons to be made between the views of the two groups of interviewees. The study identified commonality between GPs and BzUs on reasons for commencing use, the role of dependence in continued use, and the importance of lifestyle change in its cessation. BzUs felt there was greater need for GPs to routinely advise patients about non-pharmacological management of their problems and potential adverse consequences of long-term use before prescribing benzodiazepines. Few GPs had assisted a patient to cease use reportedly due to the required time and the expectation of a poor outcome. There was a perception that patients wanted a pharmacological solution to their problems. A critical gap in assessment instruments that are needed for a comprehensive assessment of the outcomes from a treatment trial was identified. In particular, there was no measure of benzodiazepine expectancy or self-efficacy concerning maintenance of benzodiazepine dose reduction. Therefore, Study 3 adapted existing expectancy and self-efficacy measures form other substance domains to verify their applicability to benzodiazepines. Current BzUs (n = 155) were invited to complete two questionnaires either online or via hard copy. Principal component analysis (PCA) of a newly developed Benzodiazepine Expectancy Questionnaire (BEQ) resulted an 18-item, 2-factor scale, while a Benzodiazepine Refusal Self Efficacy Questionnaire (BRSEQ) formed a 16-item, 4-factor scale, Confirmatory factor analysis (CFA) in a second sample (n = 139) confirmed these internal structures, reducing the BEQ to 12 items and the BRSEQ to 14 items respectively. The qualitative study suggested that many GPs would be reluctant to engage in psychological support for benzodiazepine cessation and it was evident that specialist services would be unable to provide substantial support especially in rural and remote areas. Accordingly, it was decided to develop a treatment that was remotely delivered. The initial pilot used a correspondence-based approach, delivered via the postal service. Study 4 comprised a small pilot comparing GP managed gradual dose reduction, plus CBT via mail (M-CBT), which was either delivered immediately (IM-CBT) or after 3 months (DM-CBT). Despite substantial efforts over a 2 year period to recruit GPs and BzUs, only 6 received the allocated intervention. It was decided to trial the intervention as an internet-delivered program to enhance its accessibility to BzUs. Access to the program was promoted through the project website and links from high profile support websites. Study 5 was an uncontrolled trial of internet-based CBT (I-CBT). Access was provided to all newsletters, although, participants were given a suggested sequence for access. Despite placement on the internet and cross-listing on several key websites, the study still only recruited 35 participants (3 of which received the program by mail). Of the 32 undertaking the program via the internet, 21 completed the 3-month assessments and 14 the 6-month assessments. Eight participants reduced their weekly benzodiazepine intake by at least 50%, by 3 months, with five ceasing use at 6 months. A significant increase in self-efficacy, and a decrease in depressive symptoms and dependence were seen. Providing CBT either via mail or the internet assisted some participants to reduce or cease long-term benzodiazepine use. Recruitment to both M-CBT and I-CBT was limited, despite substantial attempts to market the intervention. The studies undertaken for this doctorate make a unique contribution to improving treatment outcomes for people wishing to cease long-term benzodiazepine use. They also provide direction for more extensive studies to definitively establish the nature of effective treatment. The current evidence clearly supports the importance of gradual dose reduction and the role of CBT in further improving treatment outcomes. However, engagement of both BzUs and GPs remains challenging. Remote delivery of CBT via mail or the internet may assist with improving access to CBT, but it does not solve the problem of GP and BzU engagement. An effective system-wide program to address long-term benzodiazepine use will require that incentives for GP involvement (a disincentive for long-term prescription) are in place.

Cognitive behaviour therapy and interpersonal psychotherapy are the leading treatments for eating disorders. Little is understood regarding their mechanisms of action. The research described in this thesis investigated the purported mechanisms of action of two transdiagnostic versions of these treatments; enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy for eating disorders (IPT-ED). A series of mediation studies were embedded within a randomised controlled trial comparing CBT-E and IPT-ED in a transdiagnostic sample of patients with eating disorders. An analytic strategy using multilevel and structural equation modelling was used to assess for statistical mediation. Three of the key purported mediators of action of CBT-E (regularity of eating, frequency of weighing, and frequency of shape checking) and the key purported mediator of IPT-ED (interpersonal problem severity) were studied. Only regularity of eating demonstrated a strong case for being a mediator of the effect of CBT-E (on frequency of binge eating). The findings were inconclusive regarding other putative mediators of the effect of CBT-E, and for interpersonal problem severity being a mediator of the effect of IPT-ED. Limitations of the research included the non-optimal choice of measures and non-optimal timing of measurements for establishing temporal precedence. Future research should investigate the mediating role of both cognitive (e.g. interpretation of weight) and behavioural processes (e.g. frequency of weighing) in CBT-E, and the role of interpersonal functioning in CBT-E and IPT-ED. Research should use daily, or session by session measurement to better assess the temporal relationship between the purported mediator/s and the outcome/s. Experimental designs comparing dismantled versions of treatment would also help determine the relative effects that different treatment procedures have on treatment outcome/s.

Predicting who will benefit from what in the treatment of psychiatric disorders is incremental to future development of psychological treatments. In the current study functional magnetic resonance imaging (fMRI) data from participants with social anxiety disorder (SAD) was used to elucidate whether neural responses to negative evaluation could predict treatment response in SAD. Nine weeks prior to Internet- delivered Cognitive Behaviour Therapy (ICBT) onset, participants viewed negative social stimuli directed either at themselves or an significant other during fMRI scanning. Regression analyses including the differential activations for other-referential criticism in contrast to self-referential criticism in the posterior mid cingulate cortex (pMCC) and the lingual gyrus (LG) predicted 34% of treatment change as measured by residual gain scores on the Liebowitz Social Anxiety Scale Self-Report (LSAS-SR) in our sample. The final regression model, combining these measures with behavioural measures, which by themselves explained 27% of the variance, resulted in a model explaining 50% of the variance regarding treatment response. This lends additional support to the notion that further elucidating the neurobiological underpinnings of core processes in SAD, as well as the neural correlates of treatment response to CBT, would be of great value in predicting treatment outcome.

Background: Many women experience childbirth fear to such an extent that it seriously interferes with the woman’s daily life and affects her mental well-being. Aim: The overall aim was to conduct an overview of the midwife-led counselling for childbirth fear in Sweden, to investigate women’s birth preferences and to describe their experiences of treatment on childbirth fear, with focus on midwife-led counselling. Methods: Study I is a cross-sectional study where 43 out of 45 maternity clinics responded to a questionnaire regarding midwife-led counselling. Study II is a longitudinal survey where 889 women participated of whom 70 received counselling. Data were collected by questionnaires in mid-pregnancy, two months and finally, one year after birth. Study III is a randomised controlled study with 258 participating women assessed with childbirth fear. It compares Internet-based cognitive behaviour therapy (ICBT) with midwife-led counselling. Data were collected by questionnaires twice during pregnancy and two months after birth. Study IV is a qualitative interview study using thematic analysis, including 27 women who received midwife-led counselling during pregnancy. Results: Overall, midwife-led counselling was perceived as empowering by the women and increased their confidence when facing birth. The preference for a caesarean section decreased during pregnancy and the majority had a normal vaginal birth but an increase in preference for caesarean section appeared after birth. Half of the women who received treatment for childbirth fear experienced a less than positive birth. Women who had a positive birth experience voiced that the contributing factors were the self-confidence received from counselling and the support from the midwife during birth. Decreased or manageable fear was expressed by the women after counselling and birth, which in turn brought a strengthened confidence for a future pregnancy and birth. Furthermore, major differences exist in counselling for childbirth fear throughout the clinics in Sweden. Conclusion: Midwife-led counselling improved women’s confidence toward giving birth and fear was perceived as manageable. Continuous support is crucial to experience birth as positive. Although women’s preferences for caesarean section did not change over time, few women gave birth with a caesarean section without medial reason.

This research report is a narrative on my encounter with sport psychology. I used the metaphors of “touring” and “journal” to guide the construction of this narrative. Before embarking on my tour with sport psychology, I introduced myself as researcher (chapter 2, journal entry I) and stated the research problem, question and goal(s)(chapter 3, journal entry II). I then went on a tour with sport psychology. I visited a sport psychology museum to learn more about the history of sport psychology (chapter 4, journal entry III) and a sport psychology library to learn more about the field of sport psychology (chapter 5, journal entry IV). I also attended a sport psychology conference to become better acquainted with postgraduate sport psychology training in Psychology Departments (chapter 6, journal entry V). I also visited a sport psychology department at a university in Australia, to witness the delivery of a postgraduate training programme in sport psychology (chapter 7, journal entry VI), as well as a sport centre in South Africa and a sport institute in Australia, to see how and the extent to which sport psychology was practised (chapter 8, journal entry VII). After my tour with sport psychology I took what I had learnt and adapted the MA (Counselling Psychology) programme at the University of Pretoria, South Africa. This led to the programme having three core modules and two elective modules. The core modules are fundamental psychology, counselling psychology and career psychology. The elective modules are: community psychology and sport psychology. The sport psychology module consists of the following courses: sport psychology, sport management, sport sociology and exercise psychology. The Professional Board of Psychology at the Health Professions Council of South Africa approved this module at the end of 2003 (chapter 9, journal entry VIII). Finally, I also looked at the influence of my experience with sport psychology on my identity as a psychologist (chapter 10, journal entry IX). / Thesis (PhD (Psychology))--University of Pretoria, 2006. / Psychology / unrestricted