The overall aim of the present thesis was to examine long-term psychological distress following cancer during adolescence and to develop a tailored psychological intervention to reduce cancer-related distress experienced by young survivors of adolescent cancer that was feasible and acceptable. Study I adopted a longitudinal design, assessing health-related quality of life (HRQOL) and symptoms of anxiety and depression among adolescents diagnosed with cancer from shortly after diagnosis (n=61) up to 10 years after diagnosis (n=28). Findings suggest that development of HRQOL and anxiety and depression is not linear and whilst the majority adjust well, a subgroup report long-term elevated distress. In Study II, experiences of cancer-related psychological distress were explored using unstructured interviews. Participants described cancer treatment as a mental challenge, felt marked and hindered by the cancer experience, and struggled with feelings of inadequacy and insecurity, existential issues, and difficulties handling emotions. Study III was a preliminary investigation of individualised cognitive behavioural therapy (CBT), alongside the identification and conceptualisation of cancer-related concerns using cognitive-behavioural theory. Significant difficulties with recruitment were encountered. Participants reported cancer-related concerns conceptualised as social avoidance, fear and avoidance of emotions and bodily symptoms, imbalance in activity, and worry and rumination. In Study IV, the acceptability and feasibility of an internet-administered CBT based self-help intervention (ICBT) for young persons diagnosed with cancer during adolescence was examined using an uncontrolled design and embedded process evaluation. The study protocol for Study IV was included in this thesis along with preliminary findings demonstrating significant difficulties with recruitment. Overall, findings suggest that whilst the majority of survivors of adolescent cancer adjust well over time a subgroup report elevated levels of distress and a range of distressing cancer-related experiences. A number of cancer-related difficulties were identified in Study II and III, which may be used to inform the development of future psychological treatments for the population. Preliminary investigation of the psychological interventions examined within this thesis further highlights the need for future development work to enhance the feasibility and acceptability of psychological support for the population.

It is estimated that nearly 100% of adults had dental caries worldwide. The disease can be approached with a biopsychosocial perspective. Overall, the aim of this study was to assess how behaviour change approach is used to manage risk factors for caries, which was divided in two sub-objectives;1. To illuminate behaviour change methods used to manage risk factors for caries, 2. To explore caries incidence among adult patients who have received behaviour change therapy treatment against caries.To answer the first sub-objective a systematic literature review was performed. To explore dental health status among adults who received behaviour change therapy due to caries, data from the national register in odontology SKaPa was analysed with descriptive and analytic statistics.The findings of the systematic literature review retrieved one RCT-study in the field of behaviour change therapy and caries. Findings from the register study showed there was no corralation between behaviour change therapy and DFT, no differences in inqualities among gender regardning DFT, no differences in DFT related to behaviour change therapy, that among therapy codes for behaviour change therapy behavioural therapy, 60 minutes or more was less frequently used and that dental professionals most frequently used behaviour change therapy when treating initial caries.The conclusion of this study are that there is a lack of scientific evidence regarding managing risk factors for caries with behaviour change approach. The study indicate that qualitative as well as randomized controlled studies would contribute to more knowledge about managing risk factors for caries with behaviour change approach.

This study explored the influence of irrational beliefs on adolescent secondary school learners’ Mathematics achievement in Zimbabwe. Learner, home and school factors which influence secondary school learners’ Mathematics achievement were discussed and relevant studies were scrutinised. The theoretical views of Albert Ellis regarding the characteristics, effects, acquisition and maintenance of irrational beliefs were discussed together with the major irrational beliefs and their possible relationship with learners’ Mathematics achievement. A sample of 306 randomly selected adolescent Mathematics learners comprising 182 girls and 124 boys in the 14 to 18 year age range participated in the study. A composite questionnaire with subscales on learners’ irrational beliefs, socio-affective variables and perceptions was used during the empirical investigation. Six major hypotheses were tested. The study established that learners’ irrational thoughts about Mathematics correlate negatively with their Mathematics achievement. Learners’ irrational thoughts about Mathematics correlated negatively with motivation, self-concept, parental involvement, and teacher-learner relationships and positively with stress, anxiety and faulty perceptions. Regression analysis proved that learners’ irrational beliefs, socio-affective variables and perceptions jointly explain a greater proportion of the variance in Mathematics achievement than any one of these factors on its own. Therefore, learners’ Mathematics achievement is affected by irrational beliefs together with their socio-affective variables and perceptions. Practical recommendations were given to Mathematics education stakeholders such as teachers, school counsellors, parents and learners to minimise poor Mathematics achievement attributable to irrational beliefs and the allied variables explored in this study. / Psychology of Education / D. Ed. (Psychology of Education)

Critical Review of the LiteratureCan Borderline Personality Disorder be treated effectively in forensic settings? A systematic reviewBorderline Personality Disorder (BPD) is a common diagnosis in forensic settings. Certain features of BPD, such as impulsivity and emotional dysregulation, can create a vulnerability to impulsive acts. The condition is also associated with poor mental and physical health, making the treatment of BPD and its clinical features an important goal in forensic settings. This paper reviews evidence for the effectiveness of treating BPD and its symptoms using psychological approaches in forensic settings. A systematic search found 2913 papers, of which 13 met the inclusion criteria. The papers reported nine separate studies (six controlled) that implemented four distinct interventions, often adapted for particular forensic settings. Improvements in overall BPD symptomatology and specific BPD symptoms were reported for all types of intervention, although few differences in outcome between intervention and control groups were found. There were also reported improvements in BPD-related behaviours, but data on offending behaviour were absent. Heterogeneity in study quality and design makes it challenging to draw any firm conclusions about the effectiveness of any one form of treatment over another, nor about which treatment may best suit a particular setting. Further randomised controlled trials are needed to answer these questions. Service Improvement ProjectEvaluation of a brief educational intervention for clinical staff aimed at promoting trauma-informed approaches to careThere is growing evidence that trauma plays an important role in the aetiology of severe and enduring mental health problems. Yet staff can be reluctant to ask patients about trauma for reasons such as anxiety about harming patients and limited access to training. Where services have adopted trauma-informed approaches (TIAs) to mental health care (i.e., considering the ways in which trauma affects individuals when planning and delivering services), improved clinical outcomes have been observed. With this in mind, a new educational video was developed for mental health staff at an NHS trust. The video was intended to be (a) brief (10 minutes); (b) contemporary and engaging; and (c) accessible using computers, smartphones and tablets. Forty-one multidisciplinary staff viewed the video. Quantitative and qualitative evaluation indicated improvements in self-reported knowledge and confidence with regard to trauma, and a decrease in worries with regard to asking patients about such experiences. Participants found the video to be enjoyable, understandable and informative. Importantly, many indicated that it spurred them to further action, such as further training and asking patients about possible trauma. These findings indicate that a video of this type can offer an important ‘taster’ of trauma-related learning, constituting an important step towards embedding trauma-informed ways of working at a service. Main Research ProjectThe Role of Intrusive Imagery in Hoarding DisorderThe cardinal feature of Hoarding Disorder (HD) is persistent difficulty discarding possessions, with the resulting clutter compromising the intended use of living areas. Within the dominant cognitive-behavioural model of hoarding (Frost & Hartl, 1996), hoarding behaviours are positively and negatively reinforced in the context of certain object-related beliefs. Available treatments for HD have so far yielded modest outcomes, indicating a need for new approaches. Intrusive imagery has so far been neglected in HD research, despite the frequency of trauma in the histories of people with the condition. To address this, 27 individuals who met the DSM-5 criteria for HD and 28 community controls (CCs) were interviewed about their everyday experiences of mental imagery. Participants were also asked about the images they experienced during two recent real-life examples of actual or attempted discard of (1) an object of low subjective value; and (2) an object of high subjective value. Everyday imagery in the HD group commonly reflected themes of illness, death and reminiscence. Imagery in HD participants tended to carry negative emotional valence in comparison with CCs, and was associated with greater interference in everyday life and attempts to avoid the imagery. HD participants reported more negative experiences of intrusive imagery in comparison with CCs during recent episodes of discarding objects of low subjective value. However, HD participants experienced positive imagery when discarding, or trying to discard, high value objects. These findings indicate that although people with HD frequently report traumatic histories, this is not reflected in the everyday imagery that they experience. There is some evidence to suggest that the negative and positive memories experienced in relation to low and high value objects may aid our understanding of discarding and saving behaviour in HD. The theoretical and clinical implications of these findings are further discussed.

Der Beitrag diskutiert Probleme der raschen Weiterentwicklung von Klinischer Psychologie und der Verhaltenstherapie im besonderen. Dabei werden drei Perspektiven angesprochen: (a) Binnenbeziehungen innerhalb des Fachs Klinische Psychologie sowie zu Nachbardisziplinen, (b) Transferprobleme wissen-schaftlicher Erkenntnisse von der Forschung zur Praxis und (c) Probleme der Fort– und Weiterbildung sowie der Qualitätssicherung in der Verhaltenstherapie. Als Beispiele von Fortschritt und Erosion werden diskutiert: (a) die Verhaltensmedizin, als Muster für gut abgestimmte und in die Klinische Psychologie als Fach integrierte Entwicklung, (b) die Gesundheitspsychologie für eine schlechte Interaktionskultur mit mangelhaftem gegen-seitigem Informatiûnstransfer und (c) die Psychotherapieszene als Beispiel für Erosionsprozesse in Forschung, Praxis sowie vor allem Fort– und Weiterbildung. Der Beitrag fordert eine wesentliche Stärkung des Fachs Klinische Psychologie als fachliche und organisatorische Klammer zwischen den auseinanderdriftenden Entwicklungen. Eine erfolgreiche Übernahme dieser universitär verankerten Koordinations- und Integrationsaufgabe erfordert allerdings gleichzeitig auch eine erhebliche Ausweitung personeller Ressourcen und fachlicher Kompetenzen. Eine zentrale neue Herausforderung für klinisch-psychologische Universitätsinstitute besteht auch in der Entwicklung von Qualitätssicherungsmaβnahmen. Der Beitrag empfiehlt in diesem Zusammenhang, vor allem in der Fort– und Weiterbildung den verstärkten Einsatz von Therapiemanualen sowie die Institutionalisierung von regelmäβigen Konsensuskonferenzen mit Empfehlungen zur Therapiedurchführung. / This paper discusses progress and erosion aspects of c1inical psychology and behavior therapy in Germany from three interrelated perspectives: (a) the relationship of behavior therapy and c1inical psychology to other basic and applied psychological disciplines as weIl as neighboring disciplines, (b) the transfer problems from the scientific fields to practice, and (c) the problem of quality assurance in practice and postgraduate education. Specific emphasis is laid on a discussion of the field of behavioral medicine, as an example for well-integrated and coordinated research and practice activities; health psychology as an example for deficient communication patterns with clinical psychology and behavior therapy, and psychotherapy as an example for erosion in research, education and practice. The paper strongly recommends a more dominant steering role of clinical psychology as the most comprehensive scientific discipline. This steering role, however, would also require a considerably expanded infrastructure of clinical psychology departments in universities together with several mechanisms (competence enhancement, consensus conferences, development of postgraduate education guidelines, quality assurance activities, coordination) to be able to fulfill this mission. The paper also suggests the more frequent use of standardized treatment manuals in postgraduate courses.

Aims: To assess effectiveness and economic benefit of the psychological treatment of anxiety disorders in order to compare them with the consumed resources of the treatment. Methods: Assessment of specific and non-specific symptoms and impairments in N=493 anxiety patients (DSM-IV) receiving cognitive behavior therapy pre, post, and one year after treatment with various measures. Additional analyses of costs of the treatment and the benefits due to reduced work disability and health care utilization after therapy (including a pilot study using a willingness-to-pay approach). The treatment setting can be characterised as clinically typical for everyday practice. Core results: a) effectiveness: Effect sizes ranged from 0.9 to 1.9. All improvements were significant and lasted until 1-year-follow-up. Rates of clinically significant therapy success ranged from 63% to 79% depending on outcome measure and success criteria. b) cost-effectiveness analysis: Cost-effectiveness-indices ranged from DM 8338.- to DM 10456.- for one successful treatment (average costs taking also the costs of unsuccessful treatments into account). c) cost-benefit-analysis: Cost reduction in the year after therapy was remarkable (inpatient costs about 25%, other cost factors 87%-100%), resulting in a benefit of DM 3026.- per patient and a cost-benefit-ratio of 1:0.58 in the first year after treatment. Assuming that the improvements are stable, the cost-benefit-ratio after five years would be estimated as 1:2.63. Discussion: The present study shows exemplarily for CBT of anxiety disorders that modern psychotherapy can produce remarkable results at reasonable costs. Furthermore, clinical-psychological treatment methods show an additional economic benefit. Clinical Psychology can benefit from focusing not only the promising developments in classification, etiology, and treatment but also taking over the cost perspective (which is relatively new in scientific evaluation of psychotherapy). (Appendix: Cost-Benefit-Calculator.htm; 8,97 KB -- Usage: Referat Informationsvermittlung/ SLUB) / Fragestellungen: Ermittlung von Effektivität und monetärem Nutzen psychologischer Behandlung von Angststörungen, die dann den für die Therapie aufgewendeten Ressourcen gegenübergestellt werden. Methoden: N=493 Patienten mit Angststörungen (DSM-IV), die eine ambulante störungsspezifische kognitive Verhaltenstherapie absolviert haben, wurden prä, post und zur 1-Jahres-Katamnese untersucht. Das Spektrum der Erhebungen umfasste störungsspezifische und störungsübergreifende Symptombelastung und Beeinträchtigungen in verschiedenen Lebensbereichen, sowie eine globale Therapieerfolgseinschätzung von Patienten und Therapeuten. In einer zweiten Studie wurden zusätzlich an einer Teilstichprobe Kosten-Nutzen-Aspekte untersucht (Einsparungen durch Reduktion von Gesundheitsleistungen und Arbeitsunfähigkeit; außerdem Pilotstudie zu willingness-to-pay-Ansatz). Das Behandlungssetting der Studie ist charakterisiert durch klinisch relevante Rahmenbedingungen und Praxisnähe. Zentrale Ergebnisse: a) Effektivität: Die Effektstärken reichten in Abhängigkeit von der Meßmethode von 0.9 bis 1.9. Die Verbesserungen waren durchgängig signifikant und blieben bis zur 1-Jahres-Katamnese stabil. Die Raten klinisch bedeutsamer Besserungen betrugen 63% - 79% in Abhängigkeit von Mess- und Auswertungsmethode. b) Kosten-Effektivitäts-Analyse: Die Kosten-Effektivitätivitäts-Indices betrugen DM 8338.- bis DM 10456.- (dieser Index gibt an, was eine erfolgreiche Behandlung durchschnittlich kostet, also unter Einbezug der nicht erfolgreichen Behandlungen in die Gesamtkosten). c) Kosten-Nutzen-Analyse: Im Jahr nach Therapie reduzierten sich die Kostenfaktoren der Störungen vor Therapie beträchtlich (stationäre Kosten um 25%, restliche Kostenfaktoren 87% - 100%). Die dadurch erzielten Einsparungen betrugen durchschnittlich DM 3026.- (Kosten-Nutzen-Verhältnis im ersten Jahr: 1 : 0.58). Unter der Annahme, dass die Auswirkungen der Therapie auch über die 1-Jahres-Katamnese hinaus stabil bleiben, kann man abschätzen, dass sich die Therapie innerhalb des zweiten Jahres amortisiert und das Kosten-Nutzen-Verhältnis nach fünf Jahren (diskontiert) 1 : 2.63 beträgt. Diskussion: Wie in dieser Arbeit anhand der kognitiven Verhaltenstherapie für Angststörungen gezeigt wird, kann moderne Psychotherapie bei vertretbarem Aufwand beachtliche Erfolge verbuchen. Klinisch-psychologische Behandlungsmethoden sind darüber hinaus auch wirtschaftlich, derart, dass sie über den reinen Behandlungserfolg hinaus zu Kosteneinsparungen beitragen könnten. Es ist erstaunlich, dass die Kosten-Perspektive der wissenschaftlichen Bewertung von Psychotherapie noch recht neu ist. Die Klinische Psychologie kann davon profitieren, diese Dimension (neben den beachtlichen Erkenntnisfortschritten in bezug auf Klassifikation, Ätiologie, Verlaufsforschung und Behandlungsverfahren) mehr herauszustellen. (Anlage: Cost-Benefit-Calculator.htm; 8,97 KB -- Nutzung: Referat Informationsvermittlung der SLUB)

The ability to imagine negative or positive future events is associated with psychological well-being. The present thesis deals with depressed individual’s ability to imagine negative or positive future events. It consists of three quantitative studies (I-III) and one qualitative study (IV). Participants in studies I-III were assessed in connection with a randomized controlled trial of two ways to deliver Internet-based treatment for major depressive disorder (MDD). Their ages ranged between 19-65 years. In addition to receiving treatment participants completed the Controlled Word Association Test; the Autobiographical Memory test (AMT) and the Future Thinking Task (FTT). Participants in study IV were recruited from a psychiatric clinic in Sweden. The sample sizes varied between study I (N=40), II (N=88), III (N=47) and IV (N=15). The aim of the first study was to compare positive and negative future thinking in a group of depressed individuals (n=20) who were compared with a matched group of non-depressed persons (n=20). The results showed that depressed persons report lower scores regarding anticipated future positive events, but that they do not differ in terms of future negative events. The aim of the second study was to examine the association between FTT and AMT in a depressed sample. The results showed that positive future thinking was significantly correlated with retrieval of specific positive autobiographical memories (r = 0.23). The results only gave weak support for an association between FTT and AMT. The aim of the third study was to investigate if scores on the FTT would change following two forms of Internet-delivered cognitive behaviour therapy for major depression (guided self-help and e-mail therapy). A second aim was to study if changes in depression scores as measured by the Beck Depression Inventory would correlate with changes in future thinking. The results showed that FTT index scores for negative events were reduced after treatment. There was no increase for the positive events. Change scores for the FTT negative events and depression symptoms were significantly correlated. The aim of the fourth study was to investigate representations of the future in depressed individuals by using open-ended methodology inspired by grounded theory. The results showed that depressed individuals experienced a state of “ambivalence”. Ambivalence and its negative emotional and cognitive effects were substantially reduced in strength when participants were asked about their distant future. The conclusions drawn from these studies are that depressed persons report lower scores regarding anticipated future positive events (Study I). There is some support for a positive association between FTT and AMT, but the association is weak and only concern positive FTT and positive AMT (Study II). Negative future thinking may be reduced after Internet-delivered treatment, and changes in depressive symptoms correlate to some extent with reductions in negative future thinking (Study III). The concept of ambivalence may be an important feature of depression which deserves more attention from both a theoretical and clinical perspective (Study VI). / Förmågan att föreställa sig negativa eller positiva framtida händelser är förknippad med vårt psykiska välbefinnande. Denna avhandling fokuserar deprimerade individers förmåga att föreställa sig negativa eller positiva framtida händelser. Den består av tre kvantitativa studier (I-III) och en kvalitativ studie (IV). Deltagare i studie I-III rekryterades i samband med en randomiserad kontrollerad studie av två sätt att ge Internet-baserad behandling för egentlig depression (vägledd självhjälp och e-postterapi) . Deltagarnas ålder varierade mellan 19-65 år. Förutom att gå igenom behandling fick deltagarna genomföra olika tester ( Controlled Word Association Test (COWAT), Autobiographical Memory test (AMT) och Future Thinking Task (FTT)). Deltagarna i studie IV rekryterades från en vuxenpsykiatrisk klinik i Sverige. Sampelstorleken varierade mellan studie I (n = 40), II (n = 88), III (n = 47) och IV (n = 15). Syftet med den första studien var att undersöka positiva och negativa framtidstankar hos deprimerade individer (n = 20) vilka jämfördes med en matchad grupp av icke-deprimerade individer (n = 20). Resultaten visade att deprimerade individer rapporterade färre förväntade framtida positiva händelser, men att de inte skiljer sig åt vad gäller framtida negativa händelser. Syftet med den andra studien var att undersöka sambandet mellan FTT och AMT hos deprimerade individer. Resultaten visade att positivt framtidstänkande var signifikant korrelerat med specifika positiva självbiografiska minnen (r = 0.23). Dock visade resultaten enbart ett svagt stöd för ett statistiskt signifikant samband mellan FTT och AMT. Syftet med den tredje studien var att undersöka om poäng på FTT ändrades som en följd av två former av Internetbaserad kognitiv beteendeterapi hos deprimerade individer. Ett andra syfte var att studera om förändringar i depressionspoäng mätt med Beck Depression Inventory skulle korrelera med förändringar i FTT. Resultaten visade att FTT indexpoäng för negativa händelser minskade efter behandling. Det fanns ingen ökning gällande positiva händelser. Ändrade poäng för FTT negativa händelser och depressionssymtom var signifikant korrelerade. Syftet med den fjärde studien var att undersöka representationer av framtiden hos deprimerade individer genom att använda en ”open-ended” metodik inspirerad av grundad teori. Resultaten visade att deprimerade individer upplevde ett tillstånd av "ambivalens". Ambivalensen och dess negativa emotionella och kognitiva effekter minskade betydligt i styrka när de tillfrågades om en mer avlägsen framtid. Slutsatserna från dessa studier är att deprimerade individer rapporter färre förväntade framtida positiva händelser, men att de inte skiljer sig från en kontrollgrupp avseende antal negativa framtida händelser (Studie I). Det finns visst stöd för ett positivt samband mellan FTT och AMT, men sambandet är svag och avser endast positiva FTT och positiva AMT (Studie II). Negativt framtidstänkande kan reduceras efter Internetbaserad behandling, och förändringar i depressionssymtom korrelerar till viss del med minskning av negativt framtidstänkande (studie III). Koncepten ambivalens vid depression kan vara ett viktigt inslag av depression som förtjänar mer uppmärksamhet från både ett teoretiskt och kliniskt perspektiv (Studie VI).

This study explored the influence of irrational beliefs on adolescent secondary school learners’ Mathematics achievement in Zimbabwe. Learner, home and school factors which influence secondary school learners’ Mathematics achievement were discussed and relevant studies were scrutinised. The theoretical views of Albert Ellis regarding the characteristics, effects, acquisition and maintenance of irrational beliefs were discussed together with the major irrational beliefs and their possible relationship with learners’ Mathematics achievement. A sample of 306 randomly selected adolescent Mathematics learners comprising 182 girls and 124 boys in the 14 to 18 year age range participated in the study. A composite questionnaire with subscales on learners’ irrational beliefs, socio-affective variables and perceptions was used during the empirical investigation. Six major hypotheses were tested. The study established that learners’ irrational thoughts about Mathematics correlate negatively with their Mathematics achievement. Learners’ irrational thoughts about Mathematics correlated negatively with motivation, self-concept, parental involvement, and teacher-learner relationships and positively with stress, anxiety and faulty perceptions. Regression analysis proved that learners’ irrational beliefs, socio-affective variables and perceptions jointly explain a greater proportion of the variance in Mathematics achievement than any one of these factors on its own. Therefore, learners’ Mathematics achievement is affected by irrational beliefs together with their socio-affective variables and perceptions. Practical recommendations were given to Mathematics education stakeholders such as teachers, school counsellors, parents and learners to minimise poor Mathematics achievement attributable to irrational beliefs and the allied variables explored in this study. / Psychology of Education / D. Ed. (Psychology of Education)

Der Beitrag diskutiert Probleme der raschen Weiterentwicklung von Klinischer Psychologie und der Verhaltenstherapie im besonderen. Dabei werden drei Perspektiven angesprochen: (a) Binnenbeziehungen innerhalb des Fachs Klinische Psychologie sowie zu Nachbardisziplinen, (b) Transferprobleme wissen-schaftlicher Erkenntnisse von der Forschung zur Praxis und (c) Probleme der Fort– und Weiterbildung sowie der Qualitätssicherung in der Verhaltenstherapie. Als Beispiele von Fortschritt und Erosion werden diskutiert: (a) die Verhaltensmedizin, als Muster für gut abgestimmte und in die Klinische Psychologie als Fach integrierte Entwicklung, (b) die Gesundheitspsychologie für eine schlechte Interaktionskultur mit mangelhaftem gegen-seitigem Informatiûnstransfer und (c) die Psychotherapieszene als Beispiel für Erosionsprozesse in Forschung, Praxis sowie vor allem Fort– und Weiterbildung. Der Beitrag fordert eine wesentliche Stärkung des Fachs Klinische Psychologie als fachliche und organisatorische Klammer zwischen den auseinanderdriftenden Entwicklungen. Eine erfolgreiche Übernahme dieser universitär verankerten Koordinations- und Integrationsaufgabe erfordert allerdings gleichzeitig auch eine erhebliche Ausweitung personeller Ressourcen und fachlicher Kompetenzen. Eine zentrale neue Herausforderung für klinisch-psychologische Universitätsinstitute besteht auch in der Entwicklung von Qualitätssicherungsmaβnahmen. Der Beitrag empfiehlt in diesem Zusammenhang, vor allem in der Fort– und Weiterbildung den verstärkten Einsatz von Therapiemanualen sowie die Institutionalisierung von regelmäβigen Konsensuskonferenzen mit Empfehlungen zur Therapiedurchführung. / This paper discusses progress and erosion aspects of c1inical psychology and behavior therapy in Germany from three interrelated perspectives: (a) the relationship of behavior therapy and c1inical psychology to other basic and applied psychological disciplines as weIl as neighboring disciplines, (b) the transfer problems from the scientific fields to practice, and (c) the problem of quality assurance in practice and postgraduate education. Specific emphasis is laid on a discussion of the field of behavioral medicine, as an example for well-integrated and coordinated research and practice activities; health psychology as an example for deficient communication patterns with clinical psychology and behavior therapy, and psychotherapy as an example for erosion in research, education and practice. The paper strongly recommends a more dominant steering role of clinical psychology as the most comprehensive scientific discipline. This steering role, however, would also require a considerably expanded infrastructure of clinical psychology departments in universities together with several mechanisms (competence enhancement, consensus conferences, development of postgraduate education guidelines, quality assurance activities, coordination) to be able to fulfill this mission. The paper also suggests the more frequent use of standardized treatment manuals in postgraduate courses.

Aims: To assess effectiveness and economic benefit of the psychological treatment of anxiety disorders in order to compare them with the consumed resources of the treatment. Methods: Assessment of specific and non-specific symptoms and impairments in N=493 anxiety patients (DSM-IV) receiving cognitive behavior therapy pre, post, and one year after treatment with various measures. Additional analyses of costs of the treatment and the benefits due to reduced work disability and health care utilization after therapy (including a pilot study using a willingness-to-pay approach). The treatment setting can be characterised as clinically typical for everyday practice. Core results: a) effectiveness: Effect sizes ranged from 0.9 to 1.9. All improvements were significant and lasted until 1-year-follow-up. Rates of clinically significant therapy success ranged from 63% to 79% depending on outcome measure and success criteria. b) cost-effectiveness analysis: Cost-effectiveness-indices ranged from DM 8338.- to DM 10456.- for one successful treatment (average costs taking also the costs of unsuccessful treatments into account). c) cost-benefit-analysis: Cost reduction in the year after therapy was remarkable (inpatient costs about 25%, other cost factors 87%-100%), resulting in a benefit of DM 3026.- per patient and a cost-benefit-ratio of 1:0.58 in the first year after treatment. Assuming that the improvements are stable, the cost-benefit-ratio after five years would be estimated as 1:2.63. Discussion: The present study shows exemplarily for CBT of anxiety disorders that modern psychotherapy can produce remarkable results at reasonable costs. Furthermore, clinical-psychological treatment methods show an additional economic benefit. Clinical Psychology can benefit from focusing not only the promising developments in classification, etiology, and treatment but also taking over the cost perspective (which is relatively new in scientific evaluation of psychotherapy). (Appendix: Cost-Benefit-Calculator.htm; 8,97 KB -- Usage: Referat Informationsvermittlung/ SLUB) / Fragestellungen: Ermittlung von Effektivität und monetärem Nutzen psychologischer Behandlung von Angststörungen, die dann den für die Therapie aufgewendeten Ressourcen gegenübergestellt werden. Methoden: N=493 Patienten mit Angststörungen (DSM-IV), die eine ambulante störungsspezifische kognitive Verhaltenstherapie absolviert haben, wurden prä, post und zur 1-Jahres-Katamnese untersucht. Das Spektrum der Erhebungen umfasste störungsspezifische und störungsübergreifende Symptombelastung und Beeinträchtigungen in verschiedenen Lebensbereichen, sowie eine globale Therapieerfolgseinschätzung von Patienten und Therapeuten. In einer zweiten Studie wurden zusätzlich an einer Teilstichprobe Kosten-Nutzen-Aspekte untersucht (Einsparungen durch Reduktion von Gesundheitsleistungen und Arbeitsunfähigkeit; außerdem Pilotstudie zu willingness-to-pay-Ansatz). Das Behandlungssetting der Studie ist charakterisiert durch klinisch relevante Rahmenbedingungen und Praxisnähe. Zentrale Ergebnisse: a) Effektivität: Die Effektstärken reichten in Abhängigkeit von der Meßmethode von 0.9 bis 1.9. Die Verbesserungen waren durchgängig signifikant und blieben bis zur 1-Jahres-Katamnese stabil. Die Raten klinisch bedeutsamer Besserungen betrugen 63% - 79% in Abhängigkeit von Mess- und Auswertungsmethode. b) Kosten-Effektivitäts-Analyse: Die Kosten-Effektivitätivitäts-Indices betrugen DM 8338.- bis DM 10456.- (dieser Index gibt an, was eine erfolgreiche Behandlung durchschnittlich kostet, also unter Einbezug der nicht erfolgreichen Behandlungen in die Gesamtkosten). c) Kosten-Nutzen-Analyse: Im Jahr nach Therapie reduzierten sich die Kostenfaktoren der Störungen vor Therapie beträchtlich (stationäre Kosten um 25%, restliche Kostenfaktoren 87% - 100%). Die dadurch erzielten Einsparungen betrugen durchschnittlich DM 3026.- (Kosten-Nutzen-Verhältnis im ersten Jahr: 1 : 0.58). Unter der Annahme, dass die Auswirkungen der Therapie auch über die 1-Jahres-Katamnese hinaus stabil bleiben, kann man abschätzen, dass sich die Therapie innerhalb des zweiten Jahres amortisiert und das Kosten-Nutzen-Verhältnis nach fünf Jahren (diskontiert) 1 : 2.63 beträgt. Diskussion: Wie in dieser Arbeit anhand der kognitiven Verhaltenstherapie für Angststörungen gezeigt wird, kann moderne Psychotherapie bei vertretbarem Aufwand beachtliche Erfolge verbuchen. Klinisch-psychologische Behandlungsmethoden sind darüber hinaus auch wirtschaftlich, derart, dass sie über den reinen Behandlungserfolg hinaus zu Kosteneinsparungen beitragen könnten. Es ist erstaunlich, dass die Kosten-Perspektive der wissenschaftlichen Bewertung von Psychotherapie noch recht neu ist. Die Klinische Psychologie kann davon profitieren, diese Dimension (neben den beachtlichen Erkenntnisfortschritten in bezug auf Klassifikation, Ätiologie, Verlaufsforschung und Behandlungsverfahren) mehr herauszustellen. (Anlage: Cost-Benefit-Calculator.htm; 8,97 KB -- Nutzung: Referat Informationsvermittlung der SLUB)