Past research indicates a causal relationship between emotional writing and health benefits (Smyth, 1998). At present, little is known about the mechanisms underlying change or if the emotional writing paradigm may be applied to a clinical setting. This present study reviewed current models of trauma and hypothesised three mechanisms of change leading to future health benefits: exposure, devaluation, and benefit-finding. Instructions for the standard writing paradigm were manipulated to isolate and increase engagement with each of these processes. It was hypothesised that if any one of these processes were to underlie health benefits, participants assigned to that condition would obtain more benefit than standard writing participants. Individual differences were also hypothesised to interact with each process to amplify or detract from their influence in leading to future benefit. A total of 201 university students were recruited from Griffith University. Participants were assigned to one of five writing conditions: Control, Standard, Exposure, Devaluation, and Benefit-Finding. Sessions were conducted once a week for three weeks. Physiological and self-report measures were taken before, during and after writing sessions. Follow-up assessments of psychological and physical health were taken at 2 and 6-months post-writing. Essay content analysis suggested that participants wrote in the instructed manner. Participants assigned to each of the groups experienced expected amounts of distress and affect changes. Overall, results failed to replicate the beneficial health effects for the standard emotional writing paradigm. There were no significant physical or psychological benefits for the standard trauma-writing participants in comparison to control. However, a trend in the appropriate direction was noted for illness visits at 6-months. Furthermore, in support of Greenberg and Stone's (1992) findings, standard writing participants who disclosed more severe and personal experiences evidenced significant illness visit reductions in comparison to control. Comparisons between standard and experimental trauma writing groups failed to support hypotheses that any one mechanism was responsible for physical health benefits. Examination of psychological self-report measures indicated exposure participants experienced the greatest reduction on the Impact of Events Scale at two months. However, these participants experienced greater reduction of positive affect and growth for the experience. They also became more anxious, depressed, and stressed at six-months follow-up. Process variables were examined within the exposure condition to explain these findings. Habituation was found to be strongly associated with the alternate outcomes. Individual differences. Including alexithymia, absorption, and negative affect, were also related to outcome. Benefit-finding participants experienced the greatest increase on a measure of post-traumatic growth at two-months and positive affect for the experience, but the finding was significant only in comparison to exposure and devaluation groups. The results of this study failed to identify the process of change, but suggest specific areas for future research. The findings demonstrate the importance of comprehensive health research to avoid blanket statements that suggest a paradigm either does or does not lead to health benefits. The results also support the manipulation of the writing paradigm to examine the role of emotion processing in trauma and health research.

Einleitung: "Verhaltenstherapie" kommt in ihr zweites Jahr. Zum Start, vor einem Jahr, haben wir Aufgaben, Ziele und Erwartungen formuliert, die in bisher vier Heften der Realitätsprüfung unterzogen wurden. In unserer ersten Jahresbilanz stellt sich die Frage, welche Ziele 1991 schon erreicht wurden und welche 1992 voraussichtlich erreicht werden.

The purpose of the current study was to develop a manualized treatment for fibromyalgia syndrome (FM) and to examine the efficacy of the treatment in a randomized controlled clinical trial. FM is a chronic musculoskeletal pain disorder characterized by tender points and generalized pain. Depression, chronic fatigue, and sleep disturbance are common. A biopsychosocial model served as a framework for understanding FM by integrating psychological, social, and physical factors. Cognitive-behavioural therapy (CBT), an empirically validated treatment for arthritis, has also been used with FM patients in an attempt to improve pain control, reduce disability, and increase self-efficacy. Overall, the attention/placebo controlled studies employing CBT as a treatment for FM show that it is not superior to a credible attention placebo. The current study attempted to combine the necessary components of CBT with interpersonal therapy to address relational patterns and personality characteristics that can affect ability to cope with chronic pain. One hundred and five women diagnosed with FM by a rheumatologist were randomly assigned to the CBT-interpersonal treatment condition or an attention-control condition. There were 8 treatment groups with a mean of 6-7 participants in each. The treatment consisted of weekly 2-hour sessions over 8 consecutive weeks. Outcome measures included: FM impact, pain, health care utilization, depression, coping, and self-efficacy. An intention-to-treat analysis was conducted. Results showed that the impact of FM symptoms was reduced following treatment compared to the control group and this was statistically and clinically significant, but was not maintained at 3-month follow-up. Significant improvements were also observed in coping strategies, some of which were maintained at follow-up. Importantly, self-efficacy improved significantly following treatment compared to the control group. Self-efficacy beliefs have been related to pain, coping efforts, disability, and psychological functioning. Directions for future research may include a focus on long-term maintenance of treatment gains that may be mediated by improvements in self-efficacy. There is strong evidence that changes in self-efficacy are enduring and affect changes in health behaviours and health status.

The purpose of the current study was to develop a manualized treatment for fibromyalgia syndrome (FM) and to examine the efficacy of the treatment in a randomized controlled clinical trial. FM is a chronic musculoskeletal pain disorder characterized by tender points and generalized pain. Depression, chronic fatigue, and sleep disturbance are common. A biopsychosocial model served as a framework for understanding FM by integrating psychological, social, and physical factors. Cognitive-behavioural therapy (CBT), an empirically validated treatment for arthritis, has also been used with FM patients in an attempt to improve pain control, reduce disability, and increase self-efficacy. Overall, the attention/placebo controlled studies employing CBT as a treatment for FM show that it is not superior to a credible attention placebo. The current study attempted to combine the necessary components of CBT with interpersonal therapy to address relational patterns and personality characteristics that can affect ability to cope with chronic pain. One hundred and five women diagnosed with FM by a rheumatologist were randomly assigned to the CBT-interpersonal treatment condition or an attention-control condition. There were 8 treatment groups with a mean of 6-7 participants in each. The treatment consisted of weekly 2-hour sessions over 8 consecutive weeks. Outcome measures included: FM impact, pain, health care utilization, depression, coping, and self-efficacy. An intention-to-treat analysis was conducted. Results showed that the impact of FM symptoms was reduced following treatment compared to the control group and this was statistically and clinically significant, but was not maintained at 3-month follow-up. Significant improvements were also observed in coping strategies, some of which were maintained at follow-up. Importantly, self-efficacy improved significantly following treatment compared to the control group. Self-efficacy beliefs have been related to pain, coping efforts, disability, and psychological functioning. Directions for future research may include a focus on long-term maintenance of treatment gains that may be mediated by improvements in self-efficacy. There is strong evidence that changes in self-efficacy are enduring and affect changes in health behaviours and health status.

Despite the existence of evidence-based interventions for anxiety disorders, many barriers impede access to effective treatment services (e.g., distance from services, comorbidity). This dissertation aimed to investigate ways to overcome some of these barriers by exploring (1) the efficacy of therapist-supported distance cognitive behavior therapy (CBT) for anxiety disorders in adults, (2) the suitability of anxiety sensitivity (AS; a fear of arousal-related physiological sensations) as a target for transdiagnostic treatment, and (3) the efficacy of a distance CBT intervention for reducing high AS and its associated mental health and substance use symptoms. In Study 1, a systematic review showed that therapist-supported distance CBT was more efficacious than a waiting list and as efficacious as face-to-face CBT in reducing anxiety symptoms, increasing the likelihood of diagnostic remission, and improving quality of life. In Study 2, AS was associated with panic, posttraumatic stress, social phobia, and depressive symptoms. Of its lower order subscales, physical concerns predicted unique variance in panic, cognitive concerns predicted unique variance in depressive symptoms, and social phobia was predicted by social concerns. Together, Studies 1 and 2 suggest that distance CBT for anxiety is efficacious and that AS may be a suitable target for transdiagnostic interventions. As such, Studies 3 and 4 report on a randomized controlled trial investigating the efficacy and transdiagnostic implications of a telephone-delivered CBT intervention for high AS. The treatment significantly reduced AS relative to a waiting list and led to significant reductions in panic, posttraumatic stress, and social phobia symptoms (though not generalized anxiety or depressive symptoms). Treatment-related reductions in AS mediated these anxiety symptom changes. Participants in the treatment, vs. control, group also showed a significantly greater reduction in number of mental health diagnoses and in functional disability. Treatment also significantly reduced coping-with-anxiety drinking motives and physical alcohol-related problems for the treatment but not waiting list group. Reductions in AS mediated changes in coping-with-anxiety motives, while coping-with-anxiety motives mediated changes in physical alcohol-related problems. Taken together, findings from this dissertation provide evidence that distance-based and transdiagnostic AS-focused interventions may be two important and efficacious ways to overcome several barriers to anxiety treatment.

The effectiveness of a Group CBT programme for Social Phobia was assessed using 18 participants recruited from a routine practice setting. Therapy was based on CBT techniques as practiced routinely by the clinical practice, and were not modified for the study by factors such as strict exclusion criteria and adherence to rigid manualised treatments. Pre- to post-treatment effect sizes compared favourably with those reported in a meta-analysis (Taylor, 1996). The findings provide support for the accessibility and effectiveness of group CBT techniques for Social Phobia in field settings. While some individuals within the sample experienced dramatic improvement, some remained severely impaired even at post-treatment. The results of Hierarchical Multiple Regressions indicated that lower levels of pre-treatment depression severity, higher levels of attendance, and greater homework compliance, were predictive of more improvement on some, but not all, measures of outcome. Implications for treatment are discussed.

People who are diagnosed with ‘severe mental illness’ experience some of the most extreme and pervasive prejudice of all groups in Western society. How can this still be so? Although the term ‘mental illness’ is typically reserved for the most ‘serious’ of ‘cases’, psychiatry’s medical model is expanding into increasingly everyday realms. Thus, in concert with efforts to reduce social stigma, ‘mental illness’ is becoming ‘normal’. Nevertheless, ‘abnormality’ is a requirement of biopsychiatry and its offshoots; professionals require some ‘thing’ to remedy. How do ‘clinical’ professionals manage these tensions? And what alternatives are there to the pathologizing of such phenomena? Such concerns are considered in relation to my main thesis question: How do professionals represent ‘schizophrenia’ and hearing voices in theoretical texts, and how is that played out in the minutiae of therapy practices? Drawing on discourse analysis and conversation analysis, I critique professional categorizations of what are typically known as ‘schizophrenia’, ‘mental illness’, ‘patients’, ‘clients’, and ‘therapists’. My case in point is the experience of hearing voices - pathologically known as ‘auditory hallucinations’. ‘Delusional’ beliefs are also considered. In Part 1, accounts of voices as supernatural or ordinary phenomena, or as a ‘symptom’ of ‘severe mental illness’, are considered. Mainstream psychiatric and psychological texts are analyzed and critical alternatives are summarized. In Part 2, a selection of studies of interactions involving ‘severe mental illness’ are reviewed and ongoing analytic/methodological debates are discussed. A cognitivebehavioural therapy group for hearing distressing voices then provides data from ‘clinical’ talk-in-interaction for analysis. I focus on negotiations of ‘reality’ (the ordinary versus the psychiatric) and on what I take to be sanist prejudice-in-action. Part 3 relates findings from Part 2 to the context and findings of Part 1. There is also discussion of the positive implications of a more social and dialogical approach to understanding and otherwise dealing with the phenomena in question; for voice hearers, ‘schizophrenics’, and society at large.

Collaboration between therapist and client has been put forward as a core element of successful therapeutic encounters. There has been debate as to the nature of collaboration in cognitive behavioural therapy. In the UK this debate has intensified since the introduction of Increasing Access to Psychological Therapies (IAPT) in 2008 as CBT is the favoured therapeutic modality within IAPT. Collaboration in CBT has been conceptualised in dichotomous ways. From one perspective it is constructed in positivistic terms, in which the therapist implements manualised protocols with little consideration for the therapeutic relationship; from the other perspective collaboration is constructed in dialogic terms, in which therapist and client use CBT interventions to consider new meanings that the client deems to be relevant. The current study used a discourse analytic methodology to investigate how CBT therapists construct collaboration in their therapeutic practices. The aim was to explicate interpretive repertories that participants used in the construction of collaboration. Semi-structured interviews were used with 8 CBT therapists. Questions related to the arguments for and against the nature of collaboration in CBT. A client choice interpretive repertoire was used by all participants. It was constructed in various ways in line with either positivistic or dialogic perspectives or elements of both. Individual participants constructed client choice from both perspectives suggesting that the dichotomy in perspectives on collaboration in CBT may not be clear-cut. There is an implication for counselling psychology practitioners to reflect on their use of dichotomous perspectives to conceptualise their professional identities.

Objectives: To determine whether task-shifting the treatment of Postpartum depression (PPD) is effective in both treating mothers and mitigating the potential negative effects of PPD exposure on infant emotion regulation (ER). Methods: In Study 1, a randomized controlled trial (RCT) with a waitlist control group was used to examine whether a nine-week group Cognitive Behavioural Therapy (CBT) intervention delivered by peers can effectively treat PPD in mothers. Study 2 used data from this same RCT to determine if maternal PPD treatment with peer-delivered group CBT intervention would lead to adaptive change in markers of ER in their infants. Finally, Study 3 used data from a RCT with a treatment-as-usual control group to examine whether maternal treatment with a Public Health Nurse (PHN)-delivered group CBT intervention led to adaptive change in markers of infant ER. In both Studies 2 and 3, markers of infant ER included two neurophysiological measures and a maternal-report measure of infant temperament. Results: Study 1 found that peer-delivered group CBT led to significant improvements in symptoms of depression and anxiety in mothers and reductions in symptoms remained stable six months after treatment initiation. Study 2 found evidence of change in two neurophysiological measures of infant ER following maternal treatment with peer-delivered intervention, but not in the maternal-report measure of infant temperament. Finally, Study 3 found evidence of change in a single neurophysiological marker of infant ER following maternal treatment with the PHN-delivered intervention, but found no change following maternal treatment in a second neurophysiological marker and maternal-report measure of infant ER. Conclusions: The studies in this thesis highlight the potential of using task-shifting to fill a gap in the healthcare system’s treatment of PPD. This work suggests that interventions delivered by peers and PHNs may not only be effective in treating those with PPD, but may also benefit their infants by mitigating any PPD-related consequences on infant ER development. This thesis contributes to the evidence that suggests timely maternal treatment of PPD may disrupt the transmission of psychiatric risk from parent to infant. / Dissertation / Doctor of Philosophy (PhD) / Postpartum depression (PPD) is common and has consequences for both mothers and their infants. The negative impact of PPD exposure on infant emotion regulation (ER) is especially harmful because of its association with later psychopathology. As a result, the objectives of the present thesis were to i) determine whether task-shifting the treatment of PPD is effective in treating mothers while ii) mitigating the potential negative effects of PPD exposure on infant ER. The results of this thesis indicate that a task-shifted, peer-delivered treatment is effective in treating mothers with PPD and that treating mothers with a task-shifted treatment may also lead to adaptive changes in infant ER. This thesis indicates that task-shifting the treatment of PPD may improve outcomes for mothers, prevent PPD-related consequences on infant ER development, and ultimately, improve future outcomes for their infants.

Background: Relational depth (RD) is gaining empirical attention as a well-articulated phenomenon within therapeutic relationship literature. Despite this, with the exception of a small number of client-focused studies, research of this issue is relatively sparse and predominantly reflects upon therapeutic work from a person-centred orientation. Aims and Methods: The aim of this research was to explore clients’ experiences of RD within individual Cognitive Behavioural Therapy. Eight clients, who had self-identified at least one helpful relational moment with their therapist, were interviewed about their experience. The interviews were transcribed and analysed employing Grounded Theory methods. Findings and Discussion: Four core categories emerged from the analysis. These were: (1) the experience of the therapist, (2) the experience of self, (3) the experience of the therapy relationship, and (4) the perceived impact/effects of the moment of RD. Each core category and the corresponding subordinate codes are described by illustrative quotes from the participants. Following this, each finding is discussed in relation to RD research and beyond. Conclusions: This research project ultimately demonstrates that clients who have worked with a cognitive behavioural therapist can and do experience RD during their individual therapy. The like-by-like comparison of the findings with previous RD research indicated a high degree of convergence. Nevertheless, when differences are present, clients’ RD experience is influenced and to some extent contained by dissimilarity in experience between therapist and non-therapist clients. This is also manifested through theoretical differences of the given therapeutic approach. No negative impact or effect was described by the clients as a result of their experience of a moment of RD. The implications of the findings are highlighted and future research is suggested.