This study explores the subjective experiences of CBT therapists who have undergone personal therapy and seeks to gain insight into the significance of personal therapy in CBT clinical practice. Seven CBT therapists who have undergone personal therapy were interviewed. Interpretative Phenomenological Analysis (IPA) was chosen to generate rich interview data. Participants were asked about their experience of personal therapy in clinical practice. Participants' narratives were analysed using IPA to identify common themes. The analysis resulted in twelve interrelated themes from which three master themes emerged. The first theme, 'Personal therapy creates conflict', explores a paradox that arises between personal therapy and CBT clinical practice; participants suggest that personal therapy equips them with therapeutic tools that paradoxically hinder their capacity to practice a standardised protocol-led CBT. The second master theme, 'Personal therapy ties me to humanity', suggests that the gap between personal therapy and CBT practice narrows by participants' 'use of self': calling upon their own vulnerabilities to forge fundamental connections with their clients based on the shared experience of being human. This study finds that all participants value 'being human' with their clients, however, struggle to find the space 'to just be' within an action-focused, goal-orientated CBT model. This is further explored in the final theme, 'Personal therapy: Being and doing'. Potential implications of the themes that emerged were considered. This study contributes to the literature on CBT and counselling psychology, and to the understanding of a divide in the psychotherapy profession between evidence-based priorities and expectations of reflective practice.

Estudos em serviços-escola de psicologia questionam o quanto o modelo vigente atende adequadamente à clientela infantojuvenil, uma vez que é alta a evasão destes pacientes antes e durante o atendimento. Apesar de sugerirem propostas de mudanças no atendimento oferecido, pouco se comenta sobre a necessidade de treino de terapeutas e a baixa procura de crianças com problemas internalizantes, citados na literatura como os de maior incidência nesta população. Este trabalho teve como objetivo diminuir essa lacuna ao propor, elaborar e avaliar uma proposta de treinamento de estagiários no atendimento de crianças ansiosas, inscritas em serviços-escola, com o uso de um protocolo reconhecido internacionalmente para o atendimento dessas crianças (Gato Corajoso), adaptado para a realidade brasileira. Foram escolhidos dois serviços-escola vinculados ao serviço público de saúde, que atendem crianças ansiosas em duas capitais brasileiras, São Paulo e Brasília; treze terapeutas, alunos de graduação de psicologia, foram selecionados para receber o treinamento em duas etapas. Na primeira fase, foi realizado o levantamento da clientela atendida por serviços de saúde mental (n=112), na segunda, foram atendidas 20 crianças com idade entre 9 e 13 anos, enquanto outras 11 crianças com características similares constituíram o grupo controle. Os resultados sugerem que as crianças dos serviços-escola estudados apresentavam características similares às das crianças atendidas pelas clínicas-escolas de psicologia tradicionais, em relação a aspectos como idade, gênero, escolaridade, renda familiar e classe social. Apresentavam, ainda, outras características similares às verificadas nos serviços-escola de saúde, como forma de encaminhamento e queixas. Os resultados também indicam que o desempenho dos terapeutas, por meio de autoavaliação, avaliação por seus pares e por juízes, foi acima da média e a percepção do protocolo pelos próprios terapeutas foi favorável a seu uso. Além disso, os resultados apontam que as crianças ansiosas que participaram da intervenção obtiveram resultados clínicos nas escalas do CBCL indicativos de melhora, quando as crianças foram avaliadas antes e depois da intervenção e com os dados do grupo controle, após o tempo da intervenção. Com essas informações, conclui-se que o treinamento oferecido aos alunos com base em um protocolo de atendimento para ansiedade infantil mostrou-se útil para o atendimento clínico de crianças ansiosas, para ensinar aos alunos sobre terapia cognitivo-comportamental e para orientá-los sobre o que fazer ao longo das sessões de intervenção, diminuindo o impacto da falta de experiência em atendimento infantil e em atendimento grupal. Sugere-se, assim, que o uso de protocolos em treinamentos de terapeutas pode ser uma boa forma de difundir um conhecimento clínico com base em evidências / Studies on teaching clinics question how adequately the current model provides for children and teenage clients, since the evasion of these patients is high before and during treatment. Although suggestions are made for changes in the offered treatments, little is commented about the need for training therapists and the low demand of children with internalized problems, cited in literature as the problem with the highest incidence in this population. This study has the objective of decreasing this gap by proposing, elaborating and evaluating a proposal for training interns in the treatment of anxious children, enrolled in teaching clinics, with the use of an internationally recognized protocol for the treatment of these children (Coping Cat), adapted for the Brazilian reality. Two teaching clinics linked to public health services that treat anxious children in two Brazilian capitals, São Paulo and Brasilia, were chosen; thirteen therapists, which were undergraduate psychology students, were selected to receive training in two stages. During the first stage, we conducted a survey of the clients that used the mental health services (n=112); in the second stage, 20 children with ages varying between 9 and 13 were treated, while 11 other children with similar characteristics constituted the control group. The results suggest that the children from the studied teaching clinics present similar characteristics to children treated in traditional teaching psychology clinics, in aspects such as age, gender, schooling, family income and social class. They also present other similar characteristics to those verified in teaching clinics, such as the referral methods and complaints. The results also indicate that the performance of the therapists, evaluated by themselves, their colleagues and judges, was above average and that the therapists perception of the protocol was in favor of its use. Also, results show that when the children were evaluated before and after the intervention and with the data of the control group, anxious children who participated in the intervention obtained clinical results in the CBCL scales that indicated improvement. Based on this information, one may conclude that the training offered to students based on a treatment protocol for childrens anxiety was useful for the clinical treatment of anxious children, to teach the students about cognitive-behavioral therapy and to guide them on what they should do during the intervention, which decreased the impact of the lack of experience on childrens therapy and on group therapy. It is thus suggested that the use of protocols for training therapists may be a good way of spreading evidence based clinical knowledge

Tinnitus is common, and some individuals with tinnitus display high levels of distress. Cognitive behavioural therapy (CBT) is effective in reducing tinnitus distress, but is rarely available. CBT-based self-help, with or without guidance, has yielded positive results in other problem areas, and one initial randomized controlled trial (RCT) has shown promising results for tinnitus. This thesis is based on four studies; Study I showed that Internet-based self-help treatment with e-mail guidance alleviated tinnitus distress among consecutive patients and was rated as credible as traditional treatments. Active participation in treatment predicted outcome. Study II, an RCT, showed that an extended and more interactive version of the Internet-based self-help treatment with e-mail therapist support appeared to be equally effective as a group treatment. In study III, another RCT, a self-help book with weekly telephone support was superior to a wait-list control group. No strong evidence for the importance of telephone contact on outcome was found. In both study II and III, the positive outcome remained after one year and self-help approaches appeared more therapist time-effective compared to group treatment. Also, the received treatment-dose for patients in guided self-help was not lower than in the group treatment. Study IV found that the ‘Stages of Change’, from the transtheoretical model, are probably not the right theoretical framework to use with tinnitus patients. Predictors of outcome were found, but they were not in line with the theory behind the Stages of Change. The predictors were better understood when conceptualized as coping, showing that helplessness and less coping before treatment correlated with better outcome. In sum, guided cognitive behavioural self-help can decrease tinnitus distress. It appears to be therapist time-effective and shows effects comparable to or slightly below traditional CBT for tinnitus. Effects remain one year after treatment and generalize to a routine clinical setting.

Aus der Einleitung: "Nahezu jeder zweite Deutsche war oder ist akutell regelmäßiger Raucher. Fast ein Viertel - in manchen Altersstufen sogar mehr - aller Adoleszenten und Erwachsenen sind nikotinabhängig oder stark gesundheitsgefährdete "starke Raucher" mit mehr als 20 Zigaretten pro Tag. Fast alle regelmäßigen Raucher wissen zwischenzeitlich, daß Rauchen gefährlich und gesundheitsschädlich ist; jeder zweite Raucher bezeichnet sich sogar selbst als "abhängig. 90% haben bereits mindestens einmal über zumindest einige Tage versucht aufzuhören - ohne Erfolg. [...]"

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The aim of the present study was to examine the prevalence of eating disorder symptoms in patients with obsessive-compulsive disorder (OCD). Additional aims were to assess whether having comorbid eating disorders could influence the treatment outcome for OCD, and if symptoms of eating disorders were reduced after treatment for OCD. The sample consisted of 93 patients with a primary diagnosis of OCD. The patients underwent assessment with the Yale-Brown Obsessive-Compulsive Scale, Beck Depression Inventory, and Eating Disorder Inventory both prior to and after treatment. First, the analysis showed that the sample of OCD patients had higher prevalence of eating disorders than a population of physically active students. Moreover, the women in the sample had significantly more symptoms of eating disorders than the men. Correlational analysis showed that eating disorders did not affect the treatment outcome for OCD; the patients generally had a significant improvement of OCD symptoms. On the other hand, symptoms of eating disorders were not significantly reduced after treatment. Summarized, this study concludes that there is a high prevalence of eating disorder symptoms among patients with OCD. It further shows that comorbid eating disorders does not hinder the effect of treatment for OCD. However, as the symptoms of eating disorders persist after such treatment, an implication of the present study is that these symptoms may need closer attention.

In this study the phenomenon of persistent physical symptoms (PPS) has been examined by realist evaluation of research and practice. Nimnuan et al., (2001) have shown that up to 35% of patients in primary care and 66% in specialist out-patient clinics have presented with such ‘medically unexplained’ symptoms. The cost in medical investigation to reach diagnosis for PPS is an estimated 10% of the annual UK National Health Service budget (Bermingham et al., 2010) but poor patient outcomes prevail (Dwamena et al., 2009). Currently, PPS is linked to high comorbidity with anxiety and depression (DH 2011b) and Cognitive Behavioural Therapy (CBT) is advised as the evidence based treatment for PPS (IAPT, 2014). However, a shortfall in clinical skills to address PPS is also demonstrated and engagement could be improved (De Lusignan et al., 2014). Moreover, the pragmatic study of alternative therapy modalities and processes for PPS is recommended (Leichsenring, 2005). To obtain a broader knowledge of process for patients with or without co-morbidity, practice based experience suggests that one such alternative is a brief psychodynamic intervention (STPP) for PPS. A Realist Literature Synthesis (Wong et al. 2013) highlights effective psychotherapeutic STPP interventions in real world circumstances in 5 comparison with CBT interventions for heterogenous PPS. STPP for PPS is found at least as effective as CBT, with improved engagement rates. Additionally, common factors were discovered between ‘third generation’ STPP and CBT for effective PPS interventions and these were developed into a preliminary cross-modality theoretical analytical framework. In the realist contextual evaluation (Pawson and Tilley, 1997) of a psychosexual service delivery, the majority of PPS sufferers were found only moderately co-morbid with anxiety and depression. For complete investigative study, clinical tools are developed providing integrative CBT/STPP principles for engagement with PPS for teaching, training and practice. In conclusion, the findings suggest that the reflexive insider position of the realist Therapist-Evaluator facilitates systematically derived Practice-Based Evidence of PPS process, meeting recommendations of Deary et al., (2007) to explore and define process and outcomes with PPS. The findings contribute to development of a conceptual platform to support health professionals in overcoming physical/mental health barriers to addressing PPS and wider patient access to effective care (NHSE, 2014, 2015).

Aims: There is a well-established link between asthma and anxiety, leading to exacerbations for both conditions. National guidelines and policy documents recommend the provision of psychological interventions for this comorbidity, although evidence for their effectiveness is inconclusive. This thesis had two objectives: a) to evaluate cognitive-behavioural therapy (CBT) interventions for reducing anxiety in adults and/or children with asthma, given that CBT has a stronger evidence base for relevant respiratory and mental health conditions, b) to explore the lived experience of the interplay between childhood asthma and anxiety directly from the affected population in order to identify specific thinking and behaviour patterns that may maintain this comorbidity. Method: The first journal article outlined a systematic review. Three major electronic databases and manual searches were used to find relevant published and unpublished research. Trials meeting inclusion criteria, primarily utilising validated anxiety measures and employing both cognitive and behavioural techniques, were evaluated using adapted quality criteria. The second empirical article implemented interpretative phenomenological analysis (IPA) to explore the mechanisms maintaining the interplay between asthma and anxiety as experienced by 11 young people (aged 11-15) living with the comorbidity. Results: Fourteen trials met the inclusion criteria for the systematic review. The reviewed trials showed reasonable preliminary support for the effectiveness of CBT for anxiety in individuals with asthma across the age range. The favourable results were largely maintained long-term. The empirical article revealed three super-ordinate themes: i) ‘the influence of asthma’ by inhibiting valued activities or developmental tasks, triggering catastrophic thinking and leading to a generalisation of asthma coping strategies to managing anxiety; ii) ‘the influence of anxiety’ by affecting appropriate medication use and triggering hyperventilation-induced asthma exacerbations; and iii) ‘the interaction between asthma and anxiety’ by forming an unhelpful positive feedback loop and triggering symptom confusion. Conclusions: The systematic review discussed the moderate overall study quality and called for more methodologically robust research, examining CBT models tailored to this population and utilising clinically representative samples. The empirical article pointed to possible maintaining mechanisms identified, which lend themselves to a cognitive-behavioural framework, potentially including mindfulness-based interventions, and may be used to tailor psychological treatments.

This thesis has been prepared in the paper based format and includes a systematic review, a novel empirical piece of research and a critical reflection. The thesis focuses on the implementation of the National Institute for Health and Clinical Excellence’s (NICE) guidance recommendations for the psychological interventions for those people suffering from schizophrenia. Papers 1 and 2 have been prepared for submission in ‘Psychology and Psychotherapy: Theory, Research and Practice’ and the ‘Journal of Mental Health’ respectively. Paper 1 includes a systematic literature search and narrative synthesis exploring if the recommendations for psychological interventions for schizophrenia were being met. Rates of implementation for Cognitive Behavioural Therapy (CBT) and Family Intervention (FI) were compared. The barriers against implementation and the strategies aimed at improving implementation were reviewed. Rates of implementation varied from 4% to 100% for CBT and 0% to 53% for FI. Previously reported barriers to implementation were found, with organisational barriers being most common. Implementation strategies discovered included training packages for CBT and FI. Rates of implementation are below recommended levels suggesting inequalities in the provision of psychological interventions for schizophrenia are present. Strategies to improve implementation that are comprehensive and supported from all levels of the NHS are considered to be most effective. Paper 2 reports a quantitative piece of research exploring if behaviourally specific and plain English language guidance can improve healthcare professional intentions to perform actions in line with recommendations for schizophrenia. An independent measure, single blind, randomised controlled design was used to disseminate guidance in two formats; the ‘original’ and ‘alternative’. Self-report measures revealed no significant results when comparing the original guidance to the alternative for the cognitive determinants of behaviour, actual behaviour change, or comprehension and satisfaction with the guidance. Behaviourally specific and plain English language does not affect intentions or behaviour to implement recommended guidance for the provision of psychological interventions for schizophrenia. A more multi-factorial approach including organisational culture may be required. Paper 3 is a critical reflection of the submitted papers and research process as a whole. Strengths and limitations of the included studies, the findings in the context of wider research, implications for clinical practice and future research are discussed.

The aim of this qualitative research project was to investigate the experiences of clients who had received Cognitive Behavioural Therapy (CBT) and Person Centred Therapy (PCT) in primary care. The rationale for the investigation was to inform the assessment and referral process whereby prospective clients are assigned to the two different therapies. A total of 16 clients responded to an invitation to attend an unstructured interview (PCT = 9; CBT = 7) to talk about their experiences of therapy. The resulting transcripts were analysed using Grounded Theory methodology. Transcripts were broken down into meaning units and conceptualised as categories, using the constant comparison method. The categories were integrated, a core category conceptualised and a theory generated. A comparison of the accounts revealed similar and contrasting experiences. The main categories (eg Accessing therapy, Engaging with the therapy) could be organised in the chronological order of the client`s journey through therapy. All participants entered therapy with a particular view of reality. In successful therapy this view changed and they went on to manage their lives in a more constructive way. Participants attributed this change to different elements of the therapy (categorised as It did the trick) which brought about a new understanding (categorised as The key). Where therapy was unsuccessful this did not occur. The mechanism of change was personal to the individual and did not appear to be specific to either therapy. Some of the mechanisms appeared to be consistent with the therapy received (eg. Carrying out tasks, in the CBT group). Others appeared counterintuitive (eg. Putting me straight, in the PCT group). The differences and similarities in the participant`s experiences appeared to be due to the therapist and client`s capacity to respond to each other in order to make the therapy “work.” The Core Category, Reciprocal Responsiveness, was chosen to explain this. The findings also suggest that the ability of the therapist and client to respond to each other will affect the outcome of therapy. The theory was constructed that the outcome of therapy is determined by the occurrence of a sufficient degree of Reciprocal Responsiveness. This study has implications for the assessment process as the findings suggests that, when making a referral, it may be helpful, to take into account the potential client`s activity and responsiveness rather than relying solely on diagnosis. It also contributes to the growing body of literature emphasising the importance of therapist responsiveness to the individual needs of the client, rather than strict adherence to one therapeutic approach. The study is limited to two therapies within primary care. Future studies may consider clients experiences within other settings and with other therapeutic approaches.