This thesis follows the research portfolio format and is carried out in part fulfilment of the academic component of the Doctorate in Clinical Psychology at the University of Edinburgh. An abstract provides an overview of the entire portfolio thesis. Chapter One contains a systematic review of published research exploring staff attitudes towards computerized cognitive behavior therapy (cCBT). Chapter Two is an empirical study examining a range of potential predictor variables on well-being outcomes from cCBT. Chapter one is prepared for Behavioural and Cognitive Psychotherapy, whereas chapter two is prepared for submission to the journal, Behaviour Research and Therapy. Both chapters follow the relevant author guidelines. Background: Evidence suggests that computerised cognitive behavioural therapy (cCBT) is both effective and efficacious in treating depression and anxiety. Numerous barriers to its implementation and uptake have been identified, however, including attitudinal variables and high patient attrition rates. Research examining predictors of response from cCBT have tended to adopt the pathological model of distress, focussing on symptom reduction rather than the promotion of well-being. Furthermore, exploration of possible predictors has tended to focus on a narrow range of factors (e.g. age, gender), neglecting key psychosocial variables (e.g. social identification, baseline distress) that could be exerting an effect. Aims: A systematic review examined staff attitudes towards cCBT for depression, anxiety, and comorbid depression and anxiety, focussing on three attitudinal domains: Perceived acceptability of cCBT; staff's self-reported intention to use cCBT in the future, and perceived advantages and disadvantages of cCBT for depression and/or anxiety. An experimental study was subsequently conducted, examining a range of potential predictors on well-being outcomes from a cCBT intervention utilising Beating the Blues. Method: A systematic search across five databases was conducted, followed by manual searches. Strict search criteria were applied, resulting in the identification of 15 studies. These were subjected to quality assessment, data extraction and synthesis. For the empirical study, data from 1354 participants was collected, with subgroup-analyses conducted on those completing measures of life and mental health satisfaction, functioning and well-being. Key potential predictors of interest were level of group identification, baseline distress, and socioeconomic deprivation. Results: Findings from the systematic review indicated that staff held relatively positive attitudes towards cCBT, with some ambivalence emerging in relation to perceived advantages and disadvantages of the intervention. The empirical study obtained significant effects of group identification on life and mental health satisfaction. A mediating impact of group identity on baseline distress emerged, whereas a moderating effect of baseline distress on deprivation was obtained for the functioning model. Discussion: The current findings demonstrated both positive and negative aspects of staff attitudes towards cCBT for depression and/or anxiety, whereas the empirical project established a clear link between social identification, baseline distress, and well-being. Results from both studies are discussed in terms of clinical implications relating to the uptake of cCBT.

The objective of the current research was to test the initial feasibility and potential efficacy of a group-based Acceptance and Commitment Therapy (ACT) intervention for partner aggression, compared to a support and discussion control group, in a clinical sample of adults. Specifically, the study was intended to provide preliminary evidence of the impact of an ACT group on psychological and physical aggression, and to examine the processes responsible for any treatment effects. One hundred and one participants (mean age = 31; 68% female) were randomly assigned to receive ACT or the support and discussion control group. Both interventions consisted of 12 weekly 2-hour sessions and participants were assessed with self-report measures at pre-treatment, twice during treatment, at post-treatment, and at 3- and 6-month follow-up. Results of growth curve modeling analyses demonstrated that participants in the ACT group had significantly greater decreases in psychological and physical aggression at post-treatment and follow-up, and also showed improvements in depressive symptoms, interpersonal problems, and social functioning. Finally, the effect of the ACT group on psychological and physical aggression was mediated by experiential avoidance, suggesting that the intervention had its effects, at least in part, through increasing emotional acceptance. These results demonstrate that an ACT approach to aggression may be a viable alternative to traditional treatments.

The literature review produced for this thesis systematically analysed qualitative studies of cognitive therapy using a methodology checklist and a meta-synthesis technique. Ten papers which used qualitative analysis to look at clients’ experiences of Cognitive Behavioural Therapy (CBT) met the selection criteria. Seven themes emerged. Three were linked to a therapeutic relationships theme; the trusted listener, power and authority and others like me. Four were linked to the impact of cognitive therapy theme; empowering information, analysing the problem, thinking differently and doing things differently. It was concluded that future research should focus on the components of cognitive therapy and that differences in technique between CBT and Rational Emotive Behaviour Therapy (REBT) should be explored via a qualitative study of clients’ experiences of REBT. A qualitative approach was taken to look at clients’ experiences of REBT. Seven participants were interviewed using a semi-structured interview guide and the resulting transcripts were analysed using interpretive phenomenological analysis. Three themes emerged: one which looked at what it was like to have mental health problems; a second, which looked at clients’ expectations and experiences of the more technical aspects of therapy, and a third which examined the therapeutic relationship. All of the participants appeared to value therapy. However, the extent to which they knew about and used the theory and philosophy of REBT varied greatly. These results suggest that further research needs to be carried out which looks at how people benefit from therapy as clients views may differ from those of therapists. A critical appraisal of the research process was written using the REBT model to reflect the experience of producing the thesis.

Social Anxiety Disorder (SAD) is a mental disorder with high prevalence but low treatment accessibility. A way to facilitate care to these patients is through Internet based treatment. As is the case of most psychological treatments, much has been studied about positive effects but there is a gap regarding adverse effects. This study seeks to fill this gap in the case of an Internet delivered treatment. From a total of 127 participants who took part in a treatment that combined attention biased modification (ABM) and Internet based cognitive behavior therapy (iCBT), 21 (16.5%) presented adverse effects. Most of the adverse effects were detected after participants had received iCBT (13.4%), and these were mostly related to deterioration of symptoms (5.5%), negative wellbeing (3.9%) and emergence of new symptoms (1.6%). Perceived side effects after attention training were less common (4.7%). A thematic analysis showed also that the techniques used in treatment, the lack of time to complete treatment and becoming aware with the impairments of the disorder and its consequences could influence the emergence of adverse effects.

Having a child diagnosed with cancer is stressful and many parents of children on treatment for cancer report symptoms of posttraumatic stress (PTSS). The overall purpose was to, among parents of children on treatment for cancer, investigate the factor structure of PTSS; investigate the relationships between experiential avoidance (EA), rumination, PTSS and depression; and to develop, test, and evaluate a guided self-help intervention provided via the internet. In a longitudinal study with three assessments (n = 249-203) results indicated that a four-factor solution of PTSS including the factors re-experiencing, avoidance, dysphoria, and hyper-arousal provided best fit and that the pattern and size of factor loadings were equivalent across the three assessments (Study I). In a case study with pre-, post-, and follow-up assessments a guided self-intervention was well received with clinical significant and reliable improvements in PTSS, depression, and quality of life (Study II). Furthermore, in cross-sectional analyses (n = 79) EA and rumination were positively associated with PTSS and depression and provided incremental explanation in depression while controlling for demographic characteristics, anxiety, and PTSS. In longitudinal analyses (n = 20), EA but not rumination predicted PTSS and depression while controlling for initial levels (Study III). Finally, in a randomized controlled trial with parents fulfilling the modified symptom criteria on the PTSD-Checklist allocated to guided self-help via the internet (n = 31) or to a wait-list control condition (n = 27) there was a significant intervention effect with a large effect size for the primary outcome PTSS. Similar results were observed for the secondary outcomes depression and anxiety, but not for EA and rumination. Exploratory analyses suggested that the relationships between EA and PTSS and between EA and depression were weakened in the intervention group (Study IV). The studies included in the current thesis suggest that a four-factor solution should be used when assessing PTSS in parents of children on cancer treatment. Furthermore, rumination and EA in particular seem to be important constructs to consider when understanding PTSS and depression in this population. Finally, guided self-help via the internet shows promise in reducing PTSS and depression among parents of children on cancer treatment who report a high level of PTSS.

The present study investigated the efficacies of Individual CBT (ICBT), Parent Relationship Skill Training (RLST, which targets increasing parental acceptance of youth and increasing autonomy granting) and Parent Reinforcement Skills Training (RLST, which targets increasing parental positive reinforcement and decreasing negative reinforcement). The specific aims were to examine treatment specificity and mediation effects of parenting variables. ICBT was used as a baseline comparison condition. The sample consisted of 253 youth (ages 5-16 years; M = 9.38; SD = 2.42) and their parents. To examine treatment outcome and specificity, the data were analyzed using analysis of variance within a structural equation modeling framework. Mediation was analyzed via structural equation modeling using MPlus. Results indicated that ICBT, RLST, and RFST produced positive treatment outcomes across all indices of change (i.e., clinically significant improvement, anxiety symptom reduction) and across all informants (i.e., youths and parents). RLST was associated with incremental reduction in youth anxiety symptoms beyond ICBT, as per youth report. Treatment specificity effects were found for participants in RFST in terms of parental reinforcement, as per parent report only. Treatment mediation was not found for any of the hypothesized parenting variables (i.e., parental acceptance, parental autonomy granting, parental reinforcement). The results support the use of CBT involving only the youth and the parent and youth together for treating youth anxiety. The findings’ implications are further discussed in terms of the need to conduct further meditational treatment outcome designs in order to continue to advance theory and research in youth anxiety treatment.

Thesis (Ph.D.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / Separation anxiety disorder (SAD) is the most common and impairing childhood anxiety disorder. Left untreated, SAD is associated with heightened risk for the development of additional internalizing disorders as well as impairments in educational attainment and social functioning. Numerous clinical trials have demonstrated the efficacy of cognitive-behavior therapy (CBT) for the treatment of childhood anxiety disorders, including SAD. However, additional research is needed to enhance the compatibility (e.g., fit of the treatment to the patient population) and ultimate uptake of evidence-based interventions for anxious youth. The current research evaluates the feasibility and preliminary efficacy of an intensive, cognitive-behavioral intervention for school-aged girls with SAD provided within the novel context of a one-week camp-like setting. This alternative treatment format was predicated on evidence supporting the need for treatments that allow for creative and developmentally-sensitive applications of intervention components, incorporate a child's social context, target relevant parenting variables, and provide additional models for treatment delivery. Twenty-nine female children aged 7 to 12 with a principal or co-principal diagnosis of SAD were randomized to an immediate treatment (n = 15) or waitlist (i.e., delayed treatment; n = 14) condition during the course of this randomized-controlled trial. Measures were administered at pretreatment/ pre-waitlist, post-treatment/post-waitlist, and six weeks following treatment to assess changes in symptom reports, functional outcomes, and overall program satisfaction. Analyses of covariance were conducted to assess effects of treatment condition and repeated measures analyses of variance were conducted to evaluate change over the three data collection time points. Relative to waitlist, children in the immediate treatment group evidenced significant reductions in SAD severity by clinician report on a diagnostic interview measure. Moreover, treatment gains strengthened over time. Contrary to hypotheses, children receiving the intervention did not display significantly greater improvements relative to waitlist on parent-rated fear and avoidance scores or on parent or child self-report measures. Potential explanations for non-significant findings are discussed. Overall, the intervention's positive therapeutic response on SAD diagnostic status and severity suggests one possible delivery model for surmounting difficulties faced in the dissemination of standard, weekly treatments for this condition. / 2031-01-02

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第18648号 / 社医博第60号 / 新制||社医||8(附属図書館) / 31562 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 村井 俊哉, 教授 佐藤 俊哉, 教授 福原 俊一 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

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