Despite the growing need for depression prevention programming for university students, few programs exist and those that do are too resource-intensive for broad dissemination. Furthermore, limited research has been conducted on mechanisms of change in CBT-based prevention programs and similar research conducted on CBT for depression demonstrates mixed findings. Therefore, there is a need to incorporate a formal model of health-behaviour change in prevention (and intervention) programs to clarify mechanisms of change and improve outcomes, such as the theory of planned behaviour (TPB). This series of studies developed and tested a formal CBT-TPB “hybrid” model to predict intention to change thinking patterns and a brief depression prevention program for university students and to examine the program’s potential to change the hypothesized constructs in the hybrid model. Results indicated support for the hybrid model, in that TPB factors predict intention to change thinking patterns. In addition, across an open and randomized control trial, my “Start Making a Change” intervention promotes change in TPB factors, as well as improvement in relevant CBT and well-being outcomes. The implication of this work is that brief, easy-to-disseminate, programs, based on a formal model of change, can effectively, at least in the short term, target and change important risk factors for depression onset in university students.

Cognitive behaviour therapy (CBT) is an effective treatment for depression but access is limited. One way of increasing access is to offer CBT via the Internet. In Study I, guided Internet-based CBT was found to have a large effect on depressive symptoms compared to taking part in an online discussion group. Approximately two hours were spent on guiding each patient and the large effect found differs from previous studies that showed smaller effects, probably due to lack of guidance. The intervention had no effect on the participants’ quality of life but significantly decreased their level of anxiety. Internet-based versions of self-report measures can be more practical and efficient than paper versions. However, before implementation, evidence of psychometrical equivalence to the paper versions should be available. This was tested in Studies II and III for the Montgomery-Åsberg Depression Rating Scale – Self-rated (MADRS-S) and the Beck Depression Inventory – Second Edition (BDI-II). When the full scales were investigated, equivalent psychometric properties were found in the two versions of the MADRS-S and BDI-II. However, in the Internet-version of the BDI-II, a lower score was found for the question about suicidality and the difference was statistically significant. Although the difference was small, this indicates that suicidality might be underestimated when using the Internet-based BDI-II. As the long-term prognosis after treatment for depression is poor, in Study IV we investigated the possibility of delivering CBT-based relapse prevention via the Internet. The results revealed that fewer participants in the intervention group experienced a relapse compared to the control group and that the time spent on guiding each participant was approximately 2.5 hours. A trend towards a higher remission rate was found in the CBT group at the six-month follow-up and a reduction of depressive symptoms was associated with a lowered risk of relapse. CBT-based relapse prevention via the Internet can potentially be made available to large numbers of patients, thus improving their prognosis. The Internet increases the possibilities for health care providers in the management of depression.

There is limited research into the impact of non-specific factors on the outcome of Cognitive Behaviour Therapy (CBT). This current study aimed to investigate the relationship between client and therapist attachment styles and client interpersonal problems to the therapeutic relationship and symptom reduction over eight sessions of CBT. Seventeen therapist-client dyads were asked to complete measures of interpersonal problems, attachment style and report on the therapeutic relationship. Results showed that in this small sample there was a relationship between core alliance, as rated by clients, to reduction in symptoms of depression over the course of eight sessions of CBT (TB=0.423, p<0.05) but not anxiety. Client level of confidence in relationships was negatively correlated with the reduction in anxiety symptoms over time (TB =-.320; p<0.05). The level of difference in scores on a measure of ‘confidence in relationships’ between therapists and clients was found to be positively correlated to the level of reduction in anxiety scores over eight sessions (TB = .0428; p<0.05) and negatively correlated to the therapist rated core alliance (TB=-.428, p<0.05). These results indicate that the role of attachment styles in CBT warrants further investigation and both clinical and theoretical implications of these findings are discussed. Key words: Cognitive Behaviour Therapy, therapeutic relationship, treatment outcomes, attachment, interpersonal problems Service Improvement Project Title: What is helpful about attending an Alzheimer’s café: does it do what it says on the tin? Abstract: Alzheimer’s Cafes were developed in 1997 in the Netherlands and have since been set up all over the world. They are a post-diagnostic support group for people with dementia and their families with an aim to reduce stigma around having dementia. As yet there have been very few evaluations of these cafes. This project aimed to find out what family carers of people with dementia found helpful about attending one of two Alzheimer’s cafes. Seven carers took part in a focus group and two were interviewed individually about what they found helpful about attending an Alzheimer’s Café and what they thought could be improved on in the future. Results showed that people found the opportunities to socialise with others ‘in the same boat’ the most helpful aspect as well as meeting professionals outside of the clinic. The results of this study will enable the development of a questionnaire that can be used to continue to evaluate the café and the feedback provided used to guide future service development. Key words: Alzheimer’s Café, social support, dementia, service evaluation Critical Literature Review Title: Risk and protective factors for psychological adjustment of children born with a cleft lip and/or palate and their families: A review of the literature Abstract: Research suggests that around 30-40% of children born with a cleft lip and /or palate will develop psychological difficulties. Services supporting these individuals need to be able to identify those that might be vulnerable as early as possible so that preventative support can be offered. This review summarises findings from research studies looking at within-group differences in samples of children with a cleft and their families. Risk factors found included being male, experiencing bullying or having additional difficulties. Protective factors included satisfaction with appearance and social support. The methodological strengths and weaknesses of these studies are discussed along with implications of the findings for theory and clinical practice.

Abstract Background: Cognitive Behaviour Therapy, (CBT) is well established as an effective treatment for depression. Its applicability in routine public mental health practice is however unknown, as most published studies excluded participants with suicide risk or if co-morbid with other disorders such as schizophrenia or bipolar affective disorder. Clients of public mental health services are characterised by symptom severity, chronic course of illness, treatment resistance and / or co-morbidity. In order to determine whether CBT has utility in routine public mental health practice, it is important to find out whether symptoms of depression (and anxiety) in this client population will respond to a course of CBT provided as part of standard care. Aims and Hypotheses: This effectiveness study aimed to ascertain if CBT is effective in treating depressed and/or anxious symptoms when such symptoms exist within the clinically more complex population found within Community Mental Health Services / Settings, (CMHSs). It was hypothesised that clients receiving CBT would show reliable and clinically significant improvement in symptoms of depression and anxiety but that the amount of improvement would be less than that reported in efficacy studies with less complex client groups. Method: This was a repeated measures, uncontrolled intervention study with results benchmarked against published data. Forty six adult clients of the Inner North Brisbane Mental Health Service (INBMHS) with diagnoses of Depression and / or Anxiety, in isolation or in conjunction with Schizophrenia, Bipolar affective disorder, or a Personality Disorder were treated with an eight (8) session manualised CBT program as part of routine clinical care. Standardised measures of depression, anxiety and stress were taken at time of referral, time of the commencement of treatment, time of treatment completion and at six-month post completion of treatment. Results: Participants showed reliable and statistically significant improvement in self reported symptoms from commencement to completion of treatment. Gains were retained at follow-up. Effect sizes were in the moderate to large range and improvements were clinically significant for approximately one third of the participants. Conclusions: CBT seems to be an effective treatment for depression and anxiety where such symptoms exist within a mental health population. Further research addressing the limitations of this study would add strength to the argument that the mental health population could benefit from the broad availability of such treatment.

Objectives: To demonstrate that at 6-months post-cessation of cognitive behaviour therapy (CBT) adapted for acquired brain injury (ABI), (1) patients maintain psychological benefits, (2) coping strategy selection improves, (3) community integration is enhanced, and (4) benefits are observed in both face-to-face and telephone administrations. Methods: Participants. Seventeen ABI patients with elevated psychological distress. Outcome Measures. Pre-treatment, post-treatment and 6-month follow-up performance on the Symptom Checklist-90-revised (SCL-90-R), Depression, Anxiety Stress Scales (DASS-21), Community Integration Questionnaire (CIQ) and the Ways of Coping-Revised Questionnaire (WOC-R). Procedures. Eleven CBT sessions provided in group, face-to-face format or individually by telephone. Results: For face-to-face and telephone groups, psychological distress was significantly reduced from pre-treatment to 6-months follow-up: DASS-21 (t16= 7.32, p <.000); SCL-90-R (t16= 6.22, p <.000). Community integration (t16= -6.15 p<.000) and problem-focused coping (t16= -3.67, p<.01) were also significantly enhanced. Conclusion: CBT adapted for patients with ABI carries robust benefits even 6-months after treatment.

Objectives: To demonstrate that at 6-months post-cessation of cognitive behaviour therapy (CBT) adapted for acquired brain injury (ABI), (1) patients maintain psychological benefits, (2) coping strategy selection improves, (3) community integration is enhanced, and (4) benefits are observed in both face-to-face and telephone administrations. Methods: Participants. Seventeen ABI patients with elevated psychological distress. Outcome Measures. Pre-treatment, post-treatment and 6-month follow-up performance on the Symptom Checklist-90-revised (SCL-90-R), Depression, Anxiety Stress Scales (DASS-21), Community Integration Questionnaire (CIQ) and the Ways of Coping-Revised Questionnaire (WOC-R). Procedures. Eleven CBT sessions provided in group, face-to-face format or individually by telephone. Results: For face-to-face and telephone groups, psychological distress was significantly reduced from pre-treatment to 6-months follow-up: DASS-21 (t16= 7.32, p <.000); SCL-90-R (t16= 6.22, p <.000). Community integration (t16= -6.15 p<.000) and problem-focused coping (t16= -3.67, p<.01) were also significantly enhanced. Conclusion: CBT adapted for patients with ABI carries robust benefits even 6-months after treatment.

Anxiety sensitivity (AS; fear of anxiety-related bodily sensations) is a risk factor for anxiety and related psychological disorders. Preliminary evidence also associates high AS with reduced levels of physical exercise and fitness. The primary objectives of the five studies comprising this dissertation were 1) to further explore the relationships between AS levels and exercise/fitness levels, and 2) to evaluate outcomes and processes of a brief group cognitive behaviour therapy (CBT) that included a novel exercise-based interoceptive exposure (IE; exposure to feared anxiety-related sensations) component of running, with female undergraduate students. High AS female undergraduate participants endorsed more barriers to exercise than low AS participants, and these accounted for the inverse relationships between AS group and exercise/fitness levels (Study 1). The brief CBT/IE led to decreases in AS levels (Studies 2 and 4) and in symptoms of stress, depression, and anxiety (Study 4) for high AS participants. Processes involved in the brief CBT’s therapeutic effects were explored by examining cognitive (i.e., catastrophic thoughts), affective (i.e., feelings of anxiety), and somatic (i.e., physical sensations) reactions to the running IE component with an existing measure, the hyperventilation questionnaire (HVQ; Study 2), and a brief version of the measure, the HVQ-B, developed and validated in Study 3 (Study 5). Changes in cognitive and affective reactions to running were most closely associated with the brief CBT/IE’s therapeutic benefits, underlying the importance of changing the meaning of and emotional reaction to physiological arousal. Surprisingly, a health education control (HEC) intervention consisting of an interactive discussion on exercise, nutrition and sleep for health, including problem-solving barriers to health behaviours, also led to decreases in AS levels and in symptoms of depression and anxiety (Study 4). Physical exercise, the common link between the two interventions, may be partially driving the interventions’ therapeutic benefits. More specifically, perhaps both interventions addressed barriers to exercise, either by altering the meaning of and emotional reaction to exercise (CBT/IE), or through problem-solving (HEC). Encouraging physical exercise in high AS individuals by acknowledging and addressing barriers to exercise might help decrease these individuals’ AS levels and improve their overall mental health

Chronic pain is a one of the most common causes of disability and sick leave. Psychological factors play a central role in the experience of pain and are important in the management of pain. However, for many people with chronic pain CBT is not available. There is a need to develop alternative ways to deliver treatments that reach more individuals with chronic pain. Internet-based treatments have been shown to be effective for several disorders and recent research suggests that internet-based CBT for chronic pain can be effective. The present thesis included four randomized controlled studies with the aim of evaluating whether guided internet-based treatments based on CBT can help individuals with chronic pain regarding psychological variables. Study I investigated the effects of an internet-based CBT intervention with telephone support for chronic back pain. The study showed reductions in some variables assessed.      Study II investigated the effects of an internet-based CBT intervention for chronic back pain without telephone support and with a live structured interview before inclusion. It was found that the treatment can reduce some of the distress associated with chronic pain. Study III investigated the effects of a guided internet-delivered CBT as a secondary intervention. Participants were patients who had previously completed multidisciplinary treatment at a pain management unit. Results showed that the internet-based treatment can be a feasible option for persons with residual problems after completed pain rehabilitation. Effects remained at six-month follow-up.    Study IV focused on the effect of a guided internet-delivered acceptance and commitment therapy (ACT) for persons with chronic pain. Results suggest that an internet-delivered ACT treatment can help persons with chronic pain. Effects remained at six-month follow-up. In conclusion, guided internet-based CBT can decrease distress associated with chronic pain.

Abstract Background: Cognitive Behaviour Therapy, (CBT) is well established as an effective treatment for depression. Its applicability in routine public mental health practice is however unknown, as most published studies excluded participants with suicide risk or if co-morbid with other disorders such as schizophrenia or bipolar affective disorder. Clients of public mental health services are characterised by symptom severity, chronic course of illness, treatment resistance and / or co-morbidity. In order to determine whether CBT has utility in routine public mental health practice, it is important to find out whether symptoms of depression (and anxiety) in this client population will respond to a course of CBT provided as part of standard care. Aims and Hypotheses: This effectiveness study aimed to ascertain if CBT is effective in treating depressed and/or anxious symptoms when such symptoms exist within the clinically more complex population found within Community Mental Health Services / Settings, (CMHSs). It was hypothesised that clients receiving CBT would show reliable and clinically significant improvement in symptoms of depression and anxiety but that the amount of improvement would be less than that reported in efficacy studies with less complex client groups. Method: This was a repeated measures, uncontrolled intervention study with results benchmarked against published data. Forty six adult clients of the Inner North Brisbane Mental Health Service (INBMHS) with diagnoses of Depression and / or Anxiety, in isolation or in conjunction with Schizophrenia, Bipolar affective disorder, or a Personality Disorder were treated with an eight (8) session manualised CBT program as part of routine clinical care. Standardised measures of depression, anxiety and stress were taken at time of referral, time of the commencement of treatment, time of treatment completion and at six-month post completion of treatment. Results: Participants showed reliable and statistically significant improvement in self reported symptoms from commencement to completion of treatment. Gains were retained at follow-up. Effect sizes were in the moderate to large range and improvements were clinically significant for approximately one third of the participants. Conclusions: CBT seems to be an effective treatment for depression and anxiety where such symptoms exist within a mental health population. Further research addressing the limitations of this study would add strength to the argument that the mental health population could benefit from the broad availability of such treatment.

Cognitive behaviour therapy (CBT) is a therapeutic modality which is commonly argued to be oriented to a medical model, and so to diverge significantly in theory and practice from the traditional relational and humanistic roots of counselling psychology. A large body of literature and research exists which examines counselling psychologists’ professional identity in medical settings, but there appears to be a significant gap in the extant literature relating to how counselling psychologists experience professional identity specifically in the practice of CBT, a therapeutic modality which presently provides a considerable amount of employment for counselling psychologists. To address this gap, the present study sought to explore qualitatively whether counselling psychologists’ experience of their professional identity is affected by the inclusion of CBT in their practice. A sample of eight counselling psychologists who worked with CBT and had been qualified for at least five years were interviewed. Data gathered from the semistructured interviews were transcribed and analysed using interpretative phenomenological analysis (IPA), a method selected because it is concerned with the detailed examination of personal lived experience and the meaning of experience to participants. The methodology was approached within the contextual constructionist epistemological framework. Three superordinate themes, each containing four subordinate themes, emerged from participants’ accounts: (i) components of professional identity; (ii) the contribution of CBT to the professional self; and (iii) how CBT compromises the professional self. The findings are discussed in relation to the relevant literature, and lines of enquiry that have emerged have been located in current postmodern literature, arguments and debates. One main conclusion of the present study is that feeling comfortable with CBT can CBT, Counselling Psychology and Professional Identity 3 depend upon practitioners’ initial training, personal experience, cultural background, personal characteristics and personal beliefs – that is, the professional self as emerging from the personal self. Clinical implications, methodological limitations, directions for future research and reflections upon the researcher’s reflexivity are presented.