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.

Background: Social anxiety disorder (SAnD) is a highly prevalent condition, characterised by an intense fear of social or performance situations where individuals worry about being negatively evaluated by others. An up to date systematic review of the effectiveness of cognitive behavioural therapies for SAnD is required to guide practice. Objectives: To assess the efficacy and acceptability of cognitive behavioural therapy (CBT) compared with treatment as usual/waiting list (TAU/WL) for individuals with SAnD. Search methods: We searched the Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Controlled Trials Register and conducted supplementary searches of MEDLINE, PsycInfo, EMBASE, and international trial registers (ICTRP; ClinicalTrials.gov) in October 2011 and CINAHL in October 2012. We also searched reference lists of retrieved articles, and contacted trial authors for information on ongoing/completed trials. Selection criteria: Randomised and quasi-randomised controlled trials undertaken in out-patient settings, involving adults aged 18-75 years with a primary diagnosis of SAnD, assigned either to CBT or TAU/WL. Data collection and analysis Data on patients, interventions and outcomes were extracted by two review authors independently, and the Risk of bias in each study was assessed. The primary outcomes were social anxiety reduction (based on relative risk (RR) of clinical response and mean difference in symptom reduction), and treatment acceptability (based on RR of attrition). Results: Thirteen studies (715 participants) were included in the review, of which 11 studies (599 participants) contributed data to meta-analyses. Based on four studies, CBT was more effective than TAU/WL in achieving clinical response at post-treatment (RR 3.60, 95% CI 1.35 to 9.57), and on eleven studies (599 participants) it was more effective than TAU/WL in reducing symptoms of social anxiety. No significant difference was found between CBT and TAU/WL for attrition. No significant difference was demonstrated for social anxiety at follow-up and no studies examined follow-up data for clinical response or attrition. Authors' conclusions: The available evidence suggests that cognitive behavioural therapy might be effective in reducing anxiety symptoms for the short-term treatment of SAnD. However, the body of evidence comparing CBT with TAU/WL is small and heterogeneous.

Objectives: This thesis aims to explore evidence for the effectiveness of cognitive behavioural therapy (CBT) for non-cardiac chest pain (NCCP). Design: The systematic review aimed to evaluate evidence for CBT as an effective intervention for anxiety in the NCCP population. Study one describes the chest pain characteristics, illness beliefs and prevalence of anxiety in a NCCP sample in a cross-sectional design. Study two explores the acceptability and clinical effectiveness of a CBT-based self-help intervention for NCCP patients, using a between subjects, repeated measures design. Methods: A systematic review was completed via a comprehensive literature search for comparative studies examining CBT-based interventions for NCCP including a measure of anxiety. In the empirical study, participants completed measures of anxiety, illness beliefs and indices of chest pain (self-reported frequency, severity and impact on activities) at baseline. Comparisons between illness beliefs and anxiety were undertaken using descriptive statistics and Pearson correlations. Participants were randomised to receive a CBT-based self-help intervention booklet or treatment as usual, with questionnaires re-administered at three-month follow-up. ANOVAs were used to evaluate whether the intervention led to improvements in anxiety levels, or increased belief in participants’ personal control of symptoms. Results: Ten studies met inclusion criteria for the systematic review, with four studies showing evidence regarding the effectiveness of CBT for anxiety. Approximately two thirds of the thesis research sample reported on-going pain following clinic attendance, for the majority this was ‘very mild’ or ‘mild’ pain. Almost half (47%) reported experiencing clinically significant anxiety. Stress was the most common causal attribution advocated by the sample to explain their chest pain. Anxiety scores were significantly associated with psychological attribution scores, but not with personal control or illness coherence beliefs. In study two, 87 participants completed the study and ITT analyses were completed on 119. There were no significant differences between the groups in terms of reduced anxiety or self-reported belief in personal control of symptoms. The intervention booklet was evaluated largely positively by those who reported reading it. Conclusions: CBT-based self-help appears an acceptable intervention for those diagnosed with NCCP. Further research is needed to identify those who are most likely to benefit from such self-help intervention.

Objectives: Computer-guided CBT could help to increase much needed access to lowintensity psychological interventions. Evidence for effectiveness has led to the inclusion of certain packages in NICE guidelines but application in clinical settings is unclear. Low uptake and high dropout suggest problems with acceptability and barriers to uptake. Studies neglect to report on acceptability to clinicians despite indications that clinicianrelated variables and attitudes could influence their use of CCBT. This study investigates clinicians‟ views of CCBT and factors related to referring to it, following experience of low referrals to a CCBT pilot, with the aim of learning more about barriers to access and how this might be improved. Method: A mixed quantitative and qualitative design was used. An online survey was developed to gather views on CCBT, its implementation and demographic information. This was sent to a sample of clinicians in the clinical psychology department, mental health nurses and general practitioners, some of whom were involved in the CCBT pilot project and some not. Descriptive statistics, non-parametric correlations, chi-squared analyses and framework thematic analysis was carried out on 72 completed surveys. Results: Most clinicians identified both benefits and concerns of CCBT. Most approved of CCBT but likelihood to refer varied and many preferred to offer other interventions. Clinician-related variables associated with likelihood to refer were whether clinicians saw mild to moderate cases, approval of CCBT and perceived patient uptake. Views regarding the effectiveness of CCBT influenced choices to offer it, with negative beliefs about effectiveness including a perceived need for human contact. There was moderate interest in receiving CCBT training. Most thought it should be accessed widely, with some concern raised about access in public settings. Although GPs were not involved in the CCBT pilot, many expressed interest in receiving training and referring. Conclusions: Clinicians‟ views of CCBT are mixed and some believe it is ineffective and unacceptable to patients, which influences their decisions to offer it. This includes perceptions about key aspects of therapy, such as human contact. Therefore some clinicians need more convincing of the CCBT evidence-base before they are likely to refer to it. Nevertheless there is moderate interest in using CCBT and more so in those seeing mild to moderate cases. CCBT may have a position in stepped care services but views of referrers should be considered and training offered. More research is needed on implementing CCBT, barriers to access and its role alongside other interventions.

Sleep is essential for survival but a significant minority of the adult population are dissatisfied with their sleep, and 6-10% meet the criteria for insomnia disorder, characterised by difficulties falling asleep at bedtime, waking up in the middle of the night or too early in the morning, and daytime symptoms. Cognitive behavioural therapy for insomnia (CBT-I), an evidence-based sleep-focused intervention, has been suggested as the treatment of choice for chronic insomnia. However, access to specialised sleep therapists is sparse, and a service delivery model based on the principles of ‘stepped care’ has been proposed. Even though CBT-I is shown to be effective, there is a need to continue the development of cognitive behavioural treatments for insomnia. As a complement to traditional interventions, the potential value of acceptance, that is, to make an active choice of openness towards psychological experiences, has been recognized. However, it has not yet been systematically investigated, and specific instruments for studying acceptance in insomnia are lacking. The present thesis is based on three studies: Study I showed that manual-guided CBT for insomnia delivered by ordinary primary care personnel has a significant effect on perceived insomnia severity, sleep onset latency and wake time after sleep onset. Study II demonstrated that non-responders in Study I reported shorter sleep time at baseline than did responders, a notion that may help select patients for this type of low-end intervention in a stepped care treatment approach. Study III aimed to develop a new assessment instrument for studying acceptance of insomnia, the Sleep Problem Acceptance Questionnaire (SPAQ), resulting in an eight-item questionnaire with two factors; the first being Activity Engagement, persisting with normal activities even when sleep is unsatisfactory, and the second involving Willingness, avoiding fighting and trying to control sleep problems. In conclusion, the present thesis demonstrates that it is feasible to treat patients with insomnia using CBT-I administrated by ordinary primary care personnel in general practice, and that those with relatively longer initial sleep duration benefit most from treatment, enabling allocation to relevant treatment intensity. In addition, acceptance of sleep difficulties may be quantified using the SPAQ.