<p>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.</p><p>This thesis is based on four studies;</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p>

Cognitive behavioural therapy for insomnia (CBT-i) is the most effective treatment for insomnia. Studies show that auricular acupuncture (AA) may alleviate insomnia symptoms. The overall aim of the thesis was to compare treatment effects of auricular acupuncture (AA) with cognitive behavioural therapy for insomnia (CBT-i) on symptoms of insomnia, anxiety, depression, hypnotic drugs consumption and quality of life from short- and long-term perspectives. Paper I had a qualitative approach with a descriptive design. 16 participants received group-treatment with AA during their protracted withdrawal phase and were interviewed about their experiences. They participants experienced a reduction in protracted withdrawal symptoms, improved subjective sleep quality, a strong sensation of peacefulness and increased wellbeing. Paper II, III and IV present results from a randomised controlled trial in where the effects of group-treatment with AA and CBT-i were compared in short- and long-term using subjective (questionnaires and sleep diary) and objective (actigraphy) measurements. The results showed that CBT-i was superior to AA in reducing insomnia symptoms in both the short and long run. Both groups experienced significant long-term reduction of depressive symptoms. Further, both groups managed to maintain a decreased intake of hypnotic drugs at the end of the treatment when compared to baseline measurement. Short-term reduction of symptoms of anxiety and depression improved only in the AA group. The results from the objective actigraph recordings showed that the AA group slept more and the CBT-i group less after the treatment and that sleep patterns in both groups reverted to pre-treatment levels after 6 months. Conclusively: AA, as administered in this study, was not as good as CBT-i in treating insomnia symptoms, and should not be used as a stand-alone treatment for insomnia. Our results also demonstrate that prolonged sleep time does not necessarily yield better sleep, and that the perception of insomnia symptoms is not inevitably affected by sleep duration. AA was as effective as CBT-i in ending hypnotic drugs consumption. Moreover, AA was more successful than CBT-i in reducing symptoms of anxiety and depression in the short run. Further studies investigating AA for anxiety and depression are motivated.

The need to provide effective Cognitive Behavioural Therapy (CBT) treatments in routine clinical practice necessitates effective methods of CBT training, which are scalable and can be disseminated in populations without ready access to specialist trainers or large scale funding. This thesis seeks to add theoretical and empirical guidance to the development of evidence-based CBT training. The first chapter reviews the current literature on effective CBT training, and suggests theoretical and methodological guidance for future research on evidence-based training practices. Cohort studies (Chapters 2 – 4) examine data from former trainees for guidance on accurate CBT competence measurement and effective CBT training components. The fifth and sixth chapters report randomised-controlled trials examining the effects of internet-based training (IBT) on therapists’ competence and patient outcomes (Chapter 6). Findings from the literature review (Chapter 1) and Chapter 2 suggested the need for training effectiveness trials using treatment trial methodology, which includes ‘blind’ observer ratings of therapist behaviour as the measure of competence. Chapter 3 found that extensive training led to significant improvement in competence for trainees with a range of individual baseline characteristics. Since such extensive training is not accessible to the majority of practicing therapists, Chapter 4 examined which elements of extensive training were perceived by trainees as having the greatest positive effect on competence; thus providing empirical guidance in planning more scalable forms of training, such as IBT. Findings from the first four chapters provided guidance in planning the two randomised controlled trials outlined in Chapters 5 and 6, resulting in rigorous empirical data showing significant positive effects of IBT on therapists’ competence and on their patients’ clinical outcomes. Finally, the results of this thesis are related to the framework for developing evidence-based training, which was suggested in Chapter 1 and suggestions for future research are made.

Young people with Autism Spectrum Disorders (ASD) are more prone to experience anxiety disorders at a greater level compared to their neurotypical developing counterparts, causing lifelong impairments in family, social, academic and adaptive functioning. Early interventions in childhood have been designed to minimize these stressful events and to optimize children’s developmental outcomes. Cognitive behavioural therapy (CBT) is considered a first-line intervention of anxiety. The review aimed to synthesize empirical literature on modified CBT interventions from 2009 until 2019 focusing on reducing anxiety in children and adolescents with ASD. A systematic review of the literature was conducted in five databases. As a result, 10 articles were included to review. Modifications found were: a) audiovisual support and written materials, b) parental partic-ipation, c) sessions length, d) language, e) sensory and motor accommodations, f) emphasis into the behav-ioural component, g) enhancement of individual’s attention and participation, h) facilitating materials to access the content of CBT, and i) participants’ specific interests and worries. The interventions showed significant reductions in youth anxiety levels. Future research should focus on addressing which specific modifications contribute to anxiety reduction since to date, there is no evidence comparing standard CBT to modified CBT interventions. Moreover, there is a lack of anxiety-assessment instruments specially designed for individuals with ASD. In addition, considering the longstanding prevalence of male autistic rates, ASD diagnostic instru-ments should be revised to reduce bias that can mislead to an inattentive ascertainment of females with ASD.

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

No description available.

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.

No description available.