Cognitive behavioural guided self-help has been shown to be effective in mild and moderate depressive disorder. It is not known, however, if it is effective in individuals with partially remitted depressive disorder, which is a serious clinical problem in up to 50–60% of treated patients. This study is the first one to examine the clinical benefit of this intervention in this patient population.
For the purpose of this study, a single-blind, randomized controlled design was used.
We randomized 90 individuals with partially remitted depressive disorder either to cognitive behavioural guided self-help plus psychopharmacotherapy (n = 49) or psychopharmacotherapy alone (n = 41). They were clinically assessed at regular intervals with ratings of depressive symptoms and stress-coping strategies over a 3-week run-in period and a 6-week treatment period.
After 6 weeks, intention-to-treat analysis (n = 90) showed that patients treated with cognitive behavioural guided self-help plus psychopharmacotherapy did not have significantly lower scores on the Hamilton Rating Scale of Depression (17-item version; HRSD-17) and on the Beck Depression Inventory (BDI) compared to patients treated with psychopharmacotherapy alone. When negative stress-coping strategies were considered, there was a significant difference between the two groups at the end of treatment with respect to the BDI but not to the HRSD-17.
Guided self-help did not lead to a significant reduction in symptom severity in patients with partially remitted depressive disorder after a 6-week intervention. However, the intervention leads to a reduction of negative stress-coping strategies.
Anxiety leads to biases in processing personally relevant information. This study set out to examine whether anxious parents also experience biases in processing child-relevant material.
Ninety parents acted as a control condition, or received a social anxiety or child-related anxiety induction. They completed a task examining attentional biases in relation to child-threat words and social-threat words, and a task examining ability to categorize emotion in children's faces and voices.
There was a trend indicating group differences in attentional bias towards social-threat words, and this appears to have been only in the social anxiety condition, but not the child anxiety or control conditions. For child-threat words, attentional bias was present in the child anxiety condition, but not the social anxiety or control conditions. In the emotion recognition task, there was no difference between the control and child anxiety conditions, but the social anxiety condition were more likely to erroneously label children's faces and voices as sad.
Parents' anxious biases may spill over into their child's world.
The aims of this study were to clarify the relationship between psychological mindedness and attachment relationships in childhood and adulthood.
This analogue study examined associations between psychological mindedness and attachment using a cross-sectional design.
Participants completed questionnaire measures of psychological mindedness, parental bonding, and adulthood attachment relationships.
As hypothesized, psychological mindedness was strongly, negatively correlated with attachment avoidance in adulthood. Psychological mindedness was also positively correlated with perceived maternal care in childhood, and negatively correlated with perceived paternal over-protection. However, a regression analysis found that attachment avoidance in adulthood was a more significant predictor of psychological mindedness than parental bonding experiences in childhood.
Further research is needed to replicate associations between attachment and psychological mindedness in clinical samples and to explore additional constructs which influence psychological mindedness.
The aim of this study was to illustrate the individual accounts of a small group of substance misusers who had found psychological therapy helpful in their recovery from substance misuse. The study also aimed to highlight the roles that the psychologists played within these narratives.
Narrative analysis, a qualitative design, was used to capture the unique recovery narratives of substance users who had received psychological therapy.
Seven participants (three males and four females, age range 40–54 years, six White British, one White European) were recruited via clinical psychologists from an addictions psychology department and participated in 60–90 min interviews.
Analysis of the recovery narratives resulted in an overarching theme; role of the psychologists as a secure attachment figure leading to the development of surrogate internal working models, and the following subthemes which developed and maintained the attachments: closeness and proximity leading to positive expectations about the relationship, safe haven leading to increasing capacities for affect regulation, secure base leading to the experience of being able to mentalize regarding ones mental states and associated actions, and separation distress leading to internalizing the psychologists.
The study analysed the personal accounts of seven substance misusers regarding their use of psychological therapy in their recovery. The relationship between the therapists and the clients developed as a result of the psychologists serving as secure attachment figures, and providing closeness and proximity, a safe haven and a secure base to the clients. Clients' separation distress also led to the internalizing of the psychologists. Future studies are needed to tease out which substance user clients would most be suited to the above approach. Measures of newer more adaptive internal working models could then be applied to relationships outside of therapy to see in what way the newer, more flexible, and transferable IWMs were truly internalized and influential in the recovering minds of substance misusers.
We investigated the treatment effects reported from a high-quality randomized controlled trial of cognitive behavioural therapy (CBT) for 106 people with borderline personality disorder attending community-based clinics in the UK National Health Service – the BOSCOT trial. Specifically, we examined whether the amount of therapy and therapist competence had an impact on our primary outcome, the number of suicidal acts, using instrumental variables regression modelling.
Randomized controlled trial. Participants from across three sites (London, Glasgow, and Ayrshire/Arran) were randomized equally to CBT for personality disorders (CBTpd) plus Treatment as Usual or to Treatment as Usual. Treatment as Usual varied between sites and individuals, but was consistent with routine treatment in the UK National Health Service at the time. CBTpd comprised an average 16 sessions (range 0–35) over 12 months.
We used instrumental variable regression modelling to estimate the impact of quantity and quality of therapy received (recording activities and behaviours that took place after randomization) on number of suicidal acts and inpatient psychiatric hospitalization.
A total of 101 participants provided full outcome data at 2 years post randomization. The previously reported intention-to-treat (ITT) results showed on average a reduction of 0.91 (95% confidence interval 0.15–1.67) suicidal acts over 2 years for those randomized to CBT. By incorporating the influence of quantity of therapy and therapist competence, we show that this estimate of the effect of CBTpd could be approximately two to three times greater for those receiving the right amount of therapy from a competent therapist.
Trials should routinely control for and collect data on both quantity of therapy and therapist competence, which can be used, via instrumental variable regression modelling, to estimate treatment effects for optimal delivery of therapy. Such estimates complement rather than replace the ITT results, which are properly the principal analysis results from such trials.
Increased knowledge of factors that predict treatment outcome is important for planning and individualizing of treatment. This study analysed predictors of response to individual cognitive therapy (ICT), and intensive (3-week) group cognitive treatment (IGCT) for social phobia.
Participants (n = 54) met diagnostic criteria for social phobia within a randomized controlled trial. Predictors assessed were fear of negative evaluation, anticipatory worry, self-directedness (SD) and cluster C personality disorder. Results were analysed by means of multiple regression analyses with both groups combined, and for each of the treatment groups.
Anticipatory worry, an aspect of a harm-avoidance personality trait, was the strongest negative predictor of outcome in ICT and IGCT both at post-treatment and 1-year follow-up. Whereas low SD, signs of cluster C personality disorder and fear of negative evaluation were negative predictors of post-treatment outcome in ICT, the corresponding pattern of results was not to be found in IGCT.
Anticipatory worry appears to be a particularly important trait for explaining variance in the outcome of social phobia. The finding is consistent with the assumed stability of such personality traits over time. Further studies are warranted to replicate the finding.
To identify interaction structures (i.e., patterns of reciprocal interaction) that characterize the treatments of patients with borderline personality disorder (BPD) in crisis.
A 6-month naturalistic psychotherapy process and outcome study in which interaction structures were correlated with outcome data.
Five BPD patients in crisis participated in 6 months of three-times-per-week psychodynamic therapy. Patients completed a measure of psychological distress every week. One hundred and twenty-seven sessions were audiotaped and coded using the Psychotherapy Process Q-Set.
Four interaction structures were identified: (1) collaborative relationship with supportive, reassuring therapist (IS1), (2) therapist empathic attunement (IS2), (3) erotized therapeutic relationship (IS3) and (4) directive therapist with compliant patient (IS4). The magnitude of these four interaction structures varied within and between the five therapist–patient dyads over time. Interaction structures correlations with time were inversely proportional to interaction structures correlations with distress levels. IS2 was correlated with two different outcomes in patient 3's and patient 5's treatments – a positive outcome for patient 3's treatment and a negative outcome for patient 5's treatment.
An effective treatment model for BPD patients in crisis needs to promote the emergence of empathically attuned interactions as well as supportive and directive interventions as dictated by the patient's individual needs. These treatments require flexibility to accommodate the patient's unique presentation in crisis. The therapeutic dyad senses which interaction structures to increase or decrease over time to reduce the patient's distress.
Although anxiety plays a key role in delusions, its downregulation using specific emotion regulation (ER) strategies has not been investigated. Reappraisal has been shown to be one of the most effective strategies for healthy individuals. However, individuals with delusions might have difficulties in successfully applying reappraisal. This study therefore tests the effectiveness of reappraisal compared to expressive suppression in individuals with varying levels of delusion-proneness.
An experimental design with the independent variables ER strategy (within subject) and delusion-proneness (between subject; quasi-experimental) was used. The dependent variables were subjective ER success and physiological arousal, as well as state delusional ideation.
Eighty-six healthy participants with different levels of delusion-proneness were instructed to respond to anxiety-inducing stimuli by either using reappraisal or expressive suppression.
Overall, reappraisal was more effective than expressive suppression in regulating anxiety. However, delusion-prone individuals were less successful in applying reappraisal (interaction effect: F(2,158) = 3.70, p = .027). In addition, lower success in reappraising threat was accompanied by higher state delusional ideation (r = −0.20, p = .013).
Delusion-proneness is accompanied by difficulties in reappraising threat that might contribute to the formation and maintenance of clinically relevant delusions. Preliminary implications for the improvement of cognitive behaviour therapy for delusions are discussed.
While there has been an abundance of quantitative studies that examine the clinical features and treatment modalities of obsessive-compulsive disorder (OCD), only a few qualitative research studies examining the experience of OCD have been documented. Our objectives were to explore and understand psychosocial aspects of OCD and to provide qualitative accounts of the condition and its treatment rather than concentrating on its psychopathology. We also wanted to locate the role cognitive behavioural therapy (CBT) played in the condition for our participants.
Data for the study came from a series of nine semi-structured interviews carried out with individuals who self-identified as having OCD. Participants were recruited through two leading UK-based OCD charities.
We used interpretative phenomenological analysis (IPA) to analyse the accounts and participants gave feedback as to the validity of the themes in early stages of analysis.
We report two superordinate themes – Having OCD (with subordinate themes ‘wanting to be normal and fit it’, ‘failing at life’ and ‘loving and hating OCD’) and The Impact of Therapy (with subordinate themes of ‘wanting therapy’, ‘finding the roots’ and ‘a better self’).
Having OCD as a condition meant that individuals experienced a sense of overwhelming personal failure matched against age appropriate life cycle goals. This crisis of the self was bolstered by public and self-stigma about the condition. While clinical diagnosis and therapeutic interventions were significant, participants reported dialectical tensions experienced with OCD, pointing to the complexity of psychological functioning in the condition.
Previous studies on the autobiographical memory (AM) of depressed patients had inconsistent findings. Various severities of depression in patients in these studies may lead to conflicting results. However, the differences in the procedure of the autobiographical memory tests (AMTs) may also influence the AM results.
In this study, we analyse the results published so far to research the AM characteristics of patients with depressive disorders and identify moderators that affect the assessment results while using AMT in this field.
A systematic search was conducted using following databases: MEDLINE, PubMed, ScienceDirect, Cnki, and Google Scholar, yielding 22 studies of patients with depressive disorders and autobiographical memory published between 1986 and 2010.
The results of meta-analysis showed that, compared with the control group, the patients with depressive disorders reported less specific AMs (g = −1.051) and more overgeneralized AMs (g = 1.115). The patients with depressive disorders also recalled more slowly (g = 0.400). The effect sizes of overgeneral memory could be predicted by the self-reported depression score of the depressed patients (B = −.329, p < .01). The mean effect sizes of AMT indices were affected by the AMT characteristics (i.e., number of cue word, max response time, prompting, presentation of cue word, taping, and so on).
Our results suggest that overgeneralization and response lag are the AM deficits in patients with depressive disorders. The parameters of AMT are important factors, which are related to the inconsistency in the assessment of AM in patients with depressive disorders. Some recommendations on AMT and programme research design are given for future research.
Impulsivity is elevated among people diagnosed with bipolar disorder, and recent evidence suggests that impulsivity can predict onset among those at risk for the disorder. Impulsivity, though, is a broad construct.
The goal of this study was to examine whether some aspects of impulsivity are more correlated with risk for mania than others. We hypothesized that risk for mania would be related specifically to difficulties controlling impulsive responses to emotions.
Undergraduates (N = 257) completed a large battery of measures of emotion-relevant and non-emotional forms of impulsivity, along with a well-validated measure of risk for mania, the Hypomanic Personality Scale (HPS).
Analyses examined correlations of impulsivity scales with the HPS, and partial correlations controlling for lifetime tendencies towards depressive symptoms and current symptoms of alcohol abuse, both of which relate to impulsivity and often co-occur with mania. After controlling for these measures, risk for mania remained correlated with measures of impulsive responses to positive emotions, but not with difficulties in following through or with impulsivity in the context of general distress emotions.
Although impulsivity is a major concern among those at risk for mania and those diagnosed with mania, difficulties may be especially evident during positive affective states, and other forms of impulsivity may be less related to mania risk. Discussion focuses on limitations and future directions.
This study sought to explore the views of clinical psychologists towards the concepts of ‘risk’ and ‘recovery’ and to set those views against the context of mental health services.
An exploratory, social constructionist grounded theory methodology was adopted.
Eleven clinical psychologists working in adult mental health services each participated in one individual semistructured interview.
The clinical psychologists studied were aware of the emergence of recovery-oriented approaches, but felt unable to incorporate them in practice because of perceptions of being bound by both their own limitations and those of their circumstances, including issues of risk, thus giving rise to dilemmas in professional practice. Narrow definitions of risk as equated to danger dominated over broader conceptualizations of risk with positive consequences. The existing culture of mental health services was seen as emphasizing the need to avoid harmful consequences of taking risks, which in turn was seen to limit innovations in implementing recovery-oriented approaches.
Participants' ability to work in a recovery-oriented manner seemed to be limited by the way in which services perceived and responded to risk. Participants did not discuss risks arising from stigma, social exclusion, racism, sexism, or iatrogenic effects of psychiatric treatment. Narrow conceptualizations of risk as related to harm and danger seen in this study contribute to a sense of needing to be risk averse. However, the implications for practice included ideas about what might increase the possibilities for adopting recovery approaches across disciplines.
Although the procedure of systemic family therapy has been extensively researched in Western culture, few studies on this subject have been conducted in China. The aim of this study was to specify the therapy-delivered interventions in Chinese systemic family therapy and to explore how Western-imported systemic therapy model is delivered in Chinese culture.
A qualitative and exploratory research approach was taken in which thematic analysis was used to analyse the transcribed psychotherapy videotapes with Chinese families.
Twenty-six hours of video-recorded systemic family therapy sessions from 14 Chinese family cases were sampled. Thematic analysis was used to analyse the transcriptions of therapy sessions and identify therapist-generated interventions in therapy. Frequencies of different interventions were counted, and correspondence analysis (CA) was used to reveal the corresponding relationships between different interventions.
Analysis led to two main themes related to therapists-delivered interventions: Therapist's intention and therapy technique. Results revealed 15 types of therapist's intentions and 16 categories of therapy techniques. CA indicated that therapists’ intentions changed across different therapy stages and specific techniques were used to achieve corresponding intentions.
Interventions delivered in Chinese systemic therapy are mainly adherent with Milan and post-Milan systemic models. Due to the shortage in systemic therapy service in China and Chinese culture advocating reverence to authority, components of psycho-education, guidance, and metaphor are adopted in Chinese systemic practice. Some directions for future research are suggested.
Objective. To understand the experiences that people with early psychosis are adjusting to and their perceived barriers to recovery.
Method. Semi-structured interviews were conducted with eight participants. Grounded Theory was applied to the design and analysis. Sampling and coding ceased when saturation of the data was reached. Respondent validation was sought from participants.
Results. A theoretical model was developed using Strauss and Corbin's (1998) framework. A core category of distress was elicited, which was evident in all participants’ accounts of their recovery. Overall six main categories were identified and it was proposed that individuals were adjusting to the distress of past experiences, uncertainty, a challenged identity, being in a psychiatric system, the reaction of others and social disadvantage.
Conclusions. Recovery from the distress and trauma of early psychosis does not simply involve adjustment to and recovery from a single experience or set of symptoms. The results are discussed in relation to trauma, developmental, and social inequality frameworks. Specific implications for clinical practice include incorporating the findings within formulations, developing interventions that focus on trauma, identity, and uncertainty as well as addressing the social and systemic issues identified.
Objectives. Hearing voices groups (HVGs) are increasingly common in National Health Services and are often preferred to individual therapy by both service users and providers. Whilst a range of approaches exist, mixed results have been found and only cognitive behaviour therapy (CBT) was supported by well-controlled trials. This study aimed to explore possible predictors and mechanisms of change in a seven-session CBT group for voice hearers.
Design. An exploratory case series design was used.
Method. Fifteen outpatients with a diagnosis of schizophrenia or schizoaffective disorder completed a HVG and carried out weekly measures of distress, negative beliefs about voices, self-esteem, effective coping strategies, and activity levels. Visual inspection and quantitative rules were used to group participants with similar results and cross-correlations and t tests were used to verify key findings.
Results. Several pathways emerged across therapy. Despite measurement frequency, changes on different outcomes tended to occur simultaneously, making conclusions about mechanisms difficult. However, changes in beliefs about voice malevolence and omnipotence correlated most frequently with changes in distress. Visual analysis indicated 53% of participants improved on a measured outcome but satisfaction scores were higher, with 93% feeling the group helped them deal with their problems more effectively. Clients especially valued the chance to meet similar others.
Conclusions. The results suggest HVGs are valued by clients, regardless of their background or symptoms. HVGs should emphasize testing negative beliefs about voices and allow space for supportive discussions between clients. Recommendations for future research are discussed, including consideration of benefits not detected by outcome measures.
Objectives. Paranoid thinking has been linked to greater availability in memory of past threats to the self. However, remembered experiences may not always closely resemble events that trigger paranoia, so novel explanations must be elaborated for the likelihood of threat to be determined. We investigated the ability of paranoid individuals to construct explanations for everyday situations and whether these modulate their emotional impact.
Methods. Twenty-one participants experiencing paranoia and 21 healthy controls completed a mental simulation task that yields a measure of the coherence of reasoning in everyday situations.
Results. When responses featured positive content, clinical participants produced less coherent narratives in response to paranoid themed scenarios than healthy controls. There was no significant difference between the groups when responses featured negative content.
Conclusions. The current study suggests that difficulty in scenario construction may exacerbate paranoia by reducing access to non-threatening explanations for everyday events, and this consequently increases distress.
Background. The aim of this study was to examine the intricate relationship between some personality traits (i.e., attributional style, perceived control over consequences, self-esteem), and depressive mood in a nonclinical sample (N= 334).
Method. Structural equation modelling was used to estimate five competing models: two vulnerability models describing the effects of personality traits on depressive mood, one scar model describing the effects of depression on personality traits, a mixed model describing the effects of attributional style and perceived control over consequences on depressive mood, which in turn affects self-esteem, and a reciprocal model which is a non-recursive version of the mixed model that specifies bidirectional effects between depressive mood and self-esteem.
Results. The best-fitting model was the mixed model. Moreover, we observed a significant negative effect of depression on self-esteem, but no effect in the opposite direction.
Conclusions. These findings provide supporting arguments against the continuum model of the relationship between self-esteem and depression, and lend substantial support to the scar model, which claims that depressive mood damages and erodes self-esteem. In addition, the ‘depressogenic’ nature of the pessimistic attributional style, and the ‘antidepressant’ nature of perceived control over consequences plead in favour of the vulnerability model.
Background. People with personality disorders, especially those who also experience high self-criticism and shame, are known to be a therapeutic challenge and there is a high dropout rate from therapy. Compassion-focused therapy (CFT) was designed to address shame and self-criticism specifically, and to develop people's ability to be self-reassuring and more compassionate to themselves and others.
Aims. This study explored how CFT affected self-criticism and self-attacking thoughts, feelings, and behaviours, as well as the general symptoms of anxiety, stress, and depression of a personality disordered group within an outpatient group setting, and evaluated the extent of maintenance at a 1-year follow-up. A secondary objective was to identify some of the key characteristics that such an intervention would require. This was a pilot study exploring the feasibility, acceptability, and potential value of CFT in treating this difficult population and, as such, was designed as a pre-randomized controlled trial (RCT) to provide evidence to support applications for funding for an RCT.
Methods and design. This study utilized a mixed method combining qualitative and quantitative methods to support a programme evaluation. Eight participants were introduced to the evolutionary-based CFT model and taken through explorations of the nature of self-criticism and shame. In subsequent sessions, participants were taught the main compassion-focused exercises, and any difficulties were addressed. The group was asked to share their personal stories and experiences of practicing self-compassion and to develop compassionate encouragement for each other. Self-report measures were administered at the beginning, end, and at a 1-year follow-up.
Results. This 16-week group therapy was associated with significant reductions in shame measured by the Others as Shamer Scale (OAS), social comparison on the Social Comparison Scale (SCS) feelings of hating oneself, and an increase in abilities to be self-reassuring on the Self-Attacking and Self-Reassuring Scale (FSCRS), depression and stress measured by the Depression Anxiety and Stress Scale (DASS). There were significant changes on all CORE variables, well-being, risk, functioning, and problems. Also interesting was that all variables showed a trend for continued improvement at 1-year follow-up, albeit statistically non-significant. A content analysis revealed that patients had found it a moving and very significant process in their efforts to develop emotional regulation and self-understanding.
Conclusion. CFT, delivered in a routine psychotherapy department for personality disorders, revealed a beneficial impact on a range of outcome measures. These improvements were maintained and further changes noted at 1-year follow-up. Further research is needed to explore the benefits of CFT using more detailed analysis and RCTs.
Objectives. This research aimed to expand the existing knowledge based on the effect of professional practise by providing qualitative data on the experience of distress among clinical psychologists working in Britain.
Design. Interview data were analysed using interpretive phenomenological analysis (IPA) – a systematic procedure designed to explore lived experiences which enables interpretations of meaning, cognition, affect, and action. IPA specifically enabled an interpretation of the sense participants made of personal distress as psychologists.
Method. Eleven chartered clinical psychologists (nine females, two males) participated in individual semi-structured interviews about their experiences of distress. Interviews lasted approximately 90 min and were either face-to-face or over the telephone.
Results. Analysis of interview transcripts identified 18 sub-themes organized into five master themes: (1) manifestation of distress, (2) making sense of personal distress, (3) role and affects of others, (4) experiences of help/support, and (5) using experiences of distress.
Conclusions. Distress manifested in various ways including clinical work and attitudes towards work. Personal attributions and meaning of distress mediated how this experience was conceptualized, perceptions/interactions with others, and subsequent help seeking behaviours. Experiences were positively translated into personal/professional behaviours. Implications were considered.
Background. The quality and strength of the therapeutic collaboration, the core of the alliance, is reliably associated with positive therapy outcomes. The urgent challenge for clinicians and researchers is constructing a conceptual framework to integrate the dialectical work that fosters collaboration, with a model of how clients make progress in therapy.
Aim. We propose a conceptual account of how collaboration in therapy becomes therapeutic. In addition, we report on the construction of a coding system – the therapeutic collaboration coding system (TCCS) – designed to analyse and track on a moment-by-moment basis the interaction between therapist and client. Preliminary evidence is presented regarding the coding system's psychometric properties. The TCCS evaluates each speaking turn and assesses whether and how therapists are working within the client's therapeutic zone of proximal development, defined as the space between the client's actual therapeutic developmental level and their potential developmental level that can be reached in collaboration with the therapist.
Method. We applied the TCCS to five cases: a good and a poor outcome case of narrative therapy, a good and a poor outcome case of cognitive-behavioural therapy, and a dropout case of narrative therapy.
Conclusion. The TCCS offers markers that may help researchers better understand the therapeutic collaboration on a moment-to-moment basis and may help therapists better regulate the relationship.
Objectives. To approach the experience of ‘happiness’ and ‘mania’ for people who have been given a diagnosis of ‘bipolar disorder’ and to explore how they might differentiate or associate between these experiences.
Design. A qualitative design was used in which four participants who had been given a diagnosis of ‘bipolar disorder’ were interviewed individually regarding their experiences and ideas about ‘mania’ and ‘happiness’.
Methods. Transcriptions from the interviews were analysed using the iterative process of interpretative phenomenological analysis.
Results. Four superordinate themes were identified. Two highlighted the conceptual fluidity and similarities between their ideas about and experiences of ‘happiness’ and ‘mania’. Two emphasized the differences between these notions for the participants, which reflected the destruction, disruption, and chaos of ‘mania’ in contrast to the importance of self-acceptance, peacefulness, and social connection for ‘happiness’.
Conclusion. There may be benefit in maintaining an active dialogue or ‘poly-vocality’ about the meanings of ‘happiness’ in clinical work with people who experience ‘positive states’ of mind, which are personally problematic. This can be supported by drawing on ideas and narratives about ‘happiness’ from the field of positive psychology.
Objectives. Self-criticism and reassurance are important mechanisms for regulating negative emotions but relatively little attention has been paid to interventions aimed at improving them.
Design. This study explored the use of an expressive writing task to increase self-reassurance and reduce self-criticism using a randomized controlled design.
Method. A total of 46 participants wrote either about life goals (the expressive writing task, n= 23) or a control topic (a review of a recent book or film, n= 23) for 15 min, three times within an hour. Measures of self-criticism/self-reassurance, stress, and positive affect were completed at baseline and at 2-week follow-up. The Linguistic Inquiry and Word Count (LIWC) was used to analyse the writing of participants in the ‘life goals’ condition to identify psychological processes that might differentiate those who improved and those who did not.
Results. While there were no significant changes in self-reported stress or positive affect, participants writing about life goals decreased in their levels of self-criticism at 2-week follow-up relative to participants writing about control topics. Text analysis showed that experimental participants using words that imply the possibility of doubt or failure, including use of the subjunctive tense (e.g., could, would, should), were least likely to decrease their self-criticism.
Conclusion. Expressive writing shows promise as a means by which people may decrease in their self-criticism. Future research should determine whether such experimentally induced changes in self-criticism lead to the improvements in psychological health that is implied by previous cross-sectional research.
Objective. The supervision of counsellors, counselling psychologists, and psychotherapists is generally perceived to be an invaluable component of training and practice. The present study analysed this process to explore the meanings of supervision and to consider implications for clinical practice and training.
Design. This study presents the accounts of 19 psychological therapists who experienced supervision while working at a London-based women's therapy centre.
Method. Demographic information was collected by questionnaire, and semi-structured interviews were conducted to explore aspects of the supervisory experience. The qualitative data were thematically analysed.
Results. Supervision has complex and paradoxical meanings, and it impacts on clinical counselling practice in multifarious ways. Dominant themes highlighted were the usefulness of supervision, specifically support, empowerment, and joining; fear of exposure in supervision versus gaining new information; the comfort versus the challenge of supervision; and supervision as a containing space.
Conclusions. An experiential model of supervision was developed from the data. This model complements existing models in the field. It could be evaluated and used alongside existing models in various training and supervision contexts. Findings are discussed in relation to the literature on clinical supervision.
Objectives. This paper reports on a subset of findings from a wider ranging grounded theory analysis of therapy and recovery processes in psychosis. It describes therapist activities involved in maintaining an observational perspective during therapy and the links between these and other therapist activities.
Design. Grounded theory was used to examine the qualitative data collected.
Methods. An initial sample of 19 taped therapy sessions and 23 interviews with psychologists and their clients was collected. This sample was extended through the collection of three further interviews with psychoanalytically aware psychologists. The data were analysed using grounded theory.
Results. A grounded theory model of therapy processes in psychosis was developed that conceptualized therapist actions as providing an observational scaffold to support the client's efforts in moving to new perspectives on their situation. Consistent with the understanding of the core therapy activity as a dialogical process, this set of therapist actions was understood as occurring alongside other therapist activities involved in managing emotion and building a relationship in therapy.
Conclusions. The central activity of therapy in psychosis was understood as a dialogical process continuously negotiated between therapist and client in conversation and was conceptually summarized in the grounded theory as ‘building bridges to observational perspectives’. However, the active and strategic efforts of psychologists to sustain the dialogue implied a particular assumption of responsibility for maintaining this process. In particular, therapists appeared to be ‘working to maintain observational perspectives’, ‘managing emotion’, and ‘doing relationship’ during the therapy conversation as part of the joint effort with clients to build bridges to new observational perspectives on distress and psychosis.
Objectives. The aim of this study was to evaluate the efficacy of Cognitive Evolutionary Therapy (CET) in an intensive short residential treatment of a wide range of severe personality disorders (PDs) that resulted in a reduction of social functioning and significant personal distress.
Design. Each patient was assessed at admission, discharge, and 3 months later in order to determine if there was a reduction in symptoms and an improved adherence to former outpatient programs and to check if patients were undergoing new treatment after discharge.
Method. Fifty-one patients participated in this study. The 20-hr weekly program consisted of two individual sessions and various group modules. Outcome measures included: self-reported measures of depression, anxiety, general symptoms, number and duration of inpatient admissions after the programme, and continuation in an outpatient treatment programme.
Results. The results show an overall improvement in general psychopathology after the release and in follow-up sessions, a decrease in the number of further hospital admissions, and an increased level of attendance of outpatient therapy.
Conclusions. This study shows that intensive short residential treatment is an effective treatment for patients with a wide range of PDs.
Practitioner Points: Personality Disorders, short residential treatment, follow-up
Objective. Recovery from psychosis has been greatly studied, especially in relation to outcome. However, it is still a poorly defined concept and there has been minimal impact of service user definitions of recovery. It is a term that is being increasingly used in relation to mental health policies and guidelines; hence it is important to ensure that recovery is well defined and guided by service users’ experience of recovery. Therefore, the aim of this study was to examine what factors are important to service users in recovery from psychosis.
Design. A Q-method approach was adopted to allow a wide qualitative exploration of recovery.
Method. An opportunity sample (N= 40) was recruited, aged between 18 and 65, who experienced symptoms of psychosis for at least 1 year within mental health services in the North West of England.
Results. Analysis revealed four distinct perspectives in relation to recovery from psychosis. The first placed importance on collaborative support and understanding, the second on emotional change through social and medical support, the third group emphasized regaining functional and occupational goals, and the last group identified self-focused recovery as being important factors.
Conclusions. Although recovery from psychosis may have common elements, there are a number of idiosyncratic perspectives that should be taken into account when conceptualizing recovery and this should be reflected in service provision.
Practitioner Points
• This paper provides insight into the idiosyncratic nature of recovery and provides clarity to the current understanding of the concept.
• It outlines distinct recovery styles and explores their clinical implications.
Purpose. To examine whether cognitive behaviour therapy (CBT) reduces psychopathology in patients with schizophrenia more effectively than the use of non-cognitive psychotherapies.
Method. Systematic review and meta-analysis of the literature was performed. All Randomized Controlled Trials meeting the inclusion criteria were analysed using RevMan software. This design was used to maximize power and study efficacy. Medline, PsycINFO, and Embase were searched using free-text keywords to identify potential papers. Nine were included in the final meta-analysis. Change in psychopathology at the end of therapy was the end point investigated. A random effects model was used to assess the standard mean difference between the CBT and supportive control groups.
Results. Meta-analysis of CBT versus supportive therapy did not find significant differences between the therapy groups at the end of treatment in respect of psychopathology. There was no evidence of publication bias. Post hoc power analysis using the Z test ruled out type one error.
Conclusions. Theoretically based CBT therapies, although proving effective, may not out perform more accessible and simpler forms of therapy for patients with schizophrenia in reducing psychopathology. Consideration of supportive therapy should be made for patients with psychotic mental disorder.
Newton-Howes and Wood (published online, this journal, 8 Dec 2011) report the results of their systematic review and meta-analysis of clinical trials of cognitive-behavioural therapy (CBT) for schizophrenia. They ran a random effects analysis of endpoint data from trials where participants were randomly allocated to receive either CBT or a control therapy, which could be inactive (e.g., befriending) or active (e.g., analytic supportive psychotherapy), found no difference between the groups and concluded ‘it (CBT) does not outperform supportive therapy in effecting change in phenomenology.’ Such a conclusion is premature, if not unwarranted, for a number of reasons, including basic mistakes, lack of transparency, and failure to consider dose.
]]>Objectives. To investigate whether different self-attributes would be associated with different degrees of deservedness of persecution in a clinical paranoid sample.
Background. Some studies have shown differences between the self-esteem (SE) of individuals with ‘Poor Me’ (PM) and ‘Bad Me’ (BM) paranoia (Bentall et al., 2009; Chadwick, Trower, Juusti-Butler, & Maguire, 2005). Most studies investigating this relationship have employed a cross-sectional design, precluding the investigation of changes over time.
Methods. In the cross-sectional part of the study, 45 clinical participants and 25 controls were assessed in terms of paranoia, deservedness of persecution, SE, self-discrepancies, daily events, and coping strategies. In the longitudinal part of the study, the clinical group was re-assessed over a period of another 2 days, in order to study changes in these variables.
Results. At baseline, there were no differences between the SE of the two paranoia presentations, which was significantly lower than the controls’. However, the paired-samples repeated analysis found the SE of individuals when in a PM presentation was higher than when they were BM. Only BM paranoia was found to be associated with higher self-ideal:self-actual self-discrepancies than the other groups. The longitudinal analysis indicated that, having been PM and having low SE at the previous assessment day made it more likely that individuals would be in BM subsequently. No differences in causal attributions made for ecological events were found between the groups. Higher SE was found to be more likely when individuals coped with adversities by using social support.
Conclusions. Both deservedness of persecution and self-views appear to be unstable in individuals with paranoia and to change consistently over time, a finding which is in keeping with Bentall et al.'s (2001) dynamic model of paranoia.
Objectives. Using the model of activation and dynamics of the attachment system (Shaver & Mikulincer, 2002) and dynamic stress-vulnerability models of psychosis (Ingmar & Luxton, 2005) as the analytical frameworks, the authors tested the hypothesis that the insecure attachment styles are differentially associated with the severity of psychopathological symptoms and emotional distress among outpatients with International Classification of Diseases, Tenth edition (ICD-10) diagnosis of schizophrenia.
Methods. Attachment styles were identified using the Relationship Questionnaire (Bartholomew & Horowitz, 1991) among 100 outpatients with an ICD-10 schizophrenia diagnosis. Current symptom severity was measured by the Positive and Negative Syndromes Scale (Kay, Fiszbein, & Opler, 1987) and emotional distress by the General Health Questionnaire (Goldberg & Williams, 1988). Univariate and multivariate analyses were performed to test the hypotheses.
Results. The preoccupied and fearful-avoidant attachment patterns were associated with higher scores of psychotic (delusions, suspiciousness/persecution, and hallucinatory behaviour) and affective (anxiety, tension, guilt feeling, and depression) symptoms, whereas the dismissing-avoidant style was associated with only anxiety. All the insecure attachment styles were associated with elevated emotional distress.
Conclusions. The findings support the hypothesis of a predisposing role of the preoccupied and fearful-avoidant styles in psychotic symptom formation and call for cognitive interpersonal interventions geared to reduce symptom and emotional distress severity.
Objectives. Biased thinking (to some extent overlapping with the concepts of cognitive distortions and cognitive errors) is a key concept in cognitive therapy of Borderline Personality Disorder (BPD). Specific contents and cognitive processes related to BPD functioning are known. However, most studies are based on self-report measures which present a number of important limitations, in particular the difficulty in assessing non-conscious processes infused by affect. So far, no studies were conducted using valid observer-rated methodology addressing the question of biased thinking in BPD as it unfolds spontaneously in session.
Design. This is a controlled interview study comparing two matched groups, BPD patients and healthy controls.
Methods. A total of N= 25 clinical dynamic interviews with patients presenting with BPD were transcribed and rated using the Cognitive Errors Rating Scale (Drapeau, Perry, & Dunkley, 2008); their cognitive profiles were compared to those of N= 25 healthy controls who underwent the same procedure.
Results. Overall, results indicated that no between-group difference in the frequency of specific biases was found. However, heightened levels of negative cognitive biases, in particular over-generalizing and fortune-telling, were associated with BPD. Furthermore, negative over-generalizing was associated with the number of BPD symptoms.
Conclusions. These results have high levels of ecological validity and are promising for the refinement of cognitive theory of BPD. Clinical implications for assessment and intervention are discussed.
Objective. Expressed emotion (EE) refers to the emotional climate within a family. High EE significantly increases the risk of relapse in people with psychosis. The focus of research to date has largely been on understanding mechanisms underlying high EE. A greater understanding of low EE would help guide family interventions to build strengths within the family. The aim of this study was to understand how low EE relatives respond to having a close family member with psychosis.
Design. A subsample of eight low EE relatives, from a larger study investigating relatives' adaptation to recent onset psychosis, was interviewed. Transcripts were analysed following the principles of interpretive phenomenological analysis (IPA).
Method. Semi-structured interviews were carried out with each relative covering broad areas of their experience, including their awareness of the development of mental health problems and relationship with their relative.
Results. Four core themes emerged: witnessing the distress; empathy through acceptance and understanding; a broad range of coping strategies to reduce distress; and realistic optimism for the future.
Conclusions. The study highlights that, although relatives described distressing experiences and feelings of frustration and anger, they showed empathy and commitment to support the person. They demonstrated psychological mindedness about the psychosis and related behaviours, had developed coping strategies, and had adjusted their expectations for the future. Further research is warranted to investigate the findings in larger samples, with a view to informing the development of more effective ways of supporting families.
Objectives. The aim of this study is to explore the meaning and significance of family interventions (FI) for the individual who experiences psychosis, and its significance for recovery.
Design. A qualitative in-depth interview design was used to explore individuals’ experience of FI and its meaning to them.
Methods. Seven individuals recovering from psychosis attending integrated FI sessions were interviewed using a semi-structured interview schedule developed with service user input. Interviews were recorded, transcribed verbatim, and explored using Interpretative Phenomenological Analysis.
Results. Three central themes highlighted the participants’ experience: (1) They welcomed the shared experience with their families and felt contained and valued by the therapists; (2) They felt the sessions contributed to changed patterns of relating within the family and the creation of new meaning through the validation of multiple perspectives; and (3) They described how the family sessions supported a new positioning in the world, a sense of their own empowerment and personal responsibility, greater self-acceptance, an increased ability to manage emotions, and hope for the future.
Conclusions. Conditions in the family sessions provided an environment for changes in patterns of relating, personal meaning, and emotions to take place. Recovery, for these individuals, appeared to be about repositioning themselves in the world. The shared experience of sessions and the recognition of multiple perspectives within a containing environment may be related to recovery via the development of new perspectives and a more robust sense of self. This has clinical implications for the focus of FI sessions.
Objectives. Psychotherapy as an appropriate treatment for clients in despair is an important area of inquiry, particularly given its problematic nature in the therapy and the resulting impact on the therapeutic relationship. This study aimed to explore how psychotherapists experience working with a client in despair through a phenomenological investigation.
Design. A phenomenological epistemology and methodology was adopted as the study was focused on understanding the phenomenon in terms of the participant's meanings of the lived situation.
Method. In-depth, semi-structured interviews were conducted with eight accredited psychotherapists who had worked with clients in despair. The interviews were transcribed and analysed using the method of Empirical Phenomenological Analysis (EPA).
Results. Four main themes emerged from the analysis: Psychotherapist's experience of client's despair, Evocation in the psychotherapist, Therapeutic ways of responding, and Supporting the psychotherapist.
Conclusions. The phenomenological findings inform and support the idea of a client's despair as something that challenges the psychotherapist personally and professionally. With implications for practice, the findings also suggest that in order to prevent the despair from encompassing the psychotherapist, they must locate a therapeutic balance; one that allows them to be with the client's despair, whilst allowing a certain degree of distance from the despair which may enable the psychotherapist to consider hope and to see the client's situation from different perspectives.