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Post-traumatic stress disorder (PTSD) after traumatic birth can have a debilitating effect on parents already adapting to significant life changes during the post-partum period. Cognitive therapy for PTSD (CT-PTSD) is a highly effective psychological therapy for PTSD which is recommended in the NICE guidelines (National Institute for Health and Care Excellence, 2018) as a first-line intervention for PTSD. In this paper, we provide guidance on how to deliver CT-PTSD for birth-related trauma and baby loss and how to address common cognitive themes.
Key learning aims
(1) To recognise and understand the development of PTSD following childbirth and baby loss.
(2) To understand how Ehlers and Clark’s (2000) cognitive model of PTSD can be applied to post-partum PTSD.
(3) To be able to apply cognitive therapy for PTSD to patients with perinatal PTSD, including traumatic baby loss through miscarriage or birth.
(4) To discover common personal meanings associated with birth trauma and baby loss and the steps to update them.
Patients with social anxiety disorder (SAD) have a range of negative thoughts and beliefs about how they think they come across to others. These include specific fears about doing or saying something that will be judged negatively (e.g. ‘I’ll babble’, ‘I’ll have nothing to say’, ‘I’ll blush’, ‘I’ll sweat’, ‘I’ll shake’, etc.) and more persistent negative self-evaluative beliefs such as ‘I am unlikeable’, ‘I am foolish’, ‘I am inadequate’, ‘I am inferior’, ‘I am weird/different’ and ‘I am boring’. Some therapists may take the presence of such persistent negative self-evaluations as being a separate problem of ‘low self-esteem’, rather than seeing them as a core feature of SAD. This may lead to a delay in addressing the persistent negative self-evaluations until the last stages of treatment, as might be typically done in cognitive therapy for depression. It might also prompt therapist drift from the core interventions of NICE recommended cognitive therapy for social anxiety disorder (CT-SAD). Therapists may be tempted to devote considerable time to interventions for ‘low self-esteem’. Our experience from almost 30 years of treating SAD within the framework of the Clark and Wells (1995) model is that when these digressions are at the cost of core CT-SAD techniques, they have limited value. This article clarifies the role of persistent negative self-evaluations in SAD and shows how these beliefs can be more helpfully addressed from the start, and throughout the course of CT-SAD, using a range of experiential techniques.
Key learning aims
(1) To recognise persistent negative self-evaluations as a key feature of SAD.
(2) To understand that persistent negative self-evaluations are central in the Clark and Wells (1995) cognitive model and how to formulate these as part of SAD.
(3) To be able to use all the experiential interventions in cognitive therapy for SAD to address these beliefs.
Surveys are a powerful technique in cognitive behavioural therapy (CBT). A form of behavioural experiment, surveys can be used to test beliefs, normalise symptoms and experiences, and generate compassionate perspectives. In this article, we discuss why and when to use surveys in CBT interventions for a range of psychological disorders. We also present a step-by-step guide to collaboratively designing surveys with patients, selecting the appropriate recipients, sending out surveys, discussing responses and using key learning as a part of therapy. In doing so, we hope to demonstrate that surveys are a flexible, impactful, time-efficient, individualised technique which can be readily and effectively integrated into CBT interventions.
Key learning aims
After reading this article, it is hoped that readers will be able to:
(1) Conceptualise why surveys can be useful in cognitive behavioural therapy.
(2) Implement collaborative and individualised survey design, delivery and feedback as part of a CBT intervention.
Therapist cognitions about trauma-focused psychological therapies can affect our implementation of evidence-based therapies for post-traumatic stress disorder (PTSD), potentially reducing their effectiveness. Based on observations gleaned from teaching and supervising one of these treatments, cognitive therapy for PTSD (CT-PTSD), ten common ‘misconceptions’ were identified. These included misconceptions about the suitability of the treatment for some types of trauma and/or emotions, the need for stabilisation prior to memory work, the danger of ‘retraumatising’ patients with memory-focused work, the risks of using memory-focused techniques with patients who dissociate, the remote use of trauma-focused techniques, and the perception of trauma-focused CBT as inflexible. In this article, these misconceptions are analysed in light of existing evidence and guidance is provided on using trauma-focused CT-PTSD with a broad range of presentations.
Key learning aims
(1) To recognise common misconceptions about trauma-focused CBT for PTSD and the evidence against them.
(2) To widen understanding of the application of cognitive therapy for PTSD (CT-PTSD) to a broad range of presentations.
(3) To increase confidence in the formulation-driven, flexible, active and creative delivery of CT-PTSD.
Cognitive therapy for social anxiety disorder (CT-SAD) is recommended by NICE (2013) as a first-line intervention. Take up in routine services is limited by the need for up to 14 ninety-min face-to-face sessions, some of which are out of the office. An internet-based version of the treatment (iCT-SAD) with remote therapist support may achieve similar outcomes with less therapist time.
102 patients with social anxiety disorder were randomised to iCT-SAD, CT-SAD, or waitlist (WAIT) control, each for 14 weeks. WAIT patients were randomised to the treatments after wait. Assessments were at pre-treatment/wait, midtreatment/wait, posttreatment/wait, and follow-ups 3 & 12 months after treatment. The pre-registered (ISRCTN 95 458 747) primary outcome was the social anxiety disorder composite, which combines 6 independent assessor and patient self-report scales of social anxiety. Secondary outcomes included disability, general anxiety, depression and a behaviour test.
CT-SAD and iCT-SAD were both superior to WAIT on all measures. iCT-SAD did not differ from CT-SAD on the primary outcome at post-treatment or follow-up. Total therapist time in iCT-SAD was 6.45 h. CT-SAD required 15.8 h for the same reduction in social anxiety. Mediation analysis indicated that change in process variables specified in cognitive models accounted for 60% of the improvements associated with either treatment. Unlike the primary outcome, there was a significant but small difference in favour of CT-SAD on the behaviour test.
When compared to conventional face-to-face therapy, iCT-SAD can more than double the amount of symptom change associated with each therapist hour.
Cognitive therapy, based on the Clark and Wells (1995) model, is a first-line treatment for adults with social anxiety disorder (SAD), and findings from research settings suggest it has promise for use with adolescents (Cognitive Therapy for Social Anxiety Disorder in Adolescents; CT-SAD-A). However, for the treatment to be suitable for delivery in routine clinical care, two questions need to be addressed.
Can therapists be trained to achieve good outcomes in routine Child and Adolescent Mental Health Services (CAMHS), and what are the costs associated with training and treatment?
CAMHS therapists working in two NHS trusts received training in CT-SAD-A. They delivered the treatment to adolescents with SAD during a period of supervised practice. We examined the clinical outcomes for the 12 patients treated during this period, and estimated costs associated with treatment and training.
Treatment produced significant improvements in social anxiety symptoms, general anxiety and depression symptoms, and reductions in putative process measures. Seventy-five per cent (9 out of 12) patients showed a reliable and clinically significant improvement in social anxiety symptoms, and 64% (7/11) lost their primary diagnosis of SAD. The total cost to the NHS of the CT-SAD-A treatment was £4047 (SD = £1003) per adolescent treated, of which £1861 (SD = £358) referred to the specific estimated cost of face-to-face delivery; the remaining cost was for training and supervising therapists who were not previously familiar with the treatment.
This study provides preliminary evidence that clinicians can deliver good patient outcomes for adolescents with SAD in routine CAMHS during a period of supervised practice after receiving a 2-day training workshop. Furthermore, the cost of delivering CT-SAD-A with adolescents appeared to be no more than the cost of delivering CT-SAD with adults.
Little is known about the impact of interpersonal betrayal experiences on mental health. Research suggests a link between betrayal and mental contamination (MC) within some forms of obsessive compulsive disorder (OCD). This study represents an initial exploration of that link in clinical samples.
A measure for assessing perceptions of betrayal was developed and evaluated (Study 1) in order to assess the extent of specificity of any association between the impact of betrayal and MC, and to estimate the extent of the impact of betrayal across common psychological disorders (Study 2).
In Study 1, the Perception of Betrayal Scale (POBS) was completed by 217 community participants; an exploratory principal components analysis identified the dimensional structure of the POBS. Study 2 was based on a cross-sectional, between-groups design, with three clinical groups [OCD (n = 23), other anxiety disorders (n = 21) and depression (n = 18)] and a non-clinical control group (n = 21). Three clinical groups (OCD, other anxiety disorders, and depression) and a community group completed a selection of measures via questionnaire.
In Study 1, the POBS was found to have an internal consistency of α = .95, and four factors were identified: preoccupation with betrayal events, belief that betrayal had caused major life change, lack of trust due to betrayal and betrayal leading to traumatic responses. In Study 2, the OCD group scored more highly in terms of maladaptive perceptions of betrayal than the other groups. Regression analysis showed betrayal scores to be a moderate predictor of the experience of MC; the POBS subscales lack of trust due to betrayal and betrayal leading to traumatic responses were found to be significantly associated with MC. Although there was some overlap with bitterness, betrayal better predicted MC.
Findings support the hypothesis of a specific relationship between the construct of betrayal and MC.
Remote delivery of evidence-based psychological therapies via video conference has become particularly relevant following the COVID-19 pandemic, and is likely to be an on-going method of treatment delivery post-COVID. Remotely delivered therapy could be of particular benefit for people with social anxiety disorder (SAD), who tend to avoid or delay seeking face-to-face therapy, often due to anxiety about travelling to appointments and meeting mental health professionals in person. Individual cognitive therapy for SAD (CT-SAD), based on the Clark and Wells (1995) model, is a highly effective treatment that is recommended as a first-line intervention in NICE guidance (NICE, 2013). All of the key features of face-to-face CT-SAD (including video feedback, attention training, behavioural experiments and memory-focused techniques) can be adapted for remote delivery. In this paper, we provide guidance for clinicians on how to deliver CT-SAD remotely, and suggest novel ways for therapists and patients to overcome the challenges of carrying out a range of behavioural experiments during remote treatment delivery.
Key learning aims
(1) To learn how to deliver all of the core interventions of CT-SAD remotely.
(2) To learn novel ways of carrying out behavioural experiments remotely when some in-person social situations might not be possible.
Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioural therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD, and describe their application to treating patients with PTSD following ICU.
Key learning aims
(1) To recognise PTSD following admissions to intensive care units (ICUs).
(2) To understand how the ICU experience can lead to PTSD development.
(3) To understand how Ehlers and Clark’s (2000) cognitive model of PTSD can be applied to post-ICU PTSD.
(4) To be able to apply cognitive therapy for PTSD to patients with post-ICU PTSD.
Background: Randomized controlled trials have established that individual cognitive therapy based on the Clark and Wells (1995) model is an effective treatment for social anxiety disorder that is superior to a range of alternative psychological and pharmacological interventions. Normally the treatment involves up to 14 weekly face-to-face therapy sessions. Aim: To develop an internet based version of the treatment that requires less therapist time. Method: An internet-delivered version of cognitive therapy (iCT) for social anxiety disorder is described. The internet-version implements all key features of the face-to-face treatment; including video feedback, attention training, behavioural experiments, and memory focused techniques. Therapist support is via a built-in secure messaging system and by brief telephone calls. A cohort of 11 patients meeting DSM-IV criteria for social anxiety disorder worked through the programme and were assessed at pretreatment and posttreatment. Results: No patients dropped out. Improvements in social anxiety and related process variables were within the range of those observed in randomized controlled trials of face-to-face CT. Nine patients (82%) were classified as treatment responders and seven (64%) achieved remission status. Therapist time per patient was only 20% of that in face-to-face CT. Conclusions: iCT shows promise as a way of reducing therapist time without compromising efficacy. Further evaluation of iCT is ongoing.
Background: Mental contamination is a phenomenon whereby people experience feelings of contamination from a non-physical contaminant. Rachman (2006) proposes that standard cognitive behavioural treatments (CBT) need to be adapted here and there is a developing empirical grounding supporting the concept, although suggestions on adapting treatment have yet to be tested. Method: A single case study is presented of a man with a 20-year history of severe treatment resistant Obsessive Compulsive Disorder (OCD) characterized by mental contamination following the experience of “betrayal”. He was offered two consecutive treatments: standard CBT and then (following disengagement with this) a cognitive therapy variant adapted for mental contamination. Clinician and patient rated OCD severity was measured at baseline and the start and end of both interventions. Results: Six sessions of high quality CBT were initially attended before refusal to engage with further sessions. There were no changes in OCD severity ratings across these sessions. A second course of cognitive therapy adapted for mental contamination was then offered and all 14 sessions and follow-ups were attended. OCD severity fell from the severe to non-clinical range across these sessions. Conclusions: The need to consider adapting standard treatments for mental contamination is suggested. Limitations and implications are discussed.
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