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Excessive reassurance seeking (ERS) is believed to play an important role in maintaining mental health problems, in particular anxiety disorders such as obsessive-compulsive disorder and health anxiety. Despite this, therapists commonly give into patients’ requests for reassurance in clinical settings and are generally unsure how to handle the issue both in therapy itself and concerning advice to the patient’s loved ones. In order to increase our understanding of therapists’ perception of ERS and how interventions for ERS are managed, we examined therapists’ perception and understanding of ERS, including its function, which emotional problems therapists associate it with, and what treatment interventions they consider important for managing ERS. Qualified therapists (n=197) were benchmarked against international expert consensus (n=20) drawn from leading clinical researchers. There was evidence that clinical experience right up to the expert level may result in less reassurance giving within treatment settings. Still, there were enough inconsistencies between the experts and other clinicians to suggest that ERS remains poorly understood and is not consistently dealt with clinically. Results are discussed in terms of how current treatment interventions may be limited for treating ERS, highlighting the need to consider new approaches for dealing with this complicated interpersonal behaviour.
Key learning aims
(1) To describe the role of excessive reassurance seeking in checking behaviour, including its negative personal and interpersonal consequences.
(2) To learn that therapists commonly report finding it difficult to manage reassurance seeking.
(3) To learn that therapists’ beliefs about excessive reassurance seeking may play a key role in helping us understand how to tackle this complicated behaviour.
(4) To consider what therapeutic interventions may be appropriate and helpful for treating excessive reassurance seeking.
Hoarding disorder is a surprisingly common problem which impacts on most areas of life. People who hoard typically have multiple agencies involved in their care due to the complex health and safety impact and risks associated with hoarding. ‘Treatment’ involves finding ways of supporting discarding large amounts, typically underpinned by CBT principles. We evaluated the impact and outcomes of a conference designed to boost professionals’ confidence and understanding in working with hoarding problems, both individually and with other agencies with a view to improving inter-agency service provision. Changes in professionals’ confidence and understanding were evaluated immediately before and after the conference. Conference participants’ qualitative responses related to service improvements were analysed using content analysis. People with personal experience of hoarding issues subsequently participated in a focus group where the results of the conference were presented. These data were analysed using thematic analysis. Confidence and understanding in working with hoarding problems substantially increased from pre- to post-conference. Professionals identified a range of possible improvements, most commonly working more closely and improving communication with other agencies. People with personal experience suggested improvements across three over-arching themes: developing an improved understanding of hoarding, the need for improved resources, and improved multi-agency working. A multi-agency conference increased confidence and understanding in professionals working with hoarding problems, and improvements specified by both people with personal experience and professionals provide a useful guide to service improvement. Results provide a framework in which CBT approaches should be embedded.
Key learning aims
(1) To assess the effectiveness of a multi-agency hoarding conference at improving understanding and confidence in working with hoarding problems.
(2) To explore professionals’ perceptions of improvements to multi-agency service provision.
(3) To explore perceptions of improvements that could be made to multi-agency service provision from people with personal experience of hoarding problems.
Since its inclusion in the DSM-III, various theories and treatment approaches have been developed for generalised anxiety disorder (GAD). Aaron T. Beck was the first to offer a cognitive conceptualisation of GAD in Anxiety Disorders and Phobias: A Cognitive Perspective. This original cognitive model of GAD was initially found to be promising in treating GAD but has not been developed further. Other theoretical models and treatments of GAD have gained more research attention, such as the Intolerance of Uncertainty model and Meta-Cognitive model. This article offers a brief overview of multiple theories and treatment approaches of GAD followed by an extensive discussion about the original cognitive model and a revised cognitive model of GAD in the Beckian tradition. Specifically, this paper describes how known key psychological maintenance factors of anxiety disorders, i.e. threat beliefs, safety-seeking behaviours and selective attention, can be used to conceptualise the experience of people with GAD and guide treatment. This is done with theoretical discussion as well as clinical examples. Finally, the paper offers suggestions for key ingredients to be included in cognitive therapy for GAD and future directions for research.
Key learning aims
(1) To understand the clinical implications of the original cognitive model and the revised model of generalised anxiety disorder presented here.
(2) To understand the role of inflated responsibility for safety, safety-seeking behaviours and elevated evidence requirements in generalised anxiety disorder.
(3) To understand and be able to implement treatment recommendations of the revised cognitive model of generalised anxiety disorder.
Generalised anxiety disorder (GAD) has been an uneasy member of the anxiety disorders group since its inclusion in the third edition of the DSM. Multiple theories and treatment protocols for GAD and its defining symptom, excessive worry, have comparable efficacy in treating GAD symptoms. Crucially, these theories of GAD and excessive worry fail to explain when and why worry is excessive and when it is adaptive.
In this paper we propose a cognitive behavioural account of the difference between excessive and adaptive states of worry and explore the theme of threat and the function of safety-seeking behaviours as seen in GAD. Specifically, we incorporate the concept of inflated responsibility in a cognitive behavioural analysis of threat appraisal and safety-seeking behaviours in excessive worry and GAD.
It is proposed that when worry is used as a strategy intended to increase safety from perceived social or physical threat then it should be conceptualised as a safety-seeking behaviour. However, when worry is used as a strategy to solve a problem which the person realistically can resolve or to deal explicitly with the feeling of anxiety then it functions as an adaptive coping behaviour. We also propose that the theme of threat in GAD centres on an inflated sense of responsibility for external everyday situations, and the function of safety-seeking behaviours is to attain certainty that responsibility has been fulfilled. The clinical implications of this cognitive behavioural analysis of excessive worry are discussed, as well as future research directions.
Evidence-based treatment for panic disorder consists of disorder-specific cognitive behavioural therapy (CBT) protocols. However, most measures of CBT competence are generic and there is a clear need for disorder-specific assessment measures.
To fill this gap, we evaluated the psychometric properties of the Cognitive Therapy Competence Scale (CTCP) for panic disorder.
CBT trainees (n = 60) submitted audio recordings of CBT for panic disorder that were scored on a generic competence measure, the Cognitive Therapy Scale – Revised (CTS-R), and the CTCP by markers with experience in CBT practice and evaluation. Trainees also provided pre- to post-treatment clinical outcomes on disorder-specific patient report measures for cases corresponding to their therapy recordings.
The CTCP exhibited strong internal consistency (α = .79–.91) and inter-rater reliability (ICC = .70–.88). The measure demonstrated convergent validity with the CTS-R (r = .40–.54), although investigation into competence classification indicated that the CTCP may be more sensitive at detecting competence for panic disorder-specific CBT skills. Notably, the CTCP demonstrated the first indication of a relationship between therapist competence and clinical outcome for panic disorder (r = .29–.35); no relationship was found for the CTS-R.
These findings provide initial support for the reliability and validity of the CTCP for assessing therapist competence in CBT for panic disorder and support the use of anxiety disorder-specific competence measures. Further investigation into the psychometric properties of the measure in other therapist cohorts and its relationship with clinical outcomes is recommended.
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.
Background: In recent years, cognitive behavioural group therapies (CBGT) have been increasingly deployed as a strategy to increase the efficiency and cost-effectiveness in treatment of common mental health problems. The vast majority of these therapies are disorder specific, but in the last few years there has been growing interest in transdiagnostic CBGT. Aims: The aim of this study was twofold: to evaluate the treatment effects of transdiagnostic CBGT on disorder specific symptoms and what (if any) differences would be observed in the treatment effects with regard to general as opposed to disorder specific symptoms measured pre- and post-treatment. Method: The participants were 233 adult patients diagnosed with depression and/or anxiety disorders. They underwent a 6-week transdiagnostic CBGT. To compare treatment effects on general and disorder specific symptoms, raw scores on all measures were converted to standardized scores. Results: Pre–post differences were significant and there was no evidence that treatment was differentially effective for general and disorder specific symptoms. Effect sizes ranged from medium to large. Conclusion: The 6-week transdiagnostic CBGT is feasible for a wide range of mood and anxiety disorders. The results indicate that low-intensity transdiagnostic group therapies may have similar effects on both general and disorder specific symptoms.
Background: Multiple sclerosis (MS) is commonly associated with psychological complications. Previous research by Hayter and colleagues (2016) found that in patients with MS, health anxiety (HA) can account for part of the variance in quality of life (QoL) independent of physical and cognitive impairment caused by the disease. MS patients with HA perceived their intact physical and cognitive performance as impaired relative to those without HA and attributed the impairment to MS. These misperceptions might be useful targets in the treatment of HA in MS using cognitive behaviour therapy (CBT). Aims: Study 1 sought to replicate the main findings from Hayter et al. (2016). Study 2 examined the impact of HA-focused CBT in a case series. Method: In Study 1, twenty participants with MS were screened for HA and assigned to either a high or low HA group. They completed assessments of cognitive and physical functioning before rating their performance on these tasks, followed by measures of QoL, mood and physical disability. Four participants in the high HA group subsequently received six sessions of CBT using a consecutive AB case series in Study 2. Results: Study 1 replicated the main findings from the earlier study. In Study 2, three of the four patients who received treatment showed substantial improvements in HA and mood and all showed improvement in QoL. Conclusion: Given the high rates of HA in MS patients and its impact on QoL, this case series suggests that a brief CBT intervention could significantly improve patients’ wellbeing.
The purpose of the present study was to explore the experience of being asked for reassurance from the perspective of carers of obsessive compulsive disorder (OCD) sufferers, and to examine its relationship to sufferers’ reassurance seeking by a direct comparison with data obtained from the person they normally offer reassurance to. Forty-two individuals with OCD and their carers completed alternate versions of the Reassurance Seeking Questionnaire. Result suggest that carers report most commonly providing reassurance when asked to do so, and the frequency of their reassurance provision is associated with how carefully sufferers seek reassurance, rather than their OCD symptom severity. The carer's perspectives on the impact of reassurance provision was accurate; both sufferers and carers perceive that reassurance works only temporarily, but even if the anxiety-relieving effect of reassurance decreases in the medium term, it is likely to be perceived as beneficial because carers accurately perceived that sufferers would feel much worse if they refused to provide reassurance. The present study is the first to quantitatively investigate carer's experiences of reassurance provision, and elucidate why carers feel the need to provide it.
Physical health outcomes for patients with long-term conditions can be significantly affected by their psychological wellbeing; those experiencing psychological difficulties are less able to manage symptoms, have a poorer quality of life, and more frequent hospital admissions. National guidance recommends the assessment and treatment of psychological difficulties secondary to respiratory disease, but implementation of this across services is inconsistent. Here, we describe the process and findings of a 9-month study integrating psychological assessment and intervention into an acute respiratory department. The aim of this provision was to provide appropriate interventions for both in-patients and out-patients with identified psychological needs, and to evaluate the impact of these across a range of outcome domains. Psychological assessment and intervention was flexibly implemented as clinically appropriate within the context of the wider multidisciplinary team. Hospital admissions data were collated, and feedback obtained from both patients and staff. Results highlighted that psychological provision was well received by both patients and staff, and was associated with improved patient experiences and a greater focus on holistic care. Of the 73 patients receiving psychology input with at least 1 month of follow-up data, 75% showed a reduction in their admission frequency following intervention. The estimated savings to the wider NHS exceeded the costs of providing psychology input. In light of existing literature, national guidance, and the present findings, we highlight the need for those commissioning and managing respiratory services to consider the various potential benefits of integrating psychological provision for a patient group with high levels of psychological need.
Background: Cognitive behavioural interventions for excessive reassurance seeking (ERS) typically focus on encouraging individuals to refrain from seeking any reassurance and in some cases banning caregivers (e.g. family members) from providing it. However, this blanket consideration that reassurance is a bad thing that should simply be stopped may not always be appropriate or helpful. Cognitive behavioural treatment (CBT) targeting ERS by helping the sufferer to shift from seeking reassurance to seeking support may be a promising treatment intervention. Aims: This study aims to examine the targeted treatment of ERS in an older adult who has been suffering from severe obsessive compulsive disorder (OCD) for seven decades. Method: Using a single case quasi-experimental design (ABCD), the frequency of reassurance seeking, urges to seek reassurance, OCD beliefs and anxiety were measured daily for almost a year in addition to standard symptom measures. Results: At the end of treatment, visual inspection showed that reassurance seeking was no longer considered excessive and OCD severity fell from the severe to non-clinical range across the treatment sessions. All treatment gains were maintained at follow-up. Conclusions: This study illustrates how CBT can be successfully applied to treat long-standing OCD and ERS in an older adult. Engendering support as an alternative to reassurance seeking in CBT may be a particularly promising intervention for ERS.
Background: Health anxiety (HA), or hypochondriasis, is a psychological problem characterized by a preoccupation with the belief that one is physically unwell. A 2007 Cochrane review (Thomson and Page, 2007) found cognitive behavioural therapy (CBT) to be an effective intervention for individuals with HA. Similar findings were reported in a recent meta-analysis (Olatunji et al., 2014), which did not employ a systematic search strategy. The current review aimed to investigate the efficacy of CBT for HA, and to update the existing reviews. Method: A systematic search was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance, including randomized controlled trials that compared CBT with a control condition for people with HA. Five hundred and sixty-seven studies were found in the original search, of which 14 were included in the meta-analysis. Results: Meta-analysis was conducted on 21 comparisons and a large effect size for CBT compared with a control condition was found at post therapy d = 1.01 (95% confidence interval 0.77–1.25), as well as at 6- and 12-month follow-up. Conclusions: This systematic review and meta-analysis provides support for the hypothesis that CBT is an effective intervention for HA when compared with a variety of control conditions, e.g. treatment-as-usual, waiting list, medication, and other psychological therapies.
Increasingly, evidence suggests that computerized Cognitive Behavioural Therapy (cCBT) is effective at reducing adolescent anxiety and depression for young people in the general population or those ‘at risk’. However, less is known about the acceptability, feasibility and effectiveness of cCBT for adolescents with clinically significant levels of impairment. This study aimed to investigate the feasibility of using a novel cCBT intervention, ‘Pesky gNATs’, with adolescents aged between 13–18 years with anxiety and/or depression who met the criteria for specialist mental health services. Eleven participants were recruited from a Tier 3 child and adolescent mental health service (CAMHS). Recruitment, attendance and retention rates were recorded and qualitative feedback about the benefits and disadvantages of completing cCBT were obtained during the final session. In addition, a number of outcome measures were completed pre- and post- intervention to assess reliable and clinically significant change. The intervention was very brief comprising of just seven sessions. Participants showed high recruitment and retention rates. All participants who started the intervention completed it. All described the programme as useful and the majority identified several benefits. Four of 11 participants demonstrated reliable reductions in symptoms of depression and anxiety and six of 11 showed decreases in parent-reported symptoms of anxiety and depression following the seven-session intervention. This study demonstrates the acceptability and feasibility of using cCBT in a Tier 3 CAMHS setting. Further research is required to investigate the effect of Pesky gNATs on anxiety and depression in other Tier 3 settings.
Medically unexplained symptoms (MUS) are not only common and distressing, but are also typically poorly managed in general medical settings. Those suffering from these problems tend to incur significantly higher health costs than the general population. There are many effective treatments for different MUS; these are almost entirely based on cognitive-behavioural approaches. However, the wide range of treatment protocols tend to be ‘syndrome specific’. As such, they do not generalise well in terms of training and application, making them expensive and difficult to disseminate, suggesting the desirability of developing a transdiagnostic approach. The general basis of such a CBT grounded transdiagnostic approach is considered, and the particular need to incorporate cognitive elements of both anxiety or health anxiety (threat) and depression (loss) is highlighted. Key empirically grounded and evidence-based processes (both specific and general) previously identified as underpinning the maintenance of MUS are delineated. The way in which these can be combined in a transdiagnostic model that accounts for most MUS presentations is presented and linked to a formulation-driven transdiagnostic treatment strategy, which is described. However, the need to take more syndrome-specific issues into account in treatment is identified, suggesting that the optimum treatment may be a hybrid transdiagnostic/specific approach with formulation, shared understanding, belief change strategies, and behavioural experiments at its heart. The generalisation of such approaches to psychological problems occurring in the context of ‘long-term conditions’ is identified as a further important development that is now within reach.
While there is considerable evidence that the factors involved in hoarding typically begin to manifest early in life (mostly in adolescence), the majority of those sampled in research studies are in their later years. As so much of our understanding of the psychological factors involved in hoarding is derived from those who are older and more chronically affected, the core hoarding psychopathology may have been masked, overlaid or even disregarded in previous research and in our approaches to clinical intervention. That is, factors relating primarily to chronicity of the problem and feelings of demoralization, hopelessness, loss and the extent of the damage caused to the person's life may swamp the processes which led to and maintain the problem. The present review examines the extent to which this is so and considers theoretical and clinical implications. The literature relevant to hoarding in later life was reviewed evaluatively in relation to a number of questions placing hoarding in a lifespan developmental context. Many studies relied on purely descriptive methodologies, meaning that typical case presentations and case histories are well documented, with less attention paid to underlying causal and maintaining mechanisms. Efforts to identify and control for factors relating to age or problem chronicity were minimal. A key future direction is the identification of younger samples of people who hoard in order to identify more clearly the processes which drive acquisition and retention of excessive amounts of material.
Background: Repeated checking in OCD can be understood from a cognitive perspective as the motivated need to achieve certainty about the outcome of a potentially risky action, leading to the application of Elevated Evidence Requirements (EER) and overuse of subjective criteria. Method: Twenty-four obsessional checkers, 22 anxious controls, and 26 non-clinical controls were interviewed about and rated recent episodes where they felt (a) they needed to check and (b) checked mainly out of habit (i.e. not obsessionally). Results: Both subjective and objective criteria were rated as significantly more important in obsessional checkers than in controls; obsessional checkers also used more criteria overall for the termination of the check, and rated more criteria as “extremely important” than the control groups. The termination of the check was rated as more effortful for obsessional checkers than for the comparison groups. Analysis of the interview data was consistent with the ratings. Feelings of “rightness” were associated with the termination of a check for obsessional checkers but not for controls. Conclusion: Results were consistent with the proposal that the use of “just right feelings” to terminate checking are related to EER.
The Children and Young People's Improving Access to Psychological Therapies (CYP IAPT) programme emphasizes the meaningful contribution session-by-session routine outcome monitoring (ROM) can make to clinical practice and its importance in highlighting services’ effectiveness. Two studies on issues related to the implementation of ROM in children's services were conducted. Study 1 was qualitative; 12 Child and Adolescent Mental Health Services (CAMHS) professionals participated in focus groups. Themes identified included the idea that ROM could provide objectivity, could be collaborative and empowering. Concerns included how measures may adversely influence therapeutic sessions and how the information may be used by the service. These themes were used to develop a questionnaire about professionals’ experience of and views on session-by-session ROM. In Study 2, 59 professionals from four CAMHS teams completed the questionnaire. It was found that only 6.8% reported ‘almost always’ utilizing session-by-session ROM. Detailed analysis of questionnaire responses suggested two subscales reflecting the perceived negative and positive impact of session-by-session ROM. It was found that clinicians who currently use session-by-session ROM hold stronger positive and negative beliefs than clinicians who do not. This study suggests that session-by-session ROM is not currently routine practice within CAMHS and highlights the importance of considering how this practice can be best implemented within this setting with reference to clinician attitudes.
While the benefits of routine outcome measurement have been extolled and to some degree researched, it is surprising that service user opinions on this common therapy practice have largely not been investigated. This study aimed to assess service users’ experiences of completing measures during psychological therapy, with a view to exploring how therapists can maximize how helpful measures are in therapy. Fifteen participants completed surveys about the use of measures in their current episode of care. Ten clinicians also completed a survey about their use of, and views about, measures. Results showed that despite mixed experiences in how measures were explained and used, service users showed generally favourable attitudes towards their use in therapy, with them being perceived as most helpful when well integrated into sessions by their therapists. Clinicians reported using a wide range of measures, and generally endorsed positive beliefs about measures more strongly than negative ones. Implications for clinical practice, service development, and further research are discussed.