Melanie J. V. Fennell

Cognitive Therapy Versus Fluoxetine in Generalized Social Phobia: A Randomized Placebo-Controlled Trial

Sixty patients meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.: American Psychiatric Association, 1994) criteria for generalized social phobia were assigned to cognitive therapy (CT), fluoxetine plus self-exposure (FLU + SE), or placebo plus self-exposure (PLA + SE). At posttreatment (16 weeks), the medication blind was broken. CT and FLU + SE patients then entered a 3-month booster phase. Assessments were at pretreatment, midtreatment, posttreatment, end of booster phase, and 12-month follow-up. Significant improvements were observed on most measures in all 3 treatments. On measures of social phobia, CT was superior to FLU + SE and PLA + SE at midtreatment and at posttreatment. FLU + SE and PLA + SE did not differ. CT remained superior to FLU + SE at the end of the booster period and at 12-month follow-up. On general mood measures, there were few differences between the treatments

Cognitive therapy versus exposure and applied relaxation in social phobia: a randomized controlled trial.

A new cognitive therapy (CT) program was compared with an established behavioral treatment. Sixty-two patients meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for social phobia were randomly assigned to CT, exposure plus applied relaxation (EXP = AR), or wait-list (WAIT). CT and EXP = AR were superior to WAIT on all measures. On measures of social phobia, CT led to greater improvement than did EXP = AR. Percentages of patients who no longer met diagnostic criteria for social phobia at posttreatment-wait were as follows: 84% in CT, 42% in EXP = AR, and 0% in WAIT. At the 1-year follow-up, differences in outcome persisted. In addition, patients in EXP = AR were more likely to have sought additional treatment. Therapist effects were small and nonsignificant. CT appears to be superior to EXP = AR in the treatment of social phobia.

Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder

In a controlled clinical trial, 57 Ss meeting DSM-III-R criteria for generalized anxiety disorder, and fulfilling an additional severity criterion, were randomly allocated to cognitive behavior therapy (CBT), behavior therapy (BT), or a waiting-list control group. Individual treatment lasted 4-12 sessions; independent assessments were made before treatment, after treatment, and 6 months later, and additional follow-up data were collected after an interval of approximately 18 months. Results show a clear advantage for CBT over BT. A consistent pattern of change favoring CBT was evident in measures of anxiety, depression, and cognition. Ss were lost from the BT group, but there was no attrition from the CBT group. Treatment integrity was double-checked in England and in Holland, and special efforts were made to reduce error variance. Possible explanations for the superiority of CBT are discussed.

Cognitive therapy for depression: Individual differences and the process of change

Changes in depression over the first weeks of therapy were examined in detail in patients taking part in a trial of cognitive-behavioral therapy for depression (CBT). Within 2 weeks of starting treatment, marked differences were apparent between CBT and comparison patients and, within CBT, some patients showed a very rapid response to treatment. Such rapid responders had significantly better long-term outcome than those responding more slowly. Compared to the latter, rapid responders more strongly endorsed the cognitive conceptualization of depression initially offered, reported a more positive response to initial homework assignments, and, prior to treatment, scored higher on a measure of “depression about depression.” These results support the importance of providing an acceptable rationale for treatment, followed by homework assignments that empirically validate the rationale offered. Implications for the practice of CBT for depression are discussed. It is suggested that the process of change may well be different in rapid and slow responders, and that the delivery system of CBT should be modified to take account of these differences.

Mindfulness-Based Cognitive Therapy for Preventing Relapse in Recurrent Depression: A Randomized Dismantling Trial.

Objective: We compared mindfulness-based cognitive therapy (MBCT) with both cognitive psychological education (CPE) and treatment as usual (TAU) in preventing relapse to major depressive disorder (MDD) in people currently in remission following at least 3 previous episodes. Method: A randomized controlled trial in which 274 participants were allocated in the ratio 2:2:1 to MBCT plus TAU, CPE plus TAU, and TAU alone, and data were analyzed for the 255 (93%; MBCT = 99, CPE = 103, TAU = 53) retained to follow-up. MBCT was delivered in accordance with its published manual, modified to address suicidal cognitions; CPE was modeled on MBCT, but without training in meditation. Both treatments were delivered through 8 weekly classes. Results: Allocated treatment had no significant effect on risk of relapse to MDD over 12 months follow-up, hazard ratio for MBCT vs. CPE = 0.88, 95% CI [0.58, 1.35]; for MBCT vs. TAU = 0.69, 95% CI [0.42, 1.12]. However, severity of childhood trauma affected relapse, hazard ratio for increase of 1 standard deviation = 1.26 (95% CI [1.05, 1.50]), and significantly interacted with allocated treatment. Among participants above median severity, the hazard ratio was 0.61, 95% CI [0.34, 1.09], for MBCT vs. CPE, and 0.43, 95% CI [0.22, 0.87], for MBCT vs. TAU. For those below median severity, there were no such differences between treatment groups. Conclusion: MBCT provided significant protection against relapse for participants with increased vulnerability due to history of childhood trauma, but showed no significant advantage in comparison to an active control treatment and usual care over the whole group of patients with recurrent depression.

Immediate effects on depression of cognitive therapy interventions

The immediate effects on depression of exploring versus modifying depressive thoughts were compared in chronic moderately to severely depressed patients receiving cognitive behavioral therapy (CBT). Using a withinsubject design, it was found that periods of “cognitive” CBT consistently produced more change in belief in identified depressive thoughts than did similar periods devoted to exploring and obtaining more information relevant to the thoughts. The greater change in belief resulting from “cognitive” CBT was consistently accompanied by greater reduction in self-rated depressed mood than was obtained in the Thought Exploration condition. Differences in the effects of the two conditions on a measure of speech rate were not consistent. The results support a central prediction of the cognitive model of depression and suggest the specific therapeutic effectiveness of “cognitive” CBT techniques.

Low Self-Esteem: A Cognitive Perspective

Although low self-esteem is common in clinical populations, a cognitive conceptualization of the problem and an integrated treatment programme deriving from that conceptualization are as yet lacking. The paper proposes a cognitive model for low self-esteem, deriving from Becks model of emotional disorder. It outlines a treatment programme which integrates ideas and methods from cognitive therapy for depression, anxiety and more recent work on schemas or core beliefs. The model and treatment are illustrated with an extended case example.

Competence in Teaching Mindfulness-Based Courses: Concepts, Development and Assessment

There has been a groundswell of interest in the UK in Mindfulness-Based Stress Reduction (MBSR) and its derivatives, particularly Mindfulness-Based Cognitive Therapy (MBCT). Many health, education and social work practitioners have sought ways to develop their competencies as mindfulness-based teachers, and increasing numbers of organisations are developing mindfulness-based training programmes. However, the rapid expansion of interest in mindfulness-based approaches has meant that those people offering training for MBSR and MBCT teachers have had to consider some quite fundamental questions about training processes, standards and competence. They also need to consider how to develop a robust professional context for the next generation of mindfulness-based teachers. The ways in which competencies are addressed in the secular mainstream contexts in which MBSR and MBCT are taught are examined to enable a consideration of the particularities of mindfulness-based teaching competence. A framework suggesting how competencies develop in trainees is presented. The current status of methodologies for assessing competencies used in mindfulness-based training and research programmes is reviewed. We argue that the time is ripe to continue to develop these dialogues across the international community of mindfulness-based trainers and teachers.

Effects of meditation on frontal alpha-asymmetry in previously suicidal individuals.

This study investigated the effects of a meditation-based treatment for preventing relapse to depression, mindfulness-based cognitive therapy (MBCT), on prefrontal &agr;-asymmetry in resting electroencephalogram (EEG), a biological indicator of affective style. Twenty-two individuals with a previous history of suicidal depression were randomly assigned to either MBCT (N=10) or treatment-as-usual (TAU, N=12). Resting electroencephalogram was measured before and after an 8-week course of treatment. The TAU group showed a significant deterioration toward decreased relative left-frontal activation, indexing decreases in positive affective style, while there was no significant change in the MBCT group. The findings suggest that MBCT can help individuals at high risk for suicidal depression to retain a balanced pattern of baseline emotion-related brain activation.

Acquiring and Refining CBT Skills and Competencies: Which Training Methods are Perceived to be Most Effective?

BACKGROUND A theoretical and empirical base for CBT training and supervision has started to emerge. Increasingly sophisticated maps of CBT therapist competencies have recently been developed, and there is evidence that CBT training and supervision can produce enhancement of CBT skills. However, the evidence base suggesting which specific training techniques are most effective for the development of CBT competencies is lacking. AIMS This paper addresses the question: What training or supervision methods are perceived by experienced therapists to be most effective for training CBT competencies? METHOD 120 experienced CBT therapists rated which training or supervision methods in their experience had been most effective in enhancing different types of therapy-relevant knowledge or skills. RESULTS In line with the main prediction, it was found that different training methods were perceived to be differentially effective. For instance, reading, lectures/talks and modelling were perceived to be most useful for the acquisition of declarative knowledge, while enactive learning strategies (role-play, self-experiential work), together with modelling and reflective practice, were perceived to be most effective in enhancing procedural skills. Self-experiential work and reflective practice were seen as particularly helpful in improving reflective capability and interpersonal skills. CONCLUSIONS The study provides a framework for thinking about the acquisition and refinement of therapist skills that may help trainers, supervisors and clinicians target their learning objectives with the most effective training strategies.