Roger Hagen

Perceived Group Climate as a Predictor of Long-Term Outcome in a Randomized Controlled Trial of Cognitive-Behavioural Group Therapy for Patients with Comorbid Psychiatric Disorders

BACKGROUND Research on group therapy indicates that various dimensions of the helpful relationship qualities (cohesion, climate, empathy, alliance) are associated with outcome. However, the use of a wide variety of empirical scales makes comparisons between studies as well as generalizations somewhat difficult. Although a generic, trans-theoretical measure such as the Group Climate Questionnaire-Short Form (GCQ-S; MacKenzie, 1983) is available and applicable to most treatment conditions, it has never been tested with cognitive-behavioural group therapy. AIMS To investigate perceived dimensions of group climate (engagement, avoidance and conflict) as predictors of long-term (1 year) follow-up in a manualized, structured time-limited cognitive-behavioural group therapy (CBGT) for out-patients with comorbid psychiatric disorders. METHODS Data from 27 patients were analysed using hierarchical multiple regression analyses. Outcome measures used were general symptomatic complaints (SCL-90-R), interpersonal problems (IIP-64), specific mood- and anxiety symptoms (BDI; BAI) and early maladaptive schemas (YSQ). After controlling for scores on the relevant dependent variables at both intake and treatment termination, dimensions of group climate measured close to termination were entered as predictors in separate analyses. RESULTS Higher ratings of engagement were associated with reduced scores on all outcome measures at follow-up, except for anxiety symptoms (BAI). Higher ratings of avoidance were associated with lower anxiety symptoms at follow up, whereas ratings of conflict were unrelated to all follow-up scores. CONCLUSIONS The results provide partial support for the use of the GCQ-S as a predictor of long-term follow-up in CBGT, and highlights perceived engagement as the most important dimension. Clinical implications are discussed.

CBT for psychosis : a symptom-based approach

Part I: Cognitive models of psychosis and their assessment. Hagen & Turkington, Introduction. Kinderman, Auditory hallucinations. Turkington, Bryant & Lumley, Cognitive models for delusions. Peters, Assessment in psychosis. Part II: Treating psychotic symptoms using CBT. Hoaas, Lindholm, Berge & Hagen, The therapeutic alliance in cognitive behavioral therapy for psychosis. Dudley & Turkington, Normalisation. Addington, Manusco & Haarmans, Cognitive behaviour therapy and early intervention. Michail & Birchwood, Command hallucinations: Theory and psychological interventions. Grant & Stolar, Cognitive characterization and therapy of negative symptoms and formal thought disorder. Gumley, Staying well after psychosis. Lecomte & Leclerc, Implementing cognitive behaviour therapy for psychosis: Issues and solutions. Part III: CBT and co-morbid problems. Kavanagh & Mueser, The treatment of substance misuse in people with serious mental disorders. Callcott, Dudley, Standart, Freeston & Turkington, Treating trauma in people with first episode psychosis using cognitive behavioural therapy. McFarlane, Integrating the family in the treatment of psychotic disorders. Bell, Choi & Lysaker, Psychological interventions to improve work outcomes for people with psychiatric disabilities. Part IV: CBT and bipolar disorders. Tai, The psychology of bipolar disorders. Scott, Cognitive theory and therapy of bipolar disorder.

Cognitive Behaviour Therapy for Psychotic Symptoms: A Randomized Controlled Effectiveness Trial

Background: Cognitive behavioural therapy for psychosis (CBTp) is currently a recommended form of psychosocial treatment for persons suffering from persistent psychotic symptoms. It has been argued that effect sizes from efficacy studies cannot be generalized to real clinical settings. Aims: Our aim was to evaluate whether the positive results from randomized controlled trials conducted by experts could be replicated in clinical setting with a heterogeneous sample of patients with psychotic disorder. Method: Patients referred to the study were either randomized to CBTp + TAU (the treatment group) or to a waiting-list group, only receiving TAU. The patients were assessed on different outcome measures such as the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Negative Symptoms (SANS), and the Psychotic Symptom Rating Scales (PSYRATS), at pretreatment, at posttreatment (6 months), and at 12 months follow-up. In total, 45 patients participated in the study. Results: The results showed that 20 sessions of CBTp performed significantly better than the waiting list controls with respect to the global score on the BPRS, the delusional scale on the PSYRATS, and the GAF symptom score at posttreatment. At 12 months follow-up only the GAF symptom score remained significantly changed for the total sample. Conclusions: The study revealed that CBTp delivered by non-experts in routine clinical settings can produce improvements in positive psychotic symptoms, and also that some of these improvements can be maintained at one year follow-up.

Metacognitive Therapy for Depression in Adults: A Waiting List Randomized Controlled Trial with Six Months Follow-Up

This randomized controlled trial examines the efficacy of metacognitive therapy (MCT) for depression. Thirty-nine patients with depression were randomly assigned to immediate MCT (10 sessions) or a 10-week wait list period (WL). The WL-group received 10 sessions of MCT after the waiting period. Two participants dropped out from WL and none dropped out of immediate MCT treatment. Participants receiving MCT improved significantly more than the WL group. Large controlled effect sizes were observed for both depressive (d = 2.51) and anxious symptoms (d = 1.92). Approximately 70–80% could be classified as recovered at post-treatment and 6 months follow-up following immediate MCT, whilst 5% of the WL patients recovered during the waiting period. The results suggest that MCT is a promising treatment for depression. Future controlled studies should compare MCT with other active treatments.

Metacognitions and Mindful Attention Awareness in Depression: A Comparison Of Currently Depressed, Previously Depressed and Never Depressed Individuals

The primary aim of the study was to test (1) how metacognition relates to the concept of mindful attention awareness, and (2) whether metacognitions or mindful attention awareness best predicted symptoms of depression. Data was collected from three samples: currently depressed (n = 37), previously depressed (n = 81) and never depressed controls (n = 50). There was a moderate correlation between mindful attention awareness and three of five metacognitive subscales. Both mindful attention awareness and metacognition were significantly correlated with depression severity scores after controlling for anxiety. The depressed group had significantly more dysfunctional metacognitions and less mindful attention awareness than the never depressed group. Negative beliefs about worry and mindful attention awareness were also significantly different in the previously depressed group compared with the never depressed. This suggests that metacognitions and mindful attention awareness can be vulnerability factors for depression. The results also indicated that anxiety symptoms and negative beliefs about worry were the most important factors in predicting depression. In conclusion, the study shows that metacognitions and mindful attention awareness are two related but separate constructs and that metacognitions emerged as the best predictor of depression. These results provide support for the metacognitive model of emotional disorders. Copyright

Exposure to teacher bullying in schools: A study of patients with personality disorders

Background: The aim of this study was to examine the level and affect of exposure to teacher bullying in primary and secondary schools on patients with personality disorders (PD). Method: The study group contained 116 people (18–60 years old); 49 patients diagnosed with PD undergoing psychiatric treatment in 10 different psychiatric outpatient clinics in the Southern and Middle part of Norway, and a control group consisting of 67 people who worked in an institution for somatic/elderly people and an institution for people with drug/alcohol dependency in the Middle part of Norway. All study participants filled out a self-report questionnaire, which included demographic data, one item about whether they have been bullied by one or several teachers, and 28 items regarding subjection to negative acts from teachers based on the Negative Acts Questionnaire -Revised (NAQ-R). Results: Patients diagnosed with PD reported significantly more bullying by teachers in both primary school (OR 7.3; 95% CI 1.9–27.7) and secondary school (OR 5.8; 95% CI 1.1–30.5) than healthy controls. Patients with PD also reported a higher prevalence of negative acts from teachers than healthy controls in both primary and secondary schools, such as differential treatment, ridicule, humiliation, and being ignored or neglected at least once weekly. Conclusion: Our findings indicate a correlation between bullying from teachers, as reported by PD patients, and the development of PD in adulthood. The problem of teacher bullying deserves more attention with regard to this possible correlation between student victimization and the development of PD.

A Randomized Trial of Cognitive Group Therapy vs. Waiting List for Patients with Co-Morbid Psychiatric Disorders: Effect of Cognitive Group Therapy after Treatment and Six and Twelve Months Follow-Up

The aim of the study was to assess the effectiveness of cognitive group therapy compared to a waiting list in a sample of patients with heterogeneous non-psychotic disorders. Participants in this study were referred from either the psychiatric in- or outpatient clinic at the psychiatric university hospital in Trondheim, Norway. The patients were assessed with SCID I and SCID II, and randomized either to cognitive group therapy ( n =15) or to a waiting list ( n =17). Self-report assessments of symptoms and interpersonal difficulties were administered at the start of therapy, after termination of therapy (8 weeks), and at 6 months and 12 months follow-up. Thirty-two patients completed 8 weeks of therapy. Results showed that an 8-week program of CBGT performed better than the waiting list controls, on symptom relief at post-treatment for all patients. The effects of therapy were still upheld at 6 and 12 months follow-up. Cognitive therapy seems to be useful and effective in a group format in naturalistic clinical settings, with patients suffering from various forms of non-psychotic co-morbid psychiatric disorders.

Psychological and interpersonal distress among patients with substance use disorders: Are these factors associated with continued drug use and do they change during treatment?

Aim: This study aimed to test whether self-efficacy, interpersonal problems and psychological distress are significantly associated with substance use and if the factors associated with substance use are the same factors that are subject to change in treatment for patients with substance use disorders (SUDs). Methods: The sample consisted of 346 respondents, sampled from 16 treatment facilities for SUD treatment in Norway. Results and conclusions: Self-efficacy, interpersonal problems (sum-score and subscales) and psychological distress (sum-scale and subscales) were significantly associated with substance use. Clinical implications: The results suggest a gap between factors associated with substance use problems and factors that are subject to change in treatment.

The dimensional structure of SCL-90-R in a sample of patients with substance use disorder

Abstract Aim: To test the dimensional structure of the Symptom Check List-90-Revised (SCL-90-R) among inpatients with substance use disorders (SUD), and to examine whether the Global Severity Index (GSI) scores discriminated between SUD patients and a general Norwegian population sample. The concurrent validity of the SCL-90-R was also examined. Methods: The sample included 85 patients from inpatient SUD treatment clinics in Norway. The patients responded to a survey in the week before they were discharged from treatment. Results: The SCL-90-R is a feasible instrument for measuring general distress among patients with SUD. The patients reported higher scores on the GSI than the general population. This is coherent with the high prevalence of co-occurring psychiatric symptoms in the SUD population. The concurrent validity of SCL-90-R was satisfactory. Conclusion: The SCL-90-R is unidimensional, and the use of the earlier established factor structure is discussable. The GSI score may be a feasible alternative.

Metacognitive Therapy Applications in Social Phobia: An Exploratory Study of the Individual and Combined Effects of the Attention Training Technique and Situational Attentional Refocusing

Individuals with Social Anxiety Disorder have difficulty disengaging from self-processing in social situations. Metacognitive therapy interventions for enhancing attentional control were administered to a convenience sample of 24 with a Social Anxiety Disorder diagnosis. Using a cross-over design, 11 participants were given four weekly sessions of Attention Training Technique (ATT), followed by four weekly sessions of Situational Attentional Refocusing (SAR). For the other 13 participants the two treatment components were given in the reverse order. All participants made significant reductions on interview rated and self-reported measures of social and general levels of anxiety by the end of the first intervention (either ATT or SAR). Following completion of the second treatment components, further reductions were observed and 46% (n = 11) of the total sample no longer met DSM-IV criteria for Social Anxiety Disorder diagnosis. Two large order effects were found favoring patients receiving SAR interventions first. Overall these brief techniques aimed at increasing attentional flexibility were associated with large and clinically significant changes in Social Anxiety Disorder symptoms.