Sue Clarke

Experiential avoidance and problem behavior: a mediational analysis.

Despite their formal dissimilarity, problem behaviors (e.g., substance misuse, binge eating, self-harm) may share a common function. According to Acceptance and Commitment Therapy (ACT), this shared function is Experiential Avoidance, the process of avoiding, escaping or otherwise altering unwanted private events (e.g., thoughts, feelings, memories) and the contexts that elicit them. Structural Equation Modeling was used cross-sectionally with data from a clinical opportunity sample ( N = 290) to test (a) whether problem behavior covariance was associated with experiential avoidance, and (b) whether experiential avoidance mediated the relationships between historical and dispositional risk factors (childhood trauma and negative affect intensity, respectively) and the tendency to engage in problem behaviors. Analysis showed that experiential avoidance contributed to the covariation of problem behaviors, and that it fully mediated the relationships between both risk factors and problem behavior. Thus, experiential avoidance may be a key process to target in the management of individuals with behavior problems.

An Experimental Investigation of Emotional Willingness and Physical Pain Tolerance in Deliberate Self-Harm: The Moderating Role of Interpersonal Distress.

Although theoretical and clinical literature emphasize the role of both an unwillingness to experience emotional distress and physical pain tolerance in deliberate self-harm (DSH), research on their associations with DSH remains limited. This study sought to examine the relationships between DSH and the willingness to experience emotional distress and tolerate physical pain, including the moderating role of interpersonal distress in these relationships. To this end, young adults with recent DSH (n = 43) and controls without any DSH (n = 52) were randomly assigned to 1 of 2 emotion-induction conditions (distressing or neutral), after which behavioral measures of both the willingness to experience distress and physical pain tolerance were obtained. Consistent with hypotheses, findings indicated heightened physical pain tolerance among self-harming individuals only under conditions of interpersonal distress. Furthermore, findings provided some support for the hypothesized association between DSH and the unwillingness to experience emotional distress, suggesting that self-harming women evidence less willingness to experience emotional distress only under conditions of depleted regulatory capacity (eg, following an interpersonal stressor).

Personal constructs of survivors of childhood sexual abuse receiving cognitive analytic therapy

Increasing numbers of survivors of childhood sexual abuse (CSA) are now seeking psychological therapy; yet little evidence currently exists concerning optimum treatment formats, especially when re-victimization has occurred in adulthood. This study reports an exploratory investigation of re-victimization, and of the use of cognitive analytic therapy (CAT) with seven CSA survivor women, six of whom had experienced re-victimization and five of whom were self-abusive. Results of single element and dyad grids administered before and after therapy were consistent with the exploratory hypothesis that abuse forms a central component of the womens relationships, hence making recurrence of abuse a real possibility. Outcome of therapy using CAT was positive, although the considerable and significant symptomatic changes observed were accompanied by significant change in only a relatively small number of the womens constructs, suggesting the persistence of the centrality of abuse despite therapy. For two women, levels of disturbance remained high after termination, and some evidence of relapse was also evident at three-month follow-up.

Cognitive analytic therapy for personality disorder: randomised controlled trial

BACKGROUND Cognitive analytic therapy (CAT) is a theoretically coherent approach developed to address common processes underlying personality disorders, but is supported by limited empirical evidence. AIMS To investigate the effectiveness of time-limited CAT for participants with personality disorder. METHOD A service-based randomised controlled trial (trial registration: ISRCTN79596618) comparing 24 sessions of CAT (n = 38) and treatment as usual (TAU) (n = 40) over 10 months for individuals with personality disorder. Primary outcomes were measures of psychological symptoms and interpersonal difficulties. RESULTS Participants receiving CAT showed reduced symptoms and experienced substantial benefits compared with TAU controls, who showed signs of deterioration during the treatment period. CONCLUSIONS Cognitive analytic therapy is more effective than TAU in improving outcomes associated with personality disorder. More elaborate and controlled evaluations of CAT are needed in the future.

Treating personality fragmentation and dissociation in borderline personality disorder : A pilot study of the impact of cognitive analytic therapy

Recent findings suggest that personality fragmentation may be a core component of borderline personality disorder (BPD) and that successful treatment of BPD may depend on the extent to which this is addressed. Cognitive analytic therapy (CAT) can increase integration by strengthening awareness, and hence control, of the dissociative processes maintaining fragmentation. This pilot study aimed to conduct a systematic evaluation of the impact of CAT on BPD severity and personality integration. A patient series within-subject design was used. Five BPD participants completed a series of assessments to evaluate the impact of therapy on BPD severity, fragmentation, dissociation, symptomatology and interpersonal adjustment before, during and following 16-session CAT. By follow-up, CAT had produced reductions in the severity of BPD for all five participants, and three participants showed significant changes in their levels of personality fragmentation. Improvements in comorbid disturbance were less consistent, however. Although the small number of participants involved limits these findings, they have theoretical and clinical interest. They generally support the suggestion that integration should be enhanced with BPD patients, and suggest that CAT may be a useful method to achieve this goal.

Psychiatric symptomatology in borderline and other personality disorders: Dissociation and fragmentation as mediators.

This study considered the role of dissociation and personality fragmentation as psychological factors that might distinguish borderline and personality disorder (BPD) patients, and that might explain why BPD patients have higher levels of other psychiatric symptomatology than those with other personality disorders. Two groups of personality-disordered patients (personality disorders including BPD; personality disorders other than BPD) completed measures of dissociation, personality fragmentation, and psychiatric disturbance. The BPD group had higher levels of a number of aspects of psychiatric symptomatology. Those differences were mediated by aspects of dissociation. Personality fragmentation differentiated the two groups but was not related to the higher levels of other aspects of psychiatric disturbance. Treating the syndrome of BPD may depend on addressing both dissociation and personality fragmentation. In contrast, reducing the level of comorbid psychiatric disturbance in BPD is likely to be more strongly dependent on reducing levels of different aspects of dissociation. Psychotherapeutic techniques and targets for achieving such change are discussed.

Developing and validating the "composite measure of problem behaviors".

Clinicians frequently encounter problem behaviors such as self-harm, restrictive eating, binge eating, alcohol misuse, drug misuse, smoking, sexual promiscuity, internet addiction, excessive exercise, and aggression. Although these behaviors commonly co-occur, no scale exists to measure them concurrently. Based on data from two opportunity samples (N = 691 and N = 53), this study designed and validated a composite measure of the problem behaviors noted above. The Composite Measure of Problem Behaviors, developed using exploratory factor analysis, demonstrated good psychometric properties. Subsequent confirmatory factor analysis, using both the first (N = 691) and a third sample (N = 740), identified a common higher order factor that accounted for covariance between behaviors. Findings thus suggest that despite the formal dissimilarity of behaviors assessed, a common function may explain their covariation.

Simultaneous communication and speech comprehension. Part II: comparison of two methods of overcoming selective attention during expressive sign training

One common outcome of using simultaneous communication to train the expressive use of manual signs is overselective attention to the visual component of discriminative stimuli for manual signing. Consequently, mentally retarded children may not acquire speech comprehension as a result of such training, despite the many occasions on which they experience the co-occurrence words and their referents. This study used an alternating treatment comparison to assess the relative efficacy of two methods of overcoming selective attention during simultaneous communication training. The first method, Differential Sign Training, involved mixing simultaneous communication trials with an equal number of trials in which the cue for manual signing was the referent word alone. The second method, Extensive Sign Training, involved overtraining expressive manual signing in simultaneous communication, but with a reduced reinforcement schedule. Although the Extensive condition produced the faster acquisition of expressive manua...

Simultaneous communication and speech comprehension. Part I: comparison of two methods of teaching expressive signing and speech comprehension skills

Several previous studies have shown that when expressive signing is trained using simultaneous communication, in which both visual and spoken cues may function as discriminative stimuli for signing, children with severe mental retardation demonstrate overselectivity, usually to the visual modality. As a result, such children fail to acquire other language functions, such as speech comprehension, despite the many occasions during training that words and their referents co-occur. We report two studies, both of which used alternating treatments designs to assess the relative efficacy of two methods of overcoming overselective attention during simultaneous communication training. The first method, Extensive Sign Training, involved overtraining expressive signing in simultaneous communication, but with a reduced reinforcement schedule. The second method, Mediated Sign Training, involved training receptive speech functions prior to simultaneous communication training. In both studies, the Extensive condition pr...

Refractory depression: mechanisms and evaluation of radically open dialectical behaviour therapy (RO-DBT) [REFRAMED]: protocol for randomised trial

Introduction Only 30–40% of depressed patients treated with medication achieve full remission. Studies that change medication or augment it by psychotherapy achieve only limited benefits, in part because current treatments are not designed for chronic and complex patients. Previous trials have excluded high-risk patients and those with comorbid personality disorder. Radically Open Dialectical Behaviour Therapy (RO-DBT) is a novel, transdiagnostic treatment for disorders of emotional over-control. The REFRAMED trial aims to evaluate the effectiveness and cost-effectiveness of RO-DBT for patients with treatment-resistant depression. Methods and analysis REFRAMED is a multicentre randomised controlled trial, comparing 7 months of individual and group RO-DBT treatment with treatment as usual (TAU). Our primary outcome measure is depressive symptoms 12 months after randomisation. We shall estimate the cost-effectiveness of RO-DBT by cost per quality-adjusted life year. Causal analyses will explore the mechanisms by which RO-DBT is effective. Ethics and dissemination The National Research Ethics Service (NRES) Committee South Central – Southampton A first granted ethical approval on 20 June 2011, reference number 11/SC/0146. Trial registration number ISRCTN85784627.