An apprenticeship model in the training of psychotherapy students. Study protocol for a randomized controlled trial and qualitative investigation.

BACKGROUND: One approach towards advancing the quality of mental health care is to improve psychotherapists' skills through education and training. Recently, psychotherapy training has benefitted from adapting training methods from other professions (e.g., deliberate practice). The apprenticeship model has a long history in skill trades and medicine, but has yet to be adopted in training mental health professionals. This study aims to investigate the impact of apprenticeship training on clinical psychology students' skills. METHODS: In a pragmatic mixed-methods trial, 120 first year students in a Master's degree clinical psychology program will be randomized to either training-as-usual or training-as-usual plus psychotherapy apprenticeship. In the intervention group, students will participate, over a period of 10 weeks, in weekly treatment sessions together with licensed therapists at outpatient mental health and substance use treatment clinics. Outcomes are assessed post-intervention and at two-year follow-up. The main outcome measure is the Facilitative Interpersonal Skills (FIS) performance test. Additional self-report measures tap self-efficacy, self-compassion, worry, rumination, and stress. Weekly reflection log entries written by the students will be qualitatively analyzed in order to gain an in-depth understanding of the learning process. Students' and therapists' experiences with the intervention will be explored in focus group interviews. DISCUSSION: To the best of our knowledge, this is the first controlled study to investigate the impact of apprenticeship as an isolated training component in the education of clinical psychologists. The study is designed so as to yield a comprehensive understanding of an approach which could prove to be a valuable supplement to the existing educational methods in this field and ultimately, contribute to improve the quality of mental health care.

Early maladaptive schemas impact on long-term outcome in patients treated with group behavioral therapy for obsessive-compulsive disorder.

BACKGROUND: Some studies have previously found that certain elevated early maladaptive schemas (EMSs) are negative predictors for outcome for patients with obsessive-compulsive disorder (OCD) treated with Cognitive-Behavioral Therapy (CBT) or Exposure and Response Prevention (ERP). The current study explores whether EMS were related to reductions in OCD symptom severity at long-term follow-up (Mean = 8 years) after group ERP for patients with OCD. The central hypothesis was that patients with no response to treatment or patients who relapsed during the follow-up period were more likely to have elevated pre-treatment EMSs compared to those who responded to initial treatment and maintained gains over time. We also investigated whether there were any differences in change over time of overall EMS between patients who were recovered versus patients who were not recovered at extended follow-up. METHODS: Young Schema Questionnaire -Short Form (YSQ-SF), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI) were measured in 40 OCD patients in a general outpatient clinic before and after group ERP, after 12-months and at extended follow-up. To analyze the predictors, a multiple regression analyses was conducted. Changes in overall EMS was analyzed by mixed models procedures. RESULTS: The major finding is that patients with high pre-treatment YSQ-SF total scores were less likely to respond to initial treatment or were more likely to relapse between post-treatment and the extended follow-up. The YSQ-SF total score at pre-treatment explained 10.5% of the variance of extended long-term follow-up outcome. The entire sample experienced a significant reduction in overall EMS over time with largest reduction from pre- to post-test. There were no statistically significant differences in total EMS change trajectories between the patients who were recovered at the extended follow-up compared to those who were not. CONCLUSION: The results from the present study suggest that patients with higher pre-treatment EMSs score are less likely to recover in the long-term after receiving group ERP for OCD. A combined treatment that also targets early maladaptive schemas may be a more effective approach for OCD patients with elevated EMS who don't respond to standard ERP.

Three-Week Inpatient Treatment of Obsessive-Compulsive Disorder: A 6-Month Follow-Up Study.

Background: Specialized inpatient or residential treatment might be an alternative treatment approach for patients with obsessive-compulsive disorder (OCD) that do not respond satisfactorily to the standard outpatient treatment formats. Method: The aim of this open trial was to investigate the 6-month effectiveness of a 3-week inpatient treatment of OCD, where exposure with response prevention (ERP) was the main treatment intervention. The sample consisted of 187 adult patients with OCD, all with previous treatment attempts for OCD. Results: The sample showed significant reductions in symptoms of OCD and depression. The effect sizes were large for obsessive-compulsive symptoms and moderate to large for depressive symptoms. At discharge, 79.7% of the intent-to-treat (ITT) group were classified as treatment responders (≥35% reduction in Y-BOCS scores). However, some participants experienced relapse, as 61.5% of the ITT group were classified as treatment responders at 6-month follow-up. Antidepressant use appeared not to influence the outcome. Only pre-treatment levels of obsessive-compulsive symptoms emerged as a significant predictor of relapse. Conclusion: The 3-week inpatient programme produced similar treatment effects as previous inpatient and residential studies of longer duration (2 - 3 months). The results suggest that patients with severe OCD can be treated efficiently using this brief inpatient format. However, better relapse prevention interventions are needed.

Explaining depression symptoms in patients with social anxiety disorder: Do maladaptive metacognitive beliefs play a role?

Social anxiety disorder (SAD) is a major risk factor for developing symptoms of depression. Severity of social anxiety has previously been identified as a risk factor, and cognitive models emphasize dysfunctional schemas and self-processing as the key vulnerability factors underlying general distress in SAD. However, in the metacognitive model, depressive and other symptoms are related to metacognitive beliefs. The aim of this study was therefore to test the relative contribution of metacognitions when controlling for SAD severity and factors postulated in cognitive models. In a cross-sectional design, 102 patients diagnosed with primary SAD were included. We found that negative metacognitive beliefs concerning uncontrollability and danger and low confidence in memory emerged as the only factors explaining depressive symptoms in the regression model, suggesting that metacognitive beliefs are associated with increased depressive symptoms in SAD patients.

Paroxetine, Cognitive Therapy or Their Combination in the Treatment of Social Anxiety Disorder with and without Avoidant Personality Disorder: A Randomized Clinical Trial.

BACKGROUND: The most efficacious treatments for social anxiety disorder (SAD) are the SSRIs and cognitive therapy (CT). Combined treatment is advocated for SAD but has not been evaluated in randomized trials using CT and SSRI. Our aim was to evaluate whether one treatment is more effective than the other and whether combined treatment is more effective than the single treatments. METHODS: A total of 102 patients were randomly assigned to paroxetine, CT, the combination of CT and paroxetine, or pill placebo. The medication treatment lasted 26 weeks. Of the 102 patients, 54% fulfilled the criteria for an additional diagnosis of avoidant personality disorder. Outcomes were measured at posttreatment and 12-month follow-up assessments. RESULTS: CT was superior to paroxetine alone and to pill placebo at the end of treatment, but it was not superior to the combination treatment. At the 12-month follow-up, the CT group maintained benefits and was significantly better than placebo and paroxetine alone, whereas there were no significant differences among combination treatment, paroxetine alone, and placebo. Recovery rates at 12 months were much higher in the CT group (68%) compared to 40% in the combination group, 24% in the paroxetine group, and 4% in the pill placebo group. CONCLUSIONS: CT was the most effective treatment for SAD at both posttreatment and follow-up compared to paroxetine and better than combined treatment at the 12-month follow-up on the Liebowitz Social Anxiety Scale. Combined treatment provided no advantage over single treatments; rather there was less effect of the combined treatment compared to CT alone.

Psychotic and schizotypal symptoms in non-psychotic patients with obsessive-compulsive disorder.

BACKGROUND: Research is scarce with regard to the role of psychotic and schizotypal symptoms in treatment of obsessive-compulsive disorder (OCD). The aim of the current study was to investigate the occurrence and specificity of psychotic and schizotypal symptoms among non-psychotic OCD patients, and to examine whether such symptoms was associated with response to exposure and response prevention (ERP), and whether ERP for OCD had an impact on psychotic and schizotypal symptoms. METHODS: Non-psychotic OCD patients (n = 133) and a general non-psychotic psychiatric outpatient sample (n = 110) were assessed using self-report inventories before and after psychological treatment. RESULTS: Non-psychotic OCD patients did not report greater degree of psychotic or schizotypal symptoms than the control group. Psychotic and schizotypal symptoms were not associated with OCD symptoms before or after ERP. Psychotic and schizotypal symptom were significantly reduced following ERP. CONCLUSIONS: Psychotic and schizotypal symptoms seem to be equally prevalent among non-psychotic OCD patients and non-psychotic psychiatric controls. These symptoms were more linked to depressive symptoms than OCD symptoms. In non-psychotic OCD patients, ERP seems sufficient in reducing OCD symptoms despite the presence of psychotic- and schizotypal symptoms, and reductions in psychotic- and schizotypal symptoms were observed following ERP.

Thought Content and Appraisals in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder.

A premise for cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) is that appraisal of obsessions maintains OCD symptoms whereas obsessive content is less important. The main aim of this study was therefore to explore this notion using the autogenous and reactive classification of obsessive content and by assessing changes in appraisals and symptoms following CBT for OCD. More specifically, the study investigates whether recovery from OCD is associated with changes in appraisal and explores how thought content relates to appraisal and symptoms both before and CBT. Data from 156 adults with OCD completing CBT for OCD were analyzed. Changes in appraisals were related to improvement in OCD symptoms. Slightly more participants reported reactive intrusions (47%) than autogenous (29%), but combinations of the two were common (24%). These classifications of thought content were not related to levels of appraisal or change in symptoms, with the exception of patients with autogenous thoughts who appraised their intrusions as more important than others. OCD is heterogeneous regarding thought content and strength of appraisals but can be quite homogeneous in terms of CBT treatment response. Also, and in line with cognitive theory, recovery from OCD is associated with changes in appraisals.

The role of self-image as a predictor of psychotherapy outcome.

The present study examined the relationship between self-image and outcome in psychotherapy. Patients (n = 170) received treatment-as-usual at a university clinic, and met diagnostic criteria for mostly anxiety and depression related disorders. Self-image was measured with the Structural Analysis of Social Behavior (SASB-I) introject pre and post-treatment. Using multiple regression analyses, higher levels of Self-ignore and Self-blame pre-treatment predicted a poorer treatment outcome in terms of symptoms (SCL-90-R) and interpersonal problems (IIP-64), respectively. Increase in Self-love and decrease in Self-blame (pre to post) predicted reduced symptoms at post-treatment, whereas decrease in Self-attack and Self-control, as well as increase in Self-affirm, predicted reduced interpersonal problems. The results suggest that self-image improvement may be important in order to achieve a good outcome in psychotherapy.

A pilot randomized controlled trial of videoconference-assisted treatment for obsessive-compulsive disorder.

Evidence-based exposure and response prevention (ERP) treatment for obsessive-compulsive disorder (OCD) is not always easily accessible. Long distances from specialist treatment and other practical or motivational difficulties can interfere with ERP access and outcome. Delivery of ERP through telepsychology can help "fill the gap". The current study included 30 patients with OCD who were randomized to 12 weeks of either videoconference-assisted ERP (VCT; N = 10), self-help ERP (S-H, N = 10), or a wait-list condition (W-L, N = 10). The VCT format included use of tablet-based videoconferencing sessions (N = 6) or studio-based videoconference (N = 4), as well as telephone calls. Patients rated the VCT format as natural and reported strong working alliances with their therapists. VCT treatment produced significantly greater reductions in obsessive-compulsive symptoms compared to the two control conditions. Treatment outcomes were similar to that of regular face-to-face ERP and improvements in symptom scores remained stable at follow-up. The study indicated that ERP for OCD can be delivered efficiently with videoconferencing technology along with telephone calls. The use of such technology in psychological treatment is likely to become more common in the future and it holds promise as a method to make evidence-based treatment more accessible.

Videoconference- and cell phone-based cognitive-behavioral therapy of obsessive-compulsive disorder: a case series.

For most patients with obsessive-compulsive disorder (OCD) the availability of exposure-based therapy is limited. In our study six outpatients with obsessive-compulsive disorder (OCD) received 15 sessions of therapy delivered only over teleconference (six sessions) and cell phones (nine sessions) over a 3-month period of time. Five of the patients were women and the average age of the participants was 31.5 (SD=8.1). Patients presented a variety of OCD symptoms which were treated with standard exposure and response prevention exercises both during treatment sessions and as a part of homework exercises. All patients rated the treatment format as acceptable and rated the quality of the working alliance as high. At the end of therapy four of the six patients were highly improved and no longer met diagnostic criteria for OCD according to the Anxiety Disorders Interview Schedule for DSM-IV and the Yale-Brown Obsessive Compulsive Scale. The same was true at 3-month follow-up although some small increases in OCD symptoms had occurred. The innovative treatment format shows promise as a method of delivery that may make treatment accessible for patients with poor access to specialty clinics.

The role of early maladaptive schemas in predicting exposure and response prevention outcome for obsessive-compulsive disorder.

This is the first study that explores whether early maladaptive schemas are related to treatment outcome for patients with obsessive-compulsive disorder (OCD). The sample consisted of 88 outpatients with a diagnosis of OCD who completed exposure and response prevention treatment. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory and Young Schema Questionnaire - Short Form were administered before and after treatment. Regression analyses using post-treatment Y-BOCS as the dependent variable indicated that higher scores on the abandonment schema at pre-treatment were related to poor outcome and explained 7% of the variance in symptoms at post-treatment. Higher scores on the self-sacrifice schema at pre-treatment were related to good outcome and explained 6% of the variance in obsessive-compulsive symptoms at post-treatment. During treatment, only changes in the failure schema were significantly related to good outcome and explained 18% of the variance in symptoms at post-treatment.

The relationship between resilience and levels of anxiety, depression, and obsessive-compulsive symptoms in adolescents.

OBJECTIVE: Mental health problems affect approximately 20% of adolescents. Traditionally, the principal focus has been on vulnerability and risk factors and less on protective factors. The study, therefore, explores the relation between frequent psychiatric symptoms and resilience factors among older adolescents. METHOD: The Resilience Scale for Adolescents (READ) was completed by 307 Norwegian high school students (M = 16.4 years) along with the Depression Anxiety Stress Scales, and the Obsessive-Compulsive Inventory-Revised. RESULTS: Higher resilience scores predicted lower scores on levels of depression, anxiety, stress and obsessive-compulsive symptoms after controlling for age and gender. CONCLUSION: This study provides further evidence that it may be fruitful for clinicians and researchers to attend to resilience factors in relation to psychological symptoms among older adolescents.

Behavioural group therapy for obsessive-compulsive disorder in Norway. An open community-based trial.

The aim of the current study was to test the effectiveness of ERP-based 12 weeks group therapy for OCD patients in a community-based, general Norwegian outpatient clinic. The sample consisted of 54 patients diagnosed with OCD. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI) and the Spielberger State Anxiety Inventory (STAI-S) were administered before treatment, after treatment and at 3- and 12-month follow-ups. Analyses with mixed models for repeated measurements showed that group behavioural therapy offered to OCD patients significantly improved ratings of obsessive-compulsive symptoms, depression and anxiety. These improvements were maintained at 3- and 12-month follow-ups and an additional reduction in obsessive-compulsive symptoms was observed from post-treatment to 3-month follow-up. However, the delayed effect of therapy was no longer present at 12-month follow-up. The results also revealed that the patients had a lower chance for an increased outcome category (e.g. from unchanged to improved or recovered) with high scores on STAI-S at the given observation times (post-treatment, 3- and 12-months follow-ups). Depressive symptoms (BDI) at post-treatment and follow-ups had no significant influences on the three categories of outcome for OCD. In conclusion, the results indicate that behavioural group therapy can successfully be delivered to patients with considerable comorbidity in a real world setting conducted by therapists with limited training in the CBT.

A Norwegian version of the Obsessive-Compulsive Inventory-Revised: psychometric properties.

The aims of this study were to test the psychometric properties of the Norwegian version of the Obsessive-Compulsive Inventory-Revised (OCI-R). The study included a student/community control sample (N = 1167) and a clinical sample (N = 72) with a diagnosis of obsessive-compulsive disorder (OCD). The results indicated a good fit for the six-factor structure of the OCI-R. The mean scores and standard deviations were similar to that of studies from other countries as was the internal consistency. The OCI-R scores were significantly higher in the OCD sample compared to the control sample. All the subscales, except hoarding, were significant predictors of obsessive-compulsive severity, and the OCI-R subscales seemed to be in agreement with the different subtypes of OCD according to DSM-IV. The OCI-R showed meaningful correlations with measures related to obsessive compulsive symptoms. As expected, it showed the strongest correlation with the Yale-Brown Obsessive Compulsive Scale, followed by measures of worry, anxiety, and depression. In summary, the Norwegian OCI-R showed adequate psychometric properties suggesting it could be a suitable measure of obsessive-compulsive symptoms.

An empirical test of the metacognitive model of obsessive-compulsive symptoms: replication and extension.

The aim of the current study was to further investigate the role of metacognitive beliefs implicated in Wells' (1997) model of obsessive-compulsive disorder (OCD). The metacognitive domains of thought-fusion beliefs and beliefs about rituals were positively correlated with obsessive-compulsive symptoms in a community control sample (N=269) and in an OCD sample (N=57). The OCD sample had significantly more obsessive-compulsive symptoms as well as higher scores on the metacognitive constructs than the control sample. In order to perform a more stringent test of the metacognitive model of OCD and to explore the role of a third metacognitive construct, that of stop signals, a second study was conducted using a community control sample (N=304). All three metacognitive constructs were positively correlated with obsessive-compulsive symptoms. Thought-fusion beliefs and beliefs about rituals predicted obsessive-compulsive symptoms, even when controlling for worry, threat, and non-metacognitive beliefs such as perfectionism/certainty and responsibility. Results of this study provide further evidence for the importance of metacognitions in OCD.

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.

Change in metacognitions predicts outcome in obsessive-compulsive disorder patients undergoing treatment with exposure and response prevention.

Wells' (Wells, A. (1997). Cognitive therapy of anxiety disorders: a practice manual and conceptual guide. Chichester, UK: Wiley) metacognitive model of obsessive-compulsive disorder (OCD) predicts that metacognitions must change in order for psychological treatment to be effective. The aim of this study was to explore: (1) if metacognitions change in patients undergoing exposure treatment for OCD; (2) to determine the extent to which cognitive and metacognitive change predicts symptom improvement and recovery. The sample consisted of 83 outpatients with a diagnosis of OCD who completed exposure and response prevention treatment. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Metacognitions Questionnaire (MCQ-30) and the Obsessive Beliefs Questionnaire (OBQ-44) were administered before treatment, after treatment, and at 12-month follow-up. Treatment resulted in significant changes in symptoms, metacognition score, responsibility and perfectionism. Regression analysis using post-treatment Y-BOCS as the dependent variable indicated that when the overlap between predictors was controlled for, only changes in metacognition were significant. Changes in metacognitions explained 22% of the variance in symptoms at post-treatment when controlling for pre-treatment symptoms and changes in mood. A further regression revealed that two MCQ-30 subscales made individual contributions. The patients had significantly higher scores compared to community controls on the MCQ-30. Patients who achieved clinical significant change had lower scores on the MCQ-30 compared to patients who did not change. The results did not change significantly from post-treatment to follow-up assessment. These findings provide further support for the importance of metacognitions in treating OCD.

The efficacy of teaching psychology students exposure and response prevention for obsessive-compulsive disorder.

The aim of the study was to investigate whether inexperienced student therapists could successfully learn exposure and response prevention for obsessive-compulsive disorder. Twenty out of 21 outpatients completed treatment as delivered by ten psychology students. A total of 60 hours group supervision and approximately 30 hours with individual supervision was given to the students over the course of three semesters. Large effect sizes were observed for measures of symptoms and depression. Sixty-two percent (N= 13) of the intent to treat group achieved clinical significant change and 81% no longer met the diagnosis criteria (N= 17). The treatment effects observed at the 6 month follow-up period were promising. The results are encouraging for training students in evidence based treatment for specific disorders.