ABSTRACTSBehaviour Change
Therapist Competence in Cognitive-behavioural Therapies: Review of the Contemporary Empirical Evidence
Nikolaos Kazantzis
Massey University, New ZealandTherapist competence refers to the extent that a given treatment is conducted in accordance with the instructions or intentions of the respective treatment manual. Despite this relatively straightforward notion, existing research on cognitive-behavioural therapy (CBT) processes have been unsuccessful in defining and measuring this construct. This article reviews the contemporary empirical research on therapist competence in CBT, outlines the development and psychometric evaluation of the commonly used measures of therapist adherence, and discusses how competence has been linked to treatment outcomes. The psychometric evidence for existing measures is mixed, and in particular, there has been difficulty in the demonstration of adequate interrater reliability, even among identified experts in the field. New measures of therapist competence hold promise — most notably, in the separation of therapist adherence and competence constructs. The assessment of therapist adherence, therapist competence, and the role of supervisor ratings in the clinical context are also discussed.
Parental Monitoring: A Process Model of Parent–Adolescent Interaction
Louise Hayes, Alan Hudson and Jan Matthews
RMIT University, Australia
Empirical evidence supports parental monitoring as a moderator of adolescent problem behaviours. A methodological review shows that monitoring has been measured using self-report questions based on parental knowledge of adolescent free-time use; however, inconsistencies in the definition of monitoring have created confusion. A process model of parental monitoring is proposed. This proposed model conceptualises monitoring interactions in a temporal sequence. It proposes that parental monitoring occurs in two distinct stages: before the adolescent goes out and when they return home. Parental and adolescent responses to monitoring interactions impact on future monitoring episodes. The proposed model demonstrates that a functional understanding of parent and adolescent monitoring behaviours is essential to clinical prevention and intervention.
A Universal Prevention Trial of Anxiety Symptomology during Childhood: Results at 1-Year Follow-up
Hayley M. Lowry-Webster, Paula M. Barrett and Sally Lock
Griffith University, Australia
In 2001 we evaluated a universal prevention trial of anxiety during childhood, and also examined the effects of the program on levels of depression. Participants were 594 children aged 10–13 years from seven schools in Brisbane, Australia, who were randomly assigned to an intervention or control group on a school-by-school basis. The intervention was based on the group CBT program FRIENDS (Barrett, Lowry-Webster & Holmes, 1999a, 1999b, 1999c). Results were examined universally (for all children) and for children who scored above the clinical cut-off for anxiety at pre-test. At 12-month follow-up, intervention gains were maintained, as measured by self-reports and diagnostic interviews. Eighty-five per cent of children in the intervention group who were scoring above the clinical cut-off for anxiety and depression were diagnosis free in the intervention condition, compared to only 31.2% of children in the control group. Implications of these findings are examined, alongside limitations and directions for future research.
The Function of Sexual Fantasies for Sexual Offenders: A Preliminary Model
Dion Gee, Tony Ward and Lynne Eccleston
University of Melbourne, Australia
Although the content of sexual fantasy has been extensively researched, very little contemporary research has investigated the function of sexual fantasy within the context of offending. In this study, a qualitative analysis was used to develop a descriptive model of the phenomena of sexual fantasy during the offence process. Twenty-four adult males convicted of sexual offences provided detailed retrospective descriptions of their thoughts, emotions and behaviours before, during and after their offences. A data-driven approach to model development (grounded theory) was undertaken to analyse the interview transcripts. A preliminary model was developed to elucidate the function of sexual fantasy in the process of sexual offending, as well as the physiological and psychological variables associated with it. The sexual fantasy function model (SFFM) comprises four categories that describe the various functions of sexual fantasy in the offence process. These categories are affect regulation, sexual arousal, coping, and modelling. The strengths of the SFFM are discussed and its clinical implications are reviewed. Finally, the limitations of the study are presented, and future research directions discussed.
19.4
Volume 19 Number 4 2002
Motivational Enhancement and MEMS Review to Improve Medication Adherence
Marc I. Rosen, Caitlin Ryan, and Michael Rigsby
VA Connecticut Healthcare System, USA
Electronic caps (most often Microelectronic Monitoring Systems; MEMS) that record date and time of bottle opening have been widely used to describe medication adherence. This paper expands upon descriptions of adherence-focused therapy built around review of MEMS data with the patient, adding the application of Motivational Enhancement Therapy (MET) principles. MEMS Feedback Therapy involves (a) motivational interviewing to complement the skill-building aspects of MEMS review; (b) detailed MEMS review with discussion of patterns of missed doses, and thoughts, feelings and habits accompanying missed doses; and (c) medication-taking routines to suggest after MET and MEMS review have prepared the patient to follow advice.
A Feasibility Study of Enhanced Group Triple P — Positive Parenting Program for Parents of Children with Attention-deficit/Hyperactivity Disorder
Fiona E. Hoath and Matthew R. Sanders
The University of Queensland, AustraliaThe aim of this randomised controlled trial was to examine the efficacy of an Attention-deficit/hyperactivity Disorder (ADHD)-specific, Enhanced (Level 5) Group Triple P intervention. Twenty families with a child with clinically diagnosed ADHD aged between 5 and 9 years participated. Families were randomly assigned to either an enhanced intervention group (Enhanced Group Triple P; EGTP) or a wait list (WL) condition. Using parent reports of child behaviour, parenting practices and family functioning in addition to teacher reports of child behaviour in the school environment, parents in the EGTP condition reported significant reductions in intensity of disruptive child behaviour problems, aversive parenting practices and increases in parental self-efficacy when compared to the WL condition. Parents’ reports at 3-month follow-up indicated the gains in child behaviour and parenting practices achieved at post-intervention were maintained.
Sensory Differences and Stereotyped Movements in Children with Autism
Eynat Gal, Murray Dyck and Anne Passmore
Curtin University of Technology, Western Australia, AustraliaThis study was designed to test whether there is a functional relationship between sensory stimulation and stereotyped movements (SM). Four children with autism and intellectual disability (according to DSM-IV criteria) who showed stereotyped movements were studied. The Short Sensory Profile was used to define whether a child perceived stimulation within each sensory modality as aversive, attractive, or neutral. The Stereotyped and Self-Injurious Movements Interview was used to identify each child’s repetitive movements. Children were then exposed to sensory stimuli that were neutral, aversive or attractive. Results indicate that children: (a) initiate or increase stereotyped movements immediately following the onset of an aversive stimulus, (b) terminate or decrease stereotyped movements following the onset of
an attractive stimulus and (c) initiate or increase stereotyped movements during periods of neutral stimulation. We conclude that stereotyped movements are functionally related to sensory stimulation; individuals who frequently engage in stereotyped movements may do so in order to cope with under-stimulation and aversive over-stimulation.
Assessment of Child and Adolescent Migrants to Australia: A Crosscultural Comparison
Paula M. Barrett, Robi Sonderegger and Noleen L. Sonderegger
Griffith University, AustraliaThis study examines whether young migrants, differentiated by cultural background, (a) vary in their experience of cultural adjustment, emotional distress, levels of self-esteem, and coping ability, and (b) how they compare with Australian students on measures of self-esteem and coping ability. One hundred and seventy-three students differentiated by cultural origin (former-Yugoslavian, Chinese, Mixed-culture, and Australian) and school level (primary and high school) were recruited at random from public schools in South East Queensland. Students completed measures of cultural adjustment (Bicultural Involvement Questionnaire), anxiety and trauma (Revised Children’s Manifest Anxiety Scale, Trauma Symptom Checklist), self-esteem (Coopersmith Self-Esteem Inventory, Rosenberg Self-Esteem Scale), and coping ability (Coping Scale for Children and Adolescents). The main findings from this study indicate that culturally diverse groups residing in Australia vary in their experience of cultural adaptation, level of self-esteem, and symptoms of emotional distress, illustrating culture-specific strengths and weaknesses among young non-English speaking (NESB) students. This study reveals information on how culturally diverse migrants acculturate, the type and severity of symptoms they experience, and their capacity to cope in stressful situations. The need for culture-specific early intervention and prevention programs is discussed.
Danger Expectancies, Self-efficacy and Subjective Anxiety as Mediators of Avoidance Behaviour in Spider Phobia
Lisa J. Gilroy, Kenneth C. Kirkby and Brett A. Daniels
University of Tasmania, Australia
Ross G. Menzies
University of Sydney, Australia
Iain M. Montgomery
University of Tasmania, AustraliaForty-five participants diagnosed with specific phobia (spiders) gave ratings of subjective anxiety, self-efficacy and the probability of being bitten or injured by a spider while completing a behavioural avoidance test involving exposure to a live spider. Testing was performed before and after treatment and at a 3-month follow-up. Results indicated that subjective anxiety was a more useful predictor of avoidance behaviour than self-efficacy. Danger expectancies in relation to being bitten and/or injured by a spider were not found to be a significant cognitive symptom in the majority of spider phobia sufferers during the behavioural avoidance test with a live spider. Methodological factors that may account for the low reporting of danger-related cognitions in the present study are discussed.
Motivational Interviewing: Enhancing Engagement in Treatment for Mental Health Problems
Amanda Baker
Centre for Mental Health Studies, University of Newcastle, AustraliaJohn Hambridge
John Hunter Hospital, Newcastle, AustraliaMotivational interviewing has been employed extensively and successfully among people with alcohol and other drug problems in order to enhance involvement in treatment and to reduce substance use. Despite clear commonalities in motivating people with mental health problems to recognise their problem and adhere to treatment, motivational interviewing has not been widely adopted by mental health professionals, largely due to the separation of mental health versus substance use services. The existing evidence for the effectiveness
of motivational interviewing in improving engagement in treatment for mental health problems is reviewed. It is recommended that, based on the evidence available, motivational interviewing should be applied to people with mental health problems as well as those with substance-related problems to enhance treatment engagement, retention and response. Guidelines for its application are suggested.
Developmental Antecedents of Clinical Anxiety in Childhood
Ronald M. Rapee and Agnes A. Szollos
Macquarie University, Australia
In a retrospective recall study, mothers of 102 clinically anxious children (7–16 years) and 76 nonclinical comparison children completed questionnaires describing several aspects of their child’s early life. There were no differences between the groups on several aspects of development such as age of walking, talking and toilet training. However, mothers of anxious children reported a significantly greater number of birth complications, difficulties in the first year, early fears, and general settling difficulties. There were few differences found between anxiety disorders except that children with social phobia were more likely to be first born and tended to spend less time in day care, while children with separation anxiety disorder experienced more stressful life events. The results are described as preliminary evidence for the possible role of several factors in the development of anxiety that now require more detailed investigation.
Skills-based Treatment for Alexithymia: An Exploratory Case Series
Mataji Kennedy and John Franklin
Macquarie University, AustraliaThis paper describes a skills-based intervention for the treatment of alexithymia. The intervention incorporates components to address the following three areas: the relationship between alexithymia and early life experiences, identifying feelings and expressing feelings. The efficacy of the intervention was explored using three individual case studies extending over 16–24 weekly 1-hour sessions. A number of questionnaires were administered at five time intervals. The results suggest that the treatment was effective in reducing alexithymia within the three individuals and in helping them to clarify, identify and describe their feelings. Following treatment the participants were less ambivalent about expressing their feelings and more attentive to their emotional states. The results were generally maintained at a 1-year follow-up for two of the three cases.
A Comparison of Checking-related Beliefs in Individuals with Obsessive Compulsive Disorder and Normal Controls
Sarah M. Overton and Ross G. Menzies
The University of Sydney, Australia
The potential roles of perceived danger, responsibility, thought-action fusion, confidence in memory, intolerance of uncertainty and need to control one’s thoughts in mediating compulsive checking were examined. Belief ratings were obtained from 21 individuals with compulsive checking concerns and 21 nonclinical controls about the most prominent checking concern of each individual with obsessive compulsive disorder (OCD), with controls being yoked to individuals with OCD on the basis of gender and age. If control participants and individuals with OCD have some similar beliefs regarding, for example, locking their front door, then it follows that those beliefs are unlikely to be mediating or driving the disorder. Large and significant differences were found between sufferers of OCD and nonclinical controls on ratings of beliefs concerning the probability and severity of harm, intolerance of uncertainty and the need to control thoughts. However, no differences were found between individuals with OCD checking concerns and nonclinical controls in ratings of beliefs concerning perceived personal responsibility, thought-action fusion (TAF) and confidence in memory. The findings concerning personal responsibility are of particular interest and suggest that perceptions of harm or a negative outcome may be a necessary precursor to perceptions of responsibility and the decision to act.
Using Self-generated Feedback for Generalising and Maintaining Staff Performance in a Rehabilitation Program
Lucius Arco
Edith Cowan University, AustraliaThe aim of this study was to examine whether a low cost self-generated feedback procedure was sufficient for generalising and maintaining staff performance. Two staff members were trained to implement a communication skills program with a client with severe closed head injuries. Staff were first trained to perform competently via written instructions, videotaped models, discussion, and on-the-job supervisory feedback. Posttraining conditions consisted of staff continuing with recording and graphing gains in client skills, or rating their own performance (i.e., they continued with self-generated feedback). A multiple baseline design across client skills and staff was used to observe generalised effects on staff performance (prompts and positive consequences) and client skills. Results show that after staff attained competency, and without further supervisory feedback, their performance generalised to topographically similar performance, and the staff member who consistently participated in the study maintained her performance for 16 weeks.
The Revised Child Anxiety and Depression Scale: A Psychometric Investigation with Australian Youth
Raelene L. de Ross and Eleonora Gullone
Monash University, Australia
Bruce F. Chorpita
University of Hawaii, USA
The Revised Child Anxiety and Depression Scale (RCADS) is a 47-item self-report measure intended to assess children’s symptoms corresponding to selected DSM-IV anxiety and major depressive disorders. The scale comprises six subscales (e.g., Separation Anxiety Disorder; Social Phobia; Obsessive Compulsive Disorder; Panic Disorder; Generalised Anxiety Disorder; and Major Depressive Disorder). To date, only one normative study of youth has been published with results providing strong initial support for the reliability and validity of this new measure (Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000). The present investigation provides additional psychometric data derived from an Australian sample comprising 405 youth aged 8 to 18 years. In general, the data were found to be consistent with those reported in the initial normative study. Internal consistency for the overall scale and its subscales was found to be adequate. Good convergent validity was demonstrated through moderate to strong correlations between the subscales of the RCADS with scores on the Revised Children’s Manifest Anxiety Scale (RCMAS) and the Children’s Depression Inventory (CDI). Confirmatory factor analysis suggested reasonable fit for the six-factor model by Chorpita et al. (2000). Notwithstanding the need for additional validation, it is concluded that the RCADS is a promising instrument for use in both clinical and research settings.
The Relative Contributions of Negative Cognitions and Self-efficacy to Severity of Panic Attacks in Panic Disorder
Jeffrey C. Richards
University of Ballarat, Australia
Vanessa Richardson
University of Adelaide, Australia
Ciaran Pier
University of Ballarat, AustraliaThe aim of this study was to determine the degree to which fearful and catastrophic cognitions, and self-efficacy for managing panic predicted various panic attack characteristics in panic disorder. The cognitive variables consisted of anxiety sensitivity, the frequency of fearful agoraphobic cognitions and measures of catastrophic misinterpretation of symptoms. The panic parameters were number and severity of panic symptoms, distress associated with panic attacks, worry about future panics, duration of panic disorder, and life interference due to panic disorder. These variables were measured in 40 people with panic disorder, 31 of whom also had significant agoraphobia. The frequency of fearful agoraphobic cognitions was the strongest predictor of panic attack symptomatology, predicting number of symptoms, symptom severity and degree of anticipatory fear of panic. Catastrophic misinterpretation of symptoms and anxiety sensitivity did not independently predict any panic parameters. Only self-efficacy for managing the rapid build-up of panic symptoms was specifically related to panic severity. The results therefore suggest that cognitive behaviour therapy for panic symptoms in panic disorder should reduce fearful cognitions rather than focus on panic coping strategies. The results offer little support for the contribution of the expectancy or catastrophic misinterpretation theories to the maintenance of panic disorder.
Depression, Anxiety and Self-esteem: A Clinical Field Study
Denise A. Nisbet Wallis
Central Coast Mental Health Services, NSW, Australia
The Cognitive Behavioural Therapy Group Program at Central Coast Mental Health Specialty Clinics includes treatments for generalised anxiety disorder, panic disorder and depression. This study provides empirical validation for hypotheses developed in clinical controlled studies; that is, that cognitive-behaviour therapy provided benefits in the treatment of anxiety
and depression in a service setting. This would be reflected in decreases in the symptoms of anxiety and depression and increased self-esteem. Participants (N = 139) were referred to Specialty Clinics, Central Coast Mental Health Services for treatment for depression and/or anxiety in CBT groups. They were tested on the BDI, STAI and the SERS at three time points, prior to entering the group, at termination of the group and at 3-month follow-up. Depression and anxiety symptoms decreased and self-esteem increased between pre- and post-group and the trends continued to 3-month follow-up.
Reliability and Factor Structure of the NEO-Five-Factor Inventory for Australian Adolescents
Carl D. Sneed
University of California, Los Angeles
Eleonora Gullone
Monash University, Australia
Susan Moore
Swinburne University, Australia
This study evaluated the reliability and factor structure of the NEO Five-factor Inventory (NEO-FFI) among a sample of Australian adolescents (N = 459). With the exception of openness, the factors had good internal consistency. Item-level factor analyses using varimax and oblique rotation were used to examine the factor structure of the NEO-FFI. Visual inspection of the factor structures revealed a pattern that gave preliminary support for the five-factor model. However, statistical indices for factor structure did not support a five-factor model. Items for Conscientiousness and Neuroticism had the highest factor loadings and the fewest conflicting cross-loadings on the other factors. The discussion focuses on the importance of external validation of the traits from the five-factor model with other behavioural indicators.
19.1
Volume 19 Number 1 2002
Career Versus Motherhood? A Case Study Describing a Cognitive-existential Approach to the Dilemma
Genevieve Dingle
University of Queensland, Australia
The present paper reports a case study concerning a professional woman in her 30s, who presented to the Occupational Health department of a metropolitan hospital with work stress stemming from accelerating work demands and marital problems related to the decision about whether to start a family or continue her career. No clinical diagnosis was warranted; however, Maslach Burnout Inventory Scores indicated a high degree of emotional exhaustion and moderate levels of depersonalisation, offset by a high sense of personal accomplishment in her work role. The client also demonstrated severe stress and moderate depression on the Depression-Anxiety-Stress Scale (DASS-21). The case was conceptualised from a combined cognitive-existential perspective. The woman’s cognitions about her work, relationship, and prospective motherhood roles were identified, as well as underlying existential issues such as finding a meaning in life and a fear of being alone and unloved. Eight sessions of therapy incorporated components of cognitive and existential therapies, aimed at managing stress and improving marital adjustment. Posttreatment results showed substantial reductions in all the measures of distress, while personal accomplishment remained high. The woman and her husband decided to defer starting a family until other issues had been addressed.
Work, Women and Their Beliefs
Monica O’Kelly
Monash University, Australia
Many women now juggle the multiple roles of wife, mother, home maker, and paid worker. Although their behaviours may have changed, many of these women still adhere to traditional beliefs about their roles, which may predispose them to conflict and stress. Questionnaires were sent to all women working at a large urban teaching hospital in metropolitan Melbourne in a study to explore, among other factors, the relationship between occupational status, education level, and women’s beliefs. Of the 2562 questionnaires sent out 974 (44%) were completed and returned, 422 of the questionnaires were completed by women who were living with a male partner and children. Multivariant analyses of variance were performed on the data. Results indicated a relationship between occupational status and adherence to traditional beliefs. Blue collar women had the most traditional beliefs followed by clerical women, then nurses. Managerial women and professional women had the least traditional beliefs. A similar relationship was found between level of education and beliefs; women with lower levels of education adhered to more traditional beliefs than women with higher education levels. It is possible that, as a result of adherence to traditional beliefs, women who are blue-collar workers and those with lower levels of education may be more predisposed to stress than other women when juggling their multiple roles.
Integrating Cognitive-behavioural and Interpersonal Approaches in a Group Program for the Eating Disorders: Measuring Effectiveness in a Naturalistic Setting
Naomi A. Crafti
Swinburne University of Technology, Australia
A group treatment program, designed for post-adolescent women with a range of eating problems, was developed, implemented, evaluated and then transported to a different treatment setting to test its effectiveness. The treatment program was aimed at overcoming some of the difficulties traditionally associated with clinical trial treatment protocols. In particular, the inclusion of sub-clinical and comorbid clients, the integration of two empirically validated theoretical approaches (cognitive-behavioural therapy and interpersonal therapy), and the implementation of the program in both a generalist outpatient clinic staffed by postgraduate counselling students and a hospital specialist clinic, enabled treatment outcome to be assessed under more naturalistic conditions. Twenty-eight women (Mean age = 33 years), met in six small groups at the University clinic, and completed the 10-week group program, which incorporated both cognitive-behavioural and interpersonal components. Outcome was determined by measures of behaviour change, changes in eating psychopathology and measures of general psychopathology. In addition, treatment generalisability was assessed by running the group program in an alternative setting, with an additional 12 clients, led by two clinically trained therapists. Group data indicated improvement on most outcome measures at both posttreatment and follow-up, for treated clients (in both settings) relative to a waiting-list control group. The variables which were most affected by treatment, however, were not necessarily those specifically targeted by the intervention. The results demonstrate the need to gather empirical data on psychotherapy as it is actually practiced, with a broad range of clients, therapists and using integrated treatment approaches.
Where are the Women in End-of-Life Research?
Felicity Allen
Monash University, Australia
This article reviews research on attitudes towards, and the practice of, hastening death. The central aim of this review is to elucidate what is known about the role played by gender in shaping the behaviours of people in the diverse roles of healthcare provider, carer, and patient. It is concluded that, on the whole, researchers have neglected to acknowledge gender differences in the experience of dying. Also lacking is carefully conducted research which is contextualised so that the dying person is better understood as a member of society rather than an isolated individual.
Insights into Women’s Experiences of Hospital Stays: Perceived Control, Powerlessness and Satisfaction
Anne-Maree Polimeni and Susan Moore
Swinburne University of Technology, Australia
Understanding the psychosocial experiences of women as hospital patients is an important step in assessing the relationship to healthy outcomes of patients’ perceived experiences of power and control in hospital. Accordingly, the aims of this study of 124 adult women were (a) to document women’s psychosocial experiences during a hospital stay, and (b) to develop and psychometrically evaluate a scale to measure perceived control over treatment, management and daily routine during a hospital stay (Perceived Control in Hospital Scale; PCHS). Women who had experienced a hospital stay of at least one night were surveyed. The qualitative section of the study involved thematic analysis of the written or oral comments of 10 women concerning psychosocial aspects of their hospital experience. Results indicated that the PCHS comprised three factors describing patients’ perceptions of their hospital stay: Respect/ Communication, Lack of Dignity, and Day-to-Day Control. The survey results showed that although the majority of the women were satisfied with the psychosocial aspects of being an in-patient, there was a substantial core of perceived powerlessness. A significant proportion of women indicated that they either felt “not listened to”, experienced loss of dignity, or experienced unnecessary loss of day-to-day control.