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Plovdiv Hall - Marinela

Understanding maintenance mechanisms in CBT: Theory A vs. Theory B approach.

Saevar Mar Gustavsson, Brynjar Halldorsson, Jón Friðrik Sigurðsson, Paul M Salkovskis Speaker

Research on mechanisms of change (MOC) in cognitive behavioural therapy (CBT) has expanded in recent years. Data on transdiagnostic MOC (mechanisms that are CBT specific but applicable to more than one disorder) are non-existent. Salkovskis (1996) has proposed one such mechanism. He framed it as “the belief change from theory A (the belief the patients holds before he attends treatment: chest pains interpreted as indications about impending heart attack in panic disorder) to theory B (the more realistic alternative belief the patients learn in treatment: that they are worried about having a heart attack but no such catastrophe is taking place)”. This symposium discusses this hypothesis in three studies. The first presentation is a psychometric evaluation one possible method to measure belief change (from theory A to theory B) by measuring believability in negative automatic thoughts. The second presentation covers study which considers what perspectives therapists have concerning reassurance seeking. The main conclusions were that a CBT which focuses on helping people to shift from seeking reassurance to seeking support – presented within the context of Theory A vs. Theory B may be beneficial. The third presentation discusses study on the efficacy of a transdiagnostic CBT manual (built on Salkovskis hypothesis) and theory A vs. theory B hypothesis using non-concurrent multiple baseline with six patients suffering from OCD, PD/A and MDD. Visual analysis, indicates that the hypothesized MOC partly mediates TCBT efficacy but the results varied for each participant. Finally, this symposium terminates with discussion about the results by Paul Salkovskis.

Authors:

Convenor:
Magnus Blondahl Sighvatsson, University of Iceland and Reykjavik University

Speakers:
Sævar Mar Gustavsson, Reykjavík University
Dr. Brynjar Halldorsson, University of Reading, UK
Magnus Blondahl Sighvatsson, University of Iceland and Reykjavik University

Chair:
Professor Jon Fridrik Sigurdsson, Reykjavík University and Reykjavik University

Discussant:
Professor Paul M Salkovskis, University of Oxford; Reykjavík University

Abstract for lecture 1:

Measuring believability of negative automatic thoughts: Evaluation of the Automatic Thoughts Questionnaire – Believability Scale

Speaker: Sævar Már Gústavsson, Lecturer & Clinical Psychologist, Reykjavik University

It has been hypothesized that symptom reduction in depression occurs when believability of negative, unrealistic thoughts decreases, and believability of alternative more realistic ones increases. According to the theory A vs. theory B procedure, beliefs which the patient has about his problem when he enters therapy, are treated as “theory A” and the alternative more realistic beliefs that the therapist teaches the patient in treatment are treated as “theory B”. This procedure, of testing the reliability and validity of theory A vs. theory B has been proposed to be a general mechanism of change in Cognitive Behavioural Therapy (CBT). Attempts to empirically test whether the theory A vs. theory B procedure is a general mechanism of change (MOC) in CBT are needed. To test this hypothesis, measurements are needed that evaluates belief in key cognitive variables, such as, automatic thoughts or dysfunctional attitudes.

In this talk, we will present findings from two validation studies on the Automatic Thoughts Questionnaire – Believability Scale (ATQ-B). The ATQ-B was designed to measure how much the respondent believed, on a scale from 0% to 100%, the automatic thoughts included in the original ATQ, the last time he felt depressed/sad. Results from study 1 indicated problems with the response format and the instructions for the ATQ-B. The second study reports result for a modified version of the ATQ-B. The results indicate that the proposed modification to the ATQ-B lead to increase in response rate, and lower correlation with the original ATQ as expected. Furthermore, the results indicate that the ATQ-B measures automatic thoughts, but not other cognitive constructs, such as core beliefs.

 

Abstract for lecture 2:

Therapists’ beliefs about excessive reassurance seeking: Does experience play a role?

Speaker: Dr Brynjar Halldorsson, Clinical Postdoctoral Research Fellow & Clinical Psychologist, University of Reading, AnDY Research Clinic

It has been suggested that therapists give reassurance to their patients despite knowing that reassurance seeking and giving play a part in maintaining anxiety problems. There are numerous reasons why therapists may find it hard to withhold reassurance, including concerns about ruptures in the therapeutic relationship, fears that the client may be unable to tolerate the distress and experience symptom exacerbation, drop out of therapy and more. Indeed, such ‘therapist beliefs’ have been associated with the underutilization of exposure-based interventions in cognitive behavioural therapy. It is also possible that therapists may find it difficult to tolerate their own discomfort which point blank refusal of reassurance may trigger, or lack options in substituting reassurance with something different and less pathological.

In this talk, we will present findings from a study which considers the perspectives taken by those responsible for helping patients overcome reassurance seeking, in that it examines therapists’ perception and understanding of the behaviour. More specifically it addresses which emotional problems therapists associate reassurance with, how they understand its function and importantly what CBT treatment interventions they consider important and not important when treating reassurance seeking. This study aimed to benchmark qualified clinicians working in routine clinical practice with varying degree of experience against international expert consensus drawn from leading clinical researchers. In addition, the issue of therapeutic intervention in severe and persistent reassurance seeking will be illustrated using a single case experimental design with an older adult suffering from severe and chronic obsessive compulsive disorder. The main conclusions from that study were that a cognitive behavioural therapy which focuses on helping people who engage in excessive reassurance seeking to shift from seeking reassurance to seeking support – presented within the context of Theory A vs Theory B - may be beneficial.

Abstract for lecture 3:

Evaluation of mechanism of change in Transdiagnostic CBT using single case experimental design with six patients suffering from various mental health problems.

Speaker: Magnus Blondahl Sighvatsson, Psychologist; PhD student at University of Iceland; Lecturer at University of Iceland and Reykjavik University

Introduction: Mechanisms of change (MOC) in cognitive behavioural therapy (CBT) remain poorly understood. Data on transdiagnostic MOC (mechanisms that are specific to CBT but applicable to more than one disorder) are non-existent. Salkovskis (1996) has though proposed one such mechanism that he labelled as cognitive flexibility but at its simplest, this has been described as involving a shift in beliefs, from “theory A” (the existing most negative account) to “theory B”. To explain, in panic disorder, patients believe that symptoms such as chest pain means that they are about to have a heart attack (theory A). In treatment, (usually as part of formulation and “shared understanding”) the person is helped to consider an alternative view; for example, that what they are experiencing is understandable worry about having a heart attack based on their misinterpretation of their symptoms which creates further anxiety and thus increases symptoms as part of a vicious circle (theory B). The goal of this research is to evaluate this hypothesis with six patients suffering from depression, panic disorder and OCD.

Method: Efficacy of a TCBT manual and hypothesized MOC was evaluated using non-concurrent multiple baseline (Barlow et al., 2009) with six patients (two OCD patients, two panic disorder patients and two major depressive disorder patients).Participants were evaluated in terms of diagnosis with the MINI diagnostic interview and efficacy and the hypothesized MOC where evaluated using various self-report measures.

Results: Our results, using visual analysis, indicate that for these six individuals the hypothesized MOC partly mediates TCBT efficacy but the results for each participant varied dependent on the stimuli evaluated as negative or threatening.

Discussion: These results indicate that a TMOC exist that might be responsible for efficacy of CBT for various mental health problems. The lecture will finish by discussing why the treatment was more efficacious for some of the participants.

Co-Authors of lecture: Jon Fridrik Sigurdsson, J.F.1,2,3, Paul M. Salkovskis,3,4; Engilbert Sigurðsson1,2, Heiddis B. Valdimarsdottir3,5, Fanney Thorsdottir1

1: University of Iceland

2: Landspitali – The National university hospital

3: Reykjavik University, Iceland

4: University of Oxford, UK

5: Mount Sinai Medical school, USA