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Item The effectiveness and cultural compatability of a guided self-help cognitive-behaviour programme for Asian students in New Zealand : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University, Albany, New Zealand(Massey University, 2014) Lee, Kai-ChiWith more Asian migrants and students coming to New Zealand, there is a need to provide psychological interventions that is both effective and culturally compatible. Even though Cognitive Behaviour Therapy (CBT) has been shown to be an effective intervention in the treatment of depression and anxiety, few researches have examined the effectiveness of CBT with Asian populations outside the United States. Furthermore, no research has been identified that looked at the effectiveness of low intensity CBT with Asians in New Zealand. From an emic perspective, the cultural values and principles in which interventions were developed in, warranted that it be tested with other cultures to determine if its effectiveness was cross-cultural. The purpose of the study was to fill the gap by examining the effectiveness and cultural compatibility of a guided self-help, low intensity CBT programme, Living Life to the Full (Williams, 2007), for students of Asian descent in New Zealand. A sample of 11 East Asian and Southeast Asian participants was recruited from universities and language school around the Auckland area. Quantitative measures were administered throughout the 8 weeks of the programme, and qualitative feedback was obtained at the end of the programme. Results supported the effectiveness of the programme, in the reduction of depression and anxiety, and the improvement of quality of life, adjustment and participants’ understanding of stress and low mood. In addition, participants found the programme culturally compatible and beneficial. The findings supported the suitability of the low intensity CBT programme for use with the Asian population. Asian immigrants and students experience unique stressors and problems associated with adjusting to a new culture. Low intensity CBT helps to remove the barriers of stigma and reluctance to seek help, by providing a more accessible form of psychological interventions that is effective and culturally compatible with the Asian population.Item Group treatment of anxiety-related insomnia using cognitive-behavioural therapy : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Wellington, New Zealand(Massey University, 2013) de Lacerda Mottin, FernandaInsomnia affects 25% of the New Zealand population and up to 33% of the population worldwide. Untreated it incurs high economical costs to society and takes its toll on the people’s mental health, physical health, and quality of life. Psychological treatments for insomnia have developed over the decades to reflect the scientific literature’s knowledge about the causal and maintaining factors of insomnia (i.e., maladaptive behaviours and cognitions about sleep and the consequences of insomnia and physiological and cognitive arousal). The critical review found that although physiological and cognitive arousal play a significant role in the development and maintenance of insomnia and there is some evidence that anxiety disorders predict the development of insomnia, few published treatment programmes targeted all causal and maintaining factors as described in the literature. The current main clinical study investigated the effectiveness of a group therapy programme that targeted all the main factors described in the literature. Twenty-eight participants suffering chronic insomnia and at least subclinical anxiety or stress were randomly assigned to one of two treatment interventions, administered through five treatment groups. Each group had 5-6 participants. Two groups received the insomnia first intervention (n = 11) and three groups received the anxiety first intervention (n = 17). Within- and between-subjects analyses were performed. Follow-up assessment took place about three months after the end of each treatment group. The main study found that targeting anxiety (i.e., physiological and cognitive arousal) directly improved participants’ insomnia, t(1708) = 3.574, p <.001, d = .86. At three months post-treatment, both treatment conditions had large effect sizes on measures of insomnia severity (insomnia first d = 3.35; anxiety first d = 1.17) and sleep efficiency (insomnia first d = 1.09; anxiety first d = 1.17). However, in examining the outcome trajectories, the anxiety first intervention produced more consistent improvement across the course of the therapy sessions, which might be more desirable for both clients and clinicians. This study provided evidence that a cost-effective group intervention is beneficial for symptoms of insomnia and anxiety, and it also significantly improves participants’ quality of life. While some findings need replication (e.g., order of interventions), this study showed not only that insomnia can and should be treated, but also that its assessment and treatment must address anxiety as well as sleep. Given the high occurrence and co-morbidity of insomnia, and its detrimental effects for the individual and the society, psychological interventions for insomnia should be more readily available in New Zealand.Item Awareness : facilitating the therapeutic dance along the path of growth and change ; evaluating the psychometric properties of a therapist schema questionnaire : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University, Albany, New Zealand(Massey University, 2013) Phin, Rebekah JennyThe importance of the therapeutic relationship and the therapist’s contribution to the interpersonal processes, have been increasingly recognized as important factors in Cognitive Behavioural Therapy change and outcome. More specifically, the therapists’ understanding and awareness of their own beliefs, assumptions and schema, and the potential effect that they can have on therapy, has been increasingly emphasized. Leahy’s (2001) Therapist Schema Questionnaire (TSQ) is a potentially useful screening measure designed to identify Therapist Schema. No research has evaluated the psychometric properties of the TSQ. This study investigated the underlying factor structure and reliability of the TSQ in a therapist sample (N = 269). An exploratory factor analysis suggested a 7 factor structure and a 37 item scale that included 4 of the original 15 schema factors, as well as 3 additional factors, each containing a theoretically meaningful combination of original schema factors. The 3 most commonly identified Therapist Schemas revealed in the study were ‘self-sacrifice’, ‘demanding standards’, and ‘sensitive/rejection’. The identified factors and the 37 item scale were found to have adequate to good internal consistency. Implications of these findings are discussed and recommendations are made for further research.Item An investigation into the presence of seasonal symptoms in a sample treated for depression : a thesis presented in partial fulfillment of the requirements for a degree of Doctorate of Clinical Psychology at Massey University, Albany, New Zealand(Massey University, 2011) Page, Susan; Page, SusanThe “winter blues” would appear to be a global concept. This thesis examined features of depression, seasonal change and meteorological data in relation to theories on the development of seasonal depression and Seasonal Affective Disorder (SAD). It reviewed the neurotransmitter based theories of causation where increased exposure to light is thought to stimulate normal neurotransmitter production. It also examined the dual vulnerability hypothesis (DVH) which postulated that vegetative symptoms arose from a different vulnerability than depressive symptoms. Levels of vegetative symptoms and depression were analysed in relation to the different climate experienced in Auckland, New Zealand. Three studies were undertaken. In the first study, the sample consisted of 195 individuals in New Zealand who self-referred to participate in a separate research project examining the effects of “homework” and cognitive behavioural therapy for first time depression. Meteorological data were investigated in order to explore any potential vulnerability to seasonal depression in this sample. Additionally, age and gender were explored in relation to season of presentation. The second study involved the subsample (n = 81) who were assessed for therapy and examined season and symptom profile in relation to when the person presented. The third study traced the progress through therapy of 28 adults who were selected from the second study for CBT. The Beck Depression Inventory (BDI-II) provided additional data to test the related hypotheses Rate of change in depression scores and symptom expression in relation to seasonality were analysed using multilevel modelling (MLM). Daily hours of bright sunlight was found to have an unusual relationship to temperature in New Zealand when compared with previous research. In this setting increased sunshine was associated with lower temperatures. Therefore, the variables were separated in order to ascertain whether one affected results more than others. Bright sunshine hours affected the expression of vegetative symptoms with a decrease observed over time in relation to increased photoperiod. Subtle relationships between temperature and vegetative symptoms were observed. However, there was an overall lack of correlation between vegetative and depressive symptoms observed in the CBT sample, and sunlight was not observed to have any effect on typical depressive symptoms. The investigation provided partial support for the neurotransmitter basis of vegetative symptoms and for the dual vulnerability hypothesis. Gender and age were correlated with vegetative symptom endorsement, although over time only gender was found to have any ongoing significance in the presentation of seasonal symptoms with women more likely to exhibit vegetative responses over time.Item Is the black dog really a dalmatian? : an investigation into whether stress impact and attributional style lead to different outcomes for individuals receiving 20 sessions of cognitive behavioural therapy for depression : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Auckland, New Zealand(Massey University, 2010) Good, Kimberly SuzanneThere is a need for greater clarity in the relationship between psychosocial stress and depression and its application to outcomes in cognitive behavioural therapy (CBT). A preponderance of research focuses primarily on the causal relationship between stress and depression and is limited by the traditional assumption of homogeneity amongst first-episode sufferers of mild to moderate depression. In actual fact, the perceived intensity and type of stress as well as an individual‘s attributional style may create significant differences in how they respond to therapy and overcome depression. This research had four aims: to develop an understanding about why individuals differ in their CBT recovery trajectories; to examine how the stress-diathesis framework relates to treatment outcomes; to develop a way of effectively assessing and measuring the quantitative impact of stress; and to develop an effective approach towards assessing contextual aspects of stress. The research inquiry was guided by stress-diathesis theory and a reformulated stress-diathesis framework was proposed that specified a quantitative – qualitative stress distinction. This accorded with the study‘s development of two stress measures. A measure for objectively quantifying stress was introduced, along with a therapist questionnaire that identifies precipitating stressors in depression and the qualitative aspects of the stress experience. A final sample of 26 clients experiencing their first episode of Major Depressive Disorder (MDD) was achieved. Clients were recruited for 20 sessions of CBT with 2- and 6-month follow-ups. Depression severity was measured each session with the Beck Depression Inventory (BDI-II) and attributional style was measured at six time points with the Attributional Style Questionnaire (ASQ). Stress impact was measured using the Impact of Event Scale – Video Format (IES-VF) and the Identification of Precipitating Stressors Questionnaire (IPSQ) was developed to assess precipitating stressors of depression. Multilevel analysis suggested that attributional style moderates the relationship between change in stress and change in depression. Clients with predominantly depressogenic attributional styles showed a delay in depression improvement compared to clients with non-depressogenic styles, even when significant stress reductions were achieved. Gender, therapy completion and marital status were also significant predictors of recovery. Preliminary support was achieved for the classification of clients into three recovery subgroups, according to whether they achieved rapid, expected or minimal stress improvements. Post-hoc analyses also indicated that chronicity and impact on autonomy appear to be the most influential stressor characteristics. Implications for future research and clinical considerations are discussed.Item The relationship between case conceptualization and homework in cognitive behavioural therapy (CBT) for depression : a thesis in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Psychology at Massey University, Albany, New Zealand(Massey University, 2010) Easden, Michael HaigComprehensive case conceptualization is central to Cognitive Behavioural Therapy (CBT; A. T. Beck, Rush, Shaw, & Emery, 1979). Despite the importance attributed to case conceptualization there is limited empirical support for the utility of case conceptualization in CBT. In particular, there is limited research on the relationship between therapist competence in case conceptualization, in-session and between session treatment planning (i.e., homework), and outcomes. Furthermore, little is known about the evolution of case conceptualization over a course of CBT. In order to facilitate the empirical investigation of case conceptualization in CBT the primary aim of the current thesis was to develop a new method for evaluating case conceptualization, the Conceptualization Rating Scale (CRS; Easden & Kazantzis, 2008; 2009). Study 1 investigated how patients’ (n =10) written case conceptualizations change over a course of CBT for depression using 53 J. Beck Case Conceptualization Diagrams (J. Beck, 1995). Therapist’s resultant case conceptualizations became more complete over the course of therapy with an average of 33% more information being recorded in case conceptualizations from intake to session 10. Consistent with cognitive-behavioural theory, therapists tended to conceptualize core beliefs about the ‘self’ with relatively minimal reporting of beliefs about the ‘world / others’ and the ‘future’. Study 2 provided the training, development and preliminary psychometrics of the CRS. Independent observers (N = 4) rated 225 DVD recorded therapy sessions. The CRS was demonstrated to possess adequate internal consistency (α = .61) and excellent total scale interrater reliability for each of the four domains integration (k = .83), importance (k = .65), competence (ICC = .93), and fit / match (ICC = .86). Results revealed that independent observers were able to agree on different aspects of CBT therapist’s utilization of case conceptualizations during therapy sessions. In Study 3, using the total sample of 28 patients, therapist’s (N = 7) levels of competence were assessed by independent observers (N = 4) using the CRS based on 225 DVD recorded therapy sessions. A multilevel modelling (MLM) analysis revealed that after controlling for time, taken together, therapist competence in homework use and therapist competence in case conceptualization explained 40% of within patient variance and 19% of between patient variance associated with positive change on the BDI-II after controlling for patient beliefs about homework, symptom severity and personality beliefs. The results from each study contribute towards an understanding of the relationship between different domains of therapist competence and outcomes in psychotherapy. More specifically, empirical support is provided for the utility and systematic integration of case conceptualization in CBT for depression. Implications are discussed for supervision, training and clinical practice in CBT to ensure positive patient outcomes and evidenced-based interventions in CBT.Item The impact of attributional style and homework experiences in Cognitive Behaviour Therapy for depression : a longitudinal investigation employing multilevel analysis : a dissertation presented in partial fulfillment of the requirements of the degree of Doctor of Clinical Psychology at Massey University, Albany, New Zealand(Massey University, 2010) Sachsenweger, MiekeThis longitudinal study aimed to investigate the moderating effects of attributional style on the relationship between homework experiences and depression severity throughout the course of therapy. Through an overarching depression study at Massey University, 28 participants experiencing first-episode Major Depressive Disorder (MDD) were recruited for 20 sessions of Cognitive Behaviour Therapy (CBT) plus follow-up sessions at two months. Clients were seen by seven doctoral students, and depression severity was monitored with the Beck Depression Inventory II (BDI-II) at each session, while attributional style was measured at six time points with the Attributional Style Questionnaire (ASQ). Homework was measured with the Homework Rating Scale II (HRS-II) at each session by clients, therapists and independent observers. A three-factor structure of the HRS-II was confirmed with the current data: 'benefits and completion'; 'costs and completion' and client 'beliefs'. Following preliminary analyses, benefits of homework completion was retained as the focus in a multilevel analysis investigation which utilised sessions up to the two month follow up. Therapist competence in assigning homework, and client depression severity, gender, and age were controlled for. No overall effect was found for homework in relation to depression over the course of therapy, and therefore attributional style did not moderate this relationship. However there was a trend towards a relationship between quantity and quality of homework and depression, which was moderated by a pessimistic attributional style. No effect was found for homework in relation to attributional style independently of depression severity. Attributional style on its own was related to depression severity over the course of therapy, as predicted. Women were significantly more depressed and less optimistic at intake than men, and older age correlated with lower pessimism and depression levels. Implications for future research and clinical practice are discussed.Item The role of alliance and symptomatic change within cognitive behaviour therapy for depression : a thesis presented in partial fulfillment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Albany, New Zealand(Massey University, 2010) Osborne, Carol AnnThis thesis explores the role of alliance processes and symptomatic change within Cognitive Behaviour Therapy for depression (A. T., Beck, Rush, Shaw, & Emery, 1979). Archived session data from The Depression Outcome Study conducted at Massey University, Albany (2006-2009) and a single-case research design with multiple assessments was used to determine temporal relations between alliance and depression severity. An observer version of the Working Alliance Inventory-Short Revised (WAI-SR-O) was utilized to rate the alliance of ten client-therapist dyads every session over the first ten sessions of therapy. Symptomatic change was assessed every session with the Beck Depression Inventory–II. Increasing inter-rater reliability of the current research involved seeking guidelines for rating the WAI from researchers overseas. These guidelines were modified and expanded to rate the WAI-SR-O within CBT. A rater reliability study was conducted in two stages to provide a forum to train the raters for the current research and establish inter-rater reliability. Similar to previous research, results of the current research demonstrated that an early strong alliance may predict a positive outcome and poor early alliance may lead to premature termination of therapy. It was difficult to draw definite conclusions as to whether alliance precedes symptomatic change. However, findings suggested that a reciprocal relationship between alliance and symptomatic change may start in the assessment stages of therapy. The current research demonstrated a clear reciprocal relationship between Total Alliance scores and depression severity in some sessions in some cases. A strong alliance contributed to a decrease in depression severity which subsequently increased the alliance. However, in other sessions the reciprocal relationship was not as clear. Furthermore, definite conclusions could not be drawn about the reciprocal effects between the components of the alliance (i.e., Goal, Task and Bond subscales) and depression severity. However, symptomatic change was found to be greater in the context of a strong bond between the client and therapist. There was also some evidence of subscale scores increasing following a decrease in depression severity and decreasing following an increase in depression severity in the same session that the depression severity was rated. Furthermore, there was evidence that findings were related to variability of data, nature of the alliance and time and environmental factors.Item Te huanga o te ao Maori : Cognitive Behavioural Therapy for Maori clients with depression : development and evaluation of a culturally adapted treatment programme : a dissertation presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Psychology at Massey University, Wellington, New Zealand(Massey University, 2009) Bennett, Simon Te ManihiA manualised cognitive behavioural therapy (CBT) programme was culturally adapted for use with adult Maori clients with depression who were receiving treatment from Te Whare Marie, a Maori Mental Health service that covers the greater Wellington region. The manual was developed in consultation with local and international literature pertaining to CBT with minority groups and the recommendations of an advisory team. The treatment programme integrated significant Maori concepts with the traditional strategies associated with CBT. The intervention was trialled with 16 Maori clients from Te Whare Marie with a primary diagnosis of depression. Case study and group analysis indicated that the adapted intervention was effective in reducing depressive symptomatology and negative cognition, and increasing general wellbeing in four culturally relevant dimensions. Differences between pre- and post- treatment scores were statistically significant in each of these areas. The intervention did not have a significant impact on the construct of cultural identity. Participants expressed high levels of satisfaction with the treatment, and in general the adaptations were positively received. Treatment was characterised by particularly low dropout rates with 15 of the 16 participants attending seven or more sessions. These results were discussed with reference to their implications for effective delivery of clinical service delivery to Maori consumers of mental health services in New Zealand.Item "The map, the navigator, and the explorer": evaluating the content and quality of CBT case conceptualization and the role of self-practice/self-reflection as a training intervention : a thesis presented in partial fulfillment of the requirements of the Doctor of Philosophy in Psychology at Massey University, Albany, New Zealand(Massey University, 2008) Haarhoff, Beverly AnnCognitive Behaviour Therapy (CBT) leads the way as an evidenced based psychotherapy, and the evaluation of CBT training programs is increasingly seen as important if this position is to be maintained. In this dissertation, CBT case conceptualization, as a core psychotherapeutic competency, acquired in training, is evaluated. Case conceptualization, integrates precipitating, predisposing, maintaining, and protective factors, functioning as an explanatory and prescriptive roadmap for therapy. Gaining self-knowledge through exposure to some form of personal therapy is cited as important in gaining psychotherapeutic competency. Self-practice/ self-reflection, show promise as a form of personal therapy compatible with the principles of CBT. This study evaluates the content and quality of CBT case conceptualizations produced by a sample of 26 participants who have completed the Massey University Post Graduate Diploma, using three case conceptualization rating scales. In addition, the impact of a self-practice/self-reflection manualised training intervention designed to improve the quality of case conceptualization in trainee cognitive behaviour therapists, is explored using thematic analysis. The evaluation of the CBT conceptualizations showed predisposing factors and psychological mechanisms as receiving the most attention from participants. However, the majority of participants failed to pay attention to socio-cultural, biological, protective factors and factors pertaining to the therapeutic relationship. The majority of the participants were able to produce a 'good enough' CBT case conceptualization, however the ‘problem list’ was not well developed, and the conceptually relevant aspects of the therapeutic relationship and protective factors were given less attention. The effect of a self-practice/self-reflection training intervention on the quality of CBT case conceptualizations produced by the intervention group (n = 16) drawn from the main participant sample, was qualitatively evaluated using thematic analysis. Theoretical understanding of the model, self awareness, empathy, conceptualization of the therapeutic relationship, adaptation of clinical interventions, and clinical practice were all subjectively perceived by participants to have increased as a result of the intervention. An inferential analysis compared the performance of the intervention group (n=16) that of a comparison group (n=10), made up of the remainder of the larger sample described in the context of the first question. The comparison group had not been exposed to the manualised intervention. The comparison was both within, and between the two groups. The quality of the intervention group showed an improvement on one of the rating scales, indicating a possible link between the training intervention and case conceptualization competency, however, the improvement was not replicated by the other two rating scales. The findings are discussed in the context of improving CBT training with regard to case conceptualization.