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Health and Disability

Effectiveness of cognitive behavioral therapy on health-related quality

of life: An evaluation of therapies provided by trainee therapists

SOPHIE HENRIKSSON, MALIN ANCLAIR and ARTO J. HILTUNEN

Department of Social and Psychological Studies, Section of Psychology, Karlstad University, Sweden

Henriksson, S., Anclair, M. & Hiltunen, A. J. (2016). Effectiveness of cognitive behavioral therapy on health-related quality of life: An evaluation of therapies provided by trainee therapists. Scandinavian Journal of Psychology, 57, 215–222.

The present study was carried out to examine the treatment effect of cognitive behavioral therapy provided by trainee therapists at a university clinic, focusing on health-related quality of life (HRQOL) optimism and symptoms. The study was conducted through a repeated measures design and included a treatment group (n = 21), which received cognitive behavioral therapy for an average of 10.7 therapy sessions and a control group (n = 14), that was put on a wait list for 8.6 weeks on average. After treatment, the treatment group improved significantly concerning general health (p = 0.028) and optimism (p = 0.027). In addition, clients improved in several areas within mental health and displayed some reduction in anxiety symptoms. Concurrently, the results also indicated some improvement within the control group, which may have been caused by the initial therapeutic contact, expectancy effects or spontaneous remission. The study concluded that cognitive behavioral therapy provided by trainee therapists may have a positive effect on areas within HRQOL and optimism.

Key words: Cognitive behavioral therapy, health-related quality of life, optimism, trainee therapists.

Arto J. Hiltunen, Department of Social and Psychological Studies, Section of Psychology, Karlstad University, Universitetsgatan 2, S-651 88 Karlstad, Sweden. Tel: +46-54-700 2202; e-mail: [email protected]

INTRODUCTION

There is a lack of psychotherapeutic treatment programs in today’s society. In national guidelines for the care of patients suffering from depression and anxiety disorder, the Swedish National Board of Health and Welfare (2010) concludes that the availability of psychological treatment programs, especially cognitive behavioral therapy (CBT), should increase. Bower and Gilbody (2005) claim that stepped care offers a method for increasing the availability of psychotherapy. Stepped care is often carried out as low-intensity treatment and can be applied through CBT (van Straten, Tiemens, Hakkaart, Nolen & Donker, 2006). Stepped care has proven at least as effective as traditional forms of care (Seekles, van Straten, Cuijpers, Beekman & van Marwijk, 2011; van Straten et al., 2006). CBT provided by trainee therapists constitutes a possible form of stepped care treatment. CBT combines both behavioral and cognitive interventions

(Westbrook, Kennerley & Kirk, 2011) and is one of the most studied forms of psychotherapy. It has been proven effective for a wider range of psychological disorders than other treatments (Roth & Fonagy, 2005). There is empirical support for using CBT to treat a number of different mental illnesses and problem areas (Butler, Chapman, Forman & Beck, 2006; Herbert, Rheingold & Goldstein, 2002; Lovato, Lack, Wright & Kennaway, 2014; O’Donohue & Fisher, 2008; Tolin, Diefenbach & Gilliam, 2011; Westbrook & Kirk, 2005; Westling & €Ost, 1999). CBT is considered cost and time effective and is usually carried out as a relatively short course of treatment, often during 10–20 sessions or less (Bond & Dryden, 2002). CBT has proven effective regardless of where it takes place –

at public health centers, in psychiatric care facilities and at private clinics (Foa, Hembree, Cahill et al., 2005; Hedman, Lj�otsson, Andersson, R€uck, Andersson & Lindefors, 2010; Wattar,

Sorensen, Buemann et al., 2005). Research also indicates that CBT provided by trainee therapists has had good treatment results (Bados, Balaguer & Salda~na, 2007; Forand, Evans, Haglin & Fishman, 2011; Hiltunen, Kocys & Perrin-Wallqvist, 2013; Lappalainen, Lehtonen, Skarp, Taubert, Ojanen & Hayes, 2007; €Ost, Karlstedt & Wid�en, 2012; Stark & Hiltunen, 2016). A study by Bados et al. (2007) showed significant improvement in the areas of depression, anxiety and stress among clients treated by trainee therapists and the results were comparable to controlled trials. €Ost et al. (2012) performed a study on therapy provided by trainee therapists where clients suffering from anxiety problems and depression improved significantly, and the results were considered equivalent to therapy provided by licensed psychotherapists. Further, studies have shown similar results on major depressive disorder and post-traumatic stress disorder (PTSD) (Estupi~n�a Puig & Labrador Encinas, 2012; Foa et al., 2005). A previous evaluation study of the Karlstad University psychotherapy clinic showed a significant reduction of symptoms and increased life satisfaction (Hiltunen et al., 2013). The effects shown in these studies may however be slightly lower than in controlled trials. Most studies that have evaluated CBT have usually been

focusing on symptom reduction (e.g. Butler et al., 2006; Westbrook and Kirk, 2004). In order to evaluate treatment interventions, clinical researchers have expanded the definition of clinical results to include not only the reduction of symptoms but also the subjective experience of well-being (Gladis, Gosch, Dishuk & Crits-Christoph, 1999). It has been suggested that measurements of subjective well-being, quality of life, and general health should be included in order to distinguish effective forms of treatment (Quilty, Ameringen, Mancini, Oakman & Farvolden, 2003).

Scandinavian Journal of Psychology, 2016, 57, 215–222 DOI: 10.1111/sjop.12291

World Health Organization (WHO) (1947, p. 2) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” In addition, WHO (2014) describes mental health as a state of well-being, in which the individual possesses an understanding of his or her own capabilities, a capacity to handle normal challenges, and the ability to work and contribute to society. There is no single definition of physical health, but according

to The Public Health Agency of Sweden (2014) the concept involves health-related quality of life, including a person’s experience of well-being, symptoms, and functionality in daily activities such as ability to work, social life and mobility. Thus, the concept does not only refer to the absence of illness. Mental and physical health is usually also referred to as health-related quality of life (HRQOL) (Maruish, 2011; The Public Health Agency of Sweden, 2014). Previous research has shown a connection between anxiety disorders and depression and a lower level of HRQOL (Allgulander, Jørgensen, Wade et al., 2007; Cass, Volk & Nease, 1999; Hung, Wang, Yang & Liu, 2008; Saarni, Suvisaari, Sintonen et al., 2007). The treatment effects on physical health for clients suffering

from mental problems are uncertain. A study by Roy-Byrne, Craske, Sullivan et al. (2010) indicated that CBT is effective for the decrease of anxiety and depressive symptoms, but non- effective in terms of physical health. Meanwhile, some studies suggest increased physical health and functioning after CBT (Niles, Sherbourne, Roy-Byrne et al., 2013; Schmidt, McCreary, Trakowski, Santiago, Woolaway-Bickel & Ialongo, 2003). Hofmann, Wu and Boettcher (2014) recently performed a meta-

analysis of 44 studies on CBT for various anxiety disorders that indicated improvement within some areas of HRQOL after treatment. A study by Rufer, Albrecht, Schmidt et al. (2010) concerning CBT in groups showed significant improvements of mental and physical health among participants. However, previous research on trainee therapists has primarily been focused on symptom reduction (e.g. Bados et al., 2007; Foa et al., 2005). Optimism is another concept connected to mental health

and psychopathology (Carver, Scheier & Segerstrom, 2010). According to Scheier and Carver (1985), optimism denotes an inclination to expect generally positive outcomes in life, and is associated with a number of psychological and behavioral advantages. Advantages include less stress and increased life satisfaction (Chang, 1998) and lower frequency of depressive symptoms and negative affect (Andersson, 1996). Further, studies have indicated connections between optimism and advantageous coping strategies (Nes & Segerstrom, 2006; Tomberg, Toomela, Pulver & Tikk, 2005) and improved HRQOL (Tomberg et al., 2005). Regarding research on treatment effect, optimism remains

relatively unexamined. Our unpublished study showed increased optimism as a result of mindfulness as treatment method. Yet, the same study did not show any effect on optimism after CBT. However, optimism is considered relevant for clinical psychology due to its connection to psychopathology and mental health (Carver et al., 2010). The Swedish National Board of Health and Welfare (2010) has

pointed out the lack of psychotherapy and the scarcity of treatment staff with adequate education. CBT has been

recommended for the treatment of depression and anxiety. In order to increase the availability of CBT, the Psychology unit at the Karlstad University initiated a psychotherapy education program with emphasis on CBT. A previous study has evaluated the effectiveness of the therapy carried out as part of the education program in terms of symptom reduction (Hiltunen et al., 2013). Researchers have concluded that the individual’s increased sense of well-being is a key treatment objective, and various measurements of well-being, quality of life and health should be included when evaluating treatment interventions (Gladis et al., 1999; Quilty et al., 2003).

Purpose

The purpose of this study was to evaluate the treatment effect of the CBT provided by trainee therapists at the Karlstad University psychotherapy clinic, regarding clients’ health-related quality of life, optimism and symptoms.

METHOD

Design

This study was performed as part of the Master’s program in Psychology with an emphasis on CBT at the Karlstad University psychotherapy clinic. It was carried out in accordance with guidelines for clinical activities and included a treatment group and a wait list control group. A repeated measures design was applied. Clients were measured pre- and post- treatment (treatment group) or when applying for therapy and beginning of therapy (control group).

Participants

A total of 50 clients were invited to a pre-treatment assessment. A treatment group (n = 33) was formed, however two clients were considered unsuitable for therapy after the assessment phase (i.e., after 2–3 sessions). A total of 31 clients started CBT treatment. When all therapists had been assigned clients, a control group (n = 17) was formed, as clients who had not been placed for treatment were placed on a wait list. Clients were placed in groups in accordance with the order in which they applied for a therapy slot. A total of 21 clients (64%) in the treatment group completed their course of therapy. By the post-treatment, the control group included 14 clients (82%).

The clients had varying problems. Problem areas were: depression, anxiety, self-esteem, multiple problems, and other. Specific diagnoses were not used, since the therapy was focused on problems rather than disorders. For further demographic and clinical data, see Table 1.

Instruments

The Short Form (36) Health Survey (SF-36). SF-36 (Sullivan, Karlsson, Taft & Ware, 2002) measures HRQOL (Maruish, 2011). The health questionnaire is a self-assessment instrument consisting of 36 multiple choice questions distributed over eight subscales, including: (1) Physical functioning (PF); (2) Role-physical (RP); (3) Bodily pain (BP); (4) General health (GH); (5) Vitality (VT); (6) Social function (SF); (7) Role- emotional (RE) and (8) Mental health (MH). The subscales also provide index values regarding Physical Component Summary (PCS) and Mental Component Summary (MCS). A higher value indicates better health.

Life Orientation Test Revised (LOT). This test (Scheier, Carver & Bridges, 1994) measures dispositional optimism, which means the degree of generally positive attitude towards future events. LOT is a self-assessment

216 S. Henriksson et al. Scand J Psychol 57 (2016)

instrument comprised of eight questions and four filler items on a scale ranging from 0 (strongly disagree) to 4 (strongly agree). A higher score indicates a higher level of optimism.

Hospital Anxiety and Depression Scale (HAD). HAD (Zigmond & Snaith, 1983) measures symptoms of anxiety (HAD-A) and depression (HAD-D) through two subscales. HAD is a self-assessment instrument consisting of a total of 14 questions, seven on each subscale. The questions are answered offering four alternatives, scoring between zero and three points. The number of total possible points is 21 points per subscale. A score of 0–7 is within normal range, a score of 8–10 points indicates mild anxiety, 11–15 points moderate anxiety and over 16 severe anxiety. The scoring of the depression scale is conducted the same way, though the scores indicate depression.

Data collection and procedure

Clients were recruited through advertising on the university website, and a list was kept which reflected the order in which clients registered. It was stated in the advertisement that psychotherapy was offered free of cost to clients with limited problems.

Treatment group. Clients were invited in the order of the list to a pre- treatment assessment with a trainee therapist before the initiation of therapy, where an initial assessment of the client’s problems was conducted, as well as the collection of data. Clients were informed that

participation was voluntary and they signed a document of agreement related to the use of this information for research purposes. The questionnaire included demographic questions and the self-assessment instruments SF-36, LOT and HAD.

The clients in the treatment group then began their course of therapy with a trainee therapist as therapy slots opened up. The trainee therapists had a Bachelor’s degree in Psychology and 30 ECTS credit points (15 US Credit Hours) in CBT, as part of the Master’s program in Psychology with an emphasis on CBT. The trainee therapists had previous experience of one term of psychotherapy, including supervision for 40 hours. Therapy was carried out individually and regularly through one session per week over approximately one term. Therapy sessions took place at the university psychotherapy clinic and each session took around 45 minutes. The therapy was free of cost and neither clients nor therapists received economic compensation.

The trainee therapists were supervised by licensed psychotherapists, educated in CBT supervision. The therapy sessions were filmed, and the supervisors had access to the recordings. Supervision in groups of four students was scheduled for every other week, for around 3–4 hours per occasion, which amounted to a total of 40 hours over the term. For educational purposes, trainee therapists in the same supervision group were able to watch each other’s films.

The clients completed the course of therapy and at the final therapy session they completed all self-assessment forms.

Control group. When all trainee therapists had been assigned one client, the rest of the clients on the list were offered the opportunity to take part in a pre-treatment assessment and initiate therapy at a later date as therapy slots opened up, and were thereby moved to a wait list.

At the assessment, the same procedure was used for the control group as the treatment group. The same information was given, and clients agreed to take part in the study. The clients in the control group completed the same self-assessment forms at the assessment. They did not receive any therapy while they were on the wait list and were offered a therapy slot later in the term or the next term. As their course of therapy with a trainee therapist began, they completed the same forms as they did in the pre-treatment assessment.

Data processing

The data was analyzed in IBM SPSS Statistics (IBM, Armonk, NY). 2 9 2 mixed ANOVA-analyses were performed with group and time as independent variables and the self-assessment instrument, including subscales, as dependent variables. Simple Effects Tests were carried out to follow up on significant interaction effects.

Missing data were handled by mean substitution; however the amount of missing data was very small. Variables which were not normally distributed were transformed by means of LnGamma transformation or SQRT transformation (Field, 2013). Despite transformation, the variables Physical function (PF) and Role-Physical (RP) did not meet the demands for normal distribution data, and therefore a Mann-Whitney U Test was applied for group comparison and a Wilcoxon Signed-Rank Test applied for time effects regarding these variables. A Sequential Bonferroni correction was applied to prevent a mass significance problem (Rice, 1989). Significance levels were set as p < 0.05, p < 0.025, p < 0.017 and p < 0.0125.

Dropout

In the treatment group 12 (36%) clients were excluded. The reasons these clients were not included in the study were the following: two clients were considered unsuitable for therapy after the assessment phase (6%), five clients reported insufficient motivation or lack of time and dropped out during therapy (15%), three clients declined to complete the forms as their course of therapy ended (9%), and two client wished to continue their course of therapy after the completion of the study (6%).

In the control group, there was a dropout of three clients (18%) at the beginning of therapy. The reasons why these clients decided not to begin

Table 1. Clients’ demographic and clinical data

Variable Treatment group (n = 21)

Control group (n = 14)

Sex Female 13 (62%) 11 (79%) Male 8 (38%) 3 (21%) Age (years) Interval 20–42 20–41 M (SD) 27.8 (6.2) 26.7 (6.5) Mdn 29 24.5 Marital status Partner 16 (76%) 8 (57%) Single 5 (24%) 6 (43%) Education 0–20p 5 (24%) 7 (50%) 21–40p 2 (10%) 2 (14%) 41–80p 4 (19%) 2 (14%) 81–120p 4 (19%) 1 (7%) >120p 6 (29%) 2 (14%) Has children 5 (24%) 3 (21%) Problem areas Depression 1 (5%) 1 (7%) Anxiety 15 (71%) 5 (36%) Self-esteem 1 (5%) 1 (7%) Multiple problemsa 2 (10%) 5 (36%) Otherb 2 (10%) 2 (14%) Number of therapy sessions Interval 4–17 – M (SD) 10.7 (3.2) – Mdn 11 – Number of weeks on wait list Interval – 4–17 M (SD) – 8.6 (3.4) Mdn – 8

Notes: aMultiple problems may include problem areas such as depression, anxiety, self-esteem, relationship problems, neuropsychiatric conditions and sleeping problems. bOther may include relationship problems, crisis or addiction.

CBT provided by trainees 217Scand J Psychol 57 (2016)

therapy were the following: two clients reported insufficient motivation or lack of time (12%) and one client reported having moved to another city (6%).

RESULTS

Demographics and clinical data

Clients in the treatment group took part in 10.7 therapy sessions on average. Control group clients remained on the wait list for 8.6 weeks on average. Clients took part in around one session each week, which means that the course of treatment was approximately 11 weeks. An independent t-test showed no significant difference between how long clients in the treatment group received therapy, and how long clients in the control group remained on the wait list (p = 0.19). An independent t-test showed no significant differences

between the groups in terms of age (p = 0.63). Pearson’s chi- squared test showed no significant differences between the groups in terms of gender (p = 0.30), education (p = 0.47), marital status (p = 0.23), children (p = 0.21) or problem areas (p = 0.28).

HRQOL

Table 2 describes the outcome data for all instruments. Overall, the analyses of the SF-36 HRQOL questionnaire showed a significant interaction effect for general health (GH), as shown in Fig. 1. A Simple Effects Test was carried out to follow up on the interaction effect and showed a significant (p = 0.038, d = 0.56) difference between the treatment group and the control group at post-treatment, where the treatment group had a higher mean value than the control group. The analysis also showed significant main effects for time regarding mental health (MH), vitality (VT), social function (SF) and mental component summary (MCS). All significant time effects had higher mean values at post-treatment

than at pre-treatment. Further, there were significant main effect for group in terms of MH and VT, where the treatment group had a significantly higher mean value than the control group, and also a significant difference between groups at post-treatment for role- physical (RP).

Benchmark comparisons

Table 3 shows a comparison between the current study’s treatment group outcomes and a study by Rufer et al. (2010) on the SF-36 questionnaire. The studies are consistent regarding results on physical scales PF, RP and BP, where effects are small or non-existent. There is also consistency when comparing the current study with Niles et al. (2013) concerning physical index value PCS, where both studies indicates small or non-existent

Table 2. Results summary

Main effect: group Main effect: time Interaction: group 9 time F (gp

2) Cohen’s d F (gp 2) Cohen’s d F (gp

2) Cohen’s d

HRQOL GH 1.62 0.20 5.27* (0.14) 0.61 BP 0.60 0.34 0.92 MH 6.28** (0.16) 0.68 5.56** (0.14) 0.63 0.00 VT 4.37* (0.12) 0.53 4.27* (0.12) 0.52 0.01 SF 0.93 5.56** (0.14) 0.63 0.65 RE 2.49 1.33 0.10 MCS 4.07 5.54* (0.14) 0.63 0.19 PCS 0.004 0.94 0.12 RPa Pre: 102.00 (�1.57) Treatment: �0.59

Post: 88.50* (�2.04) Control: �0.34 PFa Pre: 121.50 (�1.02) Treatment: �1.02

Post: 131.50 (�0.66) Control: �0.69 Optimism LOT 2.12 2.58 5.33* (0.14) 0.61 Anxiety and depression HAD–A 2.68 13.42**** (0.29) 0.95 2.71 HAD–D 6,09** (0.16) 0.44 3.34 2.35

Notes: *p < 0.05, **p < 0.025, ****p < 0.0125. aMann Whitney U–tests (group effect: U (z)) and Wilcoxon Signed Ranks Tests (time effect: Z) were used for RP and PF.

Fig. 1. The clients’ mean score for the subscale General Health (GH), pre- and post-treatment (treatment) or at assessment and before therapy (control).

218 S. Henriksson et al. Scand J Psychol 57 (2016)

effects sizes. However, the current study indicates a greater effect on GH, with a medium sized effect, when comparing to Rufer et al. (2010). The current study also shows greater effects for mental subscales VT, SF, RE and MH with medium sized effects, while effect sizes in the benchmark study by Rufer et al. (2010) are small or absent.

Optimism

A significant interaction effect for LOT was found (c.f. Fig. 2). A Simple Effects Test showed: (1) a significant (p = 0.034, d = 0.57) difference between the treatment group and the control group at post-treatment and (2) that the treatment group showed a significant increase (p = 0.004) in optimism between pre- and post-treatment.

Anxiety and depression

The analysis of HAD-A showed a significant main effect, where post-treatment gave a significantly lower score than pre-treatment.

At baseline, the treatment group had a higher score than at the end of therapy. The control group also showed some decrease between measurements. A significant group effect was found for HAD-D, where the treatment group showed significantly lower points than the control group.

DISCUSSION

The purpose of this study was to evaluate the treatment effect of the CBT offered at the university psychotherapy clinic regarding HRQOL, optimism and symptoms of anxiety and depression.

HRQOL

The study showed a significant interaction effect for the physical variable general health within HRQOL, as groups had different results at post-treatment. The treatment group showed higher mean values than the control group at post-treatment. The effect size was d = 0.61, which is considered to be a medium sized effect. This result indicates a treatment effect of the CBT offered at the psychotherapy clinic. No effects appeared for the other variables in the area of

physical health. This is in agreement with previous research, which has shown that the effect of CBT on physical health is uncertain (Roy-Byrne et al., 2010; Schmidt et al., 2003). The clients turned out to score on or slightly below the Swedish norm value for women 25–34 years of age (Sullivan et al., 2002) in terms of physical health measurements PF, RP and BP, which indicates that the clients were already within the normal range at baseline. Physical health tends to decline with age (Sullivan et al., 2002), and therefore selecting an older group of informants could be interesting for assessing the effect of CBT on physical dimensions. The study showed several time effects for the mental variables

related to HRQOL (MH, VT, SF and MCS), where both groups improved over time. A previous study by Devilly and McFarlane (2009) showed that clients on a waiting list can improve over time, which may be caused by spontaneous remission, increased self-confidence after a therapeutic contact, effects of expectancy effects, and a greater understanding of one’s own problems after

Table 3. Benchmark comparisons on SF–36

Self-report scale

Current study treatment group N = 21

Benchmark study N = 43a

N = 1004b

ReferenceDifference (pre-post) Cohen0s d Difference (pre-post) Cohen’s d

Physical functioning (PF) 2.10 0.18 0.50 0.02 Rufer et al., 2010 Role-Physical (RP) 4.10 0.18 4.20 0.10 Rufer et al., 2010 Bodily pain (BP) 1.80 0.09 3.50 0.13 Rufer et al., 2010 General health (GH) 5.80 0.40 2.70 0.12 Rufer et al., 2010 Vitality (VT) 7.70 0.42 0.20 0.01 Rufer et al., 2010 Social function (SF) 15.60 0.54 9.00 0.29 Rufer et al., 2010 Role-Emotional (RE) 9.30 0.33 8.50 0.22 Rufer et al., 2010 Mental health (MH) 8.60 0.43 2.20 0.12 Rufer et al., 2010 Physical Component Summary (PCS) 0.70 0.12 0.30/0.60 0.03/0.05 Niles et al., 2013c

Notes: aRufer et al. (2010). bNiles et al. (2013). cBenchmark values describes between group differences and effect sizes at baseline/at 6 months assessment.

Fig. 2. The clients’ mean score for Optimism (LOT), pre- and post- treatment (treatment) or at assessment and before therapy (control).

CBT provided by trainees 219Scand J Psychol 57 (2016)

receiving structured assessment. The study showed that the combination of expectancy effects and an initial problem assessment interview resulted in a reduction of symptoms. The clients in the present study took part in an initial

assessment with a trainee therapist and were then placed on the waiting list. The effects reported for this group may therefore be due to the factors mentioned above, although this study does not allow making conclusions about the reasons for improvement. Due to ethical considerations, the clients taking part in the present study were offered therapy starting at a later date. In order to solve this problem, future research would require yet another control group, in which clients are not offered a therapeutic contact or promised therapy at a later date. This, however, can be unethical. Devilly and McFarlane (2009) suggest statistical methods for solving this problem. Previous research on therapy provided by trainee therapists has

not included evaluations of health or HRQOL. Research on licensed therapists indicates effects of CBT on health (Hofmann et al., 2014; Rufer et al., 2010). The present study indicates that CBT provided by trainee therapists may have an effect on HRQOL, but more research is required in this area.

Benchmarking

Overall, the benchmarking showed consistency between the current study and the study by Rufer et al. (2010) on most physical subscales, where CBT seems to have limited effect. The same conclusion can be drawn from the comparison with Niles et al. (2013) when evaluating the index value of physical health. However, the current study showed medium sized effects for GH and mental subscales, which indicates greater effects for the CBT by trainee therapists in the current study. Benchmarking on index value MCS was not possible due to a lack of reported values in the benchmark studies.

Optimism

Pre- and post-treatment measurements of optimism (LOT) showed positive results. The result showed a significant interaction effect, as the optimism of the treatment group increased over time, and there was a difference between the groups at post-treatment. The effect size was d = 0.61, which is regarded as a medium sized effect. The result can also be compared to a Swedish norm group (Bood, Archer & Norlander, 2004). At baseline, both groups showed lower levels of optimism than the Swedish norm group (M = 20.79, SD = 5.02). After treatment, the treatment group reached a value above the norm group, while the control group remained below the norm value, however these comparisons were not significant. Overall, the results indicate a good effect of CBT on optimism. Research regarding treatment effects on clients’ optimism is

scarce. However, previous research has pointed out correlations between optimism and a number of psychological and behavioral advantages as well as advantageous coping and health-related quality of life (Scheier & Carver, 1985; Tomberg et al., 2005). It would be of interest to investigate if the increased optimism of the clients leads to long-term effects, due to the connection between optimism and advantageous coping strategies and health.

Future research could examine this question further, in order to find out if a higher level of optimism enables clients to handle challenges in a more advantageous manner, and if other treatment effects last.

Anxiety and depression

The study also showed a reduction of anxiety (HAD-A) for both groups. Means indicates a greater reduction of anxiety for the treatment group between pre- and post-treatment, than for the control group which showed some decrease between measurements. The treatment group went from scoring above the limit value for mild anxiety at baseline to scoring within the normal range, while the control group still scored above the limit value by the second measurement. This indicates a greater clinical effect for the treatment group than for the control group, although the analysis showed no significant interaction effect. CBT offered by trainee therapists has previously proven effective for reducing anxiety symptoms (Bados et al., 2007; Forand et al., 2011; Hiltunen et al., 2013; €Ost et al., 2012; Stark & Hiltunen, 2016). No time or interaction effect was found for depression (HAD-

D), which might be due to the fact that the mean values for both groups were already below the limit value for depression at baseline and/or that the study included clients mainly suffering from anxiety. However, previous studies on therapy provided by trainee therapists indicate good effects on clients’ depressive symptoms (Forand et al., 2011; €Ost et al., 2012).

Exclusion and clinical data

In the treatment group 12 (36%) clients were excluded. The reasons of exclusion were varying and are explained above. Five (15%) clients decided to drop out during treatment. Previous studies on therapy provided by trainee therapists have reported varying dropout rates, ranging from 7.6% (€Ost et al., 2012) to 36.2% (Estupi~n�a Puig & Labrador Encinas, 2012). Hence, the dropout rate of clients choosing to discontinue participation in the present study can be considered relatively low. The nearly 11 therapy sessions of this study proved effective

on certain aspects of HRQOL, optimism and to some degree on anxiety. The previous evaluation of the psychotherapy clinic showed similar results, as 64% of clients improved after an average of 11 sessions of therapy (Hiltunen et al., 2013). In addition, previous studies have shown that trainee therapists are capable of offering effective treatment (Bados et al., 2007; Forand et al., 2011; Lappalainen et al., 2007; €Ost et al., 2012). This indicates that short-term therapy provided by trainee therapists can produce good treatment results.

Limitations

The present study has certain limitations. The study has a small number of participants; a bigger sample size would be favorable. The study lacks a randomized control group. Groups were not randomized because of practical and ethical reasons. The groups were homogenous in the demographic and clinical variables as well as time between measurements. However, the percentage

220 S. Henriksson et al. Scand J Psychol 57 (2016)

distribution of problem areas between groups may reflect a possible selection bias. Therefore, randomization would have been favorable. There are no reliable diagnoses. Specific psychiatric diagnoses are not used, since the therapy was focused on problems rather than disorders. Furthermore, the study does not say anything about long-term effects. Future studies on the long- term effects of treatment provided by trainee therapists are of interest.

CONCLUSION

In conclusion, the treatment group improved in terms of general health and optimism and indicated a reduction in anxiety symptoms. The clients also showed an improvement in many aspects of mental health. At the same time, the study indicates an improvement in the control group as well, which may be a result of the initial therapeutic contact, expectancy effects, or spontaneous remission. The study indicates that CBT provided by trainee therapists may have a positive effect on aspects of HRQOL and optimism. The National Board of Health and Welfare (2010) states that

the availability of CBT should increase and that there is a lack of adequately educated therapists. Previous research and the present study suggests that therapists with limited training and experience can produce good treatment results, comparable to the results attained by experienced therapists. Trainee therapists with less education and experience could then help increase the availability of CBT, for instance in the form of stepped care.

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Andersson, G. (1996). The benefits of optimism: A meta-analytic review of the Life Orientation Test. Personality and Individual Differences, 21, 719–725.

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Received 22 October 2015, accepted 7 March 2016

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