Transporting Cognitive Behavioral Therapy

(CBT) and the Improving Access to

Psychological Therapies (IAPT) project
to Japan: preliminary observations and
service evaluation in Chiba
Osamu Kobori, Michiko Nakazato, Naoki Yoshinaga, Tetsuya Shiraishi, Kota Takaoka,
Akiko Nakagawa, Masaomi Iyo and Eiji Shimizu

Dr Osamu Kobori is a Principal Abstract

Investigator for OCD, based at Purpose – The purpose of this paper is to discuss the implementation and evaluation of a cognitive
Centre for Forensic Mental behavioral therapy (CBT) training course for clinicians in Chiba, the sixth-largest province in Japan.
Health, Chiba University, Design/methodology/approach – Individual CBT for obsessive-compulsive disorder, bulimia nervosa,
Chiba, Japan. or social anxiety disorder was delivered by trainees of the Chiba CBT training course in a single study
Professor Michiko Nakazato is design.
a Principal Investigator for BN, Findings – The results demonstrated that individual CBT delivered by trainees led to statistically significant
reductions in symptom severity for all three disorders. Feedback from the trainees indicated that the training
Dr Naoki Yoshinaga is a
course achieved its aims.
Principal Investigator for SAD,
Research limitations/implications – Barriers to the dissemination of CBT in Japan such as opportunities
both are based at Centre for for training and possible solutions are discussed.
Child Mental Development, Originality/value – This paper evaluates the Chiba CBT training course, which is a Japanese adaptation of
Chiba University, Chiba, Japan. the UK Improving Access to Psychological Therapies Project and the first post-qualification CBT training
Dr Tetsuya Shiraishi is a course in Japan.
Collaborator, based at Keywords Anxiety, Eating disorders, Cognitive behaviour therapy, Outcome research,
Department of Psychiatry, Psychotherapist training/Supervision/Development
Chiba University, Chiba, Japan. Paper type Research paper
Dr Kota Takaoka and
Professor Akiko Nakagawa are
Collaborators, both are based
at Centre for Child Mental Introduction
Development, Chiba University,
Chiba, Japan.
Barriers to the dissemination of CBT
Masaomi Iyo is a Professor, Among evidence-based treatments, forms of cognitive behavior therapy (CBT) have been
based at Department of consistently shown to be effective across a wide range of disorders. While some studies have
Psychiatry, Chiba University, demonstrated the clinical effectiveness of CBT for adults in routine clinical practice (e.g.
Chiba, Japan. Westbrook and Hill, 1998; Westbrook and Kirk, 2005), several authors have noted that evidence
Professor Eiji Shimizu is a of the effectiveness of empirically supported treatments in routine practice is rarely available,
Collaborator, based at Centre
and often, the evidence may be delivered suboptimally (e.g. Andrews and Titov, 2009; Gunter
for Child Mental Development,
and Whittal, 2010; Shafran et al., 2009).
Chiba University, Chiba, Japan.
Shafran et al. (2009) identified two barriers to the dissemination of CBT. First, commonly held
beliefs, such as “Research trials have limited applicability to clinical practice” and “Non-specific

DOI 10.1108/JMHTEP-10-2013-0033 VOL. 9 NO. 3 2014, pp. 155-166, C Emerald Group Publishing Limited, ISSN 1755-6228 j THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE j PAGE 155
 therapist effects are more important than specific interventions”, hamper the availability of CBT.
Second, gaps in the current knowledge about training, measuring competence, key factors in
the etiology or maintenance of the treated disorder, and the minimum dose required for
treatment, limit the widespread adoption of the protocols to clinical settings (Shafran et al.,
2009). Gunter and Whittal (2010) also identified various barriers to the wide-scale dissemination
of CBT for anxiety disorders, including those that are applicable to empirically supported
treatments in general (e.g. lack of training opportunities, failure to address practitioner
concerns), as well as those that may be specific to CBT for anxiety disorders (e.g. practitioner
concerns about using exposure interventions). To overcome these barriers, Gunter and Whittal
(2010) advise continuing the accumulation of research-based data, advocating and appealing
for the required funding and organizational support, and training practitioners to deliver CBT
treatments. Advocates of CBT for anxiety disorders will also need to demonstrate that these
treatments are cost effective if wide-scale dissemination is to occur.
In order to address the severe under-provision of treatments and the dissemination of CBT, the
UK government has instigated a highly ambitious program, Improving Access to Psychological
Therapies (IAPT), by funding the implementation of NICE guidelines for people suffering
from depression and anxiety disorders in England. The IAPT program aims to address the
under-provision of these treatments by training 3,600 new psychological therapists between
2008 and 2011, which will provide 900,000 people access to treatment, with half of those
engaging in treatment moving to recovery, and 25,000 fewer sick pay and medical benefit
expenditures by 2010/2011. Initial evaluation of two UK demonstration sites, Doncaster and
Newham (Clark et al., 2009) has been published, and a two-year prospective cohort study was
carried out to assess the impact of implementing empirically supported stepwise psychotherapy
programs in routine practice in northern England (Richards and Borglin, 2011).

Status of mental healthcare and CBT in Japan

Awareness of the effectiveness of CBT has spread in Japan, not only among professionals
and academics but also to the public through media (e.g. books, newspapers, TV). In April 2010,
the inclusion of CBT for mood disorders in the national health insurance scheme marked
a milestone for psychiatric care in Japan, where pharmacotherapy has historically been much
more common. The inclusion of CBT in Japan’s insurance program is boosting CBT research
through randomized controlled trials and facilitating training and practice in this field. However,
many obstacles must still be overcome. For example, CBT for mood disorders is covered by
national health insurance only if it is provided by medical doctors. Thus, patients bear all costs
when other mental health professionals (e.g. clinical psychologists) conduct CBT. In addition,
CBT for other mental health problems – such as anxiety disorders – are not yet covered by
national health insurance. Most importantly, there are few competent CBT therapists in Japan,
mainly because the opportunities for training are extremely limited compared to the UK
supervision structure in the IAPT services. There are workshops during annual conferences, and
several institutions, such as the Tokyo CBT Academy and the National Centre for Cognitive
Behavior Therapy and Research, regularly provide a series of workshops. However, only
a limited number of clinicians can attend such training because it is primarily in Tokyo. Moreover,
the total training time is relatively short (two to 50 hours), and supervision is not provided (even
when available, it is not provided on a regular basis).

Chiba University training course

Chiba University was founded in 1949 by uniting several regional national colleges and schools,
including the Chiba Medical College. The university is located in Chiba province, which has
a population of approximately six million – the sixth largest among the 47 provinces in Japan.
In 2010, the Graduate School of Medicine at Chiba University set up a CBT training course, the
first post-qualification course for CBT in Japan. Trainees who enroll in the course are required
to attend a series of workshops held over two years. The training day typically consists of
a three-hour workshop in the morning, and a 90-minute clinical case conference, and 60-minute
group supervision in the afternoon. In addition, trainees receive 30-minute individual supervision.
The full course of training includes more than 400 hours. This training course started in April

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2010 with three supervisors (two psychiatrists and one psychologist) and 18 trainees; however,
the numbers of supervisors and trainees are increasing. Most trainees work in Chiba province
and are psychiatrists, psychologists, psychiatric social workers, nurses, and pharmacologists.
Our training course was inspired and influenced by the IAPT Project in the UK; our project aims
to disseminate CBT in Chiba province and to increase the number of CBT therapists equivalent
to the “high-intensity practitioners” in the UK. Similar to the accreditation for high-intensity
practitioners, our trainees are required to complete 200 hours of clinical practice, receive 70
hours of supervision, and complete written reports for a minimum of eight cases. Along with the
written reports, trainees are required to submit audio or a video record of the sessions, and their
competence in each session is assessed by supervisors using the Revised Cognitive Therapy
Scale (CTS-R: Blackburn et al., 2001). The major differences between the UK IAPT and our
course are the frequency that trainees come to the University for the course and how this training
is funded. Because the trainees do not receive government funding, they attend the course only
once per week for two years, and their training is funded by their employers. For those with
limited opportunity to conduct individual psychotherapy at their own workplaces, the course
also provides placement at Chiba University Hospital, where trainees see patients with anxiety
disorders or bulimia nervosa (BN). Furthermore, our course, unlike the UK IAPT, offers follow-up
supervision sessions, in which trainees received 30-minute individual supervision once a month
for one year after the completion of the course. Moreover, some trainees go on to a PhD course
and continue to attend the program.

Purpose of the present study

The purpose of this study is to report the preliminary outcomes of individual CBT for
obsessive – compulsive disorder (OCD), BN, and social anxiety disorder (SAD) delivered by the
trainees at Chiba University Hospital. To reflect routine clinical practice, we included patients
with comorbid mood disorders if OCD, SAD, or BN was the principal diagnosis. The outcomes of
trainee-delivered CBT are used to measure the effectiveness of our training course. We predicted
that CBT would be associated with decreased symptom severity. Additionally, a post hoc survey
was conducted to receive feedback from the trainees who completed the course.

Methods
Design
Between April 2010 and December 2011, patients were recruited by clinical referrals from both
Chiba University Hospital and other local psychiatric hospitals and clinics; these patients were
assessed by the supervisors at Chiba University Hospital using the Structured Clinical Interview
for Axis I Disorders (SCID-I; First and Gibbon, 1997). Written informed consent was obtained
from all participants. The criteria for inclusion in this study included a primary diagnosis of OCD,
BN, or SAD according to the DSM-IV and 18-65 years of age. The exclusion criteria were
psychosis, mental retardation, current high risk of suicide, substance abuse or dependence in
the past six months, antisocial personality disorder, unstable medical condition, pregnancy, or
lactation.
After enrolling in the study, the patients were placed on a waiting list. The waiting period was not
controlled because it was based on the availability of therapy rooms; the wait averaged 140.90
days (SD ¼ 62.18) for OCD, 89.6 days (SD ¼ 84.5) for BN, and 13.26 days (SD ¼ 3.21) for SAD.
After the waiting period, the participants received a 50-minute individual CBT intervention for
12 weeks. Extra sessions were flexibly added, and termination of treatment was determined
jointly by the participants and therapists in consultation with the supervisor. The average number
of sessions per participant was 16.25 (SD ¼ 3.77) for OCD, 13.75 (SD ¼ 2.87) for BN, and 13.89
(SD ¼ 1.24) for SAD. Concominant medications were permitted if the dose remained stable
throughout the study. Participants were assessed using the outcome measures at pre- (first
session) and post-CBT (final session).
This study was conducted at an outpatient clinic at Chiba University Hospital, which is used
by trainees who have limited opportunities to conduct individual psychotherapy at their
own workplaces.

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 Outcome measures
The primary outcome measures were self-reported obsessive-compulsive symptoms, as
measured by the Obsessive Compulsive Inventory distress scale (OCI; Foa et al., 1998);
self-reported bulimic symptoms, as measured by the Severity Scale of the Bulimic Investigatory
Test, Edinburgh (BITE-SS; Henderson and Freeman, 1987); and self-reported symptoms of
social anxiety, as measured by the Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987).
General severity of mood and anxiety were measured by the standard measures used in the UK
IAPT: the nine-item version of the Patient Health Questionnaire (PHQ-9; Kessler et al., 2002),
which has scores ranging from 0 to 27 and a recommended cut-off of X10 for distinguishing
between clinical and non-clinical populations; and the seven-item version of the Generalized
Anxiety Disorder scale (GAD-7; Löwe et al., 2008), which was originally developed to screen for
GAD, but also has satisfactory sensitivity and specificity for the detection of other anxiety
disorders. These scales are outcome measures commonly used in the UK.

Therapists
CBT was delivered by the trainees in the CBT training program. As a course requirement, they
attended 30-minute individual supervision sessions once every two weeks and 60-minute
weekly group supervision sessions, allowing both supervisors and other trainees to give support
and assistance in planning future sessions.
In total, 22 therapists participated in the present study (16 women and six men) with a mean
age of 42.13 years (SD ¼ 10.99). In this study, the trainees treated an average of 1.86 patients;
most therapies were allocated one or two patients. In terms of clinical licenses, there were 13
clinical psychologists, three psychiatrists, one general physician, two psychosocial workers,
and three nurses. The average number of years in practice as a clinician was 7.00 years
(SD ¼ 6.95), and the average number of days of CBT workshop they had attended before
enrolling in our course was 7.47 days (SD ¼ 9.61). The clinical or therapeutic orientation they
had used most in their practice included psychodynamic (n ¼ 1), CBT (n ¼ 3), psychiatric (n ¼ 3),
counseling/client-centered (n ¼ 6), integrated/eclectic (n ¼ 7), or a combination of these
orientations/other (n ¼ 7).

Interventions
The main steps in the CBT treatment for OCD were:
’ provision of psycho-education about the cognitive-behavioral model of OCD;
’ goal setting;
’ tailored case formulation;
’ exposure and response prevention;
’ homework; and
’ relapse prevention.
Therapists were also permitted to use other intervention strategies as needed (e.g. Houghton
et al., 2010), including behavioral experiments to test the validity of erroneous beliefs, opinion
surveys, and ratings of mastery and pleasure.
Our CBT program for BN was based on Maudsley’s model, “Getting Better Bite by Bite”
(Schmidt and Treasure, 1983). Getting Better Bite by Bite is the only self-help program that has
been evaluated in a randomized controlled trial and provides detailed, step-by-step advice for
dealing with BN. The main steps in treatment were:
’ guidelines for behavior change;
’ discussion of the pros and cons of maladaptive eating behaviors;

’ core values and goal setting;

’ psycho-education regarding nutrition, food, and weight;

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’ self-monitoring using a food diary and provision of a structure for eating;
’ action plans on how to stop bingeing and purging behaviors;
’ identification of automatic thoughts and modification of maladaptive assumptions and core
beliefs;
’ behavioral experiments to challenge maladaptive beliefs;
’ progressive actions;
’ discussion of remaining challenges;
’ dealing with interpersonal difficulties;
’ relapse prevention; and
’ homework assigned after every session.
Our CBT program for SAD was based on the model of Clark and Wells (1995). The main steps in
treatment were:
’ developing an individualized version of the cognitive behavioral model of SAD;
’ conducting role-play-based behavioral experiments with and without safety behaviors;
’ restructuring distorted self-imagery using videotape feedback;
’ practicing external focus and shifting attention;
’ conducting behavioral experiments to test negative beliefs;
’ modifying problematic pre- and post-event processing;
’ discussing the difference between self-beliefs and other people’s beliefs (reflected in survey
results);
’ dealing with remaining assumptions (schema work);
’ rescripting early memories linked to negative images in social situations;
’ preventing relapse; and
’ homework assigned after every session.

Statistical analysis
The outcomes of the CBT treatment were examined by the comparison of pre- and post-CBT
scores of each scale (OCI, BITE-SS, LSAS, PHQ-9, and GAD-7) using within-group t-tests.
Effect sizes were determined ([Mpre-CBTMpostCBT]/SDre-baseline). According to Cohen (1988),
the effect sizes were categorized as follows: small (0.20-0.49), medium (0.50-0.79), and large
(0.80 and above).

Feedback from trainees

A post-hoc survey via email was conducted with the trainees who took part in this study to
obtain their feedback on the training course. They were asked to rate the following questions on
a seven-point scale (ranging from very satisfied (7), satisfied (6), slightly satisfied (5), neutral (4),
slightly dissatisfied (3), dissatisfied (2) to very dissatisfied (1)):
1. How satisfied were you with the length (i.e. one day a week for two years) of the training
course?
2. How satisfied were you with the content and the delivery of the workshops?
3. How satisfied were you with the frequency and the duration of the supervision?
Additionally, they were asked to note the distinctive aspects of our training course compared to
the CBT training they had previously and note any difficulties faced during the training.

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 Results

Results of patients with OCD

Of the 21 patients screened, three were excluded because OCD was not their primary diagnosis
(one OCPD, one adjustment disorder, and one hypochondriasis). In total, 18 participants
satisfied the study criteria and were referred to the study. During the waiting period, four patients
declined the treatment without disclosing their reasons. Once the treatment started, the remaining
14 patients completed the study.
Table I shows the baseline demographic and clinical variables of the 14 participants (Table I).
In total, 11 were women (79 percent), and the participants’ mean age was 36.79 years. Five
participants (36 percent) were unemployed, and six (43 percent) were single. All participants met
the principal DSM-IV diagnostic criteria for OCD (mean duration: 5.21 years). Six participants
(57 percent) also met the criteria for major depressive disorder as an additional Axis I diagnosis.
Other clinical variables and participants’ demographics are shown in Table I.
The primary outcome measure was the severity score of the OCI. The mean OCI score
decreased from 64.43 (SD ¼ 3.39) to 32.54 (SD ¼ 17.49) over the course of treatment. The
PHQ-9 and GAD-7 scores reduced from 8.57 (SD ¼ 4.09) to 5.07 (SD ¼ 4.29) and from 8.14
(SD ¼ 5.63) to 4.07 (SD ¼ 2.84), respectively. A within-group t-test revealed significantly different
scores between the pre- and post-CBT scores on the assessed scales: t(1, 13) ¼ 5.153,
po0.001 for the OCI; t(1, 13) ¼ 2.775, p ¼ 0.015 for the PHQ-9; and t(1, 13) ¼ 3.277, p ¼ 0.006
for the GAD-7. The effect sizes between the pre- and post-CBT were 1.05 (large), 0.86 (large),
and 0.72 (medium) for the OCI, PHQ-9, and GAD-7, respectively.

Results for patients with BN

Of the 11 subjects screened, one was excluded from the study because her primary diagnosis
was not BN (anorexia nervosa binge-eating/purging type). After enrolling in the study, no patients
dropped out, but assessment data were not obtained from two patients. As a result, the data of
eight patients were subject to analysis.

Table I Demographic and clinical characteristics for OCD

Variable Value

Gender, female, n (%) 11 (79)

Age, years, mean (SD) 36.79 (9.88)
Comorbid Axis I diagnosis, n (%)
No comorbid condition (OCD only) 8 (57)
With comorbidity 6 (43)
Age of onset, years, mean (SD) 31.57 (9.18)
Duration of OCD, years, mean (SD) 5.21 (4.67)
Employment status, n (%)
Employed full-time 2 (14)
Part-time/homemaker 7 (50)
Unemployed 5 (36)
Marital status, n (%)
Single 6 (43)
Married 7 (50)
Dating 1 (7)
Educational background, n (%)
High school 3 (22)
Diploma 4 (28)
Degree 7 (50)
Currently on medication, n (%)
AD and/or BZ 12 (86)

Notes: n ¼ 14, OCD, obsessive-compulsive disorder; BZ, benzodiazepines; AD, antipsychotics

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Table II shows the baseline demographic information and clinical variables of the eight patients
whose data were analyzed. All of the participants were female, and their mean age was 31.3
years. One patient was employed, three were students, and four were single. Four patients had
comorbid psychiatric disorders: two had additional Axis I diagnoses of major depressive
disorder, one had bipolar disorder, and one had SAD. Other clinical variables and participants’
demographics are shown in Table II.
The primary outcome measure was the severity score on the BITE-SS. The average BITE-SS score
decreased from 9.75 (SD ¼ 4.28) to 4.00 (SD ¼ 4.34) over the course of the study. The PHQ-9 and
GAD-7 scores reduced from 12.12 (SD ¼ 7.70) to 8.13 (SD ¼ 7.42) and from 9.38 (SD ¼ 6.12) to
6.25 (SD ¼ 6.67), respectively. A within-group t-test revealed significant differences between
pre- and post-CBT in BITE-SS, t(1, 7) ¼ 2.803, p ¼ 0.026, and GAD-7 scores, t(1, 7) ¼ 2.739,
p ¼ 0.028. However, there was no significant difference in the PHQ-9 scores over the course of the
study, t(1, 7) ¼ 1.782, p ¼ 0.117. The effect sizes between pre- and post-CBT were 1.348 (large),
0.516 (medium), and 0.508 (medium) for the BITE-SS, PHQ-9, and GAD-7, respectively.

Results for patients with SAD

Of the 23 subjects screened, four were excluded: two had high risk of suicide, and the primary
diagnoses of the other two were not SAD (autism spectrum disorders). As a result, 19 patients
met the enrollment criteria and were referred to the study. All patients completed the study.
Table III shows the baseline clinical variables and demographics of the 19 patients who enrolled
in this study (Table III). In all, 14 of the participants were women (74 percent), and the patients’
mean age was 32.3 years. Four patients (21 percent) were unemployed and 12 (63 percent)
were single. All participants met the principal DSM-IV diagnostic criteria for SAD (mean duration:
14.3 years). Patients with additional Axis I diagnoses included five (26 percent) who met the
criteria for major depressive disorder, two (13 percent) for bipolar disorder type II, and one
(5 percent) for panic disorder with agoraphobia.

Table II Demographic and clinical characteristics for BN

Variable Value

Gender, female, n (%) 8 (100)

Age, years, mean (SD) 31.3 (10.4)
BMI (kg/m2) 23.5(5.7)
Comorbid Axis I diagnosis, n (%)
Without comorbidity (BN only) 5 (62.5)
With comorbidity 3 (37.5)
Age of onset, years, mean (SD) 20.8 (7.1)
Duration of BN, years, mean (SD) 10.4 (8.9)
Employment status, n (%)
Employed full-time 1 (12.5)
Full-time student 3 (37.5)
Homemaker 2 (25.0)
Unemployed 2 (25.0)
Marital status, n (%)
Single 5 (62.5)
Married 3 (37.5)
Divorced 2 (25.0)
Educational background, n (%)
Junior high school 0 (0)
High school 1 (12.5)
Diploma 3 (37.5)
Degree 4 (50.0)
Currently on medication, n (%)
BZ and/or AD and/or MS 5 (62.5)

Notes: n ¼ 8; BN, bulimia nervosa; BZ, benzodiazepines; AD, antipsychotics; MS, mood stabilizers

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 Table III Demographic and clinical characteristics for SAD
Variable Value

Gender, female, n (%) 14 (74)

Age, years, mean (SD) 32.3 (9.7)
Subtype, generalized, n (%) 16 (84)
Comorbid Axis I diagnosis, n (%)
Without comorbidity (SAD only) 11 (58)
With comorbidity 8 (42)
Age of onset, years, mean (SD) 17.9 (8.8)
Duration of SAD, years, mean (SD) 14.3 (10.5)
Employment status, n (%)
Employed full-time 6 (32)
Full-time student 5 (26)
Part-time/homemaker 4 (21)
Unemployed 4 (21)
Marital status, n (%)
Single 12 (63)
Married 6 (32)
Divorced 1 (5)
Educational background, n (%)
Junior high school 2 (13)
High school 7 (37)
Diploma 6 (32)
Degree 4 (21)
Currently on medication, n (%)
AD and/or BZ 17 (87)

Notes: n ¼ 19; SAD, social anxiety disorder; BZ, benzodiazepines; AD, antidepressants

The primary outcome measure was the severity score of the LSAS. The average LSAS score
decreased from 87.05 (SD ¼ 29.40) to 54.00 (SD ¼ 29.99) over the course of the study.
The PHQ-9 and GAD-7 scores reduced from 11.11 (SD ¼ 6.88) to 6.84 (SD ¼ 5.07) and 9.32
(SD ¼ 5.86) to 5.74 (SD ¼ 4.74), respectively. A within-group t-test revealed significantly different
scores between the pre- and post-CBT scores on the assessed scales: t(1, 18) ¼ 5.627,
po0.001, for the LSAS; t(1, 18) ¼ 3.338, p ¼ 0.003 for the PHQ-9; and t(1, 18) ¼ 2.486,
p ¼ 0.002 for the GAD-7. The effect sizes between pre- and post-CBT were 1.124 (large), 0.620
(medium), and 0.611 (medium) for the LSAS, PHQ-9, and GAD-7, respectively.

Result of feedback from trainees

Ten trainees took part in the post-hoc survey about the training course. Regarding satisfaction with
the length (i.e. one day a week for two years) of the training course, eight selected “satisfied,” and
two selected “very satisfied.” As for the workshops, six selected “satisfied,” three selected “very
satisfied,” and one selected “slightly satisfied.” With respect to the frequency and the duration of the
supervision, five selected “satisfied,” three selected “slightly satisfied,” and two selected “satisfied.”
In response the question about the distinctive aspects of our training course compared to
previous CBT training, five mentioned the continuity and practicality of our course, in contrast
to classroom lectures for a short period. Additionally, four trainees appreciated the colleagues
they had made through the training, and noted that they still support each other. Moreover, two
pointed out that they obtained a wider perspective of CBT because both psychologists and
psychiatrists were instructors in the training course. Regarding the difficulties trainees had
during the training, three referred to their reluctance to record the sessions, although their clients
usually agreed to be recorded. Finally, two noted that it was difficult to write clinical case reports.

Discussion
The purpose of this study was to report the preliminary outcomes of individual CBT for OCD, BN,
and SAD delivered by the trainees of the Chiba CBT training course. We included patients with

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 comorbid mood disorders if OCD, SAD, or BN was the principal diagnosis to reflect routine
clinical practice. The results demonstrated that individual CBT for OCD, BN, and SAD in Japan
led to significant reductions in symptom severity for these primary diagnoses. The effect size
for OCD was comparable with those obtained in past trials involving psychological treatment for
OCD (Rosa-Alcázar et al., 2008), and those for BN and SAD were large. Our study was designed
not only to recruit patients similar to those seen in routine clinical practice but also to train
clinicians who will be engaged in routine clinical practice; they were not fully trained therapists
before this study.
Although it is difficult to directly compare our effect sizes with other published data due to a variety
of factors (e.g. patient demographic and type/intensity of CBT), the overall effect sizes of 0.63 for
PHQ-9 (medium) and 0.66 for GAD-7 (medium) were less than were those in other IAPT and other
studies (Clark et al., 2009; Radhakrishnan et al., 2013; Richards and Borglin, 2011; Richards and
Suckling, 2009; Westbrook and Hill, 1998; Westbrook and Kirk, 2005). It is possible that severity of
depression and anxiety among our recruited patients was lower than that observed in previous
reports, and thus resulted in a lower effect size. However, it is noteworthy that our results showed
the lowest scores of PHQ-9 and GAD-7 at post-treatment (Table IV).
Our training course was highly evaluated by the trainees regarding the satisfaction with the
length of the training course, the content of the workshops, and the frequency and duration of
the supervision. This was confirmed by their comments suggesting that our course offered more
comprehensive training than other courses. The trainees valued colleagues, probably because
most of them do not have someone to consult (even to talk) about CBT at their workplace.
In order to address the difficulties in writing case reports, the supervisors addressed this issue by
providing a special seminar about academic writing.

Dissemination of CBT across Japan

As noted in the Introduction, CBT is only covered by national health insurance for the treatment
of mood disorders, primarily because the quantity of outcome research in CBT, particularly using
randomized control trials, is exceptionally low in Japan. As Gunter and Whittal (2010) proposed,
we need to conduct studies and evaluate more research-based data to obtain required funding
and organizational support. The other issue hindering the dissemination of CBT in Japan is the

Table IV Comparison of effect sizes among various studies

Symptom Data source Intensity of CBT a N (Dep, Anx) Outcome Pre mean (SD) Post mean (SD) ES b

Depression Current data High 45 (0%, 82%) PHQ-9 10.6 (6.3) 6.6 (5.5) 0.63
Westbrook and Hill (1998) na 36 (27%, 36%) BDI 18.2 (9.9) 10.9 (10.4) 0.79
Westbrook and Kirk (2005) na 776 (19%, 56%) BDI 16.9 (10.5) 9.8 (9.0) 0.68
Clark et al. (2009): Doncaster High and low 1,648 (95%, 5%) PHQ-9 15.8 (6.2) 7.5 (6.9) 1.34
Clark et al. (2009): Newham High and low 221 (46%, 43%) PHQ-9 15.3 (6.2) 8.2 (7.2) 1.15
Richards and Suckling (2009) High and low 1,274 (na) PHQ-9 16.0 (6.15) 8.1 (7.2) 1.28
Richards and Borglin (2011) High and low 4,183 (77%, 8%) PHQ-9 16.2 (6.2) 9.0 (7.3) 1.17
Radhakrishnan et al. (2013) High 2,230 (na) PHQ-9 14.4 (6.7) 9.2 (9.0) 0.79
Low 4,854 (na) PHQ-9 12.5 (6.3) 8.0 (9.4) 0.72
Anxiety Current data High 45 (0%, 82%) GAD-7 9.1 (5.8) 5.2 (4.6) 0.66
Westbrook and Hill (1998) na 36 (27%, 36%) BAI 15.2 (10.4) 11.4 (11.1) 0.37
Westbrook and Kirk (2005) na 473 (25%, 48%) BAI 17.0 (11.8) 10.6 (8.9) 0.54
Clark et al. (2009): Doncaster High and low 1,648 (95%, 5%) GAD-7 13.9 (5.2) 6.8 (6.2) 1.37
Clark et al. (2009): Newham High and low 221 (46%, 43%) GAD-7 13.7 (5.1) 6.8 (5.8) 1.35
Richards and Suckling (2009) High and low 1,274 (na) GAD-7 14.0 (5.2) 7.2 (6.3) 1.07
Richards and Borglin (2011) High and low 4,183 (77%, 8%) GAD-7 14.1 (5.1) 8.1 (6.4) 1.17
Radhakrishnan et al. (2013) High 2,230 (na) GAD-7 12.9 (5.3) 8.2 (8.2) 0.89
Low 4,854 (na) GAD-7 11/7 (5.4) 7.3 (9.0) 0.82

Notes: CBT, cognitive behavioural therapy; PHQ-9, patients health questionnaire-9 items; GAD-7, generalized anxiety disorder-7 items; BDI,
Beck depression inventory; BAI, Beck anxiety inventory; Dep, depressive disorder; Anx, anxiety disorder; ES, effect Size. aHigh, one-to-one,
face-to-face psychological therapy; Low, guided self-help (e.g. using books, leaflets or computer support) and group psychoeducation. bEffect
sizes (Cohen’s d ) for each study were recalculated using same formula

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 paucity of training opportunities. Opportunities are limited for both pre- and post-qualification
training. More than 160 universities and colleges provide postgraduate master’s programs in
clinical psychology, but only a few courses incorporate CBT in their curricula because of the
scarcity of CBT experts. Our hope is that post-qualification training courses will be established in
other areas of Japan so that more health professionals can attend workshops and benefit from
regularly supervised practice.
Through the development and administration of the training course, the supervisors gained a
wealth of professional knowledge concerning the dissemination of CBT in Japan. For example,
approximately two years before the commencement of the training course, a survey was
conducted with a number of psychiatric hospitals and clinics in Chiba province to identify the
type of therapies that patients desired and clinicians would like to learn (Haraguchi et al.,
submitted for publication). The result of this survey revealed the strong need for CBT and
provided rationale for establishing our training course. Additionally, as they ran the training
course, supervisors had to identify and solve problems and difficulties as these arose. For
instance, some trainees had difficulties with academic writing because they had completed their
undergraduate or postgraduate course many years ago. A special workshop was organized for
the improvement of writing skills. To modify bias in their assessments, supervisors occasionally
watched a video of a session together and compared each other’s scores on the CTS-R.
Moreover, they asked their supervisees to rate the Process Evaluation of Training and
Supervision scale (Wilson, 2007) to assess the duration, frequency, supportive, and formative
factors of supervision.
The concept of CBT as a Western therapy requiring major adaptation for effective use in
Japanese culture must be considered further in on-going research. Compared to Western
cultures, more emphasis is placed on interpersonal relationships than on self-fulfillment or
self-development in Asian cultures. However, we believe that similar factors support the efficacy
and utilization of CBT in Japan. For example, in a randomized trial, Nakatani et al. (2005)
demonstrated that behavioral therapy is highly effective for Japanese patients with OCD.
Matsunaga et al. (2008) elucidated the transcultural stability of the symptom structure of
OCD, which is consistent with the hypothesis that OCD is mediated by universal
psychobiological mechanisms.

The limitations of this study

Although the present study provided valuable information, it does have several limitations. This
was a single-arm study without a concurrent control group. Moreover, our waiting period was
not fixed, and scores were not obtained at a pre-treatment baseline point. Although these
design factors reflect the real-world nature of mental health services, it remains unknown
whether the observed improvements in symptom severity was related to the natural extinction of
the disorders. More studies employing psychological placebo conditions to control for
nonspecific factors, such as positive outcome expectancy and self-efficacy for problem
management, are needed.
This study established the acute effectiveness of the treatment, but the lack of follow-up data
limits the generalizability of the study (e.g. long-term effects, relapse rates). Further, there was no
control for the patients’ use of medication, although our patient group had typically taken
antidepressant medication for an extended period before referral to Chiba University Hospital.
Again, this circumstance reflects the reality of the population of patients who access secondary
mental health services in Japan. Further studies will need to include fixed waiting periods,
control groups, and long-term follow-up to provide more insight into the implementation of CBT
in routine practice in Japan. Currently, our research team is running a randomized control trial for
SAD (Yoshinaga et al., 2013: trial number: UMIN000007552) and single-arm trials for OCD and
BN with fixed waiting periods. Changes in employment status, such as fewer days absent from
work, should be examined after completion of the therapy. This would be a crucial test of
whether increased access to psychological therapies would largely pay for itself by reducing
other depression- and anxiety-related public costs (e.g. welfare benefits and medical costs) and
increasing revenues (e.g. taxes, increased productivity).

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This study focused on the effectiveness of CBT delivered by trainees to evaluate our training
program. However, it remains unknown if the result of the CBT is due to the training or whether
trainees had been already competent. Thus, other measures could also be employed to gain a
better understanding of the ways training should be provided. Comparing scores on the
cognitive therapy awareness scale (Sudak et al., 2003) – a multiple-choice questionnaire
(Maunder et al., 2008; Myles and Milne, 2004) – between pre- and post-training would reveal
how competent trainees felt as they progressed through training. A video assessment task
(Myles and Milne, 2004) would provide a more objective perspective of the trainee competence.

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Corresponding author
Dr Osamu Kobori can be contacted at: Osamu.Kobori@googlemail.com

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