They Just Know

How do some young animals know what to do and how to do it? Does someone teach a caterpillar what to eat? Who gives a baby shark swimming lessons? Sometimes young animals learn things from their parents, but other times… they just know! Explore animal instincts through engaging text and fanciful illustrations.

-an Oregon Firebirds romance story- The Oregon Firebirds are the very best at one thing—saving homes. Finding their own poses problems. Jasper Jones flew as Curt’s wingman since he moved in next door at the age of six. But meeting Curt’s stunning older sister? He never could talk to her when they were kids. Time hasn’t fixed the problem. Jana Williams holds herself together by the thinnest of threads. She lost her dream job as an Army helo pilot the day she lost her hand. And with that, her sense of self worth. But nothing prepared her for the impact the right man could have on her life and her heart.

The role of explicit, declarative knowledge in general health care and in psychotherapy is a growing field of research. In many areas of healthcare, knowledge is regarded as an important factor for successful interventions. Participants within mental-health interventions should ideally gain knowledge about their specific conditions and strategies to improve, in order to manage their problems in more helpful ways. In Cognitive Behaviour Therapy (CBT), explicit knowledge is a core feature when treating clients and educating them about their symptoms, problems and potential solutions. Still, the role of knowledge and its relation to treatment outcome within CBT treatments is unclear. CBT administered over the internet (ICBT), is mainly based on psychoeducative texts and thus provides a suitable format for an initial evaluation of explicit knowledge within a clinical research context. The role of explicit knowledge could be of particular importance in the study of younger target groups, who probably have their first treatment experience. Their knowledge gain and its use could be of importance both as separate constructs but also in relation to symptom reduction following treatment. The overarching aim of this thesis was to explore the role of explicit knowledge in internet-delivered CBT for adolescents with depression and anxiety. Study I explored the role of explicit knowledge in a randomised controlled trial with adolescents suffering from primary depression. A knowledge test was constructed and administered at pre- and post-treatment. Results showed that explicit knowledge and certainty of knowledge about depression, anxiety and CBT increased during treatment, but that these variables were unrelated to treatment outcome. Lower pre-treatment knowledge levels (certainty) however predicted greater improvement in depressive symptoms. Study II describes the procedure of developing a new knowledge test in the context of ICBT for adolescents with depression and anxiety. An explorative factor analysis was performed and resulted in a three-factor solution with the following factors: Act in aversive states, Using positive reinforcement, and Shifting attention. The procedure presented could illustrate one way of creating a test for knowledge evaluation in ICBT, but its clinical use needs to be evaluated further. In Study III, participants from a randomised controlled trial of ICBT for adolescent depression were asked about their acquired knowledge and knowledge use six months later. Qualitative methodology (thematic analysis) was used. The results showed two overarching ways that clients can remember and relate to CBT-principles after treatment; one more explicit way related to the active application of CBT principles, and another vague way of recalling treatment content and the passive usage of CBT. Both ways of recalling CBT principles were related to experiencing the treatment as helpful. Study IV evaluated the role of learning strategies and chat-sessions in ICBT for adolescents with anxiety and depression. A total of 120 adolescents were randomised to one of four treatment groups, in a 2x2 factorial design with the two factors: with or without learning support and/or chat-sessions. Overall, the results showed general reductions of anxiety and depressive symptoms, and increased knowledge levels. Participants receiving learning strategies during treatment obtained more immediate benefits in treatment outcome and knowledge levels, but at six months follow-up participants without learning support had reached equal amounts of knowledge and symptom reduction. Chat-sessions did not add any effect on treatment outcome or knowledge levels. In conclusion, this thesis suggests that explicit knowledge is a construct that is independent of symptom reduction and increases during ICBT treatments for adolescents with depression and anxiety. Increased knowledge, and increased certainty of knowledge, are valuable outcomes since CBT emphasises educating clients about symptoms, therapeutic principles, and strategies that they can remember and use later on. The lack of association between explicit knowledge gain and symptom reduction could indicate that explicit knowledge is a necessary but insufficient factor for symptom reduction. Adding learning strategies within a treatment programme could be of importance for enhancing short-term treatment effects. There is a continued need for more research on the role of knowledge in ICBT, both as an outcome and as a way to improve treatment effects. The findings in this thesis however suggest that research on explicit knowledge is important to understand what makes ICBT work. Explicit kunskap och dess roll i psykoterapi är ett växande forskningsområde. I kognitiv beteendeterapi (KBT) har explicit kunskap en kärnfunktion då man behandlar klienter och utbildar dem om deras symptom, problemområden och potentiella lösningar. Trots detta är kunskapens roll och dess relation till behandlingsresultat vid KBT oklar. KBT som administreras via internet (IKBT) baseras huvudsakligen på psykoedukativa texter, och kan således vara ett lämpligt format för en initial utvärdering av explicit kunskap. Syftet med denna avhandling var att undersöka om kunskap ökar under IKBT för tonåringar med depression och ångest, dess relation till behandlingsutfall, och om lärandestöd kan öka effekten av behandling. De fyra inkluderade studierna visar att explicit kunskap är ett unikt konstrukt som, oberoende av symtomminskning, ökar under behandling. Deltagare kan komma ihåg behandlingsinnehåll och uppleva KBT kunskap som användbart i deras vardag. Detta är ett värdefullt resultat då KBT betonar vikten av att utbilda klienter om symtom, principer och strategier som de kan komma ihåg och använda. Ett nytt kunskapstest utvecklades och validerades initialt för potentiell användning i framtida kliniska studier. En av studierna visade, via experimentell design, att lärandestöd i behandlingsmoduler kan förbättra kortvariga behandlingseffekter. Sammanfattningsvis är forskning om explicit kunskap viktigt för att förstå vad som får IKBT att fungera.

Issues are something that we all have, and some more than others. But it is okay. It is absolutely okay to have issues, as long as you can put things in perspective. Sometimes our issues are something that gives you strength, or they can zap the very strength from you! I am here to tell you having issues can be a blessing, as long as you can match them up with the word of God, and stand on top of them instead of them standing on top of you! I am excited about my issues! That hasn't been the case, a long time ago, but now I see the blessings, and I rejoice and praise the Lord for my issues, and the freedom I have received. Every t time I think about how many times in the name of Jesus, I have been blessed, because of, and in spite of my issues! I found out we are going to be alright!

Spaulding believes success-- in business and in life-- is all about relationships. He takes Dale Carnegie's classic philosophy to the next level, showing how by developing deeper relationships through giving to others and putting them first, we benefit as well.

Now in paperback, Pulitzer Prize-winning columnist Goodman and novelist/journalist O'Brien take a thoughtful and deeply personal look at the enduring bonds of friendship between women.