The current emphasis on Evidence Based Medicine (EBM) is both welcome as a bid to improve the empirical foundations of clinical practice and a cause for concern because it has the potential to distort the scientific approach that has underpinned the development of cognitive-behavioural approaches. It is suggested here that EBM needs to be seen in context; that is, as an approach that almost exclusively focuses on just one of the dimensions that have been and are crucial to the further development of Cognitive-Behavioural Treatments (CBT). EBM is particularly well suited to the development of Biological approaches to treatment, where treatments (and treatment development) are largely atheoretical. However, different considerations apply to CBT, where validated theory and linked research studies are key factors. It is suggested that relationship to evidence in CBT is best conceptualized in terms of Empirically Grounded Clinical Interventions. The parameters of such an approach are considered in relation to the Scientist Practitioner model that is prevalent in the field.

According to the cognitive theory, obsessional problems occur when the occurrence and/or content of intrusive thoughts are interpreted as a sign of increased personal responsibility for some harmful outcome to oneself or others. The link between normal intrusive thoughts and obsessional thoughts is outlined. Current definitions of “neutralizing” and “responsibility” within the cognitive framework are examined and clarified. Responsibility-driven attempts to control cognitive activity explain obsessional and compulsive phenomena better than generalized deficit models. Recent descriptions of “meta-cognitive” factors in obsessions echo the existing cognitive model and have similar implications. An extension of the cognitive-behavioural model suggests a link between thought suppression and the perception of responsibility and to concerns about failure to act (omissions).

Some studies of computerized cognitive behaviour therapy (CCBT) have found evidence of its effectiveness, yet a number have reported low uptake and/or completion rates. This study investigated attitudes towards CCBT for depression amongst 122 university students. The credibility of CCBT, expectancy-for-improvement and perceived likelihood of using it were all poor, although a minority (9.8%) stated a preference for CCBT over other interventions. When 20 of the original sample received a demonstration of a CCBT programme for depression, significant increases in credibility, expectancy-for-improvement and in perceived likelihood of using CCBT were found. Numbers stating a preference for CCBT increased to 30%. At both stages, most students stated a preference for CCBT to be accompanied by counselling. Qualitative analysis provided information about factors that might influence these attitudes. Implications for service delivery are discussed.

A modified version of the probe detection task was used to investigate the time course of attentional biases for emotional words in high and low socially anxious individuals. Word pairs were presented at two exposure durations, 200 and 500 msec, in order to investigate the different components of attentional bias in anxiety (e.g., vigilance or avoidance of threat). There was evidence of an attentional bias favouring initial vigilance towards (social and physical) threat words and subsequent avoidance of the same stimuli in high social anxiety. In contrast, low socially anxious individuals did not exhibit an attentional preference. The interaction of social anxiety and exposure duration for threat words remained when controlling for general negative affect. Theoretical and clinical implications of the results are discussed.

The study tested the hypothesis, derived from Teasdale and Barnard's (1993) Interacting Cognitive Subsystems (ICS) model, that two commonly used techniques in cognitive therapy, automatic thought records (ATRs) and behavioural experiments (BEs), would have their primary impact on different cognitive subsystems. Teasdale (1997a, b) has suggested that while ATRs tend to impact on a logic-based propositional information processing system, BEs impact on a more holistic implicational system, which has extensive links with emotion. Quantitative and qualitative data derived from three groups of participants undertaking cognitive therapy training courses, who practised ATRs and BEs on themselves, supported Teasdale's theory. Differences were found in participants' ratings of behaviour and belief change, with BEs being perceived as more powerful and compelling than ATRs, as predicted by the theory. There were also qualitative differences in participants' experiences of the two techniques, suggestive of different modes of processing. The data indicated the particular importance of the therapist's role in BEs. In order to provide a more comprehensive account of ATRs and BEs, it was suggested that Teasdale's theory could profitably be extended to include the role of the therapist in promoting adaptive oscillation between the implicational and propositional modes.

Background: Research has begun to examine the effectiveness of computerized cognitive behaviour therapy (cCBT) with children and adolescents. Although cCBT appears promising, the attitudes of clinicians towards this type of intervention with children and young people have not been assessed, yet these are important in determining when and if cCBT will be offered. Aims: To survey clinicians’ attitudes towards cCBT with children and adolescents. Method: A self-report questionnaire was completed by 43 mental health professionals attending a conference. Results: Clinicians were cautious but generally positive about the use of cCBT with children and adolescents, particularly for the delivery of prevention programmes and in the treatment of mild/moderate problems. Few felt that cCBT should be available freely online without any professional support. Indeed, the lack of a therapeutic relationship and professional support were identified as the biggest problems, whilst the potential to use cCBT at home was the greatest advantage identified. Conclusions: This survey suggests that clinicians are generally positive about the use of cCBT with children and adolescents for the prevention and treatment of mild/moderate problems. Further research is required to address clinicians’ concerns about the effectiveness of cCBT for more substantial problems and the level of therapeutic support required.

This paper reviews cognitive theories of eating disorders as they are usually applied in treatment. More recent theoretical contributions and theory that is not widely applied are also reviewed. A set of hypotheses is derived from these theories and evidence for the validity of each hypothesis is discussed: this includes evidence from treatment studies, questionnaire studies and from experimental psychology. Following review of existing evidence, the paper summarizes the current status of cognitive theory in eating disorders. It then considers ways in which theory and research could be developed in order to improve and extend our understanding of cognitive content and processes in eating disorders. Limitations of existing models are highlighted and gaps in our knowledge, including knowledge of variables that typically have a central role in cognitive theory, are identified. Further strategies to test the validity of hypotheses derived from cognitive theory are suggested, together with strategies that might extend existing theory. It is concluded that much further research is needed, both to test the validity of existing theoretical contributions and to extend theory so that it will be more useful in clinical practice.

Background: The tendency to employ both cognitive reappraisal and mindfulness are associated with reduced trait social anxiety; however, it is unclear whether reappraisal and mindfulness are associated with social anxiety through the same mechanisms. It has been proposed that decentering, or the process of seeing thoughts or feelings as objective events in the mind rather than personally identifying with them, may be a key mechanism underlying both cognitive reappraisal and mindfulness. Aims: To examine the relationships between reappraisal, mindfulness, decentering, and social anxiety. Method: This study utilized structural equation modeling to examine the relationships among cognitive reappraisal, mindfulness, decentering, and social anxiety in a large cross-sectional study. Results: Results indicate that the relationship between mindfulness and social anxiety is partially accounted for by decentering, whereas the relationship between cognitive reappraisal and social anxiety is more fully accounted for by decentering. Conclusions: These results imply that decentering may be a common mechanism underlying both cognitive reappraisal and mindfulness, although mindfulness may also affect social anxiety through additional mechanisms. However, given the cross-sectional nature of these findings, results should be considered preliminary, with future research being needed to further elucidate these relationships.

Background: Cognitive bias modification (CBM) is a novel treatment for anxiety disorders that utilizes computerized tasks to train attention and interpretation biases away from threat. To date, attitudes toward and acceptability of CBM have not been systematically examined. Method: We conducted qualitative interviews with 10 anxious primary care patients to examine attitudes toward and initial impressions of CBM. Interviews explored general impressions, as well as reactions to the treatment rationale and two computer programs, one targeting attention bias and one targeting interpretation bias. Three clinical psychologists independently coded transcripts and collaboratively developed categories and themes guided by grounded theory. Results: A number of facilitators and barriers emerged related to engaging in treatment in general, computerized treatment, and CBM specifically. Participants stated that the written rationale for CBM seemed relevant and helpful. However, after interacting with the attention modification program, participants frequently expressed a lack of understanding about how the program would help with anxiety. Participants reported greater understanding and engagement with the interpretation modification program. Conclusions: Participants reported a number of positive characteristics of CBM, but it may need improvements regarding its treatment rationale and credibility. Future qualitative studies with individuals who complete a CBM treatment are warranted. Implications for future CBM development and dissemination are discussed.

People with Asperger syndrome (AS) appear to have higher than expected rates of co-morbid psychiatric disorder. The main co-morbid diagnoses are anxiety disorders and depression, but eating disorders, obsessive compulsive disorder, substance abuse and bipolar affective disorder have all been reported. Cognitive Behaviour Therapy (CBT) is used effectively to treat these conditions, so could it be used in people who also have Asperger syndrome? This paper reviews important components and characteristics of cognitive behaviour therapy in relation to its use with people who have Asperger syndrome with reference to the relevant literature and to feedback from people with AS. The use of CBT in people with Asperger syndrome appears promising, but further work is needed to evaluate its effectiveness and to examine which particular aspects of therapy are helpful.

Background: It is recommended that Mindfulness-Based Cognitive Therapy (MBCT) instructors should undertake MBCT themselves before teaching others. Aim: To investigate the impact of MBCT (modified for stress not depression) on trainee clinical psychologists. Method: Twenty trainees completed questionnaires pre- and post-MBCT. Results: There was a significant decrease in rumination, and increases in self-compassion and mindfulness. More frequent home practice was associated with larger decreases in stress, anxiety and rumination, and larger increases in empathic concern. Only first-year trainees showed a significant decrease in stress. Content analysis of written responses indicated that the most commonly reported effects were increased acceptance of thoughts/feelings (70%), increased understanding of what it is like to be a client (60%), greater awareness of thoughts/feelings/behaviours/bodily sensations (55%) and increased understanding of oneself and one's patterns of responding (55%). Participants reported increased metacognitive awareness and decentring in relation to negative thoughts. Eighty-five percent reported an impact on their clinical work by the end of the course. Conclusions: Trainee psychologists undergoing MBCT experienced many of the psychological processes/effects that they may eventually be helping to cultivate in clients using mindfulness interventions, and also benefits in their general clinical work.

Background: Desire thinking is defined as a voluntary thinking process orienting to prefigure images, information and memories about positive target-related experience. Recent research has highlighted the role of desire thinking in the maintenance of addictive, eating and impulse control disorders. Currently little is known about metacognitions in desire thinking. Aim: To investigate: (1) the presence and content of desire thinking during a desire experience; (2) the presence of metacognitive beliefs in desire thinking; (3) the goal of desire thinking; (4) attentional focus during desire thinking; and (5) the impact of desire thinking on craving. Method: Twenty-four individuals with a diagnosis of either alcohol abuse, bulimia nervosa, pathological gambling or smoking dependence were assessed using a semi-structured interview. Results: Findings indicated that participants engaged in desire thinking and endorsed both positive and negative metacognitive beliefs about this process. The goal of desire thinking was to regulate internal states. Participants also reported that during a desire experience their attentional focus was continuously shifting between internal state and external context and that engaging in desire thinking increased craving. Conclusions: These findings provide preliminary evidence that metacognitions play a role in desire thinking.

Background: Health anxiety (HA), or hypochondriasis, is a psychological problem characterized by a preoccupation with the belief that one is physically unwell. A 2007 Cochrane review (Thomson and Page, 2007) found cognitive behavioural therapy (CBT) to be an effective intervention for individuals with HA. Similar findings were reported in a recent meta-analysis (Olatunji et al., 2014), which did not employ a systematic search strategy. The current review aimed to investigate the efficacy of CBT for HA, and to update the existing reviews. Method: A systematic search was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance, including randomized controlled trials that compared CBT with a control condition for people with HA. Five hundred and sixty-seven studies were found in the original search, of which 14 were included in the meta-analysis. Results: Meta-analysis was conducted on 21 comparisons and a large effect size for CBT compared with a control condition was found at post therapy d = 1.01 (95% confidence interval 0.77–1.25), as well as at 6- and 12-month follow-up. Conclusions: This systematic review and meta-analysis provides support for the hypothesis that CBT is an effective intervention for HA when compared with a variety of control conditions, e.g. treatment-as-usual, waiting list, medication, and other psychological therapies.

Foa (1979) has identified two groups of obsessional patients for whom behaviour therapy is ineffective; those with severe concurrent depression and those with “overvalued ideation”. She has also highlighted the need for the development of new treatment strategies for these individuals. A case history illustrating the development of overvalued ideation in a previously typical obsessional patient is described, together with an account of a successful treatment based on Beck's cognitive therapy combined with exposure. The implications of this report for views on the development of overvalued ideation in obsessionals are discussed. It is argued that cognitive–behavioural interventions such as the one described here may be useful as an adjunct to more traditional behavioural treatments for obsessional disorders as well as in the treatment of patients with overvalued ideation.

This paper describes the rationale for and development of an online cognitive-behavioural treatment for child and adolescent anxiety (BRAVE–ONLINE). It highlights the challenges involved in adapting a clinic-based intervention for delivery using the internet, with separate sessions for parents and their children (or adolescents). We outline strategies to ensure that young people remain engaged in online therapy, and describe techniques designed to optimize the alliance between clients and the online therapist. Two case studies are presented that illustrate the practical and technical aspects of implementing the intervention, and demonstrate the feasibility of achieving successful outcomes using online delivery of CBT for child and adolescent anxiety. However, firm conclusions regarding the efficacy of this approach cannot be drawn until the results of randomized controlled trials are available. The paper identifies directions for future research.

Definitions of treatment failure and the labelling of patients as non-responsive typically require treatments to have been offered and failed. For pharmacological treatments, treatment quality is relatively easy to define; this is much more difficult with psychological treatments. This study examined patient recollections of previous therapy for obsessive compulsive disorder (OCD). A Treatment History Questionnaire was administered to a sample of 57 apparently treatment refractory OCD patients from a specialist national OCD treatment unit and a national charity for OCD sufferers. On average, respondents reported an 8$\frac{1}{2}$ year wait between the obsessional symptoms interfering significantly with their lives and being diagnosed. Forty-three percent recalled having received either cognitive behaviour therapy (CBT) or behaviour therapy as the first treatment; 31% of the group did not know what type of therapy they had received. The components of therapy that respondents recalled were analysed and contrasted with minimal therapy criteria. These criteria appear not to have been met in most patients who understood that they had received “CBT”. The implications of this study for assessment of treatment integrity and the classification of patients as “treatment resistant” are discussed.

The quality control of therapy in routine clinical practice depends to a large degree on the ability of therapists to evaluate accurately their own performance in administering therapy. However, the literature in many fields casts doubt on the accuracy of people's self-evaluations. This study aimed to examine the accuracy of therapists' judgments about their own competence in cognitive therapy. Twenty-two therapists rated a tape of one of their cognitive therapy sessions from the middle of therapy using the Cognitive Therapy Scale (CTS) and provided information about their profession and their training in cognitive therapy. An independent expert rater, blind to all information about the therapist, also rated these tapes on the CTS. Therapists were coded as Competent or Less Competent on the basis of the observer-rated CTS score. Whilst there was a significant correlation between self-ratings and expert ratings of competence, therapists significantly over-rated their competence relative to the expert rater. Less competent therapists over-rated their own competence to a greater degree than therapists who met criteria for competence. The finding that therapists, especially less competent therapists, over-rate their competence in cognitive therapy has serious implications for ensuring effective practice of cognitive therapy in routine clinical situations.

Background: Research has demonstrated the effectiveness of computerized cognitive behaviour therapy (cCBT) for depression and anxiety in adults, but there has been little work with children and adolescents. Aims: To describe the development of a cCBT intervention (Think, Feel, Do) for young people, and preliminary outcomes and feedback from a pilot randomized controlled trial. Method: Twenty participants aged 11 to 16 with depression or anxiety were randomized to receive cCBT immediately or after a delay. Standardized measures were used to assess self-reported anxiety, depression, self-esteem and cognitions, as well as parent rated strengths and difficulties. A feedback form was also completed to assess young people's views of the programme. Results: A total of 15 participants completed the pre and post assessments in the trial, and 17 provided feedback on the intervention. Paired samples t-tests demonstrated significant improvements on 3 subscales in the control condition, compared to 7 subscales in the cCBT condition. Feedback showed moderate to high satisfaction for participants. Conclusions: This study provides encouraging preliminary results for the effectiveness and acceptability of cCBT with this age group.

Background: Obese individuals frequently experience weight stigma and this is associated with psychological distress and difficulties. The process of external devaluation can lead to negative self-perception and evaluation and some obese individuals develop “internalized weight stigma”. The prevalence of weight stigma is well established but there is a lack of information about the interplay between external and internal weight stigma. Aims: To synthesize the literature on the psychological effects of weight stigma into a formulation model that addresses the maintenance of internalized weight stigma. Method: Current research on the psychological impact of weight stigma was reviewed. We identify cognitive, behavioural and attentional processes that maintain psychological conditions where self-evaluation plays a central role. A model was developed based on clinical utility. Results: The model focuses on identifying factors that influence and maintain internalized weight stigma. We highlight the impact of negative societal and interpersonal experiences of weight stigma on how individuals view themselves as an obese person. Processing the self as a stigmatized individual is at the core of the model. Maintenance factors include negative self-judgements about the meaning of being an obese individual, attentional and mood shifts, and avoidance and safety behaviours. In addition, eating and weight management behaviours become deregulated and maintain both obesity and weight stigma. Conclusion: As obesity increases, weight stigma and the associated psychological effects are likely to increase. We provide a framework for formulating and intervening with internalized weight stigma as well as making therapists aware of the applicability and transferability of strategies that they may already use with other presenting problems.

A new model of worry is presented, differing from previous work in which worry was set within a broader theory of anxiety. It is proposed that threat is initially evaluated in terms of imminence, likelihood, and cost set against perceived self-efficacy; this evaluation can produce worry as a relatively automatic response. Worry serves the functions of alarm, prompt, and preparation; in terms of processes, it leads to an unfocused attentional style, sensitivity to emotional information, and arousal (which produces self-absorption). Threat (and worry) are maintained if there are elevated evidence requirements or inappropriate problem solving. The therapeutic implications of the model are discussed briefly.