Background: Post-traumatic stress disorder (PTSD) is a common and debilitating consequence of natural disaster in children and adolescents. Accumulating data show that cognitive behavioural therapy (CBT) is an effective treatment for PTSD. However, application of CBT in a large-scale disaster in a setting with limited resources, such as when the tsunami hit several Asian countries in 2004, poses a major problem. Aims: This randomized controlled trial aimed to test for the efficacy of the modified version of CBT for children and adolescents with PSTD. Method: Thirty-six children (aged 10–15 years) who had been diagnosed with PSTD 4 years after the tsunami were randomly allocated to either CBT or wait list. CBT was delivered in 3-day, 2-hour-daily, group format followed by 1-month posttreatment self-monitoring and daily homework. Results: Compared to the wait list, participants who received CBT demonstrated significantly greater improvement in symptoms of PTSD at 1-month follow-up, although no significant improvement was observed when the measures were done immediately posttreatment. Conclusions: Brief, group CBT is an effective treatment for PTSD in children and adolescents when delivered in conjunction with posttreatment self-monitoring and daily homework.

Background: Psychoanalytic theory and some empirical research suggest the working alliance follows a “rupture and repair” pattern over the course of therapy, but given its emphasis on collaboration, cognitive behavioral therapy may yield a different trajectory. Aims: The current study compares the trajectory of the working alliance during two types of cognitive behavioral therapy for social anxiety disorder – virtual reality exposure therapy (VRE) and exposure group therapy (EGT), one of which (VRE) has been proposed to show lower levels of working alliance due to the physical barriers posed by the technology (e.g. no eye contact with therapist during exposure). Method: Following randomization, participants (N = 63) diagnosed with social anxiety disorder received eight sessions of manualized EGT or individual VRE and completed a standardized self-report measure of working alliance after each session. Results: Hierarchical linear modeling showed overall high levels of working alliance that changed in rates of growth over time; that is, increases in working alliance scores were steeper at the beginning of therapy and slowed towards the end of therapy. There were no differences in working alliance between the two treatment groups. Conclusion: Results neither support a rupture/repair pattern nor the idea that the working alliance is lower for VRE participants. Findings are consistent with the idea that different therapeutic approaches may yield different working alliance trajectories.

Background: Substantial epidemiological research has shown that psychotic experiences are more common in densely populated areas. Many patients with persecutory delusions find it difficult to enter busy social urban settings. The stress and anxiety caused by being outside lead many patients to remain in-doors. We therefore developed a brief CBT intervention, based upon a formulation of the way urban environments cause stress and anxiety, to help patients with paranoid thoughts to feel less distressed when outside in busy streets. Aims: The aim was to pilot the new intervention for feasibility and acceptability and gather preliminary outcome data. Method: Fifteen patients with persecutory delusions in the context of a schizophrenia diagnosis took part. All patients first went outside to test their reactions, received the intervention, and then went outside again. Results: The intervention was considered useful by the patients. There was evidence that going outside after the intervention led to less paranoid responses than the initial exposure, but this was only statistically significant for levels of distress. Conclusions: Initial evidence was obtained that a brief CBT module specifically focused on helping patients with paranoia go outside is feasible, acceptable, and may have clinical benefits. However, it could not be determined from this small feasibility study that any observed improvements were due to the CBT intervention. Challenges in this area and future work required are outlined.

Background: Increasing access to evidence-based talking therapies for people with psychosis is a national health priority. We have piloted a new, “low intensity” (LI) CBT intervention specifically designed to be delivered by frontline mental health staff, following brief training, and with ongoing supervision and support. A pilot feasibility study has demonstrated significant improvement in service user outcomes. This study is a qualitative analysis of the experiences of the staff and service users taking part in the evaluation. Aims: To evaluate the acceptability of the training protocol and the therapy, and to examine the factors promoting and restraining implementation. Method: All trained staff and service users completed a semi-structured interview that was transcribed and subjected to thematic analysis. Results: Service users spoke about learning new skills and achieving their goals. Staff spoke about being able to use a brief, structured intervention to achieve positive outcomes for their clients. Both groups felt that longer, more sophisticated interventions were required to address more complex problems. The positive clinical outcomes motivated therapists to continue using the approach, despite organizational barriers. Conclusions: For both trained staff and service users, taking part in the study was a positive experience. Staff members’ perceived skill development and positive reaction to seeing their clients improve should help to promote implementation. Work is needed to clarify whether and how more complex difficulties should be addressed by frontline staff.

Background: A large body of research has identified that many therapists do not use research to inform their practice, but few studies investigate the reasons behind this. Aims: The current study seeks to understand what sources therapists use to inform their practice and why they are chosen. Method: Thirty-three interviews with psychological therapists in the UK were undertaken. These were transcribed and analysed using Interpretative Phenomenological Analysis. Results: Two superordinate themes emerged. The former focused on the nature of evidence and the latter described why certain sources were used to make clinical decisions. When discussing evidence, participants felt that research studies, specifically Randomized Controlled Trials (RCTs), used unrepresentative samples. Therapists felt that research other than RCTs, particularly qualitative research, was important. Therapist specific factors were felt to be as, or more, important than the technique used to treat patients. When discussing the sources they used, therapists preferred to use their clinical experience or their patients’ experience to make clinical decisions. Theoretical or practical information was preferred to empirical research. The presentation of information was felt to be important to encourage the implementation of research, and therapists also felt tools such as outcome measures and manuals were too rigid to be useful. Finally, patients’ choice of treatment was felt to be important in treatment decisions. Conclusions: The views of therapists were heterogeneous, but this study highlighted some of the barriers to closing the gap between science and practice. This knowledge can be used to increase the translation of science into practice.

Background: The phenomenological heterogeneity of auditory hallucinations (AHs) means individual models struggle to account for all aspects of the experience. One alternative is that distinct subtypes of AHs exist, with each requiring their own unique explanatory model and tailored cognitive behavioural intervention strategies. Aims: This exploratory study tested for the presence of one specific potential AH-subtype, hypervigilance hallucinations (HV-AHs). Method: Four specific aspects of the phenomenology of AHs (chosen on the basis of the predicted phenomenology of HV-AHs) were assessed using a semi-structured interview in 32 individual AHs taken from reports from 15 patients with psychosis. Results: Cluster analysis (at the level of the individual AH-experience) offered support for the existence of a distinct HV-AH subtype, characterized by hearing threatening, externally-located voices when attention was externally-focused. Other clusters identified all shared the contrasting properties of occurring in quiet contexts when patients’ attention was internally focused. Conclusions: The results offered tentative support for the existence of an HV-AH subcategorization and justifies future research in larger samples. Potential implications for models of AHs are also considered.

Background: High quality randomized controlled trials (RCT) of psychotherapeutic interventions should ensure that the therapy being tested is what is actually delivered. However, contamination of one therapy into the other, a critical component of treatment adherence, is seldom measured in psychotherapy trials of psychosis. Aims: The aim of the study was to determine whether a purpose-designed measure, the ACE Treatment Integrity Measure (ATIM) could detect therapy contaminations within a controlled trial of cognitive behavioural therapy (CBT) versus Befriending for first-episode psychosis and to compare the ATIM to a more traditional adherence measure, the Cognitive Therapy Scale (CTS). Method: Therapy sessions were audio-recorded and at least one therapy session from 53 of the 62 participants in the RCT was rated by an independent rater using the CTS and ATIM. Results: Ninety-nine therapy sessions were rated. All Befriending sessions and all but three CBT sessions were correctly identified. The ATIM showed that 29 of the 99 (29%) sessions were contaminated by techniques from the other therapy. Within the CBT sessions, 19 of the 51 sessions (37%) were contaminated by one or more Befriending techniques. Of the Befriending sessions, 10 of 48 (21%) were contaminated by ACE techniques. The mean CTS score was higher in the CBT than the Befriending group. Conclusions: The ATIM was able to detect contaminations and revealed more meaningful, fine-grained analysis of what therapy techniques were being delivered and what contaminations occurred. The study highlights the benefit of employing purpose-designed measures that include contamination when assessing treatment adherence.

Background: Previous meta-analyses of cognitive-behavioural therapy (CBT) for children and young people with anxiety disorders have not considered the efficacy of transdiagnostic CBT for the remission of childhood anxiety. Aim: To provide a meta-analysis on the efficacy of transdiagnostic CBT for children and young people with anxiety disorders. Methods: The analysis included randomized controlled trials using transdiagnostic CBT for children and young people formally diagnosed with an anxiety disorder. An electronic search was conducted using the following databases: ASSIA, Cochrane Controlled Trials Register, Current Controlled Trials, Medline, PsycArticles, PsychInfo, and Web of Knowledge. The search terms included “anxiety disorder(s)”, “anxi*”, “cognitive behavio*, “CBT”, “child*”, “children”, “paediatric”, “adolescent(s)”, “adolescence”, “youth” and “young pe*”. The studies identified from this search were screened against the inclusion and exclusion criteria, and 20 studies were identified as appropriate for inclusion in the current meta-analysis. Pre- and posttreatment (or control period) data were used for analysis. Results: Findings indicated significantly greater odds of anxiety remission from pre- to posttreatment for those engaged in the transdiagnostic CBT intervention compared with those in the control group, with children in the treatment condition 9.15 times more likely to recover from their anxiety diagnosis than children in the control group. Risk of bias was not correlated with study effect sizes. Conclusions: Transdiagnostic CBT seems effective in reducing symptoms of anxiety in children and young people. Further research is required to investigate the efficacy of CBT for children under the age of 6.

Background: Patients diagnosed with a personality disorder (PD) are often stigmatized by the healthcare staff who treat them. Aims: This study aimed to compare the impact on front-line staff of a self-management Acceptance and Commitment Therapy-based training intervention (ACTr) with a knowledge- and skills-based Dialectical Behaviour Training intervention (DBTr). Method: A service-based randomized controlled trial was conducted comparing the effects of 2-day ACTr (N = 53) and DBTr (N = 47) staff workshops over 6 months. Primary outcome measures were staff attitudes towards patients and staff-patient relationships. Results: For both interventions, staff attitudes, therapeutic relationship, and social distancing all improved pre- to postintervention, and these changes were maintained at 6-month follow-up. Conclusions: Although offering different resources to staff, both ACTr and DBTr were associated with an improved disposition towards PD patients. Future research could evaluate a combined approach, both for staff working with PD patients and those working with other stigmatized groups.

Background: There is controversy as to whether psychological defensive avoidance is associated with paranoia. Aims: To elucidate whether “Poor-me” paranoid patients, who believe that the persecution they perceive is undeserved, show more prominent avoidance of negative thoughts about themselves than healthy and clinical controls. Method: The act of avoidance of aversive mental contents was assessed in 27 healthy controls and 48 patients with poor-me, bad-me (perceived to be deserved) or no paranoia. Defensive avoidance was assessed via established questionnaires, a novel task based on self-discrepancy theory and research-clinician ratings. Results: Participants in all groups showed substantial levels of verbal defensive avoidance. Paranoia was associated with reduced self-reported tolerance of negative mental contents (high Experiential Avoidance, EA). Contrary to our hypotheses, poor-me and bad-me patients showed similar EA. All participant groups showed similar levels of verbal defensive avoidance. Conclusion: The findings do not support an association of psychological avoidance with paranoia.

Background: The efficiency of stepped care systems partly relies on systematic monitoring of patient outcomes and timely decisions to “step up” patients without any clear therapeutic gains to the next level of treatment. Qualitative evidence has suggested that this does not occur consistently, nor always congruently with clinical guidelines. Aims: To investigate factors that influence psychological therapists’ decisions to prolong or to conclude treatment in cases with little evidence of therapeutic gains. Method: Eighty-two clinicians in stepped care services completed questionnaires about the likelihood of “holding” non-improving patients in treatment, and factors associated with referrals and holding (FARAH-Q). The factor structure, internal consistency and test-retest reliability of the measures was examined prior to assessing correlations between FARAH-Q items and likelihood of holding. Results: A 4-factor solution indicated that clinicians’ decision making is influenced by a complex interplay between beliefs, attitudes, subjective norms and self-efficacy. Correlational analysis indicated that holding is more likely to happen if there are perceived barriers to refer the patient for further treatment, if the therapist likes the patient and has a good therapeutic alliance, and if the therapist feels confident that s/he has the ability to achieve a positive outcome by prolonging treatment. Conclusions: Decisions to prolong or conclude treatment are not only influenced by evidence and guidelines, but also subjective beliefs, norms and attitudes. Understanding this decision making process is relevant to clinicians and supervisors interested in enhancing the efficiency of stepped care.

Background: Individuals with bipolar disorder often endorse dysfunctional beliefs consistent with cognitive models of bipolar disorder (Beck, 1976; Mansell, 2007). Aims: The present study sought to assess whether young adult offspring of those with bipolar disorder would also endorse these beliefs, independent of their own mood episode history. Method: Participants (N = 89) were young adult college students with a parent with bipolar disorder (n = 27), major depressive disorder (MDD; n = 30), or no mood disorder (n = 32). Semi-structured interviews of the offspring were used to assess diagnoses. Dysfunctional beliefs related to Beck and colleagues’ (2006) and Mansell's (2007) cognitive models were assessed. Results: Unlike offspring of parents with MDD or no mood disorder, those with a parent with bipolar disorder endorsed significantly more dysfunctional cognitions associated with extreme appraisal of mood states, even after controlling for their own mood diagnosis. Once affected by a bipolar or depressive disorder, offspring endorsed dysfunctional cognitions across measures. Conclusions: Dysfunctional cognitions, particularly those related to appraisals of mood states and their potential consequences, are evident in young adults with a parent who has bipolar disorder and may represent targets for psychotherapeutic intervention.

Background: Cognitive therapy is an effective treatment for social anxiety disorder but little is known about the mechanisms by which the treatment achieves its effects. Aims: This study investigated the potential role of self-focused attention and social phobia related negative automatic thoughts as mediators of clinical improvement. Method: Twenty-nine patients with social phobia received individual cognitive therapy (ICT) in a randomized controlled trial. Weekly process and outcome measures were analysed using multilevel mediation models. Results: Change from self-focused to externally focused attention mediated improvements in social anxiety one week later. In contrast, change in frequency of, or belief in, negative social phobia related negative automatic thoughts did not predict social anxiety one week later. Conclusions: Change in self-focused attention mediate therapeutic improvement in ICT. Therapists should therefore target self-focused attention.

Background: Perfectionism is implicated in a range of psychiatric disorders, impedes treatment and is associated with poorer treatment outcomes. Aims: The aim of this systematic review and meta-analysis was to summarize the existing evidence for psychological interventions targeting perfectionism in individuals with psychiatric disorders associated with perfectionism and/or elevated perfectionism. Method: Eight studies were identified and were analysed in meta-analyses. Meta-analyses were carried out for the Personal Standards and Concern over Mistakes subscales of the Frost Multi-Dimensional Perfectionism Scale (FMPS) and the Self Orientated Perfectionism and Socially Prescribed Perfectionism subscales of the Hewitt and Flett MPS (HMPS) in order to investigate change between pre and postintervention. Results: Large pooled effect sizes were found for the Personal Standards and Concern over Mistakes subscales of the FMPS and the Self Orientated Perfectionism subscale of the HMPS, whilst a medium sized effect was found for change in Socially Prescribed Perfectionism. Medium pooled effect sizes were also found for symptoms of anxiety and depression. Conclusions: There is some support that it is possible to significantly reduce perfectionism in individuals with clinical disorders associated with perfectionism and/or clinical levels of perfectionism. There is also some evidence that such interventions are associated with decreases in anxiety, depression, eating disorder and obsessive compulsive symptoms. Further research is needed in order to investigate the optimal dosage and format of such interventions as well as into specific disorders where there is a lack of evidence for their effectiveness.

Background: Cognitive Behaviour Therapy for Psychosis (CBTp) has a strong evidence base and is practised widely in the Western World. Psycho-social interventions, on the other hand, including Cognitive Behaviour Therapy (CBT) are hardly used in the low and middle income countries for psychosis. It has been suggested that adaptations in content, format and delivery are needed before CBT can be used outside the Western cultures. We describe preliminary evaluation of Culturally Adapted Cognitive Behaviour Therapy for Psychosis (CaCBTp) in in-patient settings in Lahore, Pakistan. Aims: We aimed to evaluate the efficacy of culturally adapted CBT for psychosis (CaCBTp) in Pakistan in a pilot project. Method: In a randomized controlled trial we tested CaCBTp against treatment as usual (TAU) in in-patient settings in Pakistan. Those diagnosed with schizophrenia according to the DSM-IV-TR, and who fulfilled the inclusion criteria, were recruited into the study. Patients (n = 42) were randomized into two equal groups, i.e. CaCBTp and TAU. Assessments were carried out both at the baseline and then at the end of the therapy by raters blind to the groupings. Psychopathology was measured using PANSS (Positive and Negative Syndrome Scale of Schizophrenia), PSYRATS (Psychotic Symptom Rating Scales), and the Insight Scale. Results: Patients receiving CaCBTp showed statistically significant improvement on measures of positive symptoms (p = .000), negative symptoms (p = .000), overall psychotic symptoms (p = .000), hallucinations (p = .000), delusions (p = .000) and insight (p = .000) at the end of the therapy. Conclusions: The CaCBTp was effective in reducing symptoms of psychosis and in improving insight in in-inpatient settings in Pakistan.

Background: Depression is frequently characterized by patterns of inflexible, maladaptive, and ruminative thinking styles, which are thought to result from a combination of decreased attentional control, decreased executive functioning, and increased negative affect. Cognitive Control Training (CCT) uses computer-based behavioral exercises with the aim of strengthening cognitive and emotional functions. A previous study found that severely depressed participants who received CCT exhibited reduced negative affect and rumination as well as improved concentration. Aims: The present study aimed to extend this line of research by employing a more stringent control group and testing the efficacy of three sessions of CCT over a 2-week period in a community population with depressed mood. Method: Forty-eight participants with high Beck Depression Inventory (BDI-II) scores were randomized to CCT or a comparison condition (Peripheral Vision Training; PVT). Results: Significant large effect sizes favoring CCT over PVT were found on the BDI-II (d = 0.73, p < .05) indicating CCT was effective in reducing negative mood. Additionally, correlations showed significant relationships between CCT performance (indicating ability to focus attention on CCT) and state affect ratings. Conclusions: Our results suggest that CCT is effective in altering depressed mood, although it may be specific to select mood dimensions.

Background: In people who experience auditory verbal hallucinations, beliefs the person holds about their voices appear to be clinically important as mediators of associated distress and disability. Whilst such beliefs are thought to be influenced by broader schematic representations the person holds about themselves and other people, there has been little empirical examination of this, in particular in relation to beliefs about voice intent and the personal meaning of the voice experience. Method: Thirty-four voice hearers with a diagnosis of schizophrenia or schizoaffective disorder completed the Psychotic Symptom Rating Scales and measures of beliefs about voices (Revised Beliefs About Voices Questionnaire, Interpretation of Voices Inventory) and schemas (Brief Core Schema Scales). Results: Beliefs about voices were correlated with both negative voice content and schemas. After controlling for negative voice content, schemas were estimated to predict between 9% and 35% of variance in the six beliefs about voices that were measured. Negative-self schemas were the strongest predictors, and positive-self and negative-other schemas also showed potential relationships with beliefs about voices. Conclusions: Schemas, particularly those regarding the self, are potentially important in the formation of a range of clinically-relevant beliefs about voices.

Background: Mental contamination is a psychological sense of contamination that involves an internal, emotional feeling of dirtiness that may be evoked by unwanted thoughts and images, such as sexual assaults. Aims: This study aimed to investigate which types of unwanted sexual experiences evoke the strongest mental contamination, and to test the hypothesis that cognitive appraisals of an unwanted sexual experience predict indices of mental contamination (i.e. feeling of dirtiness, urge to wash, internal negative emotions, and external negative emotions). Method: 148 female participants were asked to recall their most distressing unwanted sexual experiences. Indices of mental contamination and cognitive appraisals of the experience were then assessed. Results: Our findings indicated that individuals recalling experiences related to rape felt more intense feelings of dirtiness than individuals recalling other types of unwanted sexual experience, such as verbal sexual assault, visual sexual assault, and forcible touching/frottage. In addition, hierarchical regression analyses demonstrated that a cognitive appraisal of perceived violation predicted all of the indices of mental contamination after controlling anxiety, depression, and fear of contact contamination. Conclusions: The present study demonstrated that an individual is at greatest risk of mental contamination if she has experienced rape/attempted rape, and if she makes a cognitive appraisal of violation regarding the incident.

Background: Engaging clients from the outset of psychotherapy is important for therapeutic success. However, there is little research evaluating therapists’ initial attempts to engage clients in the therapeutic process. This article reports retrospective analysis of data from a trial of online cognitive behavioural therapy (CBT) for depression. Qualitative and quantitative methods were used to evaluate how therapists manage clients’ expectations at the outset of therapy and its relationship with client retention in the therapeutic intervention. Aims: To develop a system to codify expectation management in initial sessions of online CBT and evaluate its relationship with retention. Method: Initial qualitative research using conversation analysis identified three communication practices used by therapists at the start of first sessions: no expectation management, some expectation management, and comprehensive expectation management. These findings were developed into a coding scheme that enabled substantial inter-rater agreement (weighted Kappa = 0.78; 95% CI: 0.52 to 0.94) and was applied to all trial data. Results: Adjusting for a range of client variables, primary analysis of data from 147 clients found comprehensive expectation management was associated with clients remaining in therapy for 1.4 sessions longer than those who received no expectation management (95% CI: -0.2 to 3.0). This finding was supported by a sensitivity analysis including an additional 21 clients (1.6 sessions, 95% CI: 0.2 to 3.1). Conclusions: Using a combination of qualitative and quantitative methods, this study suggests a relationship between expectation management and client retention in online CBT for depression, which has implications for professional practice. A larger prospective study would enable a more precise estimate of retention.

Background: Case formulation (CF) is considered a core component of cognitive behavioural therapy (CBT). Despite this, few studies have explored the content and quality of CFs in routine practice and any associated impact on treatment outcome. Aims: This study investigated (1) the content, timing and quality of CF for patients (N = 29) with Obsessive Compulsive Disorder; (2) the impact of CF on symptoms, distress and therapeutic alliance; and (3) the relationship between CF quality and treatment outcome. Method: CF content and quality were assessed from audiotapes of routine CBT sessions using a validated coding manual and evaluated against treatment outcomes at different stages of therapy. Results: CFs were developed early during treatment and contained strong behavioural and cognitive components, with a focus on symptoms and maintaining factors. CF quality ratings ranged from rudimentary to excellent. A significant improvement in distress and the therapeutic alliance occurred following the introduction of CF, but no significant relationship was found between CF quality and outcome at any stage of treatment. Conclusion: CF may be valuable in reducing patient attrition, due to its impact early in treatment. Further research is needed to explore the most important components of CF. Theoretically sound and disorder specific measurement tools for evaluating CFs are required.