Background: Internalized stigma is a significant difficulty for those who experience psychosis, but it has never been conceptualized using cognitive theory. Aims: The aim of this paper is to outline a cognitive model conceptualizing internalized stigma experienced by people who also experience psychosis. Method: Previous literature is reviewed, critiqued and synthesized to develop the model. It draws upon previous social cognitive models of internalized stigma and integrates cognitive behavioural theory and social mentality theory. Results: This paper identifies key cognitive, behavioural and emotional processes that contribute to the development and maintenance of internalized stigma, whilst also recognizing the central importance of cultural context in creating negative stereotypes of psychosis. Moreover, therapeutic strategies to alleviate internalized stigma are identified. A case example is explored and a formulation and brief intervention plan was developed in order to illustrate the model in practice. Conclusion: An integrative cognitive model is presented, which can be used to develop individualized case formulations, which can guide cognitive behavioural interventions targeting internalized stigma in those who experience psychosis. More research is required to examine the efficacy of such interventions. In addition, it is imperative to continue to research interventions that create change in stigma at a societal level.

Background: Of young people with first episode psychosis (FEP), over half report exposure to childhood trauma and consequent co-morbid post-traumatic stress disorder (PTSD) or symptoms. Currently no evidence-based interventions exist for PTSD in FEP. Clinicians report concerns that trauma-focused interventions with young people with FEP could result in distress and symptom exacerbation. Scant research suggests that talking about trauma in therapy can be distressing for some people. Aims: To explore young people's reactions to a trauma-focused treatment for PTSD in FEP. Method: Semi-structured interviews were conducted with eight participants (age 18–27 years) with co-morbid PTSD and FEP, after completing a trauma-focused intervention. Transcripts were analysed using an interpretative phenomenological approach. Participants’ baseline and end-of-treatment PTSD and psychotic symptoms were assessed. Results: Three themes related to participants’ reactions were identified from the analysis: (1) distress in session; (2) feeling relieved in and out of session; and (3) symptom exacerbation out of session. All but one participant reported experiencing increased distress in session. Four participants described PTSD, psychotic symptoms and/or suicidal ideation worsening in immediate reaction to talking about trauma in therapy sessions. 86% of participants showed improvement in their PTSD and psychotic symptoms at end of treatment. All participants described the intervention as beneficial and worthwhile. Conclusions: Results suggest that feelings of distress are to be expected from individuals with PTSD and FEP during trauma-focused treatment. Psychotic and PTSD symptom exacerbation can occur in PTSD treatment in FEP. Clinicians should be aware of, plan for, and clearly inform their clients of treatment risks.

Background: There is increasing interest in the use of metaphor in cognitive behaviour therapy. Experts advocate bringing client metaphors into case conceptualizations, but there is little empirical research to support this. Aims: This study evaluated the effect of training 12 therapists to attend to client metaphors and bring them into case conceptualizations. Method: Pre- and post-training role-played therapy sessions were conducted and video-recorded. Alliance was rated by role play ‘clients’ and an external expert rated the quality of the sessions and of the shared conceptualizations. Results: There were significant increases in some ratings of alliance, based on role play ‘client’ ratings and external ratings of role plays of therapy sessions before and after training. The greater the difference between therapist and ‘client’ on a measure of preference for producing metaphor, the lower the rating of the session by the ‘client’ on the Bond factor score of an alliance measure, the Working Alliance Inventory. This result suggests that working metaphorically may be most effective when the therapist and client have a similar degree of preference for speaking metaphorically. Conclusion: This study provides preliminary support for the idea that attending to client metaphors during conceptualization can be beneficial for alliance.

Background: Although negative beliefs have been found to be associated with worry symptoms and depressive rumination, negative beliefs have yet to be examined in relation to post-event processing and social anxiety symptoms. Aims: The purpose of the current study was to examine the psychometric properties of the Negative Beliefs about Post-Event Processing Questionnaire (NB-PEPQ). Method: A large, non-referred undergraduate sample completed the NB-PEPQ along with validation measures, including a measure of post-event processing and social anxiety symptoms. Results: Based on factor analysis, a single-factor model was obtained, and the NB-PEPQ was found to exhibit good validity, including positive associations with measures of post-event processing and social anxiety symptoms. Conclusions: These findings add to the literature on the metacognitive variables that may lead to the development and maintenance of post-event processing and social anxiety symptoms, and have relevant clinical applications.

Aims: This study aimed to assess the validity of two models which integrate the cognitive (satisfaction with life) and affective (symptoms of anxiety and depression) aspects of subjective well-being within the framework of rational emotive behaviour therapy (REBT) theory; specifically REBT's theory of psychopathology and theory of psychological health. Method: 397 Irish and Northern Irish undergraduate students completed measures of rational/irrational beliefs, satisfaction with life, and anxiety/depression symptoms. Structural equation modelling techniques were used in order to test our hypothesis within a cross-sectional design. Results: REBT's theory of psychopathology (χ2 = 373.78, d.f. = 163, p < .001; comparative fit index (CFI) = .92; Tucker Lewis index (TLI) = .91; root mean square error of approximation (RMSEA) = .06 (95% CI = .05 to .07); standardized root mean square residual (SRMR) = .07) and psychological health (χ2 = 371.89, d.f. = 181, p < .001; CFI = .93; TLI = .92; RMSEA = .05 (95% CI = .04 to .06); SRMR = .06) provided acceptable fit of the data. Moreover, the psychopathology model explained 34% of variance in levels of anxiety/depression, while the psychological health model explained 33% of variance. Conclusions: This study provides important findings linking the fields of clinical and positive psychology within a comprehensible framework for both researchers and clinicians. Findings are discussed in relation to the possibility of more effective interventions, incorporating and targeting not only negative outcomes, but also positive concepts within the same model.

Background: Cognitive behavioural interventions for excessive reassurance seeking (ERS) typically focus on encouraging individuals to refrain from seeking any reassurance and in some cases banning caregivers (e.g. family members) from providing it. However, this blanket consideration that reassurance is a bad thing that should simply be stopped may not always be appropriate or helpful. Cognitive behavioural treatment (CBT) targeting ERS by helping the sufferer to shift from seeking reassurance to seeking support may be a promising treatment intervention. Aims: This study aims to examine the targeted treatment of ERS in an older adult who has been suffering from severe obsessive compulsive disorder (OCD) for seven decades. Method: Using a single case quasi-experimental design (ABCD), the frequency of reassurance seeking, urges to seek reassurance, OCD beliefs and anxiety were measured daily for almost a year in addition to standard symptom measures. Results: At the end of treatment, visual inspection showed that reassurance seeking was no longer considered excessive and OCD severity fell from the severe to non-clinical range across the treatment sessions. All treatment gains were maintained at follow-up. Conclusions: This study illustrates how CBT can be successfully applied to treat long-standing OCD and ERS in an older adult. Engendering support as an alternative to reassurance seeking in CBT may be a particularly promising intervention for ERS.

Background: Clinicians commonly fail to use cognitive behavioural therapy (CBT) adequately, but the reasons for such omissions are not well understood. Aims: The objective of this study was to create and validate a measure to assess clinicians’ attitudes towards CBT – the Negative Attitudes towards CBT Scale (NACS). Method: The participants were 204 clinicians from various mental healthcare fields. Each completed the NACS, measures of anxiety and self-esteem, and a measure of therapists’ use of CBT and non-CBT techniques and their confidence in using those techniques. Exploratory factor analysis was used to determine the factor structure of the NACS, and scale internal consistency was tested. Results: A single, 16-item scale emerged from the factor analysis of the NACS, and that scale had good internal consistency. Clinicians’ negative attitudes and their anxiety had different patterns of association with the use of CBT and other therapeutic techniques. Conclusions: The findings suggest that clinicians’ attitudes and emotions each need to be considered when understanding why many clinicians fail to deliver the optimum version of evidence-based CBT. They also suggest that training effective CBT clinicians might depend on understanding and targeting such internal states.

Background: The value of clients’ reports of their experiences in therapy is widely recognized, yet quantitative methodology has rarely been used to measure clients’ self-reported perceptions of what is helpful over a single session. Aims: A video-rating method using was developed to gather data at brief intervals using process measures of client perceived experience and standardized measures of working alliance (Session Rating Scale; SRS). Data were collected over the course of a single video-recorded session of cognitive therapy (Method of Levels Therapy; Carey, 2006; Mansell et al., 2012). We examined the acceptability and feasibility of the methodology and tested the concurrent validity of the measure by utilizing theory-led constructs. Method: Eighteen therapy sessions were video-recorded and clients each rated a 20-minute session of therapy at two-minute intervals using repeated measures. A multi-level analysis was used to test for correlations between perceived levels of helpfulness and client process variables. Results: The design proved to be feasible. Concurrent validity was borne out through high correlations between constructs. A multi-level regression examined the independent contributions of client process variables to client perceived helpfulness. Client perceived control (b = 0.39, 95% CI .05 to 0.73), the ability to talk freely (b = 0.30, SE = 0.11, 95% CI .09 to 0.51) and therapist approach (b = 0.31, SE = 0.14, 95% CI .04 to 0.57) predicted client-rated helpfulness. Conclusions: We identify a feasible and acceptable method for studying continuous measures of helpfulness and their psychological correlates during a single therapy session.

Background: The assessment of therapeutic adherence is essential for accurately interpreting treatment outcomes in psychotherapy research. However, such assessments are often neglected. Aims: To fill this gap, we aimed to develop and test a scale that assessed therapeutic adherence to Cognitive Processing Therapy – Cognitive Only (CPT), which was adapted for a treatment study targeting patients with post-traumatic stress disorder and co-occurring borderline personality symptoms. Method: Two independent, trained raters assessed 30 randomly selected treatment sessions involving seven therapists and eight patients who were treated in a multicentre randomized controlled trial. Results: The inter-rater reliability for all items and the total score yielded good to excellent results (intraclass correlation coefficient [ICC] = 0.70 to 1.00). Cronbach's α was .56 for the adherence scale. Regarding content validity, three experts confirmed the relevance and appropriateness of each item. Conclusion: The adherence rating scale for the adapted version of CPT is a reliable instrument that can be helpful for interpreting treatment effects, analysing possible relationships between therapeutic adherence and treatment outcomes and teaching therapeutic skills.