Background: Computer-guided CBT has been shown to be a potentially useful way of closing the gap between the demand and supply for CBT. Moreover, this approach has additional benefits in terms of less travel times for treatment, accessibility in remote and unusual locations, increased confidentiality, easier disclosure of sensitive information, and more egalitarian therapist-client interactions. Research on computerized CBT has concentrated on clinical outcomes, but the views of clients on this treatment approach have been relatively neglected. Aims: The aims were to assess client satisfaction, professionals' views, and ease of programme use after completion of treatment via an internet-based CBT programme for panic and phobic anxiety (FearFighter). Method: A feasibility and effectiveness study of FearFighter was conducted in remote and rural areas of Scotland. Treatment data are available for 35 clients at post-treatment, of whom 29 completed an 18-item set of rating scales designed to assess satisfaction, including ease of use, accessibility, how far needs were met, whether changes to the programme were required, the benefits and drawbacks of not having a therapist, and quality of support. Open-ended questions were included. Referring agencies were also asked to rate their views on FearFighter. Results: Clients reported moderate to high levels of improvement and of overall satisfaction; very few difficulties in logging on to and using the programme were encountered. Similar levels of satisfaction with the programme were reported by referrers. Conclusions: It is concluded that computer-guided CBT is acceptable to clients and to professionals, and that it could play a valuable part in a “stepped care” system of delivering CBT.

Background: Increasing attention has been given to subtyping OCD with respect to different clinical profiles, response to drug treatments, comorbidity and age of onset. There are a number of studies looking at predictors of treatment outcome in OCD, but so far not for OCD subtypes. Method: Prediction of outcome after cognitive-behavioural therapy was evaluated in 63 inpatients with early obsessive-compulsive disorder (EOCD ≤ 12 years of age) and 191 patients with late obsessive-compulsive disorder (LOCD > 15 years of age). Results: For EOCD patients factors predicting a good outcome included high motivation and high initial Y-BOCS scores. Factors associated with a bad outcome were higher age at assessment, a longer duration of psychiatric inpatient treatment before assessment and a low level of social functioning (BSS). For LOCD patients living in a stable relationship, high motivation and completing treatment predicted a favourable therapy outcome, while a low level of psychological functioning (BSS) and a longer duration of inpatient psychiatric treatment before assessment were associated with an undesirable therapy outcome. Conclusions: Subtyping OCD patients according to age of onset seems to be a promising avenue towards improving and developing more specified treatment programs.

Background: In the 26 years since it was first introduced in this journal, motivational interviewing (MI) has become confused with various other ideas and approaches, owing in part to its rapid international diffusion. Methods: Based on confusions that have arisen in publications and presentations regarding MI, the authors compiled a list of 10 concepts and procedures with which MI should not be addled. Results: This article discusses 10 things that MI is not: (1) the transtheoretical model of change; (2) a way of tricking people into doing what you want them to do; (3) a technique; (4) decisional balance; (5) assessment feedback; (6) cognitive-behavior therapy; (7) client-centered therapy; (8) easy to learn; (9) practice as usual; and (10) a panacea. Conclusion: Clarity about what does (and does not) constitute MI promotes quality assurance in scientific research, clinical practice, and training.

Background: Whilst effective psychological treatments such as CBT-I have been developed for insomnia, few services provide CBT-I and awareness of CBT-I is low among referrers. In addition, men tend to seek help less frequently for their insomnia than women. This paper describes the development and evaluation of psycho-educational CBT-I workshops, each for up to 25 people, and designed to be acceptable to men. Method: The CBT-I programme was based on Morin and Espie (2003), and adapted into a self-referral one-day workshop format designed specifically to improve access. Workshops were held on Saturdays in leisure centres. A one group pretest-posttest design was used and assessments were collected before and 6 weeks after each workshop. Over a 6-month period, 74 men self-referred, and attended the Introductory Talks preceding the workshops. Of these, 49.3% had never sought help from their GP, 66.2% suffered from clinical insomnia (ISI) and 61.6% were experiencing elevated depression symptoms (BDI over 10). Results: At follow-up, the workshops were found to be effective in reducing insomnia and depression. Satisfaction ratings with the workshops were very high. Conclusions: Given these promising results, further work is now proposed for a larger controlled study with a longer-term follow-up.

Background: This study investigated the role of cognitive mechanisms underlying obsessive compulsive and panic disorders in psychosis, and in particular, their possible contributions to acute psychosis. Method: A total of 90 participants were recruited comprising three equal-size groups, including two clinical groups (acute and stable) and one non-clinical matched control group. Symptom severity and distress was assessed using the PSYRATS, and questionnaire measures of anxiety and obsessive beliefs were administered to all participants. Results: Individuals with a diagnosis of psychosis reported significantly higher levels of obsessional beliefs and anxiety sensitivity than the non-clinical group. Furthermore, acutely psychotic patients reported a significantly higher sense of responsibility and catastrophic misinterpretation than the stable psychiatric controls, and than samples of OCD and GAD patients. Conclusions: Results suggest that these anxiety processes are particularly important during acute psychotic episodes, beyond the reported comorbidity. The theoretical and clinical implications of these findings, the limitations of the methodology employed, and suggestions for future research are discussed.

Background: The long-term effectiveness of parent training for children with externalizing behaviour problems under routine care within the German health care system is unclear. We report the 1-year follow-up results of the parent training component of the Prevention Program for Externalizing Problem Behaviour (PEP) for 270 children aged 3–10 years with externalizing behaviour problems. Method: Outcome measures included child behaviour problems (externalizing behaviour problems, Attention-Deficit/Hyperactivity Disorder symptoms and Oppositional Defiant Disorder symptoms) and parenting (self efficacy of parenting and perceived ability to solve difficult parenting situations). Data were analysed using multilevel modelling. Results: Comparison of the changes during the 3-month waiting and treatment periods revealed significantly stronger treatment effects on all outcome measures, indicating a substantial decrease in child behaviour problems and a significant increase in parenting due to treatment. At 1-year follow-up, initial treatment effects on child behaviour problems were maintained, while parenting continued to improve. Conclusions: Families whose children exhibited externalizing problem behaviour profit from PEP and improvements are maintained for at least one year.

Background: Accumulating research indicates posttraumatic stress disorder (PTSD) is a universal phenomenon. However, it remains substantially unknown as to whether the processes implicated in the aetiology and maintenance of PTSD are culturally similar. Aims: This study investigated the impact of cultural differences in self on negative cognitive appraisals in those with and without PTSD. Method: Trauma survivors with PTSD and without PTSD from independent and interdependent cultures (N = 106) provided trauma narratives. Narratives were coded for negative cognitive appraisals (mental defeat, control strategies, alienation and permanent change) as in Ehlers and colleagues' previous work. Results: Replicating Ehlers and colleagues' work, trauma survivors with PTSD from independent cultures reported more mental defeat, alienation, permanent change and less control strategies than non-PTSD trauma survivors from independent cultures. In contrast, for those from interdependent cultures, only alienation appraisals differentiated between trauma survivors with and without PTSD. Those with PTSD had more alienation appraisals than those without PTSD. Conclusions: The findings suggest cultural differences in self impact on the relationship between appraisals and posttraumatic psychological adjustment. Theoretical and clinical implications are discussed.

Background: Research on group therapy indicates that various dimensions of the helpful relationship qualities (cohesion, climate, empathy, alliance) are associated with outcome. However, the use of a wide variety of empirical scales makes comparisons between studies as well as generalizations somewhat difficult. Although a generic, trans-theoretical measure such as the Group Climate Questionnaire-Short Form (GCQ-S; MacKenzie, 1983) is available and applicable to most treatment conditions, it has never been tested with cognitive-behavioural group therapy. Aims: To investigate perceived dimensions of group climate (engagement, avoidance and conflict) as predictors of long-term (1 year) follow-up in a manualized, structured time-limited cognitive-behavioural group therapy (CBGT) for out-patients with comorbid psychiatric disorders. Methods: Data from 27 patients were analysed using hierarchical multiple regression analyses. Outcome measures used were general symptomatic complaints (SCL-90-R), interpersonal problems (IIP-64), specific mood- and anxiety symptoms (BDI; BAI) and early maladaptive schemas (YSQ). After controlling for scores on the relevant dependent variables at both intake and treatment termination, dimensions of group climate measured close to termination were entered as predictors in separate analyses. Results: Higher ratings of engagement were associated with reduced scores on all outcome measures at follow-up, except for anxiety symptoms (BAI). Higher ratings of avoidance were associated with lower anxiety symptoms at follow up, whereas ratings of conflict were unrelated to all follow-up scores. Conclusions: The results provide partial support for the use of the GCQ-S as a predictor of long-term follow-up in CBGT, and highlights perceived engagement as the most important dimension. Clinical implications are discussed.

Background: Audio recording of cognitive behavioural therapy (CBT) sessions has been recommended but not yet widely adopted. It is believed to have positive effects on later recall and reflection by the patient and on supervisory quality and accuracy for therapists. Aims: To evaluate self-reported attitudes and behaviour regarding audio recording of therapy sessions in both patients and therapists in a setting where such recording is routinely carried out. Method: In a centre specializing in CBT for anxiety disorders, 72 patients completed a questionnaire at the start of therapy and 31 patients completed a questionnaire at the end of therapy. Fifteen therapists also completed a similar questionnaire. Results: Ninety percent of patients reported listening to recordings between therapy sessions to some extent. The majority reported discussing the recordings with their therapist. Patients typically planned to keep the recordings after therapy ended. Most patients and therapists endorsed positive attitudes towards the use of recordings. Similar advantages (e.g. improving memory for sessions) and disadvantages (e.g. practical issues and feeling self-conscious) of recordings were generated by patients and therapists. Therapists were more likely than patients to express concern about recordings being distressing for patients to listen to. Both patients and therapists regarded the use of recordings for therapist peer supervision purposes favourably. Conclusion: The use of audio recording of sessions as an adjunct to therapy (where patients listen to recordings between sessions) and for therapist supervision is rated as both highly acceptable and useful by both therapists and patients.

Background: A key component of cognitive therapy for psychosis is the development of a meaningful and shared formulation of the onset of the psychosis. Therapists bring an understanding of the development of psychotic symptoms based on theoretical models and try to marry these with the person's own experience and explanations. However, an important question is whether this understanding is compatible with the explanations held by the client. Aims: This study investigated what factors people believed led to the onset of their psychosis. Method: A Q set of potential causes for psychosis was identified from a literature search and interviews with people with differing experiences of psychosis. From this, 58 potential causes of psychosis were identified. Twenty-one people who had experienced a psychotic breakdown then ranked these explanations as possible causes. Results: Using Principle Components Analysis four main factors were identified as perceived causal factors for the onset of psychosis. These factors were described as: a) drug usage; b) traumatic experiences in adulthood; c) personal sensitivity; and d) developmental vulnerabilities. Conclusions: This study revealed that people with psychosis have different explanatory frameworks for the onset of their difficulties. This work is helpful as this effort to understand the person's own understanding of their problems is a first stepping stone towards a collaboratively generated formulation that may be helpful in building a therapeutic alliance, engagement in treatment, and ultimately in improved outcome. It is likely that these different explanatory frameworks could lend themselves to different treatment approaches.

Background: Recent work in the area of cognition and emotion has focused on the process as well as the content of thought. Metacognitive approaches have included studies of people's relationship with internal experience (cf. Teasdale and Barnard, 1993), and the overarching beliefs that guide allocation of internal resources to manage distress (cf. Wells, 2000). At the same time, cognitive models of psychosis have emphasized the clinical value of a multidimensional understanding of paranoia (Chadwick, 2006; Freeman and Garety, 2004b). Method: This study examined paranoia in a non-clinical group, specifically (i) the relationship between a single measure of trait paranoia and dimensions of paranoid thought frequency, belief conviction and distress, and (ii) the metacognitive strategies that people use. It was predicted that trait paranoia would be associated with (i) dimensions of thought frequency, belief conviction and distress, and (ii) the internal strategies of “punishment” and “worry.” Results: Regression analyses showed that trait paranoia uniquely predicted frequency, conviction and distress associated with paranoid thoughts. Trait paranoia accounted for the use of “reappraisal”, whereas “punishment” and “worry” were accounted for by anxiety. Conclusions: The implications for clinical work and further research are discussed.

Background: Factors that distinguish depressed individuals who become hopeless from those who do not are poorly understood. Method: In this study, predictors of hopelessness were examined in a sample of 439 clinically depressed adolescents participating in the Treatment for Adolescents with Depression Study (TADS). The total score of the Beck Hopelessness Scale (BHS) was used to assess hopelessness at baseline. Multiple regression and logistic regression analyses were conducted to evaluate the extent to which variables were associated with hopelessness and determine which cluster of measures best predicted clinically significantly hopelessness. Results: Hopelessness was associated with greater depression severity, poor social problem-solving, cognitive distortions, and family conflict. View of self, view of the world, internal attributional style, need for social approval, positive problem-solving orientation, and family problems consistently emerged as the best predictors of hopelessness in depressed youth. Conclusions: Cognitive and familial factors predict those depressed youth who have high levels of hopelessness.

Background: There is a small body of research indicating that mindfulness training can be beneficial for people with distressing psychosis. What is not yet clear is whether mindfulness effects change in affect and cognition associated with voices specifically. This study examined the hypothesis that mindfulness training alone would lead to change in distress and cognition (belief conviction) in people with distressing voices. Method: Two case studies are presented. Participants experienced long-standing distressing voices. Belief conviction and distress were measured twice weekly through baseline and mindfulness intervention. Mindfulness in relation to voices was measured at the start of baseline and end of intervention. Results: Following a relatively stable baseline phase, after 2–3 weeks of mindfulness practice, belief conviction and distress fell for both participants. Both participants' mindfulness scores were higher post treatment. Conclusion: Findings show that mindfulness training has an impact on cognition and affect specifically associated with voices, and thereby beneficially alters relationship with voices.

Background: The aim of the study was to evaluate the effectiveness of a recovery group intervention based on compassionate mind training, for individuals with psychosis. In particular, the objective was to improve depression, to develop compassion towards self, and to promote help seeking. Method: A within-subjects design was used. Participants were assessed at the start of group, mid-group (5 weeks), the end of the programme and at 6 week follow-up. Three group programmes were run over the course of a year. Nineteen participants commenced the intervention and 18 completed the programme. Results: Significant improvements were found on the Social Comparison Scale; the Beck Depression Inventory; Other As Shamer Scale; the Rosenberg Self-Esteem Inventory and the General Psychopathology Scale from the Positive and Negative Syndrome Scale. Conclusions: The results provide initial indications of the effectiveness of a group intervention based on the principles of compassionate focused therapy for this population. The findings of this study, alongside implications of further research are discussed.

Background: “Stressbusters” is an interactive computer software programme based on a clinically effective face-to-face CBT protocol for young people with depression. It was designed for teenagers with mild to moderate depression, and comprises eight 45-minute sessions. Method: Twenty-three young people (aged 12–16; mean age 14.87 years) with symptoms of depression were recruited from CAMHS teams in Manchester and London, and received the Stressbusters treatment (range 1 – 8 sessions, mode 8 sessions). Results: On the K-SADS at initial assessment, 95% met diagnostic criteria for a depressive disorder, with a high group mean score of 35.48 (SD 9.84) on the MFQ. Post-treatment, 22% of young people met criteria for a depressive disorder, with the group mean score on the MFQ falling significantly below clinical cut-off to 20.32 (SD 11.75). These gains were maintained at 3-month follow-up. Significant improvements were also found in the adolescents' global functioning (CGAS), self-reported anxiety (RCMAS), depressive cognitions and attributions (ATQ and CTI-C), and in adolescent- and parent-reported emotional and behavioural difficulties (SDQ). Conclusions: Taken together, these results provide promising preliminary data for the clinical efficacy of Stressbusters as a valid form of CCBT for adolescents with depression.

Background: This study investigated which factors are associated with the therapeutic relationship in Cognitive-Behavioural Therapy for psychosis (CBTp). Method: Measures were taken between sessions two to nine in 24 therapist-client dyads. Clients and therapists completed the Working Alliance Inventory and measures of client (gender, age, ethnicity, positive and negative symptoms of psychosis, length of illness, admissions, social contacts, employment, cognitive insight, reaction to hypothetical contradiction), therapist (empathy, expertness, attractiveness, trustworthiness, number of years qualified and previous CBTp clients seen, confidence in CBTp), and therapy (number of sessions and CBTp interventions carried out, presentation of a formulation) factors. Results: On average, clients and therapists rated the therapeutic relationship as good, with clients giving higher ratings. None of the client variables was related significantly to the quality of the relationship. However, a number of therapist and therapy factors were linked to a better therapeutic relationship, namely clients' ratings of therapist empathy, expertness, attractiveness, and trustworthiness and, at trend level, a greater number of sessions and of CBTp interventions, and the presentation of a formulation. Conclusions: These results suggest that therapists are able to develop a good therapeutic relationship with clients with psychosis, regardless of the severity of the psychosis and the confidence and experience of the therapist, although non-significant findings need interpreting with caution due to the lack of a full range of therapeutic alliances. The findings also suggest that the basic tenets of CBTp, such as empathy and collaborative goals, may be important factors for the development of the therapeutic relationship.

Background: This paper investigates the relationship between care staff perceptions' of self-harm behaviours presented by adult and adolescent inpatients and the emotional responses and helping behaviours of the staff. Method: Seventy-six nursing staff participated, including qualified and unqualified staff, who worked in either adolescent or adult secure inpatient settings within a single organization. Participants completed vignette, knowledge, and attitudes questionnaires, related to working with patients who display deliberate self-harm. Results: Further support was found for attributional theories suggesting that views on deliberate self-harm are linked to propensity to help, and that emotional responses can be a mediating factor. Staff who reported feeling more negative about patients who self-harm reported more worry about working with this patient group. Unqualified nursing staff reported more negativity and worry than qualified staff. Neither gender nor length of work experience was found to be significant factors. Conclusions: These findings indicate that training and support should be aimed at helping nursing staff, particularly unqualified staff working in inpatient settings where self-harm is frequent, feel more positive and less concerned about working with patients who self-harm. Such needs of unqualified nursing staff have not been highlighted in previous research.

Background: The clinical literature cautions against use of meditation by people with psychosis. There is, however, evidence for acceptance-based therapy reducing relapse, and some evidence for clinical benefits of mindfulness groups for people with distressing psychosis, though no data on whether participants became more mindful. Aims: To assess feasibility of randomized evaluation of group mindfulness therapy for psychosis, to replicate clinical gains observed in one small uncontrolled study, and to assess for changes in mindfulness. Method: Twenty-two participants with current distressing psychotic experiences were allocated at random between group-based mindfulness training and a waiting list for this therapy. Mindfulness training comprised twice-weekly sessions for 5 weeks, plus home practice (meditation CDs were supplied), followed by 5 weeks of home practice. Results: There were no significant differences between intervention and waiting-list participants. Secondary analyses combining both groups and comparing scores before and after mindfulness training revealed significant improvement in clinical functioning (p = .013) and mindfulness of distressing thoughts and images (p = .037). Conclusions: Findings on feasibility are encouraging and secondary analyses replicated earlier clinical benefits and showed improved mindfulness of thoughts and images, but not voices.

Background: It has been suggested that socially anxious individuals often engage in a wide range of safety behaviours in social situations that are intended to reduce the risk of social failure and humiliation. Method: This study explored the interpretations that people make for behaviours considered to be safety seeking. High and low socially anxious individuals completed one version of a questionnaire that assessed how the safety behaviours that they may exhibit are interpreted by others, and then completed a second version of the same questionnaire that assessed how they typically interpret safety behaviours in other people. Participants rated the extent to which each of eight interpretations was viewed as a likely interpretation of the behaviour. Results: Individuals high in social anxiety were more likely than low socially anxious participants to think that being arrogant, suffering from a psychological problem, or experiencing a normal level of anxiety, nervousness or fear are likely explanations for safety behaviours, regardless of who exhibits them. Additionally, high socially anxious participants were more likely than those low in social anxiety to think that others interpreted these behaviours as being indicative of intense anxiety or other negative emotional condition. Conclusions: The results suggested that socially anxious people are, at least, aware of the negative effects of certain behaviours characterized as safety seeking.

Background: Psychiatric staff play a key role in the lives of people with psychosis and the quality of staff and service user relationships is associated with relapse and recovery. One factor that might determine the capacity of staff to form positive therapeutic relationships is their appraisals of service users' mental health problems. Method: A pilot intervention was implemented with psychiatric staff that involved helping them develop psychological formulations for individual service users. Staff perceptions of service users' mental health problems were measured before and after the intervention using Likert scales. Data at the two time points were collated for 30 staff. Results: There was a significant increase in staff perceptions of the degree of control service users and themselves had over problems, an increase in the degree of effort they felt service users were making in coping, reductions in blame, and more optimism about treatment. Staff also reported an increase in understanding of service users' problems, more positive feelings towards service users, and an increase in confidence in their work. Conclusions: Results from this pilot are promising, but findings warrant replication in controlled studies. It is also important to establish whether changes in staff perceptions influence the actual nature of staff-service user relationships.