Background: Although cognitive-behavioral therapy (CBT) is established as a first line treatment for anxiety disorders in children and adolescents, there is little evidence about the effectiveness of CBT protocols in cases identified in the community in low and middle income countries (LaMICs). Aims: To evaluate the effectiveness of group CBT protocol for youths with anxiety disorders identified in a community sample in LaMICs. Method: A total of 14 sessions of group CBT for youths and 2 concurrent sessions for parents based on Kendall's Coping Cat program were offered. Participants were selected from a cross-sectional community study; 45 subjects fulfilled inclusion criteria and 28 agreed to participate in the open clinical trial. Treatment effectiveness was evaluated with standard clinical, self- and parent-rated measures of anxiety, depression, externalizing symptoms and quality of life (QoL). Results: Twenty youths completed the protocol. All scales showed an improvement of anxiety and reduction in externalizing symptoms over time, with a moderate to large effect size (d = 0.59 to 2.06; p < .05), but not in depressive symptoms or QoL. Conclusions: Consistent with previous evidence, group CBT is effective in treating anxiety disorders in youths. Results encourage further randomized clinical trials using CBT protocols adapted and developed to be used in LaMICs.

Background: Attitudes of social service providers towards computerized CBT (cCBT) might affect use of cCBT by their clients and may provide important insights that should be considered in dissemination. There is no literature exploring the attitudes of providers of youth work services towards cCBT despite the likelihood of them having close relationships with young people at high risk of mental ill-health. Method: Focus groups and semi-structured interviews were undertaken with a total of 40 providers (21 youth workers and social service staff providing alternative schooling, justice or other intensive youth work programmes to adolescents, 6 youth service managers, 2 trainers, 5 peer leaders and 6 trainees). Results: Participants considered supporting young people who were distressed to be an important part of their role. They were generally interested in cCBT, especially those who were more mental health oriented and those who saw a cCBT programme in action. Their greatest concerns regarding cCBT related to it possibly displacing human contact, while advantages were seen as its appeal to young people and its potential therapeutic power. They would utilize cCBT in a range of ways, with many wishing to offer it in group settings. Training and resources would be required for them to use cCBT. Conclusions: Many providers of youth work services would like to be involved in the use of cCBT; this might extend the reach of cCBT to vulnerable young people. They would wish to utilize cCBT in ways that fit their current approaches. Providers’ opinions need to be considered in the dissemination of cCBT.

Background: Internet-delivered cognitive behaviour therapy (iCBT) has been found to be an effective way to disseminate psychological treatment, and support given by a therapist seems to be important in order to achieve good outcomes. Little is known about what the therapists actually do when they provide support in iCBT and whether their behaviour influences treatment outcome. Aims: This study addressed the content of therapist e-mails in guided iCBT for generalized anxiety disorder. Method: We examined 490 e-mails from three therapists providing support to 44 patients who participated in a controlled trial on iCBT for generalized anxiety disorder. Results: Through content analysis of the written correspondence, eight distinguishable therapist behaviours were derived: deadline flexibility, task reinforcement, alliance bolstering, task prompting, psychoeducation, self-disclosure, self-efficacy shaping, and empathetic utterances. We found that task reinforcement, task prompting, self-efficacy shaping and empathetic utterances correlated with module completion. Deadline flexibility was negatively associated with outcome and task reinforcement positively correlated with changes on the Penn State Worry Questionnaire. Conclusions: Different types of therapist behaviours can be identified in iCBT, and though many of these behaviours are correlated to each other, different behaviours have an impact on change in symptoms and module completion.

Background: Controversy continues to exist regarding how EMDR works and whether its mechanisms differ from those at work in standard exposure techniques. Aims: To investigate first whether eye movement bilateral stimulation is an essential component of EMDR and, second, the current status of its theoretical basis. Method: A systematic search for relevant articles was conducted in databases using standard methodology. Results: Clinical research evidence is contradictory as to how essential EMs are in PTSD treatment. More positive support is provided by analogue studies. With regards to potential theoretical support, some evidence was found suggesting bilateral stimulation first increases access to episodic memories; and second that it could act on components of working memory which makes focusing on the traumatic memories less unpleasant and thereby improves access to these memories. Conclusions: The results suggest support for the contention that EMs are essential to this therapy and that a theoretical rationale exists for their use. Choice of EMDR over trauma-focused CBT should therefore remain a matter of patient choice and clinician expertise; it is suggested, however, that EMs may be more effective at reducing distress, and thereby allow other components of treatment to take place.

Background: Difficulties with comprehending and managing emotions are core features of the pathology of anorexia nervosa (AN). Advancements in understanding aetiology and treatment have been made within other clinical domains by targeting worry and rumination. However, worry and rumination have been given minimal consideration in AN. Aims: This study is the largest to date of worry and rumination in AN. Method: Sixty-two outpatients with a diagnosis of AN took part. Measures of worry, rumination, core AN pathology and neuropsychological correlates were administered. Results: Findings suggest that worry and rumination are elevated in AN patients compared with both healthy controls and anxiety disorder comparison groups. Regression analyses indicated that worry and rumination were significant predictors of eating disorder symptomatology, over and above the effects of anxiety and depression. Worry and rumination were not associated with neuropsychological measures of set-shifting and focus on detail. Conclusions: The data suggest that worry and rumination are major concerns for this group and warrant further study.

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: Acquiring proficiency in motivational interviewing (MI) may be more difficult than generally believed, and training research suggests that the standard one-time workshop format may be insufficient. Although nurses represent one of the professions that have received most training in MI, training in this group has rarely been systematically evaluated using objective behavioral measures. Aims: To evaluate an enhanced MI training program, comprising a 3.5-day workshop, systematic feedback on MI performance, and four sessions of supervision on practice samples. Methods: Nurses (n = 36) in Swedish child health services were trained in MI. Skillfulness in MI was assessed using the Motivational Interviewing Treatment Integrity (MITI) Code. Effects of training were compared to beginning proficiency thresholds. Results: Participants did not reach beginning proficiency thresholds on any of the indicators of proficiency and effect sizes were small. Conclusions: The present study adds to a growing body of literature suggesting that the current standard MI training format may not provide practitioners with enough skillfulness. Moreover, the results indicate that even enhanced training, including systematic feedback and supervision, may not be sufficient. Suggestions for improved MI training are made.

Background: Over half of children in the general population report unusual or “psychotic-like” experiences (PLEs). The development of a later at-risk mental state is associated with persistent, distressing, PLEs, which are appraised negatively and hard to cope with. We have designed a novel, manualized, cognitive behavioural intervention for children aged 9 to 14 years, which aims to reduce emotional problems, improve coping and resilience, and help children manage PLEs, before an identifiable psychosis risk develops. We report on the feasibility, acceptability and clinical impact of the intervention. Method: Four children who reported PLEs and emotional problems in a community survey completed the intervention, and gave detailed feedback. Clinical outcomes were assessed before, during, and after therapy. Results: Emotional problems, PLE frequency, and PLE impact all decreased during the intervention. Child and therapist satisfaction with the treatment was high. Conclusions: It is feasible, acceptable and helpful to offer psychological interventions to children who report emotional distress and PLEs, prior to the emergence of clear risk factors. Our intervention has the potential to increase resilience to the development of future mental health problems. A larger, randomized controlled evaluation is underway.

Background: Agoraphobia is disabling and clients find it hard to access effective treatment. Aims: This paper describes the development of an inexpensive service, delivered by trained volunteers in or near the client's own home. Method: We describe the development of the service, including selection, training and supervision. Outcomes were evaluated over 5 years, and compared with those available from the local psychology service. Results: Effect sizes on all measures were high. Benchmarking indicated that results on comparable measures were not significantly different from the local psychology service. As in many previous studies drop-out rate was fairly high. Conclusions: This model worked well, and was inexpensive and effective. Further research on long term outcome and methods of enhancing engagement is needed.

Background: The efficacy of CBT for unipolar depressive disorders is well established, yet not all patients improve or tolerate treatment. Aims: To identify factors associated with symptomatic outcome, response, and drop-out in depressive patients under naturalistic CBT. Method: 193 patients with major depression or dysthymia were tested. Sociodemographic and clinical variables were entered as predictors in hierarchical regression analyses. Results: A higher degree of pretreatment depression, early improvement, and completion of therapy were identified as predictors for symptomatic change and response. Drop-out was predicted by concurrent personality disorder, less positive outcome expectancies, and by failure to improve early in treatment. Conclusions: Our results highlight the importance of early response to predict improvement in routine CBT. Attempts to refine the quality of treatment programs should focus on avoiding premature termination (drop-out) and consider motivational factors in more depth. Routinely administered standardized assessments would enhance symptom monitoring and help to identify persons at risk of not improving under therapy.

Background: Drug-facilitated sexual assault (DFSA) has emerged as a distinct category of sexual victimization and precipitates posttraumatic stress disorder (PTSD). Few studies have examined the distinct psychological aspects of PTSD caused by DFSA. Gauntlett-Gilbert, Keegan and Petrak (2004) represent a notable exception and draw on cases, from their clinical experience, treated using Ehlers and Clarks' (2000) cognitive therapy (CT). Aims: This paper aims to further develop and refine clinical knowledge on CT for PTSD arising from DFSA and advance the findings of Gauntlett-Gilbert et al. (2004). Method: Systematic case based research was used to investigate the applicability of CT for PTSD related to DFSA. Three survivors were treated with CT within the South African context. Results: The case series corroborated existing findings but also documented the presence of somatic and visual intrusions among survivors with partial or complete amnesia for rape and illustrated the utility of imagery interventions in targeting intrusions. The study highlighted the role of physical paralysis in DFSA in compounding helplessness/powerlessness and the necessity of enhancing physical agency and building social support. Conclusion: Distinctive aspects of PTSD related to DFSA can be effectively treated by adapting CT to suit this population group.