Background: Psychological therapy services are often required to demonstrate their effectiveness and are implementing systematic monitoring of patient progress. A system for measuring patient progress might usefully ‘inform supervision’ and help patients who are not progressing in therapy. Aims: To examine if continuous monitoring of patient progress through the supervision process was more effective in improving patient outcomes compared with giving feedback to therapists alone in routine NHS psychological therapy. Method: Using a stepped wedge randomized controlled design, continuous feedback on patient progress during therapy was given either to the therapist and supervisor to be discussed in clinical supervison (MeMOS condition) or only given to the therapist (S-Sup condition). If a patient failed to progress in the MeMOS condition, an alert was triggered and sent to both the therapist and supervisor. Outcome measures were completed at beginning of therapy, end of therapy and at 6-month follow-up and session-by-session ratings. Results: No differences in clinical outcomes of patients were found between MeMOS and S-Sup conditions. Patients in the MeMOS condition were rated as improving less, and more ill. They received fewer therapy sessions. Conclusions: Most patients failed to improve in therapy at some point. Patients’ recovery was not affected by feeding back outcomes into the supervision process. Therapists rated patients in the S-Sup condition as improving more and being less ill than patients in MeMOS. Those patients in MeMOS had more complex problems.

Background: The psychological literature suggests that therapist perfectionism is common and potentially detrimental to client recovery. Little is known about the relationship between therapist perfectionism and client outcomes. Aims: This study aimed to measure perfectionism in High Intensity Cognitive Behavioural therapists, and establish any relationships between dimensions of therapist perfectionism, client outcomes and drop-out rates in treatment. Method: Thirty-six therapists took part in the study; levels of perfectionism were measured using a self-report questionnaire and these were analysed in relation to the clinical outcomes from a sample of their clients. Results: The results indicated that therapist perfectionism may be less common than previously suggested. Overall, a number of significant negative associations were observed between aspects of therapist perfectionism (e.g. having high standards for others), treatment efficacy and client retention in treatment. Conclusions: Therapist perfectionism is associated with CBT treatment outcomes; tentative recommendations for therapists managing their own schema as part of their clinical practice have been made, although further investigation is required.

Background: Misuse of codeine-containing medicines is an emerging public health issue. Aims: We present the application of Liese and Franz's (1996) cognitive developmental model of substance abuse to the trajectory from legitimate codeine use for pain, towards that of therapeutic and other forms of misuse, and physical and psychological dependence. It illustrates a cognitive behavioural analysis of the experiences of codeine misusers – which ‘surfaces’ the specific beliefs, thoughts, emotions and behaviours of this group of hidden codeine dependent individuals, who are distinct and unique from other opioid-dependent cohorts. Method: In-depth one-to-one interviews with codeine misusers and dependent individuals in Ireland (n = 21) and South Africa (n = 25) are analysed and applied to Liese and Franz's (1996) cognitive developmental model of substance abuse. Results: Misuse and dependence pathways are maintained by the interplay between physiological determinants relating to pain, withdrawal and tolerance, and psychological influences such as therapeutic need, pre-empting of anticipated physical pain, pleasure from the dreamy sedative opiate effect of codeine and relief of emotional distress. Progression towards habitual use and misuse for therapeutic and intoxication purposes appears to be mediated by external environmental triggers pertaining to availability, internal meta-cognitions around physical pain and emotional distress, and increasing importance of codeine in the life of the user. Conclusion: The concept mapping of codeine misuse and dependence presented here could provide psychological therapists working with individuals experiencing problems with codeine, misusing codeine and those with iatrogenic dependence, with an enhanced understanding of the key concepts involved in misuse and recovery pathways.

Background: Computer-delivered cognitive behavioural therapy (cCBT) is an effective alternative to provider-delivered treatment for depression and anxiety, but high attrition poses a significant challenge to its use. Peer support is a feasible approach to improving cCBT engagement, but less is known about its acceptability among Veterans. Aims: To obtain feedback from Veterans (n = 24) with depression and/or anxiety on their preferences for (a) activities of Veterans Administration Peer Support Specialists (VA PSS) in helping Veterans use Moving Forward, a cCBT-based protocol developed by VA, and (b) methods for delivering support to Veterans using this programme. Method: Four focus groups (5–7 Veterans per group) provided feedback to be used in the development of a peer-supported engagement intervention to help Veterans with depression and anxiety use Moving Forward. Content areas included roles that a VA PSS might play in supporting the use of and engagement in Moving Forward, as well as methods of delivering that support. Results: Veteran preferences for PSS activity focused on practical aspects of using Moving Forward, including orientation to the programme, technical support, and monitoring progress. Feedback also suggested that Veterans preferred more personal roles for the PSS, including emotional support, as well as application of Moving Forward to ‘real life’ problems. Conclusions: The findings extend the literature on online, patient-facing mental health protocols by identifying emotional support and ‘real life’ skills application as Veteran-preferred components of a peer-support protocol designed to enhance use of and engagement in cCBT for depression and anxiety.

Background: There is a lack of treatment plurality at step 2 of Improving Access to Psychological Therapies (IAPT) services. This project therefore sought to develop and pilot a cognitive analytic informed guided self-help treatment for mild-to-moderate anxiety for delivery by Psychological Wellbeing Practitioners (PWPs). Method: Medical Research Council treatment development guidelines were used. Phase I included development of the six-session treatment manual using practice guidelines, small-scale modelling (n = 3) and indicated manual iterations. Phase II consisted of a mixed methods case series design (n = 11) to index feasibility, uptake and clinical outcomes. Results: Cognitive analytic guided self-help (CAT-SH) met established quality parameters for guided self-help. A high treatment completion rate was observed, with 10/11 patients who attended the first treatment session subsequently completing full treatment. Six out of ten patients completing full treatment met reliable recovery criteria at follow-up. Effect sizes and recovery rates equate with extant PWP outcome benchmarks. Practitioner feedback indicated that delivery of CAT-SH was feasible. Conclusion: CAT-SH shows promise as a low-intensity treatment for anxiety, and so further, larger and more controlled evaluations are indicated.

Background: Negative mental imagery is ubiquitous in cognitive models of social anxiety and in the social anxiety literature. Previous research has shown that it is causal of increased anxiety, lower social performance ratings and lower implicit self-esteem. Despite its prevalence, few studies have investigated this imagery directly. Aims: This study aimed to provide an in-depth analysis of the phenomenology of negative imagery experienced by socially anxious individuals, and to compare recurrent and intrusive images with images deliberately generated by participants during the study. Method: Thirty-eight undergraduate students screened to be above average in social anxiety scores completed a computerized imagery questionnaire adapted from previous qualitative work. Results: Thematic analyses revealed four major image themes for intrusive images and three for deliberately generated images including interacting with others and anxiety symptoms. Most intrusive images were based on negative episodic memories and were experienced at least fortnightly. Images were primarily visual, auditory and somatic but could involve any sensory modality. Depression anxiety stress scale (DASS-21) scores were higher in participants who experienced intrusive imagery and increased with the frequency of intrusions. Emotionality was generally higher in intrusive images than generated images. Conclusions: The phenomenology of negative imagery experienced by socially anxious individuals is idiosyncratic and may be inherently different from images generated for use in experimental research. Theoretical and clinical implications are discussed.

Background: Rumination predicts depression in adults and adolescents. The development of rumination has been linked to parenting practices, but only limited research has investigated this and research has tended to rely on self-report parenting measures. Aims: To investigate the relationship between female adolescent rumination and maternal modelling, criticism and positivity using an observational measure of parental behaviour. Method: A cross-sectional design was used. Daughters aged 16–18 years and their mothers (n = 154 dyads) completed questionnaire measures of rumination and affect. Mothers of girls with rumination scores in the upper and lower quartile (both n = 26) also completed the Five Minute Speech Sample, which was used to measure maternal criticism and positivity. Results: Mothers of low rumination girls made significantly more positive comments about their daughters than the mothers of high ruminators. Mothers made very few critical comments. Self-reported rumination was not correlated in mothers and daughters, suggesting a lack of support for the potential role of modelling. Conclusion: Overall, low maternal positivity was associated with rumination in female adolescents. There was no evidence that maternal rumination or criticism were associated with adolescent rumination. The results suggest a number of implications for future research, including the need for prospective longitudinal studies using observational parenting measures.

Background: Perfectionism is strongly associated with obsessive compulsive disorder (OCD). Cognitive behavioural therapy for perfectionism (CBT-P) has been found to result in reductions in a range of symptoms in individuals with anxiety disorders, depression and eating disorders. Aim: To pilot-test the efficacy of group CBT for perfectionism in participants with OCD and elevated perfectionism. Method: Participants were randomized to receive immediate 8-week group CBT-P (n = 4) or an 8-week waitlist followed by CBT-P (n = 7). Results: Reliable reductions and a large effect size indicated that CBT-P was associated with improvements in perfectionism and OCD severity at post-test. However, these changes were not clinically significant and drop-out was high, resulting in a small final sample. Conclusions: CBT-P may be effective in reducing perfectionism and disorder-specific OCD symptoms. However, the high drop-out rate and lack of clinically significant findings suggest that further research needs to be conducted to determine the efficacy of CBT for perfectionism in OCD.