Background: Not all patients suffering from trichotillomania (TTM) recover completely using CBT and of those that do, only a few maintain their recovery over time. Aims: The purpose of the present study was to investigate the effectiveness of metacognitive methods combined with habit reversal (MCT/HRT) in trichotillomania with a relatively long-term follow-up. Method: A case series (n = 8) and a randomized wait-list controlled trial (n = 34) design were conducted in this study. In the case series, three of the eight patients dropped out of the study. Therefore, TTM-related symptoms were evaluated in five patients suffering from TTM before and after brief metacognitive plus habit reversal therapy during 1-month, 6-month, and 12-month follow-ups. The treatment consisted of detached mindfulness (DM) techniques, ritual postponement and habit reversal training (HRT) in eight sessions. Results: All patients were responders at post-treatment in case series. After the 12-month follow-up, the results were associated with higher pre-treatment levels of self-esteem and global functioning and lower pre-treatment levels of depression and anxiety with nearly complete abstinence from hair pulling immediately after treatment. A randomized wait-list controlled trial with experimental (n = 17) and waiting list group (n = 17) was then conducted to confirm the case series results. There were significant differences between the two groups regarding changes in MGH-HPS, Y-BOCS-TM, RSES, GAF, BDI, BAI and self-monitoring. Therefore, the MCT/HRT treatment was found to be more effective than the waiting list group. Conclusions: A combined treatment including metacognitive and habit reversal techniques is remarkably effective in patients with TTM.

Background: The effectiveness of enhanced cognitive behavioural Therapy (CBT-E) for adults with a range of eating disorder presentations within routine clinical settings has been examined in only two known published studies, neither of which included a follow-up assessment period. Aim: The current study aimed to evaluate the effectiveness of CBT-E within an out-patient eating disorder service in Brisbane, Queensland, Australia, and incorporated a follow-up assessment period of approximately 20 weeks post-treatment. Method: The study involved 114 adult females with a diagnosed eating disorder, who attended an average of 20–40 individual CBT-E sessions with a psychologist or a psychiatry registrar between 2009 and 2013. Results: Of those who began treatment, 50% did not complete treatment, and the presence of psychosocial and environmental problems predicted drop-out. Amongst treatment completers, statistically and clinically significant improvements in eating disorder and general psychopathology were observed at post-treatment, which were generally maintained at the 20-week follow-up. Statistically significant improvements in eating disorder and general psychopathology were observed amongst the total sample. Conclusions: The findings, which were comparable to the previous Australian effectiveness study of CBT-E, indicate that CBT-E is an effective treatment for adults with all eating disorders within out-patient settings. Given the high attrition rate, however, minimizing drop-out appears to be an important consideration when implementing CBT-E within clinical settings.

Background: Post-traumatic stress disorder (PTSD) is a highly prevalent and impairing condition for which there are several evidence-based psychotherapies. However, a significant proportion of patients fail to complete a ‘sufficient dose’ of psychotherapy, potentially limiting treatment gains. Aims: The present study investigated predictors of premature treatment discontinuation during a trial of prolonged exposure (PE) therapy for PTSD. Method: Combat veterans with PTSD were recruited to participate in a randomized clinical trial of PE delivered in person or via telehealth technologies. Of the 150 initial participants, 61 participants discontinued the trial before the completion of eight sessions (of an 8‒12 session protocol). Treatment condition (telehealth or in person) and factors identified by prior research (age, combat theatre, social support, PTSD symptoms) were tested as predictors of treatment discontinuation. Results: A Cox proportional hazards model (a subtype of survival analysis) was used to evaluate predictors of treatment discontinuation. Disability status and treatment condition were identified as significant predictors of discontinuation, with a noted disability and use of telehealth demonstrating higher risk. Conclusions: The present findings highlight the influence of telehealth and disability status on treatment discontinuation, while minimizing the role of the previously identified variables from studies with less sensitive analyses.

Background: Post-traumatic stress disorder often brings about profound, lasting, structural changes to one's sense of self. Aims: This study investigated self-complexity and self-aspect control in post-traumatic stress disorder (PTSD). Method: Trauma survivors with (n = 103) and without (n = 102) PTSD completed an online questionnaire which involved the completion of a self-complexity task and measures of PTSD. Results: It was found that those with PTSD had significantly greater overall self-complexity than those without PTSD. Furthermore, when considering self-description valence, it was found that those with PTSD had significantly greater negative self-complexity than those without PTSD, but the groups did not differ in terms of positive self-complexity. Second, those with PTSD reported significantly less control over their self-aspects. Third, for those with PTSD, lower levels of self-aspect control were significantly correlated with greater negative self-complexity and lower positive self-complexity. Finally, self-aspect control mediated the relationship between self-complexity and PTSD symptoms. Conclusion: The theoretical implications for PTSD models and the clinical implications for the treatment of those with PTSD are explored.

Background: The mechanisms and triggers of the attentional bias in social anxiety are not yet fully determined, and the modulating role of personality traits is being increasingly acknowledged. Aims: Our main purpose was to test whether social anxiety is associated with mechanisms of hypervigilance, avoidance (static biases), vigilance-avoidance or the maintenance of attention (dynamic biases). Our secondary goal was to explore the role of personality structure in shaping the attention bias. Method: Participants with high vs low social anxiety and different personality structures viewed pairs of faces (free-viewing eye-tracking task) representing different emotions (anger, happiness and neutrality). Their eye movements were registered and analysed for both whole-trial (static) and time-dependent (dynamic) measures. Results: Comparisons between participants with high and low social anxiety levels did not yield evidence of differences in eye-tracking measures for the whole trial (latency of first fixation, first fixation direction, total dwell time), but the two groups differed in the time course of overt attention during the trial (dwell time across three successive time segments): participants with high social anxiety were slower in disengaging their attention from happy faces. Similar results were obtained using a full-sample, regression-based analysis. Conclusion: Our results speak in favour of a maintenance bias in social anxiety. Preliminary results indicated that personality structure may not affect the maintenance (dynamic) bias of socially anxious individuals, although depressive personality structures may favour manifestations of a (static) hypervigilance bias.

Background: The use of maladaptive behaviors by individuals with generalized anxiety disorder (GAD) is theoretically important and clinically meaningful. However, little is known about the specificity of avoidant behaviors to GAD and how these behaviors can be reliably assessed. Aims: This study replicated and extended the psychometric evaluation of the Worry Behaviors Inventory (WBI), a brief self-report measure of avoidant behaviors associated with GAD. Method: The WBI was administered to a hospital-based sample of adults seeking treatment for symptoms of anxiety and/or depression (n = 639) and to a community sample (n = 55). Participants completed measures of symptom severity (GAD, depression, panic disorder, health anxiety, and personality disorder), and measures of checking, reassurance-seeking and behavioral inhibition. Analyses evaluated the factor structure, convergent, divergent, incremental, and discriminant validity, as well the temporal stability and treatment sensitivity of the WBI. Results: The two-factor structure found in the preliminary psychometric evaluation of the WBI was replicated. The WBI was sensitive to changes across treatment and correlated well with measures of GAD symptom severity and maladaptive behaviors. The WBI was more strongly related to GAD symptom severity than other disorders. The WBI discriminated between clinical and community samples. Conclusions: The WBI provides clinicians and researchers with a brief, clinically meaningful index of problematic behaviors that may guide treatment decisions and contribute to our understanding of maintaining factors in GAD.

Background: Little is understood about the relationship between therapist competence and the outcomes of patients treated for common mental health disorders. Furthermore, the evidence is yet to extend to competence in the delivery of low-intensity cognitive behavioural interventions. Understanding this relationship is essential to the dissemination and implementation of low-intensity cognitive behavioural interventions. Aims: The aim of this study was to explore the relationship between Psychological Well-being Practitioner (PWP) competence and patient outcome within the framework of the British government's Improving Access to Psychological Therapies (IAPT) initiative. Method: Forty-seven PWPs treating 3688 patients participated. Relationships between PWP scores on three observed standardized clinical examinations and reliable change in patients’ symptoms of anxiety and depression were explored at two time points: during the year-long training phase, and over a 12-month follow-up. Results: Results indicated that patients treated by qualified PWPs achieved superior outcomes than those treated by trainees. Little support was found for a general association between practitioner competence in delivering low-intensity cognitive behavioural interventions and patient outcome, either during or post-training; however, significantly more patients of the most competent PWPs demonstrated reliable improvement in their symptoms of anxiety and depression than would be expected by chance alone and fewer deteriorated compared with those treated by the least competent PWPs. Conclusion: Results were indicative of a complex, non-linear relationship, with patient outcome affected by PWP status (trainee or qualified) and by competence at its extremes. The implications of these results for the dissemination and implementation of low-intensity cognitive behavioural interventions are discussed.

Background: Ensuring rapid access to psychological interventions is a priority of mental health services. The involvement of peer workers to support the delivery of more accessible treatment options such as computerized cognitive behaviour therapy (CCBT) is recognized. Aims: To evaluate the implementation of a third sector remote CCBT @Home eTherapy service for people experiencing common mental health problems supported by individuals with lived experience. Method: Supported CCBT packages with telephone support were delivered over a 30-month period. Self-complete measures identifying levels of depression, anxiety and functioning were administered at each treatment appointment. Results: Over 2000 people were referred to the @Home eTherapy service; two-thirds attended an initial assessment and 53.4% of referrals assigned to CCBT completed treatment. Statistically significant improvements in anxiety, depression and functioning were found, with 61.6% of treated clients meeting recovery criteria. Conclusions: The service meets Improving Access to Psychological Therapies (IAPT) key performance targets, and is comparable to other IAPT services using CCBT. Evidence for the successful implementation of such a service by a third sector organization is provided.

Background: Previous studies have demonstrated that acceptance and commitment therapy (ACT) is effective for depression and may be useful for complex transdiagnostic clients. Aims: To conduct a preliminary evaluation of whether ACT is feasible and effective when delivered by psychologists and non-psychologists for complex clients in a National Health Service (NHS) community mental health service for adults. Method: Staff were trained in ACT and conducted one-to-one therapy with clients. Measures on general mental health, depression, fusion and values were given pre-therapy, post-therapy and at 3-month follow-up. Results: Standardized measures showed significant improvements post-therapy for global mental health, depression, cognitive fusion and values post-treatment. These were partially maintained at follow-up and remained after an intent-to-treat analysis. There were no differences in outcomes between psychologists and non-psychologists. Conclusions: ACT may be delivered effectively with limited training for complex cases in secondary care, though further research is needed.