Several previous studies have reported that cognitive/behavioural treatments have been relatively ineffective for chronic, drug-resistant depressed patients. In the present report, six chronic, drug-resistant depressed patients were treated with an integrated program consisting of cognitive/behavioural treatment, pharmacotherapy, and short term hospitalization. The obtained improvement rates were substantially better than previous studies. Potential explanations for these findings are discussed.

Background: Growing evidence supports the association between early memories of shame and lack of safeness and current shame and depression. Nevertheless, it is unclear whether shame serves as a mediator between such early memories and depressive symptoms. Aims: This study aimed at testing whether the impact of shame traumatic memory, centrality of shame memory, early memories of warmth and safeness (predictors), on depressive symptoms (outcome) would be mediated by current external and internal shame. Method: Student participants (N = 178) recalled an early shame experience and completed self-report instruments measuring centrality and traumatic characteristics of the shame memory, early memories of warmth and safeness, external and internal shame and depressive symptoms. Results: Path analysis’ results revealed that internal shame fully mediated the relationship between shame traumatic memory, centrality of shame memory, and early memories of warmth and safeness, and depression. However, current feelings of external shame, highly linked to internal shame, did not significantly predict depression. Conclusion: These findings shed light on the role of internalizing early shame and lack of safeness memories into a sense of self as globally self-condemning in the vulnerability to experience depressive symptoms.

This study investigated whether brief training in cognitive therapy for panic disorder (Clark et al., 1994) can improve the outcomes that primary care therapists obtain with their patients. Seven primary care therapists treated 36 patients meeting DSM-IV (APA, 1994) criteria for panic disorder with or without agoraphobia in general practice surgeries. Outcomes for the cohort of patients whom the therapists treated with their usual methods (treatment-as-usual) before the training (N = 12) were compared with those obtained with similar patients treated by the same therapists after brief training and ongoing supervision in cognitive therapy (CT) for panic disorder (N = 24). Treatment-as-usual led to significant improvements in panic severity, general anxiety, and depression. However, only a small proportion (17% of the intent-to-treat sample) became panic free and there was no improvement in agoraphobic avoidance. Patients treated with CT achieved significantly better outcomes on all measures of panic attacks, including panic-free rate (54%, intent-to-treat), and showed significantly greater improvements in agoraphobic avoidance and patient-rated general anxiety. In conclusion, cognitive therapy for panic disorder can be successfully disseminated in primary care with a brief therapist training and supervision programme that leads to significant improvements in patient outcomes.

Background: Perinatal mental health difficulties are highly prevalent. In England, the Improving Access to Psychological Therapy (IAPT) programme provides evidence-based psychological treatment, predominantly in the form of brief manualized cognitive behavioural therapy (CBT), to people with mild to moderate depression or anxiety. Yet little is known about the experiences of women referred to IAPT with perinatal mental health difficulties. Aims: The aim of this qualitative study was to investigate how women view IAPT support for perinatal mental health. We also gained the perspective of IAPT therapists. Method: Semi-structured interviews were conducted with twelve women who had been referred to and/or received therapy from IAPT during the perinatal period. Additionally, fourteen IAPT therapists participated in two focus groups. Thematic analysis was used. Results: Key themes centred on barriers to access and the need to tailor support to (expectant) mothers. Women and therapists suggested that experiences could be improved by supporting healthcare professionals to provide women with more help with referrals, better tailoring support to the perinatal context, improving perinatal-specific training, supervision and resources, and offering a more individualized treatment environment. Conclusions: Overall, women reported positive experiences of support offered by IAPT for perinatal mental health difficulties. However, services should seek to facilitate access to support and to enable therapists to better tailor treatment.

Background: Cognitive therapy is an effective treatment for social anxiety disorder but little is known about the mechanisms by which the treatment achieves its effects. Aims: This study investigated the potential role of self-focused attention and social phobia related negative automatic thoughts as mediators of clinical improvement. Method: Twenty-nine patients with social phobia received individual cognitive therapy (ICT) in a randomized controlled trial. Weekly process and outcome measures were analysed using multilevel mediation models. Results: Change from self-focused to externally focused attention mediated improvements in social anxiety one week later. In contrast, change in frequency of, or belief in, negative social phobia related negative automatic thoughts did not predict social anxiety one week later. Conclusions: Change in self-focused attention mediate therapeutic improvement in ICT. Therapists should therefore target self-focused attention.

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.

In selected adult neurotics, nurse-therapists have a significant contribution to make in giving behavioural psychotherapy to patients who were formerly denied it for lack of trained personnel (Marks et al. 1977). Perhaps 10% of all adult psychiatric outpatients can benefit from behavioural psychotherapy as the main approach for those categories of problem where established behavioural methods have been found to be superior to contrasting treatments (Marks, 1976).

Background: When using Motivational Interviewing (MI), once resistance or ambivalence are resolved and motivation is solidified, many practitioners struggle with how best to transition the discussion toward action planning, while still retaining the spirit and style of client centeredness, i.e., moving from the WHY phase to the HOW phase of counseling in a style that is MI-consistent. For many, there is a perception that the counseling style, skills, and strategies used to build motivation are distinct from those used in the action planning phase. The WHY to HOW transition does not, however, necessitate abandoning a client-centered style for a more overtly educational or directive style. Goal setting, action planning, provision of advice, and relapse prevention can be implemented from an autonomy supportive, MI consistent framework. Method: To this end, this article will present a new class of reflection, which we have termed “action reflections”, that can be used to help bridge the WHY-HOW gap. Action reflections (AR) allow the clinician to maintain a tone and orientation that are consistent with MI, i.e. autonomy support; guiding versus directing, during the action phase of counseling. They differ from reflecting change talk as they focus not on the WHY of change, but the HOW, WHEN, or WHERE. Action Reflections (ARs) also differ from the more common type of reflections such as those that focus on client feelings, rolling with resistance, or acknowledging ambivalence as ARs usually contain a potential concrete step that the client has directly or obliquely mentioned. Like any type of reflection, ARs represent the clinician's best guess for what the client has said or, more apropos here, where the conversation might be heading. Conclusion: This article describes the various types of ARs and provides examples of each to help clinicians incorporate them into their behavior change counseling.

An eighteen month follow-up of chronic nightmare sufferers treated with imagery rehearsal, a cognitive-behavioral method, demonstrated significant and clinically meaningful decreases in nightmare frequency. Sixty-eight percent of subjects decreased their nightmares below criteria for a “Chronic Nightmare Disorder”. Significant improvement was also noted for sleep quality and daytime anxiety. The findings support the theory that nightmares may be clinically conceptualized as a primary sleep disorder in some chronic sufferers.

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: Virtual reality exposure therapy (VRET) has been used to treat a variety of fears and phobias. Aim: To determine the feasibility (i.e. safety and efficacy) of using VRET to treat dental phobia. Method: Safety was evaluated by determining any adverse events or symptom exacerbation. Efficacy of VRET was evaluated by comparing the reduction in dental anxiety scores (measured 16 times within a 14-week study period, and at 6-month follow-up), and its behavioural effects with that of an informational pamphlet (IP) on ten randomized patients with dental phobia using a controlled multiple baseline design. Participants’ heart rate response during VRET, and their experience post-VRET, were indexed. Results: No personal adverse events or symptom exacerbation occurred. Visual analysis and post-hoc intention-to-treat analysis showed a significantly greater decrease in dental anxiety scores [higher PND (percentage of non-overlap data) scores of 100% and lower POD (percentage of overlap data) of 0%, Modified Dental Anxiety Scale, F (1,8) = 8.61, p = 0.019, and Dental Fear Scale, F (1,8) = 10.53, p = 0.012], and behavioural avoidance in the VRET compared with the IP group [d = 4.2 and –1.4, respectively). There was no increase in average heart rate during VRET. Of the nine treatment completers, six (four from the VRET group and two from the IP group) no longer had dental phobia at 6-month follow-up. Four of the five VRET participants, but none of the IP participants, scheduled a dental treatment appointment following the intervention. Conclusion: VRET is a feasible alternative for patients with dental phobia.

This study examined the effects of anticipatory processing on a subsequent speech in high and low socially anxious participants. Forty participants (n = 20 in each group) gave two speeches, one after no anticipatory processing and one after 10-minutes of anticipatory processing. In anticipatory processing, high socially anxious participants were more anxious, and experienced more negative and unhelpful self-images than low socially anxious participants did. However, both groups rated memories of past speeches as having a somewhat helpful effect on their speech preparation. High socially anxious participants tended to use the observer perspective more in the anticipated speech, while, in the unanticipated speech, they might have been switching between observer and field perspectives. Low socially anxious participants tended to use the field perspective in both speeches. High and low socially anxious participants reported better speech performances after the anticipated, compared to after the unanticipated speech. Results suggest that anticipatory processing may have both positive and negative effects on socially anxious individuals' cognitive processing and performance before and during a speech.

Background: An integrative cognitive model proposed that ascribing extreme personal appraisals to changes in internal state is key to the development of the symptoms of bipolar disorder. The Hypomanic Attitudes and Positive Predictions Inventory (HAPPI) was developed to measure these appraisals. Aims: The aim of the current study was to validate an expanded 61-item version of the HAPPI. Method: In a largely female student sample (N = 134), principal components analysis (PCA) was performed on the HAPPI. Associations between the HAPPI and analogue bipolar symptoms after 3 months were examined. Results: PCA of the HAPPI revealed six categories of belief: Self Activation, Self-and-Other Critical, Catastrophic, Extreme Appraisals of Social Approval, Appraisals of Extreme Agitation, and Loss of Control. The HAPPI predicted all analogue measures of hypomanic symptoms after 3 months when controlling for baseline symptoms. In a more stringent test incorporating other psychological measures, the HAPPI was independently associated only with activation (e.g. thoughts racing) at 3 months. Dependent dysfunctional attitudes predicted greater conflict (e.g. irritability), depression and reduced well-being, hypomanic personality predicted self-reported diagnostic bipolar symptoms, and behavioural dysregulation predicted depression. Conclusions: Extreme beliefs about internal states show a modest independent association with prospective analogue bipolar symptoms, alongside other psychological factors. Further work will be required to improve the factor structure of the HAPPI and study its validity in clinical samples.

A 4-year follow-up compared the long-term effects of two treatments for severely conduct disorder children referred to a Child and Adolescent Mental Health Service (CAMHS). Forty-two families received either the standard CAMHS treatment or a more intensive intervention. The intensive treatment involved a unit-based component for parents to practise new child management strategies. At the 6-month follow-up the intensive treatment group showed significant improvements on all measures of child behaviour and maternal mental health and improvements remained significant at the 4-year follow-up. By contrast, initial improvements for the standard treatment group, which were significant on only two measures, were not significant at the 4-year follow-up. The results suggest that the intensive treatment was advantageous in bringing about long-term improvements for these families. They also add to the growing evidence that interventions involving the rehearsal of child management strategies have better outcomes than those using more didactic methods of parent training.

Background: Cognitive behavioural therapy for psychosis (CBTp) is currently a recommended form of psychosocial treatment for persons suffering from persistent psychotic symptoms. It has been argued that effect sizes from efficacy studies cannot be generalized to real clinical settings. Aims: Our aim was to evaluate whether the positive results from randomized controlled trials conducted by experts could be replicated in clinical setting with a heterogeneous sample of patients with psychotic disorder. Method: Patients referred to the study were either randomized to CBTp + TAU (the treatment group) or to a waiting-list group, only receiving TAU. The patients were assessed on different outcome measures such as the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Negative Symptoms (SANS), and the Psychotic Symptom Rating Scales (PSYRATS), at pretreatment, at posttreatment (6 months), and at 12 months follow-up. In total, 45 patients participated in the study. Results: The results showed that 20 sessions of CBTp performed significantly better than the waiting list controls with respect to the global score on the BPRS, the delusional scale on the PSYRATS, and the GAF symptom score at posttreatment. At 12 months follow-up only the GAF symptom score remained significantly changed for the total sample. Conclusions: The study revealed that CBTp delivered by non-experts in routine clinical settings can produce improvements in positive psychotic symptoms, and also that some of these improvements can be maintained at one year follow-up.

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.

Sleeping difficulties are relatively common amongst normal young children at some stage in their development. It is estimated, for example, that approximately 20% of normal 1–2 year olds and 14% of 3 year olds wake regularly during the night (Bernal, 1973; Jenkins, Bax and Hart and Land-sown, 1980). Amongst handicapped children rates of sleeping disturbance tend to be even higher (Richman, Stevenson and Graham, 1975; Richman, Douglas, Hunt, Levere, 1982) and in autistic children, in particular sleeping difficulties are frequently severe and persistent. Thus, De Meyer (1979) found that almost all autistic children had shown sleeping problems at some stage in their development and at an average age of 5½ years, 49% still showed severe sleeping difficulties (as compared with only 3% of normal controls). This additional strain on parents, who already have to cope with many behavioural problems throughout the day, can be considerable, and frequently has a deleterious effect on many aspects of family and marital relationships.

Background: Clark and Wells’ cognitive model of social anxiety proposes that socially anxious individuals have negative expectations of performance prior to a social event, focus their attention predominantly on themselves and on their negative self-evaluations during an event, and use this negative self-processing to infer that other people are judging them harshly. Aims: The present study tested these propositions. Method: The study used a community sample of 161 adolescents aged 14–18 years. The participants gave a speech in front of a pre-recorded audience acting neutrally, and participants were aware that the projected audience was pre-recorded. Results: As expected, participants with higher levels of social anxiety had more negative performance expectations, higher self-focused attention, and more negative perceptions of the audience. Negative performance expectations and self-focused attention were found to mediate the relationship between social anxiety and audience perception. Conclusions: The findings support Clark and Wells’ cognitive model of social anxiety, which poses that socially anxious individuals have distorted perceptions of the responses of other people because their perceptions are coloured by their negative thoughts and feelings.

Background: Self-esteem is an important factor in the development and maintenance of good psychological health. Low self-esteem can be a consequence of mental health disorders (such as depression, anxiety and panic) or it can be a vulnerability factor for the development of such problems. Aims and method: The current study reports pilot findings from a Cognitive Behavioural Therapy (CBT) group intervention for 37 adult women with low self-esteem, based on Fennell's Overcoming Low Self-Esteem Self-Help Course. Results: Findings suggest that the group is (statistically and clinically) effective at increasing levels of self-esteem and at reducing levels of depression and anxiety. Conclusions: Together, results suggest that the group provides an efficient and therapeutically beneficial service. However, since these findings are limited by the lack of control or follow-up data, they warrant further investigation.

Background: Clinical supervision plays an essential role in the development of mental health professionals and is increasingly viewed as a discrete professional specialization. However, research has rarely addressed core issues such as the measurement and manipulation of clinical supervision, so there are very few direct comparisons between the different supervision methods. Aims: To operationalize two related approaches, cognitive-behavioural (CBT) and evidence-based clinical supervision (EBCS), demonstrate their fidelity, and then evaluate their relative effectiveness in facilitating the experiential learning of one supervisee. Method: Within a multiple-baseline, N = 1 design, we rated audiotapes of supervision on a competence rating scale. Results: Findings generally favoured the EBCS approach, which was associated with higher fidelity by the supervisor and increased engagement in experiential learning by the supervisee. Conclusions: This preliminary but novel evaluation indicated that CBT supervision could be enhanced. Implications follow for supervisor training and a more rigorous N = 1 evaluation.