Social phobia is a common and disabling condition for both children and adults. In recent years Clark and Wells' (1995) cognitive model of social phobia has given rise to an effective treatment protocol for the condition in adults (e.g. Clark et al., 2003, 2006). The current study investigates the applicability of this model to younger people. One hundred and seventy-one 11–14 year-old participants completed questionnaires measuring social anxiety, depression, and the variables hypothesized to maintain social phobia in Clark and Wells' (1995) cognitive model: negative social cognitions, safety behaviours, self-focused attention, and pre- and post-event processing. High socially anxious children scored significantly higher than low socially anxious children on all of the variables in Clark and Wells' model. Negative social cognitions, self-focused attention, safety behaviours, and pre- and post-event processing were all significant predictors of social anxiety, accounting for 48% of the variance in social anxiety. Furthermore, these variables showed specificity to social anxiety, predicting significantly more variance in social anxiety than in depression. Findings suggest that although Clark and Wells' (1995) model of social phobia was developed from research on adult populations, it may be equally applicable to younger people with social phobia.

Treatment of compulsive hoarding has rarely been described in the literature, apart from standard treatments for obsessive compulsive disorder of which hoarding is thought to be a subset. This paper presents preliminary findings from seven patients treated with cognitive and behavioral interventions derived from Frost and Hartl's (1996) theoretical model of hoarding. Six clients attended 15 group treatment sessions over 20 weeks plus individual home treatment sessions and one client received 20 weekly-sessions of individual treatment only. After 20 weeks, treatment resulted in noticeable improvement in several hoarding symptoms for five of the seven patients, especially reduction in excessive acquisition of possessions, although problems with clutter persisted. Three of four clients who continued in treatment for approximately 1 year showed substantial further improvement, although none felt entirely recovered. Findings are discussed in light of the model of hoarding and possible modifications to treatment to enhance motivation and benefits.

Recent research suggests that cognitive-behaviour therapy (CBT) can significantly improve outcomes for patients with severe mental health problems. However, there are no tools specifically designed to assess competence in delivering CBT to psychotic patients. This study investigates the psychometric properties of the Cognitive Therapy Scale for Psychosis (the CTS-Psy) for assessing the quality of CBT with psychotic patients. Inter-rater reliability of trained raters using the CTS-Psy was investigated using taped therapy of trainees engaged in a CBT oriented psychosis training course. Validity was investigated in relation to examining the degree to which the scale could be used to assess a range of therapist ability and patient severity and by assessing the degree to which the CTS-Psy could pick up changes in skill acquisition during the training course over a 9-month period. The CTS-Psy demonstrated excellent inter-rater reliability and good validity in relation to it being able to rate all standards of therapy and all types of patient sessions in the sample studied. In addition, the scale was sensitive to changes in clinical skills during a training course and could discriminate between those who had received training and those who had not.

Background: At present there are no measures to identify the cognitive processes and behaviours that might mediate the outcome of treatment in people with Body Dysmorphic Disorder (BDD). Aims: To develop and validate a process measure that can be used to assess the progress of patients throughout therapy and in research for BDD. Method: The psychometric properties of the Appearance Anxiety Inventory (AAI) were explored in a clinical group of participants diagnosed with BDD (Study 1) and in a non-clinical community group with high appearance concerns (Study 2). Item characteristics, reliability, and factor structure were analysed. Convergent validity with measures of related symptoms was assessed. Results: The AAI was found to have good test-retest reliability and convergent validity in the measurement of appearance anxiety. It was also sensitive to change during treatment. The scale was found to have a two-factor structure in the clinical group, with one factor characterized by avoidance, and a second factor comprised of threat monitoring. However, in the community sample it appeared to have a one-factor structure. Conclusion: The results suggest that the AAI has the psychometric properties to determine whether changes in cognitive processes and behaviours can mediate the outcome following treatment in patients with BDD. This supports its potential usefulness in clinical and research settings.

Evidence indicates that workshop training, personalized feedback, and individual consultation can increase competence in motivational interviewing (MI) among highly motivated and skilled substance abuse counselors. Little is known, however, about the translational value of these training strategies for counselors with fewer counseling skills and less stated motivation to learn MI. This study presents evidence from a randomized, controlled trial of 129 behavioral health providers assigned to receive workshop training and enrichments to learn MI. A diverse group of Air Force behavioral health providers working in substance abuse treatment programs were trained in MI and subsequently observed in clinical sessions at 4, 8 and 12 months after training. Results indicate that training was effective in increasing the skill level of these clinicians; however, these gains had decreased by the 4-month follow-up point. Training enrichments in the form of personalized feedback and consultation phone calls did not have an expected, additive effect on clinician skill level. The results of this study lend support to the hypothesis that a greater investment of resources and incentives may be necessary to achieve gains in MI skills for counselors with relatively lower baseline skills than those commonly participating in research studies.

There is active, current speculation about the relationship between trauma and psychosis. However, little is known about the information-processing mechanisms underlying the development of trauma-related intrusions in this area. Our account highlights the role of contextual integration, i.e. the need for experiential information to be effectively integrated into a temporal and spatial context in order to facilitate voluntary recall. Drawing on existing models of both posttraumatic stress disorder (PTSD) and psychosis (Brewin, 2001; Ehlers and Clark, 2000; Garety et al., 2001; Morrison, 2001), we propose a contextual integration account of trauma-related intrusions. It is argued that the strength of contextual integration, which occurs during encoding, influences the frequency and nature of subsequent intrusive experiences. Consequently, individual differences in schizotypal personality traits, which are known to be associated with levels of contextual integration, are also related to the phenomenology of trauma-related intrusions. Whilst intrusions can be seen to occur within a range of disorders, it is argued that contextual integration may be one key variable in understanding the relationship between an experienced trauma and any consequent psychiatric symptomatology. Implications for clinical interventions aimed at trauma-related psychosis are discussed, along with research aimed at developing the empirical basis for such interventions.

Background: A recommendation in original descriptions of motivational interviewing (MI) was to “explore ambivalence”. Contrasting procedures for doing so have been clarified through the evolution of MI. Aims: This article describes two conceptually distinct methods for responding to ambivalence: decisional balance (DB) and MI's evocation of change talk, and reviews empirical evidence to recommend when each procedure is appropriate (and inappropriate) in clinical practice. Method: The authors summarize findings of clinical outcome research to examine how these two interventions impact the resolution of client ambivalence. Results: With ambivalent people, a DB intervention tends to decrease commitment to change, whereas evocation (a key element of MI) promotes change. When a person has already made the decision to change, evocation is unnecessary and may deter change, whereas DB may further strengthen commitment. Conclusions: DB is an appropriate procedure when the clinician wishes to maintain neutrality and not favor the resolution of ambivalence in any particular direction. Evocation is appropriate when the clinician intends to help clients resolve ambivalence in the direction of change.

Cognitive theorists propose that each anxiety disorder is associated with a specific tendency to overestimate the danger inherent in particular situations or internal states. Studies comparing anxious patients with non-patient controls have shown that several anxiety disorders are associated with elevated subjective estimates of the likelihood (probability) and cost of negative events. The present study focuses on social phobia and extends previous findings by: a) including a control group of equally anxious patients with another anxiety disorder and b) investigating the effects of successful cognitive and drug treatments on patients' probability and cost estimates. In line with cognitive theory, the results indicate that social phobia is associated with a specific elevation in subjective estimates of both the probability and cost of potentially negative social events. Reductions in overestimation occurred in successful cognitive and drug treatment and were closely related to the degree of symptomatic improvement in both treatments. Contrary to previous findings, there was no evidence that reductions in cost were more important than reductions in probability.

This paper critically evaluates the empirical evidence of 36 studies regarding the comparative cost-effectiveness of group and individual cognitive behaviour therapy (CBT) as a whole, and also for specific mental disorders (e.g. depression, anxiety, substance abuse) or populations (e.g. children). Methods of calculating costs, as well as methods of comparing treatment outcomes were appraised and criticized. Overall, the evidence that group CBT is more cost-effective than individual CBT is mixed, with group CBT appearing to be more cost effective in treating depression and children, but less cost effective in treating drugs and alcohol dependence, anxiety and social phobias. In addition, methodological weaknesses in the studies assessed are noted. There is a need to improve cost calculation methodology, as well as more solid and a greater number of empirical cost-effectiveness studies before a firm conclusion can be reached that group CBT is more cost effective then individual CBT.

Homework assignments are an essential part of cognitive-behavioural therapy, and are included in the majority of therapy manuals and frequently used in therapeutic practice. Despite this, little is known about problems with homework completion or possible influences on homework compliance. The aim of the present practitioner survey was to provide data on problems related to homework use and compliance. Furthermore, the relationships between different variables and homework compliance were examined. Data were collected by asking 77 cognitive-behavioural therapists to recall two individual patients. Therapists described homework tasks assigned to these patients and procedures of assignment as well as problems that arose during assignment and completion. The results suggested that problems during the assignation of a task as well as during completion regularly occur. Homework compliance was positively associated both with patients' motivation for therapy, outcome at a later stage of therapy, and the provision of a written note or homework sheets on the task. Regression analyses pointed to patient variables as most crucial for homework compliance. Implications for effective homework use in clinical practice are discussed.

The experience of stigma by individuals with schizophrenia can impact on self-esteem and potential for recovery. Previous attempts to reduce stigma within society have reported variable success. The present study aimed to formulate and evaluate a therapeutic intervention for those who perceive themselves as stigmatized by their mental illness and who suffer low self-esteem. A waiting-list control design with repeated measures within participants was used. Treatment efficacy was evaluated by a principal outcome measure of self-esteem. Ancillary outcome measures included a measure of perceived stigmatization, and two symptom measures. Assessments were completed on four occasions, which covered a waiting list period, a treatment period and a follow-up. All participants (N = 21) received group Cognitive Behavioural Therapy (CBT) focused on stigma and self-esteem. Self-esteem improved significantly following treatment. Levels of depression, positive and negative symptoms of schizophrenia and general levels of psychopathology decreased significantly. A longer-term effect was found for positive and negative symptoms of schizophrenia, and general levels of psychopathology. Participant feedback was predominantly positive. In addition to societal interventions, the potential for limiting the effects of stigma within a therapeutic context should be investigated.

This paper describes a distinct clinical approach to the treatment of Posttraumatic Stress Disorder (PTSD). It is theoretically guided by recent cognitive models of PTSD and explicitly combines cognitive therapy techniques within exposure/reliving procedures. A clinically pertinent distinction is made between the cognitions and emotions experienced at the time of the trauma and, subsequently, in flashback experiences, and secondary negative appraisals. The term peritraumatic emotional “hotspot” is used to describe moments of peak distress during trauma. It is argued that a focus on cognitively restructuring these peritraumatic emotional hotspots within reliving can significantly improve the effectiveness of the treatment of PTSD and help explain some treatment failures with traditional prolonged exposure. An approach to the identification and treatment of these hotspots is detailed for a range of cognitions and emotions not limited to fear.

The project aims to investigate the efficacy of a preventive cognitive behavioural intervention delivered via the Internet to individuals at risk of developing anxiety disorders. There is increasing evidence that suggests anxiety sensitivity may act as a premorbid risk factor for the development of anxiety pathology and panic disorder. Eighty-three university students with elevated anxiety sensitivity were randomly allocated to either an intervention group (n = 43), who worked through the Internet based program over a period of 6 weeks, or a waitlist control group (n = 40). Significant treatment effects were found for anxiety related cognitions and symptoms of depression, and a non-significant trend for anxiety sensitivity. These outcomes were related to expectancy but not to program utilization. Implications for the prevention of anxiety via the Internet are discussed.

A preliminary investigation of the content and origins of intrusive imagery and core beliefs as they occur in health anxiety is reported. The exploration of patients' images proved to be a particularly effective means of determining underlying core beliefs. Images appeared to reflect a wider range of idiosyncratic meanings than were apparent in the automatic thoughts alone. Two types of core beliefs were revealed by the images: beliefs about the self, and beliefs about death and illness and their implications, which included themes to do with abandonment and isolation. All patients had metaphysical or superstitious beliefs. It is suggested that a conjunction between the beliefs about the self and those about death and illness may contribute to individual tendencies to misinterpret bodily sensations in health anxiety.

A self-directed variant of the Positive Parenting Program (Triple P) was evaluated using 63 preschool-age children at-risk of developing conduct problems. Families were randomly assigned to either Self-directed Triple P (SD), a self-administered behavioural family intervention program, or a waitlist group (WL). The 10-unit SD program teaches parents 17 parenting skills to increase pro-social child behaviours and decrease problem behaviours in home and community settings. Using mothers' reports of child behaviour and parenting practices, mothers in the SD group reported significantly less child behaviour problems, less use of dysfunctional discipline strategies, and greater parenting competence than mothers in the WL group. On measures of parental adjustment, there was no significant difference in conditions at post-intervention based on mothers' reports of depression, anxiety, stress and conflict with partners over parenting issues. Mothers' reports at 6-month follow-up indicated that gains in child behaviour and parenting practices achieved at post-intervention were maintained.

Mindfulness training has been proposed as a potentially important new approach for the treatment of generalized anxiety disorder (GAD). However, to date only a few studies have investigated mindfulness training for GAD. The aim of this study was to further investigate symptom change and recovery in pathological worry after mindfulness-based cognitive therapy (MBCT) using an uncontrolled pre-post design. Twenty-three adults with a primary diagnosis of GAD participated in the study. The MBCT program involved 9 weekly 2-hour group sessions, a post-treatment assessment session, and 6-week and 3-month follow-up sessions. Intent-to-treat analysis revealed significant improvements in pathological worry, stress, quality of life, and a number of other symptoms at post-treatment, which were maintained at follow-up. Attrition was also low, and MBCT was perceived as a credible and acceptable intervention. However, when applying standardized recovery criteria to pathological worry scores, the rate of recovery at post-treatment was very small, although improved at follow-up. Overall, the findings suggest MBCT is definitely worthy of further investigation as a treatment option for GAD, but falls well short of outcomes achieved by past research. Possible reasons for the poor rate of recovery, implications, and limitations are briefly outlined.

Background: Paramedics are frequently subjected to traumatic experiences and have higher PTSD prevalence rates than people in the general population. However, the vast majority of paramedics do not develop PTSD. While several risk factors for PTSD have been established, little is known about protective factors. It has been suggested that a good sense of coherence (SOC) and high resilience lower the risk for developing PTSD. Aims: To examine whether SOC and resilience are associated with PTSD severity in paramedics. Method: A cross-sectional study investigated SOC, resilience and PTSD in paramedics (N = 668). PTSD was assessed with the Posttraumatic Stress Diagnostic Scale (PDS); resilience and SOC were measured with the Resilience Scale (RS-11) and the Sense of Coherence Scale (SOC-L9). Further measures included preparation of dealing with traumatic events and availability of psychological help. Results: As expected, both resilience and SOC were negatively correlated with PTSD symptoms. The regression analysis showed that 19.2% of the total variance in symptom severity was explained by these variables. However, SOC was a better predictor than resilience for PTSD severity, as it accounted for more unique variance. Paramedics who were prepared for dealing with work-related traumatic events and who received psychological help had less severe PTSD symptoms and higher SOC scores than paramedics for whom these services were not available. Conclusions: Enhancing resilience, and especially SOC, seems a promising approach to reduce PTSD symptom severity in high risk groups like paramedics.

A method of teaching coping skills to patients with schizophrenia who experience unremitting psychotic symptoms is described. This method (Coping Strategy Enhancement CSE) is based on a thorough behaviour analysis of each symptom and the assessment of any coping strategy the subject may already employ. The subject is then systematically trained in the use of appropriate coping strategies in response to the occurrence of their psychotic symptoms. Two case studies are described in which CSE was used. Both patients showed considerable improvements over treatment. In one patient improvement continued at 6 month follow-up, in the other there was some deterioration at follow-up. Possible reasons for these results were discussed.

Clinical supervision is an integral aspect of training and is essential for accreditation as a cognitive behavioural psychotherapist. A questionnaire survey of a random sample of accredited British Association of Behavioural and Cognitive Psychotherapists (n = 280) is reported, 61% (N = 170) responded by describing their supervision practices in a number of areas. These included the organization of supervision, content, satisfaction, techniques, models, interdisciplinary working and supervision of others. The results indicate that satisfaction levels with supervision were high amongst accredited therapists and that the ratio of time spent in supervision to therapeutic contact is, on average, higher than recommended minimum levels. Supervision was less structured and active than therapy and little use was made of audio/video tapes of therapy sessions within supervision. The level of training for supervisors was highly variable with a substantial proportion having received no formal training in cognitive behavioural psychotherapy supervision. Dual role relationships were also common. Finally, recommendations for further research and practice are made.