The theory and principles of Metacognitive therapy (MCT) are described and data supporting its effects are summarized. MCT does not advocate challenging of negative automatic thoughts or traditional schemas. It proposes the existence of a universal maladaptive thinking style that causes disorder and focuses on helping patients regulate their cognition more adaptively. It aims to reduce worry and rumination and alter problematic patterns of attention and coping. In doing so it targets underlying metacognition that controls thinking and helps patients develop new ways of consciously experiencing inner events. Data from treatment studies suggest that individual MCT techniques and full treatment are highly effective. Further randomized trials are clearly warranted.

Background: This paper draws on cognitive psychology research and clinical observation to propose a model for the formation of auditory hallucinations that are located externally, and experienced in noisy environments. Method: This model highlights a series of cognitive processes that may make an individual prone to detecting false positives, i.e. believing they have heard something that is absent. A case study is used to illustrate the model. Results: It is suggested that the false positives may be a by-product of a perceptual system that has evolved to reduce false negatives in conditions of threat. The term hypervigilance hallucination is proposed for this type of experience. Conclusion: The clinical implications of the model are discussed.

Background: Depressive disorder is common in adolescents and largely untreated. Computers offer a way of increasing access to care. Computerized therapy is effective for depressed adults but to date little has been done for depressed adolescents. Aims: The objective of this study was to examine the feasibility, acceptability, and effects of The Journey, a computerized cognitive behavioural therapy (cCBT) program for depressed adolescents. Method: Thirty-four adolescents (mean age 15.2 years, SD = 1.5) referred by school counsellors were randomly assigned to either cCBT or a computer-administered attention placebo program with psychoeducational content (CPE). Participants completed the intervention at school. Data were collected at baseline, post-intervention and at a 1-month follow-up. The primary outcome measure was the Child Depression Rating Scale Revised (CDRS-R); secondary outcome measures were: RADS-2; Pediatric Quality of Life Inventory; Adolescent Coping Scale (short form); response and remission rates on CDRS-R. Completion rates and self-reported satisfaction ratings were used to assess feasibility and acceptabililty of the intervention. Results: Ninety-four percent of cCBT and 82% of CPE participants completed the intervention. Eighty-nine percent liked The Journey a lot or thought it was “okay” and 89% of them would recommend it for use with others as is or after some improvement. Adolescents treated with cCBT showed greater symptom improvement on CDRS-R than those treated with CPE program (mean change on cCBT = 17.6, CI = 14.13–21.00; CPE = 6.06, CI = 2.01–10.02; p< .001). Conclusions: It is feasible, acceptable and efficacious to deliver computerized CBT to depressed adolescents in a school setting. Generalizability is limited by the size of the study.

The present study investigated whether social support and family members' reactions to clients with obsessive compulsive disorder played a significant role in the follow-up outcome of an intensive behavioral treatment program. The roles OCD symptoms, moodstate, social functioning and life events were also assessed. General social support did not predict relapse, but significant others' empathy and positive interactions were associated with maintenance of gains. Negative family interactions (especially criticism and anger) and belief that clients could control their symptoms predicted relapse. Higher levels of post-treatment anxiety and depression and poorer functioning were related to negative outcome, as was distress from life events during follow-up. Results are discussed with respect to possible mechanisms of action and future research needs.

One hundred and nine patients with a primary diagnosis of GAD were allocated to either cognitive, behavioural, cognitive-behavioural or placebo versions of “Stress Control” large group didactic therapy or to a waiting list condition. Each group was run by two therapists and, with the exception of the placebo, contained between 20 and 24 patients. A wide range of measures were administered at pre-, mid- and post-therapy and at six month follow-up. At post-therapy, all therapy conditions showed highly significant change on almost all measures, with the active therapies, and to a slightly lesser degree, the placebo, being significantly different to the waiting list on most measures. At follow-up, the active treatment conditions enhanced post-therapy improvements, while the placebo condition maintained progress. No significant differences existed between the four treatment conditions at post-therapy and, with the exception of one measure, at follow-up. However, a trend at both points favours the cognitive and behavioural conditions.

Background: Cognitive Behaviour Therapy (CBT) of anxiety disorders is usually delivered in weekly or biweekly sessions. There is evidence that intensive CBT can be effective in phobias and obsessive compulsive disorder. Studies of intensive CBT for posttraumatic stress disorder (PTSD) are lacking. Method: A feasibility study tested the acceptability and efficacy of an intensive version of Cognitive Therapy for PTSD (CT-PTSD) in 14 patients drawn from consecutive referrals. Patients received up to 18 hours of therapy over a period of 5 to 7 working days, followed by 1 session a week later and up to 3 follow-up sessions. Results: Intensive CT-PTSD was well tolerated and 85.7 % of patients no longer had PTSD at the end of treatment. Patients treated with intensive CT-PTSD achieved similar overall outcomes as a comparable group of patients treated with weekly CT-PTSD in an earlier study, but the intensive treatment improved PTSD symptoms over a shorter period of time and led to greater reductions in depression. Conclusions: The results suggest that intensive CT-PTSD is a feasible and promising alternative to weekly treatment that warrants further evaluation in randomized trials.

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: Transdiagnostic Cognitive Behaviour Therapy (CBT) seeks to identify core cognitive-behavioural processes hypothesized to be important across a range of disorders and to develop a treatment that targets these. This contrasts with standard CBT approaches that are disorder-specific. Proponents of transdiagnostic CBT suggest that it may offer advantages over disorder-specific CBT, but little is known about the effectiveness of this approach. Aims: The review aimed to summarize trial-based clinical and cost-effectiveness data on transdiagnostic CBT for anxiety and depression. Method: A systematic review of electronic databases, including peer-reviewed and grey literature sources, was conducted (n = 1167 unique citations). Results: Eight trials were eligible for inclusion in the review. There was evidence of an effect for transdiagnostic CBT when compared to a control condition. There were no differences between transdiagnostic CBT and active treatments in two studies. We found no evidence of cost-effectiveness data. Conclusions: Quality assessment of the primary studies indicated a number of methodological concerns that may serve to inflate the observed effects of transdiagnostic approaches. Although there are positive signs of the value of transdiagnostic CBT, there is as yet insufficient evidence to recommend its use in place of disorder-specific CBT.

Three exploratory studies evaluated group mindfulness training (which aims to facilitate non-judgmental attention to present moment experience through the practice of meditation) in patients waiting for cognitive behaviour therapy for Chronic Fatigue Syndrome (CFS). The approaches used were based on Mindfulness Based Stress Reduction, and Mindfulness Based Cognitive Therapy. The first group showed that such training is acceptable to patients and that it results in significantly improved subjective measures of anxiety, and improvements in subjective levels of fatigue that approached significance, when compared to waiting list controls. A second uncontrolled study replicated the findings of the first study and also demonstrated an improvement in quality of life as measured by the Fatigue Impact Scale (FIS). More wide-ranging effects were demonstrated in the final study in which significant improvements in subjective levels of fatigue, anxiety, depression, quality of life and physical functioning were observed following the training programme. These effects were sustained for 3 months. Overall, the findings of the three exploratory studies indicate that MBSR/MBCT has potential for the treatment of patients with CFS.

Background: Sleep disturbance is increasingly recognized as a major problem for patients with schizophrenia but it is rarely the direct focus of treatment. The main recommended treatment for insomnia is cognitive behavioural therapy, which we have been evaluating for patients with current delusions and hallucinations in the context of non-affective psychosis. Aims: In this article we describe the lessons we have learned about clinical presentations of sleep problems in schizophrenia and the adaptations to intervention that we recommend for patients with current delusions and hallucinations. Method: Twelve factors that may particularly contribute to sleep problems in schizophrenia are identified. These include delusions and hallucinations interfering with sleep, attempts to use sleep as an escape from voices, circadian rhythm disruption, insufficient daytime activity, and fear of the bed, based upon past adverse experiences. Specific adaptations for psychological treatment related to each factor are described. Conclusions: Our experience is that patients want help to improve their sleep; sleep problems in schizophrenia should be treated with evidence-based interventions, and that the interventions may have the added benefit of lessening the psychotic experiences. A treatment technique hierarchy is proposed for ease of translation to clinical practice.

Cognitive behavioral therapy has often been criticized for ignoring the role of the therapeutic relationship. In this article, I outline several dimensions for case formulation and intervention that suggest that the cognitive-behavioral approach can be a powerful theoretical model for understanding the causes of and the strategies for overcoming impasses in therapy. I review how the clinician and patient can collaborate in understanding the importance of case conceptualization, validation, emotional philosophies, victim resistance, schematic resistance, schematic mismatch, sunk-cost commitment, and self-handicapping. The relevance of these factors for both patient and therapist are discussed. During the last decade there has been increased interest in the nature of the therapeutic relationship in cognitive behavioral therapy (Gilbert, 1992; Safran, 1998; Safran and Muran, 2000; Greenberg, 2002; Leahy, 2001; Gilbert and Irons, 2005; Leahy, 2005; Bennett-Levy and Thwaites, 2007; Gilbert and Leahy, 2007). Cognitive behavioral therapists have proposed that the therapeutic relationship reflects interpersonal schemas, earlier attachment problems, emotional processing, failures in validation and compassion, and a variety of processes underlying non-compliance or resistance. Resolving “ruptures” in the therapeutic relationship provides an often essential opportunity for using the relationship as a means to modify cognitive and emotional problems (Safran, Muran, Samstag and Stevens, 2002; Katzow and Safran 2007). In light of the emphasis on “empirically supported treatments” (such as CBT) there is the risk that the alliance in therapy may be foreshadowed by the techniques and protocols used in CBT, perhaps giving credibility to Mahoney's (1991) earlier claim that therapy can become “technolatry”.

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.

Cognitive therapy has traditionally assumed that the therapy relationship provides a necessary context for intervention but is insufficient alone to produce therapeutic change. This assumption is reviewed in the light of up-to-date evidence from research studies of cognitive therapy and recommendations are made for further research. Mechanisms by which the therapy relationship may influence outcome and factors influencing the quality of the relationship are briefly discussed and the need for further research highlighted. Implications for the practice of cognitive therapy are suggested.

Case conceptualization is a foundation of cognitive-behavioural therapy (CBT) because it describes and explains clients' presentations in ways that inform interventions. Yet the evidence base challenges the claimed benefits of case conceptualization. This paper reviews the rationale and evidence base for case conceptualization and outlines a new approach that uses the metaphor of a case conceptualization crucible in which a client's particular history, experience and strengths are synthesized with theory and research to produce an original and unique account of clients' presenting issues. The crucible metaphor illustrates three key defining principles of case conceptualization. First, heat drives chemical reactions in a crucible. In our model, collaborative empiricism between therapist and client provides the heat. Second, like the chemical reaction in a crucible, conceptualization develops over time. Typically, it begins at more descriptive levels, later a conceptualization incorporates explanatory elements and, if necessary, it develops further to include a longitudinal explanation of how pre-disposing and protective factors influence client issues. Finally, new substances formed in a crucible are dependent on the chemical characteristics of the materials put into it. Rather than simply look at client problems, our model incorporates client strengths at every stage of the conceptualization process to more effectively alleviate client distress and promote resilience.

There is controversy about the value of psychological interventions offered to refugee people through an interpreter, but little empirical evidence in this field. This study compared routine clinical outcomes of three groups of PTSD patients receiving CBT: refugees who required interpreters; refugees who did not require an interpreter; and English-speaking non-refugees. The aim of the study was to ascertain whether interpreted CBT is feasible. All three groups attended a similar number of sessions and showed significant improvements after treatment. Refugees receiving treatment with and without interpreting did not differ in treatment outcomes. The findings suggest that interpreters can be used with positive outcome in treating PTSD patients with CBT. This study supports NICE (2005) recommendations that CBT should be offered regardless of language need.

Background: Researchers in clinical trials usually pay close attention to therapist selection, training, supervision and monitoring, but the extent of this input has not been systematically documented. Aims: To describe the extent of training and supervision activity within clinical trials, and to consider any implications for transporting therapies from research to routine clinical contexts. Method: Twenty-seven randomized studies examining the efficacy of CBT interventions for people with depression or anxiety disorders were selected on the basis of their quality and impact on the field. Published and unpublished sources were used to gather information about therapist selection, training and supervision within these trials. Results: The review identified the extent of investment by researchers in assuring therapist expertise, adherence and competence. It also indicated inconsistencies in the clarity with which this input was reported. Conclusions: The ubiquity of intervention-specific training in research contexts risks being overlooked when commissioning evidence-based therapies in routine practice. This has clear implications for the likely effectiveness of interventions. Greater consistency in the reporting of training in clinical trials may help to draw attention to the role of training and supervision in maximizing clinical outcomes.

We applied Narrative Exposure Treatment (NET) to a severely traumatized Kosovar refugee living in a Macedonian refugee camp during the Balkan War. NET is a pragmatic short-term approach that integrates effective therapeutic components deriving from Cognitive Behaviour Therapy and Testimony Therapy. Outcome was evaluated by clinical examination and the Posttraumatic Stress Diagnostic Scale (PDS). Three sessions of NET were enough to afford considerable relief, although some PTSD symptoms remained. Our experience indicates that Narrative Exposure is a promising and realistic approach for the treatment of even severely traumatized refugees living in camps. In addition, it can prove valid testimonies about human rights violations without humiliating the witness.

Previous studies have shown that when normal subjects are instructed to think of a white bear (“forced” expression instructions), they do so more frequently when they have previously suppressed the thought of a white bear than when they have not suppressed this thought. It has been proposed that this rebound effect of thought suppression provides a laboratory model for the development of real-life obsessions. The present studies were undertaken in order to explore further the tenability of this model. Rebound effects were evaluated when more “liberal” expression instructions (“you might think of a white bear, but you don't have to”) were used. In Experiment 1, no evidence was obtained to suggest that suppression results in a heightened frequency and/or accelerated rate of white bear thoughts during a subsequent expression period (with “liberal” instructions). Interestingly, initial suppression lead to an immediate and stable increase of thought related electrodermal fluctuations. In Experiment 2, it was found that successful suppressors (few target thoughts during suppression) report fewer white bear thoughts during expression (with “liberal” instructions) than unsuccessful suppressors (many target thoughts during suppression). Assuming that the ecological validity of “liberal” expression instructions is greater than that of “forced” instructions, the present findings cast doubt on the claim that the rebound effect mimics the etiology of obsessions. The findings also suggest that it may be the immediate counter-productive effects of suppression that are relevant to theories concerned with obsessions.

Social phobia (SP) is characterized by a fear of one or more social or performance situations. Studies of comorbidity in SP youth find anxiety and affective disorders co-occurring. The present study examined children with primary SP and compared them to children with primary Separation Anxiety Disorder (SAD) or Generalized Anxiety Disorder (GAD) prior to treatment and in response to treatment. The groups differed significantly on self-, parent- and teacher-rated pretreatment measures. Additionally, the two groups showed differential treatment outcomes. When the SP youth with comorbid Affective Disorder were excluded in treatment outcome analyses, there were non significant differences, indicating that comorbid affective disorders likely contributed to differential treatment outcome. Results are discussed in terms of treatment recommendations for socially phobic youth.

Cognitive behaviour therapy (CBT) has proven efficacy as a treatment for depression in older people. An important debate amongst therapists working with older people is whether CBT needs to be adapted to ensure optimal treatment outcome and, if so, what adaptations are necessary. It is accepted that psychotherapy with older people can differ from psychotherapy with younger people in a number of important respects because of the higher likelihood of chronic conditions, changes in cognitive capacity, potential loss experiences and different cohort belief systems. As psychotherapists are often much less comfortable dealing with physical problems, they may become negatively biased in terms of outcome when patients present with co-morbid health issues. The impact of loss experiences in older people can also be overemphasized in their importance by inexperienced therapists and can result in lowered expectations for therapy outcome. Consequently, there is a need to develop a model that addresses age related issues within a coherent cognitive therapy framework suitable for older people. This paper describes a CBT model that is augmented with applied gerontological knowledge, taking account of cohort beliefs, intergenerational linkages, sociocultural context, health status/beliefs and role investments/transitions. Clinical examples are used throughout to illustrate clinical implications of the model.