Post traumatic stress disorder (PTSD) and other reactions including driving phobias and depression have in recent years been clearly identified as common motor vehicle accident (MVA) sequelae. To date, no treatment outcome data exist for PTSD following MVA beyond case study reports and one pilot investigation. The present study reports on the first randomized control trial for PTSD following MVA. Twenty volunteer participants who had motor vehicle accidents resulting in physical injury requiring medical attention and PTSD were recruited through rehabilitation service providers, other psychologists, community physicians, and lawyers. Assessments included a structured interview for diagnosis of post traumatic stress disorder (Clinician Administered PTSD Scale) by an independent rater, a range of self-report symptom questionnaires and a behavioural test wherein they had their heart rate and subjective distress measured in reaction to idiosyncratic audio descriptions of their accident. Participants were randomly assigned to eight to ten hours of individual cognitive-behavioural therapy (n=10) or to a wait list control group (n=10). Treatment included education about post-trauma reactions, relaxation training, exposure therapy with cognitive restructuring and instruction for self-directed graduated behaviour practice. Results demonstrated statistically and clinically significant treatment effects across structured interviews, self-report questionnaires and the behavioural test. Treatment gains were maintained over a 6 month follow-up using self-report questionnaires.

Thirty-five outpatients (25 women, 10 men) with a DSM-III-R principal diagnosis of OCD accepted exposure treatment at a psychiatric outpatient clinic. They were randomly assigned to one of two individual treatments for a 6-week exposure therapy treatment based on a treatment manual or to a 6-week waiting list condition. The 12 patients assigned to the waiting list were subsequently randomly assigned to one of the active treatments. Both treatment groups received in vivo or imaginal exposure in each of the 10 twice-weekly treatment sessions held after two assessment sessions. One group (n=16) received cognitive therapy interventions for comorbidity problems or to alter beliefs underlying patients' OCD. The other group (n=19) received relaxation training as an attention placebo control. Both groups received relapse prevention follow-up contacts. Twenty-seven patients completed intensive treatment. Both treatments overall showed satisfactory levels of clinical improvement and large effect sizes. ANCOVAS for treatment completers showed non-significantly lower levels of OCD symptoms, depression and state anxiety in the treatment condition that did not include cognitive interventions. The patients receiving additional cognitive therapy showed significantly lesser dropout than those in the other treatment condition, but there were no significant differences in the intention-to-treat analyses.

The historical origins of the case formulation approach to assessment and treatment are described and its role in clinical practice and research discussed. It is argued that treatment based on individual case formulations should not be precluded from clinical trials. The empirical evidence for the reliability and efficacy of case formulation is reviewed. The evidence that an idiosyncratic case formulation approach to treatment has any advantage over a standard protocol is equivocal; however, the studies that have been carried out are under powered and potentially suffer from a Type II error. The standard procedure for case formulation is briefly described and the argument advanced that this method of clinical assessment should be soundly based upon empirical evidence and hypothesis testing and not on speculation. Three modifications are suggested to the current practice of case formulation. These are: 1) the conceptualization of dysfunctional systems in the maintenance of clinical problems; 2) the historical background of a clinical problem should be described in terms of vulnerabilities and epidemiological evidence-base; and 3) the pivotal role of social behaviour and context should be emphasized and accommodated in a formulation. The advantages of a case formulation, in providing an understanding of the maintenance of clinical problems, in providing an integrated approach to intervention are outlined.

In the present climate of limited resources and long waiting lists, it is not surprising that there is more emphasis on making sure that psychological treatments are not only clinically sound but also cost-effective. One solution to this is to provide time-limited, focused interventions such as cognitive therapy. Another obvious solution is to deliver treatment in groups rather than individually. However, what evidence is there that therapy can be delivered as effectively in groups as individually? This review will look at which different formats have been tried, what the advantages and disadvantages of those formats might be, which client groups have been targeted for cognitive- behavioural group therapy (CBGT), and whether a group format in general offers any advantages over individual CBT. Outcome studies and their implications for the use of CBGT are considered. Results suggest that, in most client groups, there is little difference in efficacy between group and individual CBT, although there is some evidence that results for some types of patient can be disappointing in CBGT. It may be that the best compromise in terms of cost- effectiveness between quality of therapy and quantity of patients treated is offered by large-scale psychoeducational didactic group therapy.

Background: Previous studies of self-practice/self-reflection (SP/SR) CBT training have found that trainees report significant benefits from practising CBT techniques on themselves (self-practice) and reflecting on their experience (self-reflection) as a formal part of their CBT training. However, not all trainees experience the same level of benefit from SP/SR and not all types of training course produce benefits to the same extent. Aims: This paper examines the question: What factors influence trainees’ reported benefit from SP/SR? The aim was to develop a model to maximize the value of SP/SR training. Method: The authors used a grounded theory analysis of four SP/SR training courses, varying along several dimensions, to derive a model that could account for the data. Results: A model was derived comprising of seven elements: Two outcomes – “Experience of Benefit” and “Engagement with the Process” – that mutually influence one another; and five other influencing factors – “Course Structure and Requirements”, “Expectation of Benefit”, “Feeling of Safety with the Process”, “Group Process”, and “Available Personal Resources” – that mediate the impact on Engagement with the Process and Experience of Benefit from SP/SR. Conclusions: A model that provides guidance about the best ways to set up and develop SP/SR programs has been developed. This model may now be subject to empirical testing by trainers and researchers. Implications and recommendations for the design and development of future SP/SR programs are discussed.

Romme and Escher (1989) reported that 70% of voice hearers began to hear voices following a traumatic event. This study was therefore designed to examine the effects of trauma on predisposition to auditory and visual hallucinations in the general population. The study also examined the role of beliefs about voices and metacognitive beliefs about thoughts in predisposition to hallucinations, and tested the specific hypothesis that dissociative experiences would predict predisposition to auditory hallucinations. Sixty-four non-clinical subjects were asked to complete questionnaires assessing interpretations of voices, predisposition to hallucinations, metacognitive beliefs, PTSD symptomatology, experience of trauma, trauma-related cognitions and dissociative experiences. The study found an association between trauma-related measures (negative cognitions about the world and all dissociation variables) and predisposition to both auditory and visual hallucinations. It was found that participants who had experienced certain specific life events scored significantly higher on predisposition to auditory hallucinations (bereavement, physical assault and emotional abuse) and on predisposition to visual hallucinations (bullying). Multiple regression analyses demonstrated that both metacognitive beliefs and dissociative processes explained significant proportions of the variance in predisposition to both auditory and visual hallucinations. These results suggest an association between trauma and predisposition to auditory hallucinations. The theoretical and clinical implications of the findings are discussed.

Background: Social Cognition and Interaction Training (SCIT) is a manual-based group intervention designed to improve social cognition in schizophrenia. Initial studies conducted by the developers of SCIT suggest that the intervention has promise in ameliorating social cognitive dysfunction in both inpatients and outpatients. Aims: The current study is a preliminary evaluation of SCIT in community samples. Method: An uncontrolled, pre-post design was used in this initial feasibility study. A collaborative research-clinical approach was employed to enable research evaluation while also meeting the administrative goals of participating clinics, and working within the constraints of real-world clinical practice. Transportability, acceptability, and feasibility of SCIT were evaluated in terms of pre- and post-treatment evaluations, client attendance data (N = 50), and clinic administrators’ decisions about whether to integrate SCIT into regular programming. Social-cognitive outcome measures assessed emotion perception, Theory of Mind, and attributional bias. Results: These support the transportability, acceptability, and feasibility of SCIT in community settings. SCIT has been integrated into routine practice at several test sites. Tentative support was found for improvement in emotion perception and Theory of Mind, but not attributional bias. Conclusions: SCIT may be a promising intervention for community agencies serving individuals with psychotic disorders who seek to improve their social functioning.

Background: Depression is frequently characterized by patterns of inflexible, maladaptive, and ruminative thinking styles, which are thought to result from a combination of decreased attentional control, decreased executive functioning, and increased negative affect. Cognitive Control Training (CCT) uses computer-based behavioral exercises with the aim of strengthening cognitive and emotional functions. A previous study found that severely depressed participants who received CCT exhibited reduced negative affect and rumination as well as improved concentration. Aims: The present study aimed to extend this line of research by employing a more stringent control group and testing the efficacy of three sessions of CCT over a 2-week period in a community population with depressed mood. Method: Forty-eight participants with high Beck Depression Inventory (BDI-II) scores were randomized to CCT or a comparison condition (Peripheral Vision Training; PVT). Results: Significant large effect sizes favoring CCT over PVT were found on the BDI-II (d = 0.73, p < .05) indicating CCT was effective in reducing negative mood. Additionally, correlations showed significant relationships between CCT performance (indicating ability to focus attention on CCT) and state affect ratings. Conclusions: Our results suggest that CCT is effective in altering depressed mood, although it may be specific to select mood dimensions.

Experiential training and personal therapy have rich traditions in various therapies as strategies to enhance self-awareness and therapist skills. However, personal experiential work has not traditionally been part of cognitive therapy (CT) training. The purpose of the present study is to map the impact of personal experiential work on CT skills in a group of CT practitioners. Fourteen cognitive therapists undertook training courses utilizing a structured approach to self-practice of CT techniques, known as self-practice/self-reflection (SP/SR). Six therapists from one training group engaged in “co-therapy” sessions with a partner, while eight therapists from another training group practised CT techniques on their own. Both groups engaged in regular written reflections about their experience. Follow-up 1-5 months after the courses identified six areas of self-reported skill enhancement: Refinement of specific CT skills; Enriched communication of the conceptual framework of CT; Increased attention to the therapeutic relationship; Empathic attunement; Therapist self-reflection; and Therapeutic flexibility. The results suggested that SP/SR enhances the “professional artistry” of therapists, a finding consistent with literature suggesting that reflection is a key process in the development of therapist expertise. It is concluded that SP/SR represents a promising training strategy for cognitive therapists.

Background: Cognitive remediation (CR) is a psychological therapy, effective in improving cognitive performance and functioning in people with schizophrenia. As the therapy becomes more widely implemented within mental health services its longevity and uptake is likely to depend on its feasibility and acceptability to service users and clinicians. Aims: To assess the feasibility and acceptability of a new strategy-based computerized CR programme (CIRCuiTS) for people with psychosis. Method: Four studies were conducted using mixed methods. Perceptions of attractiveness, comprehensibility, acceptability and usability were assessed using self-report questionnaires in 34 non-clinical participants (study 1), and five people with a schizophrenia diagnosis and three experienced CR therapists (studies 2 and 3). The ease with which pre-specified therapy programmes could be assembled was also assessed by three therapists (Study 2). Finally, the satisfaction of 20 service users with a diagnosis of schizophrenia regarding their experience of using CIRCuiTS in the context of a course of the CR therapy was assessed in a qualitative interview study (study 4). Results: Ratings of perceived attractiveness, comprehensibility, acceptability and usability consistently exceeded pre-set high targets by non-clinical, clinical and therapist participants. Qualitative analysis of satisfaction with CIRCuiTS showed that receiving the therapy was generally seen to be a positive experience, leading to perceptions that cognitive functioning had improved and attempts to incorporate new strategy use into daily activities. Conclusions: CIRCuiTS demonstrates high acceptability and ease of use for both service users with a schizophrenia diagnosis and clinicians.

Because anxiety and other concurrent psychological problems are common among children with high-functioning autism and Asperger syndrome, research initiatives have been devoted to the development of efficacious treatments to address the multifaceted needs of youth with this presentation. Emerging research indicates that when carefully adapted to accommodate for the unique needs of children with autism spectrum disorders (ASD), cognitive-behavioural therapy (CBT) may be a viable treatment modality. Because inherent features of ASD may compromise the efficacy of traditional CBT, our preliminary work suggests that it may be important to gear intervention efforts towards directly addressing core autism symptoms to promote optimal treatment response. This article describes an evidence-based CBT treatment manual modified and expanded to address core ASD features above and beyond anxiety symptomatology. A case example of a 10-year-old boy with Asperger syndrome is presented with supporting data to illustrate the treatment modifications and their rationale. The positive treatment response attained in this case suggests that an enhanced variant of a standard CBT programme may be an efficacious treatment approach for children with ASD and concurrent anxiety.

A psychometric study was conducted with the aim of collecting basic information about anticipatory processing and its relationship to social anxiety. A self-report measure of anticipatory processing was developed and utilized in a large student sample. The results confirmed that such processing is very common before an anticipated feared social event and a significant correlation (r=0.49) between anticipatory processing scores and social anxiety was found, which remained when trait anxiety and depression were controlled. A factor analysis indicated that all items of the measure except for two loaded significantly on one factor and accounted for the 47.3% of the variance. Socially anxious individuals in the study reported that their thoughts about the event were recurrent, intrusive, interfered with their concentration and increased their state of anxiety. Also, they reported that they wished they could avoid the situation. The results are discussed in terms of the Clark and Wells cognitive model of social phobia.

Mindfulness is the latest addition to the armamentarium of cognitive behavioral therapists. Mindfulness methods from the wisdom traditions, as well as from current psychological theories, are beginning to be used as cognitive behavioral strategies for alleviating psychological distress and for personal transformation. The use of mindfulness as a clinical tool is in its infancy, with attendant growing pains in theory, research and practice. We briefly discuss the historical context of the use of mindfulness, recent developments in theory, research and practice, and future developments. We conclude that mindfulness shows a lot of promise as a clinical treatment modality, but there are inherent pitfalls in the developing approaches.

Background: Quality of attachment relations between adolescents and their parents and peers may be related to early maladaptive schemas as well as to symptoms of depression. Aims: The aim of the current study was to assess whether schema domains and maladaptive schemas mediate the relation between indices of quality of attachment relationships with parents and peers and symptoms of depression in non-clinical adolescents (N = 222). Method: A battery of questionnaires was completed, including measures of quality of attachment relations, maladaptive schemas, and depression. Results: The schema domains of disconnection and rejection and other-directedness mediated the relation between quality of attachment relationships and symptoms of depression. More precisely, the schemas’ mistrust/abuse and social isolation mediated the relation between trust in parents and depressive symptoms, whereas the schemas’ social isolation and self-sacrifice mediated the relation between alienation from peers and symptoms of depression. Conclusions: The mediation analyses suggest that treatment of adolescent depression could be focused on both attachment bonds and on changing maladaptive schemas.

Background: Mental imagery of the future has clear clinical importance, although little is known about intrusive, prospective imagery of personally-relevant events. Currently, no measure is available to assess this. Aims: The Impact of Future Events Scale (IFES) was created to assess the impact of intrusive, prospective, personally-relevant imagery. It was examined in relation to predictions about dysphoria. Method: To form the IFES, the IES-R (a measure of the impact of a past traumatic event on posttraumatic stress disorder symptomatology such as intrusive re-experiencing) was adapted item-by-item to assess intrusive “pre-experiencing” and imagery of specific, future events. Participants (N = 75) completed the IFES and assessments of depression, anxiety and general imagery use. Results: As predicted, the IFES significantly and positively correlated with depression scores. Analyses using subgroups of non-dysphoric and mild-dysphoric participants confirmed that the mild-dysphoric group reported significantly higher IFES scores, indicating higher levels of pre-experiencing of the future and related hyperarousal and avoidance. Conclusions: IFES provides a measure of the impact of “pre-experiencing” in the form of intrusive prospective, personally-relevant imagery, with sensitivity to group differences on the basis of depression scores. Further research is required to extend these finding into clinical depression and other psychopathological conditions.

Computerized Self-help (CSH) has recently been the subject of a NICE (National Institute of Clinical Excellence) review. This increase in interest is also reflected in the increase in advertising for CSH programmes. We report a national survey of a random sample of 500 therapists accredited with the British Association for Behavioural and Cognitive Psychotherapies, which is the lead organization for CBT in the UK. A total of 329 therapists responded (65.8%). A surprisingly small number of CBT therapists were using CSH (12 or 2.4%) and only 5 or 1% were using it as an alternative to patient-therapist contact. Despite this, over 90% of the responding therapists had not ruled out using CSH in the future, but the majority of these would use it to supplement rather than as an alternative to individual face-to-face therapy. The need to know more about computerized self-help and the need for training in therapy using this modality were seen as the main factors that would have to change to allow the therapists to use CSH. Knowledge of and ability to use computers did not appear to be an important factor as most therapists in this sample used computers on a regular basis. Most therapists were not aware of evidence of the effectiveness of CSH but the minority who did feel able to express views stated that CSH would be less effective than individual face-to-face therapy and result in less client satisfaction.

Individuals with posttraumatic stress disorder (PTSD) frequently report periods of intense emotional distress (“hot spots”) when asked to describe their traumatic experience in detail. “Primary” emotions felt during the trauma (i.e., peri-traumatically) are believed to consist mainly of fear, helplessness and horror. We report a preliminary investigation into the emotions associated with these hot spots. Patients with PTSD described a wide variety of emotions such as anger, humiliation and guilt present at the time of the trauma. The peri-traumatic cognitions associated with these emotions are also detailed.

Background: There is sufficient research evidence in favour of cognitive therapy in western world. However, only limited research has been carried out on its effectiveness in other countries. It is suggested that adaptations in content, format and delivery are needed before CBT can be employed in non-western cultures. We describe a preliminary evaluation of culturally adapted CBT for depression in Pakistan. Aims: We aimed to evaluate the efficacy of this culturally adapted CBT using a therapist manual. Method: In a randomized controlled trial we compared combination of CBT and antidepressants with antidepressants alone (treatment as usual) in primary care. Referred patients with ICD-10 diagnosis of depression were invited to participate and randomized to the intervention and control groups. Hospital Anxiety and Depression Scale (HADS) and Bradford Somatic Inventory (BSI) were used to measure changes in depression, anxiety and somatic symptoms. Results: Seventeen patients each were randomized to each arms of the trial. Except for financial status there were no differences between the two groups on various demographic variables. Patients receiving CBT showed statistically significant improvement on measures of depression (p < .001), anxiety (p < .001) and somatic symptoms (p < .000) as compared to antidepressant alone group. 82% patients attended six or more sessions of therapy. Conclusions: A culturally sensitive manualized CBT was effective in reducing symptoms of depression and anxiety in Pakistan.

The delivery of cognitive behaviour therapy (CBT) in the UK has moved through two phases. In the first phase specialist practitioners delivered bespoke CBT to individuals often experiencing complex and longer-lasting problems. This phase has been characterized by waiting lists and a high quality service delivered to a few. In the second phase of service delivery CBT has begun to be delivered in all sorts of different formats, including CBT self-help/guided CBT, behavioural activation, computerized CBT and group based CBT that aim to increase access to CBT delivered in these ways. It remains unclear how these varying models – “high intensity” (phase 1) and “low intensity” (phase 2) should relate – and even who does best with each. There are implicit assumptions by practitioners reflected in language such as “stepping up/down” that assumes high intensity working is superior in some way to low intensity. Few studies have however examined this in depth and what studies there are suggest these beliefs may be incorrect for many. How these new ways of working will be introduced, evaluated and integrated into existing services currently remains a challenge. A helpful way of resolving some of these issues is to view CBT using a learning/teaching paradigm. In this the focus is primarily on how the client wishes to learn to tackle their problems. This provides a helpful way for both introducing different and new ways of working, and also maintaining a focus on the client's needs at the centre of service development. Crucially, phase two CBT working does not replace phase one. How the two approaches complement each other and compare will be two of the interesting questions to be addressed over the next few years.

Background: Psychiatric staff play a key role in the lives of people with psychosis and the quality of staff and service user relationships is associated with relapse and recovery. One factor that might determine the capacity of staff to form positive therapeutic relationships is their appraisals of service users' mental health problems. Method: A pilot intervention was implemented with psychiatric staff that involved helping them develop psychological formulations for individual service users. Staff perceptions of service users' mental health problems were measured before and after the intervention using Likert scales. Data at the two time points were collated for 30 staff. Results: There was a significant increase in staff perceptions of the degree of control service users and themselves had over problems, an increase in the degree of effort they felt service users were making in coping, reductions in blame, and more optimism about treatment. Staff also reported an increase in understanding of service users' problems, more positive feelings towards service users, and an increase in confidence in their work. Conclusions: Results from this pilot are promising, but findings warrant replication in controlled studies. It is also important to establish whether changes in staff perceptions influence the actual nature of staff-service user relationships.