Background: Cognitive-behavioural therapy can change dysfunctional symptom attributions in patients with hypochondriasis. Past research has used forced-choice answer formats, such as questionnaires, to assess these misattributions; however, with this approach, idiosyncratic attributions cannot be assessed. Free associations are an important complement to existing approaches that assess symptom attributions. Aims: With this study, we contribute to the current literature by using an open-response instrument to investigate changes in freely associated attributions after exposure therapy (ET) and cognitive therapy (CT) compared with a wait list (WL). Method: The current study is a re-examination of a formerly published randomized controlled trial (Weck, Neng, Richtberg, Jakob and Stangier, 2015) that investigated the effectiveness of CT and ET. Seventy-three patients with hypochondriasis were randomly assigned to CT, ET or a WL, and completed a 12-week treatment (or waiting period). Before and after the treatment or waiting period, patients completed an Attribution task in which they had to spontaneously attribute nine common bodily sensations to possible causes in an open-response format. Results: Compared with the WL, both CT and ET reduced the frequency of somatic attributions regarding severe diseases (CT: Hedges's g = 1.12; ET: Hedges's g = 1.03) and increased the frequency of normalizing attributions (CT: Hedges's g = 1.17; ET: Hedges's g = 1.24). Only CT changed the attributions regarding moderate diseases (Hedges's g = 0.69). Changes in somatic attributions regarding mild diseases and psychological attributions were not observed. Conclusions: Both CT and ET are effective for treating freely associated misattributions in patients with hypochondriasis. This study supplements research that used a forced-choice assessment.

Background: Social Cognition and Interaction Training (SCIT) is a psychosocial treatment designed to improve social functioning in schizophrenia by improving social cognition. Positive results have been reported from several studies, mainly from the USA, but more studies are needed to determine the feasibility of SCIT in different cultural contexts. Aims: The objective of this study was to evaluate the feasibility and acceptability of the Finnish translation of SCIT in Finland. Method: This was an uncontrolled, within-group study. Thirty-three patients with psychotic disorders participated in SCIT groups and also received the standard services provided at their respective care facilities. We measured participant attendance, attrition and responses on feedback surveys. Participants also completed measures of emotion perception, Theory of Mind (ToM), attributional bias and metacognitive overconfidence both before and after SCIT. Results: The attendance rate was high, attrition was low, and the patients expressed satisfaction with SCIT. Preliminary efficacy analyses showed a statistically significant pre to posttest improvement in emotion perception and ToM, but not attributional bias or overconfidence. Conclusions: SCIT is feasible and well accepted and may remediate social cognitive dysfunction in people with psychotic disorders in Finland.

Background: Extreme appraisals of internal states correlate with and prospectively predict mood symptoms in adults, and discriminate individuals with bipolar disorder from individuals with unipolar depression and non-clinical controls. Aims: These findings required replication in adolescents. This study sought to investigate the relationships between appraisals of internal states, mood symptoms and risk for bipolar disorder in an adolescent sample. Method: A non-clinical sample (n = 98) of adolescents completed measures of mood symptoms, appraisals, and mania risk, alongside covariates. Results: Appraisals of internal states were associated with analogue bipolar symptoms, independently of impulsivity and responses to positive affect. Positive appraisals of activated mood states were uniquely associated with hypomania, whilst negative appraisals were uniquely associated with depression and irritability symptoms. Individuals who appraised activated states as both extremely positive and extremely negative were more likely to score at high or moderate risk for future mania. Conclusions: This study is the first to demonstrate associations between appraisals of internal states, analogue mood symptoms and mania risk in adolescents. Clinical implications are discussed.

Background: There is concern that diagnostic labels for psychiatric disorders may invoke damaging stigma, stereotypes and misunderstanding. Aims: This study investigated clinicians’ reactions to diagnostic labelling by examining their positive and negative reactions to the label borderline personality disorder (BPD). Method: Mental health professionals (n = 265) viewed a videotape of a patient suffering from panic disorder and agoraphobia undergoing assessment. Prior to viewing the videotape, participants were randomly allocated to one of three conditions and were given the following information about the patient: (a) general background information; (b) additional descriptive information about behaviour corresponding to BPD; and (c) additional descriptive information about behaviour corresponding to BPD, but explicitly adding BPD as a possible comorbid diagnostic label. All participants were then asked to note things they had seen in the videotape that made them feel optimistic or pessimistic about treatment outcome. Results: Participants in the group that were explicitly informed that the patient had a BPD diagnostic label reported significantly fewer reasons to be optimistic than the other two groups. Conclusions: Diagnostic labels may negatively impact on clinicians’ judgments and perceptions of individuals and therefore clinicians should think carefully about whether, and how, they use diagnoses and efforts should be made to destigmatize diagnostic terms.

Background: Ruminative negative thinking has typically been considered as a factor maintaining common emotional disorders and has recently been shown to maintain persecutory delusions in psychosis. The Perseverative Thinking Questionnaire (PTQ) (Ehring et al., 2011) is a transdiagnostic measure of ruminative negative thinking that shows promise as a “content-free” measure of ruminative negative thinking. Aims: The PTQ has not previously been studied in a psychosis patient group. In this study we report for the first time on the psychometric properties of Ehring et al.'s PTQ in such a group. Method: The PTQ was completed by 142 patients with current persecutory delusions and 273 non-clinical participants. Participants also completed measures of worry and paranoia. A confirmatory factor analysis was performed on the clinical group's PTQ responses to assess the factor structure of the measure. Differences between groups were used to assess criterion reliability. Results: A three lower-order factor structure of the PTQ (core characteristics of ruminative negative thinking, perceived unproductiveness, and capturing mental capacity) was replicated in the clinical sample. Patients with persecutory delusions were shown to experience significantly higher levels of ruminative negative thinking on the PTQ than the general population sample. The PTQ demonstrated high internal reliability. Conclusions: This study did not include test-retest data, and did not compare the PTQ against a measure of depressive rumination but, nevertheless, lends support for the validity of the PTQ as a measure of negative ruminative thinking in patients with psychosis.

Background: Few studies have examined the acceptability and usefulness of enhanced cognitive behavioural therapy (CBT-E) for adolescents with eating disorders (EDs). Aim: To investigate whether CBT-E was an acceptable and efficacious treatment for an adolescent presenting to a routine clinical service with an ED. Method: Daily self-monitoring records were completed during a baseline (A) and intervention (B) phase in addition to routine outcome measures. Results: There were reductions in both ED behaviours and “feeling fat”, and increases in weight after 11 CBT-E sessions. Progress was only partially maintained at 8-month follow-up. Conclusion: CBT-E may be an acceptable and useful intervention for adolescents with EDs.

Background: Problem anger is frequently experienced by the general population and is known to cause significant problems for the individual and those around them. Whilst psychological treatments for problem anger are becoming increasingly established, this is still an under-researched area of mental health. We present an evaluation of a series of one-day anger management workshops for the public, targeting problem anger with a cognitive-behavioural approach. Aims: The main aim was to evaluate the effectiveness of a brief group-based anger intervention in terms of subjectively reported anger provocation levels and of depression and anxiety. Method: Workshop participants completed a number of questionnaire measures at baseline before the intervention and at 1 month follow-up. The key questionnaires measured self-reported anger provocation levels (Novaco Anger Scale-Provocation Inventory), depressive symptomatology (PHQ-9) and symptoms of generalized anxiety (GAD-7). Change scores were analysed using repeated measures analyses. Results: We found a significant reduction in anger provocation among workshop participants at 1 month follow-up (p = .03). Reductions in depression and anxiety were not statistically significant. Conclusions: We conclude that this brief psychoeducational anger intervention was effective in a small community sample and suggest future work should assess the effectiveness on similar brief interventions using a larger client group and examine outcomes on a broader range of anger measures.

Background: Research has implicated causal, mediating and meaningful roles for mental imagery in the experience of psychological distress, including self-injury. Aims: The present study aimed to further the understanding of this relationship through exploring the lived experiences of mental imagery from the perspective of those who self-injure. Method: This study employed an inductive qualitative design using semi-structured interviews and Interpretative Phenomenological Analysis (IPA). Ten participants were recruited from universities in North West England. Results: Three main themes were identified from the analysis: (i) The origins and precipitants of self-injurious imagery; (ii) What it is like to experience self-injurious imagery; and (iii) The meaning and interpretation of self-injurious imagery. Conclusions: The study findings indicate that mental imagery is an important experience for those who self-injure. Clinical and research implications of the findings are discussed.

Background: Body dissatisfaction among college women is concerning given its high prevalence and associated negative consequences. While cognitive-behavioral approaches to reducing body dissatisfaction have considerable support, it may be beneficial to target the problematic relationship that some individuals have with their internal experiences. Aims: To examine the relative efficacy of an acceptance-based compared to a cognitive restructuring approach to targeting body dissatisfaction. Method: College women were randomly assigned to an acceptance (n = 21), cognitive restructuring (n = 21) or a neutral comparison condition (n = 24). Participants completed a body dissatisfaction challenge postintervention and their dissatisfaction, distress about body-related thoughts and emotions, and the extent they felt defined by their outward appearance were measured. Results: Both approaches provided a protective effect against decreases in body satisfaction and related feelings. Conclusion: Acceptance and CBT approaches to treating body dissatisfaction are worthy of future investigation.

Background: Scales for assessing competence in CBT make an important contribution to research and practice. Aims: To develop a novel scale. Method: A new structured assessment tool is described, which draws on a widely-used CBT competence framework to identify relevant areas of clinical practice. Results: Scale content was clarified through piloting and review by a range of stakeholders. Conclusion: Pending formal testing of the psychometric properties, the scale is ready for use to assess competences in cognitive and behavioural therapy.

Background: Although mental illness anxiety is described in the literature, there is very little information on which to draw when treating individuals who present with fears and worries about mental health. In fact, we identified no previous case descriptions focused on this form of anxiety and treated from a cognitive behavioral perspective. Aims: The current case study aims to advance the understanding of the clinical picture of mental illness anxiety, and facilitate the understanding of how cognitive behavioral techniques for health anxiety can be effectively adapted and implemented for such a case. Method: A case study approach was adopted in which a baseline condition and repeated assessments were conducted during an 8-week treatment and 2-month follow-up period. In the current case study, we discuss the assessment, conceptualization, and cognitive behavioral treatment of a 24-year old woman who presented with mental illness anxiety. Several common health anxiety assessment tools and cognitive behavioural techniques were adapted for her particular clinical presentation. Results: Consistent with research evidence for health anxiety, significant improvements in health anxiety and anxiety sensitivity were seen after eight sessions of therapy and maintained at 2-month follow-up. Conclusions: The results provide preliminary evidence that cognitive behavioral techniques for health anxiety can be effectively and efficiently adapted for mental illness anxiety. However, the lack of available research pertaining to mental illness anxiety contributes to challenges in conceptualization, assessment and treatment.

Background: The psychological difficulties and emotional impacts resulting from the substance use of close relatives constitute a large, underestimated and frequently unidentified health burden. The development of primary care mental health services in response to the Improving Access to Psychological Therapies initiative provides an opportunity to investigate this in more depth. Aims: A preliminary exploration of prevalence of IAPT service-users being treated for moderate-severe depression and/or anxiety who report that they have relatives with alcohol and/or drug problems. To explore the characteristics of the sample including comparison with those without a substance misusing relative. Method: One hundred service users completed a brief questionnaire. Routine data on depression and anxiety symptoms were accessed for the full consenting sample. Descriptive statistics were used to explore the family members of substance users and differences to the rest of the sample. Results: Twenty-two of the 100 IAPT service users reported having a close relative whose use of substances was of concern to them. The group with a relative who used substances were more depressed at the beginning of treatment than the rest of the sample. Conclusions: A significant number of people seeking psychological help for depression and anxiety within IAPT services reported being concerned about a close relative who misuses substances. They may be more distressed than those without a relative who misuses substances. Further exploration is warranted but preliminary findings indicate that this is an important research area with significant clinical implications.

Background: There is a high prevalence of traumatic life events within individuals diagnosed with bipolar disorder. However, currently there is limited theoretical understanding of this relationship. Aims: To explore whether non-clinical symptoms of posttraumatic stress have a direct effect on the non-clinical symptoms of bipolar disorder, or whether this relationship is mediated by cognitive emotion regulation strategies. Method: A cross-sectional design within non-clinical participants completing an online survey including the Impact of Events Scale, Cognitive Emotion Regulation Questionnaire and the Hypomanic Personality Scale. Results: Posttraumatic stress symptoms were associated with hypomanic personality. Intrusive memories contributed a small but significant proportion of the variance between these two measures. Rumination of negative emotions mediated the relationship between posttraumatic stress and hypomanic personality. Conclusions: The relationship between traumatic events and an increased prevalence of bipolar disorder remains poorly understood. Further research should explore rumination as a potential target for treatment within those suffering from both posttraumatic stress and bipolar disorder.

Background: Homework assignments are considered an essential component for a successful outcome of cognitive behavioural therapy for youths with anxiety disorders. However, only two studies have examined the association between homework adherence and outcome of cognitive behavioural therapy for youths with anxiety disorders. Aims: The study examined the association between homework adherence and treatment outcome following a generic group cognitive behaviour treatment program (Cool Kids) for anxiety disordered youths and their parents. Method: The treatment program was completed by 98 children and adolescents (ages 7–16). Homework adherence was measured as time spent doing homework assignments between each session, reported by youths as well as parents. Outcome criteria consisted of youth-reported anxiety symptoms and clinician rated severity of primary anxiety diagnosis at posttreatment and 3-month follow-up. Results: Results did not support an association between homework adherence and treatment outcome when controlling for pretreatment severity. Conclusions: The study found no convincing evidence that homework adherence predicted outcome of cognitive behavioural therapy for youths with anxiety disorders. Reasons for divergent findings on homework adherence in cognitive behavioural therapy for youths compared to adults are discussed.

Background: Randomized controlled trials have established that cognitive behavioural therapy (CBT) is effective in helping people with psychosis, though there is enormous variability in outcome. It is not clear what patient factors contribute to good outcomes. In fact, most studies considering client factors have excluded people with psychosis. It is clinicians who are deciding who is likely to benefit from CBT for psychosis (CBTp), though little is understood in terms of their views on who benefits from CBTp. Aims: This study investigated clinicians’ views on client characteristics that influence outcome in CBTp. Method: A Q-set of 61 client characteristics was developed from a literature search and interviews with clinicians experienced in working with CBT and/or psychosis. Twenty-one participants (familiar with psychosis and CBT through education, profession, practice or knowledge) rated the items based on their importance in effecting a positive outcome, on a forced normal distribution. Results: 21 completed Q-sorts yielded four factors, named as: acceptance and application of the cognitive model; attending to the present; secure base; meaningful active collaboration. Conclusions: Items regarding therapeutic alliance were highly endorsed throughout all factors. Some empirically-based items were not endorsed, although overall, clinician responses were consistent with prior research.

Background: Mental health problems have been found to be more prevalent in prison populations, and higher rates of post-traumatic stress disorder (PTSD) have been found in sentenced populations compared to the general population. Evidence-based treatment in the general population however has not been transferred and empirically supported into the prison system. Aims: The aim of this manuscript is to illustrate how trauma focused work can be applied in a prison setting. Method: This report describes a two-phased approach to treating PTSD, starting with stabilization, followed by an integration of culturally appropriate ideas from narrative exposure therapy (NET), given that the traumas were during war and conflict, and trauma-focused cognitive behavioural therapy (TF-CBT). Results: PTSD and scores on paranoia scales improved between start and end of treatment; these improvements were maintained at a 6-month follow-up. Conclusion: This case report1 illustrates successful treatment of multiple incident PTSD in a prison setting using adaptations to TF-CBT during a window of opportunity when individuals are more likely to be free from substances and live in relative stability. Current service provision and evidence-based practice for PTSD is urgently required in UK prisons to allow individuals to engage in opportunities to reduce re-offending, free from mental health symptoms.

Background: Metaphors are common in psychotherapy and have potential to enhance therapy in numerous ways. However, the empirical study of metaphors in cognitive behaviour therapy (CBT) has tended to be put in the “too hard basket”, confined to being part of the art rather than the science of therapy. The lack of research is largely due to problems with definition, lack of a consistent, reliable approach to metaphor identification and the challenges of finding appropriate methodology to study this language-based activity. Aims: This study aimed to assess the frequency of metaphors in CBT in a large sample of therapy sessions and to evaluate the reliability and utility of the discourse dynamics approach to metaphor identification. Method: The discourse dynamics approach, recently developed by linguists, was used to identify metaphors in 48 CBT session transcripts (from 12 clients and 3 therapists) and the reliability of this approach was evaluated, using an independent rater. Results: The total frequency of metaphors was 31.5 (range 17–49) per 1000 words of therapy conversation. Therapists produced metaphors twice as often (21.2, range 7–36) as clients (10.3, range 3–24). Reliability of the Discourse Dynamics approach was adequate. Conclusions: Metaphors clearly occur in CBT sessions, with therapists using them at a higher rate than clients. While Discourse Dynamics is currently the most detailed identification approach available for investigating metaphor in CBT sessions, it is challenging to acquire skill in it and we found only adequate reliability. Ways to improve reliability and future research possibilities are discussed.

Background: Psychosocial distress can contribute to avoidance, refusal, or discontinuation of cancer treatment, which could impact recovery and survival. Aims: The aim of the present study was to evaluate the effectiveness of a community based psychosocial program on alleviating mood disturbance in breast cancer survivors at different stages of their breast cancer journey. Method: A total of 37 women participated in an 8-week psychosocial program at their local community centre. The weekly 3-hour program was delivered in a small group format. Program components included health education, behavioural training, cognitive behavioural therapy, art therapy and stress-management. Questionnaires aimed at assessing psychiatric morbidity and mood adjustment were administered at the beginning of the program (Pre) and at the completion of the program (Post). Results: Group data revealed a significant reduction in psychiatric morbidity and improved psychological adjustment. When participants were divided into degree of psychiatric morbidity (mild, moderate, severe, very severe) a significant reduction in the reporting of anxiety symptoms in the mild, moderate, severe and very severe groups was reported; depression symptoms in the severe and very severe groups were noted, and anger, confusion and somatic symptoms in the mild group were noted. The level of activity was also significantly improved in the very severe group. Conclusions: A structured community based psychosocial program is beneficial to women struggling to come to terms with the emotional consequences of breast cancer at all stages of recovery.