Background: A key process in Cognitive Therapy (CT) is the development and sharing of a formulation. How clinicians develop formulations is under-researched, particularly in working with people with psychosis. Aims: This study investigated agreement between clinicians, when conceptualizing an individual's psychotic beliefs. It also explored whether agreement was dependent on qualifications and experience. Method: Eighty-two clinicians watched a video of an individual with delusional beliefs, and were asked to provide formulations using a CT template. These were compared with a “benchmark” formulation provided by three experts. Results: There was good agreement for overt behaviours, emotions, and some aspects of early experience. However, identification of theory driven components such as core beliefs or assumptions was poorer. Greater clinical experience improved the agreement with the benchmark formulation overall, and greater CT specific experience improved formulation of the theory driven items. The more experience a clinician had of working with people with psychosis the lower the rate of agreement with the expert formulation. Conclusions: Formulation of delusional beliefs from a cognitive perspective is dependant on overall experience in cognitive therapy and not knowledge of psychosis, which may hinder performance. The implications for training in CT and psycho-social interventions are considered.

Background: Obsessive-compulsive disorder (OCD) is characterized by repeated and persistent attempts to control thoughts and actions with rituals. These rituals are used in order to prevent feared or personally distressing outcomes. Cognitive behavioral group therapy (CBGT) has been reported to be effective for treating OCD patients. However, about one-third (30%) of patients do not benefit from CBGT. Some of these patients do not show significant improvement and continue to use rituals following CBGT, partially because they fail to complete the exposure and ritual prevention (ERP) exercises. Consequently, it is important to motivate patients to fully engage in CBGT treatment and complete the ERP exercises. Aims: A randomized behavioral trial examined 12 weeks of manual directed CBGT, with the addition of individual sessions of Motivational Interviewing (MI) and Thought Mapping (TM), and compared treatment outcome to the effectiveness of CBGT group alone. Method: Subjects were randomized (n = 93) into a CBGT group or a CBGT group with MI+TM. Results: When the two groups were compared, both groups reduced OCD symptoms. However, symptom reduction and remission were significantly higher in the MI+TM CBGT group. Positive outcomes were also maintained, with additional symptom reduction at the 3-month follow-up for the MI+TM CBGT group. Conclusions: Adding two individual sessions of MI and TM before CBGT successfully reduced OCD symptoms and was more effective than using CBGT group alone.

Background: There is overwhelming evidence that anxiety is associated with the tendency to interpret information negatively. The causal relationship between this interpretive bias and anxiety has been examined by modifying interpretive bias and examining effects on anxiety. A crucial assumption is that the effect of the procedure on anxiety is mediated by change in interpretive bias rather than being a direct effect of the procedure. Surprisingly, this had not previously been tested. Aim: The aim is to test whether altered interpretive bias, following Cognitive Bias Modification of Interpretations (CBM-I), affected anxiety. Method: Mediational path analyses were conducted to test the hypothesis that changes in anxiety are due to changes in interpretive bias. A separate experiment was conducted to test which elements of the procedure could be responsible for a direct mood effect. Results: Results from mediation analyses suggested that changes in trait anxiety, after performing CBM-I, were indeed caused by an altered interpretive bias, whilst changes in state anxiety appear to be caused by the procedure itself. The subsequent experiment showed that state anxiety effects could be due to exposure to valenced materials. Conclusions: Changed state anxiety observed after CBM-I is not a valid indicator of a causal relationship. The finding that CBM-I affected interpretive bias, which in turn affected trait anxiety, supports the assumption of a causal relationship between interpretive bias and trait anxiety. This is promising in light of possible clinical implications.

Background: While research indicates cognitive biases in individuals vulnerable to bipolar symptoms, the specificity of these biases to the self and others, and to low or high activation states, is underexplored. Method: These biases were investigated using individuals with high (n = 24) and low levels (n = 24) of hypomanic personality (HPS) during word rating and free recall of a list of trait words after a positive versus neutral mood induction. Results: The mood induction was not successful. Also, in contrast to the predicted self-serving bias, there was a self-denigratory bias in self-ratings relative to ratings of another person. In post hoc analyses, the study succeeded in producing a rating task of trait words that differentiated between high and low hypomania-prone individuals, as the high HPS group made higher ratings of high activation trait words (e.g. dynamic) to describe positive and neutral attributes regardless of whether it referred to themselves or another person. The high HPS group also showed a negative recall bias, but it was not specific to the self, questioning assumptions made about negative biases in existing research. Furthermore, a strong relationship emerged between greater use of imagery at encoding and greater recall of self-referent, positive, high activation words, suggesting a role for the intensity of images associated with the amplification of emotions in people with bipolar disorder (Holmes et al., 2008). Conclusions: It seems important to consider various multiple factors in memory bias research in people vulnerable to bipolar disorder, including self versus other encoding, high versus low activated states and the role of mental imagery. Further research is needed to spell out their interactive contribution.

Background: Individuals with visible differences can experience social anxiety in relation to their appearance. Social skills-based psychosocial interventions have to date shown only limited effectiveness at addressing their concerns. Aims: To incorporate user perspectives in the development of an online psychosocial intervention, known as Face IT. Method and Results: Study one consisted of a needs assessment with 12 individuals with a visible difference and six health professionals in order to identify the difficulties experienced by those with visible difference and obtain feedback on the proposed content of Face IT. The findings demonstrated support for the social skills model and the use of an online intervention. Study two consisted of an empirical usability evaluation of Face IT with 14 potential users and 14 health professionals. Based on feedback from the participants, changes were made to the graphics and navigation of the programme. The clinical content has been made more acceptable. Conclusions: The findings indicate support for the importance of social skills-based psychosocial interventions for addressing the needs of those with a visible difference, and have allowed modifications to be made to Face IT ahead of a randomized controlled trial of effectiveness.

Background: Self-Practice/Self-Reflection (SP/SR) is increasingly beginning to feature as a central component of CBT training programmes (Bennett-Levy et al., 2001). Programmes including a reflective element, however, are not unproblematic and it has been documented that simply setting time aside for reflection does not necessarily result in trainees using such time to reflect. Such limitations may be overcome by including a requirement to post reflections on reflective blogs. Aim: To examine the effect that a requirement to contribute to a reflective blog had upon a SP/SR approach to CBT training. Method: A focus group methodology was adopted with data analyzed using a general inductive qualitative approach. Results: The requirement to use blogs to reflect upon the self-practice of CBT techniques enhanced SP/SR, established a learning community, and improved course supervision, although some technical difficulties arose. Conclusions: Consideration should be given towards using reflective blogs to support a SP/SR approach to CBT training. Benefits afforded by the use of reflective blogs further establish SP/SR as a valid and flexible training approach.

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.

Background: In the UK, bibliotherapy schemes have become a widespread source of support for people with common mental health disorders such as depression. However, the current evidence suggests that bibliotherapy schemes that are offered without guidance are not effective. It may be possible to improve the effectiveness of self-help books by incorporating into them some of the “common factors” that operate in personal therapeutic encounters, for example therapist responsiveness. Aim: The aim was to test whether and to what extent authors have incorporated common factors into self-help books. Method: A model of how common factors might be incorporated into CBT-based self-help books was developed and a sample of three books were examined against the model criteria. Results: The sampled self-help books were found to have common factors to a greater or lesser extent, but some types of common factors were more prevalent than others. Factors addressing the development and maintenance of the therapeutic alliance were less often apparent. Conclusions: Self-help books have the potential to provide a valuable service to people with depression, but further work is necessary to develop them. It is suggested that future generations of self-help books should pay explicit attention to the use of common factors, in particular developing and investigating how factors such as flexibility, responsiveness and alliance-rupture repair can be woven into the text.

Background: Recent research has indicated that individuals with social interaction anxiety make biased interpretations of positive social interactions, with greater general apprehension in response to such events and more negative predictions about the future. There has also been some preliminary evidence for a second facet of interpretation bias, namely a failure to accept others’ positive reactions at face value, but this has so far not been adequately studied. Method: The present study developed a new measure of this “discounting” dimension and utilized a nonclinical sample of undergraduate students to provide an initial analysis of the scale. Results: Results provide early support for the psychometric properties of our scale, and indicate that discounting mediates the relationship between social interaction anxiety and low positive affect, over and above the previously studied aspect of positive event interpretation bias. Conclusions: The implications for treatment interventions and further research are discussed.

Background: Acceptance and Commitment Therapy advocates use of cognitive defusion techniques to reduce the distress evoked by negative thoughts, including verbal repetition (VR). In VR, a negative word is repeated until its semantic meaning is diluted (i.e. until semantic satiation is achieved). The present two studies examined whether VR is more effective than brief imaginal exposure (IE) and no intervention (CONT) in the reappraisal of contamination-related thoughts. Method: Participants high in contamination fears identified their most distressing thoughts and were randomly assigned to VR, IE, or CONT. A category membership decision task was also conducted to determine if VR produced semantic satiation. Results: In Study 1, there was no evidence of semantic satiation. Significant reductions in negative response to the thoughts was observed immediately following VR, but not IE or CONT; however, at one-week follow-up, both VR and IE groups reported similar reductions. In Study 2, the effects of VR and IE practice between post-intervention and follow-up were examined, as well as changes in behavioural avoidance. VR was found to produce semantic satiation of contamination thoughts, and VR was associated with less negative response at follow-up relative to IE and CONT, but the degree of satiation was not associated with the decreases in negative response. Only IE produced decreases in behavioural avoidance and vigilance monitoring. Conclusions: Taken together, these results suggest that VR may have potential as an additional strategy for managing obsessional thoughts, but more research is warranted.

Aim: The aim was to investigate whether high catecholamine (CA) excreters would respond less well to a group cognitive behaviour therapy (CBT) treatment for depression than others. Method: A sample of 70 adults with depression symptoms participated in a 12-week course of group CBT. Participants’ 24 hour urinary catecholamine levels at pre-therapy and post-therapy were used to classify them as High (N = 10); Low (N = 33) or Mixed (N = 27) according to a cut-off one standard deviation above a published mean for healthy adults. Beck Depression Inventory (BDI) and cognitions questionnaire (Automatic Thoughts Questionnaire; Beck Hopelessness Scale and Dysfunctional Attitudes Scale) were used. Results: Repeated measures ANOVA analyses showed an equal rate of mood improvement in all three groups over the course of CBT, despite the fact that the High excreters were on average more depressed throughout the study. Changes in depression symptoms were mirrored by improvements in cognitive measures in the three catecholamine groups. Conclusion: This study indicates that adults showing a biological marker of depression (elevated catecholamine levels) are equally able to benefit from CBT treatment as adults without this marker.

Background: Microswitches are the most commonly used input device for people with multiple disabilities to control environmental stimulation. However, little is known about adopting the commercial trackball with a revised trackball driver as a more feasible input device. Aims: To assess whether two children with profound multiple disabilities and minimal motor skills would be able to control environmental stimulation using thumb poke ability through cordless trackballs installed with a newly developed mouse driver (i.e. a new mouse driver replacing a standard mouse driver, turning a trackball mouse into a precise thumb poke detector). Method: An ABAB design and a 2-month post-intervention check were adopted to perform the study. Results: Data showed that the two children improved significantly in their target response (thumb poke) to activate the control system to produce environmental stimuli during the B (intervention) phases. This performance was maintained at the post-intervention check. Conclusions: The use of thumb poke in connection with a trackball allowed the children with multiple disabilities and minimal motor skills to increase their level of response and stimulation control.

Background: Questions underpin all aspects of therapeutic assessment and intervention and are a vital component of the clinical process. Over recent years frameworks have started to be applied to obtain a greater understanding of questioning formats and processes. Method: This paper examines the use of questions in cognitive therapy (CT). An overview of the main types of questions identified in the literature is presented. In addition, we examine a range of client and therapist characteristics that may impact on the questioning process. Conclusions: Asking questions in therapy is a complex, yet under-taught, skill. This paper provides a set of frameworks to assist in identifying helpful and unhelpful questioning skills. Thus the article has implications for further training and research.

Background: Proficient delivery of motivational interviewing (MI) is often determined by global rating of relational elements or cumulative tallies of technical elements. Yet limited empirical evidence exists to clarify how relational and technical elements are associated, or if rates of skill indices and their constituent technical elements vary within a clinical encounter. Aims: This study sought to document temporal variance in rates of MI skill indices and their constituent technical elements during brief clinical encounters with a standardized patient wherein delivery was “MI-proficient”, and to distinguish those temporal patterns from those observed in encounters with “MI-inconsistent” delivery. Method: Data were accessed from a large MI training trial wherein relational and technical elements of MI delivery were scored for 503 recordings of a simulated 20-minute clinical encounter. Notably, independent raters tallied technical elements in 5-minute segments, allowing evaluation of potential variance among the encounter's quartile intervals. Global ratings of MI spirit identified subsets of recordings with MI-proficient (n = 49) and MI-inconsistent (n = 43) delivery for stratified analyses. Results: Analyses contrast temporal trajectories of technical aspects of MI-proficient and MI-inconsistent delivery, with the former characterized by: 1) elicitation and reflective listening as primary opening strategies; 2) increased depth of reflective listening as a predominant strategy in subsequent, focused therapeutic discussion; and 3) increased use of elicitation and information provision in change planning as the encounter approached conclusion. Conclusions: Findings are generally consistent with seminal descriptions of MI (Miller and Rollnick, 1991, 2002), and document temporal aspects of skilful MI delivery in brief encounters.

Background: Physical injury and psychological trauma associated with combat in the wars in Iraq and Afghanistan frequently lead to a constellation of symptoms including pain, post traumatic stress disorder (PTSD), and depression. Method: This single case study describes the application of a behaviorally-based psychotherapy known as behavioral activation for the treatment of post traumatic stress disorder (PTSD) and depressive symptoms in a recent combat veteran with multiple physical injuries sustained from a blast injury. Treatment was provided concurrently with other rehabilitation services and consisted of weekly individual sessions for 4 months, followed by monthly sessions for 4 months. Results: Clinically significant reductions in PTSD and depressive symptoms were noted between baseline and 1 year follow-up. Conclusion: Preliminary evidence from this case suggests that behavioral activation may be a promising treatment for PTSD and depression, and can be readily tailored to individuals with physical limitations such as pain and mobility restriction. Treatment can be provided in the context of concurrent interdisciplinary medical and rehabilitation care.

Background: This pilot study was designed to investigate the efficacy of a cognitive behavioral treatment for anger. Method: Twelve (5 men and 7 women) outpatient adults completed 2-hour group sessions for 16 sessions. Participants were diagnosed with 29 Axis I and 34 Axis II disorders with high rates of comorbidity. Empirically supported techniques of skills training, cognitive restructuring, and relaxation were utilized. In this protocol, cognitive restructuring emphasized the use of the ABC model to understand anger episodes and the Rational Emotive Behavior Therapy (REBT) techniques of disputing irrational beliefs and rehearsing rational coping statements, but additional cognitive techniques were used, e.g. self-instructional training (SIT). Skills training included problem-solving and assertiveness. Relaxation training was paced respiration. Motivational interviewing, imaginal exposure with coping, and relapse prevention were also included. Results: Significant improvements were found from pre- to post-treatment on the following measures: the Trait Anger Scale of the State-Trait Anger Expression Inventory-II; and Anger Disorder Scale total scores; idiosyncratic anger measurements of situational intensity and symptom severity; and the Beck Depression Inventory-II; Conclusions: In order to extend the significant research findings of this pilot study, future investigations should involve larger sample sizes, populations drawn from various settings, and contact control groups.

Background: Behavioural parent training is effective in improving child disruptive behavioural problems in preschool children by increasing parenting competence. The indicated Prevention Programme for Externalizing Problem behaviour (PEP) is a group training programme for parents and kindergarten teachers of children aged 3–6 years with externalizing behavioural problems. Aims: To evaluate the effects of PEP on child problem behaviour, parenting practices, parent-child interactions, and parental quality of life. Method: Parents and kindergarten teachers of 155 children were randomly assigned to an intervention group (n = 91) and a nontreated control group (n = 64). They rated children's problem behaviour before and after PEP training; parents also reported on their parenting practices and quality of life. Standardized play situations were video-taped and rated for parent-child interactions, e.g. parental warmth. Results: In the intention to treat analysis, mothers of the intervention group described less disruptive child behaviour and better parenting strategies, and showed more parental warmth during a standardized parent-child interaction. Dosage analyses confirmed these results for parents who attended at least five training sessions. Children were also rated to show less behaviour problems by their kindergarten teachers. Conclusions: Training effects were especially positive for parents who attended at least half of the training sessions. Abbreviations: CBCL: Child Behaviour Checklist; CII: Coder Impressions Inventory; DASS: Depression anxiety Stress Scale; HSQ: Home-situation Questionnaire; LSS: Life Satisfaction Scale; OBDT: observed behaviour during the test; PCL: Problem Checklist; PEP: prevention programme for externalizing problem behaviour; PPC: Parent Problem Checklist; PPS: Parent Practices Scale; PS: Parenting Scale; PSBC: Problem Setting and Behaviour checklist; QJPS: Questionnaire on Judging Parental Strains; SEFS: Self-Efficacy Scale; SSC: Social Support Scale; TRF: Caregiver-Teacher Report Form

Background: Desire thinking is defined as a voluntary thinking process orienting to prefigure images, information and memories about positive target-related experience. Recent research has highlighted the role of desire thinking in the maintenance of addictive, eating and impulse control disorders. Currently little is known about metacognitions in desire thinking. Aim: To investigate: (1) the presence and content of desire thinking during a desire experience; (2) the presence of metacognitive beliefs in desire thinking; (3) the goal of desire thinking; (4) attentional focus during desire thinking; and (5) the impact of desire thinking on craving. Method: Twenty-four individuals with a diagnosis of either alcohol abuse, bulimia nervosa, pathological gambling or smoking dependence were assessed using a semi-structured interview. Results: Findings indicated that participants engaged in desire thinking and endorsed both positive and negative metacognitive beliefs about this process. The goal of desire thinking was to regulate internal states. Participants also reported that during a desire experience their attentional focus was continuously shifting between internal state and external context and that engaging in desire thinking increased craving. Conclusions: These findings provide preliminary evidence that metacognitions play a role in desire thinking.

Background: Attributions for hallucinations in the “schizophrenia” spectrum disorders have been subject to extensive investigation; however, in comparison very little is known about attributions for hallucinations in the bipolar disorders spectrum. Aims: This preliminary study is an attempt to investigate attributions for hallucinations in bipolar disorder with regard to prevalence, modality and mood state. Method: Forty participants were recruited from a larger randomized control trial into CBT for bipolar disorder and asked to provide information related to attributions for hallucinations both in and out of episode. Data was collected using a specially designed instrument based on the Belief about Voices Questionnaire (BAVQ). Results: Just under half of the participants reported experiencing true hallucinations during their illness. Participants tended to report visual hallucinations in mania and auditory hallucinations in depression. The vast majority of participants attributed hallucinations to illness when out of episode, and unlike in previously reported analyses of attributions for hallucinations in the schizophrenia spectrum, malevolent/omnipotent attributions were comparatively rare. Conclusions: Attributions for hallucinations in bipolar disorder may be clinically distinct from attributions previously observed in the schizophrenia spectrum, and CBT aimed at reducing the distress associated with these attributions may have to be tailored accordingly.

Background: Many people hear voices but do not access psychiatric services and their experiences are largely unknown, not least because of the difficulty in contacting such people. This study investigates the beliefs held about voices, distress experienced, and provides a topographical account of the experience of hearing voices in a sample of individuals who hear voices in a non-psychiatric population. Method: A quantitative questionnaire internet-based study with a within-subjects and between-subjects design was used. The internet was used to make contact with people who hear voices. One hundred and eighty-four participants in the general population who heard voices completed measures online assessing anxiety, depression, and beliefs about their dominant voice. Results: Participants reported a broad range of experiences associated with hearing voices, some in keeping with the previous research on clinical populations. Conclusion: The use of the internet to recruit and research non-clinical samples of people who hear voices is supported. This study provides details regarding demographic information and the experience of voice hearing from a fairly large sample of people who hear voices in a non-psychiatric population. It lends support to the idea that voice hearing occurs on a continuum, with evidence that many people hear voices in the general population and are not distressed by the experience.