Background: Worry is a significant problem for individuals with paranoia, leading to delusion persistence and greater levels of distress. There are established theories concerning processes that maintain worry but little has been documented regarding what brings worry to a close. Aims: The aim was to find out what patients with persecutory delusions report are the factors that bring a worry episode to an end. Method: Eight patients with persecutory delusions who reported high levels of worry participated. An open-ended semi-structured interview technique and IPA qualitative analysis was employed to encourage a broad elaboration of relevant constructs. Results: Analyses revealed one theme that captured participants’ detailed descriptions of their experience of worry and five themes that identified factors important for bringing worry episodes to a close: natural drift, distraction, interpersonal support, feeling better, and reality testing. Conclusions: Patients with persecutory delusions report worry being uncontrollable and distressing but are able to identify ways that a period of worry can stop. The present study suggests that building on individuals’ distraction techniques, reality testing ability and their social support network could be of benefit. Research is needed to identify the most effective means of bringing paranoid worries to an end.

Background: Case formulation (CF) is considered a core component of cognitive behavioural therapy (CBT). Despite this, few studies have explored the content and quality of CFs in routine practice and any associated impact on treatment outcome. Aims: This study investigated (1) the content, timing and quality of CF for patients (N = 29) with Obsessive Compulsive Disorder; (2) the impact of CF on symptoms, distress and therapeutic alliance; and (3) the relationship between CF quality and treatment outcome. Method: CF content and quality were assessed from audiotapes of routine CBT sessions using a validated coding manual and evaluated against treatment outcomes at different stages of therapy. Results: CFs were developed early during treatment and contained strong behavioural and cognitive components, with a focus on symptoms and maintaining factors. CF quality ratings ranged from rudimentary to excellent. A significant improvement in distress and the therapeutic alliance occurred following the introduction of CF, but no significant relationship was found between CF quality and outcome at any stage of treatment. Conclusion: CF may be valuable in reducing patient attrition, due to its impact early in treatment. Further research is needed to explore the most important components of CF. Theoretically sound and disorder specific measurement tools for evaluating CFs are required.

Background: Historically, it has been difficult to demonstrate an impact of training in psychological interventions for people with psychosis on routine practice and on patient outcomes. A recent pilot evaluation suggested that postgraduate training in Cognitive Behavioural Therapy for Psychosis (CBTp) increased the delivery of competent therapy in routine services. In this study, we evaluated clinical outcomes for patients receiving therapy from therapists who successfully completed training, and their association with ratings of therapist competence and therapy content. Aims: To characterize the therapy delivered during training and to inform both a calculation of effect size for its clinical impact, and the development of competence benchmarks to ensure that training standards are sufficient to deliver clinical improvement. Method: Paired patient-reported outcome measures (PROMS) were extracted from anonymized therapy case reports, and were matched with therapy ratings for each therapist. Results: Twenty clients received a course of competent therapy, including a high frequency of active therapy techniques, from nine therapists. Pre–post effect size for change in psychotic symptoms was large (d = 1.0) and for affect, medium (d = 0.6), but improved outcomes were not associated with therapist competence or therapy content. Conclusions: Therapists trained to research trial standards of competence achieved excellent clinical outcomes. Therapy effect sizes suggest that training costs may be offset by clinical benefit. Larger, methodologically stringent evaluations of training are now required. Future research should assess the necessary and sufficient training required to achieve real-world clinical effectiveness, and the cost-effectiveness of training.

Background: Patients with anxiety disorder diagnoses commonly have more than one anxiety diagnosis. While cognitive-behavioural interventions have proven efficacy in treating single anxiety disorder diagnoses, there has been little investigation of their efficacy in treating co-occurring anxiety disorders. Aims: To evaluate the efficacy of a transdiagnostic cognitive-behavioural intervention for treating co-occurring anxiety disorders. Method: An A-B single case study design (N = 6) was used to evaluate the efficacy of a 12 to 13-session modular transdiagnostic cognitive-behavioural intervention for treating co-occurring anxiety disorders across patients with at least two of the following diagnoses: GAD, Social Phobia, Panic Disorder and/or OCD. Results: Five of the six participants completed treatment. At posttreatment assessment the five treatment completers achieved diagnostic and symptomatic change, with three participants being diagnosis free. All participants who completed treatment no longer met criteria for any DSM-IV-TR Axis-I diagnosis at the 3-month follow-up assessment, and demonstrated reliable and clinically-significant improvements in symptoms. Across the participants, statistically significant improvements from pre to postintervention were found on measures of anxiety, depression and general well-being, and all improvements were maintained at 3-month follow-up. Conclusions: Results suggest that transdiagnostic cognitive behavioural interventions can be of benefit to patients with co-occurring anxiety disorders.

Background: Despite the availability of evidence-based treatments for depression, large gaps exist between empirical research and clinical practice. Aims: To make preliminary steps toward the dissemination of Behavioural Activation (BA) via online training by examining clinicians’ interest in learning BA via online training and the effects of a preliminary version of BA online training. Method: In study 1, practising clinicians (n = 540) completed a survey that assessed attitudes towards learning BA using an online training format. In study 2, we conducted a small, pilot randomized controlled trial (n = 46) to examine preliminary efficacy of teaching BA principles and treatment strategies with a precursor version of BA online training. Results: Study findings suggest that clinicians have interest in learning about BA via online training and that clinicians participating in BA online training evidence high satisfaction and significant gains in self-efficacy using BA and knowledge of BA terms and concepts. Conclusions: These results support the importance of efforts to disseminate BA and the viability of online training as an easily accessible and affordable training option.

Background: The cognitive model suggests memory biases for weight/shape and food related information could be important in the maintenance of eating disorders. Aims: The current study aims to evaluate this and extend previous research by (a) including females with eating disorder not otherwise specified (EDNOS) as a discreet group; (b) considering whether levels of hunger and the pleasantness of the stimulus words are important in word recall. Method: The study includes three groups of females, 16 with bulimia nervosa, 18 with EDNOS and 17 non-dieting general population controls. All participants completed a self-referential encoding and memory recall task. Results: A main effect of word type (p < .01) with no group by word type interaction or between group difference was found. A priori contrasts indicated that both eating disorder groups recalled significantly more weight/shape and food words compared to all other word categories (p < .01) compared to the control group; with no significant difference found between the eating disorder groups. In relation to the recall of food words, no significant differences were found between groups for levels of hunger. Both eating disorder groups rated the negative weight/shape (p < .01), negative food (p < .01) and neutral body words (p < .01) as more unpleasant than the control group. Conclusions: The implications for cognitive theory and future research are discussed.

Background: Environmental factors have been associated with psychosis but there is little qualitative research looking at how the ongoing interaction between individual and environment maintains psychotic symptoms. Aims: The current study investigates how people with persecutory delusions interpret events in a virtual neutral social environment using qualitative methodology. Method: 20 participants with persecutory delusions and 20 controls entered a virtual underground train containing neutral characters. Under these circumstances, people with persecutory delusions reported similar levels of paranoia as non-clinical participants. The transcripts of a post-virtual reality interview of the first 10 participants in each group were analysed. Results: Thematic analyses of interviews focusing on the decision making process associated with attributing intentions of computer-generated characters revealed 11 themes grouped in 3 main categories (evidence in favour of paranoid appraisals, evidence against paranoid appraisals, other behaviour). Conclusions: People with current persecutory delusions are able to use a range of similar strategies to healthy volunteers when making judgements about potential threat in a neutral environment that does not elicit anxiety, but they are less likely than controls to engage in active hypothesis-testing and instead favour experiencing “affect” as evidence of persecutory intention.

Background: Depressive symptoms are one of the main reasons for seeking psychological help. Shorter interventions using briefly trained therapists could offer a solution to the ever-rising need for early and easily applicable psychological treatments. Aims: The current study examines the effectiveness of a four-session Acceptance and Commitment Therapy (ACT) based treatment for self-reported depressive symptoms administered by Masters level psychology students. Method: This paper reports the effectiveness of a brief intervention compared to a waiting list control (WLC) group. Participants were randomized into two groups: ACT (n = 28) and waiting list (n = 29). Long-term effects were examined using a 6-month follow-up. Results: The treatment group's level of depressive symptoms (Beck Depression Inventory) decreased by an average of 47%, compared to an average decrease of 4% in the WLC group. Changes in psychological well-being in the ACT group were better throughout, and treatment outcomes were maintained after 6 months. The posttreatment “between-group” and follow-up “with-in group” effect sizes (Cohen's d) were large to medium for depressive symptoms and psychological flexibility. Conclusions: The results support the brief ACT-based intervention for sub-clinical depressive symptoms when treatment was conducted by briefly trained psychology students. It also contributes to the growing body of evidence on brief ACT-based treatments and inexperienced therapists.

Background and aims: This study explored therapists’ and clients’ experiences of paranoia about the therapist in cognitive behaviour therapy. Method: Ten therapists and eight clients engaged in cognitive behaviour therapy for psychosis were interviewed using a semi-structured interview. Data were analyzed using thematic analysis. Results: Clients reported experiencing paranoia about their therapist, both within and between therapy sessions. Therapists’ accounts highlighted a number of dilemmas that can arise in responding to clients’ paranoia about them. Conclusions: The findings highlight helpful ways of working with clients when they become paranoid about their therapist, and emphasize the importance of developing a therapeutic relationship that is radically collaborative, supporting a person-based approach to distressing psychotic experience.

Background: As a trainee cognitive therapist in the early 1990s, I was taught the Sh*t Sandwich by my supervisor. I continued to use this technique for many years without seeing the need to extend my repertoire of feedback strategies. Aims: This article describes a number of other feedback techniques, raising awareness of the processes underpinning feedback, and facilitating reflection on feedback methods. Method: This review examines feedback and the methods of feedback used to improve clinical competence. Results: Evidence informs us that the use of good feedback has a significant effect on learners’ outcomes (Milne, 2009). However, despite recognition of its importance, many supervisors fail to give adequate feedback and utilize methods that are sub-optimal. One such problematic method is the notorious “Sh*t Sandwich” (SS), which attempts to hide criticism within a cushion of two positive statements. This paper looks at various models of giving negative and positive feedback, suggesting that our repertoire of feedback methods may require expanding. Conclusion: The review suggests that feedback is a complex process and methods that place an emphasis on the learner as an active participant in the learning process (i.e. interactive approaches) should be encouraged. The paper suggests that negative feedback should generally be avoided in favour of constructive support, accompanied by specific, descriptive, balanced feedback, with new learning being consolidated by role play. Generally, feedback should be given about the task rather than the person, but when it is personalized it should relate to effort rather than ability.

Background: Current clinical models emphasize certain cognitive processes in the maintenance of distressing paranoia. While a number of these processes have been examined in detail, the role of strategic cognition and self-focused attention remain under-researched. Aims: This study examined the deployment of cognitive strategies and self-focused attention in people with non-clinical paranoia. Method: An experimental design was used to examine the impact of a threat activation task on these processes, in participants with high and low non-clinical paranoia. Twenty-eight people were recruited to each group, and completed measures of anxiety, paranoid cognition, strategic cognition and self-focused attention. Results: The threat activation task was effective in increasing anxiety in people with high and low non-clinical paranoia. The high paranoia group experienced more paranoid cognitions following threat activation. This group also reported greater use of thought suppression, punishment and worry, and less use of social control strategies when under threat. No differences were found between the groups on measures of self-focused attention. Conclusions: This study shows that the threat activation task increased anxiety in people with high non-clinical paranoia, leading to increased paranoid thinking. The use of strategic cognition following threat activation varied dependent on level of non-clinical paranoia. If these differences are replicated in clinical groups, the strategies may be implicated in the maintenance of distressing psychosis, and may therefore be a valuable target for therapeutic intervention.

Background: Evidence exists for a relationship between individual characteristics and both job and training performance; however relationships may not be generalizable. Little is known about the impact of therapist characteristics on performance in postgraduate therapist training programmes. Aims: The aim of this study was to investigate associations between the grades of trainee Low-Intensity and High-Intensity cognitive behavioural therapists and individual characteristics. Method: Trainee Low-Intensity (n = 81) and High-Intensity (n = 59) therapists completed measures of personality and cognitive ability; demographic and course grade data for participants were collected. Results: Degree classification emerged as the only variable to be significantly associated with performance across assessments and courses. Higher undergraduate degree classifications were associated with superior academic and clinical performance. Agreeableness was the only dimension of personality to be associated (positively) with clinical skill. Age was weakly and negatively associated with performance. Conclusions: Relationships between individual characteristics and training outcomes are complex and may be context specific. These results could have important implications for the selection and development of therapists for Low or High-Intensity cognitive behavioural therapy (CBT) training.

Background: Obese individuals frequently experience weight stigma and this is associated with psychological distress and difficulties. The process of external devaluation can lead to negative self-perception and evaluation and some obese individuals develop “internalized weight stigma”. The prevalence of weight stigma is well established but there is a lack of information about the interplay between external and internal weight stigma. Aims: To synthesize the literature on the psychological effects of weight stigma into a formulation model that addresses the maintenance of internalized weight stigma. Method: Current research on the psychological impact of weight stigma was reviewed. We identify cognitive, behavioural and attentional processes that maintain psychological conditions where self-evaluation plays a central role. A model was developed based on clinical utility. Results: The model focuses on identifying factors that influence and maintain internalized weight stigma. We highlight the impact of negative societal and interpersonal experiences of weight stigma on how individuals view themselves as an obese person. Processing the self as a stigmatized individual is at the core of the model. Maintenance factors include negative self-judgements about the meaning of being an obese individual, attentional and mood shifts, and avoidance and safety behaviours. In addition, eating and weight management behaviours become deregulated and maintain both obesity and weight stigma. Conclusion: As obesity increases, weight stigma and the associated psychological effects are likely to increase. We provide a framework for formulating and intervening with internalized weight stigma as well as making therapists aware of the applicability and transferability of strategies that they may already use with other presenting problems.

Background: Preliminary research has indicated that general facets of metacognition are associated with problem gambling. In the present study we aimed to investigate whether specific facets of metacognition play a role in explaining gambling initiation and perseveration in individuals presenting with gambling disorder. Aim: To investigate: (1) the presence of metacognitive beliefs about gambling; (2) the goal of gambling, and its start and stop signals; and (3) the perceived impact of gambling on self-consciousness. Method: Ten individuals with a diagnosis of gambling disorder were assessed using metacognitive profiling, a semi-structured interview. Results: Findings indicated that all participants endorsed both positive and negative metacognitive beliefs about gambling. The primary goal of gambling was to relieve economic hardship and improve cognitive-emotional state. All participants reported that they did not know when this goal was achieved. Start signals for gambling included the ideas and feelings that gambling could solve problems and sensations that it might be the right time to win. The stop signal for gambling, for all participants, was running out of money. All participants also reported a perceived reduction in self-consciousness during a gambling episode. Conclusions: These findings provide preliminary evidence that specific facets of metacognition play a role in gambling disorder.

Background: Health anxiety is common, impairing, and costly. The role of catastrophizing of bodily sensations (i.e. rumination about, overconcern with, and intolerance of bodily sensations) in maintaining health-related anxiety (i.e. anxiety about perceived health problems) is important, but understudied, in the health anxiety literature. Aims: The present study investigates the role of catastrophizing of bodily sensations as a maintenance factor for health-related anxiety over time. Method: Undergraduates (n = 226 women; n = 226 men) completed a baseline assessment, 14-day daily diary study, and 14-day longitudinal follow-up. Results: Path analysis indicated catastrophizing of bodily sensations maintains health-related anxiety from one month to the next in both men and women. Conclusions: The present study bridges an important gap between theory and evidence. Results support cognitive behavioral theories and extend cross-sectional research asserting catastrophizing of bodily sensations maintains health-related anxiety over time. A cyclical, self-perpetuating pattern was observed in the present study wherein catastrophizing of bodily sensations and health-related anxiety contribute to one another over time. Results also suggest targeting catastrophizing of bodily sensations may reduce health-related anxiety.

Background: Despite the prevalence of co-morbid anxiety and depression in older adults, evaluation of suitable clinical models is rare. Aims: This study tested the acceptability and effectiveness of a transdiagnostic approach to treating co-morbid anxiety and depression in an older adults in a routine clinical setting. Method: In an A/B single case experimental design, a patient completed five daily ideographic measures of anxiety and depression across baseline and treatment and the HADS at five time points over time, including 3-month follow-up. The 8-session treatment was transdiagnostic CBT informed by the Unified Protocol. Results: All sessions were attended. Significant baseline-treatment improvements were found for daily structure, mood, confidence and worry, with large associated effect sizes. The HADS showed that the patient met recovery criteria by the end of treatment, with some evidence of anxious relapse at follow-up. Conclusion: Transdiagnostic CBT offers promise as a treatment approach to mixed anxiety and depression in older adults. The model needs to be further tested using more rigorous and suitably powered methodologies.

Background: One of the most common interpersonal reactions to threat and anxiety is to seek reassurance from a trusted person. The Reassurance Seeking Questionnaire (ReSQ) measures several key aspects of reassurance seeking behaviour, including frequency, trust of sources, intensity, carefulness, and the emotional consequences of reassurance seeking. Aims: The current study compares patterns and consequences of reassurance seeking in obsessive-compulsive disorder (OCD) and depression. Method: ReSQ scores were compared for three groups: 32 individuals with OCD, 17 individuals with depression, and 24 healthy comparison participants. Results: We found that individuals with OCD tended to seek reassurance more intensely and employ self-reassurance more frequently than individuals with depression or healthy participants, and that if reassurance was not provided, they tended to feel a greater urge to seek additional reassurance. Conclusions: This study is the first to quantitatively elucidate differences in reassurance seeking between OCD and depression.