Animal phobias in young people with autism spectrum disorders (ASD) and intellectual disability (ID) can provoke behaviours that put them at risk and impede access to the community. Previous studies suggest that cognitive behavioural therapy including systematic desensitization and modelling are effective for people with ID, including those with comorbid ASD. Methods of adapting such treatment to people with little spoken language are not well described, and ethical issues concerning both young people and animals during treatment have not been addressed. The aim of this study was to describe, using a case series of consecutive referrals: (1) adaptations to systematic desensitization when communication of the young person is impaired, and (2) the ethics of involving animals in therapeutic interventions. Treatment was planned based on the use of systematic desensitization with a hierarchy of feared situations using visual symbols and schedules to communicate with the participants. Five young people with ASD, severe ID and minimal language were successfully treated for dog phobia. Modifications to treatment included both the use of non-verbal means of communication including printed symbols and graded activities such as jigsaw puzzles and picture matching to present information to clients in a more finely graded format. The treatment of specific phobias is possible with the use of minimal language provided that a variety of individualized stimuli approximating to the feared objects are developed and the safety of all participants is respected. Further work is required to develop sufficiently flexible treatment protocols, which in turn would enable a randomized controlled trial.

This study provides the first assessment of the latent structure of the Profile of Emotional Distress (PED). The PED is a self-report measure of emotional distress (ED) associated strongly with its links to Rational Emotive Behaviour Therapy (REBT). To date, the PED has been weakly conceptualized using both unitary and binary models of ED. In this study, the dimensionality of the PED was examined within an alternative models’ framework using confirmatory factor analysis and bifactor modelling techniques. A total of 313 law enforcement, military, and related emergency-service personnel completed the PED. Results indicated that a bifactor model conceptualization was the best fit of the data. The bifactor model included a single general factor (ED) and four grouping factors (Concern, Anxiety, Sadness, Depression). Model parameter estimates indicated that the ED factor accounts for the majority of covariance among the observable indicators. Low factor loadings were observed on each of the grouping factors, thus subscale construction is not recommended. Composite reliability results demonstrated that the ED factor possesses excellent internal reliability. The PED was found to be a reliable and valid measure of emotional distress.

Recently, autobiographical memory theorists proposed that intrusive imagery contains important information about goals. This study examined thematic links between approach and avoidance goals in two groups: a clinical group (n = 22) and a non-clinical group (n = 24). Participants completed the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM), Goals Task and an imagery interview. In the total sample, almost 90% of reported imagery matched at least one goal. Eighty-five percent of clinical participants reported imagery that matched avoidance goals, whereas only half of non-clinical participants' imagery matched an avoidance goal. The majority of imagery was found to be associated with a particular memory or a collection of memories for similar events. These findings support proposals that intrusive imagery contains important information about goals, and in particular states of the world to be avoided. Clinical implications and directions for future research are discussed.

A small body of research shows that the working alliance mediates the relation between outcome expectancy and treatment response, but this model has not been applied to the treatment of social anxiety disorder. The present study tests the hypothesis that the working alliance mediates the relation between outcome expectancy and symptom improvement within a randomized controlled trial testing the efficacy of virtual reality exposure therapy for social anxiety disorder. A sample of 54 individuals diagnosed with social anxiety disorder completed eight sessions of virtual reality exposure therapy or exposure group therapy. Participants completed standardized self-report measures of outcome expectancy at the first session, of the working alliance at each session, and three measures of social anxiety symptoms at pre- and post-treatment. The working alliance did not mediate the relation between outcome expectancy and symptom improvement across time points, dependent measures, and treatment type. Bayes factors were calculated for the relation between the working alliance and symptom reduction, while controlling for outcome expectancy and therapist effects. Results were inconclusive. These null findings are intriguing and urge further study of the mechanisms through which common factors relate to treatment response. Utilization of Bayesian analyses may help to clarify the nature of these relations.

Very little clinical work or research to date has focused on the prioritization of suicidal imagery intervention in the stabilization of risk. Current Cognitive Behavioural Therapy Suicide Prevention (CBT-SP) does not specifically address suicidal imagery as a priority intervention. This paper prioritizes imagery modification as the central task of therapy with the suicidal client. This is a single subject case review describing specific imagery interventions used to destabilize the comforting component of suicidal images, de-glamourize the suicidal image as a problem-solving method and the reconstruction of new images to offset the emotional grasp of both ‘flash-forward’ violent suicidal images and suicidal ‘daydreaming’ rumination. It is hypothesized that when suicidal images become less emotionally charged, the desire to act upon suicide decreases. Focusing on imagery intervention as a priority aims to stabilize risk in a more clinically specific and targeted way. Rob is a 19-year-old depressed young man with chronic suicidal ideation/images with repeated suicide attempts. All GP referrals are of a crisis nature since the age of 16. He was referred to a CBT clinician with specific training and experience in CBT-SP who proposed the following brief imagery intervention. Socialization to treatment rationale was pivotal at the outset to help facilitate strong therapeutic alliance, ‘buy-in’ to the intended de-glamourization of suicide planning/daydreaming/rumination and the effects of intrusive ‘flash-forward’ images on emotional well-being. Therapy was facilitated weekly, supported by telephone contact, on an out-patient basis in the HSE (Health Service Executive) Irish Adult Mental Health service. The care plan and interventions were supported by access to the 24-hour acute Adult Mental Health services, as required. There was no requirement for direct client engagement with the acute services. Rob engaged with five treatments of CBT-SP imagery intervention and full stabilization of risk to self by suicide was achieved. At the time of writing, Rob is alive, has no engagement with the services and no further GP referral requests for intervention. Despite Rob leaving therapy before full completion, brief targeted suicidal imagery intervention was observed to stabilize the risk of suicidal behaviour. This young man has completed his schooling, engaged in ‘life’ planning rather than ‘death’ planning and has not required further intervention from this service. Further research is required to engage frontline clinicians on the merits of suicidal imagery assessment in routine clinical practice.

Ways of coping with stressful situations can be categorized as problem-focused, emotion-focused, and dysfunctional. Methods of controlling intrusive thoughts, which are frequently associated with psychological distress, have also been classified into different subgroups. This study assesses associations between methods of coping and thought control, and how these relate to distress. Sixty-eight participants were recruited from outpatient psychology services and completed measures of distress, coping, and thought control. Problem-focused coping strategies and both distraction and social thought-control strategies were associated with each other and with lower distress. Conversely, dysfunctional coping strategies and both worry and punishment thought-control strategies were associated with each other and with higher distress. Future research and the clinical implications are discussed.

Autism spectrum disorders (ASD) including high-functioning types such as Asperger's syndrome (AS) are diagnosed when there is evidence of a triad of qualitative impairments in social interaction, communication, and stereotyped/repetitive behaviours. It is not uncommon for these impairments to be accompanied by social anxiety. The present single-case study investigates the use of cognitive behavioural therapy (CBT) to treat a 47-year-old man who was assessed as having difficulties with social skills and social phobia in the context of a late diagnosis of AS. He received 20 h of CBT adapted for his AS in 15 sessions including a 1-month follow-up. Following a highly individualized formulation, treatment included modelling, role-playing, reinforcement, thought challenging, and behavioural experimentation. Results from five self-report measures showed continued improvements from the start of therapy to follow-up in social anxiety, global distress, depression and self-esteem. The client gave positive feedback about his experience of treatment. The case study is discussed with reference to limitations and some reflections for CBT in ASD.

Guided CBT self-help represents a low-intensity intervention to deliver evidence-based psychological therapy within the Improving Access to Psychological Therapies (IAPT) programme. Best practice guidance highlighting characteristics associated with CBT self-help is available to help services reach decisions regarding which interventions to adopt. However, at present a single process to evaluate written CBT self-help interventions informed by guidance is lacking. This study reports on the development of a standardised criteria-driven process that can be used to determine the extent written CBT self-help interventions are consistent with guidance regarding the fundamental characteristics of low-intensity CBT and high-quality written patient information. Following development, the process was piloted on 51 IAPT services, with 23 interventions identified as representing free-to-use written CBT self-help interventions. Overall, inter-rater reliability was acceptable. Following application of the criteria framework, 14 (61%) were considered suitable to be recommended for use within the IAPT programme. This pilot supports the development and potential utility of an independent criteria-driven process to appraise the suitability of written workbook-based CBT self-help interventions for use within the IAPT programme.

Nearly half of patients with non-cardiac chest pain (NCCP) experience significant complaints after a negative cardiac evaluation, at considerable costs for society. Due to the lack of treatment capacity and low interest for psychological treatment among patients with somatic complaints, only a minority receive effective treatment. The aim of this study was to assess the feasibility and usefulness of internet-assisted cognitive behavioural therapy (I-CBT), including encouragement of physical activity for this condition. Ten patients with NCCP received a six-session I-CBT intervention with minimal support from a therapist. Questionnaires assessing cardiac anxiety, fear of bodily sensations, depression, interpretation of symptoms, frequency of chest pain and impact of chest pain symptoms were collected at baseline, post-treatment and at 3-month follow-up. Semi-structured interviews employing a phenomenological hermeneutic approach assessed the participants’ experience of the intervention. Quantitative results showed clear improvements in several measures both at end of treatment and at 3-month follow-up. The retention rate was 100% and client satisfaction was high. The intervention was feasible to implement in a cardiac setting. This setting made it easier for patients to accept a psychological approach. Qualitative interviews revealed that the participants felt respected and taken care of, and they obtained a better understanding of their chest pain and how to cope with it. This pilot study yielded promising results regarding feasibility, clinical effect and patient satisfaction from a brief I-CBT intervention for NCCP in a cardiac setting. These results indicate that a randomized controlled trial with a larger sample size is warranted.

Psychosocial Interventions (PSIs) and PSI supervision underpin the delivery of early interventions for people experiencing psychosis. Early Intervention (EI) teams are relatively new in the NHS and there is currently a lack of empirical research into PSI supervision in this area. This study aimed to elicit staff views of PSI supervision and to identify any unmet supervision needs within a newly developed EI team in the UK. Semi-structured interviews were conducted with 16 multidisciplinary team members. Descriptive statistics and a thematic analysis were used to analyse the responses. The different types of supervision available to team members, gaps in the provision of PSI supervision and aspects that supervisees found helpful and unhelpful about PSI supervision are discussed as are ideas for improving the provision of PSI supervision in EI teams. The limitations of the study and ideas for further research are also outlined.

Homeless girls suffer labour and sexual exploitation, abuse, discrimination and social exclusion at a higher rate than the rest of the population. However, worldwide information on homeless girls and intervention programmes for this group are scarce. This study examined the preliminary efficacy of a brief cognitive behavioural group therapy tailored to Mexican homeless girls. The intervention targeted subjective well-being and these determinants: symptoms of anxiety, symptoms of depression, assertive behaviours and functional emotion regulation skills. Results revealed statistically significant differences in symptoms of anxiety and depression, assertiveness, emotion regulation strategies and subjective well-being with treatment effects that ranged from moderate to large. Symptoms of anxiety and depression, and dysfunctional emotion regulation strategies decreased. Assertive skills, functional emotion regulation strategies, and subjective well-being increased. Outcomes were clinically relevant. At 2-month follow-up, participants showed improvement from pre-treatment on all measures. The current study provides unique findings in terms of a promising preliminary intervention that helps restore homeless girls to a healthier social/emotional developmental path especially in the context of Latin American cities. As a result, the clinical implications of this research highlight the urgent need to design effective interventions based on the observed characteristics and identified needs among homeless girls.

Avoidant Restrictive Food Intake Disorder (ARFID) is a condition characterised by a disturbance in eating behaviour that leads to a significant negative impact on physical, social and nutritional health. The diagnosis of ARFID relies on a comprehensive, multi-disciplinary assessment to understand the individual’s history, physical, social and mental health risk, and any co-occurring mental health difficulties. Consensus guidance suggests that psychological treatment, alongside medical and dietetic input is delivered with consideration of any appropriate adaptions to accommodate developmental stage and/or common co-occurring presentations. This paper has been authored by clinicians working in an out-patient setting for children and adolescents with ARFID, and focuses on the presentation and assessment of ARFID and cognitive behavioural therapy (CBT) approaches that can help children, young people and their families. After an introductory section, the paper is split into four sections: assessment of ARFID; drivers of avoidant restrictive eating behaviour; multi-disciplinary formulation and intervention planning; and treatment. The treatment section provides an overview of the available research on CBT for ARFID, and a brief summary of the broader evidence base for CBT in children and young people with anxiety. Following a review of the evidence base, three case descriptions are provided to illustrate the clinical application of CBT where fear-based avoidance is the main driver. The paper concludes with practice points for clinicians to take forward when working with children and young people with ARFID.

Mindfulness-based Cognitive Therapy (MBCT) was not intended for current depression, and lengthy mindfulness practices (≥30 min) can be challenging. Person-based cognitive therapy (PBCT) includes brief mindfulness practices (<10 min). While group PBCT can improve depressive symptoms whether benefits can be attributed to the brief practices is unclear. Twenty-eight participants with chronic major depression were randomly assigned to PBCT (n = 14) or treatment as usual (n = 14). Measures of mindfulness and depression were taken. Six PBCT participants were interviewed. Improvements in mindfulness in mediating the relationship between group and improvements in depressive symptoms just failed to reach statistical significance (95% confidence interval −0.97 to 14.84). Thematic analysis identified four themes: ‘altered relationship to symptoms’, ‘impact on self’, ‘the challenge of letting go’ and ‘effect of the group’. Although bootstrapped indirect effects were in the hypothesized direction they failed to reach statistical significance; this could be due to low power, but further research is needed. Qualitative themes support the potential of brief mindfulness practices and are similar to themes identified of mindfulness-based interventions with lengthier mindfulness practices. Findings suggest that some people experiencing current depression report benefit from the brief mindfulness practices included in PBCT but further research in larger samples is now needed.

Family accommodation in obsessive-compulsive disorder (OCD) refers to a condition in which a family member assists or facilitates the patient with OCD in performing the compulsion, or provides assurance to minimize or reduce the anxiety level. This condition can be significantly disabling to the individual as well as to the family dynamic. In this case report, a mother of a 14-year-old female patient carried out almost all the compulsive behaviours and rituals for her child. Family-based cognitive behavioural therapy was offered to this case over a 4-month period with a successful treatment outcome. This result provides initial evidence that this type of intervention is suitable for patients from Saudi Arabia, a non-Western culture.

Despite the understanding that unaccompanied minors’ (UAM) experience high rates of post-traumatic stress, the provision of evidence-based trauma-focused therapies is low for this population. Narrative exposure therapy (NET) is an effective short-term intervention for treating post-traumatic stress disorder (PTSD) after multiple traumatic experiences, such as those experienced by UAM. Within the existing literature, there is a lack of research investigating unaccompanied minors’ experiences of NET or any trauma-focused therapy. Participants were four UAM experiencing PTSD who formed part of a pilot delivery of NET within a dedicated child and adolescent mental health service for refugee children. Semi-structured interviews were conducted and transcripts were analysed using interpretative phenomenological analysis (IPA). This project identified five themes that encapsulated unaccompanied minors’ experiences of receiving NET, including the process of preparing for this therapy, what it was like to receive it, and the differences they identified at the end of treatment. The significance of this taking place within a safe therapeutic relationship was explored within the context of the attachment losses experienced by UAM, and the impact this has on emotion regulation was considered. The potential of a reduction in PTSD symptoms facilitating a positive spiral in adolescence was reflected on within this paper.

NHS Education for Scotland (NES) has developed a suite of training to address the learning and development needs of supervisors of psychological therapies in the National Health Service (NHS) in Scotland and to support quality of evidence-based practice in psychological therapies, in light of the recent expansion in this area of healthcare. In parallel with the structure of the recently developed supervisory competency frameworks, an initial training package addressing generic (cross-modality) supervision competences was supplemented by the development of a training package to meet the specific needs of supervisors of CBT: NES Specialist Supervision Training in CBT (NESSST CBT). A blended learning package was developed, in light of the emerging evidence around the effectiveness of e-learning, to produce a flexible and learner-centred training package. This paper describes the development, delivery and planned evaluation methods of NESSST CBT. Lessons learned during implementation are outlined, along with key challenges regarding the future of supervision training in Scotland and the UK.

Socially anxious individuals hold negative beliefs about their appearance, abilities and personality. These negative self-conceptions increase expectations of negative evaluation from others and, consequently increase anxiety. Self-verification theory states that individuals seek, accept and prefer feedback that is congruent with their self-conceptions. This study explored the assumptions of self-verification theory in social anxiety. This was achieved by examining the type of feedback socially anxious individuals seek and how positive and negative feedback is processed. Results from an undergraduate sample (n = 84) indicate that socially anxious individuals were no more or less likely to seek negative feedback than individuals with low social anxiety. However, participants with greater social anxiety rated positive feedback as less accurate, rated negative feedback as more accurate, and were more comfortable with negative feedback, compared to participants with low social anxiety. Greater social anxiety was also found to predict increased discomfort with positive feedback, and fear of negative evaluation fully mediated this relationship. These findings suggest that self-verification processes operate in social anxiety and highlight the need for researchers to include measures of fears of evaluation when examining self-verification theory in samples of socially anxious individuals.

Obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD) can take many different forms of presentations. The term ‘complex’ is common and inconsistently used in both OCD and BDD. Practitioners often refer to complex OCD or BDD when patients present with severe co-morbid problems, often in the context of personality difficulties, dissociation, difficult early relationships and trauma; or when the illness is chronic and debilitating with previous multiple treatment failures. Current best-evidence treatment protocols for both disorders focus heavily on exposure and response prevention (E/RP) but with moderate success, particularly in patients who are deemed ‘complex’, and often those with relevant shame and/or disgust-based past experiences. The aim of the present paper is to (a) describe factors that contribute to complexity in OCD and BDD, and (b) link these with theory and practice. We emphasize the importance of understanding both the function of OCD and BDD-related behaviours (rather than the content of obsessions or compulsion), and the context in which they occur such as the family. We illustrate complexity in OCD and BDD using real case material, using a functional and contextual approach to formulate the client's difficulties, and demonstrate how E/RP can be enhanced successfully with imagery rescripting, family work, and compassion-focused therapy.

Cognitive behaviour therapy (CBT) has become the first line of treatment for a wide range of mental health problems across many countries. The flexibility of CBT, and a strong evidence base and good track record of training and dissemination, has lent itself to scaling up of this therapy, and projects such as the Improving Access to Psychological Therapies (IAPT) programme in England have shown that large-scale projects to roll out CBT at a national level are possible (Clark, 2011).

Within IAPT (Improving Access to Psychological Therapies), cognitive behavioural therapy (CBT) is offered to all clients regardless of gender, religion, culture and language. Hence, the demand for working with interpreters to facilitate communication during therapy in IAPT has increased. This study explored the experience of therapists working with interpreters to facilitate communication in psychological therapies with clients with mild to moderate anxiety and depression including those with co-morbid physical health problems. Thirteen participants, including six CBT therapists and seven Psychological Wellbeing Practitioners (PWPs) working in an NHS IAPT service, were interviewed. A qualitative approach, using semi-structured interviews and thematic analysis (Braun and Clarke, 2006), was implemented. The following four major themes were identified from the participants’ accounts: negotiating a three-way communication, difficulties in expressing empathy, a lack of shared understanding and working creatively with interpreters. During this collaborative working new understandings of engaging emerged leading participants to view this work as possible.