Background: Studies of cognitive behaviour therapy (CBT) for schizophrenia demonstrate that African-Caribbean and Black African patients have higher dropout rates and poor outcomes from treatment. Aim: The main aim of the study was to produce a culturally sensitive adaption of an existing CBT manual for therapists working with patients with psychosis from specified ethinic minority communities (African-Caribbean, Black-African/Black British, and South Asian Muslims). This will be based on gaining meaningful understanding of the way members (lay and service users) of these minority communities typically view psychosis, its origin and management including their cultural influences, values and attitudes. Method: This two-centre (Hampshire and West London) qualitative study consisted of individual semi-structured interviews with patients with schizophrenia (n = 15); focus groups with lay members from selected ethnic communities (n = 52); focus groups or semi-structured interviews with CBT therapists (n = 22); and mental health practitioners who work with patients from the ethnic communities (n = 25). Data were analyzed thematically using evolving themes and content analysis. NVivo 8 was used to manage and explore data. Results: There was consensus from the respondent groups that CBT would be an acceptable treatment if culturally adapted. This would incorporate culturally-based patient health beliefs, attributions concerning psychosis, attention to help seeking pathways, and technical adjustments. Conclusion: While individualization of therapy is generally accepted as a principle, in practice therapists require an understanding of patient-related factors that are culturally bound and influence the way the patient perceives or responds to therapy. The findings of this study have practical implications for therapists and mental health practitioners using CBT with people with psychosis from BME communities.

Background: Previous research suggests that the distress experienced by clinical voice hearers is associated with the perceived relationship between voice and hearer, independent of beliefs about voices and depression. Aims: This study aimed to replicate these findings and generate further hypotheses by comparing the voice hearing experiences of clinical and non-clinical hearers. Method: A cross-sectional, quantitative design was employed and used between-subjects and correlational methods. Thirty-two clinical voice hearers and 18 non-clinical voice hearers were assessed using the PSYRATS, the Voice and You questionnaire, the Beliefs About Voices Questionnaire – Revised, and the Beck Depression Inventory-II. Results: For clinical voice hearers, distress was significantly associated with perceptions of the voice as dominating and intrusive, and hearers distancing themselves from the voice. However, these associations were not independent of beliefs about voices’ omnipotence or malevolence. Non-clinical voice hearers were significantly less distressed than clinical voice hearers and voices were perceived as less dominant, intrusive, malevolent and omnipotent. Non-clinical hearers were found to relate from a position of less distance to voices perceived as benevolent. Conclusions: Findings from previous research were only partially replicated. Clinically, the development of less maladaptive relationships between voice and voice hearer may reduce distress.

Background: The belief that we can control our thoughts is not inevitably adaptive, particularly when it fuels mental control activities that have ironic unintended consequences. The conviction that the mind can and should be controlled can prompt people to suppress unwanted thoughts, and so can set the stage for the intrusive return of those very thoughts. An important question is whether or not these beliefs about the control of thoughts can be reduced experimentally. One possibility is that behavioral experiments aimed at revealing the ironic return of suppressed thoughts might create a lesson that could reduce unrealistic beliefs about the control of thoughts. Aims: The present research assessed the influence of the thought suppression demonstration on beliefs about the control of thoughts in a non-clinical sample, and among individuals with obsessive-compulsive disorder (OCD). Method: In Study 1, we assessed the effect of the thought suppression demonstration on beliefs about the control of thoughts among low and high obsessive individuals in the non-clinical population (N = 62). In Study 2, we conducted a similar study with individuals with OCD (N = 29). Results: Results suggest that high obsessive individuals in the non-clinical population are able to learn the futility of suppression through the thought suppression demonstration and to alter their faulty beliefs about the control of thoughts; however, for individuals with OCD, the demonstration may be insufficient for altering underlying beliefs. Conclusions: For individuals with OCD, the connection between suppressing a neutral thought in the suppression demonstration and suppressing a personally relevant obsession may need to be stated explicitly in order to affect their obsessive beliefs.

Background: Cognitive Behaviour Therapy (CBT) of anxiety disorders is usually delivered in weekly or biweekly sessions. There is evidence that intensive CBT can be effective in phobias and obsessive compulsive disorder. Studies of intensive CBT for posttraumatic stress disorder (PTSD) are lacking. Method: A feasibility study tested the acceptability and efficacy of an intensive version of Cognitive Therapy for PTSD (CT-PTSD) in 14 patients drawn from consecutive referrals. Patients received up to 18 hours of therapy over a period of 5 to 7 working days, followed by 1 session a week later and up to 3 follow-up sessions. Results: Intensive CT-PTSD was well tolerated and 85.7 % of patients no longer had PTSD at the end of treatment. Patients treated with intensive CT-PTSD achieved similar overall outcomes as a comparable group of patients treated with weekly CT-PTSD in an earlier study, but the intensive treatment improved PTSD symptoms over a shorter period of time and led to greater reductions in depression. Conclusions: The results suggest that intensive CT-PTSD is a feasible and promising alternative to weekly treatment that warrants further evaluation in randomized trials.

Background: The widening scope of cognitive therapy models and strategies poses a challenge for designing cognitive therapy training. What are the core skills to be learned? What do learners view as important to learn and what are the skills and knowledge they focus on? Aims: The present study describes the perceptions of CT trainees of both what is important and what is difficult to learn. We also analyse what the trainees focus on when evaluating their professional learning. In addition, we report on changes in self-assessed skills during the training. Method: Quantitative and qualitative data were collected after 2 years of training (n = 39) in three programmes and after the entire 4-year training in four programmes (n = 53). Results: Significant progress was reported in all domains of therapist skills, most clearly in cognitive and constructivist strategies. The trainees practised most those skills they considered important to be learned and, consequently, they also attained a higher level of mastery in these skills. The trainees’ learning orientation and foci of self-reflections remained relatively unchanged. They focused on technical and conceptual skills and knowledge, whereas interpersonal skills were peripheral in their self-reflection. Conclusions: Pedagogical and theoretical implications of the findings are discussed.

Background: There is little consensus as to whether agoraphobic avoidance in panic disorder is characterized by a prominence of particular symptoms and interpretations of those symptoms. Aims: We sought to clarify the relationship between symptoms and agoraphobic avoidance and to establish whether catastrophic interpretations of symptoms mediate any such relationships. Method: The Symptom Checklist 90-Revised, Agoraphobic Cognitions Questionnaire and Mobility Inventory were administered to 117 patients with panic disorder who were attending an outpatient anxiety disorders clinic. Results: Medium to large associations were found between most symptoms and agoraphobic avoidance and between particular symptoms and the corresponding symptom interpretation items. Some interpretations of symptoms were found to mediate relationships between symptoms and agoraphobic avoidance. Conclusions: These findings suggest that the catastrophic misinterpretation model of panic disorder can to some extent be invoked to explain the extent of agoraphobic avoidance, but that there may also be other pathways leading from symptoms to agoraphobia.

Background: This project aimed to explore the experiences of people who compulsively hoard and how they make sense of their own hoarding behaviours. Method: A total of 11 compulsive hoarders were recruited and interviewed using a simple semi-structured interview format, designed for the purposes of the study. The resulting transcribed interviews were analyzed using interpretive-phenomenological analysis. Results: Four super-ordinate discrete, but interacting, themes were found: (1) childhood factors; (2) the participants' relationship to their hoarded items; (3) cognitive and behavioural avoidance of discard; and (4) the impact of hoarding on self, others and the home environment. The themes as a whole described people entrapped in massively cluttered physical environments of their own making. Efforts at discard appeared consistently sabotaged by cognitive/behavioural avoidance, thereby creating maintaining factors of associated personal distress and environmental decline. Conclusions: The results are discussed in the context of the extant evidence concerning hoarding, the distinct contribution made by the current results and the identified methodological shortcomings of the research approach.

Introduction: Inflated responsibility has been hypothesized as an important influence on OCD symptoms. According to Salkovskis and colleagues (1999) there are in turn five developmental pathways that lead to inflated responsibility. Coles and Schofield (2008) proposed the Pathways to Responsibility Beliefs Scale (PIRBS) as a measure of these pathways. Method: In the present study the psychometric properties of an Icelandic translation of the PIRBS were evaluated and its factor structure was studied in a confirmatory factor analysis. Further it was tested whether responsibility mediated between pathways to responsibility beliefs and OCD symptoms. Results: While neither a four nor a five-factor structure of the PIRBS was found to be wholly satisfactory; support for the latter was slightly better. Correlations of the PIRBS scales with measures of responsibility and obsessive-compulsive disorder symptoms were moderate as expected. Support was found for a mediating role of responsibility attitudes between pathways measured by the PIRBS and OCD symptoms in support of Salkovskis and colleagues' theory (1999). Conclusion: The PIRBS is a promising approach to study the developmental precursors of inflated responsibility and OCD symptoms but its factor structure may need a revision

Background: The exact link between the process engaged in during Motivational Interviewing based interventions, such as Motivational Enhancement Therapy (MET), and outcome is yet to be fully understood. Aims: This preliminary study examined Client Language during MET and outcome. Method: A modified Motivational Interviewing Skills Code Version 2.0 was used to code 106 audiotaped MET sessions from 28 participants who received 3–4 sessions of MET within the context of a randomized controlled trial for mild-moderate alcohol dependence. Client Language was analyzed within sessions (categorized into Early, Mid, or End Intervals) and across sessions, and in relation to six month drinking outcome (drinking within/over national drinking guidelines, i.e. Remitted/Unremitted Drinkers). Results: Unremitted Drinkers uttered a significantly higher frequency of Sustain Talk, lower Ability Language strength (over all MET and during End Intervals), and lower Commitment Language strength (during Session 2 and 4, and change over MET). Conclusions: Notwithstanding limitations, this exploratory study was unique in examining the strength of Client Language within and across sessions. It produced potentially valuable findings that warrant further investigation including supporting the clinical benefit of monitoring Client Language to predict outcome.

Background: An integrative cognitive model proposed that ascribing extreme personal appraisals to changes in internal state is key to the development of the symptoms of bipolar disorder. The Hypomanic Attitudes and Positive Predictions Inventory (HAPPI) was developed to measure these appraisals. Aims: The aim of the current study was to validate an expanded 61-item version of the HAPPI. Method: In a largely female student sample (N = 134), principal components analysis (PCA) was performed on the HAPPI. Associations between the HAPPI and analogue bipolar symptoms after 3 months were examined. Results: PCA of the HAPPI revealed six categories of belief: Self Activation, Self-and-Other Critical, Catastrophic, Extreme Appraisals of Social Approval, Appraisals of Extreme Agitation, and Loss of Control. The HAPPI predicted all analogue measures of hypomanic symptoms after 3 months when controlling for baseline symptoms. In a more stringent test incorporating other psychological measures, the HAPPI was independently associated only with activation (e.g. thoughts racing) at 3 months. Dependent dysfunctional attitudes predicted greater conflict (e.g. irritability), depression and reduced well-being, hypomanic personality predicted self-reported diagnostic bipolar symptoms, and behavioural dysregulation predicted depression. Conclusions: Extreme beliefs about internal states show a modest independent association with prospective analogue bipolar symptoms, alongside other psychological factors. Further work will be required to improve the factor structure of the HAPPI and study its validity in clinical samples.

Background: Researchers in clinical trials usually pay close attention to therapist selection, training, supervision and monitoring, but the extent of this input has not been systematically documented. Aims: To describe the extent of training and supervision activity within clinical trials, and to consider any implications for transporting therapies from research to routine clinical contexts. Method: Twenty-seven randomized studies examining the efficacy of CBT interventions for people with depression or anxiety disorders were selected on the basis of their quality and impact on the field. Published and unpublished sources were used to gather information about therapist selection, training and supervision within these trials. Results: The review identified the extent of investment by researchers in assuring therapist expertise, adherence and competence. It also indicated inconsistencies in the clarity with which this input was reported. Conclusions: The ubiquity of intervention-specific training in research contexts risks being overlooked when commissioning evidence-based therapies in routine practice. This has clear implications for the likely effectiveness of interventions. Greater consistency in the reporting of training in clinical trials may help to draw attention to the role of training and supervision in maximizing clinical outcomes.

Background: Obsessive compulsive disorder (OCD) is a chronic and disabling disorder. It profoundly compromises various aspects of patients’ everyday life, thus affecting their quality of life (QoL). Using generic instruments, several studies have confirmed severely impaired health-related QoL in patients diagnosed with OCD. However, there has been a dearth of research on illness-specific QoL. Aims: The present study aimed to further investigate subjective QoL in individuals with OCD with a focus on illness-specific aspects. Method: To assess subjective QoL in a broad OCD sample, an internet survey was conducted with 123 participants with obsessive-compulsive symptoms. The survey comprised both a generic (WHOQOL-BREF) and a novel self-developed OCD-specific QoL measure (QoLOC). Psychopathology was determined with diagnostic standard instruments (self-report forms of: Y-BOCS, OCI-R, BDI-SF). Results: Regression analyses confirmed depression as the best predictor for decreased QoL. In addition, participants reported high despair resulting from OCD-related problems that differed across symptom subtypes. An exploratory factor analysis suggested four domains of OCD-specific problems tapped by the QoLOC: (1) depressiveness in association with OCD; (2) constraints in activities due to OCD symptoms or avoidance; (3) problems with partner and/or family due to OCD symptoms or avoidance; (4) self-concept/coping of own illness. Conclusions: Results produced a comprehensive picture of QoL impairments and their relation to psychopathology in a representative OCD sample. Illness-specific concerns should be further addressed in QoL research in OCD because such problems are not sufficiently mirrored in generic QoL measures.

Background: The value of defining subtypes in obsessive compulsive disorder (OCD) has become an important issue for recent debate. Probably the most robust example of subtyping is the identification of hoarding as being different both in terms of psychopathology and response to treatment. Aims: To identify differences in psychopathology and treatment response in OCD patients with and without additional hoarding symptoms. Method: Patients who had undertaken CBT for OCD were selected as falling into either a high or a low hoarding group. The high hoarding group (n = 18) was selected on the basis of a high score on the hoarding subscale of a self-report measure of OCD symptoms in addition to reaching clinician judged “threshold” on the hoarding item of the Obsessive Compulsive Personality Disorder (OCPD) SCID-II module. The low hoarding group (n = 20) was selected on the basis of a low score on the hoarding subscale and a clinician judgement that the hoarding item of the OCPD SCID-II module was “absent”. Results: On some measures of pre-treatment psychopathology, patients with OCD with hoarding symptoms were more severely affected than those without hoarding symptoms. It was found that there was no difference in eventual treatment outcome between the two groups, although there was some evidence that the hoarding group showed greater symptom decreases. Conclusions: The presence of hoarding symptoms does not negatively impact on the treatment of OCD.

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

Background: Research has begun to examine the effectiveness of computerized cognitive behaviour therapy (cCBT) with children and adolescents. Although cCBT appears promising, the attitudes of clinicians towards this type of intervention with children and young people have not been assessed, yet these are important in determining when and if cCBT will be offered. Aims: To survey clinicians’ attitudes towards cCBT with children and adolescents. Method: A self-report questionnaire was completed by 43 mental health professionals attending a conference. Results: Clinicians were cautious but generally positive about the use of cCBT with children and adolescents, particularly for the delivery of prevention programmes and in the treatment of mild/moderate problems. Few felt that cCBT should be available freely online without any professional support. Indeed, the lack of a therapeutic relationship and professional support were identified as the biggest problems, whilst the potential to use cCBT at home was the greatest advantage identified. Conclusions: This survey suggests that clinicians are generally positive about the use of cCBT with children and adolescents for the prevention and treatment of mild/moderate problems. Further research is required to address clinicians’ concerns about the effectiveness of cCBT for more substantial problems and the level of therapeutic support required.

Background: Mindfulness-based Cognitive Therapy (MBCT) is a relapse prevention treatment for major depressive disorder. Method: An observational clinical audit of 39 participants explored the long-term effects of MBCT using standardized measures of depression (BDI-II), rumination (RSS), and mindfulness (MAAS). Results: MBCT was associated with statistically significant reductions in depression from pre to post treatment. Gains were maintained over time (Group 1, 1–12 months, p = .002; Group 2, 13–24 months, p = .001; Group 3, 25–34 months, p = .04). Depression scores in Group 3 did begin to worsen, yet were still within the mild range of the BDI-II. Treatment variables such as attendance at “booster” sessions and ongoing mindfulness practice correlated with better depression outcomes (p = .003 and p = .03 respectively). There was a strong negative correlation between rumination and mindful attention (p < .001), consistent with a proposed mechanism of metacognition in the efficacy of MBCT. Conclusion: It is suggested that ongoing MBCT skills and practice may be important for relapse prevention over the longer term. Larger randomized studies of the mechanisms of MBCT with longer follow-up periods are recommended.

Background: Theories of the development of psychotic symptoms have suggested that metacognitive beliefs might play a part. However, studies offering supporting evidence have failed to distinguish between metacognitive beliefs about the consequences of having certain thoughts, and metacognitive beliefs about one's own cognitive skills. Aims: To distinguish metacognitive beliefs and investigate the extent of their association with psychotic-like experiences. Method: Participants were 60 healthy adults recruited primarily from two university campuses. Three measures of metacognition were administered: (i) Metacognitions Questionnaire (MCQ-30); (ii) Metacognitive Assessment Inventory; and (iii) Koriat General Questions Test; and two schizotypy questionnaires: O-Life and SPQ-B and data were analysed using an exploratory principal components analysis of the metacognition measures. Results: Three principal components were identified: (i) Beliefs about thoughts; (ii) Cognitive confidence; and (iii) Beliefs about cognitive regulation. Only the “beliefs about thoughts” component was significantly associated with the “psychotic-like experiences” factor, extracted from the measures of schizotypy. Conclusions: The finding supports theories suggesting that psychotic symptoms may be caused in part by negative metacognitive beliefs about thoughts. However, metacognition is a complex construct that is currently poorly understood.

Background: This study presents a new questionnaire to assess schema modes: the Schema Mode Inventory (SMI). Method: First, the construction of the short SMI (118 items) was described. Second, the psychometric properties of this short SMI were assessed. More specifically, its factor structure, internal reliability, inter-correlations between the subscales, test-retest reliability and monotonically increase of the modes were tested. This was done in a sample of N = 863 non-patients, Axis I and Axis II patients. Results: Results indicated a 14-factor structure of the short SMI, acceptable internal consistencies of the 14 subscales (Cronbach α's from .79 to .96), adequate test-retest reliability and moderate construct validity. Certain modes were predicted by a combination of the severity of Axis I and II disorders, while other modes were mainly predicted by Axis II pathology. Conclusions: The psychometric results indicate that the short SMI is a valuable measure that can be of use for mode assessment in SFT.

Background: Cognitive behavioural models of anxiety disorders often include visual representations of feedback loops that maintain the disorder. Cognitive therapy for depression is the prototype for therapy for many other disorders, and there is now good evidence for factors that maintain depression, yet there is still no accepted diagrammatic form of the maintenance model. Aims: To develop a simple, clinically acceptable and empirically based version of the “vicious flower” for depression. Method: Current theoretical developments in depression (Differential activation and Beck's concept of modes) and empirical findings on maintenance factors were reviewed. A model was developed based on clinical utility and current knowledge of the processes and maintenance factors in depression. This model was tested for its usefulness with a small sample of IAPT trainees. Results: The model contained 6 cycles comprising 2 cognitive cycles (automatic negative thinking and rumination/self-attacking), 2 behavioural cycles (withdrawal/avoidance and unhelpful behaviour), a mood/emotion cycle, and a motivation/physical symptoms cycle. Students found it a very useful tool for understanding maintenance factors. Conclusions: This diagrammatic maintenance model of depression, like similar “vicious flowers” for anxiety, may be helpful in conceptualization, socialization and treatment planning as well as teaching CBT.

Background: The effectiveness of cognitive-behaviour therapy with young people may be influenced by a young person's capacity for self-reflection and insight. Clinicians who assess clients' proficiencies in these cognitive capacities can better tailor cognitive and behavioural techniques to the client, facilitating engagement and enhancing treatment outcome. It is therefore important that sound instruments for assessing self-reflection and insight in young people are available. Aims: The aim of the current study was to translate and adapt the Self-Reflection and Insight Scale (SRIS) for use with a child and adolescent population (Study 1), and to evaluate the psychometric properties of the resulting measure, the Self-Reflection and Insight Scale for Youth (SRIS-Y; Study 2). Method: In Study 1 (n = 145), the comprehensibility of the SRIS-Y was assessed in a community sample of children and adolescents. Study 2 (n = 215) then explored the reliability and structural, convergent, and divergent validity of the SRIS-Y. Results: The SRIS-Y was found to be comprehensible to young people, and had good reliability and structural validity. Conclusions: It appears that the SRIS-Y is a sound instrument for assessing therapy-relevant cognitive capacities in young people, of potential benefit in both research and clinical contexts. Future research foci include the predictive validity of the instrument.