Background: CBT case conceptualization is considered to be a key competency. Prior to the publication in 2009 of Kuyken, Padesky and Dudley's book, little has been documented concerning methods for training conceptualization skills and the conceptualization process is usually perceived as predominantly an intellectual process. In this paper, the Declarative-Procedural-Reflective model of therapist skill acquisition provides a route to understanding how different kinds of knowledge systems can be integrated to enhance therapist skill acquisition. Method: Sixteen recent graduates of a postgraduate diploma in cognitive behaviour therapy worked independently through a self-practice/self-reflection workbook designed to lead them through a series of CBT interventions commonly used to elicit the information required for a CBT conceptualization. Results: The participants’ self-reflections were thematically analyzed and uncovered the following inter-related themes: increased theoretical understanding of the CBT model, self-awareness, empathy, conceptualization of the therapeutic relationship, and adaptation of clinical interventions and practice. Conclusions: A tentative conclusion reached, based on the self-reflections of the participants, was that targeted self-practice/self-reflection enhanced case conceptualization skill by consolidating the Declarative, Procedural and Reflective systems important in therapist skill acquisition.

Background: In contrast to a wealth of research on the treatment of Obsessive Compulsive Disorder (OCD), there is a relative paucity of work examining how OCD begins. Available data suggest that there is often a slow progression from the onset of symptoms to meeting criteria for a diagnosis of OCD. Aims: The current study sought to add to existing data documenting the slow-development of OCD, and to extend previous findings by examining potential moderators of this symptom phase and to examine patients’ explanations for the transition from symptoms to disorder. Method: One hundred and ninety-nine individuals with OCD reported on the start of their symptoms and the disorder via an internet-based survey. Results: Over two-thirds of respondents reported that the development of their OCD was gradual. Further, participants reported having experienced obsessions and/or compulsions for an average of 5 years before experiencing full-blown OCD. This extended symptom phase was observed in individuals with early- and late-onset OCD, with an even more protracted symptom phase in the later group. Female gender and onset of compulsions prior to obsessions were also associated with slower progression to full-blown OCD. Finally, explanations for the transition from symptoms to disorder suggest that changes in daily routines and general stress may be particularly important in this transition for individuals that develop clinical OCD at age 18 or later. Conclusions: Existence of a protracted symptom phase may present opportunities for elucidating risk factors for OCD disease progression and a window of opportunity for indicated prevention programs.

Background: Research has clearly established the efficacy of pharmacotherapy and cognitive behaviour therapy (CBT) for depression. There is less literature addressing cessation of treatment, such as relapse during withdrawal from antidepressant medication. Aims: The current study examines the role of psychological constructs that may influence relapse or fear of relapse and lead to resumption of medication. This hypothesizes that during withdrawal individuals may misinterpret normal variations in mood and dysphoric or other symptoms as reduced levels of medication in their bodies in keeping with a simplistic rationale for antidepressants. Method: The study uses an intensive single case AB style design in three cases during the withdrawal process. All participants had been treated with CBT plus antidepressants and had previously attempted to withdraw from antidepressants. The first part of the study naturalistically tracks belief changes as medication decreases; the second examines changes in these if/when a CBT intervention is introduced due to relapse or potential near-relapse. Daily self-monitoring diaries were used to measure target variables, together with standardized questionnaires up to 6 months follow-up. Results: Changes in symptoms, appraisal of symptoms, and beliefs about medication changed throughout the study. All participants remained medication free at 6 months follow-up. Two cases received CBT intervention due to possible relapse; the third underwent an unproblematic withdrawal. Conclusions: Patterns of change are discussed in terms of current approaches to medication cessation and the role of CBT during withdrawal.

Background: Many patients who experience bulimia nervosa (BN) and binge eating disorder (BED) find it hard to access evidence-based treatments. Rates of failure to enter outpatient services following initial assessment are high, as are dropout rates from specialist outpatient eating disorders services. Aims: To offer CD-Rom CBT, a cognitive-behavioural multi-media supported self-help treatment, in a locality-based outpatient NHS Eating Disorders Service to patients who have binge eating disorder and bulimia nervosa. Method: Patients referred to a catchment-based NHS outpatient eating disorders service who were assessed and had an eating disorder with a binge-eating component were offered CD-Rom based CBT (Overcoming Bulimia) whilst on the waiting list for individual CBT. Results: Forty patients completed the 8 sessions and attended the evaluation appointment (13 had BN, 27 had BED). For both groups, there were significant improvements in well-being and functioning, as well as significant reductions in problems and risk. There was also a significant reduction on the “Bulimic Subscale” of the EDI. These results were comparable with the original study findings (Schmidt, Treasure and Williams, 2001). Dropouts from the CD-Rom reflected rates common to other EDS treatments suggesting that CD-Rom did not directly impact upon service dropout rates. Conclusions: Computer assisted CBT for Eating Disorders offers a promising, feasible and acceptable first step for patients who have bulimia nervosa or binge eating disorder and access treatment from specialist eating disorders services.

Background: Recent interest in the role of vulnerability factors in obsessional washing has suggested that disgust sensitivity, danger expectancy and health anxiety may be of interest. Aims: This study explores the differential impact of these factors on both behavioural and cognitive measures of washing behaviour and is based on a replication of the Jones and Menzies (1997) experiment, during which participants immersed their hands in a noxious compound while rating themselves on a range of measures: the time they subsequently took to wash their hands was measured and danger expectancies were found to be the best predictor of this. Method: The present study added measures of disgust sensitivity and health anxiety to this experimental methodology while removing factors they found to be of little import to compulsive washing. Thirty non-clinical participants took part. Results: Results confirmed that disgust sensitivity was related to the behavioural measure of washing time, but that this relationship was almost entirely mediated by the danger expectancy concerning judgements of severity of consequent disease. However, a different pattern emerged when the outcome measure was questionnaire based: danger expectancy was not at all related to this. Disgust sensitivity mediated the relationship between health anxiety and scores on a questionnaire measure of washing compulsions. Interestingly, these scores were not related to the behavioural measure of washing time. Conclusions: The implications of these relationships to the further development of subtypes of Obsessive Compulsive Disorder (OCD) are discussed.

Background: Comprehensive cognitive theories of obsessive compulsive disorder (OCD) propose that clinical obsessions and compulsions arise from specific sorts of dysfunctional beliefs and appraisals, such as inflated sense of responsibility, thought-action fusion (TAF), and thought suppression. Aims: The present study aimed to examine the mediator roles of responsibility and thought suppression between TAF and obsessive-compulsive symptoms. Specifically, it aimed to explore the relative effects of TAF factors (i.e. morality and likelihood) on inflated sense of responsibility and on thought suppression to increase the obsessive qualities of intrusions. Method: Two hundred and eighty-three Turkish undergraduate students completed a battery of measures on responsibility, thought suppression, TAF, OC symptoms, and depression. Results: A series of hierarchical regression analyses, where depressive symptoms were controlled for, indicated that TAF-morality and TAF-likelihood follow different paths toward OC symptoms. Although TAF-morality associated with inflated sense of responsibility, TAF-likelihood associated with thought suppression efforts, and in turn these factors increased OC symptoms. Conclusions: These findings provide support for the critical role of sense of responsibility and thought suppression between the relationship of TAF and OC symptoms. Findings were discussed in line with the literature.

Background: Biases in the interpretation of ambiguous material are central to cognitive models of anxiety; however, understanding of the association between interpretation and anxiety in childhood is limited. To address this, a prospective investigation of the stability and specificity of anxious cognitions and anxiety and the relationship between these factors was conducted. Method: Sixty-five children (10–11 years) from a community sample completed measures of self-reported anxiety, depression, and conduct problems, and responded to ambiguous stories at three time points over one-year. Results: Individual differences in biases in interpretation of ambiguity (specifically “anticipated distress” and “threat interpretation”) were stable over time. Furthermore, anticipated distress and threat interpretation were specifically associated with anxiety symptoms. Distress anticipation predicted change in anxiety symptoms over time. In contrast, anxiety scores predicted change in threat interpretation over time. Conclusions: The results suggest that different cognitive constructs may show different longitudinal links with anxiety. These preliminary findings extend research and theory on anxious cognitions and their link with anxiety in children, and suggest that these cognitive processes may be valuable targets for assessment and intervention.

Background: The relationship between Eating Disorders (ED) and Obsessive Compulsive Disorder (OCD) has been extensively studied in the last few years. However, little effort has been devoted to studying the link between these disorders with regard to their distorted beliefs. Aims: The first objective of the study was to analyze the differences in OCD-related beliefs among ED subtypes and the general population, controlling for age, Body Mass Index, and obsessionality. The second objective was to explore which OCD beliefs explain ED symptomatology. Method: Seventy-nine ED patients without OCD comorbidity, divided into diagnostic subtypes, and 50 community participants completed the Obsessive Beliefs Spanish Inventory-Revised and measures of ED and OCD symptomatology. Results: There were no differences found among clinical ED subtypes in obsessive beliefs, but the bulimia nervosa purgative subtype and binge eating groups obtained significantly different scores from the community group on Thought-Action-Fusion (TAF)-likelihood and TAF-moral, respectively. OCD symptomatology had the most important predictive effect on ED symptoms, followed by Overestimation of Threat, BMI and FPA-moral. Conclusions: The different patterns of beliefs among subtypes reflect what other studies have suggested about the relevance of the presentation of ED symptoms associated with restriction, purges and binge without purges. Our results agree with the transdiagnostic perspective of ED.

Background: Eating disturbances and poor body image are maintained by body-related safety behaviours and their associated cognitions. These include body checking, avoidance, comparison and display, which can be seen as safety behaviours, maintaining eating pathology and poor body image. It is not clear from the existing literature whether these behavioural and cognitive patterns are independently related to eating psychopathology. Method: This study of a non-clinical group of women and men (N = 250) explored the association of eating attitudes and behaviours with these four elements of body-related behaviours and cognitions. Results: It was found that each of the four elements had independent associations with eating attitudes and behaviours. Those associations were not explained by anxiety or depression levels. Discussion: Whilst these findings require study within a clinical group, they suggest that all four elements of body-related behaviours and cognitions need to be considered as potential maintaining factors when formulating eating psychopathology and body image disturbance.

Background: Social anxiety is a common problem among people who are recovering from psychosis. At present there is no evidence based psychological treatment targeting social anxiety in this population. Cognitive Bias Modification for Interpretation (CBM-I) has been shown to be effective in reducing social anxiety in people who do not have a history of psychosis. Aims: To assess the feasibility and acceptability of the CBM-I methodology for use in a clinical setting with people who are experiencing social anxiety following an episode of psychosis. Method: Eight participants with social anxiety were recruited from an early intervention service. A single session of computerized CBM-I was conducted, with mood and cognitive interpretation bias being assessed before and after the session. Results: All participants reported an improvement in mood immediately following the CBM-I session (n = 8). For those participants who had a negative interpretation bias, none became more negative following the CBM-I session, with three out of six participants showing a beneficial change. Conclusion: These results suggest that CBM-I is acceptable for use with people who are experiencing social anxiety following a psychotic episode. Further research looking at how CBM-I could be made more interactive and producing more applicable scenarios for use in a clinical setting is recommended.

Background: Quality of attachment relations between adolescents and their parents and peers may be related to early maladaptive schemas as well as to symptoms of depression. Aims: The aim of the current study was to assess whether schema domains and maladaptive schemas mediate the relation between indices of quality of attachment relationships with parents and peers and symptoms of depression in non-clinical adolescents (N = 222). Method: A battery of questionnaires was completed, including measures of quality of attachment relations, maladaptive schemas, and depression. Results: The schema domains of disconnection and rejection and other-directedness mediated the relation between quality of attachment relationships and symptoms of depression. More precisely, the schemas’ mistrust/abuse and social isolation mediated the relation between trust in parents and depressive symptoms, whereas the schemas’ social isolation and self-sacrifice mediated the relation between alienation from peers and symptoms of depression. Conclusions: The mediation analyses suggest that treatment of adolescent depression could be focused on both attachment bonds and on changing maladaptive schemas.

Background: Recent advances have been made in the application of cognitive training strategies as interventions for mental disorders. One novel approach, cognitive control training (CCT), uses computer-based exercises to chronically increase prefrontal cortex recruitment. Activation of prefrontal control mechanisms have specifically been identified with attenuation of emotional responses. However, it is unclear whether recruitment of prefrontal resources alone is operative in this regard, or whether prefrontal control is important only in the role of explicit emotion regulation. This study examined whether exposure to cognitive tasks before an emotional challenge attenuated the effects of the emotional challenge. Aims: We investigated whether a single training session could alter participants' reactivity to subsequent emotional stimuli on two computer-based tasks as well as affect ratings made during the study. We hypothesized that individuals performing the Cognitive Control (CC) task as compared to those performing the Peripheral Vision (PV) comparison task would (1) report reduced negative affect following the mood induction and the emotion task, and (2) exhibit reduced reactivity (defined by lower affective ratings) to negative stimuli during both the reactivity and recovery phases of the emotion task and (3) show a reduced bias towards threatening information. Method: Fifty-nine healthy participants were randomized to complete CC tasks or PV, underwent a negative mood induction, and then made valence and arousal ratings for IAPS images, and completed an assessment of attentional bias. Results: Results indicated that a single-session of CC did not consistently alter participants' responses to either task. However, performance on the CC tasks was correlated on subsequent ratings of emotional images. Conclusions: While overall these results do not support the idea that affective responding is altered by making healthy volunteers use their prefrontal cortex before the affective task, they are discussed in the context of study design issues and future research directions.

Background: Depression is common in those with MS. The hopelessness theory of depression, emphasizing the role of attributional style, is supported in this population. Cognitive behaviour therapy (CBT) that can affect attributional style can reduce depression in people who have MS. Aims: The present study aimed to consider whether changing attributional style would reduce depression in two people with MS, thereby supporting the importance of this component of CBT with this population. Method: Two female participants with MS were offered a 5-session intervention designed to alter attributional style. The study followed an ABA design. Attributional style and depressive symptoms were the principal measures considered. Negative life events and MS related stresses were also monitored. Results: The intervention appeared effective for one of the participants, with predicted changes in attributional style and sizeable reductions in depressive symptoms from pre- to post-treatment that were sustained at 3-month follow-up. Improvement was still evident at 6 months, although with some reduction of effect. The intervention was less successful for the other participant who declined further treatment after three sessions. Conclusions: Some support for the hopelessness theory of depression was found, indicating its relevance to CBT interventions for those who have MS and depression.

Background: A self-verification model of social anxiety views negative social self-esteem as a core feature of social anxiety. This core feature is proposed to be maintained through self-verification processes, such as by leading individuals with negative social self-esteem to prefer negative social feedback. This model is tested in two studies. Methods: In Study 1, questionnaires were administered to a college sample (N = 317). In Study 2, questionnaires were administered to anxiety disordered patients (N = 62) before and after treatment. Results: Study 1 developed measures of preference for negative social feedback and social self-esteem, and provided evidence of their incremental validity in a college sample. Study 2 found that these two variables are not strongly related to fears of evaluation, are relatively unaffected by a treatment that targets such fears, and predict residual social anxiety following treatment. Conclusions: Overall, these studies provide preliminary evidence for a self-verification model of social anxiety.

Background: There is emerging evidence that mindfulness groups for people with distressing psychosis are safe and therapeutic. Aims: The present study aimed to investigate the feasibility of running and evaluating a mindfulness group on an inpatient ward for individuals with chronic and treatment resistant psychosis. Method: Eight participants attended a 6-week mindfulness group on a specialist tertiary inpatient ward. Results: This study demonstrated that mindfulness exercises were acceptable and well-tolerated by participants. Measuring outcome, systemic challenges and participant experience are discussed.

Background: Inflated responsibility is the main feature of cognitive-behavioural models of obsessive-compulsive disorder (OCD). However, few studies have examined the effect of cognitive-behavioural group therapy (CBGT) on inflated responsibility. Aim: The aim of this study was to examine the effect of CBGT on OCD symptoms and responsibility beliefs. Methods: Thirty-six subjects meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for OCD were recruited to CBGT, and 28 of them completed 12 sessions. Subjects were assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Responsibility Attitude Scale (RAS), and the Responsibility Interpretations Questionnaire (RIQ) at pre- and post-treatment. Results: Y-BOCS, RAS and RIQ (belief) scores were significantly improved at the end of the treatment. Conclusion: This study indicates that CBGT improves not only obsessive-compulsive symptoms but also inflated responsibility beliefs in patients with OCD.

Background: Manualized cognitive-behavioural therapy (MCBT) approaches to treating adolescent anxiety and depression have been shown to be effective in recent years, as have MCBT for adult self-harm (SH). Aims: This paper describes the rationale for, development and pilot evaluation of the efficacy of a novel manualized CBT package for adolescent self-harm (SH). It also addresses the acceptability of this treatment package to therapists and patients. Method: Twenty-five adolescents (aged 12–18 years) presenting to a Community Child and Adolescent Mental Health Service (CAMHS) in Greater London with SH behaviour began the “Cutting Down” programme and 16 (64%) completed the treatment. Outcomes were assessed at baseline, at the end of treatment and at 3 month follow up. Results: Significant reductions in self-harm behaviour, depression symptoms and trait anxiety were reported. There was no change in state anxiety or in levels of parental expressed emotion as perceived by the adolescent. Conclusion: These pilot findings provide preliminary support for the efficacy and acceptability of this time-limited CBT package for adolescents who self-harm.

Background and Method: This naturalistic study was undertaken in routine settings and compared the clinical effectiveness, costs, treatment preference, attrition and patient satisfaction of Group and Individual CBT. Results: No significant differences were found in depressive and distress symptoms between group and individual CBT at post-treatment and follow-up. Individual CBT was 1.5 times more expensive to provide than Group CBT and the wider costs of other supports were similar between study arms suggesting a cost-effectiveness advantage for Group CBT. Patients preferred individual treatment at baseline but, despite this, there were no between-group differences in attrition or satisfaction. Conclusion: A larger RCT study is needed, but running CBT groups for depression could be considered more frequently by clinicians.

Background: Therapeutic alliance has been found to be a significant predictor of outcome in psychotherapy yet what constitutes therapeutic alliance remains unclear. Examining the common constructs of therapeutic alliance, it is possible that there may be a conceptual overlap between active components of therapeutic alliance and socialization to the treatment model. Aim: To investigate the relationship between socialization to the model and therapeutic alliance. Method: Participants (N = 43) were taken from the active treatment arm in a RCT for the treatment of chronic fatigue syndrome (CFS/ME). Therapeutic alliance was measured using a 5-item questionnaire (brief CALPAS) and socialization to the model was extracted from therapy tapes using a novel coding system. Results: Key findings were that when patients and therapists agreed about goals of treatment, there were higher levels of concordance, less evidence of applying principles incongruent to the model, and less resistance during the treatment sessions. Conclusions: The outcome of this preliminary study contributes to the potential understanding of active components in the therapeutic alliance, and supports further research to achieve a more detailed picture of “non-specific” factors in therapy, including the active process of socialization in therapeutic alliance.