Hospitalized older adults with dementia often have few opportunities for social interaction and psychological stimulation. Their psychological functioning is affected by the dementing illness, sensory impairment and the effects of living in an institutional environment. The adverse effects of sensory deprivation may be particularly relevant for this client group. Using a multiple single case design, we evaluated the effects of individual sensory stimulation sessions on four elderly patients with dementia. All were living on a hospital continuing care psychiatric ward. Detailed behavioural observations were made before, during and after sessions to assess patients’ responses. Adaptive functioning and wellbeing were also investigated. Results indicated that the intervention led to observable changes in levels of interaction, active looking and interest. The effects were transitory with the exception of active looking, which endured following the session. Adaptive behaviours also improved, though there was no change in wellbeing. The study indicates that sensory stimulation is a valuable therapeutic intervention with this client group.

The purpose of this study was to examine whether counselor adherence to Motivational Interviewing (MI) principles was associated with more productive within-session client behavior in a smoking cessation trial for African American smokers. For these analyses 89 baseline counseling sessions of the trial were audiotaped and coded using the Motivational Interviewing Skill Code (MISC). Counselor adherence indicators included a global subjective rating of MI adherence and the frequency of MI-consistent and MI-inconsistent counselor behaviors described in the MISC. Indicators of productive client behaviors included global subjective ratings of within-session client functioning and counselor-client interaction, as well as the frequency of statements by the client favorable toward changing behavior (“change talk”) and resistant regarding changing behavior (“resist-change talk”). Results provided support for the principles of MI. Counselor adherence indexed by both the global subjective rating and MI-consistent behavior frequency was significantly positively associated with global ratings of within-session client functioning and counselor-client interaction, as well as more change talk.

As a result of its expanding evidence base from randomized controlled trials, cognitive therapy is becoming increasingly widely practised in the treatment of many mental health problems. However, little is known about the extent to which it is carried out competently in practice, nor about what characteristics of therapists may be associated with competence. In therapists claiming to practice cognitive therapy, this study examined the relationship of a number of therapist factors, including training, profession, experience, supervision and accreditation, to competence. Therapists (n = 24) taped a mid-treatment cognitive therapy session. An independent rater, blind to information about the therapist, assessed the competence shown by the therapist during this session using the Cognitive Therapy Scale (CTS). Five randomly selected tapes were rated by a second rater and the inter-rater correlations were high. Although all therapists had received some cognitive therapy training during basic professional qualification, therapists with formal post-qualification training in cognitive therapy showed significantly higher levels of competence than those without. Psychologists were rated as more competent than therapists from other professions on one of the CTS subscales (Interpersonal Effectiveness). Number of years of experience, frequency of supervision, and accreditation were unrelated to ratings of competence. A number of accredited cognitive therapists scored well below a widely used criterion of competence.

Background: Computerized self-help that has an interactive, conversational format holds several advantages, such as flexibility across presenting problems and ease of use. We designed a new program called MYLO that utilizes the principles of Method of Levels (MOL) therapy - based upon Perceptual Control Theory (PCT). Aims: We tested the efficacy of MYLO, tested whether the psychological change mechanisms described by PCT mediated its efficacy, and evaluated effects of client expectancy. Method: Forty-eight student participants were randomly assigned to MYLO or a comparison program ELIZA. Participants discussed a problem they were currently experiencing with their assigned program and completed measures of distress, resolution and expectancy preintervention, postintervention and at 2-week follow-up. Results: MYLO and ELIZA were associated with reductions in distress, depression, anxiety and stress. MYLO was considered more helpful and led to greater problem resolution. The psychological change processes predicted higher ratings of MYLO's helpfulness and reductions in distress. Positive expectancies towards computer-based problem solving correlated with MYLO's perceived helpfulness and greater problem resolution, and this was partly mediated by the psychological change processes identified. Conclusions: The findings provide provisional support for the acceptability of the MYLO program in a non-clinical sample although its efficacy as an innovative computer-based aid to problem solving remains unclear. Nevertheless, the findings provide tentative early support for the mechanisms of psychological change identified within PCT and highlight the importance of client expectations on predicting engagement in computer-based self-help.

Thirty-seven (37) couples experiencing child behavior problems and concurrent marital conflict were randomly assigned to one of two variants of a group parent training program, either Standard Group Triple P (SGTP; n=19) or Enhanced Group Triple P (EGTP; n=18). SGTP incorporated 8 sessions (4 group sessions and 4 telephone consultations) and taught parents to identify the causes of child behaviour problems, promote children's development, manage misbehavior and plan ahead to prevent child behavior problems in “high risk” parenting situations. Families in the EGTP condition received SGTP plus 2 additional group sessions of parent support training that taught partners to support one another to parent as a team. These additional sessions included information and active skills training in communication skills; giving and receiving constructive feedback; holding casual conversations; supporting each other when problems occur; holding problem solving discussions; and improving relationship happiness. There were significant improvements from pre- to post-intervention for both conditions, on measures of disruptive child behavior, dysfunctional parenting style, conflict over parenting, relationship satisfaction and communication. No differences, however, were found between the two conditions, with both the EGTP and the SGTP programs resulting in similar outcomes. In the main, initial treatment effects for both mothers and fathers were maintained at 3-month follow-up.

Background: Cognitive Behaviour Therapy self-help has been recommended in the NICE guidelines for the treatment of anxiety and depression. However, little is known about who benefits from self-help and the potential drawbacks and problems of using this approach. Aims: To address the current gap in knowledge, we contacted accredited BABCP practitioners to examine practitioner use and attitudes to self-help, current trends of use, and to identify possible problems with this therapy. Method: A 50% random sample of all accredited BABCP practitioners was approached, and the overall response rate for the survey was 57.6%. Results: Self-help materials were seen positively by therapists and were used by 99.6%, mainly as an adjunct to individual therapy. Only 38.2% had been trained in the use of self-help, with those trained being more likely to recommend self-help. Higher levels of patient motivation, credibility, likely adherence, self-efficacy and a lower degree of hopelessness were the five factors identified by more than 70% of respondents as predicting successful patient outcome with self-help. Non-compliance and a lack of detection of a worsening of the patient's clinical state due to reduced therapist contact were viewed as being the most important problems with self-help by more than 70% of respondents. Conclusions: Preferable patient characteristics for self-help have been identified, as have potential problems and adverse consequences.

Background: Beliefs that it is unacceptable to experience or express negative emotions have been found to be associated with various clinical problems. It is unclear how such beliefs, which could be viewed as a form of unhelpful perfectionism about emotions, may contribute to symptomatology. Aims: This study investigated two hypotheses: a) greater endorsement of beliefs about the unacceptability of negative emotions will be associated with greater emotional avoidance and lower levels of support-seeking and self-compassion; b) these beliefs about emotions will be associated with higher levels of symptoms of depression, anxiety and fatigue and that this relationship will be mediated by social support-seeking, emotional avoidance and self-compassion. Method: Online questionnaires were completed by 451 community participants. Mediational analyses were undertaken to investigate emotional avoidance, social support-seeking and self-compassion as mediators of the relationship between beliefs about emotions and symptoms of depression, anxiety and fatigue. Results: Beliefs about the unacceptability of negative emotions were significantly associated with more emotional avoidance and less self-compassion and support-seeking. The relationships between beliefs about emotions and depression, anxiety and fatigue were significantly mediated by self-compassion and emotional avoidance but not social support-seeking. Conclusions: Future research should investigate whether interventions that pay particular attention to emotional avoidance and self-compassion, such as mindfulness-based therapy or modified forms of CBT, may be beneficial in reducing distress and fatigue associated with beliefs about the unacceptability of negative emotions.

The present study surveyed a sample of 116 Australian therapists who identified themselves as working primarily with traumatized clients. Outcome variables were measures of vicarious traumatization (VT), burnout and trauma symptomatology (intrusion and avoidance). A measure of beliefs about the therapeutic process was constructed for the present study and examined along with other predictor variables, namely years of experience as a therapist, percentage of time spent in clinical work with clients, predominant client group, and recent and direct exposure to trauma in the therapist. Therapist beliefs were found to predict vulnerability to VT and burnout, supporting a cognitive model of therapist distress. Implications of the findings for maintaining therapist health are discussed.

Background: Improving access to psychological therapies, and in particular cognitive behavioural therapy (CBT), has been a health service priority in England and Wales over the past decade. The delivery of CBT has been limited by a scarcity of resources and further limited by the inequitable geographic distribution of CBT therapists. Aims: The current study replicates and extends our previous analysis of the geography of British Association of Behavioural and Cognitive Psychotherapies (BABCP) membership (Shapiro, Cavanagh and Lomas, 2003) 10 years later in order to evaluate the progress made in improving equitable access to CBT. Method: This paper presents the absolute and comparative geographic distribution of current BABCP members, accredited CBT practitioners, and BABCP members who are nurses or clinical psychologists in England and Wales. Results: Efforts to improve the availability of CBT in England and Wales are reflected in the doubling of total membership, and a 4.5 fold increase in accredited membership over the last 10 years. There is evidence that the magnitude of inequity in the geographic availability of CBT therapists has decreased, but that inequity is still evident. Limitations of using BABCP membership data as a proxy measure of CBT availability are acknowledged. Conclusions: A five-fold discrepancy in accredited CBT practitioners between the best and least well-served population decile indicates ongoing “postcode availability” of the best qualified CBT practitioners. Possible strategies to improve the availability of CBT and remedy this inequity are discussed.

Exposure to a traumatic event may lead a person to experience posttraumatic stress. But there are wide individual differences in the severity and chronicity of reactions. Some people remain affected for considerable periods of time, but others are able to adjust relatively quickly, and some even go on to report experiencing positive personal changes as a result of experience of trauma. The psychosocial framework proposes that individual variation in response to trauma is attributable to the interaction between various personality and social psychological factors. This is a practical framework for formulation and for developing interventions with people who have problems adjusting to traumatic life experiences. In this paper we provide a retrospective account of the building of the psychosocial framework, and using case examples illustrate its use in formulation and developing intervention with individuals with varying difficulties. We also aim to look beyond this work in the past to subsequent developments and to future directions, in particular the new and emerging field of growth through adversity.

Background: Overestimation of threat (OET) is ascribed a pathogenetic role in obsessive-compulsive disorder (OCD). Aims: We hypothesized that OCD patients overestimate their personal but not the average risk for OCD-related events. Specifically, an attenuation of the common “unrealistic optimism” bias (UO) was expected for OCD patients. UO refers to the phenomenon that the subjective likelihood to personally experience a positive event is enhanced compared to other persons and vice versa for negative events. Method: Fifty-three participants with OCD as well as 40 healthy and 23 psychiatric controls participated in an internet survey. They were asked several questions about different event types (positive, negative, and OCD-related): the probability that this event will happen to oneself (block 1), to another person (block 2), comparison between oneself versus another person (block 3), appraisal of consequences (block 4), and prior encounters with event (block 5). Results: No evidence was obtained in OCD to overestimate the overall probability of negative or OCD-related events. However, whereas healthy participants displayed an UO bias, OCD participants perceived themselves as more vulnerable to experience OCD-related events. Conclusions: Results indicate that OCD is associated with inflated personal vulnerability and that this bias is not fully available to the consciousness of OCD participants.

Paradoxical Intention (PI) is a cognitive treatment approach for sleep-onset insomnia. It is thought to operate by eliminating voluntary sleep effort, thereby ameliorating sleep performance anxiety, an aroused state incompatible with sleep. However, this remains untested. Moreover, few PI studies have employed objective sleep measures. The present study therefore examined the effect of PI on sleep effort, sleep anxiety and both objective and subjective sleep. Following a seven-night baseline, 34 sleep-onset insomniacs were randomly allocated to 14 nights of PI, or to a control (no PI) condition. Consistent with the performance anxiety model, participants allocated to PI, relative to controls, showed a significant reduction in sleep effort, and sleep performance anxiety. Sleep-onset latency (SOL) differences between PI participants and controls using an objective sleep measure were not observed, although an underlying trend for significantly lowered subjective SOL amongst PI participants was demonstrated. This may relate to actigraphic insensitivity, or more probably confirms recent suggestions that insomniacs readily overestimate sleep deficit, due to excessive anxiety about sleep. Together, results help determine putative mechanisms underlying PI, have important implications for the clinical application of PI, and emphasize the need for further PI research within an experimental cognitive framework.

The relationship between effectiveness of interpersonal problem-solving and specificity of autobiographical memory was examined for 35 patients admitted to an inner-city District General Hospital following a deliberate drug-overdose. The results replicated those of Evans, Williams, O'Loughlin and Howells (1992) in finding a significant correlation between ineffective problem-solving and the over-general retrieval of autobiographical memories, giving further support to the suggestion that an over-general memory database may underpin the problem-solving deficits characteristic of parasuicide patients. However, the correlation coefficient computed was notably lower than in the Evans et al. study and an attempt is made to explain this discrepancy on the basis of differences in the levels of psychopathology between the patients involved in each study.

Primary school aged children with severe learning disabilities and behavioural problems were identified from those attending special needs schools in three adjacent Inner London boroughs. In two of the boroughs their parents/carers were randomly allocated to receive 5-7 group- or individually-based intervention sessions aimed at preventing or reducing their child's behaviour problems; teaching and support staff at their schools received a 2-day workshop with the same aims. Children in the third borough served as a “no treatment” control group. Follow-up assessments were carried out shortly after the interventions were completed and 6 months later. Individually-based intervention was superior to group-based intervention in acceptability, attendance, levels of participant satisfaction and the likelihood of reported behavioural improvement. Within the individual intervention group, behaviours that had been targeted for intervention were more likely to show improvements than those that were untargeted. However, in spite of these improvements, there were no significant differences between groups in the absolute frequency or severity of the child's behaviour problems at either post-intervention assessment, and reductions in levels of parental distress noted on completion of the interventions were no longer apparent 6 months later.

This paper describes the use of cognitive behaviour therapy (CBT) with 24 chronically depressed in-patients. These individuals had previously failed to respond to all other standard antidepressant treatments and had been persistently depressed for at least two years. The clients were divided into two cohorts. The first (n=8) received a standard CBT package of 15 sessions combined with pharmacotherapy. The second cohort received a combined treatment, but the style of delivery of CBT was changed to try to take into account the special needs of the client population. At 12 weeks, 70% of the second cohort of clients showed a greater than 50% change on their pre-treatment objective and subjective depression ratings. The implications of these findings are discussed and further therapy trials in this difficult-to-treat population are encouraged.

A novel cognitive technique, termed “association splitting”, aimed at reducing obsessive thoughts, is introduced. Association splitting draws upon the so-called “fan effect” of associative priming. Transposing this principle to the treatment of obsessive-compulsive disorder (OCD), we hypothesize that the sprouting of new and the strengthening of existing neutral associations to core OCD cognitions will reduce their fear-evoking properties by depriving the chain of OCD-related cognitions of associative strength. To test the feasibility and efficacy of this approach, an internet intervention study was implemented. Initially, 38 subjects with OCD obsessions took part in a survey. After completion of the survey they were then sent a self-help manual. Three weeks later, participants were re-contacted. One-third of the participants responded to the treatment (at least 35% decline on the Y-BOCS scale). The completer analysis revealed a response rate of 42%. It is suggested that association splitting may lead to symptom relief in a subgroup of participants and may represent a useful addition to the tool box of cognitive-behavioural techniques.

A measure of everyday risk-taking, the Everyday Risk Inventory (ERI), was developed to assess avoidance of potentially harmful ordinary activities, and some of its psychometric properties were studied. The hypothesis that outpatients with obsessive compulsive disorder (OCD) would score lower than non-patients on this and other measures of risk-taking was tested. The ERI showed good internal consistency and excellent test-retest reliability. It successfully differentiated OCD patients from non-clinical subjects. Consistent with research on sensation seeking, both age and gender were related to ERI scores, with older subjects and females showing greater risk avoidance. The ERI correlated moderately strongly with other measures of risk-taking and showed, as expected, a less strong negative association with measures of responsibility and value orthodoxy. Preliminary findings indicate that the ERI is a useful instrument for assessing non-pleasurable ordinary risk-taking. Findings are discussed in relation to possible dimensions of risk-taking in existing research on decision-making and the need for research on other patient populations.

Background: To date no research has investigated the link between Post Traumatic Stress Disorder (PTSD) and perfectionism in a clinical sample. Aims: The aim of the current study was to examine whether there is a relationship between PTSD and perfectionism. This is important to address as many studies have demonstrated a link between other anxiety disorders, eating disorders, depression and perfectionism. The research also aimed to examine whether rumination was a mediator of the relationship between PTSD and perfectionism. Method: The sample consisted of 30 participants who were currently in treatment for PTSD. Results: The results suggest that perfectionism and PTSD symptoms were significantly correlated. In addition, rumination was a significant mediator of the relationship between Concern over Mistakes and PTSD. Conclusions: These findings help increase understanding about the relationships of perfectionism and rumination in PTSD and have implications for the treatment of PTSD.

One- and two-year cognitive therapy training programs are increasingly popular in the UK and overseas. Previous research has indicated that trainees show gains in competence, though this may at times be accompanied by self-doubt and stress. The present study sought specifically to gain the trainees' perspective: What happens to self-perception of competence (SPC) during cognitive therapy training – does it change over time? Do all elements of cognitive therapy skill show the same changes in SPC? Do individuals show different patterns of change? What environmental and internal factors influence changes in SPC? Twenty-four trainees on a one-year part-time training course completed a self-rated assessment of competence at six time points during the course. They also reported attributions about experiences that might have contributed to increases or decreases in SPC. Results demonstrated that SPC increases significantly over time, but there is considerable variation across different skills, and between individuals. A model developed from trainees' qualitative data indicated that the prime influences on SPC were new learning opportunities (acquiring knowledge, implementing knowledge, external evaluation, experiences with clients), self-reflection on performance, increased awareness of the standards required of a cognitive therapist, and emotional state, in particular emotionally salient memories and current stress. Practical implications of the findings for trainees, trainers and supervisors are discussed.