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.

Obsessive-compulsive hoarding can be viewed within personality, neuroethological and cognitive-behavioural frameworks. Three cases of obsessive-compulsive hoarding are described in detail. All cases had some insight (albeit fluctuating) into their problem and were seeking treatment. There was evidence of abnormal risk assessment, fear of criticism, excessive guilt, overconscientiousness and inflated responsibility. Depression, emotional or material deprivation and significant loss during childhood and adolescence were experienced by all cases. The cases are considered to be consistent with a cognitive-behavioural model of obsessive-compulsive disorder emphasizing the importance of learning and cognition. Implications for treatment are discussed.

Background: Two ‘sibling’ disorders have been proposed for the fourthcoming 11th version of the International Classification of Diseases (ICD-11): post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD). Examining psychological factors that may be associated with CPTSD, such as self-compassion, is an important first step in its treatment that can inform consideration of which problems are most salient and what interventions are most relevant. Aims: We set out to investigate the association between self-compassion and the two factors of CPTSD: the PTSD factor (re-experiencing, avoidance, sense of threat) and the Disturbances in Self-Organization (DSO) factor (affect dysregulation, negative self-concept and disturbances in relationships). We hypothesized that self-compassion subscales would be negatively associated with both PTSD and DSO symptom clusters. Method: A predominantly female, clinical sample (n = 106) completed self-report scales to measure traumatic life events, ICD-11 CPTSD and self-compassion. Results: Significant negative associations were found between the CPTSD DSO clusters of symptoms and self-compassion subscales, but not for the PTSD ones. Specifically it was also found that self-judgement and common humanity significantly predicted hypoactive affect dysregulation whereas self-judgement and isolation significantly predicted negative self-concept. Conclusions: Our results indicate that self-compassion may be a useful treatment target for ICD-11 CPTSD, particularly for symptoms of negative self-concept and affect dysregulation. Future research is required to investigate the efficacy and acceptability of interventions that have implicit foundations on compassion.

Background: In people who experience auditory verbal hallucinations, beliefs the person holds about their voices appear to be clinically important as mediators of associated distress and disability. Whilst such beliefs are thought to be influenced by broader schematic representations the person holds about themselves and other people, there has been little empirical examination of this, in particular in relation to beliefs about voice intent and the personal meaning of the voice experience. Method: Thirty-four voice hearers with a diagnosis of schizophrenia or schizoaffective disorder completed the Psychotic Symptom Rating Scales and measures of beliefs about voices (Revised Beliefs About Voices Questionnaire, Interpretation of Voices Inventory) and schemas (Brief Core Schema Scales). Results: Beliefs about voices were correlated with both negative voice content and schemas. After controlling for negative voice content, schemas were estimated to predict between 9% and 35% of variance in the six beliefs about voices that were measured. Negative-self schemas were the strongest predictors, and positive-self and negative-other schemas also showed potential relationships with beliefs about voices. Conclusions: Schemas, particularly those regarding the self, are potentially important in the formation of a range of clinically-relevant beliefs about voices.

Background: Microswitches are the most commonly used input device for people with multiple disabilities to control environmental stimulation. However, little is known about adopting the commercial trackball with a revised trackball driver as a more feasible input device. Aims: To assess whether two children with profound multiple disabilities and minimal motor skills would be able to control environmental stimulation using thumb poke ability through cordless trackballs installed with a newly developed mouse driver (i.e. a new mouse driver replacing a standard mouse driver, turning a trackball mouse into a precise thumb poke detector). Method: An ABAB design and a 2-month post-intervention check were adopted to perform the study. Results: Data showed that the two children improved significantly in their target response (thumb poke) to activate the control system to produce environmental stimuli during the B (intervention) phases. This performance was maintained at the post-intervention check. Conclusions: The use of thumb poke in connection with a trackball allowed the children with multiple disabilities and minimal motor skills to increase their level of response and stimulation control.

Background: Image rescripting can be helpful in reducing the distress associated with intrusive images or memories across a range of disorders. Existing studies using imagery rescripting with people with psychosis have not included people who hear voices. Aims: This study aimed to explore the use of image rescripting with people with psychosis who have intrusive images or memories and hear voices. Method: This study used a one-off image rescripting session, using an A-B design with four participants with psychosis who were attending adult mental health community services. Results: Clinically significant reductions in distress, negative affect and reduced conviction in the beliefs associated with the imagery were reported at 1-week follow-up and maintained for three of the four participants at 1-month follow-up. Conclusions: The study offers early indications that image rescripting can be used as a treatment approach for people with psychosis. Exploring visual imagery and rescripting visual memories where appropriate may be a useful extension of cognitive behavioural therapy for psychosis (CBTp).

Cognitive-behavioral models (Clark & Wells, 1995; Rapee & Heimberg, 1997) and recent research suggest that individuals with social phobia (SP) experience both images (Hackmann, Surawy, & Clark, 1998) and memories (Coles, Turk, Heimberg, & Fresco, 2001; Wells, Clark, & Ahmad, 1998) of anxiety-producing social situations from an observer perspective. The current study examines memory perspective for two role-played situations (speech and social interaction) at multiple time points (immediate and 3 weeks post) in 22 individuals with generalized SP and 30 non-anxious controls (NACs). At both time points, SPs recalled the role-plays from a more observer/less field perspective than did NACs. Further, over time, the memory perspective of SPs became even more observer/less field while the memory perspective of NAC remained relatively stable.

Background: Compulsive Hoarding involves the acquisition of, and failure to discard, a large number of possessions that appear to be useless or of limited value, cluttered living spaces and significant distress or impairment in functioning (Frost and Hartl, 1996). The problem is multifaceted and appears best explained by a cognitive-behavioural framework. Aims: This study set out to test one aspect of Frost and Hartl's (1996) cognitive-behavioural model of compulsive hoarding by investigating theorized cognitive deficits in executive functioning, such as working memory and attention. Method: 24 participants with compulsive hoarding were tested on the Digit Span, Spatial Span and the Wisconsin Card Sorting Tests (WCST). Results: On the WCST, the hoarding group had a significantly higher number of perseveration errors (t = 1.67, p = .005) and significantly lower numbers of categories completed (t = −2.47, p = .001) than test norms. Only “failure to maintain set” was significantly correlated with hoarding severity (r = .435, p < .05). Conclusions: These findings lend support to the theory that people who compulsively hoard have executive dysfunction, which impacts on their ability to process information. Deficits relate to difficulties in forming effective strategies, inadequate feedback response, problems in concept formation, and impulsivity. Difficulties in sustained attention also appeared to be a factor in hoarding severity. These findings are important in directing more targeted clinical interventions.

Background and aims: This study explored individuals’ subjective experiences of Cognitive Behavioural Therapy for psychosis (CBTp) with the aim of identifying coherent themes consistent across individual accounts and any potential barriers to CBTp effectiveness. Method: Semi-structured interviews were conducted with nine individuals with experience of CBTp. A qualitative Interpretive Phenomenological Analysis was used to analyze the data collected to identify common themes. Results: Five super-ordinate themes emerged from our analyses: CBT as a process of person-centred engagement; CBT as an active process of structured learning; CBT helping to improve personal understanding; CBT is hard work; Recovery and outcomes of CBT for psychosis. Conclusions: The theoretical and clinical implications are discussed.

The present study examined the effect of a bedtime management programme which incorporated both stimulus control and contingency management procedures on the level of bedtime disruption in children. Using a multiple baseline across subjects design each of four children (ranging in age from 2–5 years) were sequentially introduced to the treatment program, which was implemented by the child's parents each night. In addition the study sought to determine whether direct treatment of bedtime disruption would be associated with any negative side effects. Systematic observational data revealed that the Bedtime Management Program was effective in reducing bedtime disruptions in all subjects and the improvements sustained during a 2-month follow-up. No evidence suggests that treatment resulted in negative side effects. The implications of the results for behavioural parent training are discussed.

The present study explored whether and how self-injurers attempt to resist urges to harm themselves. Participants were 39 young adults with a history of skin cutting and other non-suicidal self-injurious behaviors. A structured interview assessed the prevalence and perceived helpfulness of 48 methods for resisting self-injurious urges. Ninety percent of participants indicated that they had made efforts to resist urges to self-injure. These individuals had used an average of 16 different methods, and reported that they were successful in resisting the urges most of the time. “Keeping busy” and “Being around friends” were the most common methods used to resist self-injurious urges. However, “Doing sports or exercise” and “Removing the means/instruments typically used to self-harm from the home” were rated as being the most helpful for resisting self-injurious urges. Findings have implications for enhancing treatment and guiding future research.

Background: Enhanced Cognitive Behaviour Therapy (CBT-E) (Fairburn, Cooper and Shafran, 2003) was developed as a treatment approach for eating disorders focusing on both core psychopathology and additional maintenance mechanisms. Aims: To evaluate treatment outcomes associated with CBT-E in a NHS Eating Disorders Service for adults with bulimia and atypical eating disorders and to make comparisons with a previously published randomized controlled trial (Fairburn et al., 2009) and “real world” evaluation (Byrne, Fursland, Allen and Watson, 2011). Method: Participants were referred to the eating disorder service between 2002 and 2011. They were aged between 18–65 years, registered with a General Practitioner within the catchment area, and had experienced symptoms fulfilling criteria for BN or EDNOS for a minimum of 6 months. Results: CBT-E was commenced by 272 patients, with 135 completing treatment. Overall, treatment was associated with significant improvements in eating disorder and associated psychopathology, for both treatment completers and the intention to treat sample. Conclusions: Findings support dissemination of CBT-E in this context, with significant improvements in eating disorder psychopathology. Improvements to global EDE-Q scores were higher for treatment completers and lower for the intention to treat sample, compared to previous studies (Fairburn et al., 2009; Byrne et al., 2011). Level of attrition was found at 40.8% and non-completion of treatment was associated with higher levels of anxiety. Potential explanations for these findings are discussed.

The importance of clinical supervision is increasingly recognized, as is the need to demonstrate that the work we do in the NHS is effective. However, observational analyses of supervision or evidence bearing out the effectiveness of supervision are rare and narrow in focus. To contribute to the evidence base, the present N=1 content and outcome evaluation describes and then assesses the effectiveness of cognitive behaviour therapy supervision, in terms of its observed impacts on a supervisee and her patient. The supervisee was a trainee therapist participating in a diploma course in cognitive therapy. The study utilized a qualitative and quantitative content analysis methodology, based on the intensive coding of a series of 10 longitudinal, video-recorded supervision sessions, linked to the subsequent 10 therapy sessions. Based on this method, 14 supervisory themes were extracted, which served to describe the change methods employed in the supervision. The predicted transfer (generalization) of those themes from supervision to therapy was observed to occur to a surprisingly marked extent, indicating that the supervision was effective. Implications are drawn for developing supervision and related research.

Background: Cognitive Behaviour Therapy for Psychosis (CBTp) has a strong evidence base and is practised widely in the Western World. Psycho-social interventions, on the other hand, including Cognitive Behaviour Therapy (CBT) are hardly used in the low and middle income countries for psychosis. It has been suggested that adaptations in content, format and delivery are needed before CBT can be used outside the Western cultures. We describe preliminary evaluation of Culturally Adapted Cognitive Behaviour Therapy for Psychosis (CaCBTp) in in-patient settings in Lahore, Pakistan. Aims: We aimed to evaluate the efficacy of culturally adapted CBT for psychosis (CaCBTp) in Pakistan in a pilot project. Method: In a randomized controlled trial we tested CaCBTp against treatment as usual (TAU) in in-patient settings in Pakistan. Those diagnosed with schizophrenia according to the DSM-IV-TR, and who fulfilled the inclusion criteria, were recruited into the study. Patients (n = 42) were randomized into two equal groups, i.e. CaCBTp and TAU. Assessments were carried out both at the baseline and then at the end of the therapy by raters blind to the groupings. Psychopathology was measured using PANSS (Positive and Negative Syndrome Scale of Schizophrenia), PSYRATS (Psychotic Symptom Rating Scales), and the Insight Scale. Results: Patients receiving CaCBTp showed statistically significant improvement on measures of positive symptoms (p = .000), negative symptoms (p = .000), overall psychotic symptoms (p = .000), hallucinations (p = .000), delusions (p = .000) and insight (p = .000) at the end of the therapy. Conclusions: The CaCBTp was effective in reducing symptoms of psychosis and in improving insight in in-inpatient settings in Pakistan.

Background: The exploration of Mindfulness-based Cognitive Therapy through qualitative investigation is a growing area of interest within current literature, providing valuable understanding of the process of change experienced by those engaging in this therapeutic approach. Aims: This meta-synthesis aims to gain a deeper understanding of how the features of Mindfulness-based Cognitive Therapy contribute to positive therapeutic change. Method: Noblit and Hare's (1988) 7-step meta-ethnography method was conducted in order to synthesize the findings of seven qualitative studies. Results: The process of reciprocal translation identified the following five major themes: i) Taking control through understanding, awareness and acceptance; ii) The impact of the group; (iii) Taking skills into everyday life; (iv) Feelings towards the self; (v) The role of expectations. Conclusion: The synthesis of translation identified the higher order concept of “The Mindfulness-based Cognitive Therapy Journey to Change”, which depicts the complex interaction between the five themes in relation to how they contribute to positive therapeutic change. The findings are discussed in relation to previous research, theory and their implications for clinical practice.

Background: Schema Therapy (ST), a psychotherapy model integrating cognitive, experiential and behavioural interventions, was initially developed and evaluated as an outpatient treatment for patients with severe and chronic disorders, among them Borderline Personality Disorder (BPD). Two randomized controlled trials have demonstrated the effectiveness of ST for BPD, delivered in an individual or group format, in the outpatient setting. However, the most severely impaired BPD patients are referred to inpatient treatment due to suicidality and severe self-harm. Specialized inpatient treatment programs are limited, with little evaluative research. Aims: The pilot studies are designed to be first steps in naturalistic clinical settings to evaluate the effects of an intensive inpatient ST treatment program. Method: This report presents the results of three independent uncontrolled pilot studies with a total of 92 BPD patients. The programs combine individual and group modalities and are consistent theoretically with the ST model for BPD patients. Results: Results show that inpatient ST can significantly reduce symptoms of severe BPD and global severity of psychopathology with effect sizes ranging from Cohen's d = 2.84 to Cohen's d = .43. Conclusions: Differences in the effect sizes across the three pilot studies could be explained by length of treatment, number of group psychotherapists and their training. Although there are limitations to the presented pilot studies such as differences in the samples, treatment settings, variations in the treatment itself and the use of different measures, which may have influenced outcome, they are a starting point for describing and evaluating inpatient treatment for BPD in naturalistic settings.

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: Hoarding is associated with significant impairment. Although traditionally considered as a symptom of obsessive-compulsive disorder (OCD), some authors have proposed that pathological hoarding could be considered as a stand alone condition. The prevalence of pathological hoarding behaviour has been shown to be high in some countries, but little is known about the prevalence and correlates of hoarding in the non-clinical population in Italy. Method: We studied the prevalence of self-reported hoarding behaviour using the Italian version of the Saving Inventory-Revised, as well as the association between hoarding and various clinical correlates, including obsessive-compulsive symptoms, compulsive buying, anxiety, and depression. Results: The prevalence of pathological hoarding behaviour in two studies was between 3.7 and 6.0%. No differences were found between hoarding and non-hoarding participants with regard to gender, age, marital status, level of education, and employment status. Significant correlations were found between compulsive hoarding and obsessive-compulsive symptoms and also between hoarding and a measure of compulsive buying, even after controlling for anxiety and depressive symptoms. Conclusions: These results indicate that pathological hoarding may also be prevalent in Italy and highlight the need for further epidemiological studies using validated instruments to assess hoarding disorder.

Background: Although recommended in national treatment guidelines, there is much that is still unknown about CBT for psychosis (CBTp) in terms of the process and experience of the therapy. One way to investigate these gaps in knowledge is to explore service users' experiences through qualitative research. Aims: To consolidate existing qualitative explorations of CBTp from a service user perspective. Method: Qualitative synthesis and comparison with previous research findings. Results: Two analytical themes were created from initial descriptive themes common to multiple studies: “The ingredients in the process of therapy” and “What is the process of therapy?” Conclusions: Qualitative synthesis is a useful method for generating new insights from multiple qualitative studies. Service user perspectives on CBTp corroborate existing research and may also offer more novel findings regarding the ingredients and process of therapy. However, qualitative studies are limited in number and do not always maximize the prominence of service user experience.

In the absence of good quality evidence for the effectiveness of specific aspects or formats of Cognitive Behavioural Therapy (CBT) supervision, it is necessary to consider what is recommended as good quality CBT supervision. This review of the literature aims to provide an overview of the recommended practice of CBT supervision by considering general principles and goals of CBT supervision; the format of individual supervision sessions; the course and stages of CBT supervision; attending to supervisees' cognitions and affects; the importance of the supervisory relationship as well as the recording and rating of therapy sessions. This could provide a framework for setting standards to aspire to and stimulate further research in this field. Conforming to such practice would be an important step toward quality assurance in CBT supervision.