Two cases involving the cognitive-behavioural treatment of hallucinations are described. In both cases, a focusing strategy was used with a view to enabling patients to reattribute the nature and meaning of their experiences. One patient showed a marked reduction in the frequency and content of his voices. The second patient showed little change. The implications of observations made during therapy for the future development of cognitive-behavioural strategies for use with psychotic patients are discussed.

Background: Research suggests that aggressive children are prone to over-attribute hostile intentions to peers. Aims: The current study investigated whether this attributional style can be altered using a Cognitive Bias Modification of Interpretations (CBM-I) procedure. Method: A sample of 10–12-year-olds selected for displaying aggressive behaviours was trained over three sessions to endorse benign rather than hostile attributions in response to ambiguous social scenarios. Results: Compared to a test-retest control group (n = 18), children receiving CBM-I (n = 16) were less likely to endorse hostile attributions and more likely to endorse benign attributions in response to a new set of ambiguous social situations. Furthermore, aggressive behaviour scores reduced more in the trained group than in the untrained controls. Children who received attribution training also reported less perceived anger and showed a trend to report more self-control than those in the control group. Conclusions: Implications of these findings are discussed.

Background: Trauma-focused CBT (TFCBT) is an evidence-based treatment for post-traumatic stress disorder (PTSD), but little is known about whether it is an acceptable and effective treatment for asylum-seekers presenting with PTSD. Aims: This study considers the acceptability of TFCBT for asylum-seekers with PTSD by exploring their experiences of this treatment. Method: Seven asylum-seekers who had received CBT involving a TFCBT component were interviewed using a semi-structured schedule. The transcribed interviews were analysed using interpretative phenomenological analysis (IPA). Interpretative themes were developed iteratively to closely reflect participants’ common and distinct experiences. Results: Six super-ordinate interlinking themes are discussed: Staying where you are versus engaging in therapy; Experiences encouraging engagement in therapy; Experiences impeding engagement in therapy; Importance of the therapeutic relationship; “Losing oneself” and “Regaining life”. Conclusions: Participants described their ambivalence about engaging in TFCBT. Such treatment was experienced as very challenging, but most participants also reported finding it helpful. Various experiences that appeared to encourage or impede engagement are outlined. These preliminary findings suggest that fear of repatriation can impede engagement in TFCBT, but that some asylum-seekers with PTSD still report finding TFCBT beneficial. The clinical implications are discussed, including the special importance of the therapeutic relationship.

Background: An appreciation of cognitive predictors of change in treatment outcome may help to better understand differential treatment outcomes. The aim of this study was to examine how rumination and mindfulness impact on treatment outcome in two group-based interventions for non-melancholic depression: Cognitive Behaviour Therapy (CBT) and Mindfulness-Based Cognitive Therapy (MBCT). Method: Sixty-nine participants were randomly allocated to either 8-weekly sessions of group CBT or MBCT. Complete data were obtained from 45 participants (CBT = 26, MBCT = 19). Outcome was assessed at completion of group treatments. Results: Depression scores improved for participants in both group interventions, with no significant differences between the two treatment conditions. There were no significant differences between the interventions at post-treatment on mindfulness or rumination scores. Rumination scores significantly decreased from pre- to post-treatment for both conditions. In the MBCT condition, post-treatment rumination scores were significantly associated with post-treatment mindfulness scores. Conclusions: Results suggest that decreases in rumination scores may be a common feature following both CBT and MBCT interventions. However, post-treatment rumination scores were associated with post-treatment mindfulness in the MBCT condition, suggesting a unique role for mindfulness in understanding treatment outcome for MBCT.

The transfer of knowledge occurs most effectively through the stories – the narratives – that we tell others and ourselves about our experiences. Cognitive behaviour therapists may incorporate stories, metaphors and analogies within their daily practice, when assessing suitability for treatment, challenging unhelpful styles of thinking, and addressing maintaining behaviours. The collaborative development of stories can enhance rapport, enable clients to gain a new perspective upon their problems, increase personal impact and clarity of meaning, and reinforce clients' motivation to effect therapeutic change. This paper discusses the use of the story, anecdote, metaphor, analogy, and quotation within cognitive behaviour therapy (CBT). The contribution of other psychotherapies to these forms of therapeutic communication is outlined. Practical examples of stories and analogies that illustrate the main principles of CBT and its application to the treatment of common mental disorders are described. The benefits and limitations of employing individualized analogies and stories within the therapy session are highlighted.

Background: The current nonrandomized clinical trial explored changes over time in children with an anxiety disorder during stepped care, manual-based cognitive behaviour therapy (CBT). Methods: Clinically anxious children (8–12 years, n = 133) and their parents participated in child focused CBT (10 sessions). If assessments indicated additional treatment was necessary, participants could step up to a second and possibly third treatment phase (each 5 sessions) including more parental involvement. Results: After the first treatment phase 45% of the Intention-To-Treat sample was free of any anxiety disorder; after the second and third phase an additional 17% and 11% respectively. In total, 74% of the children no longer met criteria for any anxiety disorder following treatment. Child and parent reported anxiety and depression symptoms of children improved significantly during all treatment phases, as well as child reported anxiety sensitivity and negative affect. Children participating in more treatment showed significant improvements during additional treatment phases, indicating that late change occurred for the subgroup that had not changed during the first phase. Conclusions: Stepped care offers a standardized, assessment based, yet tailored treatment approach for children with anxiety disorders. A more intensive treatment is offered when initial CBT is insufficient, providing children additional opportunities to reach the desired outcome.

Self help approaches are increasingly being used in healthcare settings through over 100 book prescription schemes in the UK. The use of Cognitive Behavioural Therapy (CBT) self-help materials for depression is advocated as part of stepped care service models. This study assesses how the reading ages of the most recommended self-help books for depression compare to British literacy levels. A cross sectional survey was carried out. The most recommended self-help books for depression were identified; seven CBT based self-help books were included in this study as well as a widely used booklet for depression. Readability scores and reading ages were calculated for a randomly generated selection representing 15% of each selected book using the Readability Studio® software to generate a wide range of key readability and comprehension scores. The reading ages of the selected books were between 12.6 and 15.4. Reading ease varied amongst the texts, and their complexity (percentage of unfamiliar words, range: 14.8% – 22.6%). A significant proportion of the UK population would struggle to use some of the current CBT-based self-help books recommended. For some patient groups, non text based self-help materials as well as shorter and more easily read written materials may be more appropriate. To our knowledge, this is the first study to address this question. Publication of the reading ages of the recommended books within the book prescription schemes may allow for a more accurate match between the book and the reader.

The present study presents the development and validation of the Social Interaction and Performance Anxiety and Avoidance Scale (SIPAAS), a self-report questionnaire to assess the level of distress and avoidance in a wide range of performance and social interaction situations, and the Social Phobia Safety Behaviours Scale (SPSBS), a self-report questionnaire designed to evaluate in-situation safety behaviours in which social phobics engage to try to prevent social catastrophe. The psychometric adequacy of both scales was evaluated in three different samples: social phobic patients, other anxiety disordered patients, and normal population. Both scales were normally distributed and were shown to possess high levels of internal consistency and temporal stability. They reliably discriminate patients with generalized social phobia from patients with non-generalized social phobia, other anxiety disordered patients, and normal population. Both subscales of the SIPAAS have shown high correlations with other measures of social anxiety (SAD, FNE), whereas the SPSBS has shown low to moderate correlations with SAD and FNE. It appears that these new self-report scales are reliable, valid and useful measures of social phobia for clinical and research purposes.

This paper describes the treatment of a 4½-year-old autistic boy who exhibited phobic responses to the sounds of flushing toilets. He was successfully treated using reinforcement and laughter: the latter service as an anxiety inhibitor. At 3- and 6-month follow-ups the child was symptom-free.

Background: Although worry is common in children, empirical models of worry remain largely untested in youth. A small number of studies have established preliminary links between cognitive variables and worry in children younger than 12 years old. These cognitive variables include positive and negative beliefs about worry, intolerance of uncertainty, and problem orientation. Aims: The current study examined these variables concurrently and their association with worry. We also examined the extent to which intolerance of uncertainty mediated the association between worry and beliefs about worry. Method: Eighty elementary school children aged 8 to 12 years completed a battery of self-report measures. Results: As a group, the cognitive variables significantly predicted worry scores; negative beliefs about worry was the only significant individual predictor. As a group, the four cognitive variables discriminated clinical from nonclinical levels of worry; positive beliefs about worry and intolerance of uncertainty were the only significant individual predictors. Finally, intolerance of uncertainty mediated the association between worry and both positive and negative beliefs about worry. Conclusions: Components of a cognitive model of worry are largely applicable to children. Negative beliefs about worry were associated with worry across the continuum, while intolerance of uncertainty and positive beliefs about worry were more strongly associated with clinical levels of worry. Intolerance of uncertainty accounted for a significant portion of the association between metacognition and worry and may be a particularly effective target for treatment. Further implications for conceptual models and treatment interventions are discussed.

Cognitive-behavioural therapy (CBT) supervision has traditionally been presented as an extension of the therapy, a reflexive strategy that includes a commendable commitment to a principled approach. However, a critical review suggests that this strategy has not been implemented with fidelity. Furthermore, this strategy overlooks potentially valuable ideas from the wider field of clinical supervision, runs counter to CBT's empirical roots, and under-values supervision as a discrete professional specialization. For these reasons, it is argued that new developments should be grafted onto the current approach. In future, this augmented version of CBT supervision should be subjected to the same kinds of research and development (R&D) activity as CBT. Initially, this could include developing a manual to specify and operationalize this innovative approach, evaluation of manual-based training, and N = 1 research to assess its effectiveness. Examples of preliminary work are provided, and future R&D directions identified.

A cognitive-behavioural analysis of clinical perfectionism has recently been proposed. The aim of this study was to explore the phenomenology of clinical perfectionism and its putative maintaining mechanisms. Of the 21 participants, 15 were judged to have the core psychopathology of clinical perfectionism. The data obtained were largely consistent with the model. In particular, self-imposed dysfunctional standards, continual striving and adverse consequences appeared to be highly salient features of those people who had the core psychopathology of clinical perfectionism but not of those without. A number of other possible maintaining factors not originally described in the model were also identified.

Previous (mainly classical) conditioning and current (mainly operant) approaches to the treatment of gambling addictions are reviewed in the light of recent evidence of the central importance of heightened arousal in the experience of normal gambling. Within a general framework which views the central features of addiction as the phenomenology of arousal and the acquisition of altered states of consciousness as goals, the possible contributions of reversal theory are explored. A more detailed examination of operant and classical conditioning analyses of the maintenance and reinstatement of excessive gambling behaviour appears to point towards a return to interventions based upon classical conditioning theory, although to cue exposure and the extinction of “peak experiences” rather than to aversion therapy.

There is a substantial literature reporting the co-occurrence of maternal depression and child behaviour problems. Behavioural interventions have proven efficacy in the treatment of conduct problems, and a number of studies have reported gains in parental mental health following parent training. The mechanisms by which this is achieved are not clear, but it is likely that interventions that include parent training in observation skills and exposure to success will impact on both the child's conduct problems and maternal depression. This paper reports on the outcomes of two treatments for children with severely disruptive behaviour, the standard treatment offered by a Child and Adolescent Mental Health Service, and an intensive parent training intervention. It was predicted that the more specific skills training in the intensive treatment would make improvements in maternal health and child behaviour more likely. Significant overall improvements were found in measures of child behaviour, parental practices and maternal mental health. A correlation emerged between the improved child behaviour and the improved parenting strategies. Significant improvements for the intensive treatment group were seen on every measure. Significant improvement in the measure of maternal mental health contrasted with little change for the standard treatment group.

Kinderman (2005) presented a psychological model of mental disorder, based on a critique and reformulation of the biopsychosocial model. Kinderman suggested that disruption or dysfunction in psychological processes is a final common pathway in the development of mental disorder. These processes include, but are not limited to, cognitive processes. This ‘mediating psychological processes model’ proposes that biological and environmental factors, together with a person's personal experiences, lead to mental disorder through their conjoint effects on these psychological processes. The clinical implications of this model are discussed further here. It is proposed that formulations rather than diagnoses should predominate clinical planning, that these formulations should detail the hypothesised disruption to psychological processes or mechanisms, that psychological therapies should receive higher priority, and that medical, social and even psychological interventions are most likely to be clinically effective if they are designed on the basis of their likely beneficial impact on underlying psychological mechanisms.

Background: Hearing voices can be a common and distressing experience. Psychological treatment in the form of cognitive behavioural therapy for psychosis (CBTp) is effective, but is rarely available to patients. The barriers to increasing access include a lack of time for clinicians to deliver therapy. Emerging evidence suggests that CBTp delivered in brief forms can be effective and offer one solution to increasing access. Aims: We adapted an existing form of CBTp, coping strategy enhancement (CSE), to focus specifically on distressing voices in a brief format. This intervention was evaluated within an uncontrolled study conducted in routine clinical practice. Method: This was a service evaluation comparing pre–post outcomes in patients who had completed CSE over four sessions within a specialist out-patient service within NHS Mental Health Services. The primary outcome was the distress scale of the Psychotic Symptoms Rating Scale – Auditory Hallucinations (PSYRATS-AH). Results: Data were available from 101 patients who had completed therapy. A reduction approaching clinical importance was found on the PSYRATS distress scale post-therapy when compared with the baseline. Conclusions: The findings from this study suggest that CSE, as a focused and brief form of CBTp, can be effective in the treatment of distressing voices within routine clinical practice. Within the context of the limitations of this study, brief CSE may best be viewed as the beginning of a therapeutic conversation and a low-intensity intervention in a stepped approach to the treatment of distressing voices.

There is increasing evidence that cognitive behavioural therapy (CBT) is efficacious in treating psychosis. However, very little attention has been paid to the nature of the control treatments used in studies of this. Befriending has been used as a control treatment in several randomized control trials (RCTs) of CBT for psychosis as it is simple to learn and administer. The aim of the present study was to examine whether Befriending controlled for important non-specific aspects of therapy when compared to CBT in a RCT for acute first episode psychosis (FEP). These non-specific factors included time in, expectancy created by, and acceptability of therapy. Expectations and enjoyment of therapy were measured by questionnaire. Time in therapy and the number of drop-outs were also recorded. Results showed that Befriending was comparable to CBT on measures of expectancy, enjoyment of therapy and drop-out rate, but significantly different with regard to time in therapy. This suggests that Befriending is a credible and acceptable control therapy for FEP with modification to increase time in therapy sessions. Methodological issues are raised, and suggestions for future research are made regarding control treatments.

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: Depressive symptoms are common in schizophrenia. Previous studies have observed that depressive symptoms are associated with both insight and negative appraisals of illness, suggesting that the way in which the person thinks about their illness may influence the occurrence of depressive responses. In affective disorders, one of the most well-established cognitive processes associated with depressive symptoms is rumination, a pattern of perseverative, self-focused negative thinking. Aims: This study examined whether rumination focused on mental illness was predictive of depressive symptoms during the subacute phase of schizophrenia. Method: Forty participants with a diagnosis of schizophrenia and in a stable phase of illness completed measures of rumination, depressive symptoms, awareness of illness, and positive and negative symptoms. Results: Depressive symptoms were correlated with rumination, including when controlling for positive and negative symptoms. The content of rumination frequently focused on mental illness and its causes and consequences, in particular social disability and disadvantage. Depressive symptoms were predicted by awareness of the social consequences of mental illness, an effect that was mediated by rumination. Conclusions: Results suggest that a process of perseveratively dwelling upon mental illness and its social consequences may be a factor contributing to depressive symptoms in people with chronic schizophrenia.

Seventy-seven mental health professionals completed a 3-day cognitive behavioural training course for managing hallucinations and delusions in schizophrenia. A questionnaire measuring attitudes and empathy towards working with people who have these symptoms was administered before and after the course. Significant increases in feelings of adequacy, legitimacy, employment related self-esteem, and expectations of work satisfaction were observed after the course and participants displayed high levels of motivation for working with this clinical population at both time points. In addition, the participants showed significant increases in perceived empathy for the experience of hallucinations and delusions. This was a predicted outcome as the course included exercises designed to enhance therapists' understanding of the subjective experience of psychotic symptoms. Empathy is recognized in the wider psychotherapy outcome literature as a therapeutically important variable that influences the formation of a therapeutic alliance but it is a relatively unexamined construct in CBT for psychosis. Further investigations in this area will potentially enhance psychological treatment delivery and subsequent outcomes for people who experience hallucinations and delusions. Furthermore, explication of such “non-specific” therapeutic factors may help to explain some of the transient but beneficial effects of unstructured “control” therapies observed in recent CBT for psychosis outcome trials.