Interpretation and judgmental biases for threat-relevant stimuli are thought to play a role in anxiety disorders. To investigate whether social anxiety is associated with interpretation and judgmental biases for unambiguous external social events, individuals high and low in social anxiety (N = 36 per group) were presented with unambiguous scenarios depicting positive and mildly negative social events. Interpretations were assessed by participants' answers to open-ended questions and by their ratings for experimenter-provided, alternative explanations. In addition, for each event, participants indicated the probability that the event would happen to them and estimated their own emotional reaction to it. Compared to low socially anxious group, individuals high in social anxiety were more likely to interpret positive social events in a negative way and to catastrophize in response to unambiguous, mildly negative social events. Also, they estimated the emotional cost of negative social events as higher and the probabilities of positive social events as lower.

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.

Background: Previous studies have suggested that physical exercise can reduce symptoms for subjects suffering from panic disorder (PD). The efficacy of this intervention has so far not been compared to an established psychotherapy, such as cognitive behaviour therapy (CBT). Assessment of controlled long-term effects and the clinical significance of the treatment are also lacking. Aim: To compare physical exercise to CBT as treatment for PD, and assess controlled long-term and clinically significant effects. Method: PD-patients were randomized to either three weekly sessions of physical exercise (n = 17), or one weekly session of CBT (n = 19). Both treatments ran for 12 weeks, were manualized and administered in groups. Patients were assessed twice before the start of treatment, at post-treatment and at 6 and 12 months thereafter. Primary outcome-measures consisted of the Mobility Inventory (MI), the Agoraphobia Cognitions Questionnaire (ACQ) and the Body Sensations Questionnaire (BSQ). Results: A two-way repeated measures MANOVA of these measures demonstrated a significant effect of time, F(16, 544) = 7.28, p < .01, as well as a significant interaction effect, F(16, 544) = 1.71, p < .05, in favour of CBT. This finding was supported by the assessment of clinically significant changes of avoidant behaviour and of treatment-seeking one year later. Conclusion: Group CBT is more effective than group physical exercise as treatment of panic disorder, both immediately following treatment and at follow-up assessments.

Background: Two studies are presented that highlight the role of emotion in PTSD in which we examine what emotions in addition to anxiety may be present. Aims: The first aim was to assess the overall emotion profile across the five basic emotions of anxiety, sadness, anger, disgust, and happiness in clients attending a stress clinic. A small pilot study was also carried out to see how the emotion profiles impacted on outcome for CBT. Method: In Study 1, 75 consecutive attenders at a trauma service who were diagnosed with PTSD were assessed with a number of measures that included the Basic Emotions Scale. Results: The results showed that less than 50% of PTSD cases presented with anxiety as the primary emotion, with the remainder showing primary emotions of sadness, anger, or disgust rather than anxiety. A second pilot study involved the follow-up across exposure-based CBT of 20 of the participants from Study 1. Conclusions: The results suggest that anxiety-based PTSD is more likely to benefit from exposure than is non-anxiety based PTSD. Implications both for the classification and the treatment of PTSD are considered.

Three influential theoretical models of OCD focus upon the cognitive factors of inflated responsibility (Salkovskis, 1985), thought-action fusion (Rachman, 1993) and meta-cognitive beliefs (Wells and Matthews, 1994). Little is known about the relevance of these models in adolescents or about the nature of any direct or mediating relationships between these variables and OCD symptoms. This was a cross-sectional correlational design with 223 non-clinical adolescents aged 13 to 16 years. All participants completed questionnaires measuring inflated responsibility, thought-action fusion, meta-cognitive beliefs and obsessive-compulsive symptoms. Inflated responsibility, thought-action fusion and meta-cognitive beliefs were significantly associated with higher levels of obsessive-compulsive symptoms. These variables accounted for 35% of the variance in obsessive-compulsive symptoms, with inflated responsibility and meta-cognitive beliefs both emerging as significant independent predictors. Inflated responsibility completely mediated the effect of thought-action fusion and partially mediated the effect of meta-cognitive beliefs. Support for the downward extension of cognitive models to understanding OCD in a younger population was shown. Findings suggest that inflated responsibility and meta-cognitive beliefs may be particularly important cognitive concepts in OCD. Methodological limitations must be borne in mind and future research is needed to replicate and extend findings in clinical samples.

Background: Cognitive Behavioural Therapy (CBT) is not primarily conceptualized as operating via affective processes. However, there is growing recognition that emotional processing plays an important role during the course of therapy. Aims: The Emotional Processing Scale was developed as a clinical and research tool to measure emotional processing deficits and the process of emotional change during therapy. Method: Fifty-five patients receiving CBT were given measures of emotional functioning (Toronto Alexithymia Scale [TAS-20]; Emotional Processing Scale [EPS-38]) and psychological symptoms (Brief Symptom Inventory [BSI]) pre- and post-therapy. In addition, the EPS-38 was administered to a sample of 173 healthy individuals. Results: Initially, the patient group exhibited elevated emotional processing scores compared to the healthy group, but after therapy, these scores decreased and approached those of the healthy group. Conclusions: This suggests that therapy ostensibly designed to reduce psychiatric symptoms via cognitive processes may also facilitate emotional processing. The Emotional Processing Scale demonstrated sensitivity to changes in alexithymia and psychiatric symptom severity, and may provide a valid and reliable means of assessing change during therapy.

Trauma symptoms, coping and personality were assessed in 44 victims of the Perth flood. The sample was characterized by high levels of intrusions, numbness, arousal and general emotional distress. General levels of symptomatology were predicted by two coping strategies: emotion-focused coping and thought suppression. Overall trauma symptoms and emotion-focused coping were associated with the personality trait of neuroticism. These data are consistent with the Wells and Matthews (1994a) model of affective disorders and stress. The model proposes that certain types of emotion-focused coping tend to lead to greater access to negative self-beliefs, and that thought suppression tends to prime subsequent intruding thoughts. A second personality trait, private self-consciousness, was associated with relatively greater levels of numbing symptoms, and relatively lower levels of arousal symptoms. This patterning of symptoms may result from use of ruminative coping strategies. Hence, intrusions of trauma-related material are not simply a function of automatic activation of a fear network, but are also influenced by the person's voluntary efforts to deal with the aftermath of the event.

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 a previous effectiveness study (Havnen et al., 2014), 35 obsessive compulsive disorder (OCD) patients underwent Concentrated Exposure Treatment (cET), which is a newly developed group treatment format delivered over four consecutive days. Aims: The primary aims of the present study were to evaluate the treatment results for a new sample of OCD patients receiving the cET treatment approach and to replicate the effectiveness study described in Havnen et al. (2014). Method: Forty-two OCD patients underwent cET treatment. Treatment was delivered by different therapists than in Havnen et al. (2014), except for two groups led by the developers of the treatment. Assessments of OCD symptom severity, treatment satisfaction, and occupational impairment were included. Results: The results showed a significant reduction in Yale-Brown Obsessive Compulsive Scale scores from pre-treatment to post-treatment, which was maintained at 6-month follow-up. At post-treatment, 74% of the sample was remitted; at 6-month follow-up, 60% were recovered. The sample showed a very high degree of overall treatment satisfaction. The results from the present study were statistically compared with those obtained in the previous study. The analyses showed that the study samples had comparable demographic data and equal application of treatment. The outcome of the present and original study did not differ significantly on primary and secondary outcome measures. Conclusions: This study shows that cET was successfully replicated in a new patient sample treated by different therapists than the original study. The results indicate that cET is well accepted by the patients, and the potential for dissemination is discussed.

The growing interest in the use of cognitive behaviour therapy with children and young people has been encouraged by emerging evidence suggesting that CBT is effective with a wide range of child disorders. Typically, models and techniques developed for work with adults have been extended downwards and applied to children. This review questions the appropriateness of this approach and selectively identifies a number of key issues that need to be addressed. The absence of developmentally appropriate theoretical models to understand the onset and maintenance of maladaptive cognitive processes in children is highlighted. This lack of a coherent theoretical framework has led to a proliferation of diverse interventions falling under the general umbrella of cognitive behaviour therapy with the predominant emphasis being behavioural, rather than cognitive. Developmental factors, the nature, extent and type of cognitive processes in children and the important role of the parent in the onset and treatment of childhood problems have received comparatively little attention. There is a need to understand more about the cognitive processes of children and young people and to develop robust and testable developmentally appropriate theoretical models. In turn this will begin to address the question of which specific cognitive behaviour therapy programmes are effective for which childhood problems.

Cognitive therapy for depression is well-established. However, it is only recently that Beck and his colleagues have turned their attention to the development of a cognitive therapy for anxiety. The present article provides a brief overview of cognitive therapy for anxiety and also presents outcome data on six anxious patients who were treated with cognitive therapy. Considerable reductions in anxiety and depression occurred during the course of treatment. In addition, much of the observed improvement occurred after as little as eight sessions. These results suggest that cognitive therapy is a promising approach to the treatment of anxiety disorders. However, final evaluation of its effectiveness must await the publication of large scale, controlled trials.

Background: Childhood worry is common, and yet little is known about why some children develop pathological worry and others do not. Two theories of adult worry that are particularly relevant to children are Davey's problem-solving model in which perseverative worry occurs as a result of thwarted problem-solving attempts, and Wells’ metacognitive model, in which positive and negative beliefs about worry interact to produce pathological worry. Aims: The present study aimed to test hypotheses that levels of worry in young children are associated with poor or avoidant solution generation for social problems, and poor problem-solving confidence. It also aimed to explore beliefs about worry in this age group, and to examine their relationships with worry, anxiety and age. Method: Fifty-seven young children (6–10 years) responded to open ended questions about social problem-solving situations and beliefs about worry, and completed measures of worry, anxiety and problem-solving confidence. Results: Children with higher levels of worry and anxiety reported using more avoidant solutions in social problem situations and children's low confidence in problem solving was associated with high levels of worry. Children as young as 6 years old reported both positive and negative beliefs about worry, but neither were associated with age, gender, or level of anxiety or worry. Conclusions: Results indicate similarities between adults and children in the relationships between problem-solving variables and worry, but not in relationships between beliefs about worry and worry. This may be due to developmental factors, or may be the result of measurement issues.

Background: Individual Cognitive Behaviour Therapy for psychosis (CBTp) is the first line recommended psychological intervention for adults diagnosed with schizophrenia. However, little is yet known about service users’ subjective experiences of CBTp. Aims: This study aimed to conduct a systematic review of qualitative literature to examine service user perspective of CBTp. Method: A thematic synthesis of qualitative studies examining service users’ experiences of CBTp was conducted. A total of six studies were included in the analysis. Results: Three superordinate themes were identified: therapeutic alliance; facilitating change; and challenges of applying CBTp. Conclusion: Overall, CBTp is a helpful and acceptable therapeutic approach to service users. Developing a collaborative therapeutic relationship is essential. The applications of CBTp can be problematic and the therapist and client need to work together to overcome these difficulties.

Background: Previous research has shown that face to face cognitive behaviour therapy (CBT) is an effective treatment for chronic fatigue syndrome (CFS)/Myalgic Encephalomyelitis (ME). However, some patients are unable to travel to the hospital for a number of reasons. Aims: The aim of this study was to assess whether face to face CBT was more effective than telephone CBT (with face to face assessment and discharge appointment) for patients with CFS. Method: Patients aged 18–65 were recruited from consecutive referrals to the Chronic Fatigue Syndrome (CFS) Research and Treatment Unit at The South London and Maudsley NHS Trust in London. Participants were randomly allocated to either face to face CBT or telephone CBT by a departmental administrator. Blinding of participants and care givers was inappropriate for this trial. A parallel-groups randomised controlled trial was used to compare the two treatments. The primary outcomes were physical functioning and fatigue. Results: Significant improvements in the primary outcomes of physical functioning and fatigue occurred and were maintained to one year follow-up after discharge from treatment. Improvements in social adjustment and global outcome were noted and patient satisfaction was similar in both groups. Conclusions: Results from this study indicate that telephone CBT with two face to face appointments is a mild to moderately effective treatment for CFS and may be offered to patients where face to face treatment is not a viable option. Despite these encouraging conclusions, dropout was relatively high and therapists should be aware of this potential problem.

Background: Parental overprotection may have a direct effect on worry through hindering children's exploration experiences and preventing the learning of action-oriented coping strategies (Cheron, Ehrenreich and Pincus, 2009; Nolen-Hoeksema, Wolfson, Mumme and Guskin, 1995) and an indirect effect through fostering the development of maladaptive metacognitions that are associated with the activation of worry and the escalation of anxiety (Wells, 2000). Aim: The aim was to investigate the relative contribution of recalled parental overprotection in childhood and metacognitions in predicting current levels of worry. Method: A community sample (n = 301) was administered four self-report instruments to assess parental overprotection, metacognitions, anxiety and worry. Results: Metacognitions were found to predict levels of worry independently of gender, anxiety and parental overprotection. They were also found to predict anxiety independently of gender, worry and parental overprotection. Conclusions: The combination of a family environment perceived to be characterized by overprotection and high levels of maladaptive metacognitions are a risk factor for the development of worry.

We examined a non-specific or relationship variable as well as a specific or technical variable (i.e. homework compliance) and their prediction of cognitive behavioral treatment (CBT) outcome for children with anxiety disorders. Therapist ratings of the therapeutic relationship (TR), but not homework compliance (HC) predicted CBT outcome at posttreatment (n = 138) and at 1-year follow-up (n = 121) for anxious children (aged 9 to 13 years). Findings from this study suggest the therapeutic relationship is a hardy non-specific factor in CBT of anxious children. Implications for the treatment of children with anxiety disorders using CBT and recommendations for research are offered.

This paper summarizes a recently developed model for understanding the genesis of visual hallucinations, shows how this can be incorporated into a cognitive behavioural framework, and then illustrates possible ways in which this may be used to successfully treat the emotional distress that some older people experience as a consequence of their hallucinations. These ideas have been developed as a model-based clinical response to patients distressed by their hallucinations. The purpose of this paper is to outline this approach in order to stimulate discussion and empirical evaluation.

This article is intended to promote consideration and discussion of ethical issues in motivational interventions. The popular concept of client “denial” encompasses a broad range of motivational behaviors including lying, perceptual bias, unawareness, ambivalence, resistance and reactance. The “problem of motivation” typically arises when a therapist perceives a problem and sufficient need for change in someone who does not share this perception. In considering how to respond to such situations, one can conceive of a continuum of levels of readiness to change, and of therapeutic strategies ranging from passivity to coercion. Ethical concerns arise when there is a perceived mismatch between readiness level and intervention strategy. Motivational interviewing is a middle way between passivity and coercion, seeking to evoke intrinsic motivation for change by making salient the inconsistency of problem behavior and that which is more deeply valued. The concern that this approach is “manipulative” combines a descriptive element and an evaluative component. Three possible descriptive meanings are discussed: that it effectively alters behavior, that it does so in persons not seeking or requesting change, and that it may operate through processes not immediately apparent. Ethical concerns regarding motivational intervention are considered within this broader context.

Background: Dysfunction is an integral part of chronic insomnia. Despite this, very little effort has yet been made to design and psychometrically validate an insomnia-specific measure of dysfunction. Aims: The purpose was to examine the psychometric properties of the Work and Social Adjustment Scale (WSAS) as a measure of dysfunction in chronic insomnia. Method: Seventy-three patients with chronic insomnia from three subsamples participated. All the patients completed the WSAS, the Insomnia Severity Index (ISI), and sleep diaries over one week. Results: An exploratory factor analysis suggested a one-factor solution for the WSAS, determining dysfunction, accounting for 73.7% of the variance. The internal consistency of the WSAS was α = .91. The test-retest reliability for the WSAS items was high at .90–.99 and for the entire scale .99. A cut-off at 17 points was established, discriminating those with subclinical versus moderate or severe clinical insomnia (88% sensitivity and 78% specificity). Evidence of convergent and criterion validity was documented via (1) a significant, positive association between the WSAS and ISI and (2) a higher WSAS score among those with severe clinical insomnia, relative to those with moderate clinical and subthreshold insomnia, as well as a higher WSAS score among those with moderate clinical insomnia relative to those with subthreshold insomnia. The WSAS was also shown to be a treatment-sensitive measure for insomnia patients. Conclusions: The WSAS appears as a reliable and valid measure of dysfunction in chronic insomnia. Additional advantages are its shortness, easiness, and treatment-sensitivity.

Background: Perceptual Control Theory (PCT) suggests that psychological distress can be conceptualized as the by-product of conflicted control systems. Method: Using a program of psychotherapy based on the principles of PCT called the Method of Levels (MOL), a 12-month study was conducted with 120 patient participants and 4 clinicians. In this study, analyses of statistical significance were conducted. Qualitative data were also analysed to understand psychotherapy from patients' perspectives. Data were collected on the attendance patterns of patients, their ages, referral problem, and socio-economic background. A standardized questionnaire measured pre and post treatment effects. The null hypothesis of no difference between pre and post treatment scores was examined by the derivation of p values and the construction of 95% confidence intervals. Results: In all cases the null hypothesis was rejected. Conclusions: Results suggest that MOL is a useful form of psychotherapy that warrants further investigation.