Self-help materials can be offered to clients/patients either for use alone (unsupported self-help) or to support work with a health care practitioner (supported self-help). Structured self-help materials that use a Cognitive Behaviour Therapy (CBT) treatment approach have been shown to be clinically effective. We report a national survey of all 500 cognitive and behavioural psychotherapists registered with the British Association for Behavioural and Cognitive Psychotherapies, the lead organisation for CBT in the United Kingdom. A total of 265 therapists responded (53%). Self-help materials were used by 88.7% of therapists and were mostly provided as a supplement to individual therapy. Self-help was most frequently used to help patients experiencing depression, anxiety and obsessive compulsive disorder and was largely delivered using paper-based formats. The majority of self-help materials used a CBT approach. Only 36.2% of therapists had been trained in how to use self-help treatments, and those who had received training recommended self-help treatments to more clients/patients per week and rated self-help approaches as being significantly more helpful than those who had not received training.

Background: The IAPT services provide high and low intensity psychological treatments for adults suffering from depression and anxiety disorders using a stepped care model. The latest national evaluation study reported an average recovery rate of 42%. However, this figure varied widely between services, with better outcomes associated with higher “step-up” rates between low and high intensity treatments. Aims: This study aimed to compare the two intensity groups in an IAPT service in Suffolk. Method: This study adopted a between groups design. A sample of 100 service users was randomly selected from the data collected from an IAPT service in Suffolk between May 2008 and February 2011. The treatment outcomes, drop-out rate, and other characteristics were compared between those who received high and low intensity treatments. Results: The high intensity group received, on average, more sessions and contact time. They received more CBT sessions and less guided self-help. There were no group differences in terms of the drop-out and appointment cancellation rates. Analyses on clinical outcomes suggested no group difference but demonstrated an overall recovery rate of 52.6% and significant reduction in both depression and anxiety symptoms. Conclusions: Despite methodological limitations, this study concludes that the service as a whole achieved above-average clinical outcomes. Further research building upon the current study in unpacking the relative strengths and weaknesses for the high and low intensity treatments would be beneficial for service delivery.

Background: Acquiring proficiency in motivational interviewing (MI) may be more difficult than generally believed, and training research suggests that the standard one-time workshop format may be insufficient. Although nurses represent one of the professions that have received most training in MI, training in this group has rarely been systematically evaluated using objective behavioral measures. Aims: To evaluate an enhanced MI training program, comprising a 3.5-day workshop, systematic feedback on MI performance, and four sessions of supervision on practice samples. Methods: Nurses (n = 36) in Swedish child health services were trained in MI. Skillfulness in MI was assessed using the Motivational Interviewing Treatment Integrity (MITI) Code. Effects of training were compared to beginning proficiency thresholds. Results: Participants did not reach beginning proficiency thresholds on any of the indicators of proficiency and effect sizes were small. Conclusions: The present study adds to a growing body of literature suggesting that the current standard MI training format may not provide practitioners with enough skillfulness. Moreover, the results indicate that even enhanced training, including systematic feedback and supervision, may not be sufficient. Suggestions for improved MI training are made.

Background: This paper investigates the relationship between care staff perceptions' of self-harm behaviours presented by adult and adolescent inpatients and the emotional responses and helping behaviours of the staff. Method: Seventy-six nursing staff participated, including qualified and unqualified staff, who worked in either adolescent or adult secure inpatient settings within a single organization. Participants completed vignette, knowledge, and attitudes questionnaires, related to working with patients who display deliberate self-harm. Results: Further support was found for attributional theories suggesting that views on deliberate self-harm are linked to propensity to help, and that emotional responses can be a mediating factor. Staff who reported feeling more negative about patients who self-harm reported more worry about working with this patient group. Unqualified nursing staff reported more negativity and worry than qualified staff. Neither gender nor length of work experience was found to be significant factors. Conclusions: These findings indicate that training and support should be aimed at helping nursing staff, particularly unqualified staff working in inpatient settings where self-harm is frequent, feel more positive and less concerned about working with patients who self-harm. Such needs of unqualified nursing staff have not been highlighted in previous research.

Background: Virtual reality exposure therapy (VRET) has been used to treat a variety of fears and phobias. Aim: To determine the feasibility (i.e. safety and efficacy) of using VRET to treat dental phobia. Method: Safety was evaluated by determining any adverse events or symptom exacerbation. Efficacy of VRET was evaluated by comparing the reduction in dental anxiety scores (measured 16 times within a 14-week study period, and at 6-month follow-up), and its behavioural effects with that of an informational pamphlet (IP) on ten randomized patients with dental phobia using a controlled multiple baseline design. Participants’ heart rate response during VRET, and their experience post-VRET, were indexed. Results: No personal adverse events or symptom exacerbation occurred. Visual analysis and post-hoc intention-to-treat analysis showed a significantly greater decrease in dental anxiety scores [higher PND (percentage of non-overlap data) scores of 100% and lower POD (percentage of overlap data) of 0%, Modified Dental Anxiety Scale, F (1,8) = 8.61, p = 0.019, and Dental Fear Scale, F (1,8) = 10.53, p = 0.012], and behavioural avoidance in the VRET compared with the IP group [d = 4.2 and –1.4, respectively). There was no increase in average heart rate during VRET. Of the nine treatment completers, six (four from the VRET group and two from the IP group) no longer had dental phobia at 6-month follow-up. Four of the five VRET participants, but none of the IP participants, scheduled a dental treatment appointment following the intervention. Conclusion: VRET is a feasible alternative for patients with dental phobia.

Cognitive models of obsessive compulsive disorder (OCD) have been influential in understanding and treating the disorder in adults. Cognitive models may also be applicable to children and adolescents and would have important implications for treatment. The aim of this systematic review was to evaluate research that examined the applicability of the cognitive model of OCD to children and adolescents. Inclusion criteria were set broadly but most studies identified included data regarding responsibility appraisals, thought-action fusion or meta-cognitive models of OCD in children or adolescents. Eleven studies were identified in a systematic literature search. Seven studies were with non clinical samples, and 10 studies were cross-sectional. Only one study did not support cognitive models of OCD in children and adolescents and this was with a clinical sample and was the only experimental study. Overall, the results strongly supported the applicability of cognitive models of OCD to children and young people. There were, however, clear gaps in the literature. Future research should include experimental studies, clinical groups, and should test which of the different models provide more explanatory power.

It is argued that normalization and applied behaviour analysis represent the most significant developments of the past two decades in approaches to the design of services for people with learning difficulties. Problems in translating these approaches into practice have been compounded by an apparent conflict between them. The nature of this conflict is examined and suggestions for a rapprochement are made.

Shapiro and Shapiro (1982) argue the case that meta-analysis has made, and will increasingly make, an important contribution to the evaluation of the effects of psychological therapies. Briefly stated, they make the following claims for meta-analysis: (1) Meta-analysis provides systematic and quantitative methods for summarizing and integrating the voluminous and diverse literature on psychotherapy. (2) Meta-analysis reduces (eliminates?) the subjective bias that is said to vitiate traditional, qualitative reviews of the literature. Consistent with similar allegations by Smith et al. (1980), Shapiro and Shapiro (1982) suggest that the conclusions drawn in “some” of these traditional reviews “are a function of the assumptions, predispositions and consequent biases of the reviewer.” Meta-analysis, however, is put forward as a distinct alternative to this sorry state of affairs, since it purportedly overcomes these sources of personal and professional bias and results in more objective more accurate evaluations of the evidence. (3) Meta-analysis has “the same superiority over a traditional literature review as that enjoyed by a systematic therapy outcome study over a series of impressionistic case reports.” (4) The advent of objective, quantitative meta-analytic procedures does not abolish the need for traditional literature reviews subjective and qualitative as they might be. The latter have their limited place, just as impressionistic clinical case reports can complement well-controlled experimental outcome studies.

In this pilot study the influences of the media on suicidal ideation and behaviour were investigated through interviews with patients who had recently engaged in an episode of self-harm. They were asked about the impact of individual media stories, how they had first learned about suicide and the role of the media in the formation of images related to self-harm. Twelve patients between the ages of 17 and 25 were interviewed using a semi-structured interview. Most of the patients reported being affected by a story presented in the media; four reported that a story had prompted them to self-harm. Some also reported beneficial effects of the media on self-harming behaviour, either in terms of preventing an act or encouraging help seeking. This study has shown that in-depth interviews using qualitative and quantitative methods can provide new information about influences of the media on suicidal behaviour.

Procrastination can have deleterious effects on well-being. Despite this, little is known about cognitive-attentional processes involved in procrastination. In this study, 12 individuals self-reporting problematic procrastination were assessed using a semi-structured interview to investigate: (1) whether they held positive and/or negative metacognitive beliefs about procrastination; (2) what was their main goal in procrastinating, and how they knew if they had achieved their goal; (3) how they directed their focus of attention when procrastinating; and (4) what they perceived the advantages and disadvantages of these attentional strategies to be. Results indicated that participants endorsed both positive and negative metacognitive beliefs about procrastination, and that the goal of procrastination was to regulate cognition and negative affect. Participants reported that they either did not know how to determine if they had achieved their goal or that an improvement in mood would signal the goal was achieved. Participants also reported that the principal object of their attentional focus when procrastinating was their emotional state. All participants were able to identify disadvantages to their attentional strategies, whilst nine participants described perceived advantages. The implications of the findings are discussed.

Background: The long-term effectiveness of parent training for children with externalizing behaviour problems under routine care within the German health care system is unclear. We report the 1-year follow-up results of the parent training component of the Prevention Program for Externalizing Problem Behaviour (PEP) for 270 children aged 3–10 years with externalizing behaviour problems. Method: Outcome measures included child behaviour problems (externalizing behaviour problems, Attention-Deficit/Hyperactivity Disorder symptoms and Oppositional Defiant Disorder symptoms) and parenting (self efficacy of parenting and perceived ability to solve difficult parenting situations). Data were analysed using multilevel modelling. Results: Comparison of the changes during the 3-month waiting and treatment periods revealed significantly stronger treatment effects on all outcome measures, indicating a substantial decrease in child behaviour problems and a significant increase in parenting due to treatment. At 1-year follow-up, initial treatment effects on child behaviour problems were maintained, while parenting continued to improve. Conclusions: Families whose children exhibited externalizing problem behaviour profit from PEP and improvements are maintained for at least one year.

In recent years that has been an increasing interest in supervision within the UK's cognitive behaviour therapy (CBT) community. This is because the role of supervision has begun to be recognized in relation to the delivery of effective clinical services (Department of Health, 1998), and because of a clear recognition of the need to ensure that CBT practitioners are competent. Perhaps less well recognized in CBT are a number of interesting educational approaches to supervision, ones that may make supervision more successful. This paper summarizes some of these theories from a CBT perspective. Whilst the evidence base does not yet justify being too prescriptive, it is argued that some of these theories, such as Vygotsky's notion of the “Zone of Proximal Development”, provide helpful prompts for reflecting on CBT supervision. An integrative model is constructed from these theories, with illustrative examples and suggestions for future research.

Several previous studies have reported that cognitive/behavioural treatments have been relatively ineffective for chronic, drug-resistant depressed patients. In the present report, six chronic, drug-resistant depressed patients were treated with an integrated program consisting of cognitive/behavioural treatment, pharmacotherapy, and short term hospitalization. The obtained improvement rates were substantially better than previous studies. Potential explanations for these findings are discussed.

Forty patients suffering from persistent psychophysiological Disorders of Initiating and Maintaining Sleep (DIMS) were assigned to one of the following groups: (1) EMG-biofeedback training; (2) cognitive modification treatment, combining paradoxical instructions, cognitive restructuring and thought stopping; (3) stimulus control and progressive relaxation treatment; (4) waiting list (control). Each active treatment consisted of six sessions over a period of 2 weeks.

After treatment, the patients in the three treatment groups showed shorter sleep onset latency (37%), shorter wake time after sleep onset (50%), and more positive evaluations of sleep quality and restedness on awakening in the morning. The waiting-list group did not show any changes. Benefits were maintained and further increased during the 1 and 3 year follow-ups. Results did not suggest substantial differences, among the three treatments, in amount and/or stability of benefits. The 3 year follow-up revealed seven failures, as against 23 successes. The initial variables differentiating the failures were shorter sleep time and higher scores on the P scale of the Eysenck Personality Questionnaire.

Background: Clark and Wells’ cognitive model of social anxiety proposes that socially anxious individuals have negative expectations of performance prior to a social event, focus their attention predominantly on themselves and on their negative self-evaluations during an event, and use this negative self-processing to infer that other people are judging them harshly. Aims: The present study tested these propositions. Method: The study used a community sample of 161 adolescents aged 14–18 years. The participants gave a speech in front of a pre-recorded audience acting neutrally, and participants were aware that the projected audience was pre-recorded. Results: As expected, participants with higher levels of social anxiety had more negative performance expectations, higher self-focused attention, and more negative perceptions of the audience. Negative performance expectations and self-focused attention were found to mediate the relationship between social anxiety and audience perception. Conclusions: The findings support Clark and Wells’ cognitive model of social anxiety, which poses that socially anxious individuals have distorted perceptions of the responses of other people because their perceptions are coloured by their negative thoughts and feelings.

Background: Growing evidence supports the association between early memories of shame and lack of safeness and current shame and depression. Nevertheless, it is unclear whether shame serves as a mediator between such early memories and depressive symptoms. Aims: This study aimed at testing whether the impact of shame traumatic memory, centrality of shame memory, early memories of warmth and safeness (predictors), on depressive symptoms (outcome) would be mediated by current external and internal shame. Method: Student participants (N = 178) recalled an early shame experience and completed self-report instruments measuring centrality and traumatic characteristics of the shame memory, early memories of warmth and safeness, external and internal shame and depressive symptoms. Results: Path analysis’ results revealed that internal shame fully mediated the relationship between shame traumatic memory, centrality of shame memory, and early memories of warmth and safeness, and depression. However, current feelings of external shame, highly linked to internal shame, did not significantly predict depression. Conclusion: These findings shed light on the role of internalizing early shame and lack of safeness memories into a sense of self as globally self-condemning in the vulnerability to experience depressive symptoms.

Background: Self-esteem is an important factor in the development and maintenance of good psychological health. Low self-esteem can be a consequence of mental health disorders (such as depression, anxiety and panic) or it can be a vulnerability factor for the development of such problems. Aims and method: The current study reports pilot findings from a Cognitive Behavioural Therapy (CBT) group intervention for 37 adult women with low self-esteem, based on Fennell's Overcoming Low Self-Esteem Self-Help Course. Results: Findings suggest that the group is (statistically and clinically) effective at increasing levels of self-esteem and at reducing levels of depression and anxiety. Conclusions: Together, results suggest that the group provides an efficient and therapeutically beneficial service. However, since these findings are limited by the lack of control or follow-up data, they warrant further investigation.

Background: Women in secure psychiatric settings have gender specific treatment needs. The current study examined the feasibility of a Dealing with Feelings Skills Group training for dual diagnosis women admitted to a medium secure setting. Method: A pre-test – post-test design was used to evaluate a group programme adapted from dialectical behaviour therapy skills training. Results: Most patients had a primary diagnosis of personality disorder. Treatment completers (n = 29) were compared with non-completers (n = 15). Clinically significant changes in treatment completers were apparent on coping response measures of positive reappraisal, problem solving and alternative rewards; on measures of anxiety and suicidality; on self-reported ability to engage in activities to reduce negative mood and to recognize mood changes. Self-harming and aggressive behaviours also reduced in the 3 months following group treatment. Conclusion: An adapted coping skills component of DBT benefit many dual diagnosis patients: issues related to treatment drop-out and failure to benefit are discussed.

Background: Perinatal mental health difficulties are highly prevalent. In England, the Improving Access to Psychological Therapy (IAPT) programme provides evidence-based psychological treatment, predominantly in the form of brief manualized cognitive behavioural therapy (CBT), to people with mild to moderate depression or anxiety. Yet little is known about the experiences of women referred to IAPT with perinatal mental health difficulties. Aims: The aim of this qualitative study was to investigate how women view IAPT support for perinatal mental health. We also gained the perspective of IAPT therapists. Method: Semi-structured interviews were conducted with twelve women who had been referred to and/or received therapy from IAPT during the perinatal period. Additionally, fourteen IAPT therapists participated in two focus groups. Thematic analysis was used. Results: Key themes centred on barriers to access and the need to tailor support to (expectant) mothers. Women and therapists suggested that experiences could be improved by supporting healthcare professionals to provide women with more help with referrals, better tailoring support to the perinatal context, improving perinatal-specific training, supervision and resources, and offering a more individualized treatment environment. Conclusions: Overall, women reported positive experiences of support offered by IAPT for perinatal mental health difficulties. However, services should seek to facilitate access to support and to enable therapists to better tailor treatment.

Self-efficacy is a potentially useful concept when applied to Social Anxiety Disorder (SAD). The aims of the current study were to examine the psychometric properties of the Self-Efficacy for Social Situations Scale (SESS; Gaudiano and Herbert, 2003) and to investigate the relationship between self-efficacy and anxiety in an adolescent sample with generalized SAD. Results replicated those found in a previous adult SAD sample. The SESS showed high internal consistency and good construct and criterion-related validity. The SESS also predicted subjective anxiety and perceived performance in social role play tests after controlling for social anxiety severity. Furthermore, self-efficacy more clearly predicted self-ratings in contrast to observer ratings of performance in social role play tests. Finally, changes in social self-efficacy were strongly associated with changes in social anxiety symptoms following treatment, even after controlling for changes in fear of negative evaluation. Treatment implications for adolescent SAD are discussed.