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.

Background: Psychoanalytic theory and some empirical research suggest the working alliance follows a “rupture and repair” pattern over the course of therapy, but given its emphasis on collaboration, cognitive behavioral therapy may yield a different trajectory. Aims: The current study compares the trajectory of the working alliance during two types of cognitive behavioral therapy for social anxiety disorder – virtual reality exposure therapy (VRE) and exposure group therapy (EGT), one of which (VRE) has been proposed to show lower levels of working alliance due to the physical barriers posed by the technology (e.g. no eye contact with therapist during exposure). Method: Following randomization, participants (N = 63) diagnosed with social anxiety disorder received eight sessions of manualized EGT or individual VRE and completed a standardized self-report measure of working alliance after each session. Results: Hierarchical linear modeling showed overall high levels of working alliance that changed in rates of growth over time; that is, increases in working alliance scores were steeper at the beginning of therapy and slowed towards the end of therapy. There were no differences in working alliance between the two treatment groups. Conclusion: Results neither support a rupture/repair pattern nor the idea that the working alliance is lower for VRE participants. Findings are consistent with the idea that different therapeutic approaches may yield different working alliance trajectories.

Greenberg, Rice and Elliott (1993) elaborate in detail different applications of the two-chair method within an experiential therapy framework. In the present paper we present an adapted two-chair method for use in cognitive therapy. The principal aims of the adapted method are to elaborate a positive self-schema that has an emotional (“lived”) quality, and to use this experience to create a new model of self as emotionally and cognitively varied and changing. Procedurally, the first two steps are to (1) summarize the negative self-schema (Chair 1) and (2) draw out a positive self-schema (Chair 2). In Steps 3 and 4 the client remains in Chair 2 and is encouraged to accept the two self-schemata, and to integrate them both within a broader, more diverse metacognitive model of self. We present key themes from analysis of two clients' reflections on the method, which highlight issues of generalization and the process of change, and conclude with clinical and research implications.

Treatment non-adherence is a common problem in mental health services but little is known about non-adherence to psychological therapy for psychosis. The main aim of the present study was to investigate the role of patients' recovery style and the therapeutic alliance in provoking or forestalling patient drop-out from cognitive behaviour therapy (CBT) for psychosis. Ratings were made by two independent observers on 29 recordings of sessions from a controlled trial of CBT for psychosis. Sessions of 10 patients who dropped out of treatment prematurely were matched with sessions of 10 patients who stayed in. Another nine sessions were selected at random from the middle and late stages of treatment so that the sample was representative of all sessions in the trial. Patients who dropped out of treatment, compared with those who stayed in, were less engaged in treatment, showed less agreement with their therapists, and had a sealing-over recovery style before they dropped out but did not differ in their therapeutic bonds. The results suggest that the premature termination of the drop-outs was not provoked by the therapists but was due to the patients' lack of curiosity about their psychotic episodes and minimization of the impact of their illness.

Background: Few measures exist to examine therapist empathy as it occurs in session. Aims: A 9-item observer rating scale, called the Therapist Empathy Scale (TES), was developed based on Watson's (1999) work to assess affective, cognitive, attitudinal, and attunement aspects of therapist empathy. The aim of this study was to evaluate the inter-rater reliability, internal consistency, and construct and criterion validity of the TES. Method: Raters evaluated therapist empathy in 315 client sessions conducted by 91 therapists, using data from a multi-site therapist training trial (Martino et al., 2010) in Motivational Interviewing (MI). Results: Inter-rater reliability (ICC = .87 to .91) and internal consistency (Cronbach's alpha = .94) were high. Confirmatory factor analyses indicated some support for single-factor fit. Convergent validity was supported by correlations between TES scores and MI fundamental adherence (r range .50 to .67) and competence scores (r range .56 to .69). Discriminant validity was indicated by negative or nonsignificant correlations between TES and MI-inconsistent behavior (r range .05 to −.33). Conclusions: The TES demonstrates excellent inter-rater reliability and internal consistency. Results indicate some support for a single-factor solution and convergent and discriminant validity. Future studies should examine the use of the TES to evaluate therapist empathy in different psychotherapy approaches and to determine the impact of therapist empathy on client outcome.

This study examined the effects of anticipatory processing on a subsequent speech in high and low socially anxious participants. Forty participants (n = 20 in each group) gave two speeches, one after no anticipatory processing and one after 10-minutes of anticipatory processing. In anticipatory processing, high socially anxious participants were more anxious, and experienced more negative and unhelpful self-images than low socially anxious participants did. However, both groups rated memories of past speeches as having a somewhat helpful effect on their speech preparation. High socially anxious participants tended to use the observer perspective more in the anticipated speech, while, in the unanticipated speech, they might have been switching between observer and field perspectives. Low socially anxious participants tended to use the field perspective in both speeches. High and low socially anxious participants reported better speech performances after the anticipated, compared to after the unanticipated speech. Results suggest that anticipatory processing may have both positive and negative effects on socially anxious individuals' cognitive processing and performance before and during a speech.

Background: An integrative cognitive model proposed that ascribing extreme personal appraisals to changes in internal state is key to the development of the symptoms of bipolar disorder. The Hypomanic Attitudes and Positive Predictions Inventory (HAPPI) was developed to measure these appraisals. Aims: The aim of the current study was to validate an expanded 61-item version of the HAPPI. Method: In a largely female student sample (N = 134), principal components analysis (PCA) was performed on the HAPPI. Associations between the HAPPI and analogue bipolar symptoms after 3 months were examined. Results: PCA of the HAPPI revealed six categories of belief: Self Activation, Self-and-Other Critical, Catastrophic, Extreme Appraisals of Social Approval, Appraisals of Extreme Agitation, and Loss of Control. The HAPPI predicted all analogue measures of hypomanic symptoms after 3 months when controlling for baseline symptoms. In a more stringent test incorporating other psychological measures, the HAPPI was independently associated only with activation (e.g. thoughts racing) at 3 months. Dependent dysfunctional attitudes predicted greater conflict (e.g. irritability), depression and reduced well-being, hypomanic personality predicted self-reported diagnostic bipolar symptoms, and behavioural dysregulation predicted depression. Conclusions: Extreme beliefs about internal states show a modest independent association with prospective analogue bipolar symptoms, alongside other psychological factors. Further work will be required to improve the factor structure of the HAPPI and study its validity in clinical samples.

This study describes the development and initial evaluation of a cognitive schema questionnaire for children. The Schema Questionnaire for Children (SQC) was designed to capture the 15 early maladaptive schemas proposed by Young (1990). Face validity of the questionnaire items as assessed by a group of CBT experts (n=16) was good. Concurrent validity was assessed by asking 47 school children aged 11–16 years of age to complete both the (SQC) and a British version of the 75 item Young's Schema Questionnaire short form (YSC-S). Significant correlations were obtained for 10 of the 15 schemas, with a further two approaching statistical significance. Although some of the correlations were modest, these initial results suggest that the SQC may be a valid quick and developmentally appropriate way of assessing Young's maladaptive schema in children.

The aim of the current study was to examine how belief in the validity of hallucinations relates to the association between hallucination frequency and associated distress. In a sample of inpatients with psychotic symptoms, results demonstrated that hallucination believability predicted later distress after controlling for symptom frequency. In addition, results were consistent with the hypothesis that hallucination believability mediated the frequency- distress link. Recent randomized controlled trials have supported the efficacy of cognitive behavior therapy for schizophrenia and related psychotic disorders. Further evidence suggests that cognitive behavioral approaches that incorporate mindfulness and acceptance-based strategies may be effective in reducing the believability of positive symptoms. Future trials incorporating longitudinal designs and more detailed assessments of these variables are needed.

Childhood anxiety disorders often have a poor prognosis. Despite this, there are currently no published treatment protocols for young children with anxiety difficulties. Individually focused therapies (e.g. CBT) are useful for older children, but likely to be less so for this group. This paper describes a pilot investigation of a new CBT based parenting intervention for the treatment of children aged 9 years and under. Sixteen parents of 11 anxious children took part in a 10-week intervention, completing the Child Behaviour Checklist at three time points. The intervention was based on a new cognitively enhanced parenting package, with an emphasis on coping with internalizing symptoms, and with additional modules on the specific skills needed for managing anxiety. All children were reported to experience substantial decreases in their internalizing symptoms by the end of the study. Parents' satisfaction with the intervention was high. This is a promising new intervention for the treatment of a currently neglected group.

This study investigated whether brief training in cognitive therapy for panic disorder (Clark et al., 1994) can improve the outcomes that primary care therapists obtain with their patients. Seven primary care therapists treated 36 patients meeting DSM-IV (APA, 1994) criteria for panic disorder with or without agoraphobia in general practice surgeries. Outcomes for the cohort of patients whom the therapists treated with their usual methods (treatment-as-usual) before the training (N = 12) were compared with those obtained with similar patients treated by the same therapists after brief training and ongoing supervision in cognitive therapy (CT) for panic disorder (N = 24). Treatment-as-usual led to significant improvements in panic severity, general anxiety, and depression. However, only a small proportion (17% of the intent-to-treat sample) became panic free and there was no improvement in agoraphobic avoidance. Patients treated with CT achieved significantly better outcomes on all measures of panic attacks, including panic-free rate (54%, intent-to-treat), and showed significantly greater improvements in agoraphobic avoidance and patient-rated general anxiety. In conclusion, cognitive therapy for panic disorder can be successfully disseminated in primary care with a brief therapist training and supervision programme that leads to significant improvements in patient outcomes.

In selected adult neurotics, nurse-therapists have a significant contribution to make in giving behavioural psychotherapy to patients who were formerly denied it for lack of trained personnel (Marks et al. 1977). Perhaps 10% of all adult psychiatric outpatients can benefit from behavioural psychotherapy as the main approach for those categories of problem where established behavioural methods have been found to be superior to contrasting treatments (Marks, 1976).

This study aims to explore help-seeking thresholds, beliefs and attitudes about depression and establish how these are affected by previous treatment for depression, the type of treatment received, and current depression. Participants were a cohort of 42 individuals previously diagnosed with Major Depressive Disorder (MDD) in two groups according to previous treatment for depression; 12 individuals previously diagnosed with a psychological disorder other than MDD; and 48 individuals from a community sample. Five self-report questionnaires measured thresholds for help-seeking, beliefs about depression, current depression and self-management skills. Between-group comparisons were made for help-seeking thresholds and beliefs about depression. Results showed lower thresholds for professional help-seeking in those who had previously received psychological treatment than in those treated with antidepressants only and non-clinical controls. Perceived stigma was negatively associated with help-seeking. Depressed mood was associated with delayed help-seeking and symptom recognition, even in those who had previously received treatment for depression. We conclude that relapse prevention interventions may educate patients about the effects of depression on help-seeking. Further research should clarify the extent to which help-seeking co-varies with depressed mood. More work is needed to reduce the stigma associated with depression.

Background: The effectiveness of enhanced cognitive behavioural Therapy (CBT-E) for adults with a range of eating disorder presentations within routine clinical settings has been examined in only two known published studies, neither of which included a follow-up assessment period. Aim: The current study aimed to evaluate the effectiveness of CBT-E within an out-patient eating disorder service in Brisbane, Queensland, Australia, and incorporated a follow-up assessment period of approximately 20 weeks post-treatment. Method: The study involved 114 adult females with a diagnosed eating disorder, who attended an average of 20–40 individual CBT-E sessions with a psychologist or a psychiatry registrar between 2009 and 2013. Results: Of those who began treatment, 50% did not complete treatment, and the presence of psychosocial and environmental problems predicted drop-out. Amongst treatment completers, statistically and clinically significant improvements in eating disorder and general psychopathology were observed at post-treatment, which were generally maintained at the 20-week follow-up. Statistically significant improvements in eating disorder and general psychopathology were observed amongst the total sample. Conclusions: The findings, which were comparable to the previous Australian effectiveness study of CBT-E, indicate that CBT-E is an effective treatment for adults with all eating disorders within out-patient settings. Given the high attrition rate, however, minimizing drop-out appears to be an important consideration when implementing CBT-E within clinical settings.

Background: When using Motivational Interviewing (MI), once resistance or ambivalence are resolved and motivation is solidified, many practitioners struggle with how best to transition the discussion toward action planning, while still retaining the spirit and style of client centeredness, i.e., moving from the WHY phase to the HOW phase of counseling in a style that is MI-consistent. For many, there is a perception that the counseling style, skills, and strategies used to build motivation are distinct from those used in the action planning phase. The WHY to HOW transition does not, however, necessitate abandoning a client-centered style for a more overtly educational or directive style. Goal setting, action planning, provision of advice, and relapse prevention can be implemented from an autonomy supportive, MI consistent framework. Method: To this end, this article will present a new class of reflection, which we have termed “action reflections”, that can be used to help bridge the WHY-HOW gap. Action reflections (AR) allow the clinician to maintain a tone and orientation that are consistent with MI, i.e. autonomy support; guiding versus directing, during the action phase of counseling. They differ from reflecting change talk as they focus not on the WHY of change, but the HOW, WHEN, or WHERE. Action Reflections (ARs) also differ from the more common type of reflections such as those that focus on client feelings, rolling with resistance, or acknowledging ambivalence as ARs usually contain a potential concrete step that the client has directly or obliquely mentioned. Like any type of reflection, ARs represent the clinician's best guess for what the client has said or, more apropos here, where the conversation might be heading. Conclusion: This article describes the various types of ARs and provides examples of each to help clinicians incorporate them into their behavior change counseling.

An eighteen month follow-up of chronic nightmare sufferers treated with imagery rehearsal, a cognitive-behavioral method, demonstrated significant and clinically meaningful decreases in nightmare frequency. Sixty-eight percent of subjects decreased their nightmares below criteria for a “Chronic Nightmare Disorder”. Significant improvement was also noted for sleep quality and daytime anxiety. The findings support the theory that nightmares may be clinically conceptualized as a primary sleep disorder in some chronic sufferers.

Background: Factors that distinguish depressed individuals who become hopeless from those who do not are poorly understood. Method: In this study, predictors of hopelessness were examined in a sample of 439 clinically depressed adolescents participating in the Treatment for Adolescents with Depression Study (TADS). The total score of the Beck Hopelessness Scale (BHS) was used to assess hopelessness at baseline. Multiple regression and logistic regression analyses were conducted to evaluate the extent to which variables were associated with hopelessness and determine which cluster of measures best predicted clinically significantly hopelessness. Results: Hopelessness was associated with greater depression severity, poor social problem-solving, cognitive distortions, and family conflict. View of self, view of the world, internal attributional style, need for social approval, positive problem-solving orientation, and family problems consistently emerged as the best predictors of hopelessness in depressed youth. Conclusions: Cognitive and familial factors predict those depressed youth who have high levels of hopelessness.

A 4-year follow-up compared the long-term effects of two treatments for severely conduct disorder children referred to a Child and Adolescent Mental Health Service (CAMHS). Forty-two families received either the standard CAMHS treatment or a more intensive intervention. The intensive treatment involved a unit-based component for parents to practise new child management strategies. At the 6-month follow-up the intensive treatment group showed significant improvements on all measures of child behaviour and maternal mental health and improvements remained significant at the 4-year follow-up. By contrast, initial improvements for the standard treatment group, which were significant on only two measures, were not significant at the 4-year follow-up. The results suggest that the intensive treatment was advantageous in bringing about long-term improvements for these families. They also add to the growing evidence that interventions involving the rehearsal of child management strategies have better outcomes than those using more didactic methods of parent training.

This study investigated the role of metacognitions in high-dependency smokers, low-dependency smokers and non-smokers. A sample of high-dependency smokers (n = 27), low-dependency smokers (n = 33), and non-smokers (n = 43) completed self-report measures of negative emotion, metacognitions and smoking dependence. Results indicated that high-dependency smokers scored higher than non-smokers on Positive Beliefs about Worry. Furthermore on Beliefs about the Need to Control Thoughts high and low-dependency smokers scored higher than non-smokers. A logistic regression analysis indicated that Beliefs about the Need to Control Thoughts were the only predictor of classification as a dependent smoker when controlling for negative emotion. These results are consistent with a metacognitive conceptualization of smoking dependence.

Background: Cognitive behavioural therapy for psychosis (CBTp) is currently a recommended form of psychosocial treatment for persons suffering from persistent psychotic symptoms. It has been argued that effect sizes from efficacy studies cannot be generalized to real clinical settings. Aims: Our aim was to evaluate whether the positive results from randomized controlled trials conducted by experts could be replicated in clinical setting with a heterogeneous sample of patients with psychotic disorder. Method: Patients referred to the study were either randomized to CBTp + TAU (the treatment group) or to a waiting-list group, only receiving TAU. The patients were assessed on different outcome measures such as the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Negative Symptoms (SANS), and the Psychotic Symptom Rating Scales (PSYRATS), at pretreatment, at posttreatment (6 months), and at 12 months follow-up. In total, 45 patients participated in the study. Results: The results showed that 20 sessions of CBTp performed significantly better than the waiting list controls with respect to the global score on the BPRS, the delusional scale on the PSYRATS, and the GAF symptom score at posttreatment. At 12 months follow-up only the GAF symptom score remained significantly changed for the total sample. Conclusions: The study revealed that CBTp delivered by non-experts in routine clinical settings can produce improvements in positive psychotic symptoms, and also that some of these improvements can be maintained at one year follow-up.