Background: The impact of alcohol use disorders (AUD) on psychological treatments for depression or anxiety in primary care psychological treatment services is unknown. Aims: To establish levels of alcohol misuse in an Improving Access to Psychological Therapies (IAPT) service, examine the impact of higher risk drinking on IAPT treatment outcomes and drop-out, and to inform good practice in working with alcohol misuse in IAPT services. Method: 3643 patients completed a brief questionnaire on alcohol use pre-treatment in addition to measures of depression, anxiety and functioning. Symptom and functioning measures were re-administered at all treatment sessions. Results: Severity of alcohol misuse was not associated with treatment outcomes, although those scoring eight or more on the AUDIT-C were more likely to drop out from treatment. Conclusions: IAPT services may be well placed to offer psychological therapies to patients with common mental disorders and comorbid AUD. Patients with AUD can have equivalent treatment outcomes to those without AUD, but some higher risk drinkers may find accessing IAPT treatment more difficult as they are more likely to drop out. Alcohol misuse on its own should not be used as an exclusion criterion from IAPT services. Recommendations are given as to how clinicians can: adjust their assessments to consider the appropriateness of IAPT treatment for patients that misuse alcohol, consider the potential impact of alcohol misuse on treatment, and improve engagement in treatment for higher risk drinkers.

Background: Utero-vaginal agenesis, also called the Mayer-Rokitansky-Küster-Hauser Syndrome (MRKH), is a congenital abnormality of the female genital tract, characterized by the non-formation of the vagina and the uterus. It is a common cause of primary amenorrhoea. Little is known about the psychological impact and management of this condition. Method: We describe a specific model of the core negative psychological impact of diagnosis and medical treatment of MRKH and a cognitive-behavioural therapy of MRKH based on the model (CBT-MRKH). The Medical Research Council's (2002) framework for the development and evaluation of complex health interventions was used for intervention development and evaluation. Results: Evidence from a recent cross-sectional study and a small randomized controlled trial (RCT) provides preliminary support for the model and treatment (Heller-Boersma, Schmidt and Edmonds, in press; Heller-Boersma, Schmidt and Edmonds, 2007), and this is further validated by extensive qualitative material gathered over the course of the RCT from participants. Conclusions: The model and treatment described may also be applicable to a number of other congenital or acquired gynaecological conditions such as premature ovarian failure, breast cancer, early onset endometrial cancer, female genital mutilation, Turner's Syndrome, ovarian dys/agenesis or, Complete Androgen Insensitivity Syndrome, all of which have a psychological impact not dissimilar to MRKH in terms of these women's sense of self and femininity.

Previous research has found an association between adult attachment style and symptoms of depression among university students and indicated that this relationship may be mediated by dysfunctional attitudes. The present study represents an initial step toward extending these findings to a clinical sample with more severe forms of depression. A sample of psychiatric outpatients diagnosed with major depressive disorder (n = 54) completed measures of adult attachment style, dysfunctional attitudes, and depression. An association was found between insecure attachment style and depression severity. This association was partially mediated by dysfunctional attitudes. These findings are consistent with cognitive-interpersonal models of depression that propose that adverse early experiences may contribute to vulnerability for depression through the establishment of dysfunctional attitudes.

Recent developments in the understanding, assessment and treatment of suicidal behaviour are reviewed. The accumulated social and demographic knowledge of suicidal populations has proved to be clinically useful in shaping the general level of concern, but at the individual level an understanding of the psychological processes involved in suicidal behaviour is required. Studies examining psychological processes involved in suicidal behaviour is required. Studies examining psychological processes in parasuicidal groups have revealed a number of deficits, including poor interpersonal problem solving, hopelessness about the future, and reduced ability to regulate affect. Research has also begun to look at some of the processes underlying these deficits, such as over-general retrieval of autobiographical memories and reduced anticipation of specific positive experiences. The clinical picture is now more optimistic, with therapies, such as Dialectical Behaviour Therapy, which focus on using problem solving strategies with those clients who are most vulnerable to repeat parasuicide episodes, producing demonstrable delays in parasuicide and reduced risk of repetition. The importance of the relationship between research and clinical practice is emphasized.

The extent of intrusive traumatic memories of upsetting childhood experiences was investigated in independent samples of female subjects: out-patients with a primary diagnosis of unipolar major depression, women recovered from clinical depression, and healthy controls who had never experienced major depression. Subjects completed self-report questionnaires to measure levels of depression, and intrusive memories of traumatic childhood events. There were no differences between the groups in whether or not they experienced intrusive memories, but severity of intrusions varied significantly. The depressed sample reported significantly more intrusion and avoidance than the recovered or control groups, and the recovered sample reported normal levels of intrusion but higher levels of avoidance of traumatic memories than controls. Severely depressed subjects reported significantly higher levels of intrusion and avoidance than moderately depressed subjects. Implications for psychological models and for the treatment of depression are discussed.

In an experimental study with panic agoraphobic patients, generalized anxiety patients and normals we operationally defined and measured spatial orientation of the three research groups. The observation, that patients suffering from agoraphobia have a very narrow exploratory activity range, is as important from the point of view of therapy as theory. Our study observed panic agoraphobic patients through their exploratory abilities. We examine panic agoraphobic, generalized anxiety and normal subjects, as they utilized their exploration skills in a complicated maze. We determined that the cognitive maps drawn by the panic agoraphobic patients are inaccurate. They got lost more often and utilized far fewer navigation points during their walk in the maze, compared to the generalized anxiety or normal subjects. The frame of the conceptualization was based on personal attentional strategies, spatial orientation deficit, and exploratory activity abnormalities.

Background: Social anxiety is a common problem among people who are recovering from psychosis. At present there is no evidence based psychological treatment targeting social anxiety in this population. Cognitive Bias Modification for Interpretation (CBM-I) has been shown to be effective in reducing social anxiety in people who do not have a history of psychosis. Aims: To assess the feasibility and acceptability of the CBM-I methodology for use in a clinical setting with people who are experiencing social anxiety following an episode of psychosis. Method: Eight participants with social anxiety were recruited from an early intervention service. A single session of computerized CBM-I was conducted, with mood and cognitive interpretation bias being assessed before and after the session. Results: All participants reported an improvement in mood immediately following the CBM-I session (n = 8). For those participants who had a negative interpretation bias, none became more negative following the CBM-I session, with three out of six participants showing a beneficial change. Conclusion: These results suggest that CBM-I is acceptable for use with people who are experiencing social anxiety following a psychotic episode. Further research looking at how CBM-I could be made more interactive and producing more applicable scenarios for use in a clinical setting is recommended.

Background: This study adds to the body of evidence regarding the theoretical underpinnings of interpersonal psychotherapy and the mechanisms through which it impacts upon depression in adolescents. Aims: The aims were to determine whether the interpersonal constructs proposed to underpin interpersonal psychotherapy do indeed change in response to this therapy and whether such changes are associated with changes in depression in young people. Method: Thirty-nine adolescents, aged 13–19 years, with a primary diagnosis of major depressive disorder, were randomly assigned in blocks to group or individual treatment. Assessments were conducted at pre and posttreatment, and 12-month follow-up. Results: The results supported the hypotheses, with significant improvements in social skills, social functioning, and the quality of parent-adolescent relationships, and an increase in secure attachment style and decrease in insecure attachment style being evident following treatment. Benefits were maintained at 12-month follow-up. Adolescents who showed greater reductions in depressive symptoms over this period tended to also show greater improvement in parent reported social skills, quality of the parent-adolescent relationship, and attachment style from pretreatment to 12-month follow-up. Conclusions: The findings are consistent with the proposed underpinnings of interpersonal psychotherapy. Adolescents showed significant improvements in interpersonal functioning and changes in attachment style following treatment, and changes in social skills, parent-adolescent conflict and attachment style were associated with reductions in depression. As such, the results add to the body of knowledge regarding the construct validity of interpersonal psychotherapy as an intervention for depression in young people. Clinical implications and directions for future research are discussed.

Background: Alcohol dependence is known to impact upon sleep, and poor sleep has been shown to affect relapse rates following treatment for alcohol dependence. Aims: The aim of this study was to investigate the association between sleep problems and relapse in dependent drinkers in an inpatient setting. This was done by studying sleep related cognitions in individuals undergoing medically assisted alcohol withdrawal. Method: Sleep and sleep-related cognitions data were collected for 71 individuals undergoing detoxification treatment. Sleep was measured using sleep diaries and actigraph motion monitors. Participants completed sleep-related cognition questionnaires and were subject to telephone follow-up interviews. The results were then used to predict relapse rates 4 weeks after discharge. Results: Longer sleep onset latency recorded on the unit predicted relapse at 4 weeks. Higher dysfunctional beliefs about sleep were found to be associated with lower relapse rates. Conclusions: This study suggests that some dysfunctional beliefs about sleep may support recovery following discharge from treatment. The study further supports the need for tailored cognitive-behavioural treatments for sleep difficulties in this population to reduce relapse rates.

In this paper, we describe the progress of four male, legally-detained personality disordered offenders in a group treatment programme for angry aggression. “Controlling angry aggression” is a 15-session, structured, cognitive-behavioural programme that is part of a wider integrated, multidisciplinary treatment programme run within a specialist personality disorder treatment unit. Psychometric tests showed that three of the four patients improved over the course of the treatment programme. Behaviour ratings of staff and patients concurred, allowing confidence in patients' self-report of anger. No change in behaviour was evident over time for any patient, but initial low rates of aggression allowed little room for improvement. Self-monitored anger and aggression scores did vary markedly over time, and since behaviour remains stable despite anger, this indicates that these patients can control their behaviour. One patient did not improve, and reasons for this are examined, concluding with a reminder of the need for rigorous selection of patients for treatment programmes.

Aims: The purpose of this study was to investigate the cognitions of anxious school refusers. The cognitive constructs under investigation included negative cognition commonly linked to youth anxiety (i.e. negative automatic thoughts and cognitive errors) and positive automatic thoughts. Method: The cognition of school refusers (n = 50) and youth from a community sample (n = 181) was assessed with the Children's Automatic Thoughts Scale-Negative/Positive and the Children's Negative Cognitive Error Questionnaire-Revised. Results: When controlling for anxiety, school refusers were found to report more negative automatic thoughts concerning personal failure, fewer negative automatic thoughts concerning hostility, and fewer positive automatic thoughts. Negative automatic thoughts concerning personal failure and hostility, and the negative cognitive error of overgeneralizing were found to independently predict school refusal. Conclusions: The findings underscore the importance of further researching the role of cognition in the development, maintenance, and treatment of anxiety-based school refusal.

Background: Low social rank and external shame have been found to be significantly associated with anxiety and depression. However, their relevance to experiences of psychosis has rarely been explored. Aims: This study aims to examine the relationship of social rank and external shame to personal recovery, depression and positive symptoms in psychosis. Method: A cross sectional correlational design was adopted to examine the relationship between all variables. Fifty-two service users, aged between 18 to 65 years, with experiences of psychosis were recruited for the study. Participants were administered outcome measures examining social rank, external shame, positive symptoms of psychosis, depression and personal recovery. Multiple regression analyses were conducted on the data. Results: Significant correlations were found between all variables. Low social rank was significantly associated with lower reported personal recovery, and higher levels of external shame and depression symptomology. The relationship between external shame and positive symptoms of psychosis and personal recovery was found to be mediated by participants’ level of depression. Conclusion: Findings suggest that social rank and external shame are relevant to those who experience psychosis. Therapeutic approaches may need to focus on perceptions of social rank and external shame in working with experiences of psychosis.

This paper describes a project set up to treat four homeless men using cognitive behavioural therapy (CBT). The referral criteria were that individuals had alcohol and/or substance misuse problems, were roofless (i.e. sleeping rough) immediately before the intervention began and found it difficult or impossible to access hostel places in Southampton. Excessive alcohol use, violence (against self, others and property) and prison sentences were all features of their presentation. The project involved three levels of CBT intervention provided by the clinical psychologist: 1) training for the staff to enable them to work within this model; 2) continued supervision within model to ensure consistency and sustainability; 3) individual formulation (description of the problem within the CBT framework) and psychotherapy. The house itself was also run on a collaborative basis. A number of measures including mental health and social functioning constructs were used to evaluate the project, in addition to some qualitative data. All residents reduced incidents of theft, violence and alcohol consumption. Risk to self and others was also reduced for all residents. Perceived self-efficacy increased slightly for all residents, and staff perceived that they could be more effective, less hopeless, and therefore possibly less stressed as a result of training. More data will be gathered over time.

Background: A key process in Cognitive Therapy (CT) is the development and sharing of a formulation. How clinicians develop formulations is under-researched, particularly in working with people with psychosis. Aims: This study investigated agreement between clinicians, when conceptualizing an individual's psychotic beliefs. It also explored whether agreement was dependent on qualifications and experience. Method: Eighty-two clinicians watched a video of an individual with delusional beliefs, and were asked to provide formulations using a CT template. These were compared with a “benchmark” formulation provided by three experts. Results: There was good agreement for overt behaviours, emotions, and some aspects of early experience. However, identification of theory driven components such as core beliefs or assumptions was poorer. Greater clinical experience improved the agreement with the benchmark formulation overall, and greater CT specific experience improved formulation of the theory driven items. The more experience a clinician had of working with people with psychosis the lower the rate of agreement with the expert formulation. Conclusions: Formulation of delusional beliefs from a cognitive perspective is dependant on overall experience in cognitive therapy and not knowledge of psychosis, which may hinder performance. The implications for training in CT and psycho-social interventions are considered.

Attention Training (ATT) is an auditory attention-focusing technique that attempts to reduce the perseverative self-focused processing characteristic of anxiety and mood disorders. The present study investigated the effects of one session of ATT in the reduction and reappraisal of intrusive thoughts in a university sample reporting high levels of obsessive-compulsive symptoms. One-hundred and eight participants identified their most distressing intrusive thought and spent 7 minutes monitoring their stream of consciousness while recording occurrences of the identified thought. They then rated the unpleasantness of the intrusive thought, their attempts to dismiss the thought from consciousness, and their perceived success in reducing the frequency of the thought. Participants were then randomly assigned to receive one session of ATT, thought replacement instructions (TR), distraction instructions (DI), or no intervention (CONT). Participants then repeated the thought monitoring interval and ratings. ATT was expected to be the most effective in decreasing the frequency and unpleasantness of intrusive thoughts. However, contrary to hypotheses, all groups reported similar decreases across intervals. Implications of these findings are discussed.

Based on a behavior-analytic interpretation of the skills acquisition process, a rationale is presented for augmenting a currently available cognitive-behavioral treatment (The Adolescent Coping With Depression course: CWD-A) with a newly developed therapy focusing on the interpersonal interactions and learning occurring in-session (Learning through In-Vivo Experience: LIVE). A description of the practice of LIVE is offered and the results from an initial feasibility study are presented. Using a single-subject methodology, two groups each consisting of 5 adolescents with significant symptoms of depression received the treatment. The intervention consisted of 16 2-hour group sessions occurring over an 8-week period. The first 1-hour of each meeting was taken directly from the CWD-A manual. The second hour was based on the LIVE manual. The adolescents who completed the treatment (n = 8) improved from pretreatment to posttreatment and those who discontinued treatment (n = 2) did not. Improvements were maintained at 3 months follow-up. The treatment produced strong group cohesion and both adolescents and their guardians rated the intervention positively. These results provide initial evidence of the efficacy of complementing CWD-A with LIVE.