The aim of this study was to demonstrate the effectiveness of cognitive behavioural treatment (CBT) with a focus on academic skills and conduct problems and to increase parents' educational skills in managing aggressive and oppositional behaviour in a subsequent parent training (PMT). For this purpose 18 children with a diagnosis of ADHD combined type participated in the study. In an A-B study design the effects of a 12-week treatment phase (6 weeks CBT; 6 weeks PMT) were compared with a preceding 4-week baseline. Core symptoms of ADHD, conduct problems and individual problem behaviour were assessed by weekly administration of parent and teacher questionnaires. The results indicate a significant and generalized reduction of ADHD core symptoms, conduct problems and homework problems during CBT at home and at school. PMT resulted in a further amelioration of the cited symptoms. We conclude that CBT may be a promising component in the treatment of ADHD provided that aspects of generalization are considered during the treatment. PMT may be a useful adjunct in most cases as it is effective in situations where the ADHD child still has problems of self-guidance.

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.

Background: New technologies have slowly become a part of psychologists’ therapeutic office. However, many therapists still have doubts about the possibility of creating a good therapeutic relationship with patients in the presence of technology. Aims: This study evaluates the development of the therapeutic alliance in individuals with small animal phobia disorder who were treated with Augmented Reality Exposure Therapy or In Vivo Exposure Therapy. Method: Twenty-two participants received an intensive session of cognitive behavioural therapy in either a technology-mediated therapeutic context or in a traditional therapeutic context. Results: The results show no significant difference for the therapeutic alliance between two conditions. Conclusions: The results seem to show that technologies such as Augmented Reality do not represent a danger to negatively influence the therapeutic alliance.

The use of benzodiazepines during behavioural treatment is frequently encouraged. However, this review of clinical studies failed to find any beneficial effect of the drugs on therapy outcome. An examination of drug effects on different response variables revealed conflicting results concerning behaviour, i.e. approach. Whilst the anxiolytic nature of the drugs is well established in results on autonomic measures in the absence of the phobic object, they had no effect during its presence. Verbal report data again favour administration of benzodiazepines but studies on cognitive effects of long-term use are still to come. It is recommended that the use of this group of drugs as an adjunct to behaviour therapy should be discouraged.

Background: Thirty-three Japanese children and adolescents diagnosed with an anxiety disorder participated in individual or group Cognitive Behaviour Therapy (CBT) that was modelled after evidence-based intervention programs developed in Western countries. Method: The treatment consisted of: (a) building rapport and education; (b) identifying emotions and recognizing cognitive self-talk; (c) challenging anxious self-talk; (d) developing an anxiety hierarchy and in vivo exposures; and (e) planning for future challenges. Results: Three months following treatment, 20 of the 33 children and adolescents (60.91%) no longer met criteria for their principal anxiety disorders and 16 (48.48%) were free from all anxiety disorders. Self-reported anxiety, depression, and cognitive errors also decreased significantly from pre- to post-treatment and these gains were maintained at 3-month follow-up. For the most part, similar outcomes were found in both the group and individual formats of CBT. Conclusions: This study provides preliminary support for the transportability of CBT in both an individual and group format to Japan.

No randomized controlled trials (RCTs) have been conducted of cognitive behavioural therapy (CBT) for depressed patients who have not responded to antidepressants, yet CBT is often reserved for this group. We conducted a pilot study for a pragmatic RCT of the clinical effectiveness of CBT as an adjunct to pharmacotherapy in primary care based patients with treatment resistant depression (TRD). Patients on antidepressants for at least 6 weeks were mailed a study invitation by their GP. Those who consented to contact were mailed a questionnaire. TRD was defined as compliance with medication (self-report) and Beck Depression Inventory (BDI) ≥ 15. Those who met ICD-10 depression criteria were eligible for randomization and followed after 4 months. Of 440 patients mailed, 65% responded and 72% consented to contact. Ninety-four percent completed the questionnaire and 82 patients (42%) had TRD. Thirty were subsequently identified as ineligible and 10 did not participate further. Twenty-six of the remaining 42 patients met ICD-10 depression criteria and 25 agreed to being randomized. Twenty-three patients completed the 4-month follow-up questionnaire. Recruitment into a RCT to examine the effectiveness of CBT as an adjunct to pharmacotherapy in primary care based patients with TRD appears feasible and should now be conducted.

Background: Research in the West shows that group psychological intervention together with an antidepressant treatment leads to more effective treatment of a depressive disorder. There are no treatment trials from low income countries comparing the efficacy of antidepressant treatment with a group psychological intervention. Aim: To conduct a feasibility trial to compare the efficacy of an antidepressant to a group psychosocial intervention, for low income women attending primary health care in Karachi, Pakistan. Method: This was a preliminary RCT in an urban primary health care clinic in Karachi, Pakistan. Consecutive eligible women scoring >12 on the CIS-R and >18 on Hamilton Depression Rating Scale (HDRS) (n = 66) were randomly assigned to antidepressants or a psychosocial treatment in group settings. The primary outcome measure was HDRS score; secondary outcome measures were disability and quality of life. Results: More than half of the patients in both groups improved (50% reduction in HDRS scores); at end of therapy at 3 months 19 (59.4%) vs 18 (56.2%), and at 6-month follow-up 21(67.7%) vs 20(62.5%) for antidepressants and psychosocial intervention respectively. Although HDRS, BDQ and EQ5-D scores all improved considerably in both groups from start to end of treatment, and these improvements were largely maintained after a further 3 months, the differences between the two treatments were not statistically significant. Conclusion: Psychosocial intervention was as effective as antidepressants in reducing depression and in improving quality of life and disability at the end of therapy. However, these findings need further exploration through a larger trial.

Background: Research on group therapy indicates that various dimensions of the helpful relationship qualities (cohesion, climate, empathy, alliance) are associated with outcome. However, the use of a wide variety of empirical scales makes comparisons between studies as well as generalizations somewhat difficult. Although a generic, trans-theoretical measure such as the Group Climate Questionnaire-Short Form (GCQ-S; MacKenzie, 1983) is available and applicable to most treatment conditions, it has never been tested with cognitive-behavioural group therapy. Aims: To investigate perceived dimensions of group climate (engagement, avoidance and conflict) as predictors of long-term (1 year) follow-up in a manualized, structured time-limited cognitive-behavioural group therapy (CBGT) for out-patients with comorbid psychiatric disorders. Methods: Data from 27 patients were analysed using hierarchical multiple regression analyses. Outcome measures used were general symptomatic complaints (SCL-90-R), interpersonal problems (IIP-64), specific mood- and anxiety symptoms (BDI; BAI) and early maladaptive schemas (YSQ). After controlling for scores on the relevant dependent variables at both intake and treatment termination, dimensions of group climate measured close to termination were entered as predictors in separate analyses. Results: Higher ratings of engagement were associated with reduced scores on all outcome measures at follow-up, except for anxiety symptoms (BAI). Higher ratings of avoidance were associated with lower anxiety symptoms at follow up, whereas ratings of conflict were unrelated to all follow-up scores. Conclusions: The results provide partial support for the use of the GCQ-S as a predictor of long-term follow-up in CBGT, and highlights perceived engagement as the most important dimension. Clinical implications are discussed.

The Cognitive Therapy Scale is a well-established tool for assessing skills in delivering cognitive therapy, but has been subject to criticism. It has recently been updated by two groups, producing the Revised version or CTS-R (Blackburn, James, Milne and Reichelt, 2000) and a version designed for therapy of psychosis, the CTS-Psy (Haddock et al., 2001). The present study made a direct comparison of these scales to evaluate their inter-rater reliability, the extent to which they measure the same therapist qualities, and their utility for assessment of skills in trainee therapists working with different client-types. Twenty-six trainees submitted tapes of therapy with clients suffering either personality disorder or psychosis. Each tape was rated by two independent assessors on each of the two scales. Results suggest the scales are both fairly easy to use and produce highly similar estimates of student competence. Client diagnosis has no significant influence on the scores obtained by the therapist. However, inter-rater reliability is relatively low. It is concluded that safeguards are needed where these scales are used as a training outcome measure.

Background: Bulimia nervosa (BN) is an eating disorder with many physical, psychological and social consequences. Guided self-help (GSH) is recommended in the treatment of BN (NICE, 2004). One of the ways in which to provide GSH is via the internet using evidence-based packages with regular support from a clinician or trained support worker. Aims: The aim of this community-based survey was to investigate attitudes towards online self-help for eating disorders and the support required whilst using such an approach. Method: Two-hundred and fifty-three participants with bulimic symptoms completed the survey. The sample was recruited primarily online. The mean age was 29.11 years (SD = 8.67; min = 16, max = 64). Results: Attitudes towards online self-help (SH) for eating disorders were very positive. The inclusion of some form of support to accompany such an intervention was important to the majority of participants. Remote mediums of support such as e-mail, a forum and text messaging were most often selected as helpful. Most participants expressed a preference for weekly support contacts and for flexible support lengths that could respond to support needs as required. Conclusions: Online self-help for eating disorders is a desirable treatment option for many individuals. The information gathered regarding preferences in the type, medium, duration and frequency of support could be used in the development of future self-help strategies in order to maximize uptake, retention and outcomes.

Several psychopathological conditions include delusional beliefs as central symptoms. A conceptual model highlighting the importance of cognitive factors in regulating the bizarre internal contingencies which characterize delusional systems is presented. Cognitive–behavioral treatment emphasizes the direct modification of expectations and beliefs as well as the disordered behavior patterns they support. The efficacy of neuroleptics in treating delusional states has also been reported. Two patients with predominate delusional beliefs were treated in a cross-over design by the sequential use of cognitive–behavior therapy and pimozide. A third patient received cognitive–behavioral training alone. The delusions as well as the anxiety associated with them diminished and behavioral functioning improved significantly following cognitive therapy. The relationship between delusional symptoms, perceptions of self, and social functioning, as well as the optimal application of cognitive–behavioral and psychopharmacological interventions are discussed.

Psychological formulations are central to cognitive behavioural approaches. The use of such formulations presents a number of difficulties when working with clients with psychotic problems. Despite this, sophisticated psychological formulations can be collaboratively developed with psychotic clients. This paper presents one method of developing such formulations through an evolutionary process. Early in the therapeutic process, simple formulations involving straightforward theoretical models are presented, which are systematically elaborated as therapy proceeds. This involves developing, collaboratively with clients, successive layers of formulation. Each of these layers builds on and incorporates the previous one, yet involves an incremental increase in complexity, depth and informational content. The evolutionary process is illustrated with a case example.

Psychological treatments for sleep-maintenance insomnia have received little attention in the literature. Problems with staying asleep are commonplace, however, especially in the older age groups, and there is a need to develop effective management alternatives to night-time sedation. This single case report describes the sequential application of two cognitive interventions with treatment effects being evaluated by means of time series analysis. The mental overarousal model of sleep disturbance is discussed.

Background: Shame and disgust are often associated with posttraumatic stress disorder (PTSD) following interpersonal traumas such as sexual assault. It has been suggested that individuals with high levels of shame might do less well in standard cognitive behavioural (CBT) interventions. Aims: To see whether applying compassion-focused therapy and developing a compassionate mind can enhance trauma-focused CBT in an adolescent with high levels of shame and disgust the way it has been shown to within the adult population. Method: This single case study describes how trauma-focused CBT was enhanced by compassionate mind training. It details work using this approach with an adolescent female experiencing shame and disgust-based flashbacks. Treatment was provided for 20 sessions over 8 months. Symptoms of PTSD, depression and self-criticism, as well as the ability to self-soothe/reassure, were measured at assessment/start of treatment, mid- and end of treatment. Results: Clinically significant reductions in PTSD, depressive, shame and self-attacking symptoms were found between assessment and completion of treatment. Clinically significant increases in self-reassurance were also reported. Following treatment, symptoms of PTSD and depression were sub-clinical. Conclusion: This case study suggests that developing a compassionate mind alongside trauma-focused CBT may be beneficial to adolescents experiencing shame and disgust with consideration for the young person's level of development and personal circumstances.

Background: Drug-facilitated sexual assault (DFSA) has emerged as a distinct category of sexual victimization and precipitates posttraumatic stress disorder (PTSD). Few studies have examined the distinct psychological aspects of PTSD caused by DFSA. Gauntlett-Gilbert, Keegan and Petrak (2004) represent a notable exception and draw on cases, from their clinical experience, treated using Ehlers and Clarks' (2000) cognitive therapy (CT). Aims: This paper aims to further develop and refine clinical knowledge on CT for PTSD arising from DFSA and advance the findings of Gauntlett-Gilbert et al. (2004). Method: Systematic case based research was used to investigate the applicability of CT for PTSD related to DFSA. Three survivors were treated with CT within the South African context. Results: The case series corroborated existing findings but also documented the presence of somatic and visual intrusions among survivors with partial or complete amnesia for rape and illustrated the utility of imagery interventions in targeting intrusions. The study highlighted the role of physical paralysis in DFSA in compounding helplessness/powerlessness and the necessity of enhancing physical agency and building social support. Conclusion: Distinctive aspects of PTSD related to DFSA can be effectively treated by adapting CT to suit this population group.

Background: Common factors are important for the therapy outcome and also mediate the specific factors of therapy. As one of the common factors, client's expectations towards treatment have been understudied. Aims: The aim was to examine the pre-treatment expectations of outpatient substance abuse treatment clients (N = 327, 111 females, 216 males) and its impact on retention, effectiveness and satisfaction at 6-month follow-up. Method: Dependent variables included the clients’ attitudes towards the twelve-step principles and participation, medical treatment and therapists’ role. Results: An emphasis on the importance of medical treatment at baseline predicted dropping out. Similarly, it predicted a lower percent days abstinent (PDA6) at 6 months follow-up in comparison to those who did not consider medical treatment important for recovery. Percent days abstinent increased with a more positive attitude to mutual support. At follow-up, those who had assessed the therapist's role in recovery to be most important at the baseline were most satisfied with the treatment. Conclusions: The client's pre-treatment expectations have an impact on treatment retention and effectiveness. Further effort should be made to study how clients’ image of treatment could be improved and also how the commitment of the clients with multiple problems could be improved.

Background: Increasing access to evidence-based talking therapies for people with psychosis is a national health priority. We have piloted a new, “low intensity” (LI) CBT intervention specifically designed to be delivered by frontline mental health staff, following brief training, and with ongoing supervision and support. A pilot feasibility study has demonstrated significant improvement in service user outcomes. This study is a qualitative analysis of the experiences of the staff and service users taking part in the evaluation. Aims: To evaluate the acceptability of the training protocol and the therapy, and to examine the factors promoting and restraining implementation. Method: All trained staff and service users completed a semi-structured interview that was transcribed and subjected to thematic analysis. Results: Service users spoke about learning new skills and achieving their goals. Staff spoke about being able to use a brief, structured intervention to achieve positive outcomes for their clients. Both groups felt that longer, more sophisticated interventions were required to address more complex problems. The positive clinical outcomes motivated therapists to continue using the approach, despite organizational barriers. Conclusions: For both trained staff and service users, taking part in the study was a positive experience. Staff members’ perceived skill development and positive reaction to seeing their clients improve should help to promote implementation. Work is needed to clarify whether and how more complex difficulties should be addressed by frontline staff.

Background: While considerable attention has been focused in recent years on evidence-based practice, less attention has been placed on clinical social workers’ choice to use ineffective or harmful interventions, referred to in the present paper as Novel Unsupported Therapies (NUSTs). Method: The present study surveyed 400 Licensed Clinical Social Workers (LCSWs) across the United States in order to determine the extent of their usage of NUSTs, as well as their usage of conventional therapies that lacked support and empirically supported therapies (ESTs). Reasons for selecting interventions were also assessed. Results: While the vast majority (97.5%) reported using some form of EST, 75% of our sample also reported using at least one NUST. Logistic regression analysis revealed that NUST usage was related to female gender and trauma specialization. A split plot ANOVA revealed that respondents rated positive clinical experience higher than published research as a reason for selecting an intervention. LCSWs with a CBT theoretical orientation rated research evidence more highly than those of other theoretical orientations. However, even within the group of LCSWs with a CBT orientation, clinical experience was rated more highly than research evidence. Conclusions: Implications for practice are discussed.

Background: Recent interest in the role of vulnerability factors in obsessional washing has suggested that disgust sensitivity, danger expectancy and health anxiety may be of interest. Aims: This study explores the differential impact of these factors on both behavioural and cognitive measures of washing behaviour and is based on a replication of the Jones and Menzies (1997) experiment, during which participants immersed their hands in a noxious compound while rating themselves on a range of measures: the time they subsequently took to wash their hands was measured and danger expectancies were found to be the best predictor of this. Method: The present study added measures of disgust sensitivity and health anxiety to this experimental methodology while removing factors they found to be of little import to compulsive washing. Thirty non-clinical participants took part. Results: Results confirmed that disgust sensitivity was related to the behavioural measure of washing time, but that this relationship was almost entirely mediated by the danger expectancy concerning judgements of severity of consequent disease. However, a different pattern emerged when the outcome measure was questionnaire based: danger expectancy was not at all related to this. Disgust sensitivity mediated the relationship between health anxiety and scores on a questionnaire measure of washing compulsions. Interestingly, these scores were not related to the behavioural measure of washing time. Conclusions: The implications of these relationships to the further development of subtypes of Obsessive Compulsive Disorder (OCD) are discussed.