Four randomized controlled trials have shown out-patient cognitive behaviour therapy reduces fatigue and disability in people suffering from chronic fatigue syndrome (CFS). However, some patients referred to Kings College Hospital, London are unable to attend regular appointments. We therefore developed a self-help treatment manual using cognitive-behavioural principles for patients to use at home with telephone contact with a therapist. Nine consecutive patients with a diagnosis of CFS who were unable to attend regular out-patient appointments used this self-help treatment approach at home. The therapist (MB) carried out a face-to-face assessment at the hospital. Subsequently, patients had fortnightly telephone appointments to discuss their progress, plan and discuss their homework and any problems. Outcome was evaluated using measures of functional impairment, fatigue, mood and general health before and after treatment and at 3 and 6-month follow-up. Eight patients completed treatment. Functional impairment, fatigue and general health improved at discharge and gains were maintained at 6-month follow-up. Self-treatment at home guided by a manual with fortnightly telephone sessions was helpful in the treatment of patients with chronic fatigue syndrome. A randomized controlled trial is underway to compare telephone cognitive behaviour therapy with out-patient cognitive behaviour therapy. Patients with other conditions such as chronic pain who are unable to travel for regular appointments may benefit from a home-based treatment package involving therapist contact by phone.

Background: It is important to investigate the role of cognitive, developmental and environmental factors in the development and maintenance of Obsessive Compulsive Symptomatology (OCS). Aims: The main objective of this study was to examine the vulnerability factors of OCS in a non-clinical sample. On the basis of Salkovskis’ cognitive model of OCD, the study aimed to investigate the role of perceived parental rearing behaviours, responsibility attitudes, and life events in predicting OCS. Furthermore, the mediator role of responsibility attitudes in the relationship between perceived parental rearing behaviours and OCS was examined. Finally, the specificity of these variables to OCS was evaluated by examining the relationship of the same variables with depression and trait anxiety. Method: A total of 300 university students (M = 19.55±1.79) were administered the Padua Inventory-Washington State University Revision, Responsibility Attitudes Scale, s-EMBU (My memories of upbringing), Life Events Inventory for University Students, Beck Depression Inventory, and State-Trait Anxiety Inventory-Trait Form. Results: Regression analysis revealed that perceived mother overprotection, responsibility attitudes and life events significantly predicted OCS. Furthermore, responsibility attitudes mediated the relationship between perceived mother overprotection and OCS. The predictive role of perceived mother overprotection and the mediator role responsibility attitudes were OCS specific. Conclusions: The findings of the present study supported that perceived mother over-protection as a developmental vulnerability factor significantly contributed to the explanation of a cognitive vulnerability factor (namely responsibility attitudes), and perceived maternal overprotection had its predictive role for OCS through responsibility attitudes.

The successful resolution of a problem of school phobia using self-management strategies is reported. The clinical report is prefaced by the observation that differences of emphasis are apparent when authorative reviews of the field of self-management are considered—and the conclusion drawn is that the successful outcome could be used to lend support to Kanfer's two-stage model of self-regulation. The client, Anne, was a pupil in the first year of comprehensive schooling. She attended school on only four days during the first term. Problem analyses in terms of operant and classical learning theories are described, and intervention strategies were generated which were accommodated within Kanfer's two-stage model of self regulation. Anne self-recorded school attendance, lesson attendance and self-confidence. School attendance was immediately achieved and progress towards full lesson attendance was made over a seven-week period. Affective state (self-confidence) as assessed by self-report was observed to increase as lesson attendance improved but a temporal lag was observed. The report concludes with some observations of a theoretical nature and justification for the intervention to warrant the descriptor “self-management”.

The inherent properties of momentary time sampling (MTS) and partial interval recording (PIR) are examined. Findings derived from computer simulation investigations are discussed in terms of the mode of operation of the two time-sampling techniques. It is seen that the advantage of MTS is that it can, under certain restricted circumstances, estimate absolute duration of behaviour occurring. The important disadvantage of MTS is that it is relatively insensitive when estimating degree of change of behaviour. In contrast, although PIR cannot accurately measure absolute duration it is more sensitive to behaviour change than is MTS. It is concluded that the practitioner who wishes to use one of these methods of time sampling must carefully consider the aims and possible effects of the investigation before deciding which method to use.

This paper presents the rationale for, and implementation of, a brief form of cognitive-behavioural (termed Prescriptive) therapy based on both behavioural and cognitive traditions. Clients are seen for two sessions 1 week apart followed by a third session 3 months later. The model, termed 2 + 1 Prescriptive psychotherapy, is derived from both clinical and research bases, and is an attempt to implement a planned brief form of therapy in response to service deliver needs. The essential components of the model are presented together with outcome data from three initial clients' treatment in this model. In addition, one of these cases is presented as a clinical case study. The model is evaluated according to criteria of therapeutic effort, research parameters, and clinical mechanisms. The limitations and potenial of the model are presented.

Forty-eight children from grades 3 to 6 of two inner city primary schools were selected on the basis of poor performance on a social perception test. Subjects were randomly assigned to one of three experimental conditions: social perception training (SPT); attention placebo control (APC; drama activities) or a no treatment control (NTC; assessment only). The SPT and APC groups participated in nine twice weekly sessions over a five week period. Children receiving SPT did not show a significantly greater improvement in social perception skills than either of the control conditions. There was also no significant effect of SPT on certain measures of behavioral functioning which have previously been associated with social perception skill, namely peer sociometric status, Walker Problem Behaviour Checklist or Childrens' Depression Inventory. The findings are discussed in terms of implications for future research.

Background: Mental health problems have been found to be more prevalent in prison populations, and higher rates of post-traumatic stress disorder (PTSD) have been found in sentenced populations compared to the general population. Evidence-based treatment in the general population however has not been transferred and empirically supported into the prison system. Aims: The aim of this manuscript is to illustrate how trauma focused work can be applied in a prison setting. Method: This report describes a two-phased approach to treating PTSD, starting with stabilization, followed by an integration of culturally appropriate ideas from narrative exposure therapy (NET), given that the traumas were during war and conflict, and trauma-focused cognitive behavioural therapy (TF-CBT). Results: PTSD and scores on paranoia scales improved between start and end of treatment; these improvements were maintained at a 6-month follow-up. Conclusion: This case report1 illustrates successful treatment of multiple incident PTSD in a prison setting using adaptations to TF-CBT during a window of opportunity when individuals are more likely to be free from substances and live in relative stability. Current service provision and evidence-based practice for PTSD is urgently required in UK prisons to allow individuals to engage in opportunities to reduce re-offending, free from mental health symptoms.

Background: Scales for assessing competence in CBT make an important contribution to research and practice. Aims: To develop a novel scale. Method: A new structured assessment tool is described, which draws on a widely-used CBT competence framework to identify relevant areas of clinical practice. Results: Scale content was clarified through piloting and review by a range of stakeholders. Conclusion: Pending formal testing of the psychometric properties, the scale is ready for use to assess competences in cognitive and behavioural therapy.

Background: Metaphors are common in psychotherapy and have potential to enhance therapy in numerous ways. However, the empirical study of metaphors in cognitive behaviour therapy (CBT) has tended to be put in the “too hard basket”, confined to being part of the art rather than the science of therapy. The lack of research is largely due to problems with definition, lack of a consistent, reliable approach to metaphor identification and the challenges of finding appropriate methodology to study this language-based activity. Aims: This study aimed to assess the frequency of metaphors in CBT in a large sample of therapy sessions and to evaluate the reliability and utility of the discourse dynamics approach to metaphor identification. Method: The discourse dynamics approach, recently developed by linguists, was used to identify metaphors in 48 CBT session transcripts (from 12 clients and 3 therapists) and the reliability of this approach was evaluated, using an independent rater. Results: The total frequency of metaphors was 31.5 (range 17–49) per 1000 words of therapy conversation. Therapists produced metaphors twice as often (21.2, range 7–36) as clients (10.3, range 3–24). Reliability of the Discourse Dynamics approach was adequate. Conclusions: Metaphors clearly occur in CBT sessions, with therapists using them at a higher rate than clients. While Discourse Dynamics is currently the most detailed identification approach available for investigating metaphor in CBT sessions, it is challenging to acquire skill in it and we found only adequate reliability. Ways to improve reliability and future research possibilities are discussed.

The present study examined whether trait anxiety as indexed by the Spielberger State-Trait Anxiety Inventory (STAI) can be employed as a predictor of behaviour therapy outcome. Thirty-six female spider phobic patients completed the STAI trait anxiety scale, and then received one 2.5 hours session of exposure in vivo treatment. Therapy outcome was evaluated by means of standardized self-report measures and a behavioural approach test. Results showed that STAI trait anxiety substantially contributed to therapy success on all outcome measures: the higher the trait anxiety scores, the less patients profited from behaviour therapy.

Background: Cognitive behavior therapy (CBT) has been found to be generally effective for persons with schizophrenia. Less is known however about those who will engage in this treatment, and among those who engage, who benefits more versus less from this intervention. Aims: This study sought to identify factors associated with treatment engagement and response in persons with psychosis engaged in CBT focused on enhancing work function. Method: Participants were 50 adults with schizophrenia-spectrum disorders participating in a randomized control trial that offered both CBT and a protected employment position over 26 weeks. Survival analysis and discriminant analyses were used to analyze the data. Results: Results indicated that poor treatment engagement and engagement in work was associated with lower educational attainment, more severe baseline levels of negative symptoms, and lower baseline scores on the Arithmetic and Digit Symbol subscales of the WAIS-III. Amongst those participants who did engage, younger age and poorer working memory as assessed by the Arithmetic subscale predicted shorter initial job tenure. More severe levels of positive symptoms and lower self-esteem during the later stages of treatment were associated with worse employment outcomes across the study period. Conclusions: These findings evidence differential predictors of engagement and success and suggest that a subgroup of persons with schizophrenia engaged in CBT and a vocational placement are at risk for poor functional outcomes associated with psychological factors that evolve over time.

Hoarding has been recognized as a frequent sub-component of obsessive-compulsive disorder that can occur at lesser frequency in a primary form. The theoretical and empirical literature on hoarding is still in its infancy. The current paper attempts to expand and refine CBT theory via the identification of the specific cognitive distortion of object-affect fusion (OAF) relating to problematic emotional attachment to objects. The concept of OAF is defined and then related to sentimental saving. Two case examples are detailed in which OAF represented the main focus of the CBT intervention. The case examples illustrate how OAF recognition can be integrated into and supplement existing CBT approaches to hoarding. Future theoretical and empirical developmental tasks in relation to OAF are identified and discussed.

We assessed the use of a microswitch cluster to improve assisted ambulation in a man with multiple disabilities. The cluster included two optic microswitches at the man's heels to detect his steps and a pressure microswitch under his right arm to detect his body posture (i.e. whether he had an upright, appropriate posture or was leaning forward). The man received 2.5 seconds of favourite stimulation at each step provided that his posture was appropriate. The results showed that there was a large increase in the man's appropriate posture during walking throughout the intervention phases and the 3-month follow-up.

Behavioural Activation is a contemporary contextual psychological treatment for depression. The outcome of a series of five treatment groups involving a total of 42 patients presenting to a psychotherapy department with self-reported depression is reported. Three of the treatment groups were delivered by two cognitive behavioural psychotherapists, two of the groups were delivered by a single cognitive behavioural psychotherapist and a trainee with no previous experience of the approach. The results suggest that group Behavioural Activation is an effective and tolerable treatment as indicated by BDI-II, CORE scores and the low drop-out rate. The methodological limitations of the findings are discussed.

Background: Allocation of trainee therapist cases is often performed based on intuition and clinical circumstances, with lack of empirical evidence on the role of severity of presenting problem. This has the potential to be anxiety-provoking for supervisors, trainees and service users themselves. Aims: To determine how therapist experience interacts with symptom severity in predicting client outcomes. Method: An intention-to-treat analysis of annual outcome data for primary and secondary care clients seen by a specialist anxiety disorders service. 196 clients were stratified into mild, moderate and baseline severe symptoms of anxiety (GAD-7) and depression (PHQ-9). We measured percentage change on these measures, as well as number of sessions and therapy dropout. We also examined rates of reliable and clinically significant change on disorder-specific measures. We hypothesized that qualified therapists would achieve better outcomes than trainees, particularly for severe presentations. Results: Overall, outcomes were comparable between trainee and qualified therapists on all measures, and trainees additionally utilized fewer therapy sessions. There was however an interaction between anxiety severity (GAD-7) and therapist group, such that severely anxious clients achieved greater symptom improvement with qualified as compared to trainee therapists. Further, for trainee but not qualified therapists, baseline anxiety was negatively associated with rate of reliable and clinically significant change on disorder-specific measures. Conclusions: These findings indicate generally favourable outcomes for trainee therapists delivering manualized treatments for anxiety disorders. They additionally suggest that trainee therapists may benefit from additional support when working with clients that present with severe anxiety.

The eating disorders provide one of the strongest indications for cognitive behaviour therapy (CBT). This bold claim arises from two sources: first, the fact that eating disorders are essentially cognitive disorders and second, the demonstrated effectiveness of CBT in the treatment of bulimia nervosa, which has led to the widespread acceptance that CBT is the treatment of choice. In this paper the cognitive behavioural approach to the understanding and treatment of eating disorders will be described. A brief summary of the evidence for this account and of the data supporting the efficacy and effectiveness of this form of treatment will be provided. Challenges for the future development and dissemination of the treatment will be identified.

In the self-regulation of anger, it is unclear whether the effects are due to self-monitoring or actual self-intervention. This is especially important in the light of the reactivity often attributed to self-monitoring. The present study compared both procedures within a reversal design involving college students with moderate levels of anger. Intervention consisted of behavioral contracting and relaxation as well as cognitive strategies of reappraisal and imagery. Measures included anger frequency, duration, and intensity, all of which were obtained in naturalistic settings. Results revealed significant and dramatic reductions in anger frequency and duration during self-intervention but no such improvements with self-monitoring apart from a slight reduction in anger intensity. The return to baseline self-monitoring was associated with no relapse in anger but a maintenance of treatment gains. Secondary findings of interest were a correlation between anger intensity and anger duration and a predominance of anger directed at persons rather than situations. In general, the outcome of this study adds strength to the inference that cognitive-behavioral self-interventions are effective for anger and that this effectiveness goes beyond mere reactivity. The effects are most pronounced for anger frequency and duration and this offers clues for future focal points in the practice of anger management.

Background: Environmental factors have been associated with psychosis but there is little qualitative research looking at how the ongoing interaction between individual and environment maintains psychotic symptoms. Aims: The current study investigates how people with persecutory delusions interpret events in a virtual neutral social environment using qualitative methodology. Method: 20 participants with persecutory delusions and 20 controls entered a virtual underground train containing neutral characters. Under these circumstances, people with persecutory delusions reported similar levels of paranoia as non-clinical participants. The transcripts of a post-virtual reality interview of the first 10 participants in each group were analysed. Results: Thematic analyses of interviews focusing on the decision making process associated with attributing intentions of computer-generated characters revealed 11 themes grouped in 3 main categories (evidence in favour of paranoid appraisals, evidence against paranoid appraisals, other behaviour). Conclusions: People with current persecutory delusions are able to use a range of similar strategies to healthy volunteers when making judgements about potential threat in a neutral environment that does not elicit anxiety, but they are less likely than controls to engage in active hypothesis-testing and instead favour experiencing “affect” as evidence of persecutory intention.