Background: The assessment of therapeutic adherence is essential for accurately interpreting treatment outcomes in psychotherapy research. However, such assessments are often neglected. Aims: To fill this gap, we aimed to develop and test a scale that assessed therapeutic adherence to Cognitive Processing Therapy – Cognitive Only (CPT), which was adapted for a treatment study targeting patients with post-traumatic stress disorder and co-occurring borderline personality symptoms. Method: Two independent, trained raters assessed 30 randomly selected treatment sessions involving seven therapists and eight patients who were treated in a multicentre randomized controlled trial. Results: The inter-rater reliability for all items and the total score yielded good to excellent results (intraclass correlation coefficient [ICC] = 0.70 to 1.00). Cronbach's α was .56 for the adherence scale. Regarding content validity, three experts confirmed the relevance and appropriateness of each item. Conclusion: The adherence rating scale for the adapted version of CPT is a reliable instrument that can be helpful for interpreting treatment effects, analysing possible relationships between therapeutic adherence and treatment outcomes and teaching therapeutic skills.

Comorbidity data between Generalized Anxiety Disorder (GAD) and Social Phobia, studies of frequently reported worry themes, and various correlational studies have led to the idea that worries may have a social basis. This study investigates the social basis of worry in three samples with different ages. The samples consisted of 224 high-school students, 607 undergraduate students, and 125 older adults. All participants completed the Worry Domains Questionnaire (WDQ) and the Penn State Worry Questionnaire (PSWQ). We hypothesized that for each sample, the first factor extracted following factor analysis on WDQ items would reflect the most social content, and that social-related factors would be the best predictors of the global tendency to worry as measured by the PSWQ. Results supported the hypotheses with the exception of older adults, for whom the first extracted factor was not as obviously social as for the other two samples. Possible explanations are considered and theoretical and clinical implications are discussed.

We conducted a pilot group intervention for negative symptoms, particularly targeting avolition/apathy. A baseline control design was used. Six patients were recruited, and four completed the group. The main inclusion criteria were clinically significant negative symptoms, plus associated distress and concern. The group involved 16 sessions, which were cognitive behavioural in approach. The main outcome measures were the Scale for the Assessment of Negative Symptoms, and the Subject Experience of Negative Symptoms Scale. Patients showed a reduction in avolition/apathy, and two patients reported reduced distress. These preliminary results suggest that group CBT is a possible intervention for negative symptoms.

The “Cognitive Revolution” has involved substantial changes in the emphasis of clinical practice and research interests of behaviour therapists. Work carried out in this area suggests that earlier fears about the potentially damaging effects of cognitive-behaviour therapy were unfounded. It can be argued that cognitive orientations have gained such widespread acceptance amongst behaviour therapists because the approaches are highly compatible at clinical and research levels, and because behaviour therapy had already started to incorporate similar concepts. Furthermore, cognitive models have also provided a wealth of new ideas and methods which considerably enhance behavioural approaches whilst leaving the fundamentals intact.

Background: While Motivational Interviewing (MI) is effective in reducing client problem behaviours, including health-related behaviours, there is little evidence about how MI training enhances practitioner skills. Aims: The current pilot study addressed this lack by training two health practitioners (Diabetes Nurse Educators) in MI, and evaluated the effect of MI training on both practitioner and patient behaviour when MI was delivered in a clinical settting, with patients experiencing difficulties with diabetes self-management. Methods: Comparisons were made between the practitioners’ skills in a baseline condition (Patient Education; PE) and after training in Motivational Enhancement Therapy (MET), a four-session form of MI. At the same time, the effects of the two interventions on patient in-session behaviour were compared. Practitioner and patient data were obtained from transcripts of all PE and MET sessions, which were independently coded using Motivational Interviewing Skills Code therapist and client behaviour counts. Results: Compared with their baseline performance, practitioners, when trained to practice MET, behaved in ways consistent with MI, and this appears to have evoked beneficial in-session behaviour from the patients. Conclusions: These results suggest that the MI training was effective.

Background: Perseveration, persistence and perfectionism are traits that have been suggested to be relevant to the eating disorders. This study explored the levels and correlates of these three traits in the eating disorders and control groups. Method: A measure of these three elements (the Persistence, Perseveration and Perfectionism Questionnaire - PPPQ-22) was administered to 99 women with eating disorders, 25 women with other psychiatric disorders, and 91 non-clinical women. Differences in PPPQ-22 scores across groups were measured, as were the associations between PPPQ-22 scores and eating attitudes. Results: The eating disordered groups showed lower levels of persistence (the drive towards goal achievement) than the non-clinical group, but did not show higher levels of perseveration (the following of rules, without considering whether goals are achieved). Both women with eating disorders and non-clinical controls showed correlations between eating disorder symptoms and perseveration. Conclusions: The current study, using a relatively new measure, suggests that low levels of persistence, rather than high levels of perseveration, may be implicated in the eating disorders. It was less clear that perfectionism per se was a useful construct in understanding eating pathology. If confirmed by future research, persistence should be considered in treatment of these complex and challenging conditions.

The investigation of factors that may render an individual vulnerable to the development of suicide ideation may provide some light on the etiology of suicidal behavior and consequently contribute to the prevention of suicide. Based on this idea, an examination of the relationship between the underlying dimensions of the Dysfunctional Attitude Scale (DAS-A), the Automatic Thoughts Questionnaire (ATQ-30) and suicide ideation was conducted. The six DAS-A components and the two ATQ-30 components reported by Chioqueta and Stiles (2006a, 2006c) were among the variables employed in the present study. In a sample composed of 102 male military recruits, initially assessed at the Army School (Pretest) and re-tested 3 months later (Posttest), a series of multiple regression analyses were conducted. The results demonstrated that the two subscales of the ATQ-30 (Negative Self-Concept/Personal Maladjustment and Desire for Change/Negative Expectations), but none of the DAS-A subscales, predicted suicide ideation 3 months later. Thus, automatic thoughts reflecting ideas of negative self-concept, perceptions of personal maladjustment, thoughts of desire for change, and negative expectations seem to be more associated with suicide ideation than depressogenic beliefs.

Background: Research on post-event processing (PEP), where individuals conduct a post-mortem evaluation of a social situation, has focused primarily on its relationship with social anxiety. Aims: The current study examined: 1) levels of PEP for a standardized event in different anxiety disorders; 2) the relationship between peak anxiety levels during this event and subsequent PEP; and 3) the relationship between PEP and disorder-specific symptom severity. Method: Participants with primary DSM-IV diagnoses of social anxiety disorder (SAD), obsessive compulsive disorder (OCD), panic disorder with/without agoraphobia (PD/A), or generalized anxiety disorder (GAD) completed diagnosis specific symptom measures before attending group cognitive behavioural therapy (CBT) specific to their diagnosis. Participants rated their peak anxiety level during the first group therapy session, and one week later rated PEP in the context of CBT. Results: The results indicated that all anxiety disorder groups showed heightened and equivalent PEP ratings. Peak state anxiety during the first CBT session predicted subsequent level of PEP, irrespective of diagnostic group. PEP ratings were found to be associated with disorder-specific symptom severity in SAD, GAD, and PD/A, but not in OCD. Conclusions: PEP may be a transdiagnostic process with relevance to a broad range of anxiety disorders, not just SAD.

Background: Disengaging from maladaptive thinking is an important imperative in the treatment of depression. Mindfulness training is aimed at helping patients acquire relevant skills for this purpose. It remains unclear, however, whether this practice is helpful when patients are acutely depressed. Aims: In order to investigate effects of mindfulness on symptoms and self-regulatory capacities in this group, the current study compared a brief training in mindfulness (n = 19) to guided imagery relaxation (n = 18). Method: Participants were introduced to the respective techniques in a single session, and practised daily over one week. Self-reported severity of symptoms, difficulties in emotion-regulation, attentional control, the ability to decentre, and mindfulness were assessed pre and postintervention, and at a one-week follow-up. Results: Symptoms of depression significantly decreased and self-regulatory functioning significantly increased in both groups, with changes being maintained during follow-up. When controlling for change in depressive symptoms, results showed significantly higher improvements in emotion regulation at follow-up in the mindfulness group. The ability to decentre predicted changes in symptoms from pre to postintervention, while mindfulness skills predicted changes in symptoms during the maintenance phase. Conclusions: The findings suggest that both practices can help to instigate reductions in symptoms and enhance self-regulatory functioning in depression. However, in order to improve emotion regulation above levels explained by reductions in symptoms more intentional mental training seems necessary. Furthermore, while the ability to disengage from negative patterns of thinking seems crucial for initial reduction of symptoms, maintenance of gains might require broader skills in mindfulness.

547 patients admitted to the medical wards of a general hospital in South West England completed a computer-administered health behaviour screening questionnaire. This included a retrospective week's drinking diary and questions about alcohol-related problems. All patients were shown, via the computer, a summary of their own week's drinking in comparison with nationally recommended upper limits for safe drinking. In addition, all those who were considered to be risk drinkers on the basis of consumption or problems (23% of males, 7% of females) were advised via the computer to reduce their consumption and were given an approved self-help manual. All risk drinkers and a proportion of others were asked to complete the same questionnaire six months later. Seventy-five per cent of those asked, did so. The computer screening procedure was well accepted into ward routine and a simple before and after comparison showed a slight but significant reduction in drinking risk for the group as a whole. Regression discontinuity analysis showed that computer advice to reduce consumption plus provision of the self-help manual was of no additional benefit in helping patients reduce drinking risk.

Background: The majority of pain sufferers experience images when in pain. The most distressing of these images (the Index image) provokes intense emotional reactions, appraisal shifts, and increases in pain. The ability of pain sufferers to rescript their Index images, and the consequences of doing so, remain to be determined. Aims: To assess the effects upon emotions, appraisals and pain experience of rescripting Index images in pain sufferers. Method: The Index images of a group of 55 pain sufferers were assessed using a voluntary image induction procedure (VIE) to obtain basal levels of pain, appraisal and emotion. Participants were than randomly allocated to one of two groups: Rescripted Image repetition or Index Image repetition. The two groups were compared on their responses to their Index and Rescripted images respectively. Results: The participants found it easy to rescript their distressing Index images. During rescripting, they reported dramatic reductions in emotion, negative appraisals, and pain. The clinically and statistically significant decrements in pain were found independent of reductions in emotion. The pain levels during rescripting were significantly below their basal levels, with 49% reporting no pain at all while viewing a rescripted image. These changes were not a function of image repetition. Conclusion: Index images of pain sufferers can be easily elicited and rescripted. Rescripting leads to remarkable reductions in emotion, cognitions and pain levels that are not attributable to image repetition. The significant reductions in pain were independent of reductions in emotion. The implications of these results for CBT approaches to pain management are considered.

Background: Anger causes significant problems in offenders and to date few interventions have been described in the Caribbean region. Aim: To evaluate a package of CBT-based Anger Management Training provided to offenders in prison in Trinidad. Method: A controlled clinical trial with 85 participants who participated in a 12-week prison-based group anger management programme, of whom 57 (67%: 16 control, 41 intervention) provided pretrial and posttrial outcome data at Times 1 and 2. Results: Intervention and control groups were not directly comparable so outcome was analysed using t-tests. Reductions were noted for state and trait anger and anger expression, with an increase in coping skills for the intervention group. No changes were noted in the control group. The improvements seen on intervention were maintained at 4 month follow-up for a sub-group of participants for whom data were available. Several predictors of outcomes were identified.

This article deals with the modification of self-statements as a specific strategy in cognitive therapy. A method is described in which patients modify their self-talk by reading aloud positive self-statements that are incompatible with original self-deprecatory thoughts. Next, several cases are presented that illustrate how this intervention can effectively be integrated in the treatment of various disorders. In the discussion, the indications for using this intervention are considered and compared to other cognitive strategies.

This case study describes the collaborative development of an idiosyncratic cognitive model of the ascent into mania in a patient with bipolar affective disorder. The client held the belief that he could rise above his depression and feelings of low self-esteem through the pursuit of highly demanding goals and rewarding activity. While still depressed and anxious, small increases in positive mood and energy triggered hyper-positive thoughts about himself (e.g. “I am back to my attractive, intelligent and outgoing self again”). Consequently, he engaged in a range of “ascent” behaviours that were consistent with the pursuit of this self-view. The direct effects of these behaviours and their effects on other people led to further increases in positive mood and physiological activation, which in turn triggered more hyper-positive self-relevant thoughts. The client reported that he found the model an extremely useful component of cognitive behavioural therapy.

A schizophrenic patient and his family were provided with a nine month multi-component behavioural intervention programme as part of a controlled study. The patient was at high risk of relapse according to the High EE status of his parents. Multiple outcome measures were used to assess the efficacy of the programme. The components of the intervention are described in detail, and the specificity of component effects in this case are examined. Given the methodological limitations of this type of study, it is not possible to demonstrate conclusively intervention effects in the case reported. However, following the intervention the relapse rate of the patient was reduced, his social functioning improved and the EE status of his parents changed from High to Low.

There is empirical evidence demonstrating the effectiveness of behavioural marital therapy. However the issues of predicting outcome and the responsiveness of particular marital problems to behavioural treatments, while crucial, have been largely ignored. Forty-five couples requesting therapy were consecutively assigned to either conjoint treatment, couples group treatment or treatment of one partner alone to ascertain whether a screening profile could be developed that would predict treatment outcome. In addition, the presenting target problems were analysed to investigate their responsiveness to treatment. The effects of the treatment were evaluated using measures of marital satisfaction, sexual satisfaction, presenting marital target problems and by an independent assessor. Using demographic and treatment variables as regressors, the analyses revealed that the coefficients were not on the whole statistically significant in predicting outcome. The trend analysis of target problems showed that conjoint treatment produced a more rapid rate of change compared to the other treatments. In addition, particular marital problems failed to respond to the treatment suggesting that the behavioural approach may require modification in the treatment of these problems.

Background: Visits to the location of the trauma are often included in trauma-focused cognitive behavioural therapy (TF-CBT) for post-traumatic stress disorder (PTSD), but no research to date has explored how service users experience these visits, or whether and how they form an effective part of treatment. Aims: The study aimed to ascertain whether participants found site visits helpful, to test whether the functions of the site visit predicted by cognitive theories of PTSD were endorsed, and to create a grounded theory model of how site visits are experienced. Method: Feedback was collected from 25 participants who had revisited the scene of the trauma as part of TF-CBT for PTSD. The questionnaire included both free text items, for qualitative analysis, and forced-choice questions regarding hypothesized functions of the site visit. Results: Overall, participants found the site visits helpful, and endorsed the functions predicted by the cognitive model. A model derived from the feedback illustrated four main processes occurring during the site visit: “facing and overcoming fear”; “filling in the gaps”; “learning from experiences” and “different look and feel to the site”, which, when conducted with “help and support”, usually from the therapist, led to a sense of “closure and moving on”. Conclusions: Therapist-accompanied site visits may have various useful therapeutic functions and participants experience them positively.

This single case history reports the use of eye movement desensitization, a new cognitive therapy procedure originally developed for post-traumatic stress disorder and similar problems, to treat anxieties and body image problems resulting from operation scars and a degree of physical disability. The procedure was effective within one session and subsequent improvements in behaviour and cognitions reported.

Background: The use of maladaptive behaviors by individuals with generalized anxiety disorder (GAD) is theoretically important and clinically meaningful. However, little is known about the specificity of avoidant behaviors to GAD and how these behaviors can be reliably assessed. Aims: This study replicated and extended the psychometric evaluation of the Worry Behaviors Inventory (WBI), a brief self-report measure of avoidant behaviors associated with GAD. Method: The WBI was administered to a hospital-based sample of adults seeking treatment for symptoms of anxiety and/or depression (n = 639) and to a community sample (n = 55). Participants completed measures of symptom severity (GAD, depression, panic disorder, health anxiety, and personality disorder), and measures of checking, reassurance-seeking and behavioral inhibition. Analyses evaluated the factor structure, convergent, divergent, incremental, and discriminant validity, as well the temporal stability and treatment sensitivity of the WBI. Results: The two-factor structure found in the preliminary psychometric evaluation of the WBI was replicated. The WBI was sensitive to changes across treatment and correlated well with measures of GAD symptom severity and maladaptive behaviors. The WBI was more strongly related to GAD symptom severity than other disorders. The WBI discriminated between clinical and community samples. Conclusions: The WBI provides clinicians and researchers with a brief, clinically meaningful index of problematic behaviors that may guide treatment decisions and contribute to our understanding of maintaining factors in GAD.