Background: Increasingly, clinical psychologists and CBT trained clinicians work with and within teams. The cognitive model enables us to formulate the processes maintaining distress, and work with people to effect change. The model tends to be used to understand individuals’ difficulties, but may be effective in making sense of problems within teams. Aims: This study aimed to (i) explore the value of the cognitive model in formulating key staff-service user relationships; and (ii) determine whether such an approach would yield useful team based interventions. Method: The cognitive interpersonal model was used to develop an idiosyncratic conceptualization of key staff-service user interactions in an in-patient setting. This then informed management team planning aimed at improving provision for service users, and staff experience. Additionally, frequency of challenging behaviours and levels of staff burnout were assessed before and after service changes, as preliminary outcome data. Results: The team formulation was effective in (i) making sense of interactions contributing to the maintenance of service users’ challenging behaviours and staff burnout, and (ii) deriving systemic interventions likely to effect change. This was then used to guide service development planning. In support of a CBT approach to understanding and intervening with teams, preliminary data indicate that staff burnout and incidents of challenging behaviours reduced over time. Conclusion: The cognitive interpersonal model can be used to formulate relationships within teams and guide systemic change. This is likely to have a beneficial impact for both service users and staff.

Patient characteristics may partly explain individual differences in long-term maintenance of treatment gains in response to cognitive and behavioral therapies (CBT). This study evaluated the relative contribution of negative cognitive style, behavioral activation, and personality patterns, measured at the end of treatment among treatment responders, towards the risk of relapse of major depressive disorder over a 2-year prospective follow-up. The sample included depressed adults who were randomized and received an adequate dose of one of three forms of CBT, who then fully responded and completed a 2-year prospective follow-up (N = 93) (Jacobson et al., 1996; Gortner, Gollan, Dobson and Jacobson, 1998). Cox regression analyses revealed that for treatment responders, self-devaluative depressogenic cognitive style did not predict relapse during the 2-year follow-up. Separate cox regression analyses indicated that without considering the contribution of personality patterns, it was important to distinguish the level of behavioral activation (e.g. frequency of pleasant events) from its associated pleasure in predicting relapse. With the introduction of personality patterns; however, an integrated model revealed that only dependent personality pattern was associated with hazard of relapse during the 2-year prospective follow-up. Dependent personality pattern may increase relapse through behavioral passivity.

Over-involved parenting is commonly hypothesized to be a risk factor for the development of anxiety disorders in childhood. This parenting style may result from parental attempts to prevent child distress based on expectations that the child will be unable to cope in a challenging situation. Naturalistic studies are limited in their ability to disentangle the overlapping contribution of child and parent factors in driving parental behaviours. To overcome this difficulty, an experimental study was conducted in which parental expectations of child distress were manipulated and the effects on parent behaviour and child mood were assessed. Fifty-two children (aged 7 – 11 years) and their primary caregiver participated. Parents were allocated to either a “positive” or a “negative” expectation group. Observations were made of the children and their parents interacting whilst completing a difficult anagram task. Parents given negative expectations of their child's response displayed higher levels of involvement. No differences were found on indices of child mood and behaviour and possible explanations for this are considered. The findings are consistent with suggestions that increased parental involvement may be a “natural” reaction to enhanced perceptions of child vulnerability and an attempt to avoid child distress.

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.

This review traces the development of motivational interviewing (MI) from its happenstance beginnings and the first description published in this journal in 1983, to its continuing evolution as a method that is now in widespread practice in many professions, nations and languages. The efficacy of MI has been documented in hundreds of controlled clinical trials, and extensive process research sheds light on why and how it works. Developing proficiency in MI is facilitated by feedback and coaching based on observed practice after initial training. The author reflects on parallels between MI core processes and the characteristics found in 70 years of psychotherapy research to distinguish more effective therapists. This suggests that MI offers an evidence-based therapeutic style for delivering other treatments more effectively. The most common use of MI now is indeed in combination with other treatment methods such as cognitive behaviour therapies.

Background: Although internet-delivered cognitive behaviour therapy (ICBT) yields large clinical outcomes when accompanied by therapeutic support, a portion of clients do not benefit from treatment. In ICBT, clients review treatment materials online typically on a weekly basis. A key component of therapist-assistance involves answering questions as clients review and work on assignments related to the treatment materials. Aims: The goal of this study was to enhance understanding of the nature of client questions posed during ICBT and examine potential associations between the number of questions asked and treatment outcomes in order to provide insight into how to improve ICBT for future users. Method: Content analysis was used to qualitatively analyse and identify questions that 80 clients asked their designated therapist over the course of an 8-week ICBT programme for anxiety and depression. Results: On average, clients sent six emails during the course of treatment, of which less than two questions were asked. Of the 137 questions posed by clients, 46.72% reflected questions designed to enhance understanding and apply the material and techniques reviewed in the programme. Additional questions were categorized as clarifying the therapeutic process (22.62%), addressing technical challenges (18.25%), and seeking assistance with problems outside the scope of ICBT (12.41%). Number of client questions asked was not significantly correlated with the number of lessons completed, symptom change, or perceptions of therapeutic alliance. Conclusions: Findings can inform future practitioners who deliver ICBT of what to expect with this treatment approach and also assist in the development of future ICBT programmes.

Background: Case formulation (CF) is considered a core component of cognitive behavioural therapy (CBT). Despite this, few studies have explored the content and quality of CFs in routine practice and any associated impact on treatment outcome. Aims: This study investigated (1) the content, timing and quality of CF for patients (N = 29) with Obsessive Compulsive Disorder; (2) the impact of CF on symptoms, distress and therapeutic alliance; and (3) the relationship between CF quality and treatment outcome. Method: CF content and quality were assessed from audiotapes of routine CBT sessions using a validated coding manual and evaluated against treatment outcomes at different stages of therapy. Results: CFs were developed early during treatment and contained strong behavioural and cognitive components, with a focus on symptoms and maintaining factors. CF quality ratings ranged from rudimentary to excellent. A significant improvement in distress and the therapeutic alliance occurred following the introduction of CF, but no significant relationship was found between CF quality and outcome at any stage of treatment. Conclusion: CF may be valuable in reducing patient attrition, due to its impact early in treatment. Further research is needed to explore the most important components of CF. Theoretically sound and disorder specific measurement tools for evaluating CFs are required.

The prevention and modification of delinquent behaviour is an issue of increasing concern to society, both in Great Britain and the U.S.A. This concern is aggravated by a growing amount of evidence which suggests that the majority of intervention procedures are not successful in preventing further offending by juvenile offenders (Cornish and Clarke, 1975, Hood and Sparks, 1970, Feldman, 1976). This appears to be true of both penal methods such as fines, probation or imprisonment (Hood and Sparks, 1970) and psychotherapeutic approaches (Logan, 1972).

Background: The cognitive behavioural (CB) model of health anxiety proposes parental illness leads to elevated health anxiety in offspring by promoting the acquisition of specific health beliefs (e.g. overestimation of the likelihood of illness). Aims: Our study tested this central tenet of the CB model. Method: Participants were 444 emerging adults (18–25-years-old) who completed online measures and were categorized into those with healthy parents (n = 328) or seriously ill parents (n = 116). Results: Small (d = .21), but significant, elevations in health anxiety, and small to medium (d = .40) elevations in beliefs about the likelihood of illness were found among those with ill vs. healthy parents. Mediation analyses indicated the relationship between parental illness and health anxiety was mediated by beliefs regarding the likelihood of future illness. Conclusions: Our study incrementally advances knowledge by testing and supporting a central proposition of the CB model. The findings add further specificity to the CB model by highlighting the importance of a specific health belief as a central contributor to health anxiety among offspring with a history of serious parental illness.

Three experiments were conducted to investigate the effects of teaching chronic schizophrenic patients to verbally regulate their own behaviour by means of self-instructional training. In Experiment 1, self-instructional training on a short-term memory task produced improvements in performance which did not generalize to a second memory task. In Experiment 2 an attempt to enhance generalization by teaching a rehearsal strategy on two different memory tasks produced improvements of performance only on those new tasks that were similar to the teaching tasks. The third experiment compared task-specific and general problem solving self-instructions and showed no differences in the effectiveness of the two methods. Some of the difficulties encountered when teaching self-instructions to the subjects, together with the failure to produce adequate generalization of treatment effects, leave the clinical utility of the procedure uncertain. Before a practical cognitive therapy for chronic schizophrenics can be developed it will be necessary to explore more fully the relationships that exist between the verbal and non-verbal behaviour of these patients.

Background: Theories concerning the aetiology of functional neurological symptom disorder (FNSD; also known as conversion disorder) have historically inferred that psychological factors or dissociative states underlie patients’ symptoms. Current psychological models of functional neurological symptoms suggest that some type of ‘top-down’ representations/beliefs are activated automatically (without conscious awareness), leading to symptoms. It is assumed that these representations or beliefs are similar to the idea ‘I am neurologically damaged’, as in our clinical experience, almost all patients have some reason to doubt the integrity of their neurological system. Aims: It was hypothesized that FNSD arises from a belief of being neurologically damaged (via a mechanism akin to a nocebo response), and an interdisciplinary treatment protocol was developed consistent with this hypothesis, transparently sharing this theory with participants. Method: A retrospective consecutive case series design was utilized, measuring functional independence and symptom remission. Results: Of the 13 episodes of care, 12 resulted in complete or almost complete symptom remission. Length of stay in rehabilitation was also reduced compared with previous treatment attempts. Conclusions: It appears as if the treatment protocol may be very effective, and further controlled study appears warranted.

Consistent with cognitive-behavioural formulations of Obsessive-Compulsive Disorder (OCD), recent research has supported the association between obsessive-compulsive phenomena, specific dysfunctional beliefs and negative affective states. However, such research has not been conducted across sufficiently different cultural contexts using the same measures in comparable samples. In the present study, university psychology students from Australia and Italy completed questionnaire measures of obsessive-compulsive phenomena, inflated responsibility, perfectionism, guilt, depression, and anxiety. Australian and Italian cultures can be seen to differ in a number of ways that could impact on the pattern of expected interrelations between these measures. Similarities in the factor structure and psychometric properties of the measures were apparent across the two cultural contexts, suggesting the appropriateness of cross-cultural comparisons in the pattern of intercorrelations. Significant interrelations were found between the measure of obsessive-compulsive phenomena, dysfunctional beliefs and negative affect in both cultural contexts. While there were some differences in the specific patterns of interrelations, these were few in number and, generally, could be explained by sociocultural factors or stereotypes, although the overall pattern of intercorrelations was stronger for the Australian cohort. The results suggest that cognitive-behavioural formulations of OCD can be generalized across these two different cultural contexts, although idiosyncratic cultural factors may need to be considered in developing cognitive-behavioural treatments.

Group training in anxiety management was compared with individual general practitioner appointments as a means of reducing dosage of benzodiazepines. Subjects were encouraged to withdraw at their own pace. Drug reduction, self-ratings of anxiety, depression and Health Locus of Control comprised the outcome measures. Process changes were recorded using visual analogue scales, and daily diary records. At the end of a six-week intervention period, the average dosage had significantly reduced in both groups. This reduction was maintined at a 15-week follow-up. There were no other differences in outcome between conditions. Although subjects reported a variety of symptoms during drug withdrawal, their occurrence was not significantly associated with the degree of dosage reduction.

Background: Repeated checking in OCD can be understood from a cognitive perspective as the motivated need to achieve certainty about the outcome of a potentially risky action, leading to the application of Elevated Evidence Requirements (EER) and overuse of subjective criteria. Method: Twenty-four obsessional checkers, 22 anxious controls, and 26 non-clinical controls were interviewed about and rated recent episodes where they felt (a) they needed to check and (b) checked mainly out of habit (i.e. not obsessionally). Results: Both subjective and objective criteria were rated as significantly more important in obsessional checkers than in controls; obsessional checkers also used more criteria overall for the termination of the check, and rated more criteria as “extremely important” than the control groups. The termination of the check was rated as more effortful for obsessional checkers than for the comparison groups. Analysis of the interview data was consistent with the ratings. Feelings of “rightness” were associated with the termination of a check for obsessional checkers but not for controls. Conclusion: Results were consistent with the proposal that the use of “just right feelings” to terminate checking are related to EER.

Background: People with anxiety disorders occasionally report fears about losing control of basic bodily functions in public. These anxieties often occur in the absence of physical disorder and have previously been recognized as “obsessive” anxieties reflecting a preoccupation with loss of bowel/bladder control. Motivated by our observations of the non-trivial occurrence of such anxieties in our clinical practice we sought to fill a gap in the current understanding of “bowel/bladder-control anxieties”. Method: Eligible participants completed an internet survey. Results: Bowel/bladder-control anxieties (n = 140) tended to emerge in the mid to late 20s and were associated with high levels of avoidance and functional impairment. There was a high prevalence of panic attacks (78%); these were especially prevalent among those with bowel-control anxiety. Of those with panic attacks, 62% indicated that their main concern was being incontinent during a panic attack. Significantly, a proportion of respondents (~16%) reported actually being incontinent during a panic attack. Seventy percent of participants reported intrusive imagery related to loss of bowel/bladder control. Intrusion-related distress was correlated with agoraphobic avoidance and general role impairment. Some differences were noted between those with predominantly bowel-, predominantly bladder- and those with both bowel and bladder-control anxieties. Conclusion: This preliminary characterization indicates that even in a non-treatment seeking community sample, bowel/bladder-control anxieties are associated with high levels of distress and impairment. Further careful characterization of these anxieties will clarify their phenomenology and help us develop or modify treatment protocols in a way that takes account of any special characteristics of such viscerally-centred phobic syndromes.

We used a negative priming paradigm to test for deficits in cognitive inhibition in patients with obsessive-compulsive disorder (OCD), and to examine whether they exhibit greater inhibitory deficits when lexical targets are threat-related than when they are neutral. The results indicated that OCD patients, relative to healthy control participants, exhibited only marginally significant (p < .10) deficits in negative priming at short (100 ms), but not long (500 ms), stimulus onset asynchronies. There was no evidence that OCD patients exhibited disproportionate difficulty inhibiting negative words, nor was there any evidence that negative priming deficits differed between OCD checkers and OCD noncheckers.

Stimuli related to blood, injury and illness (BII) evoke a unique psychophysiological response, with signs of both sympathetic and parasympathetic arousal. Fainting, which occurs commonly in BII phobias, may represent the extreme of this reponse pattern. Data from the assessment and cognitive–behavioural treatment of a BII phobic subject are presented. At assessment the patient showed a massive bradycardia and near loss of consciousness on exposure to blood. This responded rapidly to treatment, although with some desynchrony between subjective and autonomic responses.

We present the case of a 31-year-old man with comorbid schizophrenia and obsessive compulsive disorder (OCD) distinct from delusional beliefs. The OCD was successfully treated to 6-month follow-up with Exposure and Response Prevention (ERP) without leading to significant deterioration of psychotic phenomena. Considerations for clinicians are discussed.

A single case study of a schema-focused cognitive therapy approach to treatment of a young woman with long-term interpersonal relationship problems and affective instability is described. There have been few accounts of this type of therapy that have incorporated outcome measures. Measures of mood and of schema have been taken throughout treatment and results would appear to offer some support for schema-focused cognitive therapy.

This study reports on the effects of a cognitive-behavioral treatment program for two pre-adolescent children with chronic headaches. The program involved a combination of training the child in self-management skills (e.g. relaxation training, attention training, cognitive self-statements), and training for parents in how to prompt and reinforce children's self-help behaviors. Self-report assessment utilized a headache diary, a general activity measure, and a depression measure, whilst parental report measures were taken of the child's headache behavior and contingent parental care-giving behavior. Child headache behavior at school was also recorded by the child's teacher. The results indicated that by six months follow-up the subjects had improved in headache intensity 100% and 61% respectively, and in headache frequency 100% and 84% respectively. Both subjects also showed decreases in headache behaviors and reductions in contingent care-giving behavior by parents. Overall, the results suggest the potential usefulness of systematic involvement of parents in cognitive-behavioral treatment of children's chronic headaches.