Social Relationships and Schizophrenia. Christine Barrowclough
On the Psychology of Psychosis. Richard Bentall
Early Intervention in Psychosis, Max Birchwood
Was Epictetus Right? Do Negative Thoughts Cause Depression? David Burns
Clinically Effective CBT for Insomnia - and How it Might Work, Colin Espie
Cognitive Behavioural Treatment for Eating Disorders, Christopher G. Fairburn
Cognitive Therapy: A Treatment for the New Millenium, Melanie Fennell
Intrusions, Obsessions, Rumination and Worry, Mark H. Freeston
Active Ingredients in Child and Adolescent Therapy, Philip C. Kendall
Depressive Decision-Making, Robert Leahy
A Regulatory Systems Approach to Anger and Violence, Raymond W. Novaco
The Development and Prevention of Anxiety Disorders, Ron Rapee,
Cognitive Models of Bipolar Disorder: Theory and Therapy, Jan Scott
1. Prognostic Factors in Cognitive Behaviour Therapy for Schizophrenia
2. Advances in the Understanding & Treatment of Body Image Disturbance
3. CBT Self-help Treatments
4. The Understanding of Cognition in Children and Adolescents.
5. Issues of Coping and Vulnerability
6. Psychological Processes and Psychotic Symptoms
7. Family Care in Psychoses
8. Sexual Dysfunction
9. Dissemination of Effective Interventions
10. Cognition And Emotion In Children And Adolescents
11. Intrusions, Rumination, Control and Suppression Across Disorders.
12. Trauma and Mood Disturbance Issues
13. Cognition and Emotion Across Disorders
14. Early Intervention in Psychosis
15. Psychological Approaches and Sleep, Part 1
16. New Developments in Anger Treatment
17. Therapeutic Strategies Across Disorders
18. Disgust - The Forgotten Emotion?
19. Is There a Role for Cognitive Behaviour Therapy in Bipolar Disorder?
20. Psychological Approaches and Sleep, Part 2: Recent Empirical Findings
21. Clinically Effective and Efficient Approaches for RoutineClinical
22. Domestic Violence
23. Investigating Imagery
24. Do the Effects of CBT Endure? Follow-up of GAD and Panic Disorder
25. Evaluating The Effectiveness Of CBT Training
26. Basic and Applied Issues in Eating Disorders
27. Issues of Cognition and Emotion
1. Analogies, Stories, Metaphors: Tools for Clinicians
2. Children and ADHD, Alternatives to Amphetamines
3. Supervision in Cognitive-behaviour Therapy: Who, What and How?
4. Voluntary Self-regulation or Statutory Registration: What Does it Mean
Social Relationships and Schizophrenia
Christine Barrowclough, University of Manchester
There is a dynamic association between social relationships and emotional
well being and this is illustrated very well in schizophrenic illness.
Schizophrenia is characterised by impairments and difficulties in interpersonal
functioning, and at the same time interpersonal problems may exacerbate
the symptoms. Understanding this dynamic association has considerable
Social relationships and schizophrenia have been studied most intensively
in the context of families where attitudes are measured using expressed
emotion (EE) dimensions which have been shown to have an influential role
on patient outcome. Recent studies have demonstrated that such a problematic
response is not something unique to the family nor to schizophrenia: negative
staff attitudes are associated with worse patient outcomes; and the relationship
between high EE and worse outcome holds for many psychiatric and medical
Given the importance of social relationships in schizophrenia, a key question
pertinent to both familial and staff -patient interactions is why do some
people develop high EE? Whilst it is widely accepted that cognitive processes
mediate people's adaptations to their own health threats, carers perception
and evaluations of the illness experience have had very limited study.
However, there is now some evidence that cognitive appraisals of illness
symptoms underlie reactions of family members to schizophrenic illness.
Well replicated work on attributions has demonstrated that carers make
many and varied spontaneous attributions about the patient's symptoms
which are related to EE dimensions. Recent studies also suggest that carers'
models of mental illness may have a similar structure to those held by
people about physical illness and that these models carry behavioural
and coping outcomes. What are the mechanisms by which high EE exacerbates
symptoms? Whilst it is acknowledged that the EE/ heightened arousal hypothesis
for symptom exacerbation is very important, a new study raises the possibility
that critical attitudes from significant others may impact on negative
self concept which in turn maintains or exacerbates positive symptoms.
On the Psychology of Psychosis: Towards a Unifying
Framework for Understanding Depression, Paranoia and Mania.
Richard Bentall, University of Liverpool
In the last decade, significant advances in understanding psychopathology
has been achieved by using psychological models to explain specific type
of behaviours and experiences ('symptoms') rather than broad diagnostic
categories such a 'schizophrenia'. However, it is unlikely that entirely
different cognitive systems are affected in each type of abnormal behaviour.
Instead, different abnormal behaviours may reflect different types of
abnormalities in the same cognitive systems. Moreover, cognitive abnormalities
are for the most part not trait-like, but vary with time. By taking into
account these factors it may be possible to gain insights into why psychopathological
phenomena sometimes covary, and why their course is often unpredictable.
These ideas will be examined by exploring the mechanisms involved indepression,
paranoia and mania. Starting with what might be called a 'generic cognitive
model', in which appraisals of events effect beliefs about the self, thereby
bringing about changes in mood, it will be shown how developments of this
model can explain persecutory delusions and manic symptomatology. This
exploration will lead to the idea of the 'attribution - self-representation
cycle', a model of the nonlinear relationships between the appraisals
and self-representations (beliefs about the self, standards of self-evaluation,
autobiographical memories) that attempts to account
for the instability of these symptoms over time. Implications of this
model for psychiatric classification, for biological research into psychopathology,
and for clinical interventions will be discussed.
Early Intervention in Psychosis
Max Birchwood, University of Birmingham
The UK Government has recently announced its firm intention to fund 50
new early intervention services for young people experiencing psychosis
for the first time.
In this paper, I will critically review the conceptual basis for the early
intervention approach and discuss the service gaps which currently exist
in our services for first episode psychosis. I will argue that CBT interventions
should be bought to bear on the key transition points in first episode
psychosis, including transitions to the first psychotic episode, the management
of treatment resistance, but most importantly, the prevention of depression,
suicidal thinking and traumatic
Was Epictetus Right? Do Negative Thoughts Cause Depression?
David Burns, Stanford University School of Medicine, Stanford, USA
Cognitive behavioral therapy (CBT) proposes that negative cognitions cause
depression, anxiety, and anger. They also propose that self-defeating
beliefs (SDBs) trigger episodes of depression and that changes in SDBs
mediate recovery. Typical SDBs include the belief that one must be perfect,
or the belief that one must be loved to be worthwhile.
It is difficult to test these theories because of the problem of circular
causality. Negative cognitions may lead to negative emotions, but negative
emotions may have reciprocal causal effects on cognitions. In addition,
it is possible that negative cognitions and emotions are not causally
linked. The correlation between these variables could result from an unknown
third variable that activates them simultaneously.
Elucidating the causal linkages is crucial. If negative cognitions do
not have a causal effect on emotions, then the theoretical basis of CBT
would be invalid. Dr. Burns will present two new studies that examine
the causal links between cognitions and emotions. The results suggest
a powerful, high speed reciprocal causal link between negative cognitions
and emotions, as proposed by Epictetus nearly 2000 years ago.
However, there no causal linkages between SDBs and depression or anxiety
were detected. Furthermore, recovery during CBT did not appear to be mediated
by changes in SDBs.
Clinically Effective CBT for Insomnia - and How it
Colin Espie, University of Glasgow
A least 10% of adults and 20% of older adults experience persistent difficulty
in getting to sleep or remaining asleep. Sleeplessness and its daytime
consequences, therefore, represent a considerable public health problem,
and one that is increasingly recognised in terms of health costs. Pharmacotherapy
is of limited benefit in chronic insomnia, but cognitive-behavioural treatments
have been widely evaluated and may now be the treatment of first choice.
This paper briefly reviews the literature on the efficacy of CBT in this
population, but concentrates primarily on addressing three commonly asked
questions. First, will CBT really work with my patients? The evidence
on clinical effectiveness will be considered, that is, whether or not
CBT is useful in ordinary clinical settings. Second, can CBT be delivered
cost-effectively in practice? A validated model using manualised, small
group intervention format will be described. Third, if CBT works, why
does it work? A recently revised, integrated model of normal sleep and
sleep disturbance will be presented. Critical pathways in the development
and maintenance of insomnia will be discussed and consideration given
to possible critical ingredients in effective therapy. In relation to
each of these questions, avenues for future research will be highlighted.
A New "Transdiagnostic" Cognitive Behavioural
Treatment for Eating Disorders
Christopher G. Fairburn, Department of Psychiatry, University of Oxford
The research on the treatment of eating disorders has focused largely
on the treatment of bulimia nervosa. The most effective treatment is a
specific form of cognitive behaviour therapy (CBT-BN). A mounting body
of evidence provides support for the cognitive behavioural theory that
underpins CBT-BN but the treatment only results in about half the patients
making a full recovery. This suggests that either the treatment procedures
need to be improved (or implemented more effectively), or the theory needs
to be modified and the treatment adapted accordingly, or both.
In Oxford we have developed an enhanced and extended form of CBT-BN. It
has been enhanced by the use of improved treatment procedures and it has
been extended to address additional maintaining mechanisms. A novel feature
of the resulting "modular" treatment is that it is "transdiagnostic";
that is, it is designed to be suitable for all forms of clinical eating
disorder. The new treatment, and the theory upon which it rests, are shortly
to be the subject of a large randomised controlled trial.
Cognitive Therapy: A Treatment for the New Millenium
Melanie Fennell, University of Oxford
The evidence base for cognitive therapy has expanded dramatically
in the last 10-15 years, encompassing not only common mental health problems
but also severe mental illness. At the same time, the resources to provide
effective, high quality psychological treatments within the National Health
Service are increasingly constrained. The presentation argues that cognitive
therapy is ideally placed to meet the standards and objectives of contemporary
mental health care - except that access to competent practitioners is
limited. Rather than trying to solve this problem by quick and dirty means,
we should think carefully about how knowledge and skills in cognitive
therapy can best be taught, so as to provide NHS patients with the high
quality treatment they need and deserve
Intrusions, Obsessions, Rumination and Worry: What
Do We Know and Where Are We Going?
Mark H. Freeston, University of Newcastle. Director of Research and Training,
Newcastle Cognitive and Behaviour Therapies Centre
There have been significant advances in the understanding and treatment
of obsessions and worry over the last decade with the development of increasingly
specific models and specific treatment strategies. Worry and obsessions
are particularly interesting because their respective disorders, Generalised
Anxiety Disorder and Obsessive-Compulsive Disorders, are in fact defined
by the very presence of these types of thinking which are naturally targets
for treatment. The knowledge acquired in the study of these phenomena
has also influenced developments in other fields where intrusive and ruminative
thinking is experienced such as insomnia, acute stress, chronic pain,
health anxiety, depression, and psychosis. Although the distinction between
obsessions and worry is relatively simple at a prototypical level, the
clinical reality suggests that there is great deal of overlap. Thus, they
may also be better conceptualised as different points on a continuum and
may share some common processes but also have some distinct features.
This presentation will present some key findings that have contributed
to current conceptualisations of obsessions and worry, which in turn have
resulted in the development of effective treatments. It will highlight
some common and distinct features of obsessions and worry and how they
may have implications for treatment. Despite the significant advances
in our understanding of these phenomena, there remain a number of paradoxes
that we have yet to account for in a satisfactory way. Two of these apparent
paradoxes will be addressed in more detail where there are currently gaps
in both the theory and in our capacity to investigate them due to limitations
in methodology. Finally, some additional areas where our understanding
of these processes may be applied in conceptualising and treating other
intrusive or ruminative thinking will be suggested.
Active Ingredients in Child and Adolescent Therapy
Philip C. Kendall, Temple University, Philadelphia, USA
The keynote address will provide an overview of several components of
psychosocial interventions for children/youth that are considered to be
influential in the achievement of positive outcomes. Specifically, therapist,
child, and type of treatment factors will be presented and discussed,
and examples from clinical and research practice will be provided.
Robert Leahy Cornell University Medical College & American Institute
for Cognitive Therapy, New York, USA
A major goal of cognitive therapy is to assist the patient in initiating
change. Rational models of decision making are offered in therapy, based
on "expected utilities", such as costs and benefits of future
action. However, individuals often ignore expected utility and base their
decisions on other considerations. I shall present two decision models
that guide depressive resistance: pessimistic risk aversion based on modern
portfolio theory and commitment to sunk costs.
According to modern portfolio theory individuals utilise different assumptions
and goals in considering how they will allocate their resources and how
much risk they will tolerate. A portfolio theory is the individual's perception
of his or her resources, ability to produce future resources, diversification,
emphasis on maximisation or minimisation of rewards or costs, potential
for regret, hedonic utility for gains and losses, and risk-tolerance.
For example, optimistic "rational individuals", who view themselves
as having abundant current resources and potential for future earnings
with a long duration, would be likely to tolerate greater risk in their
investments than would individuals lacking current and future resources
or who would view themselves as having a shorter duration of investment.
Presumably, the individual who has abundant current and future resources
can "absorb" a loss, should it occur, especially if she believes
that there is a long duration in which this recovery could occur. Furthermore,
greater risk tolerance would be assumed if the individual believed that
she had many potential replications of behaviour, for example, many potential
"hands" to play in order to win
Modern portfolio theory proposes that individuals will tolerate greater
risk if they are more highly diversified, since a loss in one investment
may be offset by the performance in other investments. Thus, diversification
may be viewed as a way in which costs may be contained or compartmentalised,
avoiding the risk of over-generalising a failure. Given the negative cognitive
schemata of depressed individuals, we would anticipate that these individuals
would view losses as having a spreading activation effect, such that they
would trigger other losses, thus adding to risk aversion. Empirical data
are reviewed that indicate that depressed individuals resist change based
on their pessimistic portfolio assumptions and strategies.
A second model---commitment to sunk costs-is reviewed that proposes that
individuals utilise prior losses and commitments as a rationale for future
escalation of commitment. Rather than extinguishing their behaviour, these
prior losses provide a "rationale" for further action aimed
at redeeming bad decisions, avoiding finality of regret, and preventing
A Regulatory Systems Approach to Anger and Violence
Raymond W. Novaco, University of California, Irvine, USA
Clinicians, researchers, and patients tend to view anger as attributable
to immediate circumstances, current thoughts, and sustained beliefs. In
contrast, systems-oriented thinking approaches anger as a contextual and
dynamic phenomenon in which personal dispositional systems of anger (cognitive,
physiological, and behavioural) are embedded in an interdependent network
of interpersonal and environmental systems. Recurrent anger and violence
are maintained by their functionality, as well as by entrenched schemas,
and by the relative absence of inhibitory controls and neutralizing influences
that counteract antagonism. The more functional and embedded anger is
within a system, the greater is its inertia or resistance to change. For
persons having serious anger difficulties, it is engaged by threat perception
with considerable automaticity that challenges its regulation.
The treatment of anger, like anger itself, should be understood contextually.
Cognitive-behavioural anger treatment augments anger-regulatory mechanisms
and seeks to do so through both person-centered and environmental intervention.
The social distancing effect of chronic anger and the negative expectations
that others form of angry people, including clinical staff in treatment
settings, interfere with therapeutic change efforts and can reverse treatment
effects. Recent treatment outcome studies with patients having severe
anger problems, compounded by other clinical conditions (PTSD, psychoses,
and developmental disabilities) have found significant gains associated
with anger treatment in both individual and group intervention. New results
will be presented, and key ingredients of successful intervention in institutional
settings will be discussed. As significant treatment gains have been achieved
with highly distressed clients having very complex needs, there is much
hope for many other people who struggle to maintain their anger and seek
Building Resilience: The Development and Prevention
of Anxiety Disorders
Ron Rapee, Macquarie University, Sydney, Australia
Anxiety disorders are responsible for a huge cost to society as
well as a great deal of personal suffering. Past research has focussed
on the formulation of detailed models of maintenance and concomitant treatment
programs. Little research has so far been directed at the more difficult
question of causation. But understanding cause may help to elucidate ways
of preventing the development of anxiety disorders from a young age. Over
the past few years, we have been focussing on several factors of possible
importance in the development of anxiety. These include a combination
of a withdrawn temperament, overprotective parenting, and modelling of
anxious behaviour from parents. This talk will describe some of our data
and integrate them with data from other laboratories to describe a model
of the development of anxiety disorders that may be amenable to change
in prevention programs. I will then describe a program that we have been
working on for the past few years to prevent the development of anxiety
disorders. The program began with 3-4 year old preschool children who
are at risk for anxiety disorders through their high scores on behaviourally
inhibited temperament. The primary focus of the program is to provide
education for their parents to help reduce inhibition and withdrawal.
In the long term, we hope that this will also alter their risk for anxiety
disorders. In this talk, I will present data from our 12-month follow-up
that provides the first evidence that temperament can be altered with
a relatively brief parent education intervention.
Cognitive Models of Bipolar Disorder: Theory and
Jan Scott, University of Glasgow, Scotland
Cognitive therapy is widely established as an alternative to medication
for individuals with acute major depression. However, arguments prevail
about the cost versus benefit of this approach as compared to treatment
with antidepressants. This view is less valid when considering the problem
of 'treatment-resistant' depression. Previous studies indicate that clients
with persistent symptoms of depression following antidepressant treatment
are common, experience considerable morbidity and have very high rates
of relapse. There is evidence that cognitive therapy may reduce relapse
rates in depression, but limited evidence about which clients with chronic
depression will most benefit from cognitive therapy.
To explore these issues, we undertook a controlled of 158 subjects with
recent major depression, partially remitted with antidepressant treatment
(mean doses approximately equivalent to 185 mg amitriptyline or 33 mg
fluoxetine), but with residual symptoms of 2 - 18 months duration. Subjects
were randomised to receive clinical management alone, or clinical management
plus cognitive therapy for 16 sessions over 20 weeks, with two subsequent
booster sessions. Subjects were assessed regularly throughout the 20 weeks
treatment and for a further year. They remained on continuation and maintenance
antidepressants at the same dose throughout.
Recovery rates in those treated with additional cognitive therapy were
more than twice that of individuals receiving clinical management. Cognitive
therapy also reduced relapse rates for acute major depression and persistent
severe residual symptoms, in both intention to treat and per protocol
treated samples. The cumulative relapse rate at 68 weeks was reduced significantly
from 47% in the clinical management control group to 29% with CT (hazard
ratio 0.54, CI 0.32-0.93 intention to treat analysis). Cognitive therapy
also reduced specific psychological and social symptoms such as guilt,
pessimism and interpersonal dependency. We found evidence that CT may
mediate its relapse prevention effects through changes in thinking style
rather than thinking content.
The paper also showed that CT for residual depression is more clinically
effective (using evidence based medicine calculations of numbers needed
to treat) than treatments for physical disorders with equivalent levels
of disability. Using cost incremental analysis we calculated that adding
CT significantly reduces use of other services, but that CT is not a substitute
for all components of treatment as usual. We calculated that it costs
about 4000 pounds to avoid a relapse with this approach, or about 12 pounds
per depression free day. The issue now is whether decision makers will
view this as value for money.
In this difficult to treat group of clients with medication-resistant,
residual depression, cognitive therapy produced worthwhile relapse reduction.
This paper will review these results in light of other recent studies
and will also address the health economic issues offering an estimate
of the cost of relapse avoidance.
Understanding and Targeting Prognostic Factors in Cognitive
Behaviour Therapy for Schizophrenia
Andrew Gumley, University of Stirling
Cognitive Approaches to the Treatment of Individuals at High Risk of Developing
Paul French, Psychology Services, Mental Health Services of Salford, Manchester.
Primary prevention of psychosis has previously been viewed as unattainable.
Currently interventions are aimed towards secondary prevention strategies
through minimising further episodes and residual symptoms. However, current
research indicates the possibility of identifying initial prodromal symptoms
and, therefore, the possibility of primary prevention. A number of primary
prevention teams have been established around the world with interventions
geared towards medication. This has problems in that there are still false
positives who will be treated with neuroleptic medication and be exposed
to the side effects of these medications. The answer is to employ psychological
interventions with no side effects that target the distress the individual
is experiencing. During the symposium early detection strategies will
be discussed and a psychological model describing the onset of psychosis
will be presented.
Cognitive Behavioural Psychotherapy for Psychosis: From Formulation to
David Fowler, University of East Anglia
Recent randomised controlled trials carried out in the UK suggest that
there is now strong evidence for the efficacy of cognitive behavioural
therapy in the management of individuals with psychosis. At the core of
this approach is the focus on the subjective experience of individuals
with psychosis, in particular, the experience of voices, paranoia, delusions
and depression. The starting point for cognitive therapy is the formulation
and conceptualisation of this experience in order to make sense of the
individual's experience of psychosis. This paper will describe an approach
to cognitive formulation, which integrates recent research findings on
cognition and emotional processing, and trauma experience of individuals
with psychosis. In particular the paper will highlight the potential role
of vulnerability to psychological disorder and distress in influencing
the course and experience of psychosis.
Cognitive Behavioural Therapy Targeted During Early Relapse in Schizophrenia:
The Results of a Randomised Controlled Trial
Andrew Gumley and the West of Scotland Early Intervention Trial Research
Group, University of Stirling & Ayrshire and Arran Primary Care Trust
Relapse in schizophrenia is associated with increased probability of future
relapse, increased residual symptoms and deteriorating social functioning.
There is evidence that targeting increases in anti-psychotic medication
during early relapse is effective in preventing relapse and re-hospitalisation.
However, this approach to prevention has a number of disadvantages. Continuing
questions concerning the sensitivity and specificity of early signs to
relapse mean that increases in medication may be unnecessary, and indeed
this treatment approach may not be acceptable to individuals due to increased
side-effects. Therefore targeting cognitive therapy on the prevention
of relapse provide a meaningful alternative treatment approach to relapse
prevention. The West of Scotland Early Intervention Trial recruited a
total of 144 individuals with a diagnosis of a schizophrenia spectrum
disorder who were considered by the assessing clinician as relapse prone.
Participants were randomised to either Treatment as Usual (n = 72) alone
or in combination with Cognitive Therapy (n = 72). Participants were assessed
at entry, 12 weeks, 26 weeks, and 52 weeks. Cognitive therapy was delivered
as a two-stage intervention; a five-session engagement/ formulation phase
between entry and 12 weeks, and a targeted cognitive therapy phase delivered
on the appearance of early signs indicative of relapse. This targeted
phase was available to participants throughout the follow-up period. Outcome
was assessed according to (1) relapse rate, (2) remission at 52 weeks
and 18 months, and (3) social functioning. Predictors of outcome were
examined using Logistical Regression Analysis. The paper will present
outcome results for the trial, alongside findings on predictors of outcome.
Consideration will be given to future research into the delineation and
targeting of psychological factors involved in the evolution of relapse
Improving Insight in Schizophrenia
Douglas Turkington, Jeremy Pelton and the Insight into Schizophrenia Research
Group, University of Newcastle
353 patients with schizophrenia according to ICD 10 research criteria
were randomised on a 2:1 basis to receive the Insight programme or treatment
as usual. The Insight Programme consisted of 6 sessions of CBT for the
patient along with psycho-educational material targeted on insight improvement.
The sessions focused on engaging, developing explanations, case formulation,
symptom management, adherence work, belief change and relapse prevention.
The main carer received 3 sessions focused on stress management, formulation,
helping with homework and relapse prevention. Insight was successfully
improved by end of therapy in the Insight Programme group but there was
evidence that improving insight does need the support of a therapeutic
relationship and much in the way of explanation or depression and increased
suicidal ideation can occur. These results are fully explored and their
pertinence to working with psychotic patients explained.
Characteristics of Good and Poor Responders in Tayside-Fife Trial of
CBT for Chronic Psychotic Symptoms
Rob Durham & R. Victor Morton, Department of Psychiatry, University
The Tayside / Fife trial of cognitive-behavioural therapy for medication-resistant
psychotic symptoms was completed in December 2000. Of 274 patients referred
to the trial 65 were suitable and consented to participate. These patients
were randomly allocated to one of three treatment conditions of 9 months
duration: CBT delivered by clinical nurse specialists as an adjunct to
routine psychiatric care (n=22), supportive psychotherapy delivered by
volunteer members of the clinical team (mainly nurses) as an adjunct to
routine psychiatric care (n=23), and routine psychiatric care alone (n=21).
Four aspects of the trial methodology promoted a rigorous evaluation of
the clinical effectiveness of CBT in routine clinical practice: (1) a
three month pre-treatment baseline to assess stability of presenting symptomatology,
(2) outcome evaluation by independent assessors blind to treatment allocation
at post-treatment and 3 month follow-up, (3) supportive psychotherapy
delivered by non-CBT trained therapists supervised by a consultant psychotherapist,
and (4) a treatment as usual control group. Patients were recruited from
Dundee, Perth and rural areas of Fife and Angus. Main outcome measures
were the Positive and Negative Syndrome Scale (PANSS), the Psychotic Symptom
Rating Scales (PSYRATS) and the Brief Symptom Inventory. In addition,
the quality of the therapeutic relationship was assessed using the Penn
Helping Alliance Scales. This paper explores the diversity of responses
to psychological intervention by comparing the characteristics of the
ten patients with the best and worst outcomes in terms of demographics,
insight, clinical state, social functioning, and quality of therapeutic
alliance and symptomatic change.
Advances in the Understanding and Treatment of Body Image
Roz Shafran, University of Oxford
Predictors of Eating Disorder Scores in Children
Rick M. Gardner, University of Colorado, Denver, USA
A longitudinal study which identified variables that predict higher eating
disorder scores in a non-clinical sample of boys and girls aged six through
fourteen will be described. A TV-video procedure was used in conjunction
with advanced psychophysical techniques to measure the perceptual and
affective components of body image. Predictor variables examined include
body sizejudgments as well as demographic, familial, sociocultural, esteem,
and clinical variables.
A New Method of Assessing Body Image Disturbance
Roz Shafran, Christopher G. Fairburn, Zafra Cooper , Oxford University
Department of Psychiatry
Body image disturbance has been proposed as a key mechanism that contributes
to the persistence of dietary restriction in patients with anorexia nervosa.
Despite the abundance of research in this area, body image disturbance
remains ill-defined and poorly understood; consequently, we suggest that
the existing methods of measuring body image disturbance may be flawed
In order to test the hypotheses relating to body image disturbance that
derive from our new theoretical model, it became necessary to devise a
new method of measurement. We suggest that this new method represents
a significant advance over existing methods for at least two reasons.
First, it uses an ecologically valid stimulus for the assessment of body
image i.e., a mirror. Second, it separates the perceptual component of
body image disturbance from the memory of body image by asking the participant
to estimate her body size whilst simultaneously looking at her reflection
in the mirror.
Results from an initial study on body size estimation with women who have
an eating disorder and non-clinical comparison women will be presented.
These results show that despite looking at their reflections in the mirror
whilst performing this task, women with an eating disorder overestimate
their body size compared to normal controls. The clinical and research
implications of the results of this study and the new method of assessing
body image disturbance will be discussed.
Development of the Body Checking Questionnaire: A Self-Report Measure
of Body Checking Behaviors
Deborah L. Reas, Brooke L Whisenhunt, Rick Netemeyer & Donald A. Williamson,
Department of Psychiatry and Behavioral Sciences, University of Texas
Medical School at Houston,
The purpose of this study was to develop a brief self-report inventory
that could be used for the assessment of body checking behaviors that
are common in eating disorder patients. Using exploratory and confirmatory
factor analyses, a 23-item measure called the Body Checking Questionnaire
(BCQ) was developed. A variety of body checking behaviors are assessed
by the BCQ, including subfactors that measure checking related to overall
appearance, checking of specific body parts, and idiosyncratic checking
rituals. The BCQ was found to have good test-retest reliability (.94)
and the subfactors had good internal consistency (.88, .92, and .83).
The measure correlated highly with other measures of negative body image
and eating disorders, demonstrating evidence for the convergent validity
of the BCQ. Additionally, the BCQ was found to differentiate normal controls
and eating disorder patients, as well as non-clinical participants scoring
high and low on the Body Shape Questionnaire. Since frequent body checking
may reinforce body dissatisfaction in eating disorder patients by directing
excessive attention to body shape and size, the BCQ may prove to be a
useful clinical tool for the assessment and treatment eating disorder
Aesthetic Sensitivity in Body Dysmorphic Disorder
David Veale. Royal Free Hospital & University College Medical School,
London & The Priory Hospital North London
Individuals with Body Dysmorphic Disorder (BDD) have an extremely distorted
body image. BDD is also associated with idealised values about the importance
of appearance to the self and increased aesthetic sensitivity. Evidence
will be presented from two studies: (1) The occupation and higher education
or training was extracted from the casenotes of 100 consecutive patients
with BDD and compared to 100 patients with a Major Depressive Episode,
100 patients with Obsessive Compulsive Disorder (OCD) and 100 patients
with Post-Traumatic Stress Disorder (PTSD). 20% of the BDD patients had
an occupation or education in art or design compared to 4% in the depressed
group, 3% in the OCD group and 0% in the PTSD group, which was highly
significant. (2) We have tested self-discrepancy theory and found that
BDD patients have a high degree of self-discrepancy between how they see
their appearance and how they would like to be in an ideal world. There
was no discrepancy between how they saw their appearance and how they
thought others saw them or would like them to look. This suggests that
BDD patients are not like patients with bulimia or social phobia and are
mainly driven by an internal aesthetic standard, which they fail to achieve.
These findings will be discussed with a cognitive behavioural model of
BDD and implications for treatment.
CBT Self-help Treatments: The Current Status of Computer-delivered
Chris Williams, University of Glasgow
Self-help approaches and computer-based treatments are very topical.
Several UK-developed treatment packages are available and are currently
being evaluated. In spite of claims for high acceptability and the possibility
that computer-based treatments will allow ready access to an effective
psychosocial intervention, few clinical units currently offer such treatments.
This symposium will review current computer packages, the evidence for
their effectiveness, and discuss ways that such packages may be seen as
part of a wider service delivery of CBT.
Evaluating a computer-based CBT treatment package for bulimia nervosa
U. Schmidt*, Williams, C., Barra-Carril, N., Reid, Y., Harkin, P., Cottrell,
D., Treasure, J., Kovacs, D. Palmer, R
*: Senior Lecturer in Psychiatry, Institute of Psychiatry, De Crespigny
Background: Bulimia nervosa (BN) is a psychologically and physically disabling
condition. The disorder is not self-limiting, and without early treatment
the risk of a chronic relapsing course is high. Cognitive behavioural
treatment (CBT) is the treatment of choice for bulimia nervosa. Self-help
formats of CBT using books have been used with good effect, but many patients
find it difficult to motivate themselves to actively engage with working
through a book.
Aims: The present study describes the ongoing pilot evaluation of a CD-ROM
based CBT package (Williams et al., 1998) in the treatment of outpatients
with bulimia nervosa. The interactive nature of this programme and the
more individually tailored delivery of information is likely to make it
acceptable to a much broader range of sufferers than traditional self-help.
Individuals with bulimia nervosa are usually young women, a group with
high computer literacy, and are therefore an ideal target group for this
type of treatment. Moreover, the shame and secretiveness surrounding bulimic
disorders may make computer-based treatment particularly appealing to
sufferers as a first line treatment.
Subjects and Method: New out-patients with bulimia nervosa referred to
two eating disorder clinics (London, Leicester) were entered into the
study. Outcome was measured in terms of bulimic symptomatology, and indicators
of psychological and social functioning. Acceptability of the programme
was assessed by questionnaire and qualitative interviews.
Results: To date 35 patients have enrolled in the CD-ROM programme. The
paper will describe take-up and drop-out rates, and preliminary symptomatic
outcomes will also be presented.
Discussion: The clinical and research implications of using this novel
approach to treatment will be discussed.
Beating the Blues' Computer CBT Program for Anxiety and Depression: Applications
Judy Proudfoot*, Institute of Psychiatry, London; Jim Willis*, Invicta
Trust, Maidstone:Research Team: David Goldberg, Isaac Marks, Anthony Mann,
Jeffrey Gray, David Shapiro, Sharon Swain
'Beating the Blues'TM is a stand-alone computer-controlled, interactive
multimedia package providing CBT for anxiety and depression (for details,
visit www.Ultrasis.com). Developed at the Institute of Psychiatry with
two private-sector companies, the program can be delivered on a personal
computer located in the GP surgery or specialist care facility. Clinical
supervision and responsibility continue to rest with the GP or other appropriately
qualified personnel (nurse or clinical psychologist), to whom reports
(including warnings of suicide or other risk) are automatically delivered
by the computer program. The program is readily usable by patients with
no previous computer experience. Like other versions of CBT, Beating the
Blues can be given alone or in combination with pharmacotherapy.
Excerpts of the programme will be demonstrated and preliminary data presented
from the various studies in which Beating the Blues is being evaluated.
If the Evidence is So Good, Why Doesn't Anyone Use Them? - Current Uses
of Computer-Based Packages.
Graeme Whitfield., Leeds Community and Mental Health Trust. And Chris
Williams, University of Glasgow.
Despite evidence that computerised CBT can be as effective as face to
face therapy less than 7 per cent of practitioners accredited by the BABCP
(British Association of Behavioural and Cognitive Psychotherapists) use
them (Keeley and Williams 2001). This low uptake may reflect patient or
therapist attitudes. Alternatively it may be the result of NHS commissioning
mechanisms that have been noted to be relatively unreceptive to computerised
CBT (Shapiro et al 2001). Preliminary results from a recent survey of
a randomised sample of 500 BABCP members will be presented which explores
practitioner attitudes to and experience of using computerised CBT. It
also addresses therapist-identified factors that would need to change
before the therapists not currently using computerised CBT would begin
to do so. Factors such as the practitioners' current computer literacy,
the availability of a secure workplace in which to house computer facilities
as well as the availability of IT (Information Technology) support all
affect uptake. Specific therapist concerns about computerised CBT such
as patient confidentiality and the Data Protection Act are highlighted.
Keeley, H, Williams C, Shapiro, DA (2001) A National Survey of BABCP Accredited
Therapists' Attitudes towards and Use of Structured Self-Help Materials,
Paper submitted to Behavioural and Cognitive Psychotherapy.
Shapiro, DA, Proudfoot J, Gray J (2001) Computer-Based Cognitive-Behaviour
Therapy of Anxiety and Depression. Paper presented at the 'Psychological
Therapies in the NHS' conference, Brighton, UK.
Using Computer-based Self-help: A Clinical Perspective.
Chris Williams, University of Glasgow.
Cognitive Behaviour Therapy (CBT) is a proven treatment for anxiety and
depression, yet access to specialist therapists is often limited. Computerised
self-help packages offer one way of delivering CBT within a clinical service.
CBT packages offer essentially an educational form of psychotherapy and
this to some extent overlaps with the goals of practitioners working in
the arena of health promotion.
A significant literature exists within the field of health promotion concerning
how to maximise change in attitudes and behaviour. When applied to CBT,
creators of self-help materials need to be aware of the potential pit-falls
in creating such materials. Average reading ages within the UK vary according
to a roughly normal distribution and have a mean of between ages 9-11
in many studies. A poor reader will quickly become discouraged by texts
that are difficult for them to read fluently. This occurs when text is
poorly printed, contains complex sentences, long words or too much material
containing entirely new ideas (www.hfht.org). This has significant implications
for the development of computerised self-help materials.
Many existing CBT computer packages have tended to "put a book"
onto computer. This is unhelpful because it takes 28% longer to read than
when the user reads the same materials printed out on paper1. Materials
should instead be produced with computer delivery in mind, and be accessible,
delivered for a specific target audience, be clearly presented, legible,
and readable. The Overcoming Depression course brings together key components
for change: a clear structure, a focus on current problems and a jargon
free content that has been produced in liaison with users. The course
is available in different formats - as a book, via the web and shortly
as an interactive CD Rom (www.calipso.co.uk). The development of the course
and an overview of its content will be described.
Muter, P., Latremouille, S.A., Treurniet, W.C., & Beam, P. (1982).
Extended reading of continuous text on television screens. Human Factors,
A Systematic Literature Review of Computer-based Outcome Studies.
Martin Neal*, Chris Williams, Ian Cameron, David Cottrell, Helen Clarke,
*Leeds Community and Mental Health Services Trust.
This presentation will focus upon the Cochrane systematic review that
is being undertaken considering those studies that specifically focus
upon computer based self-help materials for the treatment of anxiety and
depression. This presentation will identify the work that has been carried
out by a multi institutional team focusing specifically upon depression.
The presentation will not only focus upon RCTs and CCTs, but attempt to
make sense of the broader literature regarding the use of computer materials
in the treatment of depression.
Additionally the presentation will seek to set the context for how computer
assisted materials are being considered at both a national and international
Consideration of how the review was constructed and the key finding to
date will also be discussed.
New Developments in the Understanding of Cognition in Children
Jonquil Drinkwater, University of Oxford
Cognition in Younger Children: Some Theoretical Observations and Implications.
Derek Bolton, Psychology Department, Institute of Psychiatry, Kings College
Piagetian and Vygotskian theories of cognitive development include points
of direct relevance to cognitive therapy, including that cognition increasingly
regulates behaviour (including affect), that in pre-rational mentality
symbol can influence reality, and that mature rationality from adolescence
on involves various competencies including meta-representation and systematic
theory. Notwithstanding paradigm shifts from general stage theories to
information-processing models of modular domains, the early developmental
theories retain relevance and implications for cognitive therapy with
children. The theories imply that basic cognitive therapy methods including
cognitive restructuring may apply indefinitely far down the age-range
once the child is using language, though these techniques are more likely
to engage with what is regulating the child's affect and behaviour if
they focus on the child's own spontaneously produced verbally encoded
meanings. It is unclear how far regulation of affect and behaviour by
language can be promoted or accelerated by telling the child what they
are probably thinking, or what it would be helpful to think instead. Another
implication is that those cognitive therapy techniques which focus on
explicit systematic theory, core beliefs etc., are probably less applicable
prior to mid-adolescence, but this belongs with the fact that childhood
presenting problems typically do not involve explicit theory of this kind.
Meta-representation can be found in children, such as feeling bad about
having such-and-such thoughts or inclinations. Pre-teenagers can also
have beliefs about the effects of cognition on reality, as for example
in magical thinking. Again the implication is that cognitive therapy methods
are likely to be applicable to children, providing they engage with the
child's own cognitive processing.
Emotional Disclosures in School Children
Martina Reynolds, Department of Addictive Behaviour & Psychological
Medicine, St. George's Hospital Medical School, London
Recent research with adults by Pennebaker and his colleagues has found
that emotional disclosure through writing about stressful events appears
to have significant benefits in terms of psychological and physical health
outcomes. This report describes a controlled trial of emotional disclosure,
adapted for schoolchildren, with the major hypothesis that the repeated
description of negative events will have beneficial effects on measures
of mental health, attendance, and school performance. The sample consisted
of children aged 8-13 years from 4 schools, a primary and a secondary
school from both a suburban and an inner-city area. Children were randomly
assigned to 1 of 3 conditions, writing about negative events, writing
about non-emotional events, and a
non-writing control group. Children in all groups were seen 4 times during
a single week and were then followed up after 2 months with measures of
health and school performance. The intervention was well received by both
schools and children, and the scripts written by the emotional and non-emotional
writing groups differed in content in the predicted ways. Contrary to
expectation, here was little evidence of a specific effect of emotional
disclosure, and several possible reasons for this are discussed. Nevertheless,
there was a general reduction in symptom measures, indicating that children
may have benefited from their involvement in the study. Although there
are several possible explanations for our findings, they indicate that
it is both feasible and potentially valuable to give children opportunities
to engage in discussion about sources of stress and their reactions to
Beliefs and Cognitive Avoidance Associated with Worry in Teenagers:
Mark Freeston, Newcastle Cognitive and Behavioural Therapies Centre and
University of Newcastle
Current models propose that different beliefs about worry and cognitive
avoidance contribute to the maintenance of worry. This study examined
the relationship between worry intensity, beliefs, and cognitive avoidance
among a large sample of high-school students aged 12-17. A wide range
of worry intensity was reported, with surprisingly large numbers reporting
levels that approach clinical levels. There were also age and gender related
differences in worry themes. As predicted there was an association between
the degree of worry and a range of beliefs. High worriers more strongly
endorsed the notion that worry was useful than did moderate worriers.
In particular there was significant interaction between two groups of
beliefs. Although both high and moderate worriers believed that worry
helped solve problems, high worriers reported a relatively greater belief
that worry could help prevent the worst from happening. Likewise, a wide
range of cognitive avoidance strategies was endorsed with worriers reporting
greater avoidance. Once again an interaction
was observed for the perceived efficacy of the strategies. High worriers
reported greater efficacy in the short term and lower efficacy in the
long term than did the moderate worriers. The results support current
models of worry, in particular the strategic and rule-governed nature
of the worry process. In particular, this study extends findings to an
adolescent age group, suggesting the processes are already in place at
an early age. Implications for prevention and treatment are briefly discussed.
The Relationship Between Automatic Thoughts and Negative Emotions in
Children and Adolescents
Ronald M. Rapee & Carolyn A. Schniering, Macquarie University, Sydney,
Cognitive theories of emotional disorders point to links between specific
categories of beliefs and associated symptoms. For example, threat-related
thoughts are said to be associated with anxious symptomatology while loss-related
thoughts are said to be related to depressive symptoms. There has been
some support for this argument in adults. However, in children, support
for the argument has come from small studies examining individual types
of thoughts or symptoms. The two main aims of the present studies were
to examine the factor structure of a wide range of negative beliefs in
children and adolescents and to examine the links between these empirically
derived factors and symptom clusters. In study 1, 978 young people aged
7 to 16 years completed a child-generated measure of their experience
of negative thoughts. Structural equation modeling provided the strongest
support for a model in which four distinct factors were all related to
a single higher-order factor. The four lower-order factors related to
thoughts of social threat, physical threat, personal failure, and hostility.
In study 2, 790 young people completed the same measure of negative thoughts
as well as a measure of experienced symptoms. The four cognitive factors
showed relatively specific associations with expected symptom clusters
- i.e. social threat with social anxiety symptoms, physical threat with
physical anxiety symptoms, personal failure with depressive symptoms,
and hostility with oppositional symptoms. Similarly, the four cognitive
factors distinguished relatively well between young people's principal
diagnoses. These results provide support for cognitive specificity models
of emotional problems in young people.
Issues of Coping and Vulnerability
BABCP Scientific Committee
Is Dissociation the Ultimate Form of Avoidant Coping? Dissociation, Self-efficacy,
and Coping in Borderline Personality Disorder (BPD)
Dale Huey, Newcastle Cognitive & Behavioural Therapies Centre and
University of Newcastle; Peter Whewell and Jonathan Espie, Regional Department
of Psychotherapy, Newcastle; Matthew Philpott, University of Newcastle,
Dissociative phenomena co-occur with numerous forms of psychopathology
and are particularly prevalent in BPD (Zweigfrank et al., 1994). The cluster
of symptoms that we call BPD has been conceptualized as being the result
of a cluster of beliefs about oneself and others, e.g. seeing oneself
as vulnerable and inherently unacceptable and seeing others as dangerous
(Arntz, 1994). As Janet originally formulated the phenomenon of dissociation
as a response to overwhelming trauma (Gershuny & Thayer, 1999) in
BPD dissociating, or disengaging from one's surroundings, as a response
to threat is predictable given the double disadvantage of perceiving oneself
to be powerless in a perceived-to-be malignant world. We have recently
tested this conceptualization by observing the relationships between tendency
to dissociate, perceived self-efficacy, and avoidant coping. Data will
be reported from a sample of 105 participants who satisfy criteria for
BPD. The role of self-reported childhood trauma and current level of psychological
distress will also be discussed. Conceptualizing dissociation as a response
to stressors which an individual implicitly perceives to be beyond their
ability to manage demystifies and translates an involuntary response into
an active, albeit currently unhelpful, strategy, i.e. it provides a plausible
and benign conceptualization which has good potential treatment utility.
Arntz, A. (1994) Treatment of BPD: A challenge for CBT. Behaviour Research
& Therapy, 32(4), 419-430.
Gershuny, B.S. & Thayer, J.F. (1999) Relations among psychological
trauma, dissociative phenomena, and trauma-related distress. Clinical
Psychological Review, 19(5), 631-657.
Zweigfrank et al., (1994) Dissociation in
patients with borderline
and non-borderline personality disorders. Journal of Personality Disorders,
Defensive Coping and Underlying Self-esteem in Chronic Fatigue Syndrome
Cathy Creswell* & Trudie Chalder**
*Sub-department of Clinical Health Psychology, University College London
** Department of Psychological Medicine, Kings College Hospital
The cognitive behavioural model of Chronic Fatigue Syndrome (CFS) (Sharpe,
1997) proposes that low self-esteem is prevalent amongst people with CFS
yet is protected by rigid coping mechanisms. This is the first study to
investigate the prevalence of the Defensive High Anxious coping style
amongst people with CFS and the potential impact of this mechanism on
The study comprised 68 participants (24 CFS; 24 Healthy volunteers; 20
chronic illness volunteers). Participants completed the Bendig short form
of the Taylor Manifest Anxiety Scale and the Marlowe-Crowne Social Desirability
Scale, a Self-Statements Questionnaire and an Emotional Stroop Test. A
greater number of participants in the CFS group were classified as Defensive
High Anxious compared to the two comparison groups (c²(2)=8.84, p=0.012).
Participants with CFS reported lower self-esteem than the two comparison
groups on overt (c²(2)=13.44, p<.0001) and covert measures (Emotional
Stroop) (F(2,64)=8.75, p<0.001). When overt levels of self-esteem and
self-reported depression were controlled for the group differences found
for covert levels of self-esteem continued to approach a significant level
This study supports the existence of defensive coping mechanisms amongst
participants with CFS. In contrast to previous studies, participants with
CFS overtly reported lower levels of self-esteem than two comparison groups.
Overt reports of low self-esteem did not, however, fully reflect their
underlying levels of self-esteem. This discrepancy might result from the
application of rigidly held defence mechanisms. These findings highlight
the need to address low self esteem and defensive coping in cognitive
An Investigation into Cognitive, Emotional and Psychosocial Factors Influencing
Vulnerability and Recovery in Bipolar Disorders
Matthias Schwannauer, Charlotte Brodie, Mick Power., Bipolar Disorder
Service; Department of Psychiatry, University of Edinburgh.
The current study aims to investigate the efficacy and effectiveness of
a psychosocial intervention for people with a diagnosis of bipolar disorder.
This particular psychosocial intervention has been developed for the purpose
of this trial and includes elements of cognitive therapy and interpersonal
therapy in both a group and individual format. This study further aimed
to develop a multi-factorial model of aetiology and treatment of bipolar
disorders that takes account of mood specific changes in the perception
and function of various psychological factors.
It is our intention in this study to move away from a structural and solely
epidemiological understanding of psychosocial, cognitive and emotional
risk factors, towards a more process-oriented model of perception and
cognitive processing of these factors during varying stages of the disorder,
and to investigate the connection of these processes with the development
and course of the illness.
In this study we applied a partially randomised design in which patients
were randomised into waiting list control or treatment group. In the treatment
group, patients had the choice of either group or individual treatment.
All patients were assessed at intake, mid-treatment, end-treatment and
at 5 month follow-up. Psychosocial measures included quality of life,
life events, social support and expressed emotion; psychological measures
included self esteem, basic emotions, beliefs about illness, and meta-cognitions
and relevant symptom measures included measures of depression, mania,
and mixed episodes. In addition to these self-report measures, all subjects
were assessed utilising observer rated measures of severity and chronicity.
Individuals' perception of the therapeutic process was assessed at follow-up.
Circadian Rhythms, Multilevel Models of Emotion and Bipolar Disorder:
An Initial Step Towards Integration?
Steven.H. Jones, Honorary Senior Research Fellow, Department of Psychology,
University of Manchester and Consultant Clinical Psychologist, Birch Hill
Possible links between disruption of circadian rhythms in bipolar disorder
and the affective symptoms which are experienced in this disorder are
described. Evidence is drawn from Healy and Williams' (1989) review of
circadian function in manic depression, along with later reports, which
indicate a role for disrupted circadian rhythms in both depressed and
manic phases of manic depression (bipolar disorder). This is integrated
within a version of the multilevel model of emotion proposed by Power
and Dalgleish (1997,1999). The aim of this process is to propose a possible
psychological mechanism by which the disruption of circadian rhythms might
result in the observed clinical symptoms of bipolar disorder. The integration
of these approaches leads to a number of specific testable hypotheses
which are relevant to future research into the psychological treatment
and understanding of bipolar disorder.
The Relationship Between Schemas, Depression and Psychosis: An Analysis
Neshika Samarasekera, Steve Moorhead Douglas Turkington, Department of
Psychiatry, University of Newcastle-Upon-Tyne.Newcastle and London Wellcome
Research Groups, Project no. 039243.
Background: There is considerable evidence of a relationship between depressive
and psychotic symptoms at all stages of schizophrenia, but its nature
remains unclear. Cognitive therapy theory states that the affective and
behavioural response to an event is determined by its appraisal. This,
in turn, is mediated by underlying beliefs (schemas). Controlled trials
have demonstrated the efficacy of cognitive-behavioural therapy (CBT)
in schizophrenia, but there has been little systematic research into the
types of beliefs present or their association with depressive or specific
psychotic symptoms. We wished to survey schematic vulnerabilities in schizophrenia
and determine their role, if any, in the relationship between psychotic
and depressive symptoms.
Method: Schemas and symptoms were assessed in twenty-six patients with
a diagnosis of schizophrenia. These were a subgroup of patients being
followed up from a randomised controlled trial of adjunctive CBT.
Schemas were measured using the Burns Dysfunctional Attitudes Scale (DAS).
This DAS comprises 35 statements of beliefs within six schemas that are
hypothetically important in depression. These include love (need for love),
approval (need for approval) and achievement (need for achievement). Overall
symptoms were measured using the Comprehensive Psychopathological Rating
Scale (CPRS) by a rater who was blind to the use of the data and the DAS
ratings. Two subscales derived from the CPRS: the Schizophrenia Change
Scale and the Montgomery-Asberg Depression Rating Scale were used to determine
the extent of psychotic and depressive symptoms respectively.
Statistical analysis was made with Pearson's product-moment correlation
Results: The majority of patients (88%) scored in the dysfunctional range
of at least one schema. As shown in other diagnostic groups, higher DAS
scores (indicating greater schematic vulnerability) correlated with a
greater degree of depressive symptoms (p<0.001). Moreover, total DAS
scores were significantly correlated with psychotic symptoms (p<0.001).
Partial correlation demonstrated a pivotal role for DAS scores in the
relationship between psychotic and depressive symptoms in this group.
Certain schemas were associated with specific psychotic experiences; for
example, scores on the Love schema were correlated with scores on thoughts
of persecution (p<0.01) and commenting voices (p=0.02). Various models
relating psychotic phenomena and schemas to depression were tested. Control
psychotic experiences (p=0.02) and an approval schema (p<0.01) made
independent contributions to depression in a regression analysis. The
results will be presented in further detail.
Conclusions: The connections between schemas and psychotic experiences
shown in this preliminary study support the psychological meaningfulness
of psychotic and depressive symptoms in schizophrenia. Although it is
a small study, these findings are consistent with earlier literature which
emphasises that psychotic beliefs are on a continuum with non-pathological
beliefs. It may be possible to predict particular schemas on the basis
of psychotic symptoms and consider targeting interventions for brief work.
Limitations and implications of the study will be discussed.
Psychological Processes and Psychotic Symptoms
Craig Steel, Institute of Psychiatry, London.
The last decade has witnessed major theoretical developments within the
understanding of psychological processes associated with the development
and maintenance of psychotic symptoms. These advances have highlighted
the roles of attention, perception, reasoning, attribution biases, theory
of mind, metacognition and 'safety behaviours'. Recently there have been
increased efforts at incorporating the increased understanding of these
processes within integrated models. Several models will be presented within
the symposia which have individual foci on (i) inhibitory mechanisms underlying
schizophrenic symptomatology (ii) persecutory delusions (iii) a cognitive
model of positive symptoms emphasising the role of maintenance factors
such as safety behaviours and (iv) a cognitive model outlining processes
argued to underlie symptoms of depression, mania and positive symptoms.
Inhibitory Processes Underlying Schizophrenic Symptomatology
Craig Steel, Institute of Psychiatry, London
Recent influential theoretical accounts of schizophrenic symptomatology
have referred to a core dysfunction within inhibitory mechanisms or 'cognitive
inhibition'. This account states that a failure to integrate previously
occurring information with its current context underlie the heterogeneous
symptoms associated with a diagnosis of schizophrenia. It is argued that
the original use of the term 'cognitive inhibition' lacks a clear theoretical
basis. Recent studies will be discussed which contribute to a clarification
of the role of specific types of inhibitory processing in relation to
specific symptomatology. A multi-dimensional model is proposed in which
reduced levels of associative learning underlie reality-disordered symptoms
(i.e. hallucinations and delusions), whilst a failure to inhibit the spread
of activation of information is associated with disorganisation symptoms.
A Cognitive Model of Persecutory Delusions
Daniel Freeman, Institute of Psychiatry, London
A new multi-factorial model of the formation and maintenance of persecutory
delusions is presented. Persecutory delusions are conceptualised as threat
beliefs. The beliefs are hypothesised to arise from a search for meaning
for unusual experiences; the explanations formed reflect an interaction
between psychotic processes, pre-existing beliefs and personality (particularly
emotion), and the environment. It is proposed that the delusion is maintained
by processes that lead to the receipt of confirmatory evidence and processes
that prevent the full processing of disconfirmatory evidence. Novel features
of the model include the direct roles given to emotion in delusion formation,
the consideration of the content and form of delusions, and the hypotheses
concerning the associated emotional distress. A number of relevant research
studies that have been carried out by the presenter are discussed, and
the clinical implications of the model outlined.
A Cognitive Approach to Auditory Hallucinations: From Theory to Therapy
Tony Morrison, University of Manchester
In this paper, a cognitive approach to the understanding of psychotic
symptoms that focuses on the interpretation of intrusions into awareness
is outlined. It is argued that many positive psychotic symptoms (such
as hallucinations and delusions) can be conceptualised as intrusions into
awareness or culturally unacceptable interpretations of such intrusions,
and that it is the interpretation of these intrusions that causes the
associated distress and disability. It is also argued that the nature
of these interpretations is affected by faulty self and social knowledge
(including metacognition) and that both the intrusions and their interpretations
are maintained by mood, physiology, and cognitive and behavioural responses
(including selective attention, safety behaviours, and counterproductive
thought control strategies). Experimental evidence from several studies
of cognitive processes in psychotic patients that test specific predictions
of this cognitive approach will be summarised. The clinical implications
of this approach will be discussed.
Family Care in Psychoses
Liz Kuipers, Institute of Psychiatry, London
Caring for Carers of People with Psychosis
Liz Kuipers, Institute of Psychiatry, London
Carers of those with psychosis are most typically older age mothers,
although other groups such as partners, siblings and children can also
We know that such carers have needs of their own. They are more likely
to be distressed, anxious or depressed than the general population, to
ask for information, respite, practical and emotional support. The impact
of care begins at first episode and may be lifelong.
Standard 6 of the National Service Framework requires that carers needs
are assessed. The more difficult problem is to design interventions that
begin to meet such needs.
Research projects that have been offering interventions in early episodes
and beyond will be presented. The ongoing difficulties of designing and
implementing services that reduce the impact of care in psychosis will
A Randomised Controlled Trial of a Carers' Support Programme
G. Szmukler, E. Kuipers, J Joyce, T. Harris, M. Leese, W. Maphosa, E.
Staples, and M. CunninghamHealth Services Research Department, Institute
of Psychiatry, Kings College London
Background Despite an acknowledgement of the impact of serious mental
disorders on informal caregivers, we still know little about how to best
help them.Aims To evaluate the effectiveness of a carers' intervention
of 'intermediate' intensity, that is, one lying between brief educational
programmes and long-term family psychoeducational treatments.
Method A pragmatic randomised controlled trial comparing the experimental
support programme with 'standard' care. All carers of patients with a
psychotic disorder from a defined population were approached. Outcome
measures were based on a 'stress-appraisal-coping' model of caregiving.
Results Despite concerted attempts to engage carers, only 40% participated
in the study. The carers' programme did not offer any significant advantage
on any of the primary outcome measures: psychological morbidity, negative
appraisal, coping or social support. The severity of caregiving difficulties
decreased over the study period for the group as a whole.
Conclusions There is still uncertainty about the most effective interventions
for carers. Meeting 'needs' may not improve caregiver distress.
Family Work: Perspectives of Consumers and Providers
No abstract available
Family Work in Early Onset Psychosis: Perspectives from Specialist and
Frank Holloway, South London and Maudsley NHS Trust and Health Services
Research Department, Institute of Psychiatry, Bethlem Royal Hospital
Traditionally psychiatric services have been preoccupied with the needs
of people with established and severe disabilities. A controlled trial
of intensive treatment for people with "early" psychosis, defined
as within five years of initial presentation, is underway within the Croydon
Mental Health Services. This paper compares and contrasts the experiences
of practitioners working in the specialist treatment service for "early"
psychosis, the COAST Team, and staff working in one of the Community Mental
Health Teams (CMHT) serving Croydon. Both teams consist of a full range
COAST team members work with a clearly identified patient group, have
low case-loads (currently eight clients per worker) and have dedicated
weekly family supervision from an experienced therapist. Within the comparison
CMHT staff work with the full range of people with mental health problems,
have high case-loads (currently fifty clients per Community Psychiatric
Nurse) and have minimal access to supervision about family work.
The majority of staff in both COAST and the comparison CMHT lack formal
training in family management of psychosis and experience uncertainties
in working with families. Objectively COAST staff and CMHT members differ
in their capacity to undertake family work. In general staff find working
with families difficult. Practitioners identify particular problems in
working with "early onset" families because of the uncertainties
associated with diagnosis and prognosis.
Family Intervention for Schizophrenia and Comorbid Substance Misuse
Christine Barrowclough, University of Manchester
Padmal de Silva, Institute of Psychiatry, London
The Challenge of Physical Treatments in the Management of Male Erectile
Kevan Wylie, University of Sheffield
Sexual problems can occur as a consequence of disruption of any of the
four phases of the sexual response cycle.The therapist needs to obtain
a detailed description of the current sexual status in an attempt to identify
and understand psychological issues which may be either causing or contributing
to the sexual disorder. These include: family-of-origin, behavioural ,
cognitive and/or systemic issues.In addition, around two-thirds of patients
also have some physiological factors leading to the impairment of sexual
function.Assessment of these factors is important in trying to offer a
prognosis for response to specific interventions. Despite this, patient
awareness and expectations of medical -including pharmacological - solutions
to the problem can affect any resolution of the dysfunction.A review of
currently available physical treatments, including Viagra, is given. This
is followed by a consideration of potential psychological manoeuvres that
may enhance overall response to clinical interventions.
Sexual Dysfunction in Patients with Eating Disorders
Gill Todd, Gerald Russell Eating Disorders Unit, Bethlem Royal Hospital,
This paper discusses sexual difficulties in patients with eating disorders,
especially anorexia nervosa. The focus is on female patients. The theoretical
views on sexuality in anorexia nervosa is briefly reviewed. The sexual
difficulties that these patients present with are then considered, with
the help of case examples. Issues in the assessment and treatment of these
difficulties are then discussed. The need for a sensitive and individually
tailored approach in the treatment of these problems is highlighted. Timing
of therapy, partner involvement, dealing with past memories, and body
image issues are some of the problems considered.
The Role of Paraphilias in Sexual Dysfunction
Padmal de Silva, Institute of Psychiatry, King's College, London
This paper considers the role of paraphilias in sexual dysfunction . While
paraphilias are usually considered as a separate category of clinical
problme from sexual dysfunctions, there is overlap, and one domain can
influence the other. With the help of case examples, the way in which
paraphilias (e.g. fetishism, transvestism, masochism) can have an impact
on sexual functioning, leading in some cases tp frank sexual dysfunction,
is discussed. Issues in assessment and treatment are also considered.
One aspect of treatment discussed is partner involvement.
Training Issues in Sex Therapy
Mary Griffin, Maudsley Hospital, London; and Padmal de Silva, Institute
of Psychiatry, London
There are several programmes in the UK at present for the training of
sex therapists. There is an established accreditation procedure, and regular
monitoring of courses. This paper considers some of the key issues in
sex therapy training.Some of the issues have been controversial, and there
has been some debate in the literature on these matters. The topics considered
include: the feasibility and advisability of offering training in sex
therapy to those who are not in the mental health/selping professions;
the need to be knowledgeable about medication and other physical treatments;
theoretical orientations; need for training in research; evaluation of
training; ethical and professional issues.Current thinking on these issues
are reviewed, and suggestions made for discussion.
Dissemination of Effective Interventions
Christine Barrowclough, University of Manchester
Towards the Dissemination of CBT for Bulimia Nervosa
Christopher G. Fairburn, Department of Psychiatry, University of Oxford
A cognitive behavioural theory of the maintenance of bulimia nervosa was
proposed in the early 1980's together with a cognitive behavioural treatment
(CBT) derived from it. Since then, the theory has been supported by a
variety of lines of evidence and the treatment has been shown to be the
most effective treatment for the disorder.
This has stimulated interest in how to disseminate this specialised psychological
treatment. The findings of various small-scale studies suggest that it
can be simplified and abbreviated without great loss of potency. Importantly,
it has also been shown that it can be converted from a "therapist-led"
treatment into a "programme-led" format suitable for delivery
in non-specialist settings or, indeed, as a form of pure self-help. This
has led to "effectiveness" research (Carter and Fairburn, 1998)
and the proposal that a stepped care approach to management be adopted
(see Wilson et al, 2000). Such an approach is currently the subject of
a large multicentre trial.
Psychosocial Interventions for Psychosis: Promoting Clinical Change in
the Real World
Jo Smith, Worcestershire Community and Mental Health NHS Trust
Considerable research has demonstrated the effectiveness of psychosocial
interventions in improving a number of key outcomes for individuals with
psychosis and their families. These interventions include psychoeducation,
family intervention, early signs monitoring and individual cognitive behavioural
intervention. However, implementation in routine service settings has
been more problematic: the number of trained personnel remains limited,
many of these interventions are not routinely available beyond these research
settings and little work has considered the development and maintenance
of psychosocial interventions in ordinary service settings.
While it is appreciated that research findings do not automatically influence
routine clinical practice, the task of promoting effective evidence based
practice is highly complex. An understanding of the professional, educational,
political and economic factors in the real world environment may be crucial
if efforts to promote changes in services for individuals with psychosis
are to be more than marginally successful. This paper will consider a
framework which highlights key influencing factors and identifies potential
change strategies for successful implementation. The paper will draw on
the limited research evidence so far available and the author's own experience
in trying to promote successful clinical change in relation to implementing
psychosocial interventions for in Psychosis in 'the real world'.
The Politics of Training
Jan Scott, University Department of Psychological Medicine and Glasgow
Institute of Psychosocial Interventions
There is a wealth of research evidence that brief psychological therapies
such as cognitive therapy can improve the short term and long term outcome
of a wide variety of common and severe mental disorders. However, there
are major problems in ensuring that these effective interventions are
available in day to day clinical practice. The last 15 years has seen
the rise of the post qualification multi-disciplinary training course.
However, this paper suggests that the cost versus benefits of these courses
are unproven. Too often, individuals leaving these courses fail to continue
to use their new skills on return to their previous clinical setting.
This may be due to lack of skill (training in using the approach with
one group of clients and then returning to work with another), lack of
time (no-one adjusts case loads to allow for the additional time required
for the early part of therapy), or lack of support (failure to provide
This paper will present an alternative model for trying to increase the
availability of effective therapies in day to day clinical practice. The
Glasgow Institute of Psychosocial Interventions is a training research
and clinical multi-disciplinary group with the primary goal of increasing
staff skills in delivering brief therapies and in changing organisational
systems to allow people to use those skills. The project has been funded
through the Scottish Executive Waiting List Initiative which has chosen
waiting times of psychological therapies as a primary target for change.
Four Trusts in Scotland were invited to participate in this pilot scheme.
We also recruited the support of an organisational development group who
helped us in gathering baseline data and setting up steering groups to
look at gaps in training for staff within the Trust and how to develop
effective delivery systems.
The paper concludes that if we are to truly increase the availability
of psychological therapies, we need to use our skills to change the thinking
within organisations so that training is not an expensive and frustrating
waste of time!
Cognitive Behavioural Processes in the Dissemination of Evidence-based
Guidelines for Dental Practice
Marie Johnston, Department of Psychology, University of St Andrews
Background: Guidelines are published to facilitate dissemination of evidence-based
practice and procedures to promote their implementation have been developed,
derived from medical education approaches. Although not developed on cognitive-behavioural
principles, it is possible to examine a) which cognitive variables predict
evidence-based dental practice and b) whether implementation interventions
affect these cognitions and the behaviour.
Procedure: Following postal distribution of guidelines on the management
of third molars, 51 dentists were randomly allocated to one of four different
methods of disseminating guidelines of the management of third molars
i.e. they had one, both or neither of two additional implementation methods:
'audit and feedback' and 'computer-aided learning with decision support'.
Before and after these procedures, dentists completed a questionnaire
based on social cognition models addressing two specific behaviours pertinent
to the new guidelines: 1) the extraction of third molars; and 2) the use
of guidelines. Data on actual dental behaviour was obtained from patient
Results and Conclusions: Results will be reported on the prediction of
behaviour from the social cognitive variables. These results allow comparisons
of the importance of beliefs about guidelines versus beliefs about the
behaviour per se. The main study will examine how the normally used implementation
methods affect critical cognitions and behaviour related to evidence-based
practice. From that it should be possible to comment on the adequacy of
current procedures and the potential value of cognitive-behavioural procedures
in disseminating effective interventions.
The Dissemination of Anxiety Disorder Treatment: What are the Questions?
Paul Salkovskis, Department of Clinical Psychology, Institute of Psychiatry,
No abstract available
Cognition And Emotion In Children And Adolescents
Rebecca Park, Department of Psychiatry, University of Cambridge, U.K.
Specificity of Autobiographical Memory and Mood Disturbance in Adolescents.
Swales, M, & Brennan, A.: School of Psychology, University of Wales,
Bangor ; Bangor & Conwy & Denbighshire NHS Trust
Difficulty in retrieving specific autobiographical memories to cue-words
has been found to be associated with a number of psychiatric disorders;
depression, PTSD, acute stress disorder, borderline personality disorder
and certain forms of behaviour notably parasuicide. In pilot study, comparing
performance on the autobiographical memory test (AMT) of adolescents admitted
to an in-patient psychiatric unit with a non-clinical school sample, the
clinical group, who were more depressed and hopeless than the non-clinical
group, were less specific in their response to cue-words on the AMT. Within
the clinical group, greater recall of specific memories to negative cues
was strongly associated with higher levels of hopelessness in both males
and females (Swales, Williams & Wood, in press). However, this study
had a number of methodological difficulties, not least that the clinical
group were already engaged in treatment, which may have affected their
responses on the autobiographical memory test. This paper will present
data from a replication of this preliminary study comparing adolescents
who have been referred for but have not yet undergone treatment with a
non-clinical school sample. In addition this study will also examine data
on other variables relevant to autobiographical memory e.g. the intrusiveness
and avoidance of traumatic memories (as measured by the Impact of Events
Scale) and dissociation.
Reference. Swales, M., Williams, J.M.G. & Wood, P. (in press). Specificity
of autobiographical memory and mood disturbance in adolescents. Cognition
Rumination and Overgeneral Autobiographical Memory in Adolescents with
Major Depressive Disorder
Rebecca J. Park*, Ian M. Goodyer*, John Teasdale**,
*Section of Developmental Psychiatry, University of Cambridge, U.K.
**MRC Cognition and Brain Sciences Unit Cambridge,U.K.
Both rumination and overgeneral (categoric) memory retrieval have been
implicated in the maintenance of adult major depression (MDD), because
they relate to poor prognosis. Recent evidence supports the idea that
rumination may be involved in overgeneral memory retrieval. These phenomena
have not been explored in adolescence and the processes underpinning them
remain to be clarified. The current study investigated 1) whether overgeneral
memory is a feature of MDD in adolescents, and 2) the impact of rumination
on mood and overgeneral memory. In this study, 96 clinically referred
adolescents (aged 12-17 years) with MDD and 26 non-depressed psychiatric
controls were recruited from child psychiatry services in Cambridge, UK
and 33 community controls were recruited form local state schools. All
subjects were assessed using the Kiddie-Schedule for Schizophrenia and
Affective Disorders, and completed experimental procedures involving manipulation
of mood and autobiographical memory using induced rumination and distraction.
Overgeneral memories were found to be more common, but not specific to
MDD in adolescence (p<.005). In adolescents with MDD, induced rumination
as compared to distraction increased negative mood (p<.0001) and increased
overgeneral memory (p<.05) , yet had no such influence in nondepressed
psychiatric patients. These findings suggest that overgeneral memory may
be a modifiable feature of adolescent MDD, and that rumination in adolescents
with MDD may impact deleteriously on mood and memory retrieval processes.
Implications are discussed, with particular reference to psychological
interventions for adolescent MDD.Biases in second-order mindreading in
Biases in Second-order Mindreading in Middle Childhood
Carla Sharp, Ian M Goodyer, Section of Developmental Psychiatry, University
This paper discusses the link between deficits in theory of mind and emotional
behaviour disorders of childhood. To this effect a new child-centred measure
of social cognition, the Social Stories Test, was developed. The test
is proposed to measure the quality of second-order theory of mind. Quality
in this sense relates to biases in the emotional valence of children's
thoughts about their peers thoughts about themselves. Children were asked
to respond to stories that contain potentially hurtful social scenarios
such that interpersonal processes governing automatic thinking (second-order
mindreading) were accessed. Second-order mindreading was found to be positively
biased in a group of 41 psychiatrically referred children compared to
65 children from a community sample who showed neutral biases. Biases
in mindreading predicted change in subjective an objective depression
and behaviour scores over an 8-month follow-up period.
Vulnerability and the Development of Depressogenic Schematic Models of
Philip J. Barnard*, Sophie K. Scott* & Lynne Murray**
*MRC Cognition and Brain Sciences Unit Cambridge.
**Winnicott Research Unit University of Reading
The children of mothers who experience a period of post-partum depression
have a high risk of developing depression in later life. It would therefore
be expected that these children should acquire schematic models of the
self with depressogenic properties. In order to assess children's schematic
models of self and other family members, a doll's house play technique
was used to elicit discourse about the experience of daily family life
in five year old children. A case grammar analysis was then used to characterise
properties of their schematic models of self and other family members.
When referring to themselves, the children in a high vulnerability group,
whose mothers had experienced depression, expressed less agency and more
syntactic negation than did a low vulnerability group matched for age,
sex and linguistic ability, but where vulnerablity factors were minimised.
In contrast, when referring to parents both high and low vulnerability
groups showed similar profiles of case role utilization and lower levels
of syntactic negation. The data suggest that the two groups are, from
an early age, developing distinctive schematic models of the self whose
properties vary on dimensions that link nicely with those assumed for
adult depressogenic self-models, and that the effects cannot simply be
attributed to any differential use of case roles in wider discourse.
When Thinking Too Much is the Problem: Intrusions, Rumination,
Control and Suppression Across Disorders.
Mark H. Freeston, Newcastle Cognitive and Behavioural Therapies Centre
and University of Newcastle.
This symposium includes five papers that present recent work on distressing
thoughts and their control. The presentations draw on previous work on
intrusions, rumination and control in novel applications to a range of
clinical problems that span chronic pain, depression, insomnia, substance
abuse, and eating disorders.
Can the Thought of Suffering be Painful?
Paul Salkovskis & Dorothea Felten, Institute of Psychiatry, Department
of Psychology, Kings College London.
Cognitive conceptualisations of pain related to health anxiety suggest
that ruminations can be triggered by catastrophising interpretations of
episodes of pain. Such catastrophising and ruminations can both result
in an elevation of anxiety and/or depression, which in turn can increase
catastrophising. These mechanisms are hypothesised to increase the experience
of pain. Two investigations are reported addressing 1) the phenomenology
and reported impact of rumination, and 2) the affect of rumination induction.
The implications for the cognitive-behavioural theory and treatment of
some forms of chronic pain are discussed.
Ruminative Intrusions Following Failure
Ed Watkins, Institute of Psychiatry, Kings College London
Recurrent and perseverative thinking about the self, about mood, and about
problems is an important factor in the maintenance and relapse of depression
(Nolen-Hoeksema, 1996; Teasdale & Barnard, 1993; Pyszczynski and Greenberg,
1987). However, transient increases in intrusive thoughts about problems
are a common and often adaptive response to failure or goal frustration
(Martin & Tesser, 1989, 1996; Carver & Scheier, 1990). How then
do these intrusive thoughts become persistent rumination in people prone
to depression? The consensus view is that persistent rumination occurs
when people cannot resolve the problem triggering the intrusions (Martin
& Tesser, 1989, 1996) and when people cannot give up on unfulfilled
goals because they are too personally important (Pyszczynski and Greenberg,
1987). However, most experimental research has not looked at rumination
over clinically relevant time frames (e.g. hours, days) nor examined rumination
in clinically relevant or vulnerable groups. To rectify these limitations,
a series of studies has been started to examine the persistence of dysphoric
mood and intrusive thoughts over 2 days following failure feedback on
an intelligence test in more vulnerable groups (e.g. people with low self-esteem).
In particular, these studies will investigate recent suggestions (Watkins
& Teasdale, in press; McFarland & Buehler, 1998) that there are
different thinking styles within focus on self and problems, with different
implications for the maintenance of rumination. Preliminary findings will
An Investigation of Strategies of Thought Control in Insomnia.
Allison G. Harvey & Suzanna Payne, Department of Experimental Psychiatry,
University of Oxford.
A particularly robust finding in the insomnia literature is that people
with sleep-onset insomnia experience unpleasant, intrusive thoughts and
worries whilst trying to get to sleep. This paper will present the results
of two studies relating to the control of intrusive thoughts and worries
in insomnia. Study 1 involved a manipulation of one thought control strategy;
thought suppression. Specifically, insomniacs and good sleepers were asked
to either suppress their thinking during the pre-sleep period or not to
suppress. The morning following the experimental manipulation, participants
estimated sleep onset latency and rated their attempted suppression, sleep
quality, feeling on waking, frequency of target thought, and discomfort
associated with the target thought. Participants instructed to suppress
their thoughts estimated their sleep onset latency to be longer, and their
sleep quality to be worse, than participants given non-suppression instructions.
This effect was observed across diagnostic status. Study 2 investigated
whether brief training in identifying and elaborating an interesting and
engaging imagery task for use during the pre-sleep period can reduce unwanted
pre-sleep cognitive activity and sleep onset latency. Forty one people
with insomnia were given one of three instructional sets to follow on
the experimental night; instructions to distract using imagery, general
instructions to distract, or no instructions. Based on previous findings
reported by Salkovskis and Campbell (1994) and ironic control theory (Wegner,
1994), it was predicted that (1) 'imagery distraction' would be associated
with shorter sleep onset latency and less frequent and distressing pre-sleep
cognitive activity compared to the 'no instruction' group and that (2)
'general distraction' would be associated with longer sleep onset latency
and more frequent and distressing pre-sleep cognitive activity compared
to the 'no instruction' group. Support was found for the first but not
the second prediction. The success of the 'imagery distraction' task is
attributed to it occupying sufficient 'cognitive space' to keep the individual
from re-engaging with thoughts, worries, and concerns during the pre-sleep
Intrusive Thoughts in Substance Dependent Patients
Martina Reynolds, Department of Psychiatry of Addictive Behaviour and
Psychological Medicine, St. George's Hospital Medical School.
Thought processes have been hypothesised to play a role in addiction and
relapse. Salkovskis and Reynolds (1994) showed that suppression was associated
with an increase in smoking related intrusive thoughts, whilst a distracting
task (relaxation) reduced intrusion frequency. This is a report of a similar
study with a substance dependent sample undergoing detoxification. Subjects
were randomly allocated to one of three groups (mention control, relaxation
and suppress) and respectively were asked to monitor, suppress and do
relaxation exercises, and suppress substance related intrusive thoughts
in period 1. In period 2 they were told that they could think about anything.
Subjects recorded all substance related intrusions in both periods. Participants
were an inpatient substance dependent sample undergoing detoxification.
Results showed that deliberate suppression of substance related intrusive
thoughts did not result in an increase in frequency of the same for the
suppression group compared to the mention control group. Relaxation facilitated
thought suppression in the first period, but this effect was not carried
over to the second period. In conclusion, in the absence of the task which
acted as an effective structured distracter, feeling relaxed may act as
a trigger for drug related thoughts. This may have some implications for
the use of relaxation as a form of distraction in treatment for substance
Treating Obsessional Preoccupation with Body Image and Weight in Anorexia:
A Pilot Study
Mark H. Freeston, Newcastle Cognitive and Behavioural Therapies Centre
and University of Newcastle, United Kingdom; Gilles Gaudette, Yves Careau,
Nicole Mainguy, Hôpital Louis-H. Lafontaine, Montréal, Canada
'Given the efficacy of CBT in treating OCD, it is tempting to wonder whether
therapeutic leads might not evolve from the evolving analyses of obsessional
states (Wilson, 1999; p. 85)'. Based on this proposition, concern with
weight and body image was conceptualised as a form of ruminative thinking
and an intervention was designed drawn directly from CBT for obsessional
thoughts. An initial test of the intervention was conducted within an
intensive single-case design to target an aspect of anorexia that may
remain once initial weight gain has been achieved. The technique proved
to be successful in reducing preoccupation for this participant who was
not in an acute phase of the disorder.
Trauma and Mood Disturbance Issues
Nick Grey, Institute of Psychiatry, London
Did it Really Happen? The Vagaries of Spontaneous Imagery in Posttraumatic
Stress Disorder from a Clinical Perspective.
NickGrey, Centre for Anxiety Disorders and Trauma, Institute of Psychiatry
A distinguishing characteristic of PTSD is the presence of re-experiencing
symptoms in the form of flashbacks, nightmares and intrusive memories.
Most commonly these take the form of visual imagery, but also include
other somatosensory information. Whilst classically this imagery is a
replica reliving of the traumatic event it is often noted that the images
reported by patients do not exactly match their experience. This paper
makes a distinction between veridical and non-veridical images. Non-veridical
images include out-of-body experiences (dissociation), composite images,
worst-case scenarios (Merckelbach et al, 1998), and reconstructed images
(Bryant & Harvey, 1998). A second distinction is made between imagery
that can be understood as arising from during the traumatic event itself
(i.e. peritraumatically) and that which is associated with later appraisals.
A variety of clinical case examples are presented to illustrate these
differences. These are conceptualised using recent cognitive models of
PTSD (Brewin et al, 1996; Ehlers & Clark, 2000) together with specific
work on image control in PTSD (e.g. Laor et al, 1999). Possible clinical
approaches to working with the various types of imagery are highlighted.
It is argued that clinically it does not necessarily matter whether the
images are an accurate representation of the traumatic event as working
with the associated meanings for the individual is of greater importance
(see Hackmann, 1998).
Developmental Risk Factors for PTSD: The Role of Parental PTSD and Childhood
Rachel Yehuda, Ph.D., Sarah Halligan, Ph.D. (presenter), Robert Grossman,
M.D., Affiliated to the Mount Sinai School of Medicine, New York
Studies on the impact of trauma have identified a family history of psychiatric
disorder as a risk factor for the development of PTSD (e.g. McFarlane,
1988). Preliminary research in Holocaust survivors has further suggested
the parental PTSD may be a relatively specific risk factor for PTSD in
offspring (Yehuda, Schmeidler, Giller, Siever, & Binder-Brynes, 1998).
The current research represents a comprehensive examination of the role
of parental experiences in mediating vulnerability to psychopathology
in a sample of adult offspring of Holocaust survivors.
First, the contributions of parental trauma exposure versus parental PTSD
to the development of PTSD and other psychiatric diagnoses in the offspring
Second, the Childhood Trauma Questionnaire (Bernstein et al., 1994) is
used to examine early trauma exposure in the offspring. The role of negative
childhood experiences in mediating the relationship between parental symptomatology
and vulnerability in the offspring is investigated. Results and implications
will be discussed.
Bernstein,D.P., Fink,L., Handelsman,L., Foote,J., Lovejoy,M., Wenzel,K.,
Sapareto,E., & Ruggiero,J. (1994). Initial reliability and validity
of a new retrospective measure of child abuse and neglect [see comments].
American Journal of Psychiatry, 151, 1132-1136.
McFarlane,A.C. (1988). The aetiology of post-traumatic stress disorders
following a natural disaster. British Journal of Psychiatry, 152, 116-121.
Yehuda,R., Schmeidler,J., Giller,E.L., Siever,L.J., & Binder-Brynes,K.
(1998). Relationship between posttraumatic stress disorder characteristics
of Holocaust survivors and their adult offspring [see comments]. American
Journal of Psychiatry, 155, 841-843.
Poor Memory as a Predictor of Poor Treatment Response in Adults Diagnosed
with Posttraumatic Stress Disorder
Jennifer Wild, Institute of Psychiatry, London, UK, Dr Sallie Baxendale,
Institute of Neurology, London, UK, Dr Peter Scragg, University College
Introduction: This study highlights the importance of memory functioning
in cognitive-behavioural therapy (CBT) for Posttraumatic Stress Disorder
(PTSD). Most research investigating PTSD has been divided, either drawing
on biological or cognitive models. Biological models have focused on alterations
in brain morphology (e.g. decreased hippocampal size), and altered levels
of neurotransmitters. Cognitive models have focused on poor consolidation
of the trauma memory and the role of appraisals in the onset and maintenance
of PTSD. This study draws on both biological and cognitive models to explain
the role of memory functioning in PTSD. Method: This study investigated
the memory, attention and learning profiles of 27 adults diagnosed with
PTSD prior to commencing CBT at a specialist treatment centre. Memory
was assessed both subjectively and objectively. Subjective appraisal of
memory was assessed by a self-report questionnaire in which participants
rated their perception of memory difficulties. Objective assessment of
memory was assessed by a neuropsychological test battery. This included:
baseline cognitive functioning, memory, learning, attention, and executive
function. In addition, measures of PTSD, anxiety, depression, and past
and current history of alcohol/substance use were also obtained prior
to memory assessment.
Results:Twenty-three adults were followed up at session eight of treatment,
and their PTSD diagnosis was re-evaluated. The results were grouped into
two categories: (1) treatment outcome, and (2) memory appraisal. Treatment
outcome: Clients who did not improve with treatment had significantly
poorer performance on intake measures of verbal memory. In particular,
a measure of encoding meaningful verbal material was found to independently
predict outcome. Differences were not accounted for by performance on
tasks of attention and executive function. Further, severity of PTSD symptomatology,
severity of anxiety and depression, length of time since trauma, and alcohol
and substance use were not related to memory functioning. Memory appraisal:
Perception of memory difficulties was significantly correlated with memory
functioning. Those participants with a more negative appraisal of memory
functioning had poorer neuropsychological memory scores.
Conclusion: Cognitive models emphasise the nature of the trauma memory
and its meaning in PTSD. Biological models focus on areas of the brain
implicated in memory functioning in general. This study found that objective
memory performance (not merely for the trauma memory) is a predictor of
treatment outcome, thereby bringing together the biological and cognitive
perspectives on memory.
Although the sample size in this study was small and further research
is desirable, the findings suggest that a self-report questionnaire for
memory problems could be an important adjunct to initial psychological
assessment and treatment planning for PTSD. The self-report questionnaire
could indicate the potential utility of more detailed neuropsychological
testing. Neuropsychological testing could then inform the modification
of individual CBT so as to best meet the client's need. For example, progressing
at a slower pace, use of more repetition, increasing homework regarding
listening to tapes, use of visual stimuli and notes. However, testing
is rarely indicated when the client rates his/her memory as good on the
The Role of Negative Interpretation Thought Suppression and Rumination
in the Maintenance of Post-Traumatic Stress Symptoms: A Prospective Longinitial
Ben Smith, Traumatic Stress Clinic, ,London
Objective: Recent cognitive conceptualisations of posttraumatic stress
disorder (PTSD) emphasise the role of negative interpretation of initial
symptoms and avoidant cognitive coping in symptom maintenance. It was
investigated whether these factors function to maintain posttraumatic
stress symptoms following a minor road traffic accident (RTA), and the
extent of their influence compared to other variables.
Design: A longitudinal study with measurement within one month of trauma.
Follow up conducted after 4 months. Dependent variables included the IES-R
and SRS-PTSD(DSM-IV), Carlier et al (1998).
Setting: Subjects were recruited from A&E at a London Hospital and
assessed in their homes.
Subjects: 50 subjects were assessed at baseline and 39 successfully followed
Results: A maintenance factors variable consisting of negative interpretation,
thought suppression and rumination was the only variable to exhibit independent
and significant prediction of the IES-R and SRS-PTSD at follow up. This
variable was also found to strongly mediate the relationship between baseline
and follow up scores on the IES-R and SRS-PTSD.
What is already known on this subject and what does this study add?
The independent and significant role of negative interpretation, thought
suppression and rumination in the maintenance of PTSD has not been shown
before in a sample exclusively of minor trauma victims. This adds to empirical
evidence and theoretical conceptualisations of PTSD implicating these
variables in the maintenance of symptoms in a wider range of traumas.
The strong mediating role of the maintenance factors variable has important
implications for the identification and Cognitive-Behavioural Treatment
of potentially chronic PTSD in minor trauma victims
What We Think About Ourselves, or How We Think About Things? The Relationship
Between Everyday Reasoning and Mood-related Reasoning
Dale Huey, Newcastle Cognitive & Behavioural Therapies Centre &
University of Newcastle; Rosemary Stevenson, Jayne Alderdice, & Sharon
Godfrey University of Durham, England.
We are interested in the way people think about non-self-referent events
and how this may relate to thinking about self-referent events. We are
particularly interested in how balanced, or flexible, people are in their
thinking. We aim to determine how such everyday reasoning may relate to
the kind of cognitive-processes, and -content, typically associated with
psychopathology. Our theory presupposes individual differences in domain-independent
reasoning style and predicts that a more balanced approach will be more
adaptive; as, if there are generalized reasoning styles, a more balanced
approach should provide a buffer against the extremes of self-denigratory
cognition. On this view, there should be an observable relationship between
reasoning style across domains. We propose that a biased, and inflexible,
general reasoning style may provide a better predictor of vulnerability
to mental health problems than more mood-related thinking. The first stage
of the project is described and provisional data from clinical (n=40)
and non-clinical samples (n=70) are reported.
Cognition and Emotion Across Disorders: Advances in Theory,
Research and Practice
Warren Mansell, Department of Psychology, Institute of Psychiatry, London
Neurosis and Psychosis: The Influence of Emotion on Delusions and Hallucinations
Daniel Freeman, Department of Psychology, Institute of Psychiatry, Kings
A core classificatory divide exists between neurosis and psychosis, leading
to their separate study and treatment. The basis for the separation of
the disorders will be outlined and reassessed. It will then be highlighted
that emotional disorder frequently occurs prior to and accompanying psychosis,
indicating that neurosis has the potential to contribute to the development
of the positive symptoms of psychosis. Therefore, psychological theories
and experimental evidence concerning the influence of emotion on the content
and form of delusions and hallucinations will be reviewed. It will be
argued that in many cases delusions are a direct representation of emotional
concerns, and that emotion contributes to delusion formation and maintenance.
The content of hallucinations less often directly expresses the emotional
concerns of the individual, but emotion can trigger and contribute to
the maintenance of hallucinatory phenomena, although how this occurs is
not well understood. It will be concluded that study needs to be made
of the interaction between psychotic and neurotic processes in the development
of delusions and hallucinations, and that neurotic and psychotic disorders
may have a number of common maintaining factors
The Truth About Mental sSmulation
Gary Brown, Salomons, Christchurch University College, Kent
The central intuition of the cognitive model is that emotional problems
arise when people react on the basis of their misrepresentations of reality.
It is therefore surprising that we know little about how individuals come
to judge these misrepresentations as being true. This paper is a theoretical
and empirical overview of mental simulation, which is potentially the
central mechanism that people use to judge what is true or potentially
true. Thus, for example, people who are better able to simulate some future
catastrophe are more likely to be worried and anxious about such a catastrophe
occurring. That simulation has been relatively neglected is likely due
to (1) a preference in the field for convenient, static measures of cognition
(e.g., questionnaires) that are not capable of capturing dynamic processes
and (2) a neglect of the distinction between the representational function
of cognition versus its heuristic function. The various theoretical strands
relevant to mental simulation will be drawn together and the potential
of this line of research for clinical psychology will be outlined. A particular
focus will be on the implications of a new integrated framework recently
proposed by Sanna (2000). Attention will be given to conditions in which
simulation likely plays a central role (generalised anxiety disorder and
worry, obsessive compulsive disorder, postraumatic stress) as well as
its likely secondary function in other conditions. Methodological challenges
will be discussed in the context of previous and ongoing research.
Perfectionism Across the Disorders
Roz Shafran, Warren Mansell, Zafra Cooper & Christopher G. Fairburn
, Oxford University Department of Psychiatry, Oxford
Perfectionism is an important clinical problem that can impede the successful
treatment of a range of disorders. This presentation will specify the
cognitive characteristics of perfectionism as described by clinicians.
It will be argued that the existing multidimensional constructs of perfectionism
unjustifiably broaden the construct and that there is need for a return
to a unidimensional construct. The core cognitive psychopathology of this
construct is suggested to be the overdependence of self-worth on the pursuit
and attainment of personally demanding standards, in at least one salient
domain, despite adverse consequences. The existing literature suggests
that at least two of the subscales of the multidimensional measures of
perfectionism ("socially prescribed perfectionism" and "concern
over mistakes") are associated with a range of psychopathology and
are elevated in people with anxiety disorders and eating disorders. However,
a re-examination of the existing literature in terms of the core psychopathology
of perfectionism indicates that there is a specific relationship between
perfectionism and eating disorders. It is suggested that the elevation
in "socially prescribed perfectionism" and "concern over
mistakes" in people with anxiety disorders reflects their beliefs
about other people's evaluations and expectations of them, as opposed
to "perfectionism". The treatment implications of this cognitive
re-analysis of perfectionism will be discussed.
Cognitive Biases in Emotional Disorders: Current Controversies in Theory
Karin Mogg & Brendan Bradley, Department of Psychology, University
Recent cognitive theories of emotional disorders propose that cognitive
biases for negative or threatening information play a critical role in
causing and maintaining anxiety and depressive disorders, including generalised
anxiety states, phobias and major depression (e.g. Williams, Watts, MacLeod
& Mathews, 1997; Mogg & Bradley, 1998; Clark, 1999). However,
there is considerable dispute about the nature of cognitive biases in
emotional disorders. For example, some theories predict that anxiety disorders
are characterised by vigilance for threat (e.g. Williams et al. 1997),
whereas, according to other models, different anxiety disorders are associated
with different patterns of attentional bias, e.g. vigilance for threat
in simple phobia and generalised anxiety, but avoidance of threat in social
phobia (Clark, 1999). Further controversy surrounds the nature of attentional
biases in depressive disorders. These issues will be evaluated in the
light of recent research evidence. The implications of this research for
the identification of cognitive vulnerability factors in emotional disorders,
and for the development of more effective cognitive treatments will also
If Our Minds Work Like Evolution, What Should We Do About It?
Warren Mansell, Department of Psychology, Institute of Psychiatry, Kings
What have cognitive therapy, mass hysteria and evolution got in common?
Several theorists (Blackmore, 1999; Campbell, 1974; Cziko, 1995; Dawkins,
1976; Dennett, 1995) have suggested that the principles of natural selection
apply not only to evolution, but to human learning and the spread of beliefs
and behaviour through society. Natural selection relies on (a) multiple
variations of an entity, (b) the ability of the entity to copy itself,
and (c) an environment in which certain entities will be more likely to
survive and/or make copies of themselves. The case will be made that potentially
dysfunctional beliefs, cognitions and behaviours can develop through this
process during their competition for survival both within an individual's
belief system, and between individuals in a society. This approach may
have two beneficial influences on our understanding of psychological disorders.
First, it may help to clarify how and why a variety of diverse techniques
within therapy (e.g. decentering, cognitive-reappraisal, problem-solving
and operant learning) can lead to effective change. Second, by conceptualising
disorders as the end result of problems with adaptation at multiple levels
(genes, behaviour, cognition and culture), it may be possible to provide
a framework that can promote integration between different disciplines
of clinical psychology and psychiatry.
Early Intervention in Psychosis
Max Birchwood, University of Birmingham
Abstracts not available
Psychological Approaches and Sleep, Part 1: Recent Developments
Allison G. Harvey, University of Oxford
Insomniacs' Reported Use of CBT Components and Relationship to Long-term
Colin A. Espie, Linda Harvey and Stephanie J. Inglis
Dept. of Psychological Medicine, University of Glasgow
Although there is considerable evidence for the efficacy of non-pharmacological
treatment of insomnia, many of the larger trials have delivered CBT in
multicomponent format. This makes it impossible to identify critical ingredients
responsible for improvement. Furthermore, compliance with home implementation
is difficult to ascertain in psychological therapies, and even more so
when trying to differentiate across a range of elements. In the present
report, 90 patients who had completed 12 month follow-up after participation
in a clinical effectiveness study of CBT in general medical practice,
responded to a questionnaire asking them about their use of the ten components
of the programme. Reports of home use were then entered as predictors
of clinical response to treatment. Results indicated that reported home
use of stimulus control/ sleep restriction was the best predictor of clinical
improvement in sleep latency and nighttime wakefulness. Cognitive restructuring
also contributed significantly to reduction in wakefulness. In spite of
being the most highly endorsed component (by 79% of respondents) use of
relaxation did not predict improvement on any variable. Similarly, sleep
hygiene was unrelated to sleep pattern change and use of imagery training
was modestly predictive of poor response in terms of sleep latency. There
are methodological limitations to this type of post hoc analysis, nevertheless,
these results being derived from a large patient outcome series raise
important issues both for research and clinical practice.
This research was supported by grants from the Chief Scientist Office,
Scottish Office Department of Health and Ayrshire and Arran Health Board.
Psychological Treatment in the Management of Chronic Insomnia in Primary
Kevin Morgan1, Simon Dixon2, Nigel Mathers3, Joanne Thompson3, and Maureen
1Gerontology Research Unit, Department of Human Sciences, Loughborough
2Institute of General Practice and Primary Care, University of Sheffield
3Sheffield Health Economics Group, University of Sheffield
4Department of Clinical Psychology, Central Nottinghamshire Healthcare
Background. While the clinical trials evidence shows that chronic insomnia
can be effectively treated with appropriate psychological therapies, such
treatments are rarely deployed in primary care settings - where most complaints
of insomnia are made.
Objective. To evaluate the practicality, cost and clinical effectiveness
of a primary care 'sleep clinic' providing short-term cognitive/behavioural
treatment in the management of chronic insomnia in primary care settings.
Methods. Patients presenting, or recalled, for repeat hypnotic prescriptions
in 23 Sheffield general practices were invited to participate in either
the clinic (50%) or control (50%) conditions of the study. Clinic patients
were offered a package of psychological therapies for insomnia over 6
sessions (including health education, sleep hygiene, stimulus control
procedures, relaxation and cognitive approaches). Treatment was delivered
by primary care counsellors supervised by a clinical psychologist. Controls
were assessed, but received no additional treatment. Outcomes included
sleep quality, drug use, and patient ratings of service satisfaction.
Economic analyses of trial costs and NHS insomnia care were conducted
alongside the trial.
Results. A total of 101 and 109 patients participated in the control and
clinic groups respectively (total = 210). The sleep clinic was associated
with improved sleep quality, reduced hypnotic use, positive ratings of
patient satisfaction, and high take-up by general practices. Economic
analyses indicated substantial hidden costs associated with hypnotic drug
Conclusions. The primary care sleep clinic model described here can offer
a high quality, low risk response to chronic insomnia in general practice
*This project was funded by the NHS Health Technology Assessment Programme
The Efficacy of a Pennebaker-like Writing Intervention for Poor Sleepers
Clare Farrell1 and Allison G. Harvey2
1Department of Psychiatry, University of Oxford
2Department of Experimental Psychology, University of Oxford
Insomniacs commonly complain that they are unable to get to sleep because
of unwanted thoughts and worries. This excess cognitive activity has been
attributed to incomplete processing of daytime stressors and hassles.
Previous research has demonstrated the benefits of writing about emotional
experiences as a method to facilitate emotional processing. The present
pilot study tested the hypothesis that writing about worries and concerns,
with an emphasis on the expression and processing of emotion, will reduce
sleep onset latency among poor sleepers. Forty two poor sleepers were
randomly allocated to one of three groups for three nights; the instructions
for the 'problems' writing group emphasised the expression and processing
of worries and concerns, the instructions for the 'hobbies' writing group
emphasised distraction from worries and concerns by writing about hobbies
and interests, the 'no writing' group were not given a writing task. The
'problems' writing group reported shorter sleep onset latency compared
to the 'no writing' group. It is concluded that a writing intervention,
designed to enhance emotional processing, may assist poor sleepers to
fall asleep faster and has potential to be a useful treatment component.
Correcting Inaccurate Perception of Sleep Onset and Total Sleep Time
in Insomnia: A Novel Treatment Component?
Nicole K.Y. Tang and Allison G. Harvey, Department of Experimental Psychology,
University of Oxford
Insomniacs tend to overestimate their sleep onset latency and underestimate
the total number of hours they slept. These findings raise the possibility
that distorted perception of sleep may contribute to the maintenance of
insomnia. Aaron T. Beck (1976) has highlighted the importance of 'distortions
of reality' in the maintenance of emotional disorders. Since then clinical
researchers have been interested in identifying distortions and developing
interventions to correct distorted perceptions across a wide range of
disorders. This paper will present the results of a study that explored
the role of distorted perception in the maintenance of insomnia and piloted
the utility of a novel intervention to correct distorted perception. Insomniacs
were asked to wear an actiwatch and keep a sleep diary for 3 nights. On
the following day, half of the participants were shown the discrepancy
between the actiwatch recording and their sleep diary (discrepancy demonstrated
group), while the other half were not shown the discrepancy (no demonstration
group). Participants were then asked to wear the actiwatch and keep a
sleep diary for 3 further nights. On the following day, the discrepancy
demonstrated group reported reduced sleep-related anxiety and were more
accurate in their estimation of the amount of sleep they obtained. Clinically,
these findings highlight the potential benefits of targeting inaccurate
sleep perception when treating insomnia and provide a possible method
to achieve this. Theoretically, the results provide evidence that inaccurate
perception of the amount of sleep obtained may be involved in the maintenance
Psychological and Clinical Predictors of Compliance with Continuous Positive
Airway Pressure Therapy for Obstructive Sleep Apnoea: A Prospective Study.
Matt Wild1, Colin A. Espie1, Neil Douglas2, and Heather Engleman2
1Dept. of Psychological Medicine, University of Glasgow
2 Scottish National Sleep Laboratory, Universiy of Edinburgh
Objectives: Obstructive sleep apnoea (OSA) is a disorder which is associated
with excessive daytime sleepiness, cardiovascular disease and road traffic
accidents. Continuous positive airway pressure therapy (CPAP) is the current
treatment of choice and is highly effective. However, compliance with
this treatment is low. As yet, compliance rates have not been consistently
explained by physical or clinical variables. Wallston's modified social
learning theory was applied to a population of OSA sufferers to establish
whether an amount of variance could be explained on the basis of psychological
Design: A prospective, naturalistic study was conducted. Psychological
clinical and physical variables were considered in order to establish
the best model of compliance.
Methods: One hundred and twenty consecutive OSA sufferers were recruited.
Measures of heath locus of control, self-efficacy and health value were
administered prior to initiation of CPAP therapy. Clinical and physical
data were also collected at this time. Participants were followed up at
three months and objective compliance rates were collected from their
Results: Initial between group analysis found that Wallston's model did
not usefully differentiate between compliers and non-compliers. However,
logistic regression analysis revealed that a model comprising health value,
body mass index and Epworth scores (i.e., a subjective measure of daytime
sleepiness) explained a small, but clinically significant amount of variance.
Conclusions. These results support previous research findings that compliance
with CPAP may be most productively researched by considering psychological
as well as physical and clinical variables. This bio-psychosocial approach
is to be encourages in other areas of medical research.
New Developments in Anger Treatment
Raymond W. Novaco, University of California, Irvine
Central Issues in Anger Treatment: Theoretical, Methodological, and Practical
Raymond W. Novaco, University of California, Irvine, USA
Anger is an important clinical subject for mental health professionals
who work in a wide range of community and institutional settings, not
only because it is a significant activator of violent behaviour, but also
because it is evoked by many stress-related conditions. Recurrent anger
is often a product of troubled life histories and readily becomes part
of a dysfunctional style of dealing with life's challenges. Intrinsic
to the predicament of people with serious anger problems is treatment
resistance, and clinicians are often less than keen on seeking to engage
them in the therapeutic enterprise. Major issues arising in the recruitment,
referral, assessment, and preparation of angry patients will be outlined.
Significant treatment gains that have been achieved with patients having
serious anger problems will be overviewed. Key elements of successful
treatment interventions, grounded in outcome evaluation research, will
be presented. As significant gains have been achieved with highly distressed
clients having very complex clinical needs, there is much hope for many
other people who struggle to manage their anger and seek clinical assistance.
Anger Treatment Outcomes for Offenders with Learning Disabilities
John L. Taylor, University of Northumbria at Newcastle / Northgate &
Prudhoe NHS Trust
Rates of aggression are high amongst people with intellectual disabilities
living in institutional settings. Anger is a significant activator of
aggressive behaviour. There is some limited evidence for the value of
cognitive-behavioural treatments for anger problems with people with intellectual
disabilities. No controlled studies of anger treatment involving intellectually
disabled offenders living in secure settings have been conducted to date.
In a pilot study, detained patients with intellectual disabilities and
histories of offending were allocated to specially modified cognitive-behavioural
anger treatment or to routine care waiting-list control conditions. Eighteen
sessions of individual treatment were delivered over a period of 12 weeks.
Patients' self-report of anger intensity to an inventory of provocations
was significantly lower following intervention in the treatment condition,
compared to the wait-list condition. Limited evidence for the effectiveness
of treatment was provided by staff ratings of patient behaviour post-treatment.
Detained offenders with intellectual disabilities can benefit from intensive
individual cognitive-behavioural anger treatment. Further research is
required to examine the mechanisms for change and their sustainability.
Anger Management with Offender Patients
Yvonne Shell and Estelle Moore, Department of Psychology, Broadmoor Hospital,
This paper will draw on the experience of working with a group of young
male offender-patients with complex clinical presentations detained in
a high security hospital. The group participants undertook a 12-month
programme of anger treatment utilising a cognitive-behavioural approach
which incorporated the need for a 'preparatory phase' as identified by
Renwick, Black, Ramm, and Novaco (1997). Using case material, we will
consider: individual differences in response to the treatment; the progress
of the group as rated by independent observers; and clinical outcome,
as evidenced in their subsequent pathways through treatment in the hospital.
Within this we will give voice to the patients feedback on the groupwork
experience and discuss how this might inform our understanding of the
offender-patients' use of strategies for managing anger. Particular attention
will be given to the role of shame and its links with earlier trauma and
the expression of anger, as this evolved from work within the group on
offending behaviour. The impact of a high intensity of emotion on the
group process, and on the therapists involved, will be considered. We
will conclude with a brief discussion of the implications for the design
and delivery of interventions for anger in the context of a period of
detention for young men with offending histories.
Group Anger Management with Mentally Disordered Offenders
Mark Ramm, The Orchard Clinic, Edinburgh
Mentally ill patients who are detained because of their "dangerous
and criminal propensities" often have substantial difficulties associated
with anger. An integrated programme was therefore developed to address
these needs at the State Hospital for Scotland and Northern Ireland. It
involves comprehensive assessment and the provision of clinical intervention
at several therapeutic levels. The presentation focuses on "anger
management" groupwork, during which participants are helped to understand
their anger-mediated difficulties and to develop effective self-control
skills. The approach is based on the cognitive-behavioural approach developed
by Novaco, but the groupwork intervention incorporates a number of innovative
developments, which will be described. A brief account will be given of
the group sessions and the weekly individual support sessions. Preliminary
results of a comprehensive evaluation study will be reported and some
Therapeutic Strategies Across Disorders
BABCP Scientific Committee
A Multi-dimentional Approach to Working with Methadone Maintained Families:
Preliminary Results from a Randomised Controlled Trial
Sharon Dawe1, Paul Harnett2, Petra Staiger3 & Vanessa Rendalls1
1School of Applied Psychology, Griffith University, Brisbane, Qld 4111,
2 University of Queensland, Brisbane, Qld, 3Psychology Department, Deakin
Children raised in substance abusing families show high rates of behavioural
and emotional problems, in particular oppositional, defiant behaviours.
Problems at the level of the individual parent, family relationships,
and life-style factors are related to poor child outcomes and adult substance
abuse. In order to decrease child behaviour problems, improve family relationships
and decrease parental substance use, we have developed a multi-dimensional
program, Parents Under Pressure, that address problems at each ecological
level (individual, family, and community) in a structured but non-sequential
format (SNS) for families who are currently on methadone maintenance.
In PUP family problems are conceptualised more broadly than as a parenting
skills deficit. Specifically, low confidence in parenting ability, guilt
associated with poor parenting practices, emotional, and social problems
of the parents, and high levels of stress (and the effect that each of
these has on ongoing, nonprescribed drug use) are seen as factors that
interfere with the provision of good enough parenting. Interventions are
structured insofar as each identified problem area is addressed by a manualised
intervention. However, the program is non-sequential in that the problems
targeted vary from family to family, with the order of presentation determined
by the salient presenting problem for the family in each session. Problem
solving strategies for dealing with pressing issues provide parents with
some control and direction for dealing with their immediate stress. Critically,
the problem solving strategy allows parents to attend to other aspects
of the intervention.
The current study aims to determine the relative effectiveness of this
intensive, multidimensional approach compared to a brief behavioural parenting
intervention and standard care in families in which either or both parents
are currently enrolled in a methadone maintenance program. The intensive
program, PUP, is delivered in families' homes and consists of up to 12
sessions focusing on child behaviour, the parent-child relationship, beliefs
about parental adequacy and parental functioning (including drug abuse).
The brief behavioural parenting intervention consists of 2 sessions and
is delivered in the clinic. Standard care consists of the current treatment
program of once monthly contact with a caseworker. Using measures sensitive
to child behaviour (including behavioural observation of parent child
interactions), parental functioning and parental substance abuse, we present
outcome data on the first 50 families who have taken part in the trial.
Stress Control' Large Group CBT for GAD: Eight Year Follow-up
Jim White, Clydebank Health Centre, Scotland
This paper will look at an eight year follow-up study. The controlled
trial involved cognitive therapy, behaviour therapy, cognitive-behavioural
therapy, placebo ('Subconscious Retraining') and waiting list. 109 (DSM-III-R)
GAD patients took part. The approach involved 6, 2 hour 'evening class'
sessions. The sessions involved didactic teaching, slide and video presentations,
workshops and homework. Patients in each treatment condition were given
a booklet specific to that approach. This paper will describe outcome
in terms of questionnaire data (pre, post, 6 month, 24 month and 8 year),
further psychological and pharmacological treatment and patients experiences
of the approach.
Goal Planning: A Retrospective Audit of Rehabilitation Process and Outcome
Jane Duff, Matthew Evans, Paul Kennedy, National Spinal Injuries Centre,
Stoke Mandeville Hospital NHS Trust, Aylesbury, UK.
Background: Goal Planning is a well recognised approach used in a number
of clinical settings. The approach is based on behavioural change principles
(Houts and Scott, 1975) which emphasise the identification of specific
goals and targets in relation to the strengths and needs of the individual.
Within spinal cord injury rehabilitation, this multi-disciplinary approach
aims to enhance client involvement and adaptation to injury. Active in-patient
involvement in rehabilitation has been found to the best predictor of
long-term medical and behavioural outcome (Norris-Baker et al, 1981).
However, inspite of the general acceptance and wide usage of the approach,
little research has been conducted on its application (Wade, 1998). The
Goal Planning system used in this research integrates behavioural management
strategies with a clinical outcome measure, the Needs Assessment Checklist
(Kennedy and Hamilton, 1999), formed from 216 behavioural indicators.
Objectives: To evaluate the outcome, utility and effectiveness of the
Needs Assessment and Goal Planning approach within spinal cord injury
rehabilitation and audit the application of the approach against previously
set standards for the service.
Method and Design: A retrospective audit of sixty-four patients who participated
in the Needs Assessment and Goal Planning approach between 1997 - 2001
within an in-patient hospital based rehabilitation centre. The sample
included 48 men and 16 women, with a mean age of 41 years (range 15-71
years). The sample were representative of a spinal cord injury population
in relation to level and neurological completeness of injury.
Results: The total number of goal planning meetings for the sample was
381 (range of 1 to 15), with an average of 6 meetings per patient being
held. A total of one thousand, two hundred and eight goals were set across
the sample at the first goal planning meeting, with 75% of these goals
being achieved by the second meeting. The total achievement rate across
the meetings was 71%, with an average of 13.6 goals being set per meeting.
Staff attendance at meetings was very high with 83.5 % of meetings being
attended by physiotherapists, 77.9 % by Occupational Therapists and 68.2
% by Nursing Staff. Qualitative information about the process of rehabilitation
and functional outcome were also obtained. In addition, information will
be presented comparing the process of goal planning with the Needs Assessment
Checklist, a tool used to assess outcome in this population.
Conclusions: This study provides evidence that Goal Planning is an effective
tool for a patient-centred, multi-disciplinary team approach to rehabilitation
management. The benefit of systematic audit of a service in providing
information about the rehabilitation process is also highlighted.
Increasing the Odds for Change: Utilising Motivational Strategies with
Alison Salmon and David Ryder, Edith Cowan University, Perth, Western
The 1990's witnessed an unprecedented proliferation of gambling venues
in Australia in the form of casinos and electronic gaming machines, which
have been patronised enthusiastically by Australians. In 1998 over 80
per cent of Australians gambled at least once and 40 per cent gambled
on a regular basis. According to a 1999 report by the Australian Productivity
Commission 15 per cent of regular (non-lottery) gamblers are problem gamblers.
It is estimated that problem gamblers represent 2.1 per cent of the Australian
adult population and account for expenditure of A$ 3.5 billion annually.
Problem gamblers lose around A$12,000 per head each year compared with
under A$650 for other gamblers. In addition to financial costs, there
are significant emotional costs associated with problem gambling; for
example one in ten problem gamblers said they have contemplated suicide
due to gambling. Clearly in an environment where gambling continues to
be increasingly accessible there is a need to provide effective treatment
for problem gamblers.
In 1999 a study was carried out by Edith Cowan University in Western Australia
to identify best practice strategies for the treatment of problem gambling.
The study reviewed 46 research papers and interviewed 17 key informants.
It was concluded that at this stage there is a dearth of methodologically
sound research to support the efficacy of specific interventions although
there is some support for the use of cognitive-behavioural strategies
such as imaginal desensitisation, cue exposure/response prevention and
the addressing of erroneous beliefs regarding gambling. The need to attend
to motivational issues was consistently raised in the literature and emphasised
by key informants. The study also identified a need to provide services
for those who are unwilling or unable to attend specialist gambling services.
These may be people who are ambivalent about changing their gambling behaviour
or those who feel uncomfortable attending specialist gambling counselling
services. The latter may include women or members of ethnic minority groups.
Despite the paucity of rigorous research in the area of problem gambling,
it is suggested that as in the treatment of other addictive behaviours,
non-specialist services and practitioners are well placed to respond to
problem gamblers providing that staff have appropriate training. Such
training necessarily includes motivational strategies. It is also suggested
that other strategies that have been successful in the alcohol and other
drug area such as brief interventions and self-help manuals may be useful
in assisting problem gamblers. This paper will explore ways in which existing
knowledge and practice in the alcohol and other drug field can be incorporated
into interventions with problem gamblers. In particular the author will
discuss how non-specialists can incorporate motivational strategies for
problem gamblers into their work. Drawing upon the Australian experience
the paper will also suggest that whilst maintaining a focus upon the individual
problem gambler, it is important to pay attention to environmental factors
which can encourage or restrain gambling behaviour.
Coping Effectiveness Training: A Group Controlled Intervention for People
With Traumatic Spinal Cord Injuries
Paul Kennedy, Jane Duff, Matthew Evans, National Spinal Injuries Centre,
Stoke Mandeville Hospital NHS Trust, Aylesbury, UK.
Objectives: To evaluate the efficacy of a group based intervention programme
to improve psychological adjustment and reduce anxiety and depression
following traumatic spinal cord injury. The Coping Effectiveness Training
(CET) programme is grounded on the cognitive theory of stress and coping
and this study develops the results of a previous pilot investigation.
Design: A trial comparing patients receiving the CET intervention with
matched controls on measures of adjustment and coping. Methods: Forty-two
intervention group participants and forty matched controls were selected
from in-patients at a hospital based rehabilitation centre. Outcome measures
of depression (BDI), anxiety (SAI) and coping (COPE) were collected before,
immediately following and at six weeks post intervention. Results: Intervention
group participants showed a significant reduction in depression (p<0.01)
and anxiety (p<0.05) compared to matched controls immediately after
the intervention and at six weeks follow-up. The pattern of coping strategies
did not alter. Conclusions: These results confirm the results of the pilot
study, that the CET intervention reduced mood disturbance following injury.
Low depression is associated with a reduction in secondary complications,
such as pressure sores. The issues of altering negative appraisals and
post traumatic growth are considered.
Disgust - The Forgotten Emotion?
David Veale, The Priory Hospital North London
Fear and loathing in OCD: Does Disgust Play a Role in This Anxiety Disorder?
Paul Salkovskis & K. Wahl, Institute of Psychiatry, London
Abstract not available
"Only a Wafer Thin Mint, Sir?" A Survey of Vomit Phobics.
David Veale. Royal Free Hospital and University College Medical School,
Vomit is a prototypal stimulus for the emotion of disgust. Little is known
about the psychopathology or treatment of vomit phobia with only a few
isolated case reports. Vomit phobics are generally regarded as difficult
to treat by exposure because of the complexity of obtaining credible stimuli,
which can be repeated and prolonged. The aim of this study was to learn
more about the psychopathology of vomit phobia, the degree of handicap
and their experience of treatment. Patients with vomit phobia were compared
to patients with agoraphobia and panic and non-patient volunteers on a
number of measures to compare beliefs about nausea and vomiting, avoidance
behaviours, safety behaviours, and symptoms of anxiety.
Disgust in Eating Disorders: Sensitivity and Emotional Responses
Nicholas Troop1, Tara Murphy2 and Professor Janet Treasure3
1 Department of Psychology, London Guildhall University, London
2 Department of Psychology, Institute of Psychiatry, London
3 Department of Psychiatry, Institute of Psychiatry, London
Disgust is an emotion of avoidance where the focus of core disgust is
considered to be food. Despite this, however, very little attention has
been paid to disgust in eating disorders, disorders in which issues concerning
food and its avoidance are clearly of importance. This talk will present
the results of a series of studies on the relationship between disgust
sensitivity, disgust emotions and eating disorders.
Two studies are presented on disgust sensitivity and categories of disgust.
Study 1 uses patients from an eating disorder clinic and Study 2 uses
women with a history of eating disorders from a Research Volunteer Register.
Despite the use of different measures and very different samples, the
results suggest that women with a history of eating disorders do report
higher levels of disgust sensitivity but that this is restricted to categories
of disgust related to food and the body.
Two more studies are presented on reported disgust and fear responses
to food, body and emotion stimuli. In Study 3, women with abnormal eating
attitudes reported higher levels of both fear and disgust in response
to high calorie foods and overweight body shapes than did women scoring
low on abnormal eating attitudes but groups did not differ on emotional
responses to drinks or slim body shapes. Study 4 replicated and extended
these results in a group of patients with anorexia nervosa.
Overall these results suggest that disgust sensitivity may play a role
in eating disorders. In particular, while eating disorders have traditionally
been conceptualised in terms of fear (e.g. fear of weight gain, morbid
dread of fatness, weight phobia), disgust may be an equally salient emotional
response to "dangerous" foods and "undesirable" body
shapes. It is proposed that this disgust response may facilitate the avoidance
of such stimuli.
The Role of Disgust Sensitivity in Body Dysmorphic Disorder
Kate Cavanagh & Ann Stevenson, University of Glasgow
Body Dysmorphic Disorder (BDD) is characterised by preoccupation and torment
elicited by an imagined or exaggerated defect in appearance (e.g. a large
nose, thinning hair, facial scarring). Whilst classified in DSM-IV as
a somatoform disorder, considerable evidence suggests BDD is better understood
as an affective disorder within the obsessive-compulsive spectrum (K.
Phillips, McElroy, Hudson & Pope, 1995). Whilst, there is a growing
body of research into the nature and treatment of BDD, the causes of BDD
remain largely unexplained and its vulnerability factors largely unexamined.
One candidate vulnerability factor for BDD is sensitivity to disgust.
Recent research has linked the pathological experience of disgust to a
variety of nominally anxiety and affective disorders, including animal
and medical phobias, obsessive-compulsive sympomatology and the eating
disorders (e.g. Davey, Tantlow & Dallos, 1998; Matchett & Davey,
1991; Muris, Merckelbach, Nederkoorn, Rassin, Candel & Horseleberg,
2000; Tolin, Lohr, Sawchuk & Lee, 1997). The idea that BDD (dysmorphophobia)
may be linked to the emotion of disgust is not new (M.Phillips, Senior,
Fahy & David, 1998), however this relationship has not been tested
empirically. This paper presents the findings from two studies investigating
the link between disgust and BDD in non-clinical populations. The first
study 1 measured disgust sensitivity, anxiety and depression in a group
of undergraduates who had completed a screening measure for BDD. In a
second study the relationship between BDD symptom severity and disgust
sensitivity, anxiety and depression was investigated in a second undergraduate
Whether disgust plays a significant role in Body Dysmorphic Disorder is
discussed within the context of the research findings.
Disgust, the Self and the Brain.
Mary L. Phillips and Maike Heining, Institute of Psychiatry, London..
The basic emotion disgust (literally, "bad taste") has been
defined as "...something offensive to the taste". Objects of
disgust include waste products of the human/animal body, violation of
body borders at non-mouth points, animal-origin disgust, interpersonal
contamination, and moral or socio-cultural disgust. Human lesion and functional
neuroimaging studies, employing as stimuli standardised facial expressions,
have demonstrated that the amygdala is critical to the perception of fear,
and the insula and putamen are important for disgust. The insula is also
important for perception of disgust depicted either as a facial expression,
or as an emotionally-salient odour or flavour, and for pain.
Inappropriate disgust, and the complex emotions derived from disgust (e.g.
shame and guilt), may underlie disorders of self and body image. Self-perception
includes several cognitive processes, in particular, recognition of physical
attributes as self (e.g. one's own face, and information presented in
other sensory modalities), and the experience of specific emotions, both
positive and negative (e.g. disgust) in response to these. Studies of
split-brain patients, and those employing psychophyical, psychophsiological
and neuroimaging techniques have indicated that self-recognition is associated
with right and left prefrontal cortex, and limbic regions, including the
insula. These findings indicate that similar areas are important for perception
both of emotionally-salient information and the self. Abnormalities of
self-perception, e.g. body image disorders, may therefore be associated
with dysfunctional regulation by the prefrontal cortex of activity in
brain regions important for emotion, and disgust, perception.
Is There a Role for Cognitive Behaviour Therapy in Bipolar
Jan Scott, University of Glasgow
Social Cognition in Bipolar Disorder
Peter Kinderman, Reader in Clinical Psychology, University of Liverpool
Studies of social cognition in bipolar disorder and paranoid ideation
have revealed both similarities and differences between the processes
operating in manic and paranoid states. Both conditions appear related
to defensive or self-protective responses to personal threat. Both conditions,
for example, appear to be associated with abnormalities in self-concept
and causal attributions. However there appear subtle differences in the
manner in which these defensive processes manifest themselves. Further
research, in apparently unrelated conditions, suggests that schematic
processes, rather than psychological deficit states, may explain these
patterns. A tentative model of these schematic processes will be presented.
It is hypothesised that appraisals of potentially threatening events precipitate
specific circular feed-back loops that are self-maintaining. This model
will be supported and illustrated with qualitative case material from
CBT and with a year-long series of daily records of 'positive and negative
activation'. These data will illustrate schematic thought, specific appraisal
processes, as well as the behavioural and affective consequences. The
possible research and clinical consequences of models such as this will
Teaching Bipolar Disorder Patients to Identify and Manage Early Symptoms
Richard Morriss, Alison Perry, Nicholas Tarrier, Eilis McCarthy, Kate
We conducted a single blind randomised controlled trial of teaching patients
to recognise early symptoms of manic and depressive relapses and then
seek early conventional treatment from psychiatric services. 69 patients
with DSM-IIIR bipolar disorder were recruited with a relapse in the previous
12 months. The intervention was conducted in 7-12 sessions by a psychology
assistant and involved in recognising early and late early warning symptoms
of manic or depressive relapse. A treatment-seeking plan was devised involving
three points of contact with psychiatric services. The intervention was
introduced in addition to standard psychiatric care. The 25th centile
time to first manic relapse was 65 weeks as opposed to 17 weeks (p=0.008).
there was a 30% decrease in manic relapses, improved social functioning
and employment. In contrast there was no effect on depression and higher
doses of antidepressants were used in the intervention group. Problems
in implementing such an intervention into routine practice will also be
Cognitive Theory and Therapy of Bipolar Disorders
Jan Scott, University of Glasgow
This paper will give a brief overview of 3 pieces of research on cognitive
therapy for bipolar disorders. First, it will describe cognitive style
in people at risk of episodes of mania and depression. Second, it will
highlight similarities and differences in cognitive style of individuals
with unipolar and bipolar disorders. Third, it will look at a pilot study
of the use of cognitive therapy for individuals with bipolar disorders.
In the pilot study, 42 individuals were randomly allocated to usual treatment
or cognitive therapy plus the usual treatment. The group receiving cognitive
therapy showed significant reductions in symptoms, improvements in quality
of life and lower relapse rates over the one year after cognitive therapy
as opposed to the year prior to cognitive therapy. The paper will also
briefly describe ongoing work in this area.
Cognitive Therapy for Bipolar Affective Disorder: A Randomised Controlled
Study: Preliminary Findings
Lam, D., Watkins, E., Hayward, P., Bright, J., Wright, K. & Sham,
P., Institute of Psychiatry, London, UK
One hundred and three patients suffering from bipolar 1 affective disorder
were recruited in a randomised controlled trial of cognitive therapy (CT)
specifically designed for bipolar affective disorder. The study targeted
bipolar patients who are vulnerable to relapses. All subjects had to be
taking a mood stabiliser on recruitment. The control group received minimal
psychiatric input, i.e. mood stabilisers and outpatients follow-up. The
therapy group received up to twenty sessions of CT plus minimal psychiatric
input. With the exception of age of onset of the illness, there were no
significant differences between the two groups in terms of demographics
or the number of previous bipolar episodes. At the end of therapy, intention
to treat analysis revealed that the therapy group had significantly fewer
bipolar episodes, fewer days in a bipolar episode, higher social functioning
and better medication compliance. Moreover, subjects in the therapy group
had fewer episodes of bipolar depression and number of days hospitalised.
The therapy group also had significantly less fluctuation according to
the Activation subscale of the Internal State Scale that subjects returned
monthly. The therapy group had significant reduction in BDI scores over
the six months. When the subjects who received inadequate treatment (fewer
than six sessions) were excluded, the therapy group also had significantly
fewer hospital admissions and fewer manic and hypomanic episodes. This
study replicated our earlier pilot study.
Psychological Approaches and Sleep, Part 2: Recent Empirical
Colin A. Espie, University of Glasgow
Attentional Processes in Insomnia: The Role of Monitoring the Environment
and the Body for Sleep Related Cues.
Christina Neitzert Semler and Allison G. Harvey, Department of Experimental
Psychology, University of Oxford
Introduction: Previous research has implicated heightened attention to
and monitoring of body sensations in the maintenance of a range of psychological
disorders. Monitoring processes have also been highlighted as of potential
importance in the maintenance of insomnia. The present study was undertaken
to investigate the following six types of monitoring among insomniacs
and good sleepers: (1) monitoring of physical state/body sensations during
the pre-sleep period for bodily signs consistent with falling asleep (e.g.,
slowed heart rate, loss of muscle tone, physical signs of 'drifting off'),
(2) monitoring of the environment during the pre-sleep period for signs
of not falling asleep (e.g., being able to hear a dog barking and for
noises outside and inside the house), (3) monitoring of the clock during
the pre-sleep period to see how long it is taking to fall asleep, (4)
monitoring of physical state/body sensations on waking for signs of poor
sleep (e.g., sore head, achy and heavy eyes), (5) monitoring of physical
state/body sensations during the day following a bad night of sleep for
signs of fatigue (e.g., heavy legs, sore shoulders), and (6) monitoring
of the clock on waking to determine how many hours of sleep were obtained.
Methods: Eighty participants between 18 and 35 years of age (40 good sleepers
and 40 insomniacs) completed an extensive semi-structured interview assessing
for the presence, nature and consequence of each of the six types of monitoring.
Measures included an assessment of the frequency of each type of monitoring,
along with associated thoughts, emotions, and safety behaviors.
Results: The results indicated that insomniacs attended to time and noise
in their environment more frequently than good sleepers during pre-sleep
and reported more frequent attention to their bodily sensations on waking
compared to good sleepers.
Insomniacs reported more negative thoughts, more negative emotion and
greater use of safety behaviors as a consequence of monitoring. A path
analysis indicated that frequency of attending to cues related to sleep
was positively related to negative thoughts, and that negative thoughts
in turn were positively related to both negative emotion and safety behaviors.
Conclusions: These findings suggest that heightened attention to and monitoring
of body state and the environment for sleep-related cues during the pre-sleep
period, on waking and during the day following a poor night of sleep may
Clock Monitoring in the Maintenance of Insomnia
Allison G. Harvey and D. Anne Schmidt, Department of Experimental Psychology,
University of Oxford
Introduction. Attentional bias toward threat-related material has been
implicated as a trigger to threat perception and excessive negatively
toned cognitive activity across a range of psychological disorders. In
the context of insomnia, clinical observation has implicated 'clock watching'
during the pre-sleep period to be a trigger for excessive negatively toned
pre-sleep cognitive activity. The present study was designed to index
the effect of 'clock watching' during the pre-sleep period on sleep-onset
latency, anxiety and worry about not getting enough sleep. There were
three predictions: (1) that participants instructed to monitor the clock
would take longer to get to sleep than participants instructed not to
monitor the clock, (2) on the basis that one mechanism by which clock
monitoring may be detrimental to sleep onset is that it triggers worry,
we expected that participants instructed to monitor the clock would report
that worrying about how long it was taking them to fall asleep interfered
with getting to sleep more than participants instructed not to monitor
the clock and (3) on the basis of previous findings showing that a simple
cognitive manipulation can induce a 'state' of insomnia in good sleepers
we reasoned that hypotheses 1 and 2 would hold for both good sleepers
Methods. Sixty adults participated; 30 good sleepers and 30 insomniac.
Good and insomniacs were randomly allocated to one of two experimental
conditions. In the first, participants were instructed to monitor the
clock during the pre-sleep period and in the second participants were
instructed not to monitor the clock during the pre-sleep period. Sleep
onset latency was measured by self-report and actigraphy. Worry was measured
Results. The results indicated that participants instructed to monitor
the clock experienced longer sleep onset latency and more worry about
falling asleep compared to participants instructed not to monitor the
clock. These findings were observed across diagnostic status. Interestingly,
instructions to monitor the clock lead participants to overestimate sleep
onset latency relative to instructions to not monitor the clock. This
finding may be explicable with reference to two factors. First, previous
research indicates that time seems longer as the number of units of information
processed per unit of time is increased. Monitoring the clock involves
processing more units of information than not monitoring the clock. Second,
detailed analysis of the actigraphic data revealed that in the first 60
minutes after sleep onset those instructed to monitor had more awakenings
than those instructed not to monitor (p < 0.001). It is possible that
these awakenings may have been perceived as continuous wakefulness.
Conclusions. Consistent with the predictions, the present study demonstrated
that monitoring the clock lead to longer sleep onset latency and more
worry about not getting to sleep compared to not monitoring the clock.
These findings are consistent with previous clinical observations and
support the hypothesis that clock checking may be involved in the maintenance
The Evolution of Sleep-onset Latency Problems: An Experimental Investigation
of Pre-sleep Cognition and Attribution in People with Cancer
Lynne Taylor, Colin A. Espie and Craig White, Dept. of Psychological Medicine,
University of Glasgow
This study examined the evolution of insomnia by investigating pre-sleep
cognition and attribution, through the administration of the emotional
Stroop task, to two groups of cancer patients who had developed sleep-onset
latency (SOL) problems since diagnosis: 15 individuals with cancer 0-3
months from diagnosis (early group); and 18 individuals with cancer 12-18
months from diagnosis (late group). Consistent with the hypothesis, both
groups demonstrated attentional bias for cancer-related words but only
the late group demonstrated attentional bias for sleep-related words.
High levels of pre-sleep cognitive arousal were evident in both groups
despite lower levels of psychological distress in the late group. Findings
are discussed within the context of the current literature and implications
for future research are proposed.
Pre-school Children with Attention Deficit Hyperactivity Disorder: A
Naturalistic Assessment of Activity and Sleep
Stephanie J. Inglis and Colin A. Espie , Dept. of Psychological Medicine,
University of Glasgow
Researchers and clinicians in the field of Attention Deficit Hyperactivity
Disorder have recognised the importance of sleep problems in children
with ADHD. However, little is known about the circadian rest-activity
pattern of the preschool child with ADHD. This study investigated the
nature of sleep and activity in a sample of 12 preschool children fulfilling
diagnostic criteria for ADHD relative to age and gender matched controls
using both objective and subjective measurements. Results indicated that
parents of ADHD children reported significant daytime over-activity and
sleep disruption in their children. Objective evaluation using actigraphy
failed to detect differences in daytime activity between the ADHD group
and their matched controls. ADHD children were found to be more active
during sleep than their comparisons; however, this was only apparent in
a sub-set of ADHD children. No significant difference was found in sleep
pattern or sleep quality parameter between the groups. There was high
variability both between and within groups in activity and sleep measures
and objective evaluation of activity and sleep failed to consistently
differentiate children diagnosed with ADHD from controls. Various explanations
are provided to account for these findings and implications for future
research are discussed.
The Role of Cognitive Coping Styles and Sleep Hygiene in Acute and Chronic
Jason Ellis and Mark Cropley, Department of Psychology, University of
To date, little attention has been paid to the factors which may explain
why some acute insomniacs progress to chronic whilst others do not. Recent
advances suggest that the role of cognitive coping styles may be important.
This research, although in its infancy, provides a comprehensive framework
from which to examine the cycle of chronic insomnia. Chronic insomnia
is considered to be a progressively heterogeneous disorder, which includes
sleep incompatible practices and negative conditioning. This conceptualisation
however questions the utility of a cognitive approach for the creation
of a preventative intervention, as the link between cognitive and behavioural
factors can not be delineated.
The present, cross-sectional study examined the relationship between different
cognitive coping styles and sleep hygiene factors in self-identified acute
and chronic insomniacs, as well as normal sleepers. The Thought Control
Questionnaire, a measure of cognitive coping styles, and the Sleep Disturbance
Questionnaire (SDQ) were distributed to 1104 participants from the general
population, along with questions on demographic and sleep hygiene practices.
The definition of insomnia, based on the DSM-IV recommendations, identified
162 participants with chronic insomnia, 146 with acute insomnia, and 304
A series of stepwise multiple regression analyses identified the role
of punishment in acute and chronic insomnia for each insomnia subtype,
whereas sleep hygiene was only significantly related to chronic insomniacs
who scored highly on the Mental Anxiety dimension of the SDQ. Differences
in the cognitive coping styles used by acute and chronic insomniacs, and
normal sleepers, who scored highly on each dimension of the SDQ are also
highlighted. Distraction, as a cognitive coping strategy was found to
be a 'buffer' against chronic insomnia but not acute insomnia, further
highlighting differences between these groups.
These results are discussed in relation to tailored preventative strategies
to stop an acute period of sleep disturbance from becoming a chronic condition.
Developing Clinically Effective and Efficient Approaches
for Routine Clinical Work.
Jim White, Clydebank Health Centre
Three Session CBT for Common Mental Health Problems: How Far Can We Get?
Dale Huey, Pauline Callcott, Gary Robinson, & Mark Freeston, Newcastle
Cognitive & Behavioural Therapies Centre.
Trying to meet an increased demand for psychological therapy with limited
resources is an international problem. Brief interventions, e.g. less
than six sessions, may provide a partial solution for this problem. For
example, the '2+1' model appears to be a potentially effective option
for sizeable proportion of 'sub-syndromal neuroses' (Barkham et al., 1999).
As part of a waiting-list initiative we offered clients on our treatment
waiting-list the opportunity to participate in a brief intervention project.
The main aims of the project were: to establish whether we were able to
provide effective brief interventions for our 'syndromal' clients; to
test-out a three-session protocol; to provide an accessible interim service
for people waiting for therapy; and where appropriate to reduce the waiting-list.
Twenty-nine clients completed three sessions of CBT. The Clinical Outcomes
in Routine Evaluation questionnaire was completed at two points prior
to intervention, prior to each session and post-session three. The Beck
Depression Inventory was completed prior to intervention and post-session
three. Participants also completed a satisfaction questionnaire asking
for their views on aspects of the therapeutic relationship and changes
as a result of the sessions. The BDI and CORE measures were completed
again prior to a naturalistic follow-up appointment (around three-months
later). The outcome data from the project will be reported (self-reported
symptomatic change, client satisfaction, and proportion discharged), the
three-session protocol described, and our reflections on suitability issues
Barkham, M., Shapiro, D.A., Hardy, G.E., & Rees, A. (1999) Psychotherapy
in two-plus-one sessions. Journal of Consulting & Clinical Psychology,
Developing a Primary Care Service Around the Routine Evaluation of Clinical
Tony Turvey , Tayside Area Clinical Psychology Dept
An adult primary care service is described that has been developed from
the findings of an eight year service audit (n=8,500), a one year follow-up
survey (n=288) and a brief therapy project (n=30). The current service
uses the HAD (Hospital Anxiety & Depression Scale) routinely and its
correlation with to the SCL90r is reported. A pilot measure for predicting
allocation of referrals to brief, routine or longer term therapy is described.
Some strengths & weaknesses in the current service are discussed.
Finally a method for quantifying the generalisation from research studies
to routine service provision is presented that can help clinicians determine
if their service to a more heterogeneous client group is as effective
as might be expected based on research using more carefully selected client
Offering Choice in the Community: CD-ROM vs Written Self-help vs GP Treatment
Jim White, Clydebank Health Centre, Ray Jones, Dept of Public Health,
University of Glasgow
Given the significant imbalance between need and resources in the community,
there is a need for mental health therapists to innovate existing services
to provide readily accessible and easily understood approaches for common
disorders such as anxiety and depression. Following a successful pilot
study with a chronic, severe and highly comorbid heterogeneous anxiety
disorder population*, this paper will describe a recently completed controlled
trial. We compared a three session interactive multi-media touch screen
CD-ROM treatment based in public libraries, a self-help written version
(directed by practice nurse or research assistant) and GP treatment as
usual. The computer and written versions were based on a well validated
CBT self-help package - 'Stresspac' - written by JW. Clients meeting DSM-IV
criteria were recruited from (mainly) socially deprived districts across
Glasgow. A 'one plus two' format was used - one information and self-assessment
session followed by two self-treatment sessions. Seven options were available
- Controlling your - (1) thoughts, (2) actions, (3) body, (4) panic attacks,
(5) sleep problems, (6) depression and (7) future. Personalisation was
achieved by computer-patient interview and on-screen completion of the
Hospital Anxiety and Depression Scale. Results to six month follow-up
will be presented. The discussion will look at how to further develop
these approaches and how they can help offer real choice to service users.
*White, J., Jones, R. and McGarry, E. (2000). Cognitive behavioural computer
therapy for the anxiety disorders: A pilot study. Journal of Mental Health,
Short versus Long CBT for Clients with 'Severe and Chronic Difficulties':
A Pilot Study
David Westbrook and Gillian Butler, Warneford Hospital , Oxford
The Oxfordshire Adult Psychology Department generally offers short courses
of cognitive behavioural treatment to patients with a wide variety of
psychological problems. Most patients have 10 treatment sessions, with
an overall mean of around 13 sessions including assessment. In an evaluation
of this service, there was some indication that patients whom an assessor
thought had more severe and chronic difficulties were less likely to benefit
from such brief treatment. There is also some evidence from the literature,
although not consistent, that patients with personality disorders may
benefit less from ordinary CBT. We therefore set up a small pilot study
to examine (a) whether patients classified at assessment as having chronic
difficulties by our criteria also met criteria for personality disorder,
and (b) whether they would benefit more from longer treatment. Thirty
such patients were randomly allocated to receive either 10 sessions or
30 sessions of CBT from experienced therapists, and they were assessed
on a variety of measures through the course of treatment and up to a one
year follow-up. The results of this pilot study will be presented, and
their implications discussed.
Large-scale Self-confidence Workshops: A Pilot Study
June Brown, Institute of Psychiatry
In line with the NSF goal of improving the health of the population, large-scale
(for up to 30 people per workshop) day-long Self-Confidence workshops
were run and members of the general public given the opportunity to self-refer.
This study had two aims. One was to assess if 'Self-Confidence' workshops
could be effective in reducing symptoms of anxiety and depression. The
other was to establish if these workshops could reach those with hidden
problems of depression. Previous 'depression workshops' had failed to
reach this group This study therefore attempted to see if a different
label - 'self-confidence' - could attract those with depressive problems
and who may not have consulted their GPs.
The results were promising. 231 people enquired and 149 attended Introductory
talks preceding the workshops. 113 went on to attend the workshops, with
59 in the experimental group and 54 in the control group.
Those who attended the workshops reported significant decreases in their
anxiety and depression scores as well as increases in their self-esteem
scores as compared to a waiting list control group at the 3 month follow-up
These workshops were also successful in attracting those with depression
but who had not consulted their GPs about these problems. Most attenders
had mild and moderately severe problems of anxiety and depression.
It is therefore concluded that the results from this pilot study show
that this line of enquiry is worth pursuing further.
Fast Access for Brief Interventions for Anxiety and Depression in Primary
Care : A Pilot Study
Karina Lovell, David Richards, Peter Bower, Dianne Oliver, University
A fast access self-help clinic for anxiety and depression has undergone
a 1 year pilot phase. The clinic offers fast access for patients in primary
care with anxiety and depression and offers brief evidence based interventions
(usually via self-help books and manuals). An evening telephone clinic
is also available for those patients not able to attend during the day.
Patients are seen for a 30 minute assessment and offered 15 minute follow-up
appointments usually on a 2-4 week basis. Such a system allows for between
12-17 contacts each session. In the course of the past 10 months 130 patients
have been referred with an average of 3-4 new referrals weekly. Patients
are usually seen within a week of referral and no waiting list has accrued.
Clinical outcomes measures include the CORE, GHQ and satisfaction, and
are administered at baseline, 3 and 6 month follow up. Qualitative interviews
have been conducted with both GP's and users of the service. Preliminary
results have found significant reduction in the outcome measures and initial
qualitative analysis is demonstrating satisfaction with the interventions
and fast access to the clinic from both users and GP's.
Raymond W. Novaco, University of California, Irvine
Working Systemically with Family Violence: Risk, Responsibility and Collaboration
Arlene Vetere, The Tavistock Centre and University of East London, and
Co-director of "Reading Safer Families" and Jan Cooper, Co-director
of "Reading Safer Families"
A risk assessment and risk management approach to working with violence
in family relationships and the associated ethical problems will be outlined.
Our aim is to ensure prevention and continued protection from violence
for family members. Such violence often occurs in the context of intergenerational
patterns of repeating violence, with children as both
victims and witnesses. In our therapeutic work with couples and families
we identify three recurrent themes: collaboration, responsibility and
risk. We try to develop a collaborative relationship with our clients
using systemic processes of reflection, reflexivity and consultation.
We establish responsibility for the violence and develop a no-violence
contract with the perpetrators. Therapists, families, and referrers all
share the risk of the therapeutic work, with the referral agency acting
as a stable "third" in the therapeutic triangle, enabling risks
monitored in the rehabilitation of families in the aftermath of violence.
An example from practice will be illustrated with a violence-focused genogram
to show how we work systemically with violence in family relationships.
A Therapeutic Jurisprudence Approach in Legal Interventions for Domestic
Violence: How do the Children Fare?
Kathleen A. Ham-Rowbottom and Raymond W. Novaco, University of California,
Legal interventions can have a therapeutic purpose but may instead have
an anti-therapeutic impact. Therapeutic jurisprudence suggests that the
consequence of the law's application be compared against legal/judicial
objectives so that the practice of the law, like that of medicine, strives
first to do no harm, and ideally acts to improve the well-being of those
who come in contact with it. Children involved in the legal system as
a result of domestic violence tend to be a neglected constituency. Legal
interventions, including police action, criminal court involvement, and
civil action, and the very study of the effects of these interventions,
focus on adult victims and abusers. Children exposed to domestic violence
are largely served by courts through the application of a "best interest
of the child" standard in custody and visitation decisions. Just
as witnessing violence in the home can be detrimental to children, judicial
inaction or misguided legal action can short-term and long-term adverse
effects. Understanding the family context is imperative, especially to
the extent that the consequences of intervention operate through the mother's
well being. The therapeutic efficacy of legal interventions should be
assessed for all parties involved. Illustrative data from a family court
intervention project will be presented to highlight dilemmas bearing on
decisions regarding child visitation.
Development of Networks for a Comprehensive Service to Support Adolescents
Affected by Violence Within Families
Matthias Schwannauer, University of Edinburgh, Royal Edinburgh Hospital
The key dynamic that this research describes is how different ways of
understanding domestic violence lead to different responses by service
providers. These different responses clash with (or bypass) each other,
and this leads to a fragmentation of service provision. Lack of dialogue
and conflict between service providers mirrors the lack of dialogue, blame,
and demonisation that exists in situations of domestic violence. Service
providers appear to find it hard to collaborate and seek advice and support
from other agencies, without turning the whole case over to to the other
agency. A lack of clarity concerning what each agency is able to do, an
absence of procedures whereby different service providers can take joint
responsibility for a case, a lack of trust resulting from the lack of
a shared understanding, means that dialogue is very difficult. Rather
than working in isolation, or passing individuals between service providers
(who often know little of each other or are in conflict with each other),
the need for much better networking. This approach could be taken further
by setting up a specialist neutral agency (e.g. A centre for family relationships)
that could address the needs of the individual or family by drawing upon
and further developing expertise of the different service providers. As
it is, the current difficulty of achieving a healthy dialogue among service
providers, mirrors the difficulties, blame, and lack of dialogue prevalent
in situations of domestic violence.
Domestic Violence Exposure and Children's Behavioural Adjustment: Impact
of Maternal Depression Before and After Shelter Residence
Kelly L. Jarvis, Erin E. Gordon, and Raymond W. Novaco, University of
California, Irvine, USA
Mothers and children from domestically violent homes who have sought assistance
from a battered women's shelter in Orange County, California, were studied
in two contexts, as provided by two samples: (1) women and children currently
residing in an emergency shelter, and (2) women and children who had previously
resided in the shelter but were now living in the community. Mothers participated
in structured interviews and completed psychometric assessments of their
depression and trauma symptoms and of the child's recent behavioural functioning.
Maternal emotional health was found to be associated with maladaptive
behaviours in children, particularly with respect to older children. Maternal
depression was associated with child internalising behaviours, particularly
being withdrawn and feeling anxious or depressed; maternal trauma was
associated with more child internalising and externalising behaviours,
such as aggression. Our results suggest that efforts to intervene therapeutically
with children who have been exposed to domestic violence ought to also
address maternal emotional health. Major reductions in the subsequent
violence exposure of the clients receiving the community-based intervention
service will also be discussed.
Exploring the Nature of Motivation to Change in Two Samples of Domestic
Violence Offenders Attending CBT programmes
Erica Bowen, School of Psychology, University of Birmingham
Patient motivation for treatment has been considered to be vital to psychotherapy
progress and outcome for some time. The most frequently stated hypothesis
is that those people who are self motivated to change ie who volunteer
for treatment are the most likely to successfully alter their behaviour
in comparison to those who attend prescribed intervention. This assumption
has been fed by the development of the transtheoretical model of change
(Prochaska & DiClimente, 1985) which has identified several independent
stages of motivation to change - pre-contemplation, contemplation, action
and maintenance. The goal of treatment is to move the individual from
the position of acknowledging the problem behaviour, to actively seeking
to change the behaviour and maintaining the altered behaviour. Tools developed
to aid the identification of levels of motivation to change include the
URICA - a non-specific motivation to change tool based on the identification
of stages commensurate to those identified by the trans theoretical model
of change. Although the majority of research in this area has focused
on clinical populations, there is a rapidly expanding literature questioning
the efficacy of pro feminist cognitive-behavioural domestic violence interventions
in which arguments regarding the effect of motivation to change upon intervention
outcome are rife. Despite this, to date there is no evidence that explores
precisely differences in motivation to change between those offenders
who are court mandated, and those who volunteer for treatment. This paper
presents the preliminary findings of a study comparing the motivation
to change levels as measured by the newly developed domestic violence
specific URICA-DV (Levesque et al 2000) of domestic violence offenders
before court mandated and voluntary treatment. The URICA- DV has been
validated on a sample of court mandated batterers, but differences between
mandated and voluntary samples have yet to be explored. Results are discussed
in relation to the potential of using motivational interviewing as a pre
treatment intervention for these two groups
Emily Holmes, University College London & Ann Hackman, University
Recurrent Images: Would Mirrors Do Well to Reflect Again?
Ann Hackmann, Department of Psychiatry, University of Oxford, Warneford
Recurrent, distressing images have been noted in a number of disorders.
Clinical observation suggests that whilst these images are often present
or future orientated they generally appear to have very similar content
to memories of past upsetting experiences. Like intrusive memories in
PTSD they frequently have situational triggers, and may involve not only
the visual modality, but also other sensory modalities. They are often
accompanied by emotion, and may also involve some response components.
The person experiencing them is sometimes unaware initially of any connection
between the images and past experience. Sometimes the images are so fleeting
that although they affect emotions and behaviour they may not immediately
be noticed by the individual. However, once brought into awareness distressing
images do have face validity: to the person experiencing them they appear
to reflect reality.
In this paper consideration is given to the idea that the imagery system
provides information from memory to guide behaviour in the present. Acting
without reflection in response to such images may be adaptive to some
extent, but can also result in a lack of updating and contextualisation
of the meanings originally given to events. Other autobiographical memories
and knowledge may not be brought to bear once images are triggered. Implications
of these observations for cognitive therapy will be explored. Accessing
and reflecting on images and their meanings and origins may be a beneficial
prelude to ushering in a more realistic view, by comparing image and reality.
What Parts of a Trauma Become Images? -Examining Peri-traumatic 'Hotspots'
Emily Holmes, Sub-Department of Clinical Health Psychology, University
Why do patients with Post-traumatic Stress Disorder (PTSD) have intrusive
imagery of some moments of a trauma and not others? In exposure/reliving
therapy patients describe their trauma in detail. Within this they note
distinct 'worst moments' of intense emotional distress and reliving, known
as 'hotspots'. Examining hotspots provides information about trauma memory
and what happened at the time (peri-traumatically) at points that give
rise to images. Dual Representation Theory (Brewin, 2000) predicts in
general why intrusive images arise. That is, where conscious, verbally
accessible memory for trauma is most disrupted, sensory and emotional
memory can be triggered as images. Ehlers et al (in preparation) propose
intrusions indicate moments with greatest emotional impact. Points of
verbally accessible memory disruption could occur at the time of trauma
due to dissociation (Holmes and Brewin, 2000), and intense emotion . In
PTSD such emotions are commonly assumed to be fear, helplessness or horror.
Hotspots analysis in 8 patients illustrates a wider range of emotions
such as intense disgust, sadness and shame also occur (Grey, Holmes and
Brewin, in press). Further data will be discussed indicating the types
of cognitions and meanings associated with hotspots. These illustrate
shattering positive assumptions, and confirming prior negative beliefs
about the self (Ehlers and Clark, 2000). Reported peri-traumatic cognitions
and emotions in hotspots indicate specifically why points have high emotional
impact, and illustrate their diversity. However, it appears not all reported
hotspots in a trauma memory are linked with current intrusive images in
patients with PTSD.
The Course of Intrusive Memories During Cognitive Behavioural Treatment
Anne E.M. Speckens, Department of Psychology, Institute of Psychiatry,
Ann Hackmann, Oxford Cognitive Therapy Centre, Warneford Hospital, Oxford
Anke Ehlers, Department of Psychology, Institute of Psychiatry, London
One of the most characteristic features of post traumatic stress disorder
(PTSD) are intrusive memories. We investigated intrusive memories in 55
patients included in two different trials investigating the effectiveness
of cognitive behavioural therapy for PTSD. Patients had suffered from
different types of trauma, such as road traffic accidents, physical or
sexual assaults. They received 12 regular and 3 booster sessions of cognitive
behavioural therapy. Frequency, distress, vividness and nowness of the
intrusive memories were measured at baseline and at every treatment session.
At baseline, the mean frequency of intrusive memories was 5.6 (SD 6.1)
a week. Frequency of intrusive memories slightly increased after the first
reliving session, but steadily decreased over the number of treatment
sessions after that. According to the frequency of their intrusive memories
after reliving, patients were classified as dramatic responders, responders
and non-responders. The only variable that was related to response to
reliving was negative interpretation of symptoms. Patients who endorsed
beliefs like: "If I cannot control my thoughts and feelings about
the event I will go crazy" or "Something terrible will happen
if I do not try to control my thoughts about the event" improved
significantly more after reliving than the other patients. Response to
reliving did not seem to be related to depression, anxiety, self-blame
Compulsive Images in Post-Traumatic Reactions
Padmal de Silva, Institute of Psychiatry, London
This paper discusses the phenomenon of imagery occurring in post-traumatic
reactions, with special reference to compulsive images. Much is known
about intrusive images in post-traumatic reactions; little has been written
about compulsive images in those with a history of trauma. Data are presented
from clinical cases of post-traumatic disorder and other traumatic reactions
on the presence, and prominence, of compulsive imagery. In some, the compulsive
imagery is the predominant symptom in the domain of imagery. Comparisons
are made with compulsive images in obsessive-compulsive disorder. The
significance of this phenomenon is commented on. Some comments are also
made on treatment issues.
Do the Effects of CBT Endure? Long-term Follow-up (5-14
years) of Clinical Trials for Generalised Anxiety and Panic Disorder
Rob Durham, University of Dundee
Aims and Methodology of Long-term Follow-up of CBT Clinical Trials in
Julie Chambers, Department of Psychology, University of Stirling, &
Department of Psychiatry, University of Dundee
A 5 year project to follow-up 10 clinical trials of CBT for anxiety disorders
and psychosis in central Scotland is now at the half-way stage. The project
has been funded by the NHS Executive Health and Technology Assessment
Programme and is a collaborative venture between the Universities of Dundee
and Stirling and several NHS Trusts (Tayside Primary Care, Fife Healthcare,
Forth Valley Healthcare and Ayrshire and Arran Health Board). Extended
follow-up is needed to investigate the scope and limitations of psychological
treatment in changing the overall trajectory of mental disorders and to
clarify the relative costs and benefits of CBT in comparison with medication
and other forms of therapy. In this paper an overview of the methodology
used in the project is presented and illustrated with reference to follow-up
data from the first three trials (two on generalised anxiety disorder
and one on panic disorder with or without agoraphobia).
In summary, attempts have been made to trace all 414 patients (including
drop-outs) entered into these three trials and a total of 52% of patients
available for contact have taken part in the follow-up study. A comprehensive
picture of overall functioning at follow-up has been collected using a
combination of standardised questionnaires (including SF36 II, BSI), structured
interview (Diagnostic status, social adjustment and attitude to original
treatment) and case note review. A number of methodological issues resulting
from the lengthy period of follow-up (7-14 years in the case of the first
three trials) have arisen of which the most important concerns the degree
to which the follow-up sample is representative of the original cohort.
Extensive analysis of the characteristics of participants and non-participants
in the follow-up study has, in fact, revealed few differences although
there has been a tendency for those who had completed initial treatment
to be more likely to respond. Ethical issues concerned with obtaining
access to medical case note data which might shed light on the status
of non-participants at long-term follow-up have been actively debated
by the research team and these issues are presented for open discussion.
Long-term Follow-up of Two Clinical Trials of CBT for Generalised Anxiety
Kevin Power, Department of Psychology, University of Stirling, & Tayside
Primary Care NHS Trust
Generalised anxiety disorder (GAD) is a complex and variable condition
which typically runs a fluctuating and often chronic course associated
with heavy demands on healthcare resources. There is evidence that CBT
can be an effective treatment in the short to medium term with 50-60%
of patients achieving recovery. However, investigations of the long-term
effects of CBT in changing the course of GAD are of limited scope and
duration. Current follow-up studies consist mainly of postal questionnaire
of symptom severity over relatively short periods (6-12 months). In this
paper results are reported from an extended follow-up (8-14 years) of
two clinical trials of CBT for GAD in which self-report data were supplemented
by a structured interview with an assessor blind to initial treatment
condition. Study 1 was conducted in primary care settings in the Forth
Valley in a mixed rural and urban setting and compared Diazepam, Placebo,
CBT alone, CBT plus Diazepam and CBT plus Placebo (Power et al, 1990).
Study 2 was conducted in a psychiatric outpatient clinic in the City of
Dundee and compared cognitive therapy, analytical psychotherapy and anxiety
management training (Durham et al, 1994).
Data was collected on 55% of original Study 2 participants and 30% of
original Study 2 participants. The relatively lower figure in Study 2
was almost certainly due to the longer period of time since the original
trial and the absence of a central medical record for tracing patients.
Despite the rather low overall contact rate the follow-up samples were
broadly representative of the original cohorts. The results were broadly
consistent across measures with marked differences in outcome between
the two studies. About two thirds of Study 1 patients were substantially
recovered whereas only about one third of Study 2 patients could be categorised
in this way. Study 1 patients treated in primary care settings had less
severe and less chronic problems at the time of the initial clinical trial
and came from a more affluent area.. In contrast, Study 2 patients had
more chronic and severe problems and came from a more economically deprived
urban setting. Despite these differences the majority of patients (60-70%)
in both studies reported varying degrees of improvement over the years
with about 50% of the sample markedly improved and about 30% free of symptoms.
For a minority of patients (30-40%) overall outcome was poor with evidence
of continued disability, complex clinical presentations and moderate or
considerable dependence on medication and/or psychological treatment over
the follow-up period. In comparison with medication and analytic psychotherapy,
treatment with CBT was found to confer an advantage in terms of significantly
lowering the overall severity of symptomatology. This advantage, however,
did not affect diagnostic status or the likelihood of recovery in terms
of Jacobson criteria for clinically significant change. It is concluded
that CBT does not presently have the power to alter the long-term course
of GAD but it does have the power to make the disorder more manageable.
Long-term Follow-up of Two Clinical Trials of CBT for Panic Disorder,
With or Without Agoraphobia, in Primary Care.
Donald Sharp, Institute of Rehabilitation, School of Medicine, University
Kevin Power, Tayside Clinical Psychology Department, & Anxiety and
Stress Centre, University of Stirling
Vivien Swanson, Anxiety and Stress Centre, University of Stirling
Panic disorder, with or without agoraphobia, is a prevalent condition
which presents most commonly in the primary care setting. The disorder
places high demands on primary care treatment resources and effective
treatments are therefore of considerable clinical interest. Previous research
has shown efficacy for both psychological (usually CBT) and pharmacological
treatments. Most treatment outcome research has however shown efficacy
in the short term only with most studies reporting treatment outcome data
at 6 months to one year. The efficacy over the longer term of CBT and
pharmacological treatments for panic disorder is not well researched.
Long-term efficacy is of considerable relevance to the applicability of
such treatments in wider clinical practice. Results will be presented
for the long-term follow-up of two trials of CBT in the treatment of panic
disorder and agoraphobia in primary care. The first study comprised a
controlled comparison of the antidepressant fluvoxamine and CBT, used
alone and in combination, in the treatment of panic disorder and agoraphobia.
The second study was a controlled comparison of CBT for panic disorder
and agoraphobia delivered with standard therapist contact, minimum therapist
contact, and as a bibliotherapy. Patients were followed up between 5 and
8 years post treatment. The overall efficacy of CBT in long term follow-up
will be discussed as will the comparative efficacy of the CBT and drug
treatments. Clinical implications of the findings will be discussed.
Health Economic Analysis of the Long-term Efficacy of CBT for Anxiety
Kirsten Major, Health Economist, Ayrshire and Arran Health Board
Economic evaluation is the comparative analysis of the costs and consequences
of particular actions. As part of the long-term follow up of CBT clinical
trials in central Scotland a cost effectiveness analysis is being conducted
with a view to examining if CBT is an efficient treatment option across
a range of diagnoses when compared to alternative regimes. The measure
of effectiveness being utilised for this element of the study is the generic
health status measure, the SF36. This paper will explore the resource
implications associated with the first three trials analysed - two in
GAD and one in panic disorder - as well as draw tentative conclusions
on the cost effectiveness of CBT, based on initial findings. The method
employed has been to collect data on levels of resource use across all
health care sectors from general practitioner case notes. A deliberate
decision was made to include non mental-health services given the likelihood
of chronic use of wider health services associated with mental health
morbidity. Data have been collected for 2 years prior to initial treatment
and 2 years prior to the date of long-term follow-up. One hypothesis would
be that successful treatment of mental disorder should be associated with
a reduced need for all types of healthcare resources.
A number of factors have been raised by the analysis thus far. The first
of these is the highly positively skewed nature of the data, such that
a few individuals consume very high levels of resources, whilst the bulk
consume fairly low levels. This is problematic for economic analysis,
where there is a requirement to use means to summarise data to allow the
calculation of budgets. Novel approaches to non-parametric analysis of
means have therefore been pursued in an attempt describe the mean levels
of resource use and the uncertainty which surround these estimates. A
further complexity associated with the use of case note based measurement
and valuation of resource use is the number of imputed values due to difficulties
in accurate interpretation of items recorded in case notes. Finally, the
measurement of costs, which include the costs of original treatment, have
been compared for those receiving and not receiving CBT. The total cost
has then been compared with the SF36 as a generic measure of outcome to
assess if CBT treatments are more or less cost effective than alternatives.
The results of this interim analysis from the study will be presented.
What Influences the Long-term Outcome of Generalised Anxiety Disorder?
The Development of Prognostic Indices Based on Complexity of Presenting
Problems and Response to Original Treatment
Dr. Rob Durham, Department of Psychiatry, University of Dundee
Dr. Mike Dow, Fife Healthcare NHS Trust and University of St Andrews
Andrew Gumley, Ayrshire & Arran Primary Care NHS Trust and University
Although extended follow-up studies provide some evidence of the positive
long-term influence of CBT on the severity of generalised anxiety disorder,
it is clear that the overall course of anxiety disorders are influenced
by a number of different factors. In this paper we first describe a general
framework for conceptualising the influences on long-term outcome and
then present results from an analysis of prognostic factors within this
framework based on the cohort of patients from the central Scotland long-term
follow-up study. The conceptual framework assumes that accurate prediction
of long-term outcome requires knowledge of two sets of variables: (1)
general prognostic indicators of the overall likelihood of change irrespective
of treatment offered and (2) specific treatment response indicators of
the individual's ability to engage with, and respond to, the demands of
a particular therapy. General prognostic factors reflect the overall complexity
and severity of presenting problems. Thus, there is persuasive evidence
from both psychotherapy outcome research and epidemiological psychiatry
that greater symptom severity and comorbidity, economic adversity (chronic
indebtedness, low socio-economic status, unemployment) and social disadvantage
(absence of intimate confiding relationships, chronic social difficulties
and low support) are all associated with a poorer long-term outcome irrespective
of the effectiveness of treatment over the short-term. Treatment response
indicators, on the other hand, concern the quality of the therapeutic
alliance, the power of the treatment offered and the degree of improvement
over the course of therapy. The model assumes that general prognostic
factors will be of most influence in determining long-term outcome and
that if general prognosis is poor at the start of original treatment (i.e.
complexity and severity is high), the long-term outcome will be either
moderate (i.e. a partial recovery) if the original treatment was positive,
or poor if the original treatment was ineffective. Conversely, if general
prognostic factors are favourable then either a moderate or good outcome
is predicted depending on the effectiveness of the original treatment.
Although general in character this model does have the merit of making
testable predictions. It would be undermined, for example, by evidence
that patients who were found to have recovered at long-term follow-up
had a combination of poor prognostic factors and negative treatment response
indicators at the original treatment trial. In the second part of the
paper we present evidence on the validity of the model using logistic
regression analysis with overall outcome defined in terms of diagnostic
status and Jacobson methodology for clinically significant change. Finally,
we discuss the clinical and ethical challenges to our current treatment
technology of identifying at an early stage those referrals who are likely
to do relatively poorly. In particular, we suggest the potential value
of independent audit and clinical supervision becoming an essential part
of routine clinical work with poor prognosis patients.
The Road Less Travelled: Evaluating The Effectiveness Of
Anne Garland, Glasgow Primary Care NHS Trust.
Psychological Skills Training of Primary Care Practitioners: Report of
a pilot Project Developed by Calderdale and Kirklees Health Authority.
Project Facilitator, Frances Cole; Trainers Jo Hardy, Vicki Dutchburn
The aim of training primary care practitioners in psychological skills
was to improve the ability of primary health care team members to enable
patients to manage their own psychological problems by using specific
Primary care provides the initial assessment and further management of
90% of patients with mental health care problems. This training project
was developed around the concept of self help materials being used to
supplement therapeutic encounters by mental health workers or in consultation
in primary care. A meta-analysis of 40 self-help studies form 1974-1990
indicated that depression and anxiety are amenable to change using this
approach. Cognitive behaviour therapy is an effective treatment depression
and anxiety but is time and therapist intensive, a current problem locally
with a lack of adequately trained therapists. Cognitive behavioural approaches
using structured self help materials facilitated by trained primary care
practitioners offers an alternative approach. This approach was evaluated
in the pilot project by the Health Authority to ascertain its overall
efficacy in changing practitioner skills.
The initial evaluation results provide evidence that the project is addressing
real perceived needs by the practitioners. They have provided constructive
feedback believing firmly that this type of training should continue because
is very relevant to their practice
is structured compared to previous woolly practice
is a safe training environment which allows increase in skills
is valuable for personal development
gives skills useful in other areas of work
is helpful in working with patients with multiple problems
The evaluation assessed the skills change by practitioners before and
after training using videotape simulated consultations. There were skill
improvements in use of problem based interviewing skills, suicidal risk
assessment, negotiation skills and setting agendas. Other skill improvements
were in collaboration with the patient resulting improved relationship
building and ennoblement. Practitioners were taught to implement a cognitive
based five areas model and results indicate its successful implementation
in the simulated consultations.
Further qualitative evaluation is planned to assess the impact of skills
training on the practitioner and the outcome of use of self help materials
Three Years on the Road: But Are We Going in the Right Direction?
*Mark Latham, Department of Health Studies, University of York and Chris
Atha., Wakefield & Pontefract Community Mental Health Trust
Data from three courses will be presented, showing an evaluation of the
effectiveness of a one year part-time introductory CBT course. Measures
were taken (pre and post) of both clinical skill and knowledge levels,
and rated by two independent blind assessors. Skills were measured on
the Cognitive Therapy Scale and on the scale designed by the authors,
via a videotaped role-play of an initial assessment interview. Knowledge
was rated by means of a written questionnaire that was related to course
content. Results showed statistically significant change in both aspects,
thus indicating the effectiveness of the training.
The authors will raise several key issues in relation to their own work
and to the wider field of CBT training and clinical practice including
How can the "active ingredients" of CBT training be identified?
Which competencies should be measured in evaluating CBT training?
How can tools be developed for evaluating effectiveness of CBT training?
How can evaluation be standardised nationwide across courses?
To what extent does CBT training influence clinical practice through improving
Proposals will be put forward as an initial attempt to answer these questions.
An invitation will be made to others in the field to join an open discussion
of the important issues.
A Short Course in Cognitive Behaviour Therapy Techniques for Palliative
*Kathryn Mannix, Consultant in Palliative Medicine, Newcastle Marie Curie
Anne Garland, Nurse Director, Glasgow Primary Care NHS Trust, Ivy Blackburn,
Consultant Psychologist, Newcastle upon Tyne, Jennifer Gracie, Assistant
Psychologist, Newcastle Marie Curie Centre, Stirling Moorey, Consultant
Psychiatrist, Maudsley Hospital and Jan Scott, Professor of Psychiatry,
University of Glasgow
Psychological distress is common amongst patients with advanced illness,
with problems ranging from adjustment reactions to severe anxiety, panic
and depression. Palliative care professionals are therefore often called
upon to support patients with such psychological problems, and yet few
have received training in techniques for psychological intervention beyond
counselling training. Our study was designed to assess whether a brief
course in CBT techniques would allow palliative care professionals to
acquire skills, which they could apply to help their client group (patients
25 palliative care professionals were recruited for the study. The majority
were nurses working in the hospices or as clinical nurse specialists in
palliative care teams. The group also included 2 social workers and 2
occupational therapists. All were naïve to CBT training.
The training team comprised 2 experienced cognitive therapists with experience
of delivering CBT training (IMB & AG), a palliative care consultant
who is a trained cognitive therapist (KAM) and a consultant in CBT with
experience of delivering CBT to cancer patients (SM)
Core elements of Cognitive Theory and key techniques were identified by
the training team.
9 days equivalent training was delivered as a 3 day block followed by
12 half days at weekly intervals, with homework assignments (skills practice)
Trainees received a minimum of 3 months supervision in small groups following
their training. Thereafter they were randomised to continue or discontinue
supervision, in order to assess the effect of supervision on maintenance
Acquisition of skills was assessed using audiotapes of interviews provided
by the trainees prior to training, at the end of 12 weeks didactic training,
after 3 months with regular supervision, and 3 monthly for a further 6
months. Tapes were assessed blind by raters using a modified Cognitive
Therapy Rating Scale.
Outcomes of training will be presented and the implications for developing
structured, brief training in CBT techniques for non-mental health practitioners
will be discussed.
Practical Psychological Skills for Community Teams: Accessible CBT Skills-Based
Training Using the Overcoming Depression Format.
*Chris Williams, University of Glasgow and Anne Garland, Greater Glasgow
Primary Care NHS Trust
Specialist training in CBT often involves the practitioner completing
an expensive (in terms of time and cost) specialist postgraduate course.
After completion of such courses, 71% of practitioners alter their job
and many migrate into specialist CBT posts. The consequence is that trained
practitioners often become separated clinically from general clinical
services thus reducing the formal and informal dissemination of skills
within these settings. A second difficulty that may prevent ready dissemination
of skills to non-CBT specialists is that the traditional language of CBT
is highly technical and inaccessible to those who have not received a
similar training. This can cause problems when trying to work with patients/clients
clinically where concepts such as dysfunctional assumptions and selective
abstraction have to be "translated" as specific knowledge is
required to understand the concepts. The language used not only affects
our clinical work with patients, but also can affect the take-up of CBT
skills across health service settings within both primary and secondary
We described the development and evaluation of training courses offering
multidisciplinary team-based training in generic CBT skills for primary
and secondary based community teams. The training course of six 3-hour
sessions encourages attendees to apply what they learn in their own clinical
settings. Generalisation of the training - to ensure that training does
not become compartmentalised only within the teaching sessions - is emphasised
as is clinical supervision embedded within the training sessions.
Ashworth P, Wiliams C J, Blackburn I-M. What becomes of Cognitive Therapy
trainees? A survey of trainees' opinions and current clinical practice
after postgraduate Cognitive Therapy training.
Behavioural and Cognitive Psychotherapy, 1999, 27,3,267-277
Experiences of Palliative Care Professionals Receiving Cognitive Therapy
*Jennifer Gracie, Assistant Psychologist, Newcastle Marie Curie Centre,
Kathryn Mannix, Consultant in Palliative Medicine, Newcastle Marie Curie
Centre, Anne Garland, Nurse Director Glasgow Primary Care NHS Trust, Ivy
Blackburn, Consultant Psychologist, Newcastle upon Tyne, Stirling Moorey,
Consultant Psychiatrist, Maudsley Hospital and Jan Scott, Professor of
Psychiatry, University of Glasgow
Twenty palliative care professionals participated in teaching and supervision
in a study that investigated the efficacy of brief training in Cognitive
Therapy interventions. The experiences the participants had during the
training were illuminating, giving and insight into palliative care practitioners'
achievements and problems when applying newly learned cognitive therapy
techniques to their unique patient group. Outcome measures were administered
at three month intervals and the participants were interviewed regarding
their participation concurrently. Among the questionnaires administered
were psychometric measures of occupational stress, job satisfaction and
psychological well being. Subjective measures of job stress and satisfaction
were taken, along with qualitative information regarding the participants'
experiences of using their new skills. Their views on the teaching, supervision
and participating in the study were also reported.
Basic and Applied Issues in Eating Disorders
Glenn Waller, St georges Hospital Medical School, University of London
Bulimics' Responses to Food Cravings: Is Binge-eating a Product of Hunger
or Emotional State?
Anne Waters, Doctoral Programme in Clinical Psychology, Department of
Psychology, University of Southampton
Introduction: This study examined the roles of hunger, food craving and
mood of 15 women with bulimia nervosa. The participants used food intake
diaries and Craving Records to self-monitor their nutritional behaviour,
hunger levels and affective state.
Results: Cravings leading to a binge were associated with higher tension,
lower mood and lower hunger than those cravings not leading to a binge.
Levels of tension and hunger were the critical discriminating variables.
Conclusions: The findings of the study support empirical evidence and
models of emotional blocking in binge-eating behaviour, and challenge
the current cognitive starve-binge models of bulimia. The role of food
cravings in the emotional blocking model is discussed in terms of a classically
conditioned motivational state. Implications for treatment are addressed.
Social Anxiety and Coping Strategies in the Eating Disorders
Hendrik Hinrichsen. Eating Disorders Service, South West London and St
George's Mental Health NHS Trust, Fiona Wright, Department of Psychology,
University of Hertfordshire, Glenn Waller
Department of Psychiatry, St. George's Hospital Medical School, University
of London, Caroline Meyer, Department of Psychology, University of Warwick
Background: A range of affective states are linked to eating pathology.
There is some evidence that women with eating disorders experience high
levels of social anxiety. However, it is not clear whether this form of
anxiety pertains equally to all eating disorders, and how patients with
different eating disorders cope with social anxiety.
Method: Women with eating disorders (N = 114) and a non-clinical group
(N = 50) completed a standardized measure of social anxiety (Fear of Negative
Evaluation scale; FNE), along with measures of bulimic and dissociative
Results: The clinical group had higher levels of social anxiety than the
non-clinical group, although the binge-purge anorexia nervosa patients
scored higher than those with either restrictive anorexia nervosa or bulimia
nervosa. However, there were also differences across the groups in the
use of emotional regulation mechanisms. Among the non-clinical and the
bulimia nervosa groups, social anxiety was positively correlated with
levels of bulimic behaviours. In contrast, the restrictive anorexics showed
a correlation of social anxiety with dissociation.
Conclusions: Social anxiety is very prominent in the eating disordersin
the binge-eating episodes of bulimic patients, and identified the critical
factors involved in the processes surrounding binge-eating episodes that
Method: This was a prospective study of the binge-eating behaviour, and
merits clinical attention in such cases. However, it will be important
to understand how women with different eating disorders use different
strategies to help them cope with that affective state.
Anger and Core Beliefs in the Eating Disorders
Rhonda-Jane Milligan, Department of Psychology, Royal Holloway, University
Michelle Babbs, Eating Disorders Unit, South West London and St. George's
Mental Health NHS Trust , Caroline Meyer, Department of Psychology, University
of Warwick. Glenn Waller, Department of General Psychiatry, St. George's
Hospital Medical School, University of London
Background: Clinical and empirical research suggests a role for anger
in the eating disorders, but this relationship is not well understood.
This paper examines levels of different facets of anger in the eating
disorders, and investigates whether those aspects of anger are related
to the individual's core beliefs.
Method: A case series of 140 eating-disordered women and 50 non-clinical
women completed the State-Trait Anger Expression Inventory (STAXI) and
the short version of the Young Schema Questionnaire (YSQ-S).
Results: There were different levels of two specific forms of anger across
the groups. The women with bulimic disorders had more pathological levels
of state anger, but anger suppression was linked to both restrictive and
bulimic disorders. Among the clinical group, there were also links of
specific eating-disordered behaviours with particular aspects of anger.
While women with eating disorders had generally higher levels of unhealthy
core beliefs, those beliefs were related to a limited set of anger constructs.
Unhealthy core beliefs were strongly associated with anger suppression
in the clinical women, but not in the non-clinical group.
Conclusions: When working with the eating disorders and their constituent
behaviours, it is important to treat anger as a complex construct. In
particular, it is necessary to understand the role of state anger and
anger suppression. Treatment of anger suppression in eating-disordered
women may depend on modifying cognitions at the schema level.
Preconscious Processing: Impact on Body Percept and Concept
Glenn Waller, Department of Psychiatry, St. George's Hospital Medical
School, University of London
Background: There is considerable evidence that body image is an elastic
construct, which can be influenced by environmental and internal factors.
However, knowledge of the factors that influence this elasticity is confounded
by the demand characteristics inherent in the research paradigms that
have been used to date. To overcome this problem, the present study used
a visual subliminal processing paradigm, with the aim of determining the
impact of preconscious processing of body-related cues upon body image
(percept and concept).
Method: Forty non-clinical women were divided into those with more or
less healthy eating attitudes. They completed measures of body percept
(body size estimation) and concept (body satisfaction) before and after
being exposed to very rapid presentations of fatness and thinness cues
(the word 'fat' or 'thin', presented ten times at 4ms each).
Results: The women with relatively unhealthy eating attitudes were influenced
by the fatness stimulus, with a worsening of their body percept and concept.
In contrast, the women with healthier eating attitudes showed an improvement
in their body percept in response to the thinness stimulus, although their
body concept was not affected.
Conclusions: The findings support the centrality of body image schemata
in eating psychopathology, although there is a need for replication and
extension in clinical groups.
Family Work in the Treatment of Patients with Anorexia Nervosa
Gill Todd, Kay Gavan and Tara Murphy, Bethlem Royal Hospital, Beckenham,
This paper describes a programme of family work undertaken as part of
the treatment given to patients with anorexia nervosa in a specialist
eating disorders service. The family work is a specific element in a multi-faceted
in-patient treatment programme. The rationale for this work is the recognition
that family attitudes and conflicts play an important part in the maintenance
of anorexia nervosa, and that family members need advice, guidance and
support. We describe a trial where some of the families are seen on their
own, and other families are seen in groups of two or three families. The
same therapeutic principles are used for both groups. The allocation is
random. Four therapists are involved in the treatment. Therapy time is
held equal across the families. Outcome measures include the patient's
clinical state at the end of therapy and at follow-up, and changes in
family attitudes and reactions.
The paper describes the rationale and the implementation of this programme;
it also supports preliminary results. Issues arising in such family interventions
are also discussed.
Issues of Cognition and Emotion
Gary Brown, Salomons Centre, Tunbridge Wells, Kent
Distinguishing Depression from Dementia in Later Life: Performance on
the Emotional Stroop task.
Robert Dudley1 John O'Brien2 Nichola Barnett2 Liz McGuckin2 Peter Britton3
1 Newcastle Cognitive and Behavioural Therapies Centre, Newcastle.
2 Wolfson Unit, Centre for the Health of the Elderly, Newcastle
5. Department of Clinical Psychology, University of Newcastle.
Objectives: In later life, cognitive impairment is common in depression
often making it difficult to distinguish a dementing illness from depression.
We examined whether people with depression could be differentiated from
those with dementia on their performance on a task that examines attentional
bias to depression related material. Methods: Twelve older adults who
fulfilled DSM-IV criteria for major depression were compared with 12 people
with Alzheimer's Disease and 12 age matched controls on a test of cognitive
biases: the emotional Stroop task. In this task participants were presented
with words written in different coloured inks, and they had to name the
colour the word was written in. Four types of material were presented
Neutral, Positive, and Negative emotion words as well as a condition of
meaningless symbols. Results: People with depression and those with Alzhiemer's
disease were both slower than the controls on the task generally. However,
the depressed group alone showed a statistically significant and specific
increase in response time when colour naming the negative emotion words.
The other two groups did not demonstrate such a pattern and colour named
neutral, positive and negative words equally quickly. Conclusions: The
biased processing of depression related material may have a valuable role
in distinguishing depression from dementia in later life. Although the
emotional stroop in its present form is not sufficient for such a purpose.
Furthermore, the demonstration that older adults with depression exhibit
such biases helps provide a theoretical basis for the application of cognitive
behavioural treatments with older adults.
Stimulus Generalisation in Social Phobics and Healthy Controls
Antje Horsch, University of Oxford, Department of Psychiatry, Warneford
Christiane Hermann, Department of Neuropsychology, Central Institute of
Mental Health, Mannheim, Germany
Despite the significance of conditioning models that aim to explain the
etiology of phobias, there has been a great deal of criticism regarding
their inability to explain why and how conditioned fear responses are
generalised from the original traumatic situation to other similar situations.
The aim of the present study was to test the generalisation of a conditioned
fear response by comparing generalisation gradients of 20 social phobics
(generalised subtype) and 20 healthy controls when confronted with fear-relevant
or fear-irrelevant stimuli. The aversive classical conditioning experiment
consisted of two phases. During the first phase (differential conditioning),
the participants learned to discriminate between the conditioned excitatory
stimulus (CS+) and the conditioned inhibitory stimulus (CS-): CS+ was
followed by the presence of a mildly aversive electric shock (UCS), while
CS- served as a safety signal through the absence of such a shock (no
aversive UCS). During the second phase (generalisation test) individual
generalisation gradients were obtained. Seven similar pictures, which
differed from the original conditioned stimulus in only one specific feature,
were presented to each subject along with the CS+ and CS-, and subjects
were again asked to predict the outcome (presence or absence of mild electric
shock). Our findings provide evidence that the learning of a fear-relevant
conditioned inhibitory stimulus as a safety signal is delayed in anxiety
patients. Moreover, they suggest that social phobics show a greater tendency
to generalise the conditioned fear response towards stimuli that share
similar features with the original traumatic stimulus, thus contributing
to the development and maintenance of social phobia.
'It Has to Be Perfect': Anxiety Attitude and Belief Scale Factor structure,
Psychometric Properties and Validity in an Anxious Population
Nick Hawkes, Department of Psychology, Birkbeck College, University of
London, UK, Gary Brown, Salomons: Cantebury Christchurch University College,
UK and Anne Richards, Department of Psychology, Birkbeck College, University
of London, UK
The Anxiety Attitude and Belief Scale (AABS; Brown et al, 2000) aims to
index a stable, long-term, cognitive vulnerability to anxiety and anxiety
disorders. Its factor structure and psychometric properties were examined
in a sample of anxious people (N=108). An exploratory factor analysis
identified three theoretically interesting factors: external catastrophising,
vigilance-avoidance and internal catastrophising. The internal reliability
of the scale and its factors were high. The AABS predicted scores on measures
of psychiatric distress, anxiety and insomnia (GHQ28; Goldberg and Hillier,
1979) and negative affect (PANAS; Watson et al, 1988), adding incrementally
to information from a measure of Anxiety Sensitivity (ASI-R; Taylor and
Cox, 1998). The AABS internal catastrophising factor was closely related
to the ASI-R. Qualitative data from the sample, based on first hand experience
of significant anxiety, was used to suggest future improvements to the
"I Have to Wash Until it Feels Right.' An Experimental Study Investigating
the Use of Inappropriate StoppingCcriteria in Obsessional Washers.
Karina Wahl, University of London; Paul Salkovskis, PhD, University of
London; Imogen Cotter, D.Clin. Psych, University of Oxford
Recent modifications of CBT suggest that obsessional clients might rely
on inappropriate stopping criteria in order to decide when to stop a compulsive
action. These criteria are believed to be at least partly responsible
for the repetitiveness and prolongation of a compulsion. A previous study
from our group had found that obsessional washers were more likely to
use subjective criteria in the decision to stop a hand wash compared to
a group of non-washing obsessionals and non-clinical controls who used
more external criteria. The obsessional washers also considered a greater
number of criteria before they reached a decision and the decision making
process required more conscious control compared to the control groups.
The current study investigates whether the use of inappropriate stopping
criteria can be observed during an experimental hand wash and whether
the criteria are linked to the length of the hand wash. 40 obsessional
hand washers, 40 non-washing obsessionals and 40 non-clinical controls
were asked to wash their hands in one of two conditions: after covering
their hands in floor wax that allegedly comes from a) an old tin that
has been used in a hospital or b) a brand new tin. The use of inappropriate
criteria was expected to be more prominent in the 'hospital condition'
with the greatest effect for the obsessional washers. Results are presented
A Cognitive-Emotional Model of Desire
David J. Kavanagh, Department of Psychiatry, University of Queensland,
Jackie Andrade and Jon May, Department of Psychology , University of Sheffield
Recent mode1s of craving still do not account for the full range of empirical
data. A general model of motivation and desire is described, in which
two types of appetitive cognitions are distinguished: intrusive thoughts
and elaborations. Intrusive thoughts are fleeting and require few cognitive
resources, and represent the usual gateway to desire cognitions. Elaborative
processing typically involves the construction of appetitive: images.
Both types of thought increase the probability of subsequent consumption,
but they operate within a causal model with additionalfactors including
other incentives, coping skills, self-efficacy and target availability
. Both intrusivethoughts and elaboration are initially pleasurable, but
delay in consumption makes them aversive. Attempted suppression of desire-related
thoughts increases their intrusive quality. The paper briefly illustrates
how the model accounts for existing research and offers new opportunities
Analogies, Stories, Metaphors: Tools for Clinicians
Margret Hovanec, Private Practice, Toronto Canada
All of us use unique metaphors, stories, images and analogies in psychotherapy.
In this Roundtable, experienced clinicians will share the interesting
and amusing tools they have found helpful in clinical work. Clinicians
in the audience will be encourage to offer their own experiences with
analogies, stories and metaphors.
Metaphor and Meaning.
Gillian Butler, Department of Psychology, Warneford Hospital, Oxford.
Metaphors can provide an extremely efficient way of encapsulating meanings.
The way that they work enables therapists to use them in many different
ways. Working with people with long term, complex difficulties, most of
whom have suffered abusive experiences in childhood, I have found that
metaphors can be helpful at many different stages of therapy: when helping
people to talk about painful, avoided, memories; when putting together
a formulation so as to apply the theory to the case; when developing an
understanding of processes that maintain problems or reactions to problems,
and in the many other aspects of therapy that focus more specifically
on bringing about change. Illustrations of the metaphors used with this
client group will be provided with the aim of helping us to think more
clearly about how we use metaphor, and to raise questions about how it
works, or does not work.
Metaphor, anecdote and analogy in the treatment of obsessive-compulsive
Norma Morrison, Oxford Cognitive Therapy Centre.
Central to the cognitive-behavioural approach to the treatment of obsessive-compulsive
disorder is the need to target the individual's appraisal of the intrusive
thoughts rather than the thoughts themselves. These appraisals are based
on the patient's particular interpretation of what the occurrence and
content of these thoughts mean to them and on their background assumptions
about responsibility, need for control and overestimation of danger. As
these assumptions and appraisals are often longstanding and firmly held,
it is useful to have some extra tools to help the patient see them from
a new perspective. Metaphors, anecdotes and the use of humour can provide
these tools which facilitate a new perspective, make therapy more understandable
and increase the likelihood of the patient remembering important information.
Ways of using these to demonstrate how the strategies used to cope with
the problem actually maintain it and to help modify appraisals and assumptions
will be discussed.
Using Stories, Metaphors, Pictures and Music to work with Core Beliefs
and Assumptions in Cognitive Therapy.
Ann Hackmann, University Department of Psychiatry, Oxford
Verbal discussion and behavioural experiments can be helpful when working
with core beliefs and assumptions. However, where these are strongly entrenched
it may be difficult to bring about cognitive change accompanied by a real
shift in affect and meaning. Experiential tools such as stories and metaphors
can tap into meaning at the implicational level, and suggest new perspectives
to the patient. This can help develop a meta-perspective from which individuals
can reflect on their problems. Examples of the use of such material in
cognitive therapy for people with long standing interpersonal issues will
be provided in this presentation
Listening to Rumours and Gossip: Information Processing in Anxiety Disorders
Margret Hovanec Private practice, Toronto, Canada
Many people have a vicarious attachment to listening to rumours and gossip.
Whether they gather bits and pieces of information from friends or tabloids
they combine fragments into plausible but frequently sensational and false
This presentation poses the possibility that patients with anxiety disorders
are analogous to people engaged in gossip gathering. Specifically with
regard to health anxiety, patients are inclined to listen to their bodies
and symptoms and reach the same conclusions that those who listen for
the sensational in unrelated pieces of information. If the cardinal feature
of anxiety is believing in mis-information, then people suffering from
anxiety disorders can be seen to listening to their bodies looking for
ominous, reinforcing signs of sensational diseases and conditions.
Differences in rumours and gossip will be explored.
Spontaneous Therapeutic Analogies
Lorna Tener, Private practice, Ottawa, Canada and Margret Hovanec, Private
Practice, Toronto, Canada
Spontaneous analogies are a creative and useful way of deepening understanding
and improving alliance at many points in therapy. For example, patients
frequently bring to sessions information about themselves or their predicaments
that they don't fully understand. The therapist can improve the richness
of the summary or feedback to such patients by creating analogies, drawn
from traditional or contemporary sources, from the patient's areas of
expertise, or from the therapist's imagination. This presentation will
illustrate the use of analogies to facilitate case conceptualization,
goal setting, accessing automatic thoughts, challenging dysfunctional
thinking, constructing & evaluating behavioural experiments, and teaching
factual knowledge. The use of analogies may be a helpful skill to teach
patients as well as supervisees. The examples described here are intended
to "prime the pump" and lead to contributions from the audience.
Children and ADHD, Alternatives to Amphetamines
In Memory of Professor Stephen Baldwin
ADHD is the most frequently diagnosed disorder of childhood (Kazdin 1999),
Despite 100 years of clinical investigation and research there are few
outright solutions to the problems of hyperactivity and impulsivity in
children. Practitioners in the field need a clear direction with the provision
of proven effective treatment. This roundtable aims to provide practitioners
with at least two effective alternatives to amphetamine therapy for children/teenagers
with ADHD, Roundtable participants are encouraged to plan and provide
more ideal solutions to ADHD in their own locality,
The roundtable will include reviews of effectiveness of chemical treatments
for ADHD; the MTA study, Patterson's social learning approach (1971) and
Stein's Caregiver Skills Program (1999).
Supervision in Cognitive-behaviour Therapy: Who, What and How?
Mark Freeston, Director of Training and Research, Newcastle Cognitive
and Behavioural Therapies Centre and University of Newcastle
The current popularity of cognitive-behaviour therapy among clinicians
and government initiatives that increase the demand for CBT among management
has created an unprecedented demand for supervision. With the number of
courses, both short and long, springing up all over the UK, and growing
demand for CBT input to various training initiatives such as PSI, there
is an increasing pressure on the capability to deliver supervision. Compared
to the ever-increasing literature on CBT for a wide variety of disorders,
there is very little written on supervision in CBT. This roundtable addresses
the question of supervision from a number of perspectives. The first part
of the round table will allow speakers to present briefly from each of
the perspectives. The second half will invite discussion involving panel
members and the audience.
Current Supervision Practice Among BABCP Accredited Therapists.
Michael Townend, Assistant Programme Director, Community Mental Health,
University of Birmingham
This paper will report on a national survey of supervision practice among
BABCP accredited therapists. The survey addresses who currently receives
supervision, from whom they receive it, the nature of the supervision
they receive, and whether dual relationships interfere with supervision.
Anni Telford, Head of Counselling & Psychotherapy, University of Derby
This paper will address formal supervisor training, an endeavour that
provides as many challenges as training therapists themselves. The training
is based on the idea that supervisors must work from a supervisory framework
rather than simply adopting strategies from the CB model. As a group of
people who perceive themselves as expert practitioners, supervisors must
understand organisational influences on both themselves and trainees,
negotiate different relationship skills from those employed in therapy,
and identify and respond to different levels of supervisee competence
Organising Internal Supervisor and Accreditation.
Joe Findlay, North Tyneside, and Northumberland NHS Mental Health Trust
This presentation will report on experiences in meeting the challenges
of rapidly expanding CBT services within the former Northumberland MHT.
The Trust greatly increased the number of CBT-trained staff both at foundation
and advanced level over the last 8 years and plans are for further expansion.
Supervision during and following training has been a priority. The results
of planning on organisational issues and internal accreditation of supervisors
will be discussed.
Who Supervises the Supervisors?
Peter Armstrong. Clinical Nurse Specialist, Newcastle Cognitive and Behavioural
This paper will address the particular challenges of supervision that
may arise for experienced CBT therapists, most of whom are in fact themselves
supervisors. Although supervision models are clearer when there is a substantial
experience gap between the supervisor and the supervisee, it is less clear
what are the appropriate models when there is little gap. Based on a series
of in house discussions at the NCBTC, common problems and potential solutions
will be discussed.
Supervision in CBT: The Whys and Wherefores?
Melanie Fennell, University of Oxford
This presentation will consider some fundamental questions about supervision
in cognitive behaviour therapy. What is the purpose of supervision? What
should cognitive therapy supervisors be aiming to achieve? How can supervision
enhance learning by echoing the empirical collaboration that is at the
heart of cognitive therapy? What makes a good cognitive therapy supervisor?
Voluntary Self-regulation or Statutory Registration:
What Does it Mean for You?
This session will include two short presentations by Chris Williams (President-Elect
of BABCP and BABCP's representative on the Alderdice Advisory committee)
and Francis Lillie (Chair of the UKCP sub-committee and on the Governing
Board of UKCP). The session will provide an update on definite moves by
the Government towards the regulation of Psychotherapy and Counselling,
and offer you the opportunity to discuss the issues involved. In addition,
Amanda Cole, Chair of the BABCP Accreditation and Registration sub-committee
will be available to discuss current accreditation arrangement, and moves
towards the voluntary registration of clinical supervisors.
Cognitive Therapy and the Elderly. What is the State of the Evidence
and What Awaits Investigation?
Paul L Merrick, Massey University at Albany, Auckland, New Zealand
As with other age cohorts, Cognitive Therapy has begun to look promising
as an efficacious psychological treatment for a number of disorders in
older people. Investigations in the 80's provided a platform for a series
of controlled studies, that promised positive outcomes for mild to moderately,
depressed elderly. A smaller body of evidence also suggests that, as with
younger people, Cognitive Therapy may be helpful in the management of
some anxiety disorders.
This paper will briefly canvass the evidence in support of Cognitive Therapy
as a useful therapeutic approach in the management of mood and anxiety
disorders in the elderly. Reasons for the relative paucity of findings
in the past 10 years with this age group despite the projected large growth
in client numbers will be explored and directions for future research
will be raised. Finally the importance of incorporating modifications
in treatment delivery and research for this age group will be highlighted.
A Group Rehabilitation Approach to Chronic Fatigue Syndrome
Vanessa Russell, Christine Atkinson, Bob Lewin, Andrea Gaston, Peter Campion,
Hull and East Riding Community Health NHS Trust, Department of Psychology,
Victoria House, Park Street, Hull, HU2 8TD.
Chronic Fatigue Syndrome (CFS) is characterised by prolonged disabling
fatigue of at least 6 months duration for which no medical explanation
can be given. This fatigue is exacerbated by once tolerated physical activity
and affects both physical and mental function. It is usually associated
with a range of other difficulties, which may include sleep disturbance,
painful limbs and joints, sore throat and headaches. Research also suggests
considerable overlap between CFS and anxiety and depression (Chalder et
al 1996). A number of research studies have examined the efficacy of cognitive
behavioural approaches in the management of CFS, with mixed results. Three
randomised controlled trails have found beneficial effects of using the
cognitive behavioural approach (e.g. Sharpe et al 1996; Deale et al 1997;
Fulcher and White 1997) whilst two have shown no benefit (Lloyd et al
1993; Friedberg and Krupp 1994). Chalder et al (1997) have demonstrated
the efficacy of a self-help approach to the management of CFS. They found
that the provision of a self-help booklet with a cognitive behavioural
emphasis and specific advice from a research nurse was more effective
than no treatment in improving fatigue and psychological distress. There
are limited references in the literature concerning the evaluation of
group approaches in the management of CFS. Pemberton et al (1994) described
a group rehabilitation approach, which was not based on a particular theory
but focused on helping patients overcome dysfunctional behaviours and
the personal consequences of CFS. They cite the power of group facilitation
as a positive aspect for people with CFS. This paper reports the initial
findings of a multi-disciplinary group rehabilitation approach to the
management of CFS. The group entails the use of cognitive-behavioural
approaches, including graded resumption of physical and mental tasks and
the challenging of attitudes that may reduce the likelihood of recovery.
Measures used include the Fatigue Scale (Chalder et al 1992), Handicap
Scale (Harwood et al 1994), Automatic Thoughts Questionnaires (Hollon
and Kendall 1980, Ingram and Wisnicki 1988) and the HAD (Zigmond and Snaith
1988). A cross-over design is employed to allow comparisons between groups
who are on the waiting list with those already involved in the rehabilitation
group. One year follow up data is also reported.
Cognitive Style of Depression
Viktoras Keturakis , Department of Clinical and Social Psychology,Vilnius
Cognitive style concept yielded big amount of research and publications.
Clinical view of depression appeared to be non-homogeneous cognitively
Cognitive style may be applied differentiating depressive client cognitively
employing concept of field dependency and checking the hypothesis against
recognized notion of attribution style. 114 subjects participated at the
research, 59 from control group and 55 experimental(depression) group.
There were used Raven Progressive Matrices test to control eductive ability
variable, Group Embedded Figures Test, House-Tree-Person drawing test
plus cognitive style scoring system, Attribution Style Questionnaire,
Sociotropy-Autonomy-Scale. Preliminary analysis conform the hypothesis
of heterogeneity of depression along the dimension of field dependency.
Negative attribution style relates more prominently and significantly
to depression than Positive attribution style. Field dependency is not
related with eductive ability when comparing among depression and control
groups. Cognitive style being heterogenic concept cannot be related linearly
to occurrence of depression. So we can distinguish field dependent and
field mindependent styles present in the depression.
Effect of Cognitive-behavioral Therapy on the Delusion in Patients with
Young-Chul Chung, M.D.,* Jae-Hyun Kim, M.D.,** Hong-Bae Eun, M.D.,* Ik-Keun
*Department of Psychiatry, School of Medicine, Chonbuk National University,
**Department of Neuropsychiatry, School of Medicine, Wonkwang National
University, Iksan, Korea
Objective: The effect of cognitive-behavioral therapy on the delusion
in patients with schizophrenia was evaluated. Method: The patients admitted
to psychiatric ward from September 1999 to June 2000 and diagnosed as
schizophrenia, schizophreniform disorder, and schizoaffective disorder
by DSM-IV were randomly assigned to cognitive-behavioral therapy group(n=9)
and supportive psychotherapy group(n=8). During the 10 weeks' therapeutic
period, conviction, preoccupation, and anxiety of delusion, explanatory
mode about symptom, and recovery style were regularly measured and compared
between the study groups. Results: 1) As for conviction and anxiety of
delusion, both groups showed gradual reduction over time but there was
no significant difference between the two groups. 2) As for preoccupation
of delusion, both groups showed gradual reduction over time and CBT group
had a significant reduction compared to ST group. 3) As for explanatory
mode and recovery style, CBT group had more marked positive changes compared
to ST group. Conclusion: Cognitive-behavioral therapy is effective on
preoccupation of delusion, explanatory mode about symptom, and recovery
style compared to supportive psychotherapy.
Clients' Perspectives of Change Processes in Cognitive Therapy
Helen Clarke, Anne Rees, & Gillian Hardy, University of Leeds and
Leeds Mental Health and Community NHS Trust
There is substantial evidence demonstrating the usefulness of cognitive
therapy for depression. However there has been little attention given
to clients' experiences of therapy, and how clients' might help understand
the processes through which therapeutic change is achieved. The present
study reports on the analyses of five end-of-therapy evaluation interviews
with clients who had received between 12 and 20 sessions of cognitive
therapy for depression. One client was selected from each of the therapists
working at a jointly managed health service and university research clinic.
All clients achieved reliable clinical change on the Beck Depression Inventory
at the end of treatment.
Clients were interviewed using the Client Change Interview approximately
two weeks after the
end of therapy. The Client Change Interview is a semi-structured interview
and assesses three aspects of the clients' experience of therapy: a) changes
perceived by client s that have occurred over the course of therapy; b)
clients' understanding of the sources of these changes, including helpful
aspects of therapy; c) hindering or difficult aspects of therapy. The
interviews were transcribed and then analysed using Grounded Theory analysis.
Three categories emerged concerning changes clients attributed to therapy.
Observable Changes and were often changes that other people had commented
statements include 'Everyone says how much better I look' and 'My mother
sees a massive difference in my behaviour'. The second category comprised
Cognitive Changes noted by clients: 'I've altered my attitude towards
myself, and '1 internalise everything less'. The final category! "
comprised statements such as '1 feel easier with myself as though I don't
have so much to carry' and is summarised in the statement 'Letting Go
of the Illusion of Control'.
Clients descriptions of how they thought therapy had helped formed two
core categories, and
included difficult aspects as well as positive aspects of therapy. The
first comprised the Big Idea and included categories of CT techniques
( 'The one I'm still using is the thought diary'), ('..that one little
model stayed in my head throughout'), testing things out ('Work that I
between sessions was just as productive'), and patterns or core beliefs('
A realisation within
myself.of my old beliefs').
The second core category was labelled General Therapeutic Principles.
These principles included Resistance ('1 was a bit dubious at first because
I didn't trust the methods'), Engagement (Being sort of excited, and I
got very into it'), and ~ ('1 never felt that she switched off once, I
always felt she was listening').
This study highlights clients awareness of the importance of both specific
and non-specific therapeutic factors that promote client change. One case
is presented in detail as an example of a client's view of the change
process. Interestingly the changes the client describes map onto the levels
of change described in the assimilation model.
POSTER SESSION 1
A Social Skills Group for Children: The Importance of Liaison with Parents,
Teachers and Professionals
Estelle Macdonald, Uttom Chowdhury, Jackie Dabney, Miranda Wolpert and
Samuel Stein Bedfordshire and Luton Community NHS Trust
Due to a recent increase in referrals of children with numerous social
communication difficulties the trust decided to set up groups, using a
cognitive behavioural framework, to teach children and adolescents various
forms of social skills. We describe one particular group and highlight
the importance of liaison with professionals and parents to ensure that
adequate transfer of skills takes place.
Seven children (5 boys and 2 girls) were referred to the group. Their
parents were invited to a parallel parents group. Each group lasted for
90 minutes and ran weekly for six weeks. Teaching of social skills was
based on cognitive behavioural techniques. Extensive liaison with parents
and teachers took part before, during and after the group in the form
of meetings, telephone calls, letters and homework given to the children.
Pre and post group questionnaires were sent to parents and teachers for
evaluation purposes. Qualitative analysis of the results indicated that
parents valued the on-going dialogue with professionals and often felt
understood and supported by therapeutic professionals for the first time.
Therapists' contact with teachers ensured a complete picture of the child's
behaviour was obtained and that some of the skills learnt were transferred
to the school setting. We, thus, argue that the use of cognitive behavioural
techniques with children undergoing group work requires an intensive level
of liaison in order to facilitate generalisation of skills learnt.
The Prediction of Delusional Ideation In College Students
Yoshihiko Tanno, Sachiko Morimoto and Shinji Sakamoto 1) Department of
Life Sciences (Psychology), Graduate School of Arts and Sciences, The
University of Tokyo, JAPAN. 2) Department of Human Relations, Otsuma Women's
The purpose of the present study is to test the diathesis-stress model
of delusional ideation in college students and to predict the development
of delusional ideation. The diathesis-stress model is a popular model
in the study of the development of psychopathologies, such as schizophrenia
and depression. People with a strong diathesis are more likely to show
symptoms of psychopathology than those with a weak diathesis, when they
Questionnaires were administered to college students three times, at fortnightly
intervals, in a longitudinal study design. At time 1, diatheses of persecution
ideation were assessed using 18 subscales. The subscales were selected
from the Self-As-Target Bias Questionnaire (Fenigstein, 1984), Paranoia/
Suspiciousness Questionnaire (PSQ; Rawlings & Freeman, 1996), Auditory
Hallucination Experiences Scale (AHES; Tanno, Ishigaki & Morimoto,
1998) and Evaluative Beliefs Scale (Chadwick, Birchwood & Trower,
1996). At time 2, persecution ideation was assessed. At time 3, persecution
ideation and stressors experienced between time 2 and time 3 were assessed.
Persecution ideation was measured using the Persecution Ideation Scale
(Tanno, Ishigaki & Sugiura, 2000) in which an example item was "Thoughts
that someone may intend to entrap me." Stressors were measured using
the College Life Experience Scale (Hisada & Niwa, 1987).
The data from 117 college students were analysed. A set-wise hierarchical
multiple regression analysis (Cohen & Cohen, 1983) was used which
could predict the change in persecution ideation between time 2 and time
3. This prospective research design allows us to analyse the causality
of persecution ideation and diathesis.
A set-wise hierarchical multiple regression analysis showed significant
interactions between stressors and four diathesis subscales: a) subscale
of Anger/Impulsiveness in the PSQ, b) subscale of Resentment/Perceived
Hardship in the PSQ, c) subscale of Auditory Illusion in the AHES, and
d) subscale of Hearing Negative Voices in the AHES. These interactions
could significantly predict the increase of persecution ideation from
time 2 to time 3. The direction and form of the interactions were in keeping
with the diathesis-stress model.
The present results predict that students who have high scores for these
four diatheses will show increased persecution ideation when they encounter
stressors. Where the development of delusional ideation is predicted,
we may be able to prevent the high-score students' increase in persecution
ideation by using psycho-education methods.
Use of Millon's MCMI-III to Assess Frequency of Personality Disorder in
Referrals to a Primary Care Clinical Psychology Service: Impact on Treatment
Process and Outcome
Steven Jones,University of Manchester, Academic Division of Clinical Psychology,
Graham Tate, Barry Fowler and Amy Tattersall, Laurence Burns Unit, Birch
Hill Hospital, Rochdale
149 people routinely referred to a primary care clinical psychology service
for cognitive behaviour therapy were asked to complete Millon's MCMI-III
(1997). Although none of the GP referrals cited personality disorder as
a primary problem, 57% met Millon's criteria for at least one personality
disorder and 31% met criteria for two or more. In terms of the three personality
clusters used by DSM-IV (American Psychiatric Association, 1994), 34.5%
were 'anxious-fearful', 18% 'dramatic-erratic' and 11.5% 'odd-eccentric'.
These figures are at least suggestive that significant levels of personality
disorder exist in routine caseloads of clinical psychologists working
in primary care. In addition, following Millon's classification, 16% of
the sample met criteria for one of the three 'severe personality disorder
scales' (schizotypal, borderline or paranoid).
A clinician's questionnaire was also developed which assessed a number
of clinical process and outcome variables as well as clinician's opinion
as to whether each patient had a personality disorder. Results indicated
a significant association between MCMI-III and clinician detection of
personality disorder, although this association was weaker when individual
personality disorder categories were considered. 11 out of the 14 personality
styles assessed by MCMI-III were associated with significant difficulties
with therapy process and outcome.
The Treatment of Comorbid Anxiety Disorders in a Patient with a Diagnosis
of Schizophrenia and the Effect of this Treatment on Psychotic Symptoms:
A Case Study
John Good, Severn NHS Trust, Gloucester.
It is well known that anxiety disorders frequently exist comorbidly with
psychotic disorders but are rarely diagnosed or treated. Stress vulnerability
models are one possible explanation for the link between these disorders,
suggesting that stress can push a person beyond their threshold for the
experience of psychotic symptoms. If this is the case, it is suggested
that the presence of comorbid anxiety disorders could provide the necessary
stressors. Treatment of these stressors should then lead to a reduction
in psychotic symptoms. The case study presented here concerns the treatment
of agoraphobia and social phobia in a patient with residual psychotic
symptoms. These symptoms consisted of hearing voices referring to his
illness and experiencing his thoughts being read and reading the thoughts
of others. These symptoms were not dealt with directly during therapy.
Treatment consisted of CBT and an exposure programme for the agoraphobia
and CBT for social phobia. This resulted in a reduction in both of these
phobias as measured by the Fear Questionnaire and an elimination of the
psychotic symptoms as measured by the KGV Symptom Scale.
More research is needed in this area but this case study would seem to
uphold the stress vulnerability models and suggest that treatment of comorbid
anxiety disorders may have a profound effect on psychotic symptoms in
at least some individuals.
The Role of Case Formulation in Therapeutic Change
Penny Stevens, Lakeside Counselling and Psychotherapy Service, Lakeside
Surgery, Corby, Northants.
Aspects of the process of case formulation are considered with reference
to the literature relating to the research theme of how the process of
case formulation may facilitate therapeutic change. A comparison between
case formulation and diagnosis suggests limitations of diagnosis. Aspects
of the role of case formulation in the mechanisms of cognitive change,
and in the establishment and maintenance of the therapeutic relationship
are explored. Case formulation is argued to offer advantages with regard
to positive therapy outcome by providing opportunities for understanding
the problem, for motivation towards engagement in therapy, collaboration,
empowerment of the client, providing a rationale for therapeutic strategy,
and for constructive ending of therapy with guidelines for relapse prevention.
Evidence from the literature is presented which points to a number of
ways in which the process of case formulation may operate to facilitate
therapeutic change. These appear to comprise three main interrelated areas:
(1) the individuality of the case formulation (2) the function of the
case formulation and (3) the process of the development and updating of
the case formulation.
The importance of the appropriate management of the balance of power within
the therapeutic relationship during the process of the development of
the case formulation is considered with regard to its potential to motivate
the engagement of the client in therapy and to promote empowerment of
the client, and thereby initiate therapeutic change.
The implications for clinical practice, the training of therapists, and
for further research are discussed.
Sudden Gains in Cognitive Therapy
Jane Cahill, Gillian Hardy, Caroline Massey, David Shapiro, Anne Rees,
Michael Barkham, Norman MacGaskill, University of Leeds, Psychological
Therapies Research Centre
Sudden gains in therapy is an important phenomenon that may enable us
to progress our understanding of client change processes and enhance therapy
outcome. Tang and DeRubeis ( 1999), using data from two efficacy studies,
found that 29 out of 61 clients experienced sudden gains between single
sessions of cognitive-behavioural therapy (CBT). These clients enjoyed
superior outcomes post-treatment and at 18 month follow up to non-sudden
gainers. The authors set out to establish if this phenomenon exists more
generally. The object of the study therefore was to attempt to replicate
Tang and DeRubeis' findings using data from a study carried out in an
NHS service within a University/NHS collaborative environment, using usual
referral routes for clients and involving NHS therapists with regular
The authors followed the procedure and terminology of Tang and DeRubeis
( 1999) to identify between sessions sudden gains. The criteria were as
follows: 1) the gain had to be at least 7 BDI points between two consecutive
BDIs; 2) the gain represented at least 25% of the pregain session BDI
score; 3) the mean BDI score of the three therapy sessions before the
gain was significantly higher than the mean BDI score of the three therapy
sessions following the gain. In addition, the
authors followed Tang and DeRubeis in identifying "reversals"
which indicate a significant increase in depressive symptoms and significantly
impact on therapy outcome. Reversals were defined as whenever a client
gave up 50% of their symptom improvement resulting from the "sudden
gain". This sample comprised 62 clients who were offered at least
12 sessions of cognitive therapy. Twenty-two of the 62 clients experienced
at least one sudden gain during therapy. The median 50% of sudden gains
occurred between session 4 and 10, with the 4th session being the mode
and the 5th session being the median pregain session. Of those 22 clients
who experienced sudden gains during therapy, 9 clients experienced a reversal
before the end of therapy, more than the 4 reported in Tang & DeRubeis
On average sudden gainers dropped 20.82 BDI points (SD = 8.50) during
therapy. The mean total decrease in BDI points across therapy for the
whole group was 13.56 (SD = 11.69). To compare the outcomes of sudden
gainers and non-sudden gainers the BDI before the last therapy session
was used. Sudden gainers presented with a significantly lower BDI pre
final session than non-sudden gainers (p < .05). On the follow-up data
currently available, there is a non significant trend for sudden gainers
to be doing better at 4 month follow up than non-sudden gainers. When
non-completers were removed from the analysis, there were no significant
differences in outcomes between sudden gainers and non-sudden gainers.
However, there was still a non- significant trend (p = .094) for sudden
gainers to be doing better pre-final session, suggesting that the relationship
between sudden gains and improved therapy outcome is not spurious.
Therapist Competence as a Predictor of Outcome in the Cognitive Therapy
Chris Trepka, Anne Rees, David Shapiro, & Gillian Hardy, Bradford
Community Health NHS Trust, Leeds University
Therapy process measures can show how well therapy is being performed,
as well as providing a means of monitoring the progress of therapists
learning new or more advanced techniques. Unfortunately there is a lack
of well-developed process measures specific to cognitive therapy.
The Cognitive Therapy Scale (CTS) is the only established measure of how
competently cognitive therapy is carried out by therapists. Although the
CTS has been used widely in cognitive therapy training centres there is
little published data on its validity . The only substantial study of
the relationship of cognitive therapy competence and outcome found only
support for such an association. It seems inconceivable that therapist
competence should not beclearly related to clinical outcome, but the relationship
may be easily obscured, for instance by other factors affecting outcome
or if there are only small differences in competence between therapists.
In this study an external expert rater used the CTS to rate audiotapes
of one randomly selected therapy session from each of 30 clients. Clients
were taken from a cognitive therapy clinic for the treatment of depression.
They completed the Beck Depression Inventory (Bill) at the beginning and
end of therapy and before each session. Following each session clients
also completed a measure of therapeutic alliance. Therapist scores on
the "cognitive therapy skill" subscale of the CTS were associated
with outcome for the whole sample of clients. The relationship between
competence and outcome was
appreciably stronger for clients who persisted in therapy; other competence
measures, including the CTS total score, also predicted outcome when dropouts
were excluded from the analysis. While therapists obtaining lower CTS
scores tended to achieve substantial reductions in depressive symptoms
with therapy completers, complete resolution of symptoms occurred more
often for therapists who scored higher on the CTS. Regression analyses
showed that therapeutic
alliance was a stronger predictor of outcome than competence, although
both measures independently contributed to outcome.
These results suggest that the CTS is a valid measure of cognitive therapy
competence. Weaknesses are apparent in the scale, however, and development
of an improved version could provide an even more valuable instrument
in quality control and clinical governance, as well as the training and
supervision of therapists.
A Comparative Study on Personality Characteristics of Learning Disabled
and Non Learning Disabled Among Primary School Children
Gitanjali Sharma,Consultant Psychologist, Chennai, India
A modest attempt was made in the present study to examining the personality
characteristics of 180 subjects, both boys & girls of ages 8,9 &10yrs
old with specific learning disabilities (LD) From 3rd,4th&5th Grades
of Urban & Rural primary schools & also an equal number of normal
children(180 Subjects both Boys & Girls of non-LD)with the same age
group & grades examined for a comparative study. An adopted version
Cattell's Children Personality Questionnaire (CPQ) was Administered to
the subject with LD & Non-LD. The results find that there is a significant
difference on personality characteristics of LD & Non-LD Children,
the study also points out the older LD children tend to show more maladaptive
behavioural disposition than the younger LD & also a Significant gender
effect among LD children.
Structured Group Behavioural Psychotherapy for Depressive Disorder: A
Prospective, Randomised, Controlled Trial of Clinical Efficacy and Cost-utility
John Swan Department of Psychiatry, University of Dundee
It is proposed to test the clinical efficacy, utility and cost-effectiveness
of a structured group behavioural psychotherapy in the management of outpatients
meeting ICD-10 criteria for a moderate to severe depressive episode (F32.1,
32.2, 33.1 or 33.2) referred to the Tayside Affective Disorders Service.
Structured group psychotherapy will be compared with optimised antidepressant
drug treatment, placebo-drug treatment and individual cognitive behavioural
psychotherapy. Trained therapists will deliver both psychological treatments
in 12 sessions over a period of 10 weeks with additional 'booster' sessions
after 14, 18 and 22 weeks. Drug and placebo-drug treated groups will be
managed according to protocolised assessment and treatment procedures
that guide practice in the Tayside Affective Disorders Clinic. Clinical
assessments will be conducted by raters blinded to treatment conditions
at 0, 4, 8, 12, 26 and 52 weeks. Structured group behavioural psychotherapy
may represent a potent, cost-effective non-stigmatising treatment for
depression that can be delivered by a broad range of mental health care
POSTER SESSION 2
'Assisted Self-Help' for Chronic Pain: A Pilot Study Using Cognitive
and Behavioral Interventions
Helen Macdonald, Pain Management Unit, Doncaster and Bassetlaw Hospitals
NHS Trust, S.Yorkshire.
Cognitive-behavioural psychotherapy is effective for many sufferers of
chronic pain. (Morely, Eccleston and Williams, 1999) It is usually delivered
in in-patient or out-patient groups, or as a one-to-one intervention.
There is increasing evidence that an 'assisted self-help' format can be
both clinically and cost-effective as a mode of CBT treatment delivery,
(Lovell and Richards, 2001). Manual-assisted therapy with brief therapist
contact has been shown to be useful in treatment for depression and several
anxiety disorders, for example. It is also argued that pain sufferers
benefit from perceived control over interventions used.
A small pilot study was carried out in a hospital outpatient Pain Management
Unit, to investigate the effectiveness of an assisted self-help format
for cognitive-behavioural interventions for chronic pain.
An 'assisted self-help' manual was developed, using existing evidence
on effective interventions for chronic pain. 13 people took part in the
pilot study, sampled from usual referrals for CBP for chronic pain, by
invitation to participate.
For the treatment group, mean scores significantly improved on measures
of mood. Quality of life, self-reported pain intensity and evaluative
ratings all showed changes in the desired direction, but did not reach
significance. Those waiting for treatment tended to become more depressed,
but there were no significant trends in the waiting list group.
The outcome of this study indicates that changes tended to be in the desired
direction, therefore a larger-scale study is planned, in which this approach
will be compared directly with Cognitive-Behavioural 'Treatment as usual'
for chronic pain.
Lovell, K and Richards, D (2001) Multiple Access Points and Level of Entry,
(MAPLE): Ensuring Choice, Accessibility and Equity for CBT Services Behavioural
and Cognitive Psychotherapy 28 379-391
Morley, S., Eccleston, C., and Williams, A. C. (1999), Systematic review
and Meta analysis of randomised controlled trials of cognitive behaviour
therapy and pain in adults, excluding headache. Pain 80, 1-13
Developing a "First Class" CBT Service: The Newcastle Approach.
Vivien Twaddle, Newcastle Cognitive and Behavioural Therapies Centre,
Newcastle City Health NHS Trust & Derek Milne, Department of Clinical
Psychology, University of Newcastle upon Tyne.
Quality is a fundamental and increasingly important requirement of the
"New NHS", as epitomised by "A First Class Service"
(Department of Health, 1998). In response, the Newcastle Cognitive and
Behavioural Therapies Centre (NCBTC) has attempted to (i) evaluate the
quality of the cognitive therapy service it provides, using a new measure,
The NCBTC Patients' Needs Questionnaire and (ii) use the data to improve
the quality of the service via a stakeholder-collaborative evaluation.
By means of a longitudinal, quasi-experimental design, the study involved
183 stakeholders, (patients, referrers, managers, purchasers and staff)
who completed the Questionnaire. On the basis of the questionnaire data,
28 stakeholders rated the quality of different aspects of the service,
prioritised the areas for improvement and provided suggestions for change.
Furthermore, on the basis of these extrapolated opinions, NCBTC staff,
in turn, produced service objectives, clear action plans and explicit
methods of evaluation which were ratified by the Trust Board and resulted
in an improved service delivery model, "cascading cognitive therapy
skills", designed for staff across the mental health service. The
results showed that that, overall, the service was perceived as "good"
with pockets of "excellence". Clear priorities for improvement
emerged, including the need to disseminate therapeutic skills to staff
outside the NCBTC via a systematic model of supervision and training.
The study illustrates the viability and impact of a stakeholder-collaborative
approach; one, it is argued, that is inherently cognitive-behavioural
in philosophy and principles. It has also led to the development of a
staff CBT training needs assessment tool and has generated ideas about
a cascade model of training.
Panic Disorder in Primary Care. Research into a Novel Approach Using
Group Work and Exercise
Pauline Callcott, Paul Cromarty, Gary Robinson, Mark Freeston, Newcastle
Cognitive and Behaviour Therapies Centre
An initial service development by the Newcastle Cognitive Behavioural
Therapies Centre and health and fitness staff in a healthy living centre
combines Clark's panic model (1986, 1996) in a group format with a formal
exercise programme. It is reported in 'Physical Activities and Health'
a national consensus statement, that there is a clear beneficial effect
of exercise on anxiety, however it quotes that 'certain people will not
become less anxious as a result of physical activity alone (e.g. people
with panic disorder and agoraphobia.)' The evaluation of the pilot groups
has been encouraging with evidence of clinically significant improvement
in participants post therapy scores on standardised assessments such as
the Clinical Outcomes in Routine Evaluation, Beck Anxiety and Depression
Inventories, as well as specific measures for panic disorder and agoraphobia
and avoidance. However it is less clear why some participants are benefiting
and the NCBTC is researching characteristics that might predict a better
response for group participants. It is hypothesised that a combined CBT
exercise package is superior to exercise alone in eliminating panic, reducing
symptoms and increasing well being and functioning. The poster will outline
clinical findings as well as discuss how a service like this can be cascaded
to other settings. The pilot project work fits with National Service Framework
(1999) guidelines, in that it targets gaps in service provision, involves
users in their own care and promotes interagency working. The project
also tackles social exclusion in that it provides the sort of service
normally found in tertiary centres and delivers it in an effective manner
in a non-stigmatising local community setting such as the West End Health
Clark D.M.(1986) A Cognitive Approach to Panic. Behaviour Research and
Therapy 24. 461-470
Department of Health (1999). National Service Framework For Mental Health:
Modern Standards and Service Models. London. HMSO.
Grant T. (ED.) (2000). Physical Activity and Mental Health: National Consensus
Statements and Guidelines for Practice. Health Education Authority.
Department of Health (1999) National Service Framework For Mental Health:
Modern Standards and Service Models London. HMSO.
The Impact of Postgraduate Clinical Training on Clinical Performance.
Analise O'Donovan, M. Dyck, and J. Bain, Griffith University, Australia
This paper addresses the ongoing issue of the effectiveness of clinical
training, a topic that has led to many debates over a number of decades.
The necessity of higher degrees is based on the belief that additional
years of training produce a more effective practitioner. However, the
evidence for this argument has been consistently equivocal. There have
been a number of explanations suggested in the literature for the limited
evidence of training effectiveness, with lack of methodological rigour
(e.g. unreliable measures, lack of control groups), frequently suggested
as a reason for the failure to observe training effects. To a large extent,
ethical and practical constraints on the random assignment of participants
to training or no-training conditions, contribute to these problems. However,
in Australia, graduates of 4-year psychology courses can obtain professional
registration by one of two routes: postgraduate training or supervised
practice. These alternative pathways to professional development afforded
the opportunity to assess the effectiveness of postgraduate training courses
by comparing the clinical performance of individuals who are selected
for postgraduate training, with the clinical performance of individuals
who do not enter postgraduate training.
A quasi-experimental design was used to evaluate the effectiveness of
clinical training programs. As the scientist-practitioner model has been
adopted as the basis for training in Australia, training outcome was assessed
using measures representative of both clinical knowledge and clinical
practice ability. 31 clinical psychology trainees sampled from 7 Australian
universities were evaluated at the beginning of their postgraduate training
courses and one year later; 30 psychology graduates from 5 Australian
universities who did not pursue postgraduate clinical training served
Results showed that following training, trainees perform significantly
better than non-trainees on a measure of assessment, treatment, and evaluation
ability, a measure of diagnostic ability, and a measure of the ability
to set goals and effective tasks with a standardised client. No differences
were observed in their ability to develop an accurate case conceptualisation
of a client that had just been interviewed, to develop an effective bond
with that client, or to communicate empathic understanding.
As suggested by the scientist-practitioner model, results indicated that
so-called clinical knowledge and practice ability do represent distinguishable
knowledge structures. But our results also indicate that both clinical
knowledge and practice ability contribute to a higher-order knowledge
structure that we call global clinical ability. These results may be important
because they illustrate something about the "ingredients' of clinical
practice that, although obvious, is frequently overlooked. Clinicians
can only use or apply their clinical knowledge in the context of the relationships
that they have with their clients; the relationships that clinicians develop
with their clients always develop in tandem with the clinicians' application
of their clinical knowledge to helping clients achieve their aims.
Although the data to date is encouraging as indicated by the moderate
to large effect sizes on some measures of trainees' knowledge and practice
abilities, the way forward is to also consider some other variables which
are likely to be influencing effectiveness of practitioners to understand
the role of training within a wider context of relevant outcome. factors.
Factor Analysis of CBT Supervision Activity
O'Carroll, P.J. Chester College of Further Education,
The current literature on cognitive behavioural therapy (CBT) supervision
is primarily about trainees with only a small part concerned with post-accredited
CBT practitioners. This situation is seriously out of step with current
NHS reforms where Clinical Governance requires health service providers
to ensure quality and effectiveness in the delivery of health care in
the UK, including psychological therapies. Effective supervision between
accredited practitioners is a necessary component for ensuring maintenance
and effectiveness of psychotherapy practice. Supervision is necessary
both during training and during post-accredited practice. On this basis,
there is a pressing need to increase research and development that should
underpin post-accredited supervision practice.
One issue for examination in developing post-accredited CBT supervision
practice concerns the perceived functions of supervision: whether supervision
should be essentially personal or whether educative, that is, whether
one examines the supervisees' experience or whether one examines what
they do. Often this duality has led to polarisation and or compromise
amongst other psychotherapy approaches, a situation that has also been
observed within CBT. CBT has tended to be characterised as more pragmatic,
educative and task focussed compared to other psychotherapy approaches.
With these issues in mind, this study aims to explore and analyse the
content of supervision activities of post-accredited CBT practitioners
in the UK.
A postal survey of 240 UKCP registered CBT practitioners was carried out
looking at the nature and extent of specific supervision activities. One
hundred and twenty four (54%) questionnaires were returned. The questionnaire
included 16 items about the content of supervision activities. The content
areas were derived from a number of sources, including, competency checklists
and literature on the structure, content and process of CBT supervision
(e.g. Padesky, 1996). The items addressed several areas of activity including:
assessment, formulation, intervention, evaluation, inter- and intra-personal
processes, therapy alliance and ethics. Respondents were asked to rate
the relative level of these activities over the previous 12 months.
The findings highlighted differences in the level of supervision activities
with practical task activities reported more frequently than inter- and
intra-personal process issues. A principle component factor analysis yielded
4 components labelled (1) tasks, (2) bond, (3) supervision and (4) critical
decisions. These components equate closely with the dual personal and
educative functions identified in other psychotherapy orientations. However,
it is suggested that contemporary models of CBT supervision (Padesky,
1996) provide a more effective and theoretically consistent resolution
of the multiple functions of supervision suggested in this study. The
work of Padesky (1996) not only provides a basis for research but also
a framework for CBT supervision practice and training.
The Development of Two New Instruments for the Evaluation of Foundation
Level Training in Cognitive Behaviour Therapy
Pamela Myles-Kelly, Department of Psychological Therapies & Research,
Northumberland Mental Health NHS Trust, Northumberland
Evaluation of training programmes is essential and requires the development
of appropriate measures. Two new instruments were developed to assist
in an evaluation of a new foundation level training programme in Cognitive
Behaviour Therapy (CBT). The measures are described and their reliability
and validity presented. Ninety mental health professionals were trained
in foundation level CBT over a 12-week period, receiving a total of 48
hours of shared learning, covering core theory and techniques for depression
and anxiety within an experiential workshop format. The research took
the form of a waiting list, control group design. In this longitudinal
design, participants served as their own controls. Multiple measures were
administered during a double baseline assessment, a post-training re-assessment
and a three-month follow-up assessment.
Instrument one, The Foundation Cognitive Behaviour Therapy Multiple Choice
Questionnaire (FCBT-MCQ), was developed to assess knowledge of CBT. The
original MCQ had 25 items and, following an item analysis, was reduced
to thirteen items.
Instrument two was a Video Assessment Task (VAT), developed to measure
CBT-relevant skill. An actor described a typical Panic Disorder, which
included three symptoms from each of the following domains: cognitive,
behavioural, physical, and affective. Participants were shown the video
clip twice and given a total of 10 minutes to answer three questions related
to what they had seen. Participants were asked to identify symptoms, name
the problem and consider up to six suitable cognitive-behavioural techniques.
Good reliability and validity data were obtained for these two instruments,
which are available as sound instruments to support training in evidence-based
Group Cognitive Therapy for Low Self-Esteem: A Preliminary Evaluation
Craig Simpson, Manchester Mental Health Partnership
Low self esteem is commonly encountered in clinical practice. In many
cases, self confidence can be restored by treating the individual's presenting
problem. However, for some individuals, low self esteem is more pervasive,
and may act as an underlying vulnerability factor that precedes the onset
of their problems, and that predisposes them to multiple, recurrent or
persistent psychological difficulties. In these cases, low self esteem
in itself may warrant clinical attention. A recent cognitive model of
low self esteem and associated treatment programme has been proposed (Fennell,
1997). The current study is a preliminary evaluation of a group cognitive
therapy programme for low self esteem which is based on this conceptualisation,
and which employs a modified version of the individual treatment protocol.
The contents of the group therapy programme will be outlined and the theoretical
and practical considerations of treating low self esteem in a group setting
discussed. Finally, pilot outcome data will be reported.
Modified Dry-Bed Training for Treating Childhood Nocturnal Enuresis: A
Replacement for the Bell-and-pad Method?
Shazia Nawaz, Peter Griffiths, Department of Psychology, University of
Stirling & David Tappin, Department of Child Health, University of
We compared the efficacy of modified Dry-Bed and urine alarm training
for treating monosymptomatic nocturnal enuresis in children aged 7-12
years attending health centres? in Glasgow. We simplified the original
1974 Dry-Bed method and described it in an illustrated instruction manual.
Parents and children followed the procedure at home, aided by a videotape.
We also wrote instructions forn conventional urine-alarm ('bell-and-pad')
training as a self-help manual with an accompanying videotape. Dry-Bed
training is based on an operant learning model and emphasises the complex
sequence of skills the child needs to acquire to stay dry at night, such
as wakening to the sensation of a full bladder and moving rapidly from
bed to toilet. Urine-alarm treatment focusses more narrowly on promoting
arousal in response to bladder fullness. The methods also differ in that,
in Dry-Bed Training, the bedwetting alarm is used to alert the parent/trainer
as opposed to the child directly, as happens in urine-alarm conditioning.
Between November 1999 and July 2000, 36 children with primary enuresis
were assigned to Dry-Bed, urine-alarm and waiting list control groups,
each group being of equal size and matched for age, sex , social class
(deprivation category) and baseline wetting frequency. In the two treated
groups, initial interview was followed by two review appointments, otherwisefamilies
carried out the training independently at home with fortnightly telephone
support for16 weeks or until initial success was achieved (14 consecutive
dry nights). Of the 12 children treated by the Dry-Bed method,8 achieved
initial success compared with only 3 of the 12 treated by the conventional
urine-alarm method. One waiting-list control child remitted spontaneously.
Analysis of variance showed highly significant differences in wet nights
per week immediately after intervention for both treatment and time factors
(p<0.001) and their interaction (p<0.01). The Dry-Bed group averaged
a mere 0.8 nights per week wet at short-term outcome compared with 3.25
for the urine-alarm group and 5.00 for the controls. Moreover, only the
Dry-Bed group were superior to both the urine-alarm and control groups,
the urine-alarm group's wet-night average being not significantly different
from that of the controls. At follow-up, three months after treatment,
no child had relapsed or spontaneously remitted in any group. Our results
point strongly to modified Dry-Bed Training being more efficacious than
orthodox urine-alarm conditioning over comparable invervention periods.
It may be that modified Dry-Bed Training, delivered as a self-help package,
will become the treatment of choice for primary nocturnal enuressis in
childhood. We are currently investigating the method with a larger sample.
Therapist Competence as a Predictor of Outcome in Cognitive Therapy for
Chris Trepka, Anne Rees, David Shapiro & Gillian Hardy
Bradford Community Health NHS Trust (CT), Leeds University (co-authors)
The Cognitive Therapy Scale (CTS) has been widely used in cognitive therapy
training centres to assess therapist competence but competence has not
previously been shown to predict cognitive therapy outcome clearly. We
compared competence with alliance as process variables that might moderate
change in therapy. A randomly selected therapy session from each of 30
courses of cognitive therapy for depression was rated using the CTS. Regression
analysis showed that therapeutic alliance was more strongly related to
outcome than therapist competence, although both measures independently
contributed to outcome. Prediction of outcome was better for clients who
persisted longer in therapy. All six therapists in the study demonstrated
competence, but three averaged higher CTS scores and achieved symptom
reduction to low levels on the Beck Depression Inventory more often.
These results indicate that both modality-specific cognitive therapy ability
and non-specific facilitation of alliance are moderators of change, and
thus determinants of outcome, independently of each other. The effects
upon outcome appear to be mediated by the extent to which subjects persist
in therapy. Weak relationships between CTS scores and outcome in previous
studies might be attributable to less variation in therapist competence
levels. The validity of the CTS as a measure of cognitive therapy competence
is supported by this study, although weaknesses are apparent in the scale.