British Association for Behavioural and Cognitive Psychotherapies
30th Annual Conference
University of Warwick
17th-20th July 2002
Table of Contents
The Temple-Wisconsin Cognitive Vulnerability to Depression Project: Progress and Implications for Prevention
Professor Lauren B Alloy, Temple University, Philadelphia, PA, USA
According to cognitive models of depression (eg Hopelessness Theory; Beck’s Theory), people with negative cognitive styles are at greater risk for depression than people with more positive cognitive styles. The Temple-Wisconsin Cognitive Vulnerability to Depression (CVD) Project is a two-site, prospective longitudinal study designed to test the vulnerability and other aetiological hypotheses of the major cognitive theories of depression. The CVD project utilized a behavioural high-risk design and selected non-depressed participants with no current Axis I psychopathology (n = 349) who were at hypothesized high vs. low risk for depression based on the presence vs. absence of the negative cognitive styles hypothesized to serve as vulnerabilities to depression in Hopelessness Theory (negative inferential styles) and Beck’s Theory (dysfunctional attitudes). These cognitively high-risk (HR) and low-risk (LR) participants were assessed on a variety of cognitive, coping, and information processing measures at Time 1 and were then followed prospectively every 6 weeks for 2.5 years and then every 16 weeks for another 3 years with self-report and structured interview assessments of life events, cognitions, and psychiatric disorders/symptoms. In this talk, I will present data based on the first 2.5 years of follow-up. Consistent with prediction, HR participants showed greater prospective incidence than LR participants of major depression, minor depression, and the hypothesized subtype of hopelessness depression (HD). Moreover, these risk group differences held for both first lifetime onsets and recurrences of depressive disorders and exhibited some specificity to depressive disorders as compared to other Axis I disorders. HR participants were also more likely than LR participants to exhibit greater suicidality, mediated by hopelessness, across the 2.5-year follow-up. In addition, these cognitive vulnerability effects were moderated by other hypothesized cognitive risk factors for depression. Specifically, HR participants who also tended to ruminate in response to stressful life events at Time 1 or who exhibited negative self-referent information processing at Time 1 were at the greatest risk for developing episodes of depression. Given that the CVD Project findings suggest that negative cognitive styles do, indeed, confer risk for clinically significant depressive disorders, I will also present data on some of the possible developmental antecedents of negative vs. positive cognitive styles and subsequent risk for depression. Based on data from a direct study of 320 of the parents of our cognitively HR and LR participants as well as the maltreatment histories of CVD Project participants, I will present data suggesting a role for parenting styles, inferential feedback from parents, and a history of emotional abuse in the development of cognitive vulnerability to depression and depression itself. Finally, the implications of the CVD Project findings for the prevention of depression will be discussed.
"Applied Behaviour Analysis and Behavioural Phenotypes (or ABA meets AGAGAGTCCGTA)"
Professor Chris Oliver, School of Psychology, University of Birmingham
Social trends, the expanding remit of clinical psychology and the historical and controversial association between psychology, genetics and severe intellectual disability have militated against the psychological study of individuals with genetically determined syndromes. In the last two decades behavioural phenotype research has grown significantly with an emphasis on gene-brain- behaviour relationships with minimal consideration given to social environmental influences on behaviour. This trend has the potential to marginalise effective psychological interventions for individuals who have genetically determined syndromes. In this paper it is argued that the behavioural phenotype perspective is compatible with an applied behaviour analytic approach and that by encompassing both approaches more sophisticated models of the determinants of behaviour disorder can be developed and employed in clinical practice.
Psychological Processes in Suicidal Behaviour
Professor J Mark G Williams, University of Wales, Bangor
Suicide and non-fatal deliberate self-harm are some of the most serious aspects of psychiatric illness. One in seven patients hospitalised for major depression and one in ten patients with a diagnosis of schizophrenia or alcohol abuse die by suicide. Eight to ten times this many will attempt suicide or harm themselves in some way. Identifying ways to treat such patients in order to reduce risk of suicidal behaviour has proven very difficult. Recent systematic reviews of the RCT's to date show that there remains considerable uncertainty about which treatments are most effective. For treatment to be successful, we need to understand the psychological processes that underlie both long-term vulnerability, and the short-term state-dependent exacerbation of these risk variables. In this talk I shall elaborate a cognitive model of suicidal behaviour. This model assumes that both environmentally and biologically-mediated risk variables affect individuals through a final common pathway involving (a) a high sensitivity to cues in the environment signalling loss, rejection and defeat; (b) a sense of entrapment (that there is no escape - 'arrested flight' - Gilbert & Allen, 1998); (c) the escalation of these processes in some patients due to their differential sensitivity to negative mood. While a sense of loss, rejection and defeat is common in depression, the model suggests that it is only when such defeat is combined with entrapment (arrested flight) that suicidal ideation and behaviour occurs. We suggest that such feelings of entrapment arise from a combination of increased hopelessness for the future and decreased problem solving ability. Our research shows that deficits and biases in autobiographical memory are critical contributors to such hopelessness and problem solving deficits. Further treatment development needs to take account both of these underlying variables, and of how they contribute to the rapidly escalating suicidal thinking and behaviour that occurs in response to negative events.
Evolved Brian - Social Mind: Implications for Cognitive Therapy
Paul Gilbert, University of Derby
There is now considerable evidence that evolution has shaped many of our dispositions for thinking and feeling (Panskepp, 1998). It is also clear that early life experiences can have a significant impact on development of the brain and vulnerability to psychopathology (Schore, 2001). Given these two powerful influences on the development of self-other schema this talk will offer a personal journey into possible interactions between our innate dispositions (e.g., to form attachments, to belong to groups) and how key strategies are socially shaped through experience. The talk will explore the nature of defensive behaviours (e.g., fight, flight, submit), the importance of evolved social competencies (e.g., theory of mind), and motivational dispositions that guide social role and schema formation (e.g., for attachment, for friendship). The talk will highlight possible implications for the future of cognitive theory in the light of increasing knowledge of our evolved brains and social minds.
Gilbert, P. (1998) The evolved basis and adaptive functions of cognitive distortions. British Journal of Medical Psychology, 71, 447-463.
Gilbert, P. (2000). Varieties of submissive behavior as forms of social defense: Their evolution and role in depression. In, L. Sloman & P. Gilbert (eds.). Subordination and Defeat: An Evolutionary Approach to Mood Disorders and their Treatment (pp. 3-45). Mahwah: N.J. Lawrence Erlbaum.
Gilbert, P. (2000) Social Mentalities: Internal ‘Social’ Conflicts and The Role of Inner Warmth and Compassion in Cognitive Therapy. In, P. Gilbert & Bailey K.G (eds.) Genes on the Couch: Explorations in Evolutionary Psychotherapy (p.118-150). Hove: Brenner-Routledge.
Gilbert, P. (2001) Depression and stress: A biopsychosocial exploration of evolved functions and mechanisms. Stress: The International Journal of the Biology of Stress, 4, 121-135.
Gilbert, P. (2001) Evolution and social anxiety: The role of social competition and social hierarchies. In F, Schnieder (ed's). Social Anxiety: Psychiatric Clinics of North America, 24, 723-751.
Gilbert, P. (2001) Evolutionary approaches to psychopathology: The role of natural defences. Australian and New Zealand Journal of Psychiatry, 35, 17-27.
Panskepp, J. (1998) Affective Neuroscience. New York: Oxford University Press.
Schore, A.N. (2001). The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22, 201-269.
The Unconventional Implications of a New Theory of Cognition
Professor Steven C Hayes, Department of Psychology, University of Nevada
Steven C. Hayes is Nevada Foundation Professor and Chair of the Department of Psychology at the University of Nevada. An author of twenty books and more than 275 scientific articles, his career has focused on an analysis of the nature of human language and cognition and the application of this to the understanding and alleviation of human suffering. In 1992 he was listed by the Institute for Scientific Information as the 30th "highest impact" psychologist in the world during 1986-1990 based on the citation impact of his writings. Dr. Hayes has been President of Division 25 of the American Psychological Association, of the American Association of Applied and Preventive Psychology and of the Association for Advancement of Behavior Therapy.
Depressive Rumination: Vulnerability, Consequences, and Maintenance
Convenor & Chair: Costas Papageorgiou, Institute for Health Research, University of Lancaster
Discussant: Chris R Brewin, University College London
Repetitive negative thinking, in the form of rumination, is a key cognitive feature of dysphoria and major depressive disorder. Recent studies have demonstrated that the tendency to ruminate in response to experimentally induced or naturally occurring depressed mood has a number of deleterious outcomes. For instance, rumination has been shown to maintain and exacerbate depressed mood (Nolen-Hoeksema, 2000), and predict elevated levels of depressive symptoms (Just & Alloy, 1997) as well as episodes of major depression (Kuehner & Weber, 1999). From a therapeutic perspective, rumination has been found to delay recovery from major depression in cognitive-behaviour therapy (Siegle, Sagrati & Crawford, 1999). Thus, further investigation of the factors linked to vulnerability to and maintenance of rumination may contribute to our understanding of the ruminative mechanisms involved in the onset, persistence, and recurrence of depression and inform the development of more effective treatments. This symposium offers a series of empirically based presentations that investigate vulnerability, consequences, and maintenance of rumination in depression. As a body, these papers may offer new directions for treatment and insights for understanding ruminative mechanisms in depression.
Cognitive Vulnerability to Depression: Measurement and Process
Cognitive Reactivity (CR) to the experimental induction of sad mood has been found to predict relapse in recovered depressed patients (Segal, Gemar, & Williams, 1999). However, the assessment of CR involves a procedure (sad mood induction) that is both impractical and psychometrically weak. Therefore, a questionnaire was developed that measures CR by self-report, independently from a mood induction procedure: the Leiden Index of Depression Sensitivity (LEIDS) (Van der Does, 2002). The LEIDS was tested further in two separate studies involving recovered depressed patients and normal controls. Relationships with personality, rumination, and thought suppression were also investigated. Cognitive reactivity, as measured with the LEIDS, was correlated with thought suppression as measured by self-report, and with an experimental procedure that aims to unmask thought suppression tendencies. The use of the LEIDS scale facilitates research into the correlates and mechanisms of CR. Active suppression of unwanted thoughts may be responsible for the apparent inactive state of depressive cognitions during remission.
Rumination: A Common Mechanism Linking Vulnerability Factors to Depression
Initially non-depressed university freshmen (n = 137) participating at the Temple site of the Cognitive Vulnerability to Depression (CVD) Project (Alloy & Abramson, 1999) were assessed for the presence of a ruminative response style and four other hypothesized risk factors for depression (negative cognitive styles, self-criticism, dependency, and history of past depression) at Time 1. They were subsequently followed longitudinally for 2.5 years. Negative cognitive styles, self-criticism, dependency, and history of past depression were all significantly associated with rumination. Further, rumination fully mediated the predictive relationships of negative cognitive styles, self-criticism, and history of past depression with the number of prospective onsets of DSM-III-R major depressive episodes during the 2.5 year follow-up period. In contrast, private self-consciousness did not mediate any of the relationships between the risk factors and number of subsequent major depressive episodes. These findings suggest that rumination, as a special kind of self-focus, may act as a general proximal mechanism through which other vulnerability factors affect depression.
Rumination and Attention in Depression
The present study used an experimental design to investigate the effects of rumination and distraction on attention in depressed patients. In line with the rumination and attention literature, the predictions were that rumination should be associated with difficulty in disengaging attention from negative information, while distraction would be associated with less difficulty in disengaging attention. Measurements of attentional responses prior to the rumination and distraction inductions were also made in the depressed and control subjects. 36 depressed patients and 36 normal controls participated in the study. Rumination and distracting responses were achieved using appropriate induction materials. Attention was assessed using the dot probe task. The results of the study showed that while an attentional bias for negative information was found in depressed patients, this bias was not influenced by the rumination or distracting inductions. However the findings did show a relationship between measurements of trait rumination and attentional biases in depression. The implications of these findings for relevant theories are discussed and the limitations of the present study and directions for future research are described. An attempt is also made to outline some clinical recommendations that can be derived from the study.
Rumination and Depression: A Clinical Metacognitive Model
Recently, we proposed a clinical metacognitive model of rumination and depression. This model is grounded on Wells and Matthews’ (1994) information processing theory in which vulnerability to, and maintenance of, emotional disorders is associated with metacognitions that lead to threat monitoring, self-focused attention, and selection of perseverative negative thinking styles as coping strategies. According to our clinical model, positive metacognitive beliefs about rumination are likely to motivate individuals to engage in sustained rumination. Once rumination is activated, individuals may appraise this process as both uncontrollable and harmful and likely to lead to negative interpersonal and social consequences. The activation of negative metacognitive beliefs about rumination contributes to depression. Finally, decreases in metacognitive confidence and efficiency may be an important depressogenic by-product which contributes to negative beliefs about the interpersonal and social consequences of rumination and maintains the activation of positive beliefs concerning the need to ruminate in order to facilitate effective coping. Thus, a number of vicious cycles of rumination, depression, and metacognition may be responsible for the perpetuation of depression. Experimental, cross-sectional, and prospective data supporting this model will be presented and implications for the treatment of depression will be discussed.
Investigating Recurrent Thinking Across Disorders
Convenor & Chair: Dr Ed Watkins, Institute of Psychiatry, London
Discussant: T D Borkovec, Department of Psychology, The Pennsylvania State University
Characteristics and Functional Relationships Involved in Worrisome Thinking
It is remarkable how little empirical knowledge we have about the nature and functions of human thought in general, despite the fact that this system is likely one of evolution's crowns of creation and the fact that it is likely a major source of one's sense of self. Recurrent thought has, however, become the focus of increasing attention in clinical psychology, given the apparent importance of various types of recurrent negative thinking in different psychological disorders. Considerable research has been conducted over the past two decades on worrisome thinking, resulting in some initial understandings about its specific nature and functions. This presentation will review some of the recent investigations into a variety of features of worry, including dimensions of abstractness and concreteness, thought/imagery differences during worry versus trauma recall, evaluative conditioning involving negative words, the effects of attempted suppression on thoughts versus images, the effects of processing worrisome topics in imaginal versus thought modes, and attempts to condition the occurrence of worry to environmental discriminative stimuli. Such investigations are focused on attempts to understand how human thought operates, becomes stuck in certain ways, and is open to change in other ways. Identification of the principles governing worrisome thought would hopefully provide hints about the nature of human thinking in general, and recurrent thought present in other disorders in particular, while knowledge from research on other types of recurrent thinking would contribute to further our attempts to understand worry.
Intrusive Thoughts and Contamination Fears in Obsessive-Compulsive Disorder
The frequently reported finding that obsessive thoughts are not universally regarded as senseless or unlikely to happen by obsessive compulsive patients is examined. Sixty-three patients with OCD completed a paper and pencil task requiring them to appraise a range of intrusive thoughts and contamination fears on two variables: senselessness and likelihood to happen. The results suggest that not all obsessive thoughts are regarded as senseless or unlikely to happen by OCD patients and that these appraisals may be mediated in part by the content of the obsessive thought and the sub-type of OCD. The possible implications for the cognitive-behavioural model of OCD and the methodological limitations of the study are discussed.
Counterfactual Thinking and Posttraumatic Stress Reactions
Recent theories of posttraumatic stress reactions have provided a basis for investigating how trauma victims struggle to come to grips with what has happened to them and to develop a coherent account of the trauma. However, it is likely that a full understanding of adjustment to trauma may turn out also to depend on a better understanding not just of how trauma victims process what actually did take place but also how they think about what could have happened. Preoccupation with alternative outcomes is recognised as being a central component of the ruminations of people who have experienced traumatic events. The general question that was investigated was whether such so-called counterfactual thinking should be distinguished from general rumination and whether a fine-grained examination of different aspects of counterfactual thinking might provide insights into the process of adjustment to a traumatic event. A sample of assault victims was recruited from a large urban hospital. They were interviewed concerning the assault and completed a battery of self-report scales and thought-listing procedures. The results confirmed the basic expectation that all forms of retrospective simulations of alternative outcomes and current prospective simulations of possible similar events were associated with negative affect. However, high availability of counterfactuals, in contrast to frequency of counterfactuals, appeared to be related to the re-establishment of personal meaning as reflected in a positive association with repair of fundamental assumptions, the generation of adaptive behavioural plans, and the relative improvement in posttraumatic symptoms. Finally, it was found that counterfactual activation and accessibility over time were moderated by metacognitive control strategies. Implications for theory and practice are discussed.
Toward an Understanding of Excessive Pre-Sleep Cognitive Activity in Primary Insomnia: An Experimental Manipulation of Imagery and Verbal Thought
A distinction can be drawn between cognitive activity that occurs as a visual image and that which occurs as verbal thought. Based on empirical findings, Borkovec, Ray and Stober (1998) have accounted for the maintenance of worry in generalised anxiety disorder by suggesting that thinking about an emotional topic in verbal thought results in a drop in physiological response, inhibition of emotional processing, and maintenance of worry and the associated emotion. Conversely, the translation of a concern into an image will increase physiological response in the short-term, but will ultimately facilitate successful processing and resolution of the worry and associated emotion. Patients with insomnia report that the main reason they cannot get to sleep and stay asleep is because of excessive pre-sleep cognitive activity. The present study aimed to index the effect of manipulating imagery and verbal thought during the pre-sleep period. Individuals with insomnia were exposed to a stressor (speech threat) prior to getting in to bed and were instructed to think about the speech and its implications in either images (Image Group, N = 14) or verbal thought (Verbal Group, N = 17). Participants completed questionnaires about speech anxiety, arousal, affect, and degree of resolution. Measures were taken of subjective (sleep diary estimates) and objective (actigraphy) sleep-onset latency. The results were broadly consistent with the proposals of Borkovec and colleagues. In the short term, the Image Group reported more negative affect and arousal relative to those in the Verbal Group. In the longer term, the Image Group fell asleep more quickly and reported less negative affect the following morning compared to the Verbal Group.
Ruminative Intrusions Following Failure and Loss
Recurrent 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, recurrent focus on self, mood and problems can also be an adaptive response, reducing depressed mood (e.g. expressive writing, Pennebaker, 1993) and improving problem solving (Carver & Scheier, 1990). How can we make sense of these paradoxical effects of recurrent thinking? One possibility is that there are different thinking styles within focus on self and problems (Watkins & Teasdale, 2001; McFarland & Buehler, 1998) with different implications for the consequences of recurrent thinking. In particular, it is hypothesized that focus on self, mood and problems that involves more abstract and more conceptual thinking (e.g. "Why?" type thinking) produces the negative consequences typical of depressive rumination. To test this prediction, a series of studies are being conducted to examine whether the thinking style employed when writing about upsetting events (whether induced failure or a past loss) influences the persistence of dysphoric mood and intrusive thoughts over days/weeks. Unlike previous writing studies, these studies compare high and low vulnerability groups (e.g. high and low ruminators). The results, theoretical and clinical implications of these studies will be reported.
Investigating Imagery Across Disorders
Convenors: Emily Holmes & Ann Hackmann
Chair: Emily Holmes, Sub-department of Clinical Health Psychology, University College London
Discussant: Ann Hackmann, Department of Psychiatry, University of Oxford, Warneford Hospital
The Application of Imagery Research to Clinical Problems, Part 1: The Cognitive Psychology of Mental Imagery
This paper briefly compares two models of mental imagery, Kosslyn's (1994) model, which views visual imagery as an integral part of visual perception, and Baddeley's (1986) working memory model, which views imagery as function of specialised storage and manipulation processes in working memory. Although Kosslyn's model is better specified, Baddeley's model has advantages for researching imagery in an applied context. We will present data supporting the claim that imagery depends at least in part on working memory: a) vividness of imagery is reduced by concurrent working memory loads in the same modality, b) concurrent working memory loads reduce the vividness and emotionality of emotive memories (see Andrade, 2001 for a summary). We will argue that tasks taken from the working memory field potentially form useful treatment aids for people with conditions such as post-traumatic stress disorder (Kavanagh et al, 2001).
Andrade, J. (2001) The contribution of working memory to conscious experience. In J. Andrade (Ed.) Working Memory in Perspective (pp.60-78). Hove, UK: Psychology Press.
Baddeley, A. D. (1986) Working Memory. Oxford: OUP
Kavanagh, D., Freese, S., Andrade, J. & May, J. (2001) Effects of visuo-spatial tasks on desensitization to emotive memories. British Journal of Clinical Psychology, 40, 267-280.
Kosslyn, S. M. (1994) Image and Brain: The resolution of the imagery debate. Cambridge, MA: MIT Press.
The Application of Imagery Research to Clinical Problems, Part 2: The Role of Imagery in Craving
Kavanagh, Andrade and May (submitted) recently proposed a new model of craving. We argue that imagery lies at the heart of craving and desire. An episode of craving may be triggered by an intrusive thought of the desired substance or activity, but elaboration, i.e., construction of an image of the target, is the essential component of craving. Imagining the desired target has immediate benefits, eliciting positive emotions associated with reward or relief. However, in the longer term, the image is aversive, increasing awareness of deficit and lowering mood, but also increasing motivation to achieve the target. Our model explains findings that imagery is a very effective way of deliberately inducing craving in the laboratory (e.g. Drobes & Tiffany, 1997) and predicts that craving episodes will mutually interfere with ongoing cognitive activities in the same modality. This paper describes a cognitive-behavioural treatment, based on the model, that aims to help clients: (i) predict and prevent some intrusive thoughts, (ii) address problematic cognitions and distress associated with craving, and (iii) reduce the functional impact of craving episodes, and perhaps even reduce their duration. We will argue that the model illustrates the benefits of applying theoretical laboratory research to clinical problems.
Drobes, D. J., & Tiffany, S. T. (1997). Induction of smoking urge through imaginal and in vivo procedures: Physiological and self-report manifestations. Journal of Abnormal Psychology, 106, 15-25.
Kavanagh, D. J., Andrade, J. & May, J. (submitted) Imaginary relish and exquisite torture: The elaborated intrusion model of desire.
How Do Concurrent Tasks Affect the Development of Intrusive Imagery for a Traumatic Film?
Intrusive images of a trauma are those which pop into mind spontaneously, may take you by surprise, and may feel to some extent as if the memory is happening 'now'. They can occur across a variety of disorders including PTSD, depression, schizophrenia and agoraphobia. How does peri-traumatic (i.e. during trauma) information processing affect the development of intrusive memories? This was investigated by exposing student participants to analogue trauma - a stressful film of road traffic accidents. Participants then kept a one-week diary to record intrusive memories. In a series of experiments, the effect of various concurrent tasks while watching the film were compared with watching the film 'as usual' i.e. with no task. Initial studies (Brewin & Saunders, 2001; Holmes and Brewin, 2001) found that a visuospatial tapping task reduced intrusions compared to a no-task condition. However, it could be argued that this is simply due to distraction from the film, and that the effect may have little to do with the nature of the task. Therefore, in subsequent experiments alternative visuospatial as well as non-visuospatial tasks were used. It was found that 1) varying levels of visuospatial task complexity showed a predicted linear trend in increasingly influencing intrusion development, 2) a different visuospatial task (plasticine manipulation) also led to reduced intrusions and 3) a non-visuospatial task (counting backwards in three's) led to increased intrusions. This indicates that the reduction of intrusions brought about by tapping a pattern during analogue trauma is not a simple effect of distraction and may be attributable to the visuospatial nature of the task. Further, that a verbal task can increase intrusions. The findings are interpreted within the framework of Dual Representation Theory (Brewin, Dalgleish & Joseph, 1996), and task competition for resources in verbal or perceptual memory systems. Clinical peri-traumatic implications will be discussed.
Imagery and Psychotic Symptoms
Recent cognitive accounts of psychotic symptoms have suggested that processes involved in the maintenance of emotional disorders may also be implicated in the maintenance of hallucinations and delusions, and particularly emphasise the appraisals of such symptoms as important. Imaginal appraisals have been identified in emotional disorders, and many studies have reported spontaneously occurring images in patients with anxiety disorders. Such images appear to be linked to affect, beliefs and memories. This study examined the occurrence of imagery, using a semi-structured interview, in 35 patients who were experiencing hallucinations and/or delusions and receiving cognitive therapy. The majority of patients (74.3%) reported images, and most of these were recurrent and associated with affect, beliefs and memories. Common themes included images about feared catastrophes associated with paranoia, traumatic memories, and images about the perceived source or content of voices. The theoretical and clinical implications of these findings are discussed and directions for further research considered.
Intrusive Thinking and Images in Weight and Shape Preoccupation: A Preliminary Study
Models of intrusive thinking have been developed specifically in OCD and GAD. However, in recent years there have extensions to a wide range of other disorders. In a preliminary study that is part of a programme investigating the applicability of some parts of these models to eating disorders, intrusive thoughts about weight and shape were studied in a sample of 119 undergraduates. The main findings found support for general models of intrusive thoughts with some particular features related to weight and shape concerns, such as behaviour related to monitoring and controlling weight. As in previous studies, many people report mixed experiences of thoughts, doubts, impulses, images and vague ‘feelings’, although individual events may be more clearly of one type. The focus of this presentation is those intrusive experiences that were reported as having high image content. Particular characteristics associated with high image content were appraisals concerning responsibility for thoughts and the need to control them and behaviour such as checking and other control strategies. Actual Body Mass Index and the discrepancy between actual and ideal weight were not associated with high image content. Analysis of the reported content indicated that weight and shape concerns or shape alone were proportionally over-represented in high image events whereas thoughts about weight alone were proportionally under-represented. Questions will be raised as to how images may, at least in some cases, play an important role in the aetiology and maintenance of eating disorders.
The Role of Negative Imagery in Social Anxiety and Contamination of Social Situations
Patients with social phobia often experience negative self-imagery in social situations, while individuals without high social anxiety do not (Hackmann, Surway & Clark, 1988). The negative imagery may result in greater levels of anxiety, poorer performance and greater use of safety behaviours. In turn these mechanisms may contaminate the social situation. People with high social anxiety are liked less when people first meet them and are viewed as less likeable, sympathetic and easy to talk to by friends (Alden and Wallace, 1995; Jones and Carpenter 1986). The present study investigates how negative self-imagery contaminates the social situation. The hypothesis is that negative imagery will be associated with greater anxiety, more use of safety behaviours, poorer performance and more visible anxiety on the part of the socially anxious individual and more negative appraisal of the interaction by the conversation partner. High socially anxious participants participated twice in a conversation with another volunteer who was not socially anxious and who was not aware that the study related to social anxiety or imagery. During one conversation, the socially anxious volunteer held in mind their negative self-image and during the other conversation they held a more positive self-image, with order counterbalanced across participants. As predicted, when holding the negative image, as compared to the positive one, the socially anxious person felt more anxious, used more safety behaviours, believed that they looked more anxious and performed less well. The conversational partner also rated the socially anxious individual as performing less well and looking more anxious in the negative image condition and that the conversation was less enjoyable and flowed less well.
Cognitive Therapy for People with Learning Disabilities: Models, Values and Treatments
Convenors: Andrew Jahoda, University of Glasgow, & Dougal Julian Hare, Academic Division of Clinical Psychology, Wythenshawe Hospital, University of Manchester
Social Construction, Self-Presentation and Anger
Many recent developments in interventions in interventions for problems of anger or aggression make implicit reference to the self. Terms such as self-control, self-regulation, self-management and self-instruction are used without actually defining the or clarifying the concept or its causal role in the development of these emotional and inter-personal problems. Indeed there has been a move away from the stimulus-response model to a cognitive model emphasising the centrality of the individual’s perception and appraisal of events. This must logically be assuming a concept of self, since a person’s appraisal necessarily entails a self that does the appraising. Consequently, the self needs to be explicitly incorporated into theories of aggression with people with learning disabilities. This paper draws upon recent research examining the role of social cognitive factors in frequent aggression to support this thesis. Constructivist and symbolic interactionist traditions place theself in an inter-personal context, and may provide theoretical foundations for this model. Generating a more sophisticated model of inter-personal aggression could generate a body of empirical work with direct clinical utility.
Developing Cognitive Theories and Interventions for Psychological and Emotional Distress in People with Autistic Spectrum Disorders
People with high-functioning autism / Asperger's syndrome are known to present with increased levels of psychological and emotional distress relative to the general population, such distress involving paranoia, anxiety, social anxiety and self-harm. The need for psychological therapies in response to such distress is largely self-evident and a case may be made for the utility of cognitive-behavioural approaches, on both an a priori basis and on available clinical evidence. However, the theoretical and research basis for such work has been limited. Therefore, a process involving investigations into the phenomenology and mechanisms of such distress coupled with the development of theoretical models is required to advance clinical practice. The first stage in this process is the examination of the role of meta-representational mechanisms in the development of psychological distress in people with high-functioning autism / Asperger's syndrome, such meta-representational mechanisms having being extensively investigated in terms of their role in the development and presentation of the diagnostic features of these conditions. Studies to date have examined the phenomenology of paranoia and other delusional beliefs in this group, using both Bentall & Kinderman's attributional model of paranoid ideation and Frith & Corcoran's models of persecutory delusions implicating mentalisation and retrieval biases in memory. Data from studies of these phenomena in people with high-functioning autism/Asperger's syndrome indicate that such models may not directly applicable to this group of people. To this end, a cognitive model of the development and maintenance of delusional beliefs in high-functioning autism / Asperger's syndrome has been developed to account for the present research findings and for the known cognitive parameters relating to Asperger’s syndrome. The proposed models indicates the scope for both further research and clinical practice.
The Impact of Stigma on Negative Self-Evaluation And Social Comparison in People with Learning Disabilities
The models used to understand the development of distress in people with learning disabilities have often had either a social focus or an individual focus. This paper explores a cognitive model that takes into account the unique social experiences of people with learning disabilities. Thirty-nine adults with learning disabilities completed adapted measures of perceived stigma, evaluative beliefs, self-esteem and social comparison. Statistical analysis showed that individuals who are more aware of being stigmatised are more likely to have negative evaluative beliefs, low self-esteem and to engage in negative social comparisons. Evaluative beliefs were shown to mediate perceived stigma and social comparison. We conclude that evaluative beliefs play the same role in mediating the external and internal experiences of people with learning disabilities as they do with people without learning disabilities. They may therefore be a suitable focus for cognitive therapy with this population.
Models, Values and Interventions in Cognitive Therapy for People with Learning Disabilities
As therapies associated with cognitive models are increasingly applied to people with learning disabilities we need to be aware of the values associated with these approaches. Cognitive therapy promotes individual skills and meaning and thus tends to present people as responsible for their emotional disturbance this is in contrast to the dominant models that have shaped learning disability services, which identify the environment, and/or social structures as the source of difficulty for people with disabilities. In this presentation I will consider the nature of evidence in cognitive models in relation to people with learning disabilities. I will use data from our won recent studies of depression in people with learning disabilities, the results of a qualitative review of other studies that have examined the nature of the relationship between self-concept and depression in people with learning disabilities and a consideration of the process of formulation within cognitive therapy to ask whether the dominant value base in learning disabilities services can be taken as a benchmark for the development of cognitive models to be applied to people with learning disabilities.
Development of the Compassionate Mind in Cognitive Therapy
Convenor & Chair: Paul Gilbert, University of Derby
Discussant: Mark Williams, University of North Wales, Bangor
The Role of Inner Warmth and Compassionate Mind in Cognitive Therapy
Cognitive therapy has traditionally focused on helping people re-evaluate their negative, self-evaluative or dysfunctional cognitions by evidence testing, generating alternatives and problem solving. Recently, however, it has been suggested that it can be the affect of the negative cognitions (e.g., anger, rage, contempt at the self for failing or suffering) that can fuel secondary dysfunctional moods and emotions (e.g., depression). Furthermore, individuals who are self-critical, condemning or self-hating can experience these attacks as being bullied or persecuted. When they use evidence-based techniques to counteract their attacks they can find that the bullying part of them is ‘not interested’ in the evidence. The ‘compassionate mind’ approach has been developed to work with self-hating and criticalness, in people who may have little inner warmth or care for themselves. In the context of a warm containing relationship it seeks to: understand the functions of self-criticism; learn how to be empathic to one’s own distress; develop the capacity for and toleration of genuine grief; use compassionate imagery and visualizations; practice cognitive re-evaluations with warmth; use appropriate help seeking; and work with blocks to self-forgiveness. This talk will give a brief flavour of the theory behind compassionate mind and possible interventions.
Gilbert, P. (2000) Social Mentalities: Internal ‘Social’ Conflicts and The Role of Inner Warmth and Compassion in Cognitive Therapy. In, P. Gilbert & K.G. Bailey (eds.) Genes on the Couch: Explorations in Evolutionary Psychotherapy (p.118-150). London: Brunner-Routledge.
Empathy in Cognitive Therapy
Cognitive therapy stresses the importance of identifying and testing negative thoughts, often with the implication that these thoughts may be extreme or distorted and that “rational” examination, stressing logic and evidence, will assist the patient in developing a more “adaptive” perspective. In the case in which the negative thoughts are true, the patient may be urged to identify “problem-solving” strategies. However, some patients may view this approach as invalidating, activating personal schemas about self-other in attachment or supportive relationships. Conversely, other patients avoid validation and, in fact, discount their rights to have feelings or needs. Pathological strategies of eliciting validation are described, including rumination, escalation, “projective elicitation”, emotional distancing, splitting the “transference” and rejection of the cognitive-behavioural model. Examples of self-invalidation are reviewed, including unwillingness to discuss needs, viewing needs as weakness, using cognitive therapy as a “superficial defence” against emotional experience, and attempts to lower expectations. Therapeutic conceptualisations and strategies are described for helping patients, within a cognitive therapy model, cope with validation problems. The model that directs coping with validation resistance is based on the dilemma that arises in trying to find the validity in the patient’s current “position” and trying to advocate change to another perspective. By identifying the potential limitations and internal conflicts of a cognitive model, the patient may be assisted in recognizing the paradoxical and dialectical nature of change. Clinical interventions, based on a developmental-cognitive case conceptualisation of the patient’s invalidation history and validation needs and the use of experiential and dialectical models are outlined. Schema-mismatch, between patient and therapist personal schemas, is described and interventions are identified to overcome these potential impasses.
Leahy, R (2002) Overcoming Resistance in Cognitive Therapy. New York. Guilford
The Use of Compassionate Imagery in Cognitive Therapy to Promote Self-Acceptance: A Case Example of a Woman with Internalised Body Shame, Depression and PTSD
Shame can be usefully categorised as externally focused (negative feelings associated with belief about how others see and judge the self) or as internal focused (negative feelings associated with judgements about oneself). Although people who are sensitive to external shame may have various social difficulties, they may still have relatively self-accepting attitudes. Internal shame is likely associated with problems with self-acceptance and increased risk of self-dislike and contempt. Gilbert (2000) has suggested that when shame is highly internalised, people may benefit from developing inner warmth and compassion as a vehicle to self-acceptance. Shame can be a common experience accompanying trauma, one that complicates treatment (Lee Scragg & Turner, 2001). This paper presents a case using compassionate mind with a woman, severely burned in childhood, and who later developed severe depression with suicidal intent, PTSD and an eating disorder. Her experience was characterised by high levels of internalised shame, associated with disgust and hatred of her body and of herself. Compassionate imagery, combined with cognitive therapy techniques, were used in the final stages of therapy to de-activate self-attacking and promote self-acceptance. The process of compassionate imagery and cognitions will be described and possible mechanisms as to its therapeutic effectiveness will be discussed.
Gilbert, P. (2000) Social Mentalities: Internal ‘Social’ Conflicts and The Role of Inner Warmth and Compassion in Cognitive Therapy. In, P. Gilbert & K.G. Bailey (eds.) Genes on the Couch: Explorations in Evolutionary Psychotherapy (p.118-150). London: Brunner-Routledge.
Lee, D.A., Scragg, P., & Turner, S. (2001). The role of shame and guilt in traumatic events: A clinical model of shame based PTSD. British Journal of Medical Psychology, 451-466.
The Use of Compassionate Imagery in Cognitive Therapy
Axis I work in the anxiety disorders usually concentrates on the "here and now", and changing current appraisals through discussion and behavioural experiments. However, in some cases, whilst clients can logically see that their appraisals are faulty, the emotion does not shift. Recurrent intrusive images and memories of recent trauma can often have roots in early traumatic experiences. In this presentation, cases will be described in which profound changes in current pathology were achieved by addressing childhood memories. Relevant early memories were accessed by examining current intrusions, and then the meanings of the memories accessed were transformed using the patient's own "compassionate mind". This involved interweaving discussion and imagery techniques. This work will be discussed within the framework of a recent model of PTSD.
The Role of Compassion in the Group Process for Social Phobia
This talk will focus on the role of ‘compassionate mind’ in the context of group cognitive therapy for social phobia. While cognitive therapy focuses on helping people identify and test out their beliefs, and try alternative behaviours, the context in which such occurs is often crucial to outcome. Within a group the compassion of individuals for each other can offer forms of warm acceptance and containment. Hence the compassionate mindset of the group provides a context to enable the bearing of and exploration of our various fears, shames and constrictions.
Bates, A. & Clark D.M (1998). A new Cognitive Treatment for Social Phobia: A Single-Case Study. Journal of Cognitive Psychotherapy, 12, 289-322.
Investigating Dissociation Across Disorders: Theory, Assessment and Treatment
Convenors & Chairs: Warren Mansell, Institute of Psychiatry, London & Emily Holmes, University College London
The Clinical Utility of the DES-Taxon in Understanding Dissociation in the Eating Disorders
Background: High levels of dissociation can be conceptualised as a quantitative extension of normal experience, or as a pathological feature that is qualitatively different from normal experience. Recent work suggests that the latter approach will have greater clinical utility. The present study compares levels of dissociation across groups of eating-disordered women, investigating the utility of dimensional and categorical measures of dissociation in understanding diagnoses and behaviours.
Methods: The Dissociative Experiences Scale (DES-II) was completed by 170 eating-disordered women (drawn from outpatient assessment clinics) and 203 non-clinical women. The clinical group also supplied information regarding eating behaviours and related features (alcohol abuse; reported history of sexual abuse). The DES-II and a subset of its items (DES-Taxon) were used as dimensional and categorical discriminators of the groups and of the presence/absence of specific features and symptoms.
Results: When treated as dimensional measures, the DES-II and DES-Taxon had similar levels of clinical utility (particularly discriminating the binge-purge anorexics from other clinical groups). However, the DES-Taxon was a superior categorical measure, discriminating groups more clearly and predicting the presence of many symptoms and features (e.g. purging, alcohol abuse, reported sexual abuse) much more powerfully.
Conclusions: The DES-Taxon is a potentially valuable self-report measure for indicating the level and presence of dissociative psychopathology in the eating disorders. As well as being convenient to administer and score, it has the clinical and research value of indicating those patients where treatment might need to include addressing pathological dissociation.
Cognitive Predictors of Dissociative Experiences in Non-Patient Samples
Dissociation is seen as one symptom of a number of disorders, and as a psychological process in its own right. Although a wealth of research has been carried out in the area, the findings relate predominantly to the association between certain types of trauma and dissociative experiences. Little is known about the relationship between dissociative experiences and different forms of anxiety, coping styles and negative beliefs about such phenomena. Moreover, dissociation is a normal experience and knowledge about its prevalence and nature in non-clinical samples is limited. The objective of the study was to construct an optimal model of predictors of dissociation. In order to achieve this the relationships between dissociative experiences (measured by 2 methods: the Dissociative Experiences Scale, DES, and a diary) and a range of psychological factors were investigated. The nature and occurrence of normally occurring dissociative phenomena were explored by the collection of diary data. Results suggest there to be a number of different pathways to increased tendency to dissociate within the general adult population. The strongest individual predictors of dissociative frequency were found to be meta-worry and avoidance of trauma related stress. Negative beliefs about dissociation (as an immediate threat to the individuals state of awareness, as well as beliefs about negative appraisals by others) and age also contributed significantly. However, further work is needed to investigate further the relationship between specific types of dissociation and a range of cognitive and anxiety related factors.
Depersonalisation Disorder: A Cognitive-Behavioural Approach
Depersonalisation (DP) and derealisation (DR) are subjective experiences of unreality in, respectively, one’s sense of self and the outside world. These experiences occur on a continuum from transient episodes that are frequently reported in healthy individuals to a chronic psychiatric disorder that causes considerable distress (Depersonalisation Disorder: DPD). Very little research has been conducted into psychological treatments for this disorder. This paper suggests that there is compelling evidence to link DPD with the anxiety disorders, particularly panic, rather than the dissociative disorders. This conceptualisation facilitates a cognitive-behavioural model of DPD, similar to those of anxiety disorders, which proposes that if the DP/DR symptoms that occur commonly in high states of anxiety are catastrophically misinterpreted as indicative of severe mental illness or brain disorder, this will result in a vicious cycle of increasing anxiety and consequently increased DP/DR. Moreover, cognitive and behavioural responses to symptoms, such as specific avoidances, ‘safety behaviours’ and attentional biases, serve to maintain the disorder and by these mechanisms initially transient symptoms can develop into a chronic disorder. The results from a small scale CBT trial with patients diagnosed with DPD found that patients were significantly improved on measures of symptom severity and general functioning at end of treatment and at 6 months follow-up. These initial findings suggest that CBT for Depersonalisation Disorder may be efficacious.
Dissociation and Conversion Disorder
Up to a quarter of the neurological symptoms encountered in specialist settings defy adequate physical explanation. ICD-10 classifies such “unexplained” neurological symptoms as dissociative conversion disorders, reflecting the assumption that dissociation is the primary mechanism in the genesis of these conditions. At present, however, the role of dissociation in the conversion disorders remains poorly understood. In this presentation, a novel model of conversion disorder will be described. The model attempts to extend the dissociation concept by reference to contemporary cognitive psychological research and theory concerning attention, cognition and consciousness. By this view, conversion symptoms should be regarded as disturbances of consciousness and behavioural control, resulting from the chronic activation of stored symptom representations within memory. The model offers a fresh perspective on the nature of conversion symptoms, providing an explicit account of the factors involved in the creation and maintenance of these phenomena. The implications of this model for the psychological treatment of conversion disorders will be discussed.
Towards a Clinically Useful Concept of ‘Dissociation’
This talk provides an overview of a series of discussions that a group of our colleagues have been engaged in that has focused on the phenomenon of dissociation and the conceptual difficulties that clinicians and researchers are faced with when trying to tackle this complex subject. Our main objective was to come to some kind of shared conceptual language with which to understand dissociation in a clinical context, something that proved a challenging and ultimately illuminating process. In this overview, we attempt to alert clinicians to the many inconsistencies in the definition and use of the term and to suggest initial steps for clarification. In particular, we suggest that current definitions of dissociation are too broad, and we question the clinical utility of the classical notion of a dissociative continuum. A brief review of recent attempts to redefine dissociation suggests that greater clinical utility could be achieved by replacing the term ‘dissociation’ with a dichotomy of two qualitatively different concepts: ‘detachment’ and ‘compartmentalisation’. The dichotomy is consistent with emerging evidence from psychometric studies of self-report scales, theoretical work, emerging biological evidence and clinical observations. We believe that the two concepts lead to different recommendations for psychological therapy and we discuss some pertinent examples.
Thoughts and Beliefs in Eating Disorders: New Ideas and New Data
Conveners: Myra Cooper, Isis Education Centre, Warneford Hospital, Oxford & Glenn Waller, St George’s Hospital, University of London.
Discussant: Caroline Meyer, University of Birmingham
Assessing Thoughts and Beliefs in Eating Disorders
New developments in cognitive theory of eating disorders highlight the importance of negative self-beliefs, and underlying assumptions. In bulimia nervosa, a detailed maintenance model has been proposed, incorporating cognition, emotion, behaviour and physiology. This paper focuses on assessing the cognitions in these models. Part 1 describes the development of a new measure. It is designed to assess eating disorder related automatic thoughts. Factor analysis identified three dimensions of thoughts: positive thoughts about eating, e.g. “if I eat it means I don’t have to think about unpleasant things”, negative thoughts about eating, e.g. “I’ll gain weight”, and permissive thoughts, e.g. “It doesn’t matter if I keep eating”. The measure possesses promising psychometric properties, including good construct and criterion related validity. Examples of the items will be presented, and the paper will explain how the cognitions it assesses fit into new theoretical developments in bulimia nervosa. It is concluded that the measure may be a useful addition to those currently available to researchers (and clinicians) interested in eating disorders. Part 2 describes the use of a measure designed to assess two types of underlying assumptions, e.g. “if my stomach is flat I’ll be more desirable”, (weight and shape as a means to self acceptance), “if I gain weight it means I’m a bad person” (weight and shape as a means to acceptance by others), and negative self-beliefs, e.g. “ I’m a failure”, in eating disorders. Young women and young men, with and without a history of dieting, were studied. The unique predictive power of the measure was also assessed by including a generic measure of underlying assumptions. Both women and men with a history of dieting scored more highly than those who had never dieted on assumptions related to weight, shape and eating, but did not differ in negative self-beliefs. Assumptions and beliefs related to eating disorders, as well as female gender, but not Body Mass Index, history of dieting, or generic assumptions and beliefs, predicted eating disorder related symptoms. The findings add to knowledge about the relationship between gender, dieting, and eating disorder related symptoms. They also support the usefulness of a measure of eating disorder specific assumptions and beliefs. As before, the paper will also explain how the assumptions and beliefs assessed by the measure fit into recent developments in cognitive theory for eating disorders. Further work is needed to establish the psychometric properties of the two measures (this is particularly true for the automatic thoughts questionnaire), and to evaluate their usefulness. Ideas for the further development of both measures are presented, and suggestions for their application in research and clinical settings are discussed. A particularly important application is their ability to test recent developments in the cognitive theory of eating disorders, including both bulimia nervosa and anorexia nervosa.
Schema Processes in the Eating Disorders
Background: While women with eating disorders have relatively unhealthy levels of core beliefs (schema content), this does not differentiate the different diagnostic groups. A model of eating pathology is proposed, in which restrictive and bulimic pathology are differentiated not by schema content but by schema processes (the way in which information is processed in order to maintain the schema and to reduce negative affect). It is hypothesised that bulimic disorders will be characterised by secondary avoidance of affect (i.e., methods used to reduce the experience of negative affect that has already been activated), while restrictive disorders will be characterised by primary avoidance of affect (i.e., methods used to avoid the activation of negative affect in the first place).
Methods: Large samples of eating-disordered women and non-clinical women completed the Young-Rygh Avoidance Inventory (measure of secondary avoidance of affect) and the Young Compensatory Inventory (measure of primary avoidance of affect). Factor analyses were conducted to determine the factors present in each scale.
Results: The YRAI yielded two scales (behavioural/somatic avoidance of affect; cognitive/emotional avoidance of affect), and the YCI yielded three scales (avoidance of affect through establishing personal control; avoidance of affect through establishing social control; avoidance of affect through individualization). Scores on these scales were capable of distinguishing the three clinical groups (restrictive anorexia nervosa; anorexia nervosa of the binge/purge subtype; bulimia nervosa) from each other and from the non-clinical women.
Conclusions: The findings support the proposed model of cognitive differences between restrictive and bulimic pathology, stressing the critical role of schema processes in understanding the psychopathology and treatment of the eating disorders.
Exercise-Moderated Eating Problems: Dysfunctional Beliefs in Female Exercisers with Sub-Clinical Eating Disorders
This research was part of a larger study that examined the relationship between exercise behaviour and eating disorder psychopathology in a community sample of 260 female regular exercisers. This particular study reports the types and influence of dysfunctional beliefs in three subgroups: those with the highest, median and lowest levels of eating psychopathology (n=90). Preliminary analysis revealed that the index group with the most severe eating problems had mainly sub-clinical levels of eating psychopathology. This group reported more commitment to exercise than the two comparison groups, but this was not reflected in their exercise frequency or duration, which did not differ. The index group also had significantly higher levels of depression and anxiety. Cognitive analysis was conducted at two levels: (1) automatic thoughts; (2) conditional beliefs and assumptions. These levels were each concentrated on eating, shape, weight, exercise and interpersonal topics using a stem-completion test developed for this purpose. As predicted, the index group was significantly more dysfunctional than the comparison groups at both cognitive levels. Effects were concentrated on eating, shape and weight beliefs, not exercise, which was positively regarded by all groups. Positive exercise cognitions in the index group suggested their eating problems may be moderated but also maintained by exercise behaviour. Negative shape and weight beliefs were also observed in the comparison groups, questioning their specificity to eating psychopathology. At the conditional beliefs level, group differences were attributable to co-morbid depression, not eating psychopathology. The results address the complex relations between exercise and eating problems, suggesting that high-frequency exercise behaviour is not in itself a good indicator of eating psychopathology. Rather, cognitive factors have more explanatory potential, and future research on clinical eating groups should focus on cognitive content, level, and the influence of co-morbid depression in maintaining eating problems that are exercise-moderated.
Socio-Cultural Predictors of Eating Disorder Symptoms and Cognition in Young Girls
Socio-cultural factors in eating disorders have recently been summarised by Stice (1998). There is evidence for a relationship between most of the factors in the model proposed and disordered eating, or concerns. However, the role of individual cognition in this, as outlined in recent theoretical accounts (Cooper, Todd & Wells, 2000), has not yet been investigated. The current study had three main questions. Firstly, which of the socio-cultural factors investigated (parental, peers and the media) predict girls’ eating disorder related symptoms? Secondly, do individual’s cognitions add to this prediction? Finally, which of the socio-cultural factors predict girls’ cognitions? A secondary aim of the study was to investigate the role of maternal cognitions in these relationships. Thirty-eight girls and their mothers participated. The mothers completed the Eating Disorder Belief Questionnaire (EDBQ), and measures of dietary restraint and involvement in their daughter’s weight/shape. Girls completed the Eating Attitudes Test (EAT), the EDBQ, measures of parental, peer and media influence, and a measure of their awareness and internalisation of societal standards of attractiveness. Several of the sociocultural factors were related to girls’ EAT score. The belief that being thinner would make boys like them was the most significant predictor (particularly in younger girls). The younger girls’ cognitions did not add significantly to this prediction. For older girls, the importance of magazines as a source of information about beauty and ideals was the strongest predictor of EAT score. Their cognitions added significantly to the prediction of EAT score. Several socio-cultural factors predicted girls’ cognitions, including being liked by boys, magazine information, and internalisation of socio-cultural ideals. Maternal cognitions did not significantly predict girls’ EAT score. The results suggest that socio-cultural factors are important determinants of girls’ eating disorder related symptoms. Cognitions identified in recent theoretical developments add to this relationship. Socio-cultural factors are also predictive of girls’ cognitions. Different factors may be influential in younger and older girls. The clinical and research implications are briefly considered.
The Role of Compensatory Behaviours in the Eating Disorders: Time for a Rethink
Background: It is often assumed that compensatory behaviours (vomiting, laxative abuse, fasting, etc.) are simple behavioural consequences of having overeaten. However, there is some indication that compensatory behaviours and attitudes play a much more central role in the psychological maintenance of the eating disorders. This study describes the development of a self-report scale of compensatory behaviours and attitudes, and its clinical validation relative to measures of mood and core beliefs. Methods: A large clinical sample of eating-disordered women completed the (newly developed) Compensatory Behaviours Scale (CBS), as well as standardised measures of anger (STAXI), dissociation (DES-II) and core beliefs (YSQ-S).
Results: The CBS yielded four sub-scales. Different behaviours appeared to have specific psychological functions, and different attitudes to compensation were associated with specific core beliefs.
Conclusions: The cognitive and affective correlates of different compensatory behaviours and attitudes indicate that compensation is a central part of the pathology of the eating disorders (rather than a simple consequence of having overeaten). However, those patterns suggest that existing conceptualisations of compensatory behaviours are flawed, in both diagnostic and formulation-based models.
Cognition and Emotion Across Disorders
Selective Attention and Emotional Processing in Bipolar Disorder
There is growing evidence that bipolar patients are characterised by selective attention impairments which might also define the identification of an emotional processing default system, markedly different in style from unipolar depressed patients during mood state. Although evidence for a bias towards negativity might also exist against positive directivity, between the two conditions, we hypothesise that this impairment is defined by dysregulation in configuration within attentive processes in bipolar disorder. This is also reflective of the severity of symptomatology and its residual noise affect in the remitted state, and hence defines the affective component between these two conditions.
Methods: Participants were 42 medicated DSM-IV bipolar 1 depressed (13), manic (14), and remitted (15) patients, and 15 unipolar and 15 normal controls, aged between 18-65. All subjects were matched for age and IQ. Subjects completed the Golden (1978) version of the Stroop test and a version of the Emotional Stroop test. The Stroop test assesses selective attention using the reading of colours and words in an allocated time span. The Emotional Stroop assesses selective attention by the reading of colours of words that are typically emotional in valence (positive or negative) alongside neutral words.
Results: Repeated ANOVAs indicated that the bipolar patients were longer on the reading of colour-congruent words on the Stroop test F (4, 70), =3.034, P= < .03. Remitted bipolars showed worst performance across all the conditions, with manics’ showing similar results. The depressed bipolars were most impaired on the conflict condition. On the Emotional Stroop, when words were defined by a negative tone, the manics performance reached significance when colour words card were read F (4, 70), p= < .03. The unipolar group showed similar results but showed less significance. Post Hoc tests showed that the remitted bipolars were more impaired than unipolars and normal controls across all conditions. The pattern of selective attention impairment shown on these tests between these groups is indicative of a general attentive dysfunction in bipolar disorder, and that this impairment is influential in directivity and control within emotional processing mechanisms. Comparative studies have also shown that bipolar patients show marked impairments in their ability to focus attention (Murphy, F.C., Sahakian, B.J., Rubinsztein, J.S., Michael, A., Rodgers, R.D., Robbins, T.W., & Paykel, E.S.: 1999), alongside attentional biases for emotional stimuli congruent with their current mood. The regulatory involvement in bipolar patients which is reflected by the versatility in selective attention processes is consistent with impairments reported for patients with frontal lobe dysfunction caused by lesions. Inconsistencies in attentional processes in bipolar subjects caused by dsysregulation of receptor sites within the limbic and hippocampal structures and of hyperfunctional cAMP-mediated signalling has also been suggested. We conclude that attentional irregularities in bipolar disorder contribute to both style of emotion perception and evaluative trajectories, and are additionally influential in severity of symtptomatology. The implications of these findings suggest the identification of an attentive baseline for assessing attentional configurement. Advocating regularity of routine and detection of prodromes without knowingly justifying attentive configurement and ensuing emotionality could have adverse affects on treatment efficacy in some bipolar patients.
The Role of Pre-sleep Cognitive Activity and Pre-sleep Anxiety in Distorted Perception of Sleep in Insomnia
A recent cognitive model has proposed that distorted perception of sleep is one of the core cognitive processes that perpetuates insomnia (Harvey, in press). Yet, the mechanisms underpinning distorted perception of sleep, characteristic of insomnia patients, are largely unknown. Previous research has implicated anxious pre-sleep cognitive activity as one possible mechanism. This study aimed to experimentally manipulate and separate the effects of pre-sleep cognitive activity and pre-sleep anxiety in distorting sleep perception using an analogue sample. Fifty-four good sleepers were randomly allocated to one of three groups: Cognitive-Activity-Plus-Anxiety Group (CAG), Cognitive-Activity-Only Group (COG) and Control Group (CG). Prior to a one-hour afternoon nap, the CAG were told that they would be asked to give a speech on waking, the COG were told to write an essay on waking, the CG were simply told to “take a nap”. It was expected that the hypothesised mechanism(s) would induce a ‘state’ akin to insomnia in good sleepers. Following the nap, checks of pre-nap cognitive activity and anxiety confirmed that the experimental manipulations had the desired effect, i.e., the CAG and the COG experienced more pre-nap cognitive activity than the CG. Additionally, the CAG was more anxious than the other two groups during the pre-nap period. Relative to the CG, the CAG significantly overestimated their sleep onset latency and underestimated their total sleep time. These findings suggested that anxious pre-sleep cognitive activity may be a mechanism underpinning distorted perception of sleep. Specifically, the valence of pre-sleep cognitive activity is key to sleep misperception.
Future-Directed Cognition in Depression: The Role of Overgeneralization
Depressed people are known to hold pessimistic views of the future, but relatively little is known about the cognitive processes that influence and maintain those beliefs. Measures of hopelessness suggest that when pessimistic outlooks become global and generalized, there are associated risks of deeper depression and self-harm. This research investigated overgeneralization as a cognitive process that might underlie future-directed cognition in depression, and possibly also link to hopelessness. A stem-completion method was used to elicit thoughts about various construals of future time, and different levels of generalization (e.g., “all of”, “some of”, “none of”) were pitted against a range of time periods to test for effects on negative cognition. A depressed group (n=36) and a non-depressed control group (n=36) also completed self-report measures of depression, anxiety and hopelessness. Averaged across conditions, the depressed group were more negative than the controls, but not less positive (in contrast to event-based measures of future-directed cognition in prior research). In the depressed group, there were only minimal effects of time-period on negative cognition, but large effects of generalization. The depressed were most negative when making extreme generalisations (e.g. “Hardly any of the future…will be bright”), but surprisingly, under conditions where participants were forced to make moderate generalizations, the depressed were sometimes more positive than the controls (e.g. “Some of next year…will be good”). Implications for models of overgeneralization, future-directed cognition and hopelessness will be discussed.
A Model of Emotional Schemas
Three theoretical models of the relationship between cognition and emotion are examined: (a) ventilation theory (the greater expression of emotion, the better the outcome), (b) emotionally-focused therapy (activation, expression and validation of emotion facilitates acceptance and self-understanding), and (c) a cognitive model of emotional processing (individuals differ in their conceptualization and strategies in responding to emotion). A self-report assessment of emotional schemas reflecting 14 dimensions related to cognitive processing and strategies of emotional response is presented. Fifty-three adult psychotherapy patients were assessed and their responses on the emotional schemas evaluation were correlated with the Beck Depression Inventory and the Beck Anxiety Inventory. There was strong support for a cognitive model of emotional processing. Higher depression was related to greater guilt over emotion, expectation of longer duration, greater rumination, and viewing one’s emotions as less comprehensible, less controllable, and as different from the emotions others have. Greater anxiety was related to greater guilt over emotion, a more simplistic view of emotion, greater rumination, viewing one’s emotions as less comprehensible, less acceptance of feelings, viewing emotions as less controllable, and as different from the emotions others have. Dimensions related to the ventilation model - such as validation, numbness, and expression - were not related to depression or anxiety, although acceptance of feelings was related to less anxiety. Support was obtained for the emotional focused model. Validation was related to less guilt, less simplistic ideas of emotion, expectation of shorter duration, less rumination and to viewing emotion as more comprehensible, more controllable, more similar to emotions of others, and more acceptance of feelings.
Is Magical Ideation a Core Feature of OCD? Two Clinical Studies
Magical Ideation may be a core feature of Obsessive Compulsive Disorder (Amir, Freshman, Ramsey, Neary & Brigidi, 2001; Einstein & Menzies, submitted). Magical Ideation was hypothesized to be correlated with obsessive compulsive symptoms in an outpatient OCD sample and to be reduced with standard treatment of the disorder. In the first study, 60 OCD outpatients completed the Magical Ideation Scale (MI), the Thought Action Fusion-Revised scale (TAF-R), the Obsessive Compulsive Inventory –Short Version (OCI-SV) and the Padua Inventory (PI). In the second study, 19 participants completed the MI scale, the Maudsley Obsessional Compulsive Inventory, the PI and OCI-SV, pre and post treatment. Magical Ideation was shown to be significantly related to obsessive compulsive scores in the first study, with correlations reaching .69 with the Padua Inventory. The TAF scales appeared to be related to obsessive compulsive symptoms by virtue of their relationship with magical ideation. In the second study, Magical Ideation was shown to be correlated with symptom improvement across treatment.
On Being Overweight and Obese: How Much and Where Does It Matter?
Considerable evidence attests to high levels of body dissatisfaction in overweight and obese women. Moreover, negative stereotypes of large women abound in Western society. In a culture that prescribes a thin-is-beautiful ideal for women, large women are regarded as less attractive, feminine, successful, industrious, and popular than their normal weight counterparts and they are considered to have less to offer in intimate relationships. Despite heightened levels of body dissatisfaction and the pervasive social stigma of obesity, differences in self-esteem, happiness, anxiety, and depression are rarely apparent in community samples of women of varying weights, indicating that the psychological well-being of overweight and obese women is similar to that of women of normal weight. The effects of being overweight and obese on other important psychological domains of a woman’s life have been neglected, however. What, for instance, is the impact of being large on a woman’s sense of self as a sexual being, and on her relationship status and the level of satisfaction she experiences in close relationships? These questions remain largely unanswered. The present research was therefore designed to replicate and extend previous research on the psychosocial effects of being overweight and obese by examining body dissatisfaction, psychological well-being, sexual self-schema, and relationship status and satisfaction in a large and diverse nonclinical sample of women. It was predicted that increased weight would be associated with heightened levels of body dissatisfaction, a negative sense of self as a sexual woman, a greater likelihood of an unpartnered, single relationship status, and lower levels of relationship satisfaction. In keeping with previous findings, it was also predicted that body shape and size would have little impact on various indices of psychological well-being and self-esteem. Participants were 503 women recruited from a wide cross-section of communities in rural and metropolitan Australia. Age ranged from 14 to 86 years (M = 33.6) and participation was anonymous. All women completed a number of questionnaires designed to tap the constructs of interest. Based on their Body Mass Index, the women were categorised as underweight (n = 85), normal weight (n = 214), overweight (n = 116), and obese (n = 88). Results revealed that overweight and obese women reported higher levels of body dissatisfaction than underweight and normal weight women but no effects of weight on psychological well-being were apparent. These findings replicate those of previous research. Of particular interest, weight had no impact on the women’s sense of self as sexual beings nor on their ability to form intimate relationships and feel satisfied in them. Being overweight or obese appears to have remarkably little detrimental effect on many important domains of a woman’s life.
Insomnia in People with Anxiety Attending a CMHT: What Cognitive Factors are Maintaining the Insomnia?
Research has implicated cognitive factors in the maintenance of insomnia, such as beliefs about sleep, attentional processes and thought control strategies. However, little is known about the maintaining factors of insomnia in people who have co-morbid anxiety disorders. Literature suggests that for people with co-morbid diagnoses, the insomnia would be alleviated through a focus of treatment on the mental health problem (Morin, 1993), not the sleep problem. This therefore assumes that cognitive factors involved in the insomnia are anxiety-related rather than sleep-related. The present study aims to examine cognitive factors of night time cognitions, beliefs about sleep and thought control strategies in people with a diagnosis of an anxiety disorder plus insomnia (based on DSM-IV classifications), compared with those with either an anxiety disorder only, insomnia only or good sleepers. This should highlight the cognitive factors involved in the maintenance of insomnia in people with co-morbid anxiety disorders. Results will have important implications for the treatment of insomnia in people who also have anxiety disorders. They should highlight whether insomnia may be expected to improve following a standard treatment focus on the anxiety, or whether it would be more appropriate to include a treatment specifically targeting the insomnia.
Morin, C.M. (1993) Insomnia: Psychological Assessment and Management. New York: Guilford Press
Mirror-Related Behaviours and Body Dissatisfaction
Mirrors play an obvious and important role in repeated shape checking, which is a clinical feature of eating disorders and has been suggested to contribute to the maintenance of body image disturbance (Rosen, 1997, Fairburn et al, 1999). We hypothesised that women with body dissatisfaction would differ in their use of mirrors from women who were satisfied with their bodies. The present study tested this hypothesis using a semi structured questionnaire on mirror-related behaviours. The ‘Mirror Questionnaire’ was completed by 114 women, of whom 50 reported high levels of body dissatisfaction and 21 of whom had a clinical eating disorder. Compared to women who were satisfied with their bodies, women with high levels of dissatisfaction looked in the mirror more frequently (z = 3.02, p = 0.003), paid more attention to disliked body parts (χ2 = 4.8, p= 0.029), were more likely to engage in idiosyncratic checking behaviours in front of the mirror (χ2 = 9.33, p = 0.002) and had fewer positive or neutral cognitions or emotions when looking in the mirror (χ2 = 21.8, p < 0.001). Although frequency of looking was greater in dissatisfied group, avoidance of looking in the mirror was also greater (χ2 = 36.0, p < 0.001). These findings support the notion that women with high body dissatisfaction differ from those with low dissatisfaction in their use of mirrors, and argue for further investigation of the role of mirror-related behaviour in the maintenance of body image disturbance.
Eating Disorder Not Otherwise Specified (EDNOS): Profiles of Clients Presenting at a Community Eating Disorder Service
Background: Despite suggestions that up to 61% of eating disorder presentations fulfil the DSM-IV diagnostic criteria for EDNOS, relatively little research has been conducted examining this group and how they differ from other eating disorder diagnoses.
Aim: To describe the clinical profiles of 200 clients assessed in a Community Eating Disorder Service.
Method: DSM-IV diagnoses were generated using the Eating Disorder Examination (Fairburn & Cooper, 1993). Clinical profiles of the EDNOS group are commented upon and compared with those who fulfil full diagnostic criteria. Cluster analysis was used to explore whether there were meaningful subgroups, based on presenting features, within the clinical sample.
Results: 190 of the 200 participants had an eating disorder of clinical severity. The DSM-IV diagnostic breakdown of the clinical sample was as follows: 11 had AN, 45 had BN and 134 had EDNOS. Within EDNOS 54 missed one of the diagnostic criteria for AN and 66 missed one of the diagnostic criteria for BN. Cluster analysis suggested four sub-groups within the clinical sample (N=190); three clusters had similar levels of cognitive psychopathology but varied in behavioural presentation, and one cluster contained participants whose cognitive and behavioural features were less severe, but whose mean BMI was low.
Discussion: Although a high proportion of participants received a diagnosis of EDNOS very little research is carried out on this group of patients. These results highlight the need for further investigation into the usefulness of EDNOS as a diagnostic category, as well as the value of the diagnostic system in its current form.
The Acquisition of Washing Behaviours in Obsessive Compulsive Disorder (OCD)
The present study provided further investigation of associative learning and non-associative accounts of OCD among OC washers. In addition, the possible relationship between the mode of OCD acquisition and treatment outcome was explored. Nineteen individuals, who met the DSM-IV criteria for OCD with washing/cleaning behaviours, completed a battery of assessment measures to evaluate their level of OCD severity. Each participant also completed the OCD Origins Questionnaire (OOQ), devised by Jones & Menzies (1998a). Following assessment, participants received twelve individual sessions of either a cognitive/information-based treatment package or a behaviour-based treatment package. All assessment measures were re-administered at post-treatment, with the exception of the OOQ. The present study offered less support for a non-associative account of OCD onset than previous studies of OCD or the phobic disorders. Only 26% of the sample reported that they had always been excessively fearful or anxious in the presence of OC thoughts or activities, or had experienced a non-conditioning traumatic event at the onset of their disorder. No relationship was found between mode of acquisition and severity or treatment intractability. Subjects receiving treatment consistent with the way in which they acquired their OC washing behaviours (i.e. an information-based treatment package for an indirect/informational onset event) performed at a similar level to those subjects who received treatment which was discordant with their onset classification (i.e. an information-based treatment package for a direct conditioning event at onset). Thus, it may not necessarily be the case that concordant treatment provides the most successful outcome for the client.
Responsibility Insight in Obsessive Compulsive Disorder
Cognitive models have proposed that inflated responsibility for harm plays a central role in Obsessive Compulsive Disorder (OCD) (Salkovskis, 1985, 1989). This study aimed to explore the concept of ‘responsibility insight’, i.e. the awareness in people with OCD of the idiosyncrasy of their own responsibility biases. 32 adults with OCD participated. A new scale was developed, the Self Compared to Others Reactions to Events Scale (SCORES), employing hypothetical scenarios with a theme of responsibility for harm. Ratings were taken for ‘oneself’ and ‘others’ (i.e. “How would the average person in the street react?”). In general, the OCD group demonstrated good evidence of responsibility insight. Consistent with previous studies, responsibility predicted severity of OCD. Moreover, on the SCORES, poor responsibility insight was also predictive of greater severity of OCD. Furthermore, this association was independent of responsibility levels. It was also found, contrary to expectation, that a subgroup who had experience of therapy scored significantly lower on responsibility insight on the SCORES. Poor responsibility insight may predict severity of OCD independently of responsibility, although more research is needed. One explanation is that obsessive individuals can use their specific insight to partially ameliorate their difficulties by employing strategies such as cognitive self-talk. The maintenance of responsibility beliefs despite good responsibility insight deserves exploration. It is argued that responsibility insight, not previously studied, may have a significant bearing on both models and treatment of the disorder.
Cognitive Biases in Social Anxiety
Beck, Emery, and Greenberg (1985) suggest that social anxiety is associated with selective attention towards threatening stimuli in the environment. In contrast, Clark and Wells (1995) propose that during social interaction the attentional bias is self-focused and directed away from the threatening stimuli. The present experiment addressed this theoretical conflict by investigating the direction of the attentional bias in high (n=40) and low (n=40) socially anxious individuals, selected using the fear of negative evaluation scale (Watson and Friend, 1969). A modified version of a probe detection task was employed incorporating four different threatening word groups (physical, negative evaluation, somatic and situational), included to assess the specificity of the bias, under either a social-evaluative threat condition or a non-threatening condition. Reaction times and attentional bias scores for each word group were analysed using analysis of variance. The results are discussed in relation to previous findings and theoretical perspectives.
Intrusive Memories in a Non-Clinical Sample: The Roles of Affect and Vividness
Recent work by Brewin and colleagues (e.g. Brewin, Phillips, Carroll, & Tata, 1996) has highlighted the occurrence of distressing intrusive images during depressive episodes. In addition, Brewin, Christodoulis and Hutchinson (1996) found evidence of intrusive memories in a non-clinical undergraduate sample. The study reported here extends Brewin et al.'s (1996) study, to investigate mood and intrusive memories in an undergraduate sample. Participants were pre-selected into two groups of 20, on the basis of BDI scores (three or below, and nine or above). Participants were asked to generate as many intrusive memories as possible from the previous 2 weeks, and to match these with pleasant and unpleasant non-intrusive memories from roughly the same time period. Participants then rated each of these memories on scales of pleasantness and arousal. In addition, participants also rated their imagery vividness, leading to the finding that intrusive memories are more vivid than non-intrusive memories, even after controlling for pleasantness and arousal. Furthermore, participants in the low mood group had more vivid imagery than the high mood group, regardless of the memory valence. These results will be discussed with regard to the findings of Kavanagh, Freese, Andrade and May (2001). They found that concurrent visuo-spatial tasks during exposure to emotional memories lead to less vivid imagery for those memories, and less extreme emotional responses. Advantageously, this reduction in vividness and emotional response did not affect the habituation to the emotional memory. Avenues of potential future clinical interventions using visuo-spatial tasks to reduce image vividness will be discussed.
Avoidant Encoding in Acute Stress Disorder: A Prospective Study
General Adult Disorders
A Cognitive Model and Treatment of Posttraumatic Stress Disorder
Professor Anke Ehlers, Department of Psychology, Institute of Psychiatry, London
After traumatic events such as assault, severe accidents, natural disaster or bombings, many people develop symptoms of posttraumatic stress disorder (PTSD). While many people will recover in the first year after the event, a significant proportion stay symptomatic. Ehlers and Clark (2000) have recently described a cognitive model of PTSD. The model comprises three maintaining mechanisms.
· People with chronic PTSD interpret the trauma and/ or its sequelae as a sign of a current severe threat.
· The (involuntary) reexperiencing symptoms of PTSD are mainly the result of a failure to establish an organised memory of the trauma in which the event is linked to its context in time, to other autobiographical memories, and to previous and subsequent information. Retrieval is therefore driven by cue-driven memory mechanisms such as associative learning and perceptual priming of stimuli that accompanied the event.
· The dysfunctional appraisals motivate the individual to engage in behaviours and cognitive strategies that are intended to control the perceived current threat/ the PTSD symptoms, but maintain the problem, for example thought suppression, cognitive avoidance, rumination, safety seeking behaviours.
A series of studies of trauma survivors, including prospective longitudinal studies and laboratory experiments, supported the role of these factors in chronic PTSD. On the basis of the model, we have developed a cognitive behavioural treatment of PTSD. By changing appraisals directly, we have substantially reduced the number of imaginal reliving sessions compared to previous studies. Two randomised controlled trials showed that the treatment is highly acceptable to patients, and more effective than wait list or self-help instructions. Effect sizes were twice as high as the mean effect size reported for cognitive behavioural treatments in the meta-analysis by van Etten and Taylor (1998). Comparable effect sizes for the treatment were achieved by trained clinicians in a community setting (Gillespie, Duffy, Hackmann & Clark, 2002).
Gillespie, K., Duffy, M., Hackmann, A., & Clark, D.M. (2002). Community based cognitive therapy in the treatment of post-traumatic stress disorder following the Omagh bomb. Behaviour Research and Therapy, 40, 345-357
Ehlers, A., & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345
Van Etten, M.L. and Taylor, S. (1998). Comparative efficacy of treatments for posttraumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy 5, 126-144
Body Dysmorphic Disorder: What You See Is Not What I See
Fugen Neziroglu, PhD, ABBP,ABPP, Bio-Behavioral Institute, NY, USA
Attractiveness has been a topic of interest from philosophers to advertisers. Its role has been widely studied as part of normal adolescent development, social psychology, and body image development. During adolescence, individuals become preoccupied with their appearance and may spend time trying to improve it. Also, they are more concerned about the evaluation of others and are quite sensitive to teasing and any possible physical defects no matter how slight. The extent to which they become involved in their looks depends on many factors from biological disposition to environmental pressures. Their body image becomes disturbed when their subjective perception of themselves differs from the objective evaluations. There are varying degrees of body image disturbance, with body dysmorphic disorder (BDD) at the extreme end. BDD is a preoccupation with an “imagined” defect in one’s appearance and when there is a slight physical anomaly the person’s concern is markedly excessive. There is significant distress and impairment in functioning. It is highly prevalent both in males and females and a very serious disorder with a high percentage of suicidal attempts. BDD can be conceptualized from a Darwinian, perceptual, cognitive, affective, behavioral, neuropsychological and neurobiological perspective. Its treatment consists of cognitive, behavioral and pharmacological treatment. No singular treatment has been found to be more effective than behavioral therapy.
Dr. Neziroglu is a behaviour and cognitive therapist who has been involved in the research and treatment of anxiety disorders and depression for over twenty years. She is a scientist and practitioner who has presented and published over 100 papers in scientific journals and books. She is co-author of six books with Dr. Yaryura-Tobias. Dr. Neziroglu received her Ph.D. in clinical, school-community psychology from Hofstra University. She is Board Certified in Cognitive and Behavior Therapy from the American Board of Behavioral Psychology (ABBP) and in Clinical Psychology from the American Board of Professional Psychology (ABPP). She is also a Board Member and a Fellow of ABBP's Academy. She has done post-graduate work in behaviour and cognitive therapy. She is an Associate Professor at Hofstra University, Department of Psychology and Clinical Professor of Psychiatry at New York University. At the Bio-Behavioral Institute, Dr. Neziroglu provides direct services, supervises all assistant psychologists and psychology interns, sponsors many doctoral dissertations and conducts research. She is a member of many national and international societies and is on the Scientific Advisory Board of the Obsessive Compulsive Foundation.
Aaron T Beck: Mind, Man and Community Mentor
Christine A Padesky, PhD, Center for Cognitive Therapy, Huntington Beach, California, USA
This keynote address includes a retrospective review of Aaron T. Beck’s contributions to the field linking conceptual, empirical and psychotherapy developments to show their overlapping historical evolutions. The impact of his intellectual contributions were enhanced by the historical contexts in which they emerged and also by Beck’s personal qualities which amplified their acceptance by the broader psychological community. In addition, Beck developed a new model of psychological community in which he personally invested great time and energy to create an international network of researchers, clinicians and academics. This review of Beck’s intellectual, personal, and community contributions reveals principles which guide his career and points to values which can guide each of us engaged in the continuing evolution of cognitive therapy and our professional community.
Cognitive-Behavioural Treatment of Posttraumatic Stress Disorder in People with Severe Mental Illness
Kim Mueser, Dartmouth Medical School, USA
People with severe mental illness (SMI) have a high prevalence of comorbid posttraumatic stress disorder (PTSD), but there are no established guidelines for treating PTSD in this population, nor have any controlled studies been completed. This presentation will describe the background and development of such an intervention. The presentation will begin with a review of the high prevalence of trauma and PTSD in this population, followed by discussion of an interactive model that posits PTSD worsens the course of SMI. Next, a 12-16 session individual, manualized cognitive-behavioral treatment (CBT) program for PTSD in clients with SMI will be presented. Results from a pilot study of 15 clients will be presented, demonstrating the feasibility and promise of the intervention. The design of a randomized controlled trial of this program, currently underway, will be described. The presentation will conclude with a discussion of how manualized interventions can be adapted to address the needs of clients with multiple problems, including comorbid psychiatric and substance use disorders.
Past Progress and Future Challenges in Understanding and Treating Anxiety Disorders
David M Clark, Department of Psychology, Institute of Psychiatry
Anxiety disorders are common, under diagnosed, and under treated. A cognitive science approach to developing more effective treatments is outlined. The approach attempts to identify factors that prevent patients’ excessively negative appraisals of danger from self-correcting and targets these factors in therapy. Illustrations of key maintaining factors and the way they can be reversed in therapy will be presented from a range of anxiety problems including: panic disorder, hypochondriasis, social phobia, and PTSD. Surprise findings and the way these have influenced practice will be particularly highlighted. A review of the effect sizes that can currently be expected for cognitive therapy programmes in anxiety disorders will lead on to a discussion of two types of future challenge. First, how can treatments be made more effective and acceptable? Second, how can they be disseminated in a way which will make them accessible to most patients?
The Understanding and Treatment of Social Anxiety: Retrospect and Prospect
Professor Richard G Heimberg, Adult Anxiety Clinic of Temple
Richard G. Heimberg is Professor of Psychology and Director of the Adult Anxiety Clinic of Temple. He is currently President of the Association for Advancement of Behavior Therapy. Dr. Heimberg is well known for his efforts to develop and evaluate cognitive-behavioural treatments for social anxiety. More recently, he and his colleagues have initiated a program for the study and treatment of generalized anxiety disorder. Dr. Heimberg has published more than 200 articles and chapters on social anxiety, the anxiety disorders, and related topics. In addition, he is co-editor or co-author of the books Social phobia: Diagnosis, assessment, and treatment and Managing social anxiety: A cognitive-behavioural therapy approach, as well as the forthcoming Cognitive-behavioural treatment for social phobia: Basic mechanisms and clinical strategies and Generalized anxiety disorder: Advances in research and practice. Dr. Heimberg was recently named one of the four most influential psychological researchers in anxiety in a survey of members of the Anxiety Disorders Association of America. He is a founding fellow of the Academy of Cognitive Therapy and the recipient of the Academy’s inaugural Award for Significant and Enduring Contribution to Cognitive Therapy.
Thirty Years of Cognitive Therapy for Depression: What Have We Learned, What Have We Yet to Learn?
Professor Keith Dobson, University of Calgary, Canada
Advances and Traps in the Understanding and Treatment of Obsessive Compulsive Disorder
Paul Salkovskis, Psychology Department, Institute of Psychiatry, London
The understanding and treatment of obsessive-compulsive disorder has been transformed by the development of behavioural and cognitive-behavioural theories. Whilst the development of biological theories has also considerably improved the treatment of OCD, these have generally failed to improve understanding of the condition, and in certain respects may have interfered with it. Recent findings of direct relevance to psychological aspects of obsessional problems will be described. The way these inform treatment development is considered. Unhelpful psychological theories are also identified. Problems inherent in current neurobiological work are discussed. An agenda for future clinical and research development is set.
CBT for Anxiety Disorders: What Progress Have We Made After 35 Years of Randomized Clinical Trials?
Lars-Göran Öst, Department of Psychology, Stockholm University, Sweden
The purpose of this presentation is to attempt to answer two questions: 1) Are CBT methods for anxiety disorders more effective now than they were 10, 20, 30 years ago?, and 2) Are the follow-up results better now than they were 10, 20, 30 years ago? Searches for randomized clinical trials (RCT) were done in Medline and Psychlit 1965-2002 and effect sizes (ES) were calculated for the most central measures in each study. In addition clinically significant improvement (CSI) was calculated according to various models, as well as treatment time and attrition rate. A total of 318 studies were found and for 229 of these ES could be calculated. For another 22 studies CSI was calculated yielding a total of 251 studies that were used in the analysis. The studies were classified into three periods according to decade of publication (1970's, 80's and 90's) and ESs were compared separately for independent assessor ratings (IA), self-ratings of the anxiety disorder (SR), BAT, CSI, treatment time and attrition rate. For specific phobia there was a significant positive development over time on IA, SR and BAT and a negative development regarding treatment time. For social phobia the development was first positive and then negative on BAT, and negative on treatment time and attrition. For agoraphobia there were negative developments on SR and BAT. For panic disorder the development was negative on CSI. Generalized anxiety disorder showed first a positive and then a negative development on SR and negative on treatment time and attrition. OCD had negative developments on SR and attrition, and PTSD a negative development of CSI. When looking at the follow-up results the outcomes were mainly not significant across time. For specific phobia, however, there were positive developments on IA, SR and follow-up duration. Social phobia also had longer follow-up durations across time. Agoraphobia first had a positive and then a negative development on CSI. GAD showed longer follow-up durations across time. OCD displayed a negative development on SR. Panic disorder and PTSD did not have any significant developments. Only when the individual studies having the highest ES on self-report measures each decade were compared, were there positive developments for all disorders, except for panic disorder (which remained stable) and OCD (which showed a negative development). One conclusion that can be drawn is that, with the exception of specific phobia, there is not much increase in mean ES across time. A second conclusion is that the picture looks the same regarding follow-up results. Some of the possible explanations to these results will be discussed.
Body Dysmorphic Disorder: New Research
Convener: David Veale, Royal Free Hospital, West London Mental Health NHS Trust and University College London
Chair & Discussant: Ann Hackmann, University of Oxford, Warneford Hospital
Cognitive Therapy and Exposure and Response Prevention in the Treatment of Body Dysmorphic Disorder: A Comparative Investigation
Body dysmorphic disorder (BDD) is characterized by an intense preoccupation with an imagined or slight defect in appearance which significantly interferes with all aspects of functioning. Individuals with BDD are often quite difficult to engage in behavioral treatment due to low levels of motivation, presence of multiple co-morbid diagnoses, high overvalued ideation, and tendency to seek non-psychiatric treatment, such as cosmetic surgery and dermatological procedures. The purpose of the current study, therefore, was to evaluate the effectiveness of adding a regime of cognitive therapy to exposure and response prevention for the treatment of BDD. It was hypothesized that those receiving a combined treatment approach would demonstrate a greater decrease in BDD symptoms as compared to participants receiving behavioral therapy only. A total of 10 participants were randomly assigned to one of two intensive treatment conditions. Condition 1 consisted of four weeks of intensive cognitive treatment followed by four weekd of intensive in-vivo exposure and response prevention. Condition 2 consisted of eight weeks of intensive exposure and response prevention. Both groups consisted of a two-week baseline prior to treatment. Multiple self-report and interview measures were given weekly to assess treatment efficacy: Yale-Brown Obsessive Compulsive Scale for BDD, Beck Depression Inventory-II, Beck Anxiety Inventory, and the Overvalued Ideation Scale. Results indicate that participants showed significant improvement on all measures regardless of treatment condition. A combined approach, however, led to greater decreases in self-report anxiety compared to behavioral therapy alone. In summary, cognitive therapy has an additive effect to behavioral therapy.
Cosmetic Rhinoplasty and Body Dysmorphic Disorder
Introduction: Retrospective surveys of BDD patients preoccupied by the size and shape of their nose have shown that they are dissatisfied with the results of cosmetic rhinoplasty. There is very little research on the prevalence of BDD in private cosmetic surgery clinics.
(1) Aim: To determine prevalence of BDD and predictors of predictors of satisfaction prior to surgery. Method: We found it difficult to obtain the cooperation of private cosmetic surgery clinics but managed to recruit 29 subjects (a) pre-rhinoplasty (b) three months post-surgery and (c) nine months post-surgery. They completed a BDD screening questionnaire, the Hospital Anxiety and Depression scale, Attitudes about Appearance scale and a questionnaire to test predictors of satisfaction. Results: 6 out of the 29 scored positive for BDD. The possible BDD patients had higher scores on the YBOCS than the non-BDD group. These decreased post-rhinoplasty in both groups.
(2) Aim: To determine features that distinguish patients who have a good outcome with cosmetic rhinoplasty with BDD patients who would like cosmetic surgery. Method: We removed the “possible BDD” patients from the previous study to leave a sample of 23 patients who screened negative for BDD and were satisfied with their cosmetic rhinoplasty. We compared them with 15 BDD patients preoccupied with their size and shape of their nose who were seen in a psychiatric clinic and who would wanted cosmetic surgery but had not had it (for example they could not afford it). The results will be discussed and guidelines for cosmetic rhinoplasty presented.
Social–Evaluative Versus Self-Evaluative Concerns in Body Dysmorphic Disorder
The cognitive model of body dysmorphic disorder (BDD), (e.g. Veale et al 1996) proposes that exaggerated beliefs about the importance of appearance in terms of identity lead to processing of the self as an aesthetic object in situations associated with perceived threat. This results in a variety of distorted cognitive, perceptual and behavioural processes. Appearance-related threat may be perceived in both social and non-social contexts, and the literature describes both concerns about negative evaluation of appearance by others, (social-evaluation) as well as internal self-evaluation as core underlying components of BDD (e.g. Veale et al, 1996b; Rosen and Reiter, 1996). However, there has been little systematic investigation into the degree of importance of social-evaluative concerns relative to self-evaluative concerns, and the existence of possible sub-groups. It is felt that increased clarification of the role of social-evaluative anxiety in BDD, including the association with Clark and Wells’ (1995) cognitive model of social phobia, will be of significant benefit in developing the cognitive model of BDD. Preliminary data will be presented from a study investigating the above factors amongst patients with BDD, social phobia and depression, as well as normal controls. There are two parts to the study. The first involves the administration of three newly-devised questionnaires, investigating the following: self-ratings and perceptions of others’ ratings of the subject’s actual and ideal appearance; ratings of the importance of the subject’s own opinions and the importance of others’ opinions of the subjects’ appearance; and levels of anxiety/discomfort, camouflaging/safety behaviours, checking and grooming in various social and non-social settings. The second part of the research involves a replication of the modified dot probe task designed by Mansell et al (1999) to investigate selective attention to social threat cues (emotional faces) in social anxiety. These authors found that high socially anxious subjects showed an attentional bias away from emotional faces, but only when tested under conditions of social-evaluative threat. In the present study the threat induction has been altered in order to relate to body dysmorphic concerns, and includes comparison of self-evaluative and social-evaluative threat conditions, in addition to a no threat condition.
Imagery in People with Body Dysmorphic Disorder: A Study of Its Characteristics, and Links to Beliefs and Early Memories
Introduction: Our clinical experience suggests that body dysmorphic disorder (BDD) is associated with characteristic images about appearance. Recently, it has been suggested that different types of images may differ in their characteristics, including modality in which they are experienced. Evidence in other disorders also suggests that such images are important in accessing the meaning attached to beliefs and attitudes, and that they may be similar in content to upsetting childhood memories. However, almost nothing is known about the phenomenology of images, or how the images we have observed clinically in BDD patients, link to beliefs and early memories. The study had two aims: (1) to investigate the presence and phenomenological characteristics of images in patients with BDD. (2) to investigate the link between any spontaneous, recurrent imagery, beliefs and early memories in this group.
Method: Eighteen patients with BDD and 18 control participants completed a semi-structured interview. This investigated the presence and characteristics of spontaneous, recurrent imagery related to concerns with appearance, using the last time the participant had felt worried and anxious about their appearance as a starting point. It then used the downward arrow technique, based on this situation, to identify associated beliefs and early experiences. Self report questionnaire measures of BDD symptoms, other relevant psychopathology and imagery ability were also completed. Information on the reliability of the interview was obtained.
Results: Preliminary analyses suggest the following: Reports of spontaneous, recurrent imagery concerned with their appearance were common in the BDD patients, but not in the controls. These were generally associated with high levels of anxiety, vividness and were also seen from the observer perspective, i.e. as if the patient were looking in on themselves from outside. Visual and organic (inside the body) sensations were very common. The recurrent image was usually related to an early memory, and these were generally rated as similar in sensory characteristics, interpersonal meaning and emotional response. Negative self-beliefs were also reported. Analyses of themes in the images, beliefs and early memories is underway, and will be reported at the presentation, along with information on the reliability of the interview.
Conclusion: The findings to date suggest that there are differences between BDD patients and controls in presence and characteristics of spontaneous, recurrent imagery related to concerns with appearance. The observer perspective is typical of BDD patients’ images, and visual and organic sensations are common features. The images link to beliefs and early memories, and there are similarities between these. Inspection of the data suggests definite themes are likely to emerge in content analysis of images, beliefs and early memories. The implications of the study for the development of cognitive theory and therapy in patients with BDD will be considered.
EMDR in the Treatment of Body Dysmorphic Disorder: A Case Series
This paper describes a consecutive case series of patients with a DSMIV diagnosis of Body Dysmorphic Disorder and/or Delusional Disorder, Somatic Type, treated with Eye Movement Desensitization and Reprocessing. The rationale for treatment is described with reference to the role of imagery and "small trauma" in the development of the disorder. Indications for the use of this intervention are discussed and some cases outlined. Outcome data (to date) on 13 successful cases and 3 failures is presented.
Towards Evidence-Based Advances in the Treatment of Eating Disorders
Convenor & Chair: Professor Christopher G Fairburn, Oxford University Department of Psychiatry
Discussant: S Rachman, Psychology Department, University of British Columbia, Vancouver, British Columbia
Schema-Focused Cognitive Therapy: A Critical Analysis
Cognitive behavioral therapy (CBT) has proved to be effective for many clinical disorders, including bulimia nervosa (BN) and binge eating disorder (BED). But its efficacy is often limited. We need more potent treatments that will help a wider range of patients with more diverse problems than is currently the case. Schema-focused cognitive therapy (SFT) has been put forward as a means of enhancing CBT. However, at least at present, both the utility of SFT and the claim that it represents the continuing evolution of CBT as an effective, science-based approach to treatment can be questioned on both conceptual and empirical grounds. Five areas of current concern will be discussed: (1) a lack of empirical evidence. Claims that SFT is uniquely effective in Axis I and Axis II disorders cannot be substantiated. (2) recent findings have raised serious questions about some of the theory of cognitive change in demonstrably effective "standard" cognitive therapy for depression. These findings have implications for the elaborated and more speculative cognitive concepts of SFT. For example, SFT may emphasize the content of dysfunctional beliefs as opposed to the growing evidence of the importance of the functional properties of cognitions. (3) premature incorporation of ST into existing evidence-based CBT for BN may not only fail to provide added value, but also potentially undermine the efficacy of existing CBT-BN. (4) the principle of parsimony. In eating disorders, some advocates of SFT have emphasized extension of CBT-BN (e.g., the role of negative affect) that is endorsed by proponents of the latter. Moreover, some of the strategies for addressing "schemas" are the same as those used in routine CBT-BN. The specific, added value of appealing to the schema concept and any derivative techniques must be empirically documented. (5) in contrast to more behaviorally-based versions of CBT, SFT could complicate the successful dissemination of effective treatment. Alternative options exist for improving upon existing CBT-BN that are both theoretically and practically more compelling.
A New Transdiagnostic Theory and Treatment for Eating Disorders
The leading evidence-based treatment for eating disorders is the cognitive behavioural treatment for bulimia nervosa yet, at best, only half the patients who receive it make a full and lasting recovery. Three factors appear to be responsible for poor response. First, the treatment is not always implemented optimally. This is particularly true of those procedures directed at the over-evaluation of shape and weight. Second, even when well implemented, certain procedures are not effective for everyone. We suggest that a third explanation for limited response is that among certain subgroups of patients potent maintaining mechanisms operate that are not addressed by the current treatment. Based on empirical data combined with clinical experience, we believe that these mechanisms arise as a result of the influence of perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. Empirical evidence also suggests that this broader cognitive-behavioural approach is highly relevant for all forms of clinical eating disorder. This presentation will describe the new cognitive-behavioural treatment and its empirical and conceptual basis.
Advancing Treatment by Integrating Experimental and Clinical Analyses
Significant advances have been made in the treatment of various psychiatric disorders by integrating methods from experimental psychology with clinical concepts and evidence-based interventions. This integration allows mechanisms that contribute to the maintenance of the psychiatric disorder to be identified, and helps in the development of new methods to reverse these mechanisms. The new cognitive-behavioural theory of the maintenance of severe eating disorders can be tested both directly (by experimental analyses) and indirectly (by evaluating the efficacy of the treatment that derives from the theory). This paper will follow the description of the treatment that derives from the theory by presenting the experimental analyses designed to test the model directly. These experimental analyses are both laboratory and clinically based, and they include the therapeutic manipulation of body checking, clinical perfectionism and mood intolerance. It is argued that such analyses are essential to facilitate evidence-based advances in the understanding and treatment of eating disorders.
What predicts PTSD and What to do About It?
Convenors: Freda McManus & Nick Grey, Institute of Psychiatry, London
Chair: Anke Ehlers, Institute of Psychiatry, Kings College, London
Implicit Memory Bias for Trauma-Related Material Predicts Posttraumatic Stress Disorder
Several theorists have suggested that intrusive re-experiencing in posttraumatic stress disorder (PTSD) results from implicit memory representations of the trauma. A cross-sectional (N = 78) and a prospective longitudinal study of assault survivors (N = 69) investigated perceptual priming, a form of implicit memory, using a new version of the word stem completion task. In both studies, trauma survivors with PTSD showed enhanced priming for trauma-related words. Furthermore, priming for trauma-related words measured soon after trauma predicted subsequent PTSD severity. The enhanced priming effect was specific to trauma-related words. The results could not be attributed to response bias or explicit knowledge. Implicit memory bias for traumatic material appears to be one of the cognitive processes operating in persistent PTSD.
Gender, Social Support and PTSD in Victims of Violent Crime
Gender differences in social support levels and benefits were investigated in 118 male and 39 female victims of violent crime assessed for PTSD symptomatology 1 and 6 months post-crime. Within 1 month post-crime both genders reported similar levels of positive support and support satisfaction, but women reported significantly more negative responses from family and friends. The effects of support satisfaction and negative response on 6-month symptoms were significantly greater for women and negative response accounted for the gender difference in symptoms. Positive support was not significantly correlated with symptom outcome in either gender. The findings are consistent with previous studies of assault victims concerning the stronger impact of negative over positive support, and might help explain women's higher PTSD risk in civilian samples.
Screening for PTSD: Are Dissociative Symptoms Best?
The development of good screening instruments is important if we are to improve the identification and appropriate referral of trauma survivors suffering from PTSD, particularly in non-specialist settings. One approach is to compare the utility of early symptoms from the dissociation, re-experiencing, avoidance, and arousal clusters of Acute Stress Disorder in predicting a current ASD or PTSD diagnosis. New analyses of data from a study of 157 victims of violent crime will be presented, demonstrating the relative predictive power of varying numbers of symptoms from each cluster. Based on these findings, we adapted the self-report version of the PTSD Symptom Scale to yield a screening instrument that asked simply about the presence or absence of the ten re-experiencing and arousal symptoms, using a frequency threshold of at least twice in the past week. This instrument was administered to 41 rail crash survivors, followed by a structured clinical interview to establish diagnoses of PTSD. Excellent prediction of a PTSD diagnosis was provided by respondents endorsing at least six re-experiencing or arousal symptoms, in any combination. The performance of the new measure was equivalent to the level of agreement achieved between two full clinical interviews.
Predicting PTSD: Is ASD The Answer?
Much debate exists in the literature regarding the identification of abnormal responses to traumatic events and the specific criteria required for a diagnosis of acute stress disorder (ASD). Particular interest has focused on dissociative phenomena, their importance in the acute phase of trauma responses, and their predictive validity. This paper highlights these issues in its discussion of multiple pathways to PTSD by examining the constellations of acute symptoms that predict PTSD at 3 and 12 months post-trauma. Consecutive admissions to a Level 1 Trauma Service following severe accidental injury (N=274) were assessed at three time periods: shortly following admission, at 3 months and at 12 months post-accident. The CAPS-IV, including the additional dissociation questions, as well as heart rate and a range of self-report measures, was administered at each time period. Sensitivity, specificity, and predictive power of various combinations of acute stress symptoms in the prediction of subsequent PTSD were examined. While a categorical diagnosis of ASD showed high specificity, sensitivity was poor resulting in a very high rate of false negatives. Other combinations of early symptoms improved diagnostic accuracy.
New Directions in Affective Disorders: Cognitive Theory and Therapy of Bipolar Disorder
Chair, Convenor & Discussant: Jan Scott, Institute of Psychiatry, University of London, London.
Dysfunctional Attitudes: Extreme Goal-Attainment Beliefs in Remitted Bipolar Patients
The issue of whether there are unique stable personality traits or attitudes which can influence the course of illness in bipolar patients is important. The Behavioural Activation Model (Depue et al. 1994; 1996; Gray 1994; Johnson and Robert 1995) postulates that positive affect, extraversion and achievement striving should be linked to increased levels of mania across time. Lam et al (1999), based on clinical observation, have also speculated that high goal attainment could lead to higher frequencies of relapses. The existing subscales in the Dysfunctional Attitude Scale (DAS) were derived from patients and relatives of patients suffering from unipolar depression, patients with a mixed psychiatric diagnosis or normal controls. None of the current factor analysis studies produced subscales, which reflect the extreme goal attainment attitudes. Bipolar patients may be different. Using a sample of bipolar patients may yield different factors. Furthermore, the DAS was found to correlate significantly with the BDI, r=0.65 (Weissman and Beck 1978). Hence similar dysfunctional attitudes may exist between bipolar and unipolar patients when they are in a depressive episode. However, euthymic bipolar patients may exhibit certain characteristic attitudes that are distinct from remitted unipolar depressives. This study reported the principal component analysis of the DAS 24 using 141 bipolar 1 patients. Four factors were derived: factor 1 “goal-attainment” accounted for 25.0% of the total variance. Factor 2 “dependency” accounted for 11.0% of the total variance. Factor 3 “achievement” accounted for 8.2% of the total variance and factor 4 “anti-dependency” accounted for 6.6% of the total variance. There were no significant correlations between manic symptoms and any of the four factors in the bipolar sample. However all four factors correlated significantly with the BDI scores in the unipolar sample and factors 2 and 3 correlated significantly with the BDI scores in the bipolar sample. No significant differences were found in any of the four factors when the 141 bipolar 1 patients were compared with 109 patients suffering from unipolar depression. However when only euthymic subjects (BDI <16) were included, the scores of bipolar patients (n= 80) were significantly higher than euthymic unipolar patients (n= 30) in factor 1 “goal attainment” and factor 4 “anti-dependency”. The clinical implications of these findings will be discussed.
Interacting Cognitive Subsystems and Bipolar Disorders
Depressive and manic states differ markedly in their characteristic levels of activation and in the types of mental models or "schema" that figure prominently in ideation. In this paper, we link activation to a set of theoretical ideas about two different modes that can be adopted in "central executive" mechanisms. In one mode cognitive-affective processing is controlled and co-ordinated by specific "propositional thoughts." In the other it is co-ordinated and controlled from a more generic level of meaning or "implicational senses" (Teasdale & Barnard, 1993). In this paper, we discuss these ideas both in relation to bipolar symptomatology and in the context of evidence on how mood influences schema use in a picture arrangement task and in a question-answering task.
Possible Relationships Between Chronobiological and Psychological Factors in Bipolar Disorder: Implications for Research and Therapy
There is evidence from a number of sources which indicates disrupted chronobiological (circadian) functioning in both the manic and depressed phases of bipolar disorder. However, these studies have generally not assessed psychological variables in any detail. It is therefore not clear how such disruption might be implicated in the development of the symptoms observed in mania and depression. One possibility for understanding how circadian disruption and clinical symptoms might be linked is through the use of recent psychological models of emotion. In particular, an adaptation of the SPAARS model of Power and Dalgleish (1997) is proposed as a means for integrating circadian and psychological research findings. This approach is described in relation to mania and depression. Implications for future research into psychological treatment approaches include evaluation of : a) the relative importance of structure and routine in managing circadian fluctuations and associated attributions for these; b) the relationship between activity patterns and mood symptoms through direct non-invasive assesment (e.g. by actigraph); c) possible benefits of ‘in vivo’ experiments to test stability of cognitive changes; d) balance between associative and cognitive links in therapy and possible association with duration of illness in individual patients.
Variability in Positive and Negative Affect in Bipolar Disorder
Variability in positive and negative affect is central to definitions and causal theories of bipolar disorder. Psychological models of bipolar disorder frequently invoke defensive or maladaptive self-regulatory processes - processes that imply particular patterns of temporal change in both positive and negative affect. A longitudinal study of seven patients diagnosed with rapid cycling bipolar disorder using a simple visual analogue scale suggested that variability in self-rated mood in bipolar disorder was chaos in nature and therefore unpredictable. That study, however, did not study positive and negative affect independently. In this paper, longitudinal data on positive and negative affect (PA and NA) are reported for a patient with DSM-IV bipolar II disorder over a continuous period of 420 days. Positive affect was significantly elevated during the hypomanic phase and significantly lower during the depressive and mixed phases compared with euthymia. The mixed affective phase was also associated with high variability in PA, and the depressed phases with high variability in NA. There was no evidence that NA was elevated during the hypomanic phase. The temporal patterns of PA and NA were found to be non-random, but non-cyclical. These findings are consistent with the suggestion that mood variability in bipolar disorder is chaotic with a small number of mathematical attractors, and with the suggestion that bipolar disorder is characterized by maladaptive self-regulation.
Cognitive Theory and Therapy of Bipolar Disorder
The efficacy and effectiveness of brief psychological therapies such as cognitive therapy (CT) are well established for unipolar disorders. However, treatment studies have always excluded individuals with bipolar disorders, so until recently, relatively little was known about the utility of psychological approaches in this disorder. This paper draws on the previous presentations in this symposium to explore the feasibility and efficacy of using CT in bipolar disorders. Key studies conducted on cognitive therapy (CT) in bipolar disorders are reviewed, followed by comments on the implications for a cognitive model of bipolar disorders, particularly mania. There are only five published outcome studies available. Some of these studies have focussed on selected areas such as medication adherence or monitoring and management of the prodromal phase, whilst others have used a more formal CT approach tackling key problems and core beliefs that make the individual vulnerable to relapse. The data suggest that brief approaches targeted only at prodromes are more effective in reducing manic or hypomanic relapses rather than depressive relapse. More traditional CT approaches appear to be particularly beneficial in treating bipolar depressive symptoms as well as preventing full manic relapse. The implications for cognitive theory will be discussed. Also, the problems of designing a clear cognitive model of mania will be explored and new approaches to exploring the interaction between cognitive, biological, behavioural and emotional variability will be presented and commented on. The use of CT in subjects with bipolar disorders appears to be effective. However, this must not mask the fact that there is considerable work to do if we are to provide a coherent conceptualisation of the onset of mania.
We Know What Goes Wrong: How do We Change It? Modifying Cognitive Processes in Social Anxiety
Convenors: Jennifer Wild and Colette Hirsch, Institute of Psychiatry, London
Chair: Jennifer Wild
Discussant: Rick Heimberg, Temple University, USA
Turning On and Off 'On-Line' Inferences in Social Anxiety: Negative Self-Images Block ‘On-Line’ Inferences
Research has shown that, contrary to non-anxious individuals, people with social phobia lack the normal bias to generate positive inferences when ambiguous social information is first encountered (i.e. ‘on-line’; Hirsch and Mathews, 2000). Patients with social phobia often experience negative self-imagery in social situations, while individuals without high social anxiety do not. One explanation for the lack of positive inferences in social phobia is that the negative self-imagery prevents them from generating positive inferences. If so, then training non-anxious individuals to generate and hold in mind a negative self-image should remove the ‘on-line’ positive inferential bias normally evident in this population. In the present study, low anxious volunteers were randomly allocated to negative image training (experimental group) or a control imagery task that did not manipulate self-imagery (control group). Following negative image training, or the control task, volunteers read description of job interviews and at certain points during the text performed lexical decisions. Some decisions were made after ambiguous text that could have been interpreted in both a positive and a negative manner. In a baseline condition, decisions were made following text that forced all volunteers to generate a particular inference (either positive or negative). The results for the control group replicated earlier findings of a positive inferential bias for non-anxious individuals. In contrast, non-anxious volunteers who were trained to hold a negative image in mind lacked any positive inferential bias. This absence of a positive inferential bias is similar to people with social phobia. Implications for the role of negative self-imagery in influencing inferential processes in social phobia will be discussed.
The Observer Perspective and Social Anxiety – Bringing on the field perspective: Improving Speech Performance in Social Anxiety
The D.M. Clark & A. Wells’ (1995) cognitive model of social phobia proposes that individuals with social phobia generate a negative impression of how they appear to others, constructed from their own thoughts, feelings and internal sensations. This impression can occur in the form of a visual image from an external, or “observer perspective”. This paper presents the results of a study that manipulated perspective (observer and field) while giving a speech in high and low socially anxious participants. The high socially anxious group had more negative thoughts, safety behaviours and higher self-rated anxiety in both conditions than the low socially anxious group. However, participants in both groups reported more frequent negative thoughts, and more safety behaviours in the observer perspective than in the field perspective. There were clear trends towards higher belief ratings in negative thoughts and higher anxiety in the observer condition compared to the field condition. High socially anxious participants in the observer condition also rated their speech performance as worse before viewing themselves on videotape compared with after viewing. This suggests that either the observer perspective produces greater distortions in self-perception than the field perspective, or that high socially anxious participants have a more negative and distorted observer image of themselves. There may be times when the use of the observer perspective is inevitable and in these situations, the nature of the observer image may be critical in determining how much anxiety is experienced. The clinical implications of these findings are discussed.
Modifying Attentional Processes: Public Versus Private Feedback in Social Anxiety
According to newer cognitive behavioural models of social phobia, experience and perception of bodily symptoms play a key role in maintaining social anxiety (). Allegedly, not direct observation of people but rather bodily symptoms are used by social phobics as a main source of information concerning social evaluation by others. In order to assess the effects of anxiety visibility on patients and controls we focused on the effects of public and private feedback of veridical heart sounds. 32 social phobics and 32 controls were asked twice to sit in a chair and appear as relaxed as possible while three observers were evaluating them. To half of the participants these heart sounds were first presented by headphones inaudible to the observers and then by loudspeakers. For the other half, presentation of heart sounds was first by loudspeakers and then by headphones. The majority of social phobics preferred the private to the public condition, whereas most controls had no such specific preference. Generally, controls reported much less anxiety or embarrassment than social phobics. Physiologically both groups showed a habituation effect in heart rate from the first to the second social stress test. Social phobics reported a significant decrease in anxiety from the public to the private condition, but no change in anxiety from the private to the public condition. There was no evidence for such an interaction effect in controls. In conclusion, this paradigm highlights the significance of the visibility of bodily symptoms in social phobia.
Clark, D.M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg (Ed.), Social phobia - diagnosis, assessment, and treatment. (pp. 69-93). New York: The Guilford Press.
Rapee, R.M., & Heimberg, R.G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741-756.
Manipulating the Perception of Bodily Cues of Anxiety: Effect on Anxiety, Attention, and Perceived Performance
Introduction: This study tests the prediction that in social interactions, socially anxious individuals direct attention to internal cues of arousal, and use this information to erroneously infer how they appear to others.
Method: High and low socially anxious adults were instructed to have a conversation with a research assistant. During the task, participants were given false feedback through a small vibrating sensor. One third of the participants were led to believe that the sensor measured physiological symptoms of arousal and caused the solenoid to vibrate when there was an increase in arousal. One third were led to believe that the sensor and vibrating solenoid registered a decrease in arousal. Finally, one third were led to believe that the vibrating solenoid was being piloted for a future experiment and that any vibrations had been pre-programmed by a technician. The effect of the manipulation on measures of anxiety, perceived performance and actual performance was assessed.
Results: Attention to internal cues suggestive of increased arousal led to an increase in anxiety and more negative perception of performance in high and low socially anxious individuals. The effect was significantly more marked for high anxious individuals. Attention to cues suggestive of decreased arousal led to a significant decrease in anxiety and more favourable perception of performance in high and low socially anxious individuals.
Conclusion: The results have implications for the treatment of Social Phobia. They would imply that a change of attentional focus may be an important element of treatment.
Integrating Theory, Research and Treatment in OCD: Stuck in a Rut or Moving Forward?
Convenor & Chair: Paul Salkovskis, Institute of Psychiatry, London
The Growing Impact of Cognitive Construals on our Understanding of OCD
There is no abstract for this talk.
Readiness for Change in Obsessive Compulsive Disorder
There is little attention in the psychological literature addressing variables which influence treatment failure for obsessive compulsive disorder (OCD). What characteristics determine whether patients seek treatment, comply with recommendations, or drop out? Are those who enter treatment for the first time different from individuals who have been in previous treatment? Prochaska (1979) proposed processes and stages of change within the transtheoretical models, which involve constructing the best model of psychotherapy and necessary requirements for behavior change. Prochaska stated that there are ten processes of self-change, which occur within four stages of change: precontemplative, contemplative, action and maintenance. Although cognitive behavioral therapy has been shown to be effective in OCD treatment, there are still a significant amount of patients who do not seek or improve in treatment. We propose that treatment history effects patient's readiness for change upon entering current treatment. Furthermore, we predict that readiness for change significantly impacts treatment attendance and drop out. A total of 30 patients with OCD were given the University of Rhode Island Change Assessment (URICA), The Yale Brown Obsessive Compulsive Scale (YBOCS), the Beck Depression Inventory-Second Edition (BDI), and the Beck Anxiety Inventory (BAI) at baseline. All patients enrolled in individual cognitive behavioral treatment. The readiness for change and its relationship to treatment outcome will be discussed.
Elevated Evidence Requirements in Compulsive Checking?
The cognitive behavioural theory of OCD suggests that obsessional patients use inappropriate criteria for the decision when to stop a compulsive action (Salkovskis, 1999). These criteria are characterized by an internal reference point, and are more subjective than criteria used by non-obsessional individuals (Richards, 1995). It is hypothesized that the use of problematic ‘stop’-criteria is at least partly responsible for the prolongation and repetitiveness of compulsive rituals. The employment of such inappropriate criteria could be embedded in the use of elevated evidence requirements. This means that obsessional patients do not only tend to use qualitatively different criteria than non-obsessional individuals, but they also consider multiple criteria before they reach a decision to stop the action as part of a responsibility motivated strategy. Previous studies of the groups have found support for elevated evidence requirements in obsessional washers. The current structured interview study investigates the use of elevated evidence requirements in obsessional checkers. 24 obsessional checkers, 22 anxious controls and 26 healthy controls were interviewed about a situation when they checked something. Results are consistent with the idea of elevated evidence requirements.
Richards, C. (1995). The cognitive phenomenology of OCD repeated rituals. Poster presented at World Congress of Behavioural and Cognitive Therapies, Copenhagen.
Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder. Behavior Research and Therapy, 37, S29-S52.
The Effects of Neutralization on Interpretations of Obsession-Like Intrusive Thoughts: An Analogue Experiment
The cognitive behavioural models of Obsessive Compulsive Disorder (OCD) propose that neutralizing plays a maintenance role through a number of mechanisms including maintaining faulty interpretations of intrusive thoughts. This study aims to investigate the effects of neutralization on interpretations of intrusive thoughts. A new paper and pencil task was used in an analogue experimental design. Non-clinical subjects imagined themselves in a scenario that described the occurrence of an intrusive thought, an interpretation of this thought and a reaction to the thought. Interpretations were either threatening, with themes of responsibility, over-importance of thoughts and harm to self or others, or non-threatening. Reactions to the thoughts were either a typical neutralization strategy (thought control, reassurance seeking, washing, checking) or a non-neutralization, such as simply returning to the pre-intrusion train of thought. After imagining themselves in the scenario, subjects were asked to rate the strength of their belief in the given interpretation. Four different intrusive thoughts were used.
Results suggest that neutralizing a non-threatening interpretation tends to reduce the strength of the belief in that interpretation. On the other hand, neutralizing a threatening interpretation tends to increase the strength of the belief in the interpretation. The experiment supports the proposal that neutralization maintains faulty interpretations of intrusive thoughts in OCD. The findings will be discussed in terms of the way that threatening interpretations of intrusive thoughts may be maintained or even strengthened.
‘Sleeping With The Enemy’: Cognitive Theory and Treatment May Be Advanced by Examining Biological Factors
There has been a long standing tension between biological and psychological accounts of obsessional problems. Thus far, these different approaches to the understanding and treatment of OCD have not cross-fertilised. Given the advanced state of cognitive-behavioural theories, the time is ripe to consider marrying the two approaches. Ways in which they could relate are described, together with strategies which might allow cohabitation. The possible fruits of such a union are described. It is concluded that psychological and biological approaches are not necessarily incompatible.
Cognitive Therapy for PTSD: Responding to the Neuropsychological Challenges
Convenor & Chair: Dr Jennifer Wild, Institute of Psychiatry
An Overview of Neuroanatomical and Neuropsychological Findings in PTSD
Memory and concentration difficulties are key symptoms of trauma reactions specifically associated with Posttraumatic Stress Disorder (PTSD). They may be a result of biological and/or cognitive factors and can adversely affect treatment response. Neuroimaging studies have identified the amygdala and hippocampus as the main areas of the brain involved in memory function and PTSD symptomatology. This presentation will consider what goes on in the brain in response to stress and what happens in PTSD. The main neuropsychological and neuroanatomical findings of PTSD will be discussed, including the hippocampal debate, the role of neuroendocrinology, and the implications of these findings for the course and treatment of PTSD.
Mild Traumatic Brain Injury and PTSD
There is much debate as to whether an individual can develop PTSD if they have acquired a traumatic brain injury (TBI). In the current study, a population of 363 injury survivors with and without mild TBI are compared on PTSD prevalence at 12 months post injury, symptom profile, and memory for the event across time. Fifty two percent of all participants had a MTBI. A large proportion of these remembered feeling fear, helplessness or horror at the time of the trauma, although 17% were totally amnesic to the traumatic event and thus did not remember their emotional response. A total of 10% of all participants went on to develop PTSD at 12 months. None of the participants who denied experiencing fear developed PTSD at 12 months. There was no difference in the incidence of PTSD in those with and without a MTBI. Non-MTBI PTSD sufferers tended to show higher levels of arousal and re-experiencing symptoms. Those with MTBI and PTSD tended to report a reduction in percentage recall of the event over the first 3 months compared with PTSD sufferers without MTBI. Whether or not an individual acquired a MTBI was irrelevant to the subsequent development of PTSD. The key factor was remembering the experience of fear, helplessness or horror, suggesting that experiencing fear (or remembering experiencing fear) is fundamental to the subsequent development of PTSD.
Autobiographical Memory in Posttraumatic Stress Disorder
This study investigates whether people with Posttraumatic Stress Disorder (PTSD) have problems in accessing non-trauma autobiographical memories. Recent research has suggested that individuals with PTSD show an over-general memory bias compared to traumatised individuals without PTSD. However, it remains unclear to what extent the memory deficit observed in the laboratory is due to differences in intelligence and whether the memory deficit persists in the individual’s natural environment. The present study addresses these issues by assessing participants’ abilities to retrieve autobiographical memories both in the laboratory and in the natural environment. We are further investigating whether features of autobiographical memory are related to symptoms and other cognitive characteristics of PTSD such as a sense of foreshortened future, the feeling of being permanently changed, dissociation and rumination. Participants are adults with and without PTSD who have experienced a variety of different traumas. Autobiographical memory is being examined in different ways: (1) a widely used cued autobiographical memory test, (2) a picture version of the same test, (3) a diary of spontaneously occurring memories to assess memory specificity as well as other memory characteristics such as pleasantness, perceived distance, and frequency, and (4) a questionnaire of perceived changes in autobiographical memory in respect to range and frequency, hedonic tone and different life periods. Preliminary results will be presented.
Memory in PTSD – Implications of the Neuropsychological Findings for Accessing Memories in Treatment
Acute stress has two contrasting effects on memory. One of these involves interference with the functioning of the hippocampus and with the formation of verbal, declarative memories that can be deliberately retrieved and are situated in a temporal and spatial context. The other effect is an enhancement of memories consisting of emotionally laden visual and other sensory images that are retrieved automatically and are independent of the normal autobiographical memory system. According to the dual representation theory of PTSD, encounters with trauma reminders lead to retrieval competition between the two kinds of memory. Because the images have no associated sense of time, if they are retrieved, the brain responds as though the person is still in danger. Only by sustained attention to the images can the details that act as retrieval cues be recoded into a verbally based, declarative memory which will classify the threat as past rather than present. This process is a major component of cognitive-behavioral therapy for PTSD. However, it is likely to be impeded by the verbal memory deficits which are common in PTSD. Treatments such as EMDR may work by creating highly distinctive declarative memories that have a retrieval advantage in the presence of trauma reminders.
Identifying Memory and Concentration Deficits in PTSD and Adapting CBT
Approximately one half of clients with Posttraumatic Stress Disorder (PTSD) still meet diagnostic criteria for the disorder after a standard course of cognitive-behavioural therapy (CBT, the current psychological treatment of choice). Clients with PTSD frequently report everyday memory and concentration difficulties. Further, research has documented impaired learning and memory processes in adults with PTSD. Memory difficulties appear to adversely affect the ability of these clients to respond to cognitive behavioural therapy (CBT) for PTSD. Good treatment planning requires the prior identification of clients unlikely to respond to a specific therapy. Screening for memory problems will inform initial psychological assessment and treatment planning for PTSD. This presentation will propose specific screening procedures for memory deficits in PTSD. Data will be presented on a self-report questionnaire used to identify the type and severity of memory difficulty in adults with PTSD. The use of such screening procedures will optimise treatment planning, inform modifications to CBT, and raise therapeutic response rates for sufferers of PTSD.
Treatment Models for Emotional Disorders
A randomised controlled trial of internet-based cognitive behavioural treatment for panic disorder
In Australia, only 25% of people with an anxiety disorder seek professional assistance with most consulting their primary medical care practitioner. A small minority seek specialised mental health assistance. People with an anxiety disorder who live outside the major urban centres are particularly disadvantaged because of scarce specialist mental health resources and relative geographical isolation. Panic disorder, one of the more commonly presenting anxiety disorders, afflicts 2.4% of the community but is more common among patients attending primary medical settings. To address the mental health needs of people in regional Australia, we developed an internet-based treatment for panic disorder that involves two components - a detailed cognitive behavioural program for panic disorder on our website together with therapist email assistance for people participating in the program. This paper reports on a randomised controlled trial (N = 55) comparing this treatment to a self-help print-based CBT manual with limited therapist telephone assistance and to an information-only control condition. The effects of the interventions were measured upon completion of treatment and at three months’ follow-up. The internet-based treatment was superior on measures of panic disorder severity and agoraphobic cognitions. It was also superior on measures of end-state functioning such as number of subsequent visits to primary care medical practitioners and self-rated health status. Attrition rates were lower in the internet-based intervention and treatment was completed more speedily than for those receiving the print-based manual. This form of treatment therefore offers considerable promise for people who are unable to easily access face-to-face treatment.
A Randomised Controlled Trial Comparing Two Forms of Internet-Based CBT for the Treatment of Depression
Interest in the delivery of psychological therapies without the use of psychological therapists has gathered momentum in the past few years, both as a capitalization of advances in the power and sophistication of information technology and because of clinical necessity. Cognitive-behaviour therapy is ideal for self-administration because it is simple, educative, skills-based, and makes sense quickly. A reasonable evidence base exists for the effectiveness of cognitive-behavioural self-help books for mild and moderate psychological problems, but the evidence for similar programs that are made available via computers is in its infancy. Although CD-ROM-based self-administered treatments are now commercially available, the use of the Internet for the delivery of self-help has been relatively neglected. Nevertheless, the Internet potentially offers some distinct advantages over packages that are installed onto a personal computer. This paper will present work in progress of a RCT comparing two forms of Internet-based CBT for depressed adults – (1) interactive CBT bibliotherapy, (2) interactive CBT bibliotherapy + weekly online supportive group therapy in a chatroom. Preliminary outcomes will be presented. So too will the ethical considerations of conducting online treatments specifically for depression such as confidentiality, security and dealing with psychiatric emergencies remotely. This study will also investigate the relationships between personality attributes such as locus of control and introversion/extroversion, and take-up of the different treatment modalities.
The Superiority of Danger Ideation Reduction Therapy (DIRT) over Exposure in the Management of Compulsive Washing.
Danger Ideation Reduction Therapy (DIRT) is a recent development in the treatment of Obsessive Compulsive Disorder (OCD). Based on the premise that patients with OCD hold excessive beliefs of threat, DIRT was developed to target these beliefs and appraisals in a specific subtype of OCD, namely, the OC washer/cleaner. It is believed that once these excessive danger-related cognitions are diminished, the patient will experience less obsessive ideation and as a consequence, display significantly less ritualistic behaviour. The present study involved the random allocation of a number of OC washer/cleaners to one of two treatment conditions: DIRT, or the standard treatment option (Exposure with Response Prevention - ERP). DIRT subjects experienced significantly greater before to after-treatment (post and follow-up averaged) reductions in symptomatology on six outcome measures. On 10 of the remaining 11 measures, post-treatment mean scores were lower in the DIRT condition than in the ERP condition, though differences between groups failed to reach significance. Of note, on three of the 17 measures, DIRT subjects experienced significantly greater post-to-follow-up symptom reduction. Finally, and most importantly, symptom change (regardless of treatment condition) was shown to significantly correlate with change in threat expectancies across the trial. This suggests that both DIRT and ERP may be working by reducing beliefs in threat, the former treatment being more effective in producing such change than the latter.
A Case-Based Evaluation of a Group Treatment for Social Phobia Based on the Model of Clark and Wells
This study evaluated a group treatment for social phobia based on Clark and Wells’ (1995) model. The programme was highly structured and closely followed Clark’s (1997) guidelines for individual treatment. It was adapted for a group format by the inclusion of structured exercises in pairs, guided discussions in which the facilitator used participants’ experiences as teaching examples, and use the group to set up role plays and provide feedback. Sessions ran once or twice weekly for 1-2½ hours. At each session participants were given homework tasks. The entire programme consisted of 13 group sessions and a two hour individual session for each participant. In their individual session (between sessions seven and nine) participants did the safety behaviours role play followed by review of the videotape, as described by Clark (1997). Participants were seven students who met the criteria for social phobia (age range: 19-21; ethnicity: 1 = white; 6 = black; gender: 3 = female, 4 = male). Two participants dropped out after session 5. The research methodology was a multiple case study design. For each participant, we constructed graphical records on several self-report scales administered before the programme, at every session and at two follow-up evaluations (BDI-II, BAI and three measures of social anxiety used by Clark). Against these records, we juxtaposed case narratives of each participant constructed from extensive qualitative data derived from the following: a case history, video-recordings of every session, copies of all records of in-session and homework exercises, responses to post-session feedback questionnaires, a debriefing interview conducted a few weeks after the formal programme was over, and a follow-up interview conducted six weeks after that. Although the methodology does not provide a means of comparison with other treatment programmes, the data show that the response to the programme was extremely positive, and the group format employed is worth further investigation. All participants who completed showed substantial progress in terms both of overcoming their phobia behaviourally and of changes in dysfunctional cognitions. Some progressed more rapidly than others and one participant only improved markedly after the programme was over. It was not possible to establish why the two drop-outs did not continue. Their involvement was comparable to that of other members until the time they dropped out, and they did not make themselves available for follow-up interviews, despite the researchers’ best efforts. The methodology allows researchers to examine individual differences in the processes set in motion by the programme and in this way to evaluate the clinical model underlying case conceptualization and rationale for the treatment programme. The paper examines individual differences in response to the different components of the programme and discusses what seemed to be the critical factors contributing to change in each case. The psychological processes described in the case narratives strongly support the Clark and Wells model in terms of the factors underlying the phobic behaviour, the importance of exposure in the form of behavioural experiments, and the importance of participants’ learning to shift from a self-focussed, anxiety driven mode of social interaction to a conversation-focussed and spontaneous mode.
Clark, D, M. (1997). Cognitive therapy for social phobia: Some notes for therapists. Oxford: University of Oxford, Department of Psychiatry.
Clark, D.M. & Wells, A.(1995). A cognitive model of social phobia. In R. M. Heimberg, M. Leibowitz, D. Hope & F. Schneier (Eds): Social phobia: Diagnosis, assessment and treatment (pp. 69-93). New York: Guilford.
Cascading Cognitive Behaviour Therapy Skills
The pilot project to cascade cognitive therapy skills followed a comprehensive evaluation of the service provided by the NCBTC. This involved multiple stakeholders and identified that cognitive therapy training for staff in the adult mental health service locally as a major area of unmet need and a top strategic priority (Twaddle 2000). This paper looks at the process of planning the needs assessment strategically via a Project management board and liaison with Community Mental Health teams; the results of which were fed back to the stakeholders and service units, it also explores the year long supervision project that has ensued with some of the preliminary finding from this process. The project arose from a number of issues, both local and national, that are relevant in understanding why CBT needs to be promoted in CMHT’s:
1) CBT has a strong evidence base across a wide range of mental health problems (D.O.H. 2001)
2) The Government in the National Service framework for Mental Health (D.O.H. 2000) made clear that that both serious and enduring and common mental health problems are priority target areas. 3)CBT has developed treatment models with a strong supporting evidence base across these areas.
4) Recent guidelines on the delivery of psychological therapies (NHS Executive, 2000) emphasises the importance of collaboration between different services in order to meet patient’s needs. One implication of the above is that specialist psychological therapy services, such as the NCBTC, should be more integrated with main-stream mental health services for the purpose of staff training and the dissemination of skills, and thus allow greater patient access to effective forms of treatment.
The paper will report the findings from different stages of the pilot. First, a needs assessment was conducted to identify the type of problems most frequently seen in CMHT settings, evaluate the perceived level of training needs cross professionally in CMHT staff, investigate whether there were any variations across the six CMHT’s , and to establish a level of interest in CBT training. From a response rate of 87%. The most frequent problems encountered by clinicians matched those shown to improve with CBT .There was a significant difference between current and ideal levels of skills and outcome. The conclusions and findings of this initial process led to the identification and training of 16 CMHT staff in CBT foundation skills over five days. The evaluation of the continuing supervision of 12 of the CMHT staff is ongoing tracking a number of variables including there comfort and confidence working within a CBT model , and marking to what extent they are able to track behavioural indicators around use of CBT skills across their clients range of problems.
Department of Health (2001). Treatment choice in Psychological Therapies and Counselling. Evidence Based Clinical Practice Guideline.
Department of Health (2000). A National Service Framework for Mental Health.
NHS Executive (2000). The Newcastle Cognitive and Behavioural Therapies Centre: A First Class Service? Doctoral Thesis. University of Newcastle Upon Tyne.
Psychological Treatments for Psychosis in the Past Thirty Years: Where Have We Been and Where Are We Going?
Professor Philippa Garety, Guy’s King’s and St Thomas’ School of Medicine and the Institute of Psychiatry, King’s College, London
Psychological treatments for psychosis are coming of age in the United Kingdom. The past three decades have seen the emergence and development of cognitive behavioural therapy and family interventions as credible and effective treatment choices for people with psychosis and their carers. The National Service Framework for Mental Health (1999) commends them, while the National Institute of Clinical Excellence has commissioned a Schizophrenia Guideline in which a major component, alongside recommendations on medication and service models, will be influential recommendations for the provision of psychological treatments. Exciting theoretical and empirical advances in cognitive models of psychosis have accompanied therapeutic developments. The field has been characterised by mutually enhancing feedback between theory and practice. This paper will offer both an overview of cognitive theory of psychosis and an up-to-date review of the evidence for the effectiveness of CBT and family interventions, based on meta-analyses of randomised controlled trial data. In doing so, it will look to the future, highlighting key clinical questions in the provision of these therapies: The stage of illness at which therapy is best offered (early, acute, recovery, longer-term?); The clinical focus of interventions (distressing symptoms; risk of relapse; past trauma; mood and self esteem?); The duration and frequency of therapy. And it will address recent and future developments in theory and therapy: Work in the first episode and before the onset of psychosis; Developments in studies of reasoning and attributions; The role of traumatic experiences and emotional disorders in psychosis; Understanding the cognitive mediators of treatment effectiveness.
Is It Time For A New Therapy For Cognition In Psychosis? Cognitive Remediation Therapy (CRT)
Til Wykes, Institute of Psychiatry, London
Many people who develop schizophrenia show evidence of cognitive deterioration which occurs before the onset of the disorder and continues even when the symptoms have abated. More recently these cognitive difficulties have been shown to predict up to 60% of the variance in future functioning, limit the rate of improvement in rehabilitation programmes and seem to interact with environmental stressors to produce toxic effects on symptoms. These difficulties seem to be stable over the course of the disorder, although longitudinal data are rare. This stability has led clinicians to assume that they are immutable and has led to therapeutic pessimism. Immutability can only be concluded after all possible therapeutic interventions have been attempted and therapeutic interventions for specific information processing difficulties have taken a long time to be tested, especially in the UK. Both laboratory and clinical studies suggest some improvements following a therapy called cognitive remediation. However, cognitive remediation is a term that covers a variety of therapeutic techniques which frustrates the systematic evaluation of therapy specific efficacy. The improvement in cognition is important not only because people with schizophrenia want to improve their attention and concentration but it is also essential for the development and testing of theories relating cognitive processes and the experience of hallucinations and delusions.
Can Psychosis Be Normalised?
Convenor: Craig Steel, Institute of Psychiatry, London.
Chair: Max Birchwood, University of Birmingham.
Discussants: Philippa Garety, Guy’s King’s and St Thomas’ School of Medicine and the Institute of Psychiatry, King’s College, London & Douglas Turkington, University Of Newcastle
People experiencing or who have experienced psychoses often feel, and may be, cut adrift from their communities - normalisation can be a life raft for them. But whether it acts as a temporary solution, leaving them drifting off over the horizon, or making a permanent way back to the shore can depend on many factors. Experimental evidence supporting the occurrence of 'psychotic phenomena' can be accepted gratefully or dismissed as irrelevant depending on how it is presented or better still, elicited. Personal experiences - the patient's or therapists - can be useful, or intrusive and irrelevant. Use of colloquial language can be engaging or perceived as patronising. What helps, what hinders? Will be tentatively discussed.
A normalising cognitive approach to the understanding of psychosis will be outlined. This approach highlights several common cognitive processes and structures that appear to be involved in the development and maintenance of both psychosis and anxiety disorders (central to this is the concept of misinterpretation). This approach suggests that it is the cultural acceptability of interpretations that distinguishes psychotic disorders, and that basic cognitive dysfunction or anomalous experiences are neither necessary nor sufficient for the development of psychosis (and are prevalent in many non-psychotic disorders and the general population). Treatment approaches should be conscious of the importance of avoiding minimising psychotic experiences, in addition to the importance of normalising such experiences. The results of several experimental studies supporting this approach to the understanding of psychosis will be referred to.
Understanding Unusual Experience: An Important Feature of Working with People with Psychosis
Psychosis as presented in the clinical setting is a typically a complex, heterogeneous and severe problem. In making sense of psychosis a fundamental principle of most cognitive behaviour therapists is that people with psychosis, like all of us, are individuals actively attempting to search for meaning so as to adapt and make sense of their experiences, emotions, their selves and their worlds. In making sense of the problems experienced by people with psychosis it is therefore useful to draw on general psychological theory concerning how people in general attempt to create meaning and adapt to adversity. Furthermore, as people with psychosis suffer from emotional distress (and symptoms of depression anxiety, trauma) and have strong beliefs and intrusive images and thoughts it is often also useful to draw on the body of theory that relates to this phenomena as well. However, is psychosis only a reaction to adversity and stress (akin to other types of stress reaction such as depression and anxiety) or does it have its own unique qualities? In this brief paper I will attempt to illustrate aspects of the experience of people with psychosis that may be best understood with reference to theories which suggest that psychosis is associated with a episodes of altered cognitive state and characteristic anomalies of experience. This altered cognitive state and the anomalies associated with it are assumed to be continuous with normality but form a dimension of psychological disorder specific to psychosis.
It is important to view psychosis normally. By viewing psychosis as abnormal pathology, we have neglected the normal way of understanding behaviour - that it relates to learning and social experience. There is strong evidence that psychotic reactions may be understandable response processes that are attempts to cope with distressing life events (including trauma and alienation experiences). The question whether psychosis is normal or not, implies there is a normal way to respond to trauma and adversity. There is not. There are clearly a range of ways of responding to adversity, some are socially sanctioned, psychotic experiences by definition are not. A large proportion of the abnormality that shrouds psychosis is the social response to it. This distinguishes psychosis to a large extent from problems labelled as depression and anxiety. Problems that get labelled as psychotic are perceived as more challenging to influential people around that person, than problems that come under neurotic definitions. Traditionally this has lead to a catastrophising of the problems themselves, heavy-handed medical interventions and a lack of enthusiasm for meaningful understanding and creativity in generating solutions. Rather than focussing on the normality of the experience we need to advocate a normal approach to the problems psychotic experience presents. We should be asking how debilitating is the experience to that person and how can we help them negotiate their experience in their social environment.
Professor Philippa Garety
Professor Doug Turkington
Psychosis: Developments in Case Conceptualisations
Convenor & Chair: Craig Steel, Institute of Psychiatry, London
Case Conceptualisation, Schema Vulnerability and Psychotic Symptoms.
A detailed case of acute schizophrenia with an emerging systematised delusion is described. The process of therapy indicates the need for case formulation before effective symptom management can take place. In particular the technique of inductive formulation is fully described. The importance of schema vulnerability in relation to specific life events and the subsequent psychotic content and meaning is explored. The issue of sexuality in schizophrenia is specifically explored in relation to the case formulation and symptom maintenance. A psychodynamic formulation of this case is presented and contrasted with the cognitive formulation. Implications for psychological treatment of schizophrenia are debated.
Up Against God: Working Therapeutically with Religious Delusions
A case study will be presented of a cognitive-behavioural intervention with an inpatient displaying religious delusions. The case will be put in the context of a continuum model of psychosis and the multidimensionality of delusional beliefs. A number of issues about the intervention will be touched upon, including the advantages and disadvantages of working within a ward environment and the problems in engaging an individual who is not distressed by his beliefs. The main discussion will pertain to the specific difficulties inherent in working with delusions of a religious kind. How can God be challenged? How can you reality-test being sent to Hell? The limitations of behavioural work in this context, and the benefits of a more cognitive approach, will be demonstrated. The overlap between CBT for psychosis and CBT for other psychological difficulties will be highlighted. Ethical issues in working within a delusional system and using faith as a therapeutic tool will also be considered.
Social Rank Theory and Psychosis: Application to Command Hallucination and Delusional Dysmorphobia
Cognitive therapy focuses on thoughts, schema, and associated feelings and embraces personality characteristics that act as vulnerability factors. The application of cognitive therapy to psychosis has imported this theoretical and clinical framework with some adjustment to the process of engagement and challenging of (delusional) beliefs. We have also applied the insights from cognitive theory to explain the maintenance of delusions eg safety behaviours, threat appraisal bias, defensive processes etc. However vulnerability to relapse in psychosis and psychotic beliefs themselves are inherently interpersonal in nature, and a theory is needed that can take account of highly dysfunctional relationships. We have therefore used social rank theory to understand the dynamics of high 'expressed emotion' relationships and the nature of delusions themselves, whether this is the relationship with a voice, a supposed persecutor or supernatural being. The theory helps to explain why people with psychosis are so sensitive to interpersonal threats and why delusions about voices focus on the power and control they can exercise over the individual. An understanding of dominant-subordinate aspects of human relationships helps us to unravel these questions and provides a framework both to formulate and to develop new treatments. We illustrate this with two cases: one an individual with a command hallucination that is responded to with unquestioning obedience; and another who acts on a delusion linked to a dysmorphobia.
Using the Interacting Cognitive Subsystems (ICS) Model to Guide Cognitive Behavioural Interventions During Relapse
There is a narrow window of opportunity for early psychological intervention to prevent relapse in psychosis. Therefore cognitive behavioural interventions delivered during this phase need to be provided promptly, and also be accurately targeted on key cognitions involved in the acceleration of relapse. Using case material the presentation will detail the main problems associated with implementing early psychological intervention for relapse and will show how the Interacting Cognitive Subsystems (ICS: Teasdale and Barnard, 1993) model can be useful in overcoming these problems. In particular the presentation will illustrate how ICS can be used to conceptualise the psychological factors involved in the initiation and acceleration of relapse and how this conceptualisation aids the implementation of strategies aimed at relapse prevention. Finally, the theoretical and clinical limitations to this approach will also be discussed, with reference made to other multilevel conceptualisations of cognition and emotion.
Psychosis And Substance Misuse
Convenors: Christine Barrowclough & Gillian Haddock, Academic Division of Clinical Psychology, University of Manchester and Tameside & Glossop Community and Priority Services NHS trust.
Chair and Discussant: Professor Kim Mueser
A Systematic Review of Treatment Outcome Studies for People with Both Substance Misuse and Psychosis Problems and It’s Implications for Cognitive Therapy
In 1999 we published our systematic review of randomised controlled trials (RCT’s) in the Cochrane database (Ley, Jeffery, McLaren and Siegfried, 1999). At the time there was no clear evidence supporting an advantage of any type of substance misuse intervention for those with severe mental health problems over the value of standard care. In this paper I will report on the results of a major update of our review, taking into account the results of recent RCT’s. I will describe the interventions evaluated, some of the methodological difficulties encountered, and the outcomes achieved, and end with an examination of the implications of this work for cognitive therapy with combined substance misuse and psychosis problems.
Ley, A., Jeffery, D.P., McLaren, S. & Siegfried, N. Treatment programmes for people with both severe mental illness and substance misuse. The Cochrane Library  (1999) Oxford, Update Software
Evaluating Integrated Treatment For Co-Existing Substance Use & Severe Mental Health Problems: Preliminary Results
The evaluation of an integrated treatment approach for clients with co-existing severe mental health and drug/alcohol use problems within Assertive Community Treatment Teams will be described. The intervention involved training teams to use a manualised-based approach, Cognitive Behavioural Integrated Treatment (C-BIT) and incorporated ongoing support to deliver the intervention. The two main questions the study sought to answer were; firstly, can integrated treatment be achieved within existing assertive community treatment teams. Secondly, does integrated treatment have a positive impact on clients? The quasi-experimental research design utilised involved randomly allocating five assertive outreach teams to one of two conditions: ‘training plus ongoing support’ (case) and ‘standard practice’ (control). Over an 18-month period 94 eligible clients in assertive community treatment teams were followed up at 6-monthly intervals, 58 of whom agreed to be interviewed. Some preliminary results and findings from this study will be discussed and thought given to the issues involved in developing evidence based interventions for this client group.
Motivational Interviewing, Cognitive Behaviour Therapy and Family Intervention for People with Schizophrenia and Co-Existing Substance Misuse Problems: Long Term Follow-Up Outcomes.
Co-morbid substance misuse in people with a diagnosis of schizophrenia is associated with poor clinical and social outcomes. There are few studies investigating psychological treatment approaches for this population and little long-term follow-up of their benefits. This paper will describe a randomised single blind controlled trial that evaluated motivational interviewing, cognitive-behaviour therapy and family intervention for patients with a dual diagnosis of schizophrenia and substance. The treatment intervention was a 9-month, integrated, intensive intervention that combined individual CBT for psychosis with a family intervention. Motivational interviewing strategies were integrated into both family and individual approaches to address substance use needs. The study demonstrated the effectiveness of the treatment programme over routine psychiatric care for this client group over the long term on a range of outcomes relating to illness and service use. The treatment approach and patient and health economy outcomes will be described. Outcomes were collected over 18 months and included: psychotic and psychotic symptoms, substance use, social functioning and service use and costs.
Family Characteristics and Treatment Issues for Clients with Schizophrenia and Substance Misuse.
For family members, when clients with mental health problems are using drugs and/or drinking excessively, additional burdens are likely to be experienced over and above those incurred by supporting a person with a mental illness. This paper will present data comparing family members’ Expressed Emotion and causal attributions for the clients’ problems in patients with a schizophrenia diagnosis with and without a substance misuse problem. It was found that “dual diagnosis” carers had more blaming attributions for the patients’ problems than those carers of clients with schizophrenia alone; and that these attributions had serious consequences for the relative-patient relationship. The presentation will describe how family intervention was adapted for working with the specific problems of families of clients with schizophrenia and substance misuse in a recent study in Manchester. Key issues arising from the work will be discussed with reference to case examples and the outcomes for carers in the study will be reported.
Psychosis and Emotional Disorders
Chair: Julia Renton, Salford Mental Health Services
Persecutory Delusions & Emotion
A multi-factorial model of the formation and maintenance of persecutory delusions is presented. Emotion, principally anxiety, is hypothesised to have a direct role in their development. Persecutory delusions are conceptualised as threat beliefs that arise from a search for meaning for internal or external experiences that are unusual, anomalous, or emotionally significant for the individual. The persecutory explanations formed reflect an interaction between psychotic processes, emotional processes, and the environment. A new study is reported in which persecutory ideation in a non-clinical population is investigated using virtual reality. The results indicate that feelings of interpersonal vulnerability and anxiety may directly contribute to the occurrence of persecutory ideation in response to essentially neutral contexts. The study provides support for the hypothesis that emotion has a direct role in the development of persecutory ideation.
Common Cognitive Processes in Auditory Hallucinations and Anxiety Disorders
In this paper, a cognitive approach to the understanding of the maintenance of auditory hallucinations will be outlined, which has been influenced by current conceptualisations of anxiety disorders (particularly the cognitive model of panic). This approach highlights several common cognitive processes and structures that appear to be involved in the maintenance of both voices and anxiety, and suggests that the catastrophic misinterpretation of hallucinations causes the distress and disability associated with them. The common processes include misinterpretation, self-focused attention, safety behaviours, and metacognitive beliefs. The results of several recent experimental studies examining the roles of such processes in voice hearers will be summarised, demonstrating the importance of each of these factors. The implications of this approach for research and practice will be discussed.
Group Treatment of Posttraumatic Stress Disorder in Persons with Severe Mental Illness
Growing evidence documents high rates of trauma and posttraumatic stress disorder (PTSD) in persons with severe and persistent mental illness. However, few interventions have been developed to address this problem. We have recently developed and pilot tested a group intervention for PTSD in severe mental illness. The intervention is provided over 21 weeks and incorporates the following treatment components: psychoeducation about PTSD, breathing retraining, cognitive restructuring, coping skills enhancement, and developing a personal recovery plan. A pilot study of this group intervention has been conducted, with outcome assessments performed at baseline, post-treatment, and 3-month follow-up. The results of clients treated in eight group cohorts will be presented. The implications of the findings for the treatment of PTSD and severe mental illness will be discussed, as well as further steps in research, including the need for controlled evaluation of the group intervention.
A Psychological Model of Relapse in Psychosis: The Role of Negative Beliefs About Illness, Intrusive Memories and Safety Behaviours.
Relapse is a major factor that is involved in the development of psychological co-morbidity, chronicity and disability associated with having psychosis. Historically clinicians and researchers have viewed relapse as either an inevitable part of a deteriorating illness or the consequence of non-adherence with treatment. These appraisals of control and / or responsibility for relapse are not lost on individuals who have experience a recurrent psychotic illness. The paper will propose an evolving psychological model of relapse based on the view that the experience of psychosis represents a major life event, which can lead to the development of a range of negative beliefs about self and psychosis. The model incorporates factors proposed to be associated with cognitive vulnerability to relapse (negative beliefs about self and illness), and factors associated with transition to relapse (safety behaviours and intrusive memories). The paper will also describe empirical evidence supporting the proposed model of relapse. Implications for psychological treatments in the prevention of relapse and the modification of medium to long-term vulnerability will be discussed.
Management of Psychosis
Convenor & Chair: David Kavanagh, University of Queensland, Brisbane, Australia
This symposium examines two sets of issues that arise in the management of people with psychosis. The first are problems that arise in family management of the disorder, and particularly the difficulties family members have in identifying whether behavioural or relationship problems are due to the psychosis. The second are problems with comorbid substance misuse, which occurs very commonly in psychosis. Both problems have particular importance in early psychosis, when long-term difficulties can potentially be accentuated or averted by the management approach that is used. The symposium describes brief CBT interventions that appear useful as first-line approaches to these problems.
The Strengthening Ties Family Program- A Brief Intervention for Parents of Young People with Recent Onset Psychosis
Over 50% of young people with psychosis live with their families, and the importance of early intervention for psychosis is increasingly recognised. Current family intervention research on recent onset psychosis is limited, and most interventions are adapted from programs for long-term severe mental illness. These programs have been 9-24 months in duration, which has raised significant cost, participation and delivery issues for families and mental health services. What is required is a brief, time-limited family intervention that is tailored to the unique needs of families of young people with recent onset psychosis. A 6-session, individualised family intervention (The Strengthening Ties family program) for parents of young people with recent onset psychosis was developed. The program focused on enhancing illness knowledge and understanding, positive adaptation, coping and relationship strategies within the family. A range of burden and relationship assessment tools including the Experience of Caregiving and the Family Questionnaire were used. Current issues, problems, coping strategies, and interpersonal and family strengths were identified, and family enhancement, problem-solving and strengths approaches were then utilised to facilitate families working through their key identified issues. Results of families randomly allocated to receive the program during their young person’s admission were compared with those of a waitlist control group. Findings indicate that the Strengthening Ties Family program has potential as an early-stage intervention that may readily be implemented by existing mental health services.
An Examination of the Influence of Cannabis Use on the Course and Relapse of Early Psychosis
The use of illicit drugs such as cannabis, amphetamines, cocaine and hallucinogens is higher amongst young adults with schizophrenia compared with people who do not suffer from schizophrenia or people with other psychiatric conditions and normal control groups. In recent years there has been particular concern about the impact of cannabis use on the onset, course and relapse of schizophrenia. Evidence from retrospective and a small number of prospective studies has suggested that chronic cannabis use may precipitate a latent psychosis, exacerbate psychotic symptoms and increase the likelihood of psychotic relapse. However, the majority of studies have been retrospective and the few prospective studies that have been conducted have used small sample sizes, are brief in duration, and have not monitored ongoing substance use. The current study prospectively examines the relationship between cannabis and other drug use and psychotic symptoms in a sample of recent onset schizophrenics. 81 inpatients with less than three episodes of psychosis were followed up for a 6 month period. Interviews were conducted using a combination of telephone and face to face interviews. Random urine samples were also taken to corroborate self reported drug use. Measures consist of a structured diagnostic interview, measures of family functioning, premorbid adjustment, quality of life, substance use and psychotic symptoms. Predictors of psychotic relapse and symptom exacerbation were identified using survival analysis. Stress was the only predictor of psychotic relapse. The frequency and quantity of cannabis use and the age of onset of psychosis were predictive of psychotic symptom exacerbation. Medication compliance and measures of family functioning were not predictive of psychotic relapse or symptom exacerbation. Implications for interventions and for the stress/vulnerability model of schizophrenia are explored.
Family Intervention in Co-Occurring Disorders
Substance abuse is common in persons with severe and persistent mental illness, but few interventions have been demonstrated to be effective with this population. Because of the high rates of contact between clients with co-occurring disorders and their relatives, we developed a family intervention program to address substance abuse and severe mental illness, and to reduce the burden of care on family members. This treatment, the Family Intervention for Dual Disorders (FIDD) program involves both single family and multiple family group formats, and is designed to take the collaborative approach to reducing substance abuse and stress in the family. The FIDD model will be described, followed by the results of a pilot study demonstrating its feasibility and promise as a clinical intervention. The design of a randomized control trial to evaluate the FIDD program, currently underway, will be briefly summarized.
CBT for Substance Misuse in Mental Disorder: Results of Outcome Trials
Substance misuse is common in people with mental disorders, and is seen in the majority of young people attending health services. Most treatment trials for co-morbid substance misuse have been undertaken in people with psychosis. We know very little about specific approaches to treatment, but integrated treatment appears to be more effective than sequential or parallel treatment. Good quality trials are still rare, as are powerful effects on symptoms or substance use. Brief motivational intervention has predominantly been used as a route of engagement to longer forms of treatment. This paper focuses on two trials of brief intervention by the authors as stand-alone treatment for co-morbid substance misuse in psychosis. The first study—a small-scale trial with early psychosis—compared a brief motivational intervention with standard care, and obtained significantly stronger reductions in substance use in participants who received motivation enhancement. The second study examined the relative benefits of the brief intervention and a rapport-building control for people with psychosis and substance misuse: Preliminary results from this study will be presented and discussed. Suggested directions for further development of CBT for co-morbid substance use will be described.
An Empirical Investigation of Mental Health Problems and Treatment Needs of Amphetamine Users: A Cross Sectional Study
Amphetamine use has emerged as a major drug problem in Australia and especially in SE Qld where its use far exceeds that of heroin. Among amphetamine users there appears to be a substantial but poorly described experience of mental disorders that range from frank psychoses to subclinical symptoms that include abusive and aggressive behaviors, suspiciousness and impulsivity. In order to define the extent and nature of mental health problems and to gauge what treatment responses are appropriate for the health care system, we conducted a systematic examination of these symptoms in a cohort study of 200 amphetamine users presenting at a Needle Syringe Exchange Program. In order to investigate the relationship between amphetamine use and the development of mental health problems we used measures that assess (a) anxiety and depression and (b) sub clinical psychotic symptoms and overt psychosis. These include the Brief Psychiatric Rating Scale and the Psychosis Screening measure (Degenhardt & Hall, 2001) in addition to a new measure designed to assess "psychosis proneness", the Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE). This measure taps into the four domains associated with subclinical features of psychosis - Unusual Experiences, Cognitive Disorganisation, Introvertive Anhedonia and Impulsive Nonconformity. The relationship between these measures and current use of amphetamine and other drugs is explored.
Issues in Psychosis
Are People with Delusions Irrational? A Review of, and an Integration of the Evidence With a Model Of “Normal” Reasoning
Delusions are usually thought of as erroneous beliefs. However, opinion has differed as to how these false beliefs are formed. On the one hand the delusional belief is seen as a reasonable explanation of an unusual experience (such as an auditory hallucination). On the other, the delusion is the result of faulty or biased reasoning processes. This presentation will review a series of experiments investigating the reasoning processes of people with delusions. Specifically, performance on tasks of probabilistic reasoning (the beads task) and deductive reasoning (Wason Selection tasks) will be discussed. It is noted that people with delusions exhibit subtle but definite differences in reasoning even when the task bears little, if any relationship, to the content of the delusion. The data suggest that people with delusions exhibit a confirmatory reasoning style that leads to a hasty acceptance of an hypothesis owing to the person having undertaken a limited search for evidence consistent with the hypothesis. Hence, people with delusions seek confirmatory rather than disconfirmatory evidence. It is argued such reasoning differences are understandable in terms of a recent model of normal reasoning (Evans and Over, 1996) and are presumed to play an important role in the formation and maintenance of delusions. Accordingly, such a reasoning style may need to be addressed when offering cognitive therapy to people with delusional beliefs.
An Investigation into Command Hallucinations across Forensic and Non-Forensic Populations
Command hallucinations have long been regarded as a significant risk factor for violent behaviour by both forensic and non-forensic clinicians (e.g. Rudnick, 1999). However, the research evidence for this assertion is equivocal, as research has demonstrated compliance rates of between 39.2% and 88.5% with command hallucinations (e.g. Hersh and Borum, 1998). Beck-Sander, Birchwood and Chadwick (1997) demonstrated how cognitive mediation plays an important role in understanding an individual’s reaction to command hallucinations. They found that beliefs about power, benevolence and malevolence played a pivotal role in understanding individual reaction to the voice (e.g. whether it complied with or not). Moreover, these authors argued, drawing on transgression theory (e.g. consequences of infringement of the command), that individuals used a variety of strategies to ‘appease’ the command (e.g. self-harm instead of suicide). Moreover, according to Beck-Sander et al (1997), benevolent beliefs about a voice would predict compliance (e.g. ‘the voice is God’), whilst malevolent beliefs about a voice led to the command being resisted or appeased (e.g. ‘the voice is the Devil and it is trying to corrupt me’). Even though it is apparent that cognitive mediation (e.g. beliefs about the voice) about the commanding voice is important, it does raise some interesting questions about command hallucinations where the individuals have acted upon command hallucinations and committed violent offences (e.g. GBH, murder, etc.). These questions include: Why was the person unable to resist these commands? Were there any differences in the topography of the voice (e.g. louder, more frequent, etc.)? Are there personality factors in operation that inhibit or facilitate compliance with a command hallucination (e.g. impulsivity)? This paper hopes to address a number of these questions and present some ideas about role of these and other factors in understanding individual reaction to command hallucinations, with particular reference to risk assessment.
Psychological Interventions in the Prepsychotic Phase: Can The Risk of Transition to Psychosis be Reduced?
Since 1994 the PACE Clinic has been working with young people thought to be at imminent risk of developing a psychotic disorder, with the ultimate aim of applying preventive interventions to this early phase of illness. Based on early experience with this group and the results of prospective studies, clinical criteria defining a group that has been termed ‘Ultra High Risk’ (UHR) for progression to psychosis were developed, and have proved to yield a transition rate of approximately 40%. As this rate of transition to psychosis occurred despite the provision of supportive therapy and active treatment of co-morbid anxiety and depression, the development and evaluation of a specific treatment package aimed at preventing the transition to psychosis seemed warranted. This paper will describe the psychological intervention, based on cognitive-behavioural principles, that was developed and included with low-dose atypical neuroleptic medication as the specific treatment in the first PACE Intervention Study. This specific preventive intervention was compared with needs-based supportive treatment. The results of this study, which suggested that the more specific treatment package reduced the risk of early transition to psychosis, will be presented. A further ongoing study designed to allow evaluation of the individual treatment components (i.e., psychological treatment vs medication) will also be described.
Psychosis in People With Learning Disabilities - A Suitable Case For Treatment?
The utility of cognitive and behavioural approaches in the treatment of specific psychotic symptoms and in relapse prevention work is increasingly being demonstrated in work with people without learning disabilities. The aim of the current paper is toexamine the putative utility of such approaches with people with learning disabilities. In order to do so, there is a need to examine the validity of concept of schizophrenia with people with learning disabilities by focussing on individual psychotic symptoms. In the case of people with learning disabilities, this is further complicated by the additional social, psychological and neurological factors implicit in learning disabilities. The clinical implications of such an examination of psychotic symtomatology are the possibilities of work on both symptom treatment and in relapse prevention. The current paper aims to look specifically looking at the management of relapse in this population. By means of case examples, the applicability of relapse prevention models to people with moderate learning disabilities is demonstrated, with a focus on both staff training and support using cognitive-behavioural approaches and on self- reporting and self-management of precipitating distress in the prodromal stage. The lessons learnt from these initial sucessful interventions are discussed together with models of service delivery and staff training in services for people with learning disabilites.
Group and Individual Pychological Intervention for People Suffering from Bipolar Disorders – Results and Theoretical Implications from a Clinical Randomised Control Trial.
The current study investigates 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 etiology and treatment of bipolar disorders that takes account of mood specific changes in the perception and function of various psychological factors and the clinical processes that can be employed to change the effect of these vulnerabilities. The development of a comprehensive intervention model seems necessary considering the high relapse rates, co-morbid physical and psychological difficulties and premature mortality observed for people suffering from bipolar disorders, despite state of the art pharmacological management. There is a growing evidence base that in bipolar disorders, psychosocial, emotional and cognitive factors play a significant part in relapse and overall quality of life. Moreover, psychosocial intervention has been found to be effective for the treatment of severe psychiatric disorders including major depression, recurrent depression and schizophrenia but there is less systematic research conducted in this area for bipolar disorders. Given the high relapse rate despite medication, the impact of psychosocial factors and the evidence of the effectiveness of psychosocial interventions in other disorders, it seems necessary to expand this line of research into this patient group. 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. The evaluation follows a mixed design of a cross-sectional analysis between the three groups and a longitudinal analysis of those within the treatment groups. Patients were recruited from referrals to a specialist department within adult psychiatric services in Edinburgh. All patients were assessed at intake, mid-treatment, end-treatment and at follow-up with a number of psychosocial, cognitive, emotional and relevant clinical measures. These factors were assessed by self-report and observer rated measures and semi-structured interviews. Individuals’ perception of the therapeutic process was assessed at follow-up. Results for 160 patients that have completed the treatment and follow-up, the and theoretical implications of this study will be presented in this paper. The results of a first episode sub-sample reveal significantly lower relapse rates and inter-episode residual symptoms, as well as better psychosocial functioning, these findings have strong theoretical implications for the early intervention paradigm for bipolar disorders.
Issues in Psychosis
Promoting Personal Recovery From First Episode Psychosis: A Randomised Controlled Trial
Depression and suicidal thinking in people with psychosis affects up to 40% of individuals with as many as 10% taking their lives (Westermeyer 1991). Research has shown that such reactions are particularly high in young people with a first episode of psychosis and are frequently accompanied by symptoms of PTSD associated with the trauma of the diagnosis and management of the symptoms. Although this problem remains largely overlooked and untreated it maybe amenable to a CBT approach. This poster presents preliminary findings from randomised controlled trial designed to evaluate an original cognitive therapy to aid personal recovery in first episode patients. The therapy is aimed at exploring their experiences of trauma and key cognitive appraisals of humiliation, loss and entrapment, as suggested by social ranking theory, (Gilbert 1992).
Differences Between Main Substance of Use in Schizophrenia Patients with Associated Drug and Alcohol Misuse
Background: A recent review has shown that 40-50% of individuals with schizophrenia also have a co-morbid substance use disorder (Blanchard et al, 2000). Multiple substance use is common in many patients. However, there has been little investigation into the differences in type of substance and the effects on both symptomatology and treatment outcome.
Aim: Data from a recent trial (Barrowclough et al, 2002) is examined to investigate whether differences exist between the clinical presentation of schizophrenia patients with co-morbid substance use, where the most frequently used substance is either alcohol or a non-prescribed drug.
Method: The identification of the patients most frequently used substance (MFU) was conducted. Differences in demographic details, symptomatology and outcome, were investigated in the form of symptoms, relapse rates, and stages of motivation to change.
Results: Results indicated that drug users (MFU) were significantly younger, and had more and longer hospital admissions, compared to those who used alcohol most frequently. There were no significant differences in symptomatology on entry into the study. However the alcohol (MFU) group had a greater proportion of participants with a high motivation to change, compared to the drug (MFU) group which showed the opposite. Results also indicated differences in symptoms such as anxiety, between groups at later time-points.
Conclusions: Owing to the above results, it would appear that those patients whose most frequently used substance is a drug fair less well in terms of relapse rates and certain symptoms, which are important factors in terms of their care and treatment.
Interventions With Severe Mental Health and Substance Use Problems in Community Orientated Mental Health Services
This poster will outline the structure of services within Northern Birmingham Mental Health Trust (NBMHT) and the development of The Combined Psychosis and Substance Use (COMPASS) Programme within this framework. One of the interventions The COMPASS Programme is involved in, is the development and evaluation of integrated services in NBMHT for individuals with co-existing Severe Mental Health and Substance Use problems. The evaluation of an integrated cognitive behavioural treatment approach implemented within Assertive Outreach Teams will be described and progress with this evaluation will be reported on. Some thought will be given to the issues involved in developing evidence-based interventions for this client group to improve mainstream service delivery.
The Prevalence of, and Beliefs About Voices in Non-Psychotic Populations.
Recent research has shed light on the psychological processes involved in auditory hallucinations or “voices”. Studies of the non-psychotic population have indicated that it is not the presence of voices per se that leads to distress but the view taken of them. Hence, beliefs about voices are crucial to our understanding of voice phenomena. This presentation describes two related studies that examined the prevalence of voice experiences in a student population and a non-psychotic but clinically unwell sample of participants. Then the specific beliefs associated with voice hearing were examined. A version of the Launay Slade Hallucination Scale (LSHS) which measures predisposition to visual and auditory phenomena was distributed to two groups of participants. The first group consisted of 357 undergraduate students and the second, 60 people with a non-psychotic emotional disorder. This second group consisted of people with depressive and anxiety disorders. The prevalence of voice type experiences between the groups was compared. As with previous reports there was evidence of a substantial minority of people in the non-psychotic population reporting voice like phenomena. However, there were no differences on the voice items between the groups indicating that hallucinatory phenomena are not associated with emotional distress alone. Given that people with non psychotic emotional disorders experienced voices but were not apparently unduly distressed by their presence ( as they had not been reported at assessment or during therapy) we investigated whether beliefs about voices may help us understand what leads to a voice being perceived as a problem or not. Drawing on a methodology employed by Morrison, Wells and Northard (2000) we asked 60 clients from the Cognitive therapy centre to complete measures on predisposition to hallucinations (LSHS), mood (BDI, BAI), meta-cognitive beliefs and thought control strategies and beliefs about unusual experiences. As with previous studies (Morrison et al., 2000) it was found that the high predisposition to voices group demonstrated different negative metacognitive beliefs to those with low predisposition. Moreover, the high predisposition group reported higher positive and negative beliefs about voice phenomena than the low predisposition group who reported more negative then positive beliefs. These studies reveal that a substantial proportion of a student population and of people seeking help for emotional disorders report hallucinatory phenomena and that beliefs about such phenomena appear to be important in understanding when they are experienced as distressing. The theoretical and clinical implications will be discussed.
Predicting Psychosis: A Longitudinal Investigation of Prodromal Features and Cognitive Vulnerability Indicators in Young People at Risk of Psychosis.
Early detection of prepsychotic individuals involves the exploration of two theoretical concepts linked to the development of psychosis: the concept of prodromal symptoms that are posited to herald an imminent psychosis, and the concept of vulnerability indicators or ‘markers’ that are hypothesised to point to an underlying biological predisposition to psychosis. Potential markers include psychophysiological deficits, information processing deficits and neuropsychological abnormalities that are found in individuals with established psychotic illnesses, and also in their healthy relatives suggesting that these deficits may signal risk of psychosis. The current study investigated the validity of utilising a combination of prodromal symptoms (i.e., an ‘at risk mental state’) and vulnerability indicators to predict the imminent onset of psychosis. The Continuous Performance Test - Identical Pairs Version (CPT-IP), and a number of other neuropsychological tests, were selected as the focus for this study. Subjects meeting criteria for inclusion as high risk subjects were assessed on these potential marker variables at study entry, and their outcome, in terms of transition to psychosis or not after 12-months was determined. The high-risk group was also compared with a normal comparison group and a first-episode psychosis group. The PACE group exhibited performance deficits, compared to the NC group on the CPT-IP and tests of verbal memory and executive functioning. Within the PACE group, those who developed psychosis were not distinguishable from those who did not on any of the putative neurocognitive marker variables. The Global Assessment of Functioning Scale was the only significant predictor of psychosis.
Group CBT for People with Schizophrenia: A Further Evaluation
Evidence continues to grow in support of the effectiveness of the cognitive behavioural treatment of psychotic experiences within individual and group formats. These interventions have tended to focus almost exclusively upon homogenous experiences, e.g., voices and delusions. This study built upon the work of Gledhill et al (1998) by applying the principles of CBT to a range of psychotic experiences in a group setting. Data are reported from the first two of a series of groups that were conducted within inpatient settings. The groups were informed by the normalising rationale and Coping Strategy Enhancement (CSE). The location of experiences on a continuum with ‘normality’ encouraged participants to be critical of ‘professional’ views of their experiences and to explore their own understandings. The formulation of individual ‘problems’ within a simplified model of CSE enabled the coping strategies generated by participants to have high face validity. Effectiveness was demonstrated in terms of attendance, use of coping strategies in vivo between sessions, feedback from participants and facilitators and impact upon the inpatient environment. Self report data indicated a trend towards effectiveness with respect to control and distress, thereby supporting the expectation that the groupwork would be the start of a process of change embedded within collaborative working that utilised the expertise of the participants.
Clinical Applications, Therapeutic Issues and Other Issues
Successful and Unsuccessful Ideas in Behaviour Therapy: An Historical Analysis
Professor S.J. Rachman, University of British Columbia, Vancouver, Canada
Sifting through the origins of BT it is possible to discern the successful ideas and the failures, and to understand the differences between them. The ideas can be classified into high and mid-level theories, ideas on methodology, ideas for specific techniques. Broadly, the high theories such as the two prevailing learning theories that provided a basis for BT, had only temporary success. They provided scaffolding for BT but then fell away, and now are no more than footnotes. Some of the specific theories, such as the conditioning theory of fear-acquisition, were partly successful but proved to be limited. The comprehensiveness that was claimed for the theory could not be sustained. The ideas that shaped the methodology of BT, with the emphasis on experimental rigour, have had success and played a significant role in establishing the necessity for randomised control trials to test the effects of Behaviour Therapy. At the level of specific techniques those that clung too closely to a conditioning model were moderately successful but insufficient. One of the most interesting evolutions was the emergence from systematic desensitisation of the fear-reducing exposure methods that are still in widespread use. Desensitisation was allied to a specific theory but the ubiquitous exposure techniques are less well anchored. Some of the ad hoc techniques, such as thought-stopping and the use of a rubber-band aversive method, seemed at the time to be simplistic. They still do. To a degree BT developed as a reaction to psychoanalysis, introspectiveness, overly medical construals of abnormal behaviour. The criticisms of these competing approaches led to a search for better alternatives, one of which was BT. As part of this alternative approach, psychologists tried to link BT to general psychology and the advocacy of empiricism was a major influence on the acceptance of the need for an evidence-based clinical discipline. Incidentally, the development of BT and the modern profession of clinical psychology were closely linked, sharing many aims and methods. The high-level theories seem to have failed because they were overly ambitious and based on learning theories that proved to be flawed. Some mid-level theories, such as Mowrer's two-stage theory of fear and avoidance, and Lang's three-systems analysis of fear, have legs. Aim high, but not too high?
Thirty Years of Behavioural and Cognitive Therapy: Where Have We Been and Where Might We Be Going (Through the Eyes of a Short Yank)
Professor Thomas Borkovec, Penn State University, Pennsylvania, USA
Behavioural and cognitive therapies developed over the past several decades have provided significant ways for intervening with a variety of psychological problems. Well over 100 treatment-by-disorder combinations have been empirically validated. Importantly, many of these techniques have clearly been grounded in applications of operant and classical conditioning principles. Despite these successful developments, available interventions often are limited in the degree of clinical change that they produce, and many disorders remain for which there are no demonstrably effective techniques. This presentation will speculate about directions that our thinking and research might take in order to maximize the application of existing knowledge and the acquisition of further knowledge upon which to base the development of increasingly effective forms of intervention. Some of these speculations arise from extensions of current knowledge based on logical deductions from existing techniques and empirical relationships, and some of them have to do with ways of conducting treatment research in the future that can potentially accelerate our production of useful knowledge.
Manual-Based Treatment: The Evolution of Evidence-Based Therapy
Professor G. Terence Wilson, Ph.D., Rutgers University, New Jersey, USA
Manual-based treatments have become a valuable means of providing effective and efficient therapy for a range of clinical disorders within the general framework of cognitive behavioral therapy (CBT). Manual-based treatment can be seen as an important step in the evolution of evidence-based CBT. A brief history of manual-based treatment will be followed by a summary of their clinical advantages and critical analysis of common misconceptions. Manual-based treatment provides more individualization of therapy than is often recognized. Nevertheless, a major challenge now is to balance the focus and structure of manual-based therapy with the flexibility inherent in tailoring specific interventions to individual patients within a framework that goes beyond diagnostic categories. Ultimately, useful matching of specific treatments to particular problems will hinge on better understanding of (a) the mechanisms that maintain clinical disorders, and (b) the mechanisms whereby treatments work.
Working With PTSD in Challenging Clinical Cases
Convenors: Deborah Lee, Traumatic Stress Clinic, Camden and Islington Mental Health and Social Care Trust & Emily Holmes, Sub-department of Clinical Health Psychology, University College London, & Traumatic Stress Clinic, Camden and Islington Mental Health and Social Care Trust
Chair: Deborah Lee, Traumatic Stress Clinic, Camden and Islington Mental Health and Social Care Trust
Discussant: Padmal De Silva, Institute of Psychiatry, London
Working with Chronic PSTD in the Context of Co-Morbid Depression and Intense Shame: A Case Example of a Woman Who Was Gang Raped
PTSD has traditionally been defined as an anxiety disorder where fear, helplessness and horror are thought to be the key subjective and emotional experiences in the aetiology of the disorder. This has lead to the development of treatment techniques aimed at treating fear as the primary emotional response to the traumatic event, most often with various forms of imaginal exposure (Shalev et. al., 1996; Marks, Lovell, Noshirvani, Livanou & Thrasher, 1998). Recent evidence has demonstrated however that both anger and shame (experienced at the time or in the aftermath of the incident) are also strong predictors of PTSD symptoms (Andrews, Brewin, Rose & Kirk, 2000). These emotions can be very disabling, contribute to later psychopathology, impede and may seriously disrupt the therapeutic effects of imaginal exposure (Ehlers & Steil, 1995; Lee, Scragg & Turner, 2001). Thus shame and anger may create barriers to traditional exposure techniques utilised in trauma therapy. A case example of a woman who experienced a gang rape 25 years prior to her referral will be presented. Her case is characterised by chronic PTSD, severe depression and intense shame. Formulation issues and treatment approaches will be discussed with respect to the timing/execution of exposure work and schema focused therapy to treat underlying shame and depression.
Andrews, B., Brewin, C.R., Rose, S. and Kirk, M, (2000). Predicting PTSD in victims of violent crime: The role of shame, anger and sexual abuse. Journal of Abnormal Psychology, 109 (1), 40-48.
Ehlers, A. & Steil, R. (1995). Maintenance of Intrusive Memories in Posttraumatic Stress Disorder: A Cognitive Approach. Behavioural and Cognitive Psychotherapy, 23, 217-249
Lee, D.A., Scragg, P. & Turner, S.W. (2001). The role of shame and guilt in reactions to traumatic events: A clinical formulation of shame-based and guilt-based PTSD. British Journal of Medical Psychology, 74, 451-466
Marks, I, Lovell, K, Noshirvani, H, Livanou, M & Thrasher, S (1998). Treatment of Post-Traumatic Stress Disorder by exposure and/or cognitive restructuring: A controlled study. Archives of Psychiatry, 55, 317-325
Shalev, A.Y., Bonne, O & Eth. S. (1996). Treatment of Posttraumatic Stress Disorder: A Review. Psychosomatic Medicine, 58, 165-182
Treating PTSD Associated with Involvement in the Perpetration of Violent Acts: A Case Example in an Ethiopian Refugee
Participation in atrocities has been found to greatly increase the probability of developing PTSD in combat veterans (Breslau and Davis, 1987). In addition, combat-related guilt is known to be a significant predictor of suicide attempts amongst Vietnam veterans (Hendin and Pollinger Haas, 1991). However, the treatment of PTSD associated with perpetration of violent acts has received little attention. Moral and legal arguments may complicate clinical judgements about therapy (Kruppa, Hickey and Hubbard, 1995). A case example of a refugee with PTSD who had been involved in the perpetration of violent acts in his native Ethiopia will be presented. Current cognitive-behavioural treatments for traumatised refugees will be reviewed and case material using one such treatment, 'testimony' (Cienfuegos and Monelli, 1983), will be discussed. Traditional approaches to working with trauma-related guilt were incorporated into the therapy, with some modification. Implications for the treatment of perpetrator guilt in PTSD will be discussed.
Breslau, N. & Davis, N. (1987). Posttraumatic stress disorder: The etiologic specificity of wartime stresses. American Journal of Psychiatry, 144, 578-583.
Cienfuegos, A.J. & Monelli, C. (1983). The testimony of political repression as a therapeutic instrument. American Journal of Orthopsychiatry, 53, 43-51.
Hendin, H. & Pollinger Haas, A. (1991). Suicide and guilt as manifestations of PTSD in combat veterans. American Journal of Psychiatry, 148, 586-591.
Kruppa, I., Hickey, N. & Hubbard, C. (1995). The prevalence of posttraumatic stress disorder in a special hospital population of legal psychopaths. Psychology, Crime and Law, 2, 131-141.
Getting On: Changing Attachments and Other Complexities of Working With Traumatised Older People in Cognitive Therapy
Cognitive therapy (CT) for Post Traumatic Stress Disorder (PTSD) is an established clinical intervention. A number of lifespan and late life specific issues may complicate CT intervention for traumatised older people. Ageism may lead to bias in interpreting traumatic symptomatology as cognitive or physical degeneration. High levels of physical and psychiatry co-morbidity may complicate CT for traumatised elders. Old Age is a developmental phase when independence has to be renegotiated and life review is the common existential process. Earlier life attachment issues may re-visit with a vengeance in such a context. Living a lifetime with traumatic memories may have led to the adoption of highly evolved avoidance strategies in which families as well as individuals may be heavily invested. For the wartime generation of older Britons the imposed social narrative of stoical heroism may complicate the therapeutic process in CT. PTSD is a recent concept, which has less impact on older people's often more pejorative accounts for trauma than younger age groups. Case accounts demonstrating adaptations of CT for traumatised older people will be presented. A model attempting to integrate lifespan and late life specific complexities for traumatised older people and their CT therapists will also be considered.
Hotspots In PTSD: A Window Into Complex Emotional Reactions to Trauma
The diagnostic criteria for Post-traumatic Stress Disorder (PTSD) lead us to focus on emotional reactions of patients at the time of their trauma, in particular, fear, helplessness and horror. However, a wider spectrum of emotional reactions may have occurred e.g. shame, disgust and sadness (Grey, Holmes & Brewin, 2001). These ‘emotion-cognition dyads’ are frequently re-experienced in the form of intrusive memories. Identifying them can be key in formulating a complex case, as they may tap into longstanding themes and may require targeted treatment strategies (Grey, Young & Holmes, 2002), e.g. for humiliation versus fear reactions. The array of emotions and associated cognitions experienced during trauma can be investigated by focussing on ‘hotspots’. Hotspots are particular parts of a trauma memory that cause intense levels of emotional distress, that may be difficult to recall deliberately and are associated with reliving (Ehlers & Clark, 2000). They are elicited by asking patients to describe their trauma in detail (at assessment or during reliving therapy) and to identify their ‘ worst moments’ using a structured protocol. Research will be presented using ‘hotspots’ as a clinical tool for assessing and treating patients with PTSD, useful for both simple and complex cases. The relative frequencies of a wide range of emotions will be presented. Themes of peri-traumatic cognitions will be discussed, highlighting their idiosyncratic nature. The study also shows the clear link between intrusive images and hotspots in memory. Using a ‘hotspots approach’ aids working with complex cases. For patients where more extensive cognitive restructuring (e.g. via schema work) is necessary before completing reliving therapy, hotspot themes direct which beliefs to target. The approach can help make links with previous traumas, e.g. a current assault bringing back themes in childhood abuse. Interestingly, it also helps to pick up flashbacks to past trauma that may have been activated during a recent trauma. Further, identification of dissociative hotspots helps inform management of triggers for dissociation.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.
Grey, N., Young, K. and Holmes, E. (2002) Cognitive restructuring within reliving: a treatment for emotional ‘hotspots’ in Posttraumatic Stress Disorder. Behavioural and Cognitive Psychotherapy, 30, 37-56.
Grey, N., Holmes, E. and Brewin, C. (2001) It’s not only fear: Peri-traumatic emotional ‘hot spots’ in posttraumatic stress disorder. Behavioural and Cognitive Psychotherapy, 29, 367-372.
Real World Research in CBT
Convenors: Allison Harvey, University of Oxford and Warren Mansell, Institute of Psychiatry.
Chair: Allison Harvey, University of Oxford
Randomised Controlled Trials
Randomised controlled trials (RCT’s) are clinical experiments involving the comparison of an index treatment with one or more alternative treatment conditions (which may include delayed treatment). Since RCT’s involve manipulating patients’ treatment, they should be done with care and forethought. RCT’s may be used to address a variety of questions including those concerning the relative effectiveness of treatments, their mode of action and theories concerning the nature of the disorder being studied. The basic generic requirements of RCT’s are that there is genuine randomisation, blind assessment, sufficient power to address the question(s) being asked and, by default, analysis by intent-to-treat. Psychological treatments are amenable to testing using RCT’s. The principles are the same as those that apply when evaluating other forms of treatment. To date, however, many psychological treatment RCT’s have had important methodological shortcomings, the most common being that they have been underpowered. A particular challenge is ensuring that the psychological treatments are implemented appropriately. With certain designs it may be necessary to define operationally the boundaries between the treatments concerned as well as their areas of overlap. As much attention should be paid to the nature and quality of the “control” condition(s) as to those of the index treatment. Relatively neglected is the use of RCT’s to generate hypotheses about mediators and moderators of treatment effects (see Kraemer et al, in press). Hypotheses generated in this way may be tested in subsequent treatment experiments. Kraemer, HC, Wilson, GT, Fairburn, CG & Agras, WS. Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry (in press).
Qualitative Research Methods
Qualitative methods have become much more widely adopted within clinical psychology and related fields over the last ten years or so. The initial debate about their scientific status has largely been resolved; the important questions now concern “when, which and how,” i.e., when are qualitative methods best used, which of the many possible approaches is suitable for each given application, and how best to carry out the research in practice. This paper will address these three questions. The guiding framework will be one of methodological pluralism (see Barker, Pistrang, and Elliott, 2002) -- that no single research method or epistemological approach is superior in all cases, and that the researcher’s skill partly lies in fitting the research method to the research question. The issues will be illustrated with examples, drawn from the authors’ own research on the process of psychological helping, and also more broadly from studies in the current literature.
Real World Research for CBT Utilising Single Case Methods: Innovative Researchers and Accountable Practitioners
The origins and development of single case methods will be outlined. Examples are given of the range of applications and rationales underlying their use. In particular, the potential contribution of single case methods to clinical research will be discussed. Different single case paradigms suitable for evaluating CBT will be critically reviewed. Problems of implementing these methods in research and practice will be highlighted. These include: the reversibility problem, suitability of statistical methods and integration into clinical practice. The claims that single case methods may provide an opportunity for clinicians to become involved in and conduct their own research will be critically examined. It will be argued that despite the aspirations, most clinicians do not operate as single case practitioners and conduct case studies. Reasons for the failure of clinicians to adopt these methods will be examined. These include training, workloads, perceived applicability to clinical practice, and organisational constraints on research. Finally, research on the dissemination and uptake of single case methods within the social work profession in the US will be presented and questions raised by this research for single case practice in the UK will be posed. It is suggested that clinicians might appreciate the benefits of single case methods, if their relevance to evaluating and enhancing the effectiveness of their own clinical practice is emphasized. Greater utilisation of these methods within practice might encourage their exploitation for clinical research.
Real World Experiments
One of the best ways of conducting research that will readily generalise from experimental investigations to the clinic is by conducting field experiments. This approach first came into its own in the 1970s with the landmark studies of Rachman, de Silva and colleagues on obsessional behaviour. Examples of the types of questions that can be addressed by this type of research will be given, drawing upon recent and ongoing studies on anxiety disorders and related fields. Ways of maximising ecological validity of “real world experiments” are considered.
Developments in Interventions for People with Learning Disability in Secure Settings
Convenor: John L Taylor, Northumbria University and Northgate & Prudhoe NHS Trust
Chair & Discussant: Raymond W Novaco, University of California, Irvine, USA
Preliminary Results from a Cognitive Behavioural Treatment Group for Men with a Learning Disability Who Sexually Offend
Sex offending in the general population has been a focus of clinical and forensic interest for some time due to the damaging and dangerous nature of the behaviour, an understandable desire to reduce recidivism among released offenders, and recent theoretical and clinical advances (Marshall, Anderson, & Fernandez, 1999). This same approach has recently been extended to sex offenders with learning disabilities (Lindsay & Smith, 1998; O’Connor, 1996; Swanson & Garwick, 1990). This paper describes a cognitive behavioural treatment group for men with a learning disability who sexually offend which was offered in Kent in1999-2000. The treatment programme was a weekly two-hour cognitive-behavioural group which ran for fifty-sessions over one year. Seven of the eight participants completed the programme, all of whom were male, aged between 20 and 45 years of age, with a history of sexual offences. The programme included several components: group purpose, rules and interpersonal skills; human relations and sex education; cognitive model of behaviour; four stage model of sexual offending; victim empathy; and relapse prevention. The study used a simple and uncontrolled one-shot pre-test post-test design. Preliminary data on changes in cognitions, sexual knowledge, victim empathy and recidivism are presented.
Development and Evaluation of a Group-Based Treatment Programme for Fire-Setters with Learning Disabilities
It has been suggested that fire-setting is one form of criminal activity that is more likely to be associated with learning disabled offenders. Whilst there are several studies which address the prevalence and aetiology of fire-setting behaviour, the description and evaluation of treatment interventions for this client group remains a neglected area of research. The present paper describes a cognitive-behavioural group treatment programme, developed and piloted on separate male and female groups of adults with learning disabilities (total n = 10), detained in hospital under the Mental Health Act (1983). The programme is based upon a functional analytical framework and further incorporates psycho-educational elements. Emotional, cognitive and situational antecedents are examined and relapse prevention principles applied in the development of appropriate coping strategies. The theoretical basis of the programme is described along with initial outcome data which indicate significant post-treatment improvements on a number of dimensions including interest in and attitudes towards fires, self esteem and depressive symptoms. The implications of the findings of this study in terms of both practice and research are discussed.
Working with Self-Harm in People with Learning Disabilities – A Case Study
As a consequence of the number of people, predominantly women, presenting with self-harm in the referral population of a medium security unit for people with learning disabilities, the current study set out to examine the effectiveness of approaches employed with the non-learning disabled clinical population. The participant of the study was a 40-year-old woman with a learning disability in the mild range, who also presented self-harming behaviours. Previous behavioural approaches had made little impact on reducing the frequency of these behaviours. The study compared the frequency of self-harm during the behavioural intervention phase with the subsequent study phase, when other approaches derived from those used with the general population were employed. These approaches included verbal and written work with the participant to identify the possible functions of different self-harm topographies, the development of ‘individual support guidelines’ for staff based on this information, and engagement in individual cognitive-behavioural therapy to address the underlying issues highlighted. Qualitative and frequency data are presented that indicate that these approaches were more effective than behavioural approaches more typically employed with people with learning disabilities.
A Controlled Trial of Individual CBT for Anger in Offenders with Learning Disabilities: Outcome and Process Issues
Aggressive behaviour is common in learning disability populations and is the most frequent reason for hospitalisation and prescription of behaviour control drugs amongst people with learning disabilities. It also carries high costs for staff and service working with this client group. Anger is highly associated with and predictive of aggression, and is a common feature of dysfunctional mental health. There are encouraging indications that CBT approaches in the management of anger and aggression can be effective in the management of people with learning disabilities. This has recently been extended to a group of hospitalised offenders with such disabilities. Anger treatment is distinguished from anger management by an emphasis on the modification of beliefs that maintain anger, the enhancement of self-monitoring of anger arousal, and the development of self-control strategies through therapeutically titrated exposure to provocation. It is based on a detailed analysis of the individual’s anger problems. A new protocol-guided cognitive behavioural treatment approach designed specifically for the needs of offenders with learning disabilities (Taylor & Novaco, 1999) will be described. The outcomes from an intervention study using this new treatment are outlined briefly. Further, issues of development and content are detailed, with an emphasis on process issues with this client population. Problems of engagement and the importance of working on the content and restructuring of cognitions are illustrated with case material.
CBT Self-help Treatments: Delivery Challenges for Self-help in Everyday Practice
Convenor and Chair: Chris Williams, University of Glasgow
Self-help approaches are increasingly used by health care practitioners yet there are many potential difficulties in providing their delivery. These include practical issues such as access to self-help resources as well as wider issues such as the structure and readability of materials. This symposium will review the current status of self-help delivery, summarise the evidence for its effectiveness, and discuss the challenges that must be addressed in order to establish effective delivery.
Training Practitioners in the Use of Self-Help – The SPIRIT Project
The Development and Evaluation of a Self-Help Support Worker Based in Primary Care
Readability matters – How Readable Are Popular Self-Help Materials?
The Current Evidence-Base for the Effectiveness of Written Self-Help Materials
The Results of the Cochrane Review of Computer-Based CBT
Communication and Cognitive Behavioural Approaches in the Medical setting
Convenor and Chair: Trudie Chalder, Guy’s King’s and St Thomas’ School of Medicine, London
A Randomised Controlled Trial of a Psycho-Educational Intervention to Aid Recovery in Infectious Mononucleosis
Background: Evidence from other studies suggests that up to 22% of patients with infectious mononucleosis have fatigue 6 months later (White, 2001). Certain psychological factors, such as illness perceptions, have been associated with fatigue following severe infections. These factors may lead to behavioural change, such as inactivity, and thereby cause de-conditioning, which may perpetuate fatigue. Physical de-conditioning however is amenable to intervention.
Aim: We tested the hypothesis that at diagnosis of infectious mononucleosis a simple psycho-educational intervention that aimed to reduce medium term fatigue was more effective than no treatment.
Method: An exploratory randomised controlled trial. Patients were randomised to either receiving an illness fact sheet (control) or a session giving advice on graded activity and life-style factors relevant to the prevention of fatigue. This session was supported by a booklet and two brief phone calls at 2 and 4 weeks. All patients were followed up, by postal questionnaire, to 12 months after diagnosis of acute infectious mononucleosis.
Main outcome measure: Fatigue score (Chalder 1994) 6 months after diagnosis of infectious mononucleosis.
Results: Sixty-nine out of one hundred and thirty-nine patients referred were recruited and randomised. Eighty-seven percent of those recruited completed the Fatigue Questionnaire at 6 months. At six months there were less fatigue cases in the intervention group than the control group (odds ratio 0.31, 95% confidence interval 0.09 to1.04).
Conclusions: This study suggests that a brief psycho-educational intervention at the diagnosis of infectious mononucleosis may help prevent prolonged ill health.
A Cognitive Behavioural Model for Poorly Controlled Diabetes
Diabetes is a chronic and potentially disabling disease. The obstacles to effective self- care are related to poor medication adherence, poor diet and a chaotic life style. Long-term complications may include blindness, kidney failure, foot ulcers, gangrene and sexual dysfunction. The role of psychological issues in the development of poor adherence is unclear. Recent research has shown that a number of psychological approaches may be useful (e.g.: CAT, CBT) in improving adherence. Using case examples, we will present a cognitive behavioural model of poorly controlled diabetes based on Beck's model for depression. By modifying beliefs and coping, we aim to improve the patients understanding of their destructive behaviours and unhelpful assumptions. We will discuss specific interventions and some of the common problems we find when treating this client group.
Cognitive Behaviour Therapy With Haemodialysis Patients.
Haemodialysis is a high technology, palliative treatment used for patients with irreversible renal failure. It involves connecting the patient to a machine, with direct access to the blood, in order to remove excess fluid and waste products three times a week for between three and five hours at a time. Without such treatment patients would die. Haemodialysis patients occupy a unique position amongst the chronically, medically ill because of their intensive and long-term contact with an intrusive and often problematic medical intervention. However, they are conspicuous by their absence from much of the more recently published literature on psychological interventions for depression and anxiety in medically ill patients. This may be attributable in part to the difficulties involved in trying to research this particular patient group, but may also be accounted for by uncertainty about the nature and role of psychological distress in patients with end stage renal disease. These patients are understandably, and to a large extent necessarily, heavily socialized into a medical model of illness, yet a cognitive behavioural approach to the problems that they face has much to offer them. This presentation will illustrate the particular challenges involved in treating this patient group with two clinical examples. The first outlines the intervention strategy used to treat an elderly, depressed patient with multiple medical problems, and the second describes the treatment of a patient with an anxiety disorder, also with multiple medical problems. Lastly, the application of cognitive behavioural techniques in relation to treatment concordance is considered.
Premenstrual Problems - A Comparison of the Outcome and Process of Cognitive Behavioural and SSRI Treatment
Premenstrual problems have been variously labelled and defined since Frank's first definition of premenstrual tension in 1931. More recently the DSM-IV definition of Premenstrual Dysphoric Disorder (PMDD) has been developed, providing an operational definition of severe premenstrual problems. Treatments available for women who experience moderate to severe symptoms have ranged from hormonal to psychotropic medication to psychological approaches and self-help. Recent evidence suggests that Selective Serotonin Reuptake Inhibitors (SSRI's) and cognitive behaviour therapy (CBT) are effective treatments for PMDD. In this presentation a study, comparing the relative effectiveness of Fluoxetine (SSRI) and CBT with a combination of the two treatments, is described. Overall Fluoxetine and CBT proved to be equally effective but the combined treatment was no more effective than the individual treatments. Differential effects of the two treatments were evident in terms of speed of effects, side effects and maintenance at follow-up. Treatment decisions should be based on patient preference and the consideration of the differential effects of the two treatments.
To Be Reassured Or To Understand? A Dilemma in Communicating Normal Cervical Screening Results
Purpose: Receiving negative test results may be associated with two problems: a) not being reassured and wanting further, unnecessary screening, and b) not understanding residual risk and not attending future recommended screening. This study tests the hypotheses that: 1.Emphasising low residual risk and test accuracy when giving negative test results reduces a) a desire for unnecessary screening, and b) correct understanding of the result. 2. Those who are not reassured by their negative test result show a stronger desire for further, unnecessary screening.
Methods: This experimental, vignette based study had a 2 x 2 factorial design. 184 women were asked to imagine that they had recently undergone a cervical screening test and received a normal result. They were given one of four hypothetical letters from their GP, differing in whether or not it emphasised test accuracy and low residual risk of developing cervical cancer. Participants completed a questionnaire assessing perceived risk, reassurance, confidence, worry, desire for further screening within six months and understanding of test result. Analysis of covariance and logistic regression were used.
Results: Receiving test result information emphasising low residual risk and high test accuracy increased reassurance and lowered the desire for further screening within six months. However, it also reduced the understanding that a residual risk exists now and in the future. The effect of emphasising low risk on desire for future screening was mediated by reassurance.
Conclusions: Emphasising low residual risk and test accuracy is a double-edged sword: it reduces a desire for unnecessary screening, but also reduces correct understanding of the result.
Cognitive behavioural treatment of somatic symptoms
Convenor and Chair: Trudie Chalder, Guy’s King’s and St Thomas’ School of Medicine, London
Linking Beliefs and Behaviours in Chronic Fatigue Syndrome
Although the cognitive behavioural model of Chronic Fatigue Syndrome has been shown to be useful in terms of patient management, little experimental support exists for the links between beliefs and behaviour in this population. It is also unclear the exact nature of the beliefs postulated to be important in predicting behaviour. This presentation reports the development of a model centring on the importance of beliefs about movement and activity, based on the models in the pain literature (Vlaeyen et al, 1995). A self-report measure of patient beliefs (TSK-F) was validated for this population (N=132). This measure was used to examine fear of physical movement and activity (over and above existing measures) as a predictor of patient persistence with a behavioural task (riding an exercise bike). The main outcomes of this research was that a subscale of the TSK-F, ‘Beliefs about Activity’ predicted a highly significant 12% of the variance in distance or rather 12% of the avoidance of persistent exercise (p<0.01). The TSK-F was the most predictive measure of distance travelled and this has wide theoretical and practical implications particularly in light of the recent Government Report on CFS/ME which supports both CBT and graded exercise as useful treatments for patients.
Mindfulness Based Stress Reduction (MBSR) as a Treatment for CFS: a Pilot Study.
Chronic Fatigue is a major public health problem with a poor prognosis if left untreated. Several studies have now clearly indicated the beneficial effects of CBT. However waiting lists are often long and some patients, particularly those who are very physically oriented, can find therapy difficult. MBSR is a group treatment, the core of which is an intensive training in mindfulness meditation, to enhance people's awareness of their bodies, the patterns of their minds, their emotions and the connections between all of these. There is good evidence for its efficacy in the treatment of chronic pain, anxiety, and in the prevention of depressive relapse. The study we undertook was a pilot to ascertain both the acceptability and clinical value of the approach in a group of CFS patients waiting for individual CBT. The results so far are promising. The approach was very well received by everyone who took part. There were positive changes in personal goals, and in measures of fatigue and mood. There is a clear need for more exploratory work with this population as MBSR could prove cost effective.
The Cognitive Behavioural Treatment of Tinnitus: How and Why. Evidence for Such an Approach.
Tinnitus is defined as “sounds which apparently emanate from the ear(s) or head of the perceiver”. It rarely indicates serious disease, but can cause significant distress and interference with functioning. Habituation usually occurs naturally but can be impaired by anxiety and negative cognitions about the tinnitus and its consequences. There is promising evidence that CBT is helpful in addressing these. This presentation will summarise the relevant evidence and go on to describe a service for people with tinnitus based in an audiology department. Issues in service delivery will be discussed and case examples will be used to describe how the cognitive-behavioural model was adapted to the needs of individual patients.
Cognitive Behavioural Therapy and Antispasmodic Therapy for Irritable Bowel Syndrome in Primary Care: A Randomised Controlled Trial
Irritable Bowel Syndrome (IBS) is a common gastro-intestinal disorder that accounts for significant morbidity and health care expenditure. Mebeverine hydrochloride has been shown to be an effective therapy for IBS and hospital-based studies have shown psychological therapies such as cognitive behavioural therapy (CBT) to be of use. There is insufficient evidence that either are beneficial for those patients attending a general practitioner (GP). The aim of this study was to establish in a randomised controlled trial whether early intervention with CBT was advantageous over mebeverine hydrochloride alone in patients identified as having IBS by a GP. Patients with IBS aged 17-50 were recruited from 12 general practices. After two weeks those with moderate or severe IBS (determined by the validated Symptom Severity Score Questionnaire (SSS)) were prescribed 275mg of mebeverine hydrochloride three times a day. After a further four weeks, patients who continued to score as moderate or severe on the SSS were randomised to either continue on medication alone or have 6 additional sessions of CBT. The CBT focused on identifying and challenging the patient's behaviours and beliefs associated with IBS. We trained four practice nurses to deliver the therapy in the general practices. Symptom Severity, global satisfaction, work and social adjustment, depression and anxiety were measured before randomisation, after treatment and at 3 and 6 months post treatment. Of 334 patients initially referred, 145 were randomised; 74 to drug alone and 71 to drug and CBT. At discharge those who received the combined treatment were less symptomatic than those who received drug alone.
Cognitive Behavioural Therapy and Non – Epileptic Seizures: A Two-Year Follow – Up.
Background: Despite a growing literature on Non – Epileptic Seizures (NES), little is known about the treatment of this disorder. We report on the first study of treatment using a cognitive behavioural approach and the results at two-year follow-up.
Purpose: To evaluate the effectiveness of cognitive behavioural therapy as a treatment for adults who experience NES and to determine whether a reduction in seizure frequency and global functioning has been maintained at 2-year follow-up.
Method: Twenty adults were offered 12 sessions of cognitive behavioural therapy on a weekly basis for one hour. Clinical measures were administered at weeks 1,6 and 12 and then at follow-up intervals of 1, 3, 6, 12 and 24 months to measure treatment outcome, seizure reduction and global functioning.
Results: Sixteen subjects completed treatment. Results at 12-month follow-up demonstrate a significant reduction in seizure frequency in 14 subjects (P = 0.001) and improvement in global functioning was apparent in all subjects (p = 0.00). We will report year follow-up data which will include a comparison of health service contacts at pre-treatment and 2 year follow-up.
The Role of Exercise in Improving Psychological Well-Being
This paper will review the evidence that suggests that exercise has a role in maintaining or improving psychological well-being. The evidence suggests that aerobic exercise is better than anaerobic exercise. It suggests that exercise undertaken within a group is more efficacious than exercise undertaken alone. Evidence also suggests that mood improves independently of increased fitness, whereas physical capacity improves with increased fitness. Exercise has been shown to play a role in psychosomatic disorders in general, mood and fatigue disorders in particular, and in other specific medically unexplained syndromes, such as chronic widespread pain, and irritable bowel syndrome. I will conclude by speculating about the mechanisms by which exercise improves psychological well-being.
Cognitive Case Formulation: Is the Emperor Clothed?
Chair: Willem Kuyken, University of Exeter, Jan Scott, Institute of Psychiatry
Discussant: Melanie Fennell
This symposium asks the questions, “What conceptual issues underpin cognitive case formulation?” “To what extent is cognitive case formulation evidence-based?” “What research agenda would enable this cornerstone of cognitive-behavioural practice to be evidence-based?” It will begin by critically evaluating some of the conceptual issues underpinning cognitive case formulation. Each of the symposia papers then presents preliminary research addressing current practice in cognitive case formulation, the reliability of cognitive case formulation, and the relationship of cognitive case formulation to the therapeutic relationship and therapeutic outcome in bipolar disorder and psychosis.
Is Cognitive-Behavioural Case Formulation Science or Science Fiction?
Since their inception, cognitive theory and cognitive therapy of emotional disorders have been extensively researched and applied in mental health settings. As with all systematic models of therapy, cognitive therapy distills a theory to the understanding of particular cases through the case formulation method. This paper sets out criteria to evaluate whether cognitive case formulation follows the process of scientific inquiry and questions whether the formulation method meets these criteria. In terms of the evidence base for the cognitive case formulation process, current evidence for the reliability of the cognitive case formulation method is modest, at best. There is a striking paucity of research examining the validity of cognitive case formulations or the impact of cognitive case formulation on therapy outcome. Implications for the clinical use of cognitive case formulation within a scientist-practitioner model are discussed and potential programs of research to evaluate the case formulation method are described.
Clinical Psychologists’ Contemporary Practice of Cognitive-Behavioural Case Formulation and General Case Formulation
It has been argued that case formulation is of central importance to how clinical psychology defines itself as a profession (Crellin, 1990). Despite this, there are limitations in our understanding of the meaning of case formulation for clinical psychologists and how practicing psychologists reach a case formulation. Clinical psychologists’ contemporary practice of cognitive case formulation and general case formulation was examined in two separate semi-structured interview studies; study 1 (Redman, Burgoyne & Chadwick) examined case formulations of cognitive behavioural practitioners; study 2 examined case formulations of practitioners’ from a variety of theoretical backgrounds. The first study (Redman, Burgoyne & Chadwick) invited clinical psychologists who work predominantly from a cognitive-behavioural perspective to participate in semi-structured interviews regarding their reflections of how they would try to understand a clinical problem that might be referred to them. Data collection was informed and analysed using grounded theory. Subsequent analysis attempts to generate a theory of the process of CBT case formulation as perceived by practising clinical psychologists. In study 2 (Day & Kuyken) clinical psychologists working from a range of theoretical orientations were asked; what they understood by the term case formulation and how they are developed; how they decide when this process is complete; how case formulations help them work and whether they believe it improves therapeutic outcome. The results and implications are presented.
Can Clinicians Reliably Identify Underlying Cognitive Structures and Processes That Cause and Maintain Abnormal Behaviours Using the J.S. Beck Cognitive Conceptualisation Diagram?
There has been a paucity of research on whether cognitive-behavioural therapists can reach agreement in their case formulations. Recent studies (Persons, Mooney & Padesky, 1995; Persons & Bertagnolli, 1999) suggest good reliability can be obtained for the descriptive, but not the inferential aspects of cognitive case formulation. This paper reports on two studies that aimed to establish whether the systematic J.S. Beck case formulation method would lead to acceptable reliability in the inferential aspects of cognitive case formulation. Participants were mental health professionals with differing levels of knowledge and training in CBT who attended one of three one-day workshops on cognitive-behavioural case formulation. All participants received the same basic training and were asked to provide a provisional formulation about a case that had been previously written up (Kuyken, 1999). Participants used the systematized J.S. Beck cognitive formulation model. The first study (Fothergill & Kuyken) was based on the first workshop in the series and examined whether level of participants’ previous training and experience affect the reliability and quality of case formulations The second study (Musa, Kuyken, & Chadwick) extended this work by asking whether certain types of information are more helpful in enabling high quality and reliable formulations. While the same training tools were used, the amount of data about the case that was presented to workshop participants was varied in consecutive workshops (write up of the case only, write up of the case with video-taped downward arrow, and write up of the case with access to video-taped description of thought records). The extent that the participants agreed with each other on the concepts and themes that should be formulated, and the extent that they agreed with a ‘gold standard’ formulation of the case completed by J. S. Beck were measured. The results will be presented and the clinical and research implications of the study will be highlighted in the discussion.
Case Formulation in Cognitive Therapy for Psychosis: Impact on Therapeutic Relationship
Case formulation is argued to be the cornerstone of cognitive behaviour therapy for psychosis, and to improve outcome in various ways. The aim of this paper is to research the impact of case formulation on both the therapeutic relationship and symptoms of anxiety and depression. First, the practice of case formulation is operationalised clearly to address reliability. Experiment 1(a) uses a single case multiple baseline design across four participants. Experiment 1(b) uses a repeated measures design (n=13); Friedman 2-way ANOVA and Wilcoxon Signed Ranks Test were used to assess the impact of case formulation on measures of therapeutic relationship, anxiety and depression. Case formulation had no effect on patients’ perception of therapeutic relationship- though it did significantly improve therapists’ perception. There was no effect on anxiety or depression.
Cognitive Therapy in Bipolar Disorders: Has the Technology Overtaken the Science?
Recent interest in the application of cognitive therapy to severe mental disorders has produced a number of critical empirical questions. This paper will address three of the obvious issues. First, is the use of therapy in a disorder where no adequate cognitive model exists (we have no clear theory of mania), simply an example of therapists applying techniques in hope rather than truly formulation driven? Second, is there consistency in how cases are formulated and third does formulation help the clients understand bipolar disorders and engage with therapy. To explore these issues, this paper will present an overview of three pieces of research:
1) Data exploring different models of bipolar disorders and possible key elements of conceptualization derived from theoretical research.
2) Findings from a questionnaire survey exploring agreement about the core elements of the formulation and its perceived impact on their collaborative relationship with the client. This was completed by some of the key advocates/experts in cognitive therapy in bipolar disorders in the UK, and a group of therapists recently trained to use cognitive therapy in bipolar disorders
3) Information from clients in a research trial of cognitive therapy in bipolar disorders who were surveyed about the benefits or otherwise of being offered a ‘formulation’ and its effect on therapeutic alliance.
The paper will summarize key areas of agreement and disagreement between these databases
Group Cognitive Behaviour Therapy
Chair: Dr Fiona Lobban, Academic Division of Clinical Psychology, Wythenshawe Hospital
During the past 30 years and more, a considerable body of evidence has grown to support the use of individual CBT in a wide range of emotional disorders. More recently, attempts are being made to offer CBT in a group rather than individual setting. Group CBT may offer a number of advantages over individual treatment. These include increased normalisation of experiences, sharing of coping strategies, and an opportunity to test out key beliefs and/or behavioural strategies. In this paper, recent work in developing and testing treatment protocols of Group CBT are described across a range of disorders including psychosis, depression, anger, and low self esteem. The presenters have all been involved in running these groups and hope to share their experiences of this exciting and quickly developing area.
Changing Voices: A Randomised Control Trial Of Group Cognitive Treatment
Group cognitive treatments have many possible advantages over individual treatments, particularly for the social support and opportunities they offer for critically evaluating cognitive distortions that are thought to play a role in the experience of auditory hallucinations. Although group treatment has been reasonable successful for disorders such as depression and anxiety it has not been rigorously tested with patients who have diagnoses of schizophrenia. This study is the first randomised control trial of such group cognitive treatment. The treatment incorporates the general components of cognitive behaviour therapy that have been developed for individual therapy: client engagement, developing a shared model of psychosis, belief modification with guided discovery and strategies to promote self regulation and reduce relapse. It was provided over 7 weeks by trained therapists. People with a diagnosis of schizophrenia who were continuing to experience distressing voices and who had a stable medication regime were recruited. They were randomised to either group treatment or treatment as usual and were assessed at week 0, 10 and 36 weeks. The main outcome measure was a self report measure of the experience of voices but secondary measures include self reported insight and psychiatric symptoms rated by a blind assessor. Analyses in which the baseline measure was the covariate showed significant gains following therapy which was effective in reducing voices. This effect was durable, i.e. it lasted to the follow-up.
Group CBT for Anger: A Pilot Study
Patients referred with anger problems often do not attend for treatment. The aim of this study was to determine if group CBT for patients with anger was feasible. Patients routinely referred to a clinical psychology service for help with their anger were assessed, given 6 sessions of group CBT and re-assessed. Of 119 patients referred, 49 (41%) did not attend the initial appointment. Sixty-seven patients were invited to participate in the group CBT. Only 9% of those referred for therapy attended for the full course of CBT. More than half of patients (56%) did not attend for any therapy. Patients who attended for some or all of the CBT treatment, reported reductions in the frequency and intensity of their angry outbursts. There was also a significant reduction in measures of their anger traits. It could be concluded that group CBT is an appropriate way to deliver this therapy to patients with anger problems, but it is clear that many of those referred are ambivalent about therapy and will not attend.
Reviewing the Efficacy of Eight Years of ‘Coping With Depression’ Groups
A review and evaluation of the ‘Coping With Depression’ therapy group indicating directions for future research: The ‘Coping With Depression’ course has been jointly run by Clinical Psychology and Occupational Therapy since 1993. Twenty-six groups have been conducted and evaluated over the past eight years. The course adheres to a cognitive-behaviour therapy (CBT) model. Referrals are made by Consultant Psychiatrists working in the Acute Adult Service and are screened for suitability by Clinical Psychology and Occupational Therapy. The presentation will describe the content and structure of the eight weekly sessions, illustrating the application of the CBT model. Statistical data, showing a highly significant improvement, will be presented for pre- and post-treatment measures on the Beck Depression Inventory (BDI) and a tailor-made course evaluation instrument will be described. Current research is examining the demographic profiles of those patients who benefit most and least from the course. Proposals for a future comparison of outcome data with groups consisting of Primary Care patients will be discussed.
Group Cognitive Therapy for Low Self-Esteem – A Preliminary Evaluation
Low self-esteem is commonly encountered in clinical practice, and in many cases, it can be restored by treating the individual's presenting problem. However, for some individuals, low self-esteem may act as underlying vulnerability factor that precedes the onset of psychological disorder and which predisposes the individual to multiple, recurrent or persistent psychological difficulties. In these cases, low self-esteem in itself may warrant clinical attention. A recent cognitive model and associated treatment programme has been proposed (Fennel, 1997). The current study is a preliminary evaluation of a group cognitive therapy programme for low self esteem based on Fennell’s conceptualisation, which employed 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 will be discussed. Finally, pilot outcome data will be reported.
Group Cognitive Behaviour Therapy for Positive Symptoms in Chronic Psychosis; A Pilot study for an RCT
This paper reports the results of group cognitive behaviour therapy for people with persistent positive symptoms of schizophrenia. Two groups were run (total n = 10) in order to pilot a treatment protocol for a larger multi-site randomised controlled trial of group cognitive behaviour therapy for this client group in the North West. The group consisted of eighteen sessions and the style and content of the protocol is outlined. People who took part in the group treatment experienced a reduction in negative symptoms and an increase in global self esteem during the group. Excluding one person who experienced a major relapse during the group, there was a mean reduction in depression, hopelessness scores, and delusional beliefs. At six months follow-up, the data suggests that participants were experiencing fewer symptoms overall, were less depressed and had greater self esteem. Feedback from group participants were generally very positive.
Towards an evidence base: New research into clinical supervision in CBT
Chair: Professor Mark Freeston, Newcastle Cognitive and Behavioural Therapies Centre and University of Newcastle
Clinical supervision is a cornerstone of training, continuing professional development, and accreditation in CBT. Many members of BABCP are involved in the delivery, training and accreditation of supervision. However, there is only a small evidence base for supervision in CBT. Given the complexity of supervision and the lack of strong and specific theoretical models, there is clear need to develop research methods to understand and evaluate the supervision process. This symposium will illustrate some current approaches to research into CBT supervision. The presentations, drawing on widely different methodologies, will emphasise the methodological and conceptual challenges as much as the emerging results in order to encourage dialogue, creative thinking and the development of a network of supervision research.
Post-Accredited Cognitive-Behavioural Therapy Supervision and Training: The Weakest Link!
In the NHS, quality is a key concept underpinning health service delivery. Quality for psychological therapies is based on: (1) a theory of therapy supported by empirical research, (2) qualified practitioners from accredited training programmes, (3) post-accredited supervised practice and (4) continuing professional development. If one component is missing the whole system fails. The weakest link in this quality system is post-accredited supervision. There is a need to develop both a process model of CBT supervision and post-accredited training programmes in CBT supervision. This presentation outlines research which begins to address these issues. O’Carroll and Western, (1997) carried out a postal survey looking at the supervision activities of 124 post-accredited CBT practitioners. The focus of the questionnaire was limited to clinical supervision and covered seven activity areas: (1) assessment, (2) formulation, (3) alliance, (4) intervention, (5) evaluation, (6) interpersonal process, and (7) ethical and suitability issues. Participants were asked to rate the level of activity for each item over the past 12 months. Factor analysis of this data identified four distinct areas of activity labelled: (1) Tasks, (2) Bonds, (3) Supervision and (4) Critical Decisions. The components were used as a framework for developing a process model of CBT supervision, utilising the concept of supervision map (Padesky, 1996), which is briefly described here. The CBT supervision process model has been further developed within the context of a post-graduate certificate training programme in CBT supervision at Chester College. Planned research projects are described looking at assessing supervisor competencies.
Clinical Supervision in CBT – Do We Have a Model?
The importance of clinical supervision has long been recognised within psychotherapy as an essential adjunct to effective therapy. This paper will describe an exploratory study, which has sought to investigate clinical supervision within CBT with a specific focus on models which therapists and programme directors in the UK use within practice. The purpose of the study has been to explore the question – Do we have a model of supervision that is unique to CBT? The methodology and preliminary data will be presented from this qualitative study. An outline model will also be presented which represents a “best fit” conceptualisation of CBT supervision from the data. Finally, additional areas where our understanding of supervision in CBT needs to be refined will be outlined and future research suggested.
Supervision, Therapist Competency & Client Complexity in Psychological Treatments
This paper comprises two parts. The first explores key elements of supervision of novice therapists that may be relevant across brief specific therapies. Tapes of supervision for therapists training in CT and others training in brief IP-dynamic therapy were all rated by experts in each approach. Shared elements that contributed to therapist competency level, and key targets for intervention by the supervisors were identified. The expert’s ratings of their own practise model were compared with their ratings for the other model to see if there are any basic cross-therapy supervisor behaviours that were repeatedly identified as important in the early stages of therapist training. The second part of the paper examines whether therapist competence and case complexity interact in the prediction of outcome in CT. That is to say, does therapist competence only become salient when clients have more complex presentations? In a naturalistic study set in an outpatient cognitive therapy clinic, clients diagnosed with unipolar depression and with varying degrees of complexity were seen by a range of cognitive therapists. Therapists were rated by supervisors and clients as either exceptionally, highly or moderately competent. Pre- / post-therapy comparisons examined whether patients characterized as having differing degrees of complexity in their presentation fared better with more competent therapists in “real world” cognitive therapy.
An Idiographic Measure of the Impact Of CBT Supervision: The Experiences of a Trainee Clinical Psychologist.
Supervision is typically a process that unfolds over time. Although the impact on the supervisee of individual sessions or a course of supervision on could be studied, an alternative is to consider single case designs. This presentation describes the use of an idiographic methodology for examining the impact of CBT supervision. An individual twelve-item scale was developed using two main methods. Firstly, the supervisee completed various questionnaires designed to measure beliefs about cognitive therapy and their learning needs. Secondly, guided questioning was employed during a pre-placement meeting to explore and clarify particular concerns or needs on the part of the supervisee. The supervisee subsequently rated the constructed twelve items on a weekly basis. The data are discussed for a trainee clinical psychologist over a nine month year elective within a specialist CBT centre and over the first 6 months as an A Grade within a generic Adult Mental Health service. It is suggested that this quick and easy methodology provides one useful type of self-report data and is sensitive to changes in the clinical confidence of the supervisee. Suggestions are made regarding the future use of such a methodology.
What Can Supervisees Tell Us About Supervision? Mapping Feedback Onto Concepts and Using Concepts to Elicit Feedback.
Clinical supervision in CBT is procedurally and conceptually complex. Most of us develop a procedural knowledge of supervision which is in contrast to the formulation driven approach that we try to use in therapy and try to develop in the supervises. In recent workshops on supervision at NCBTC we have worked on developing a conceptual framework for supervision to help understand why we do what we do. It also has potential for thinking about how we may improve on our practice. It is current practice to collect feedback on helpful and unhelpful aspects of supervision during training courses. This presentation looks at feedback routinely collected from trainees in current practice using a typical ‘Helpful’, ‘Unhelpful’, and ‘Suggestions for improvement’ format. The data was categorized in face-valid categories and mapped on to areas of the conceptual model. Although feedback was overwhelmingly positive (8:1), the most common categories tended to occur in all three areas. Thus, the use of tapes and feedback on them were reported as among the most helpful, the most unhelpful, and as suggestions for improvement. The same was true for another technical aspect, role play, as well as in some structural and interpersonal categories. Based on this preliminary study, suggestions are made as to how routine feedback may be solicited in ways that better inform supervisory practice, but may also help to develop our conceptual understanding of supervision.
Issues in Behavioural Medicine
Potentially Modifiable Correlates of Non-Adherence with Immunosuppressants
Following Renal Transplantation
Kidney transplant failure is expensive for the NHS, devastating for patients and strains the supply of scarce donor organs. Existing studies suggest non-adherence with immuosuppressants increases the risk of graft loss by a factor of three. Interventions to reduce non-adherence require identification of modifiable predictors. 172 transplant recipients recruited to a cross-sectional study of non-adherence with immunosuppressants received standardised assessment of potentially modifiable correlates of non-adherence (interview, Illness Perception and Beliefs about Medicines Questionnaires, Revised Clinical Interview Schedule; Social Support Questionnaire, SF36) and demographic and medical details. Other measures of non-adherence performed poorly when tested against electronic monitoring, restricting further analysis to 58/60 subjects with data from electronic monitors. Subjects had a mean(SD) age of 48(13) years. 61% were male, 82% had a primary transplant and 88% a cadaveric graft. 14% subjects missed at least 20% of their medication (median zero, IQR 0-12%) and the median standard deviation of inter-dose intervals was 5 (IQR 2-9) hours. Logistic regression showed type of transplant, lack of dialysis, low emotional support and belief in the need for immunosuppression predicts missing medication and dosing frequency, type of transplant and disappointment with the transplant predicts chaotic timing of doses. Bivariate analyses also suggested relationships (all p = 0.05) with non-adherence for age, post-transplant problems and emotional response. Results suggest that recipients of live-related transplants are at high risk of non-adherence. Pre-transplant expectations, beliefs regarding immunosuppressants and the limitations imposed by a transplant may be targets for interventions to improve adherence. Acknowledgement: MRC funding by Clinical Research Training Fellowship for Dr Butler
Symptoms of Depression and Attributional Style in Persons with Multiple Sclerosis
The study was designed to assess hypotheses derived from the hopelessness theory of depression (Abramson, Metalsky & Alloy, 1989), specifically that negative attributional style would be associated with depressive symptoms, and that negative life events would interact with negative attributional style, to explain depressive symptoms, in a sample of persons with multiple sclerosis (MS). Data was collected via survey from 495 persons with MS. Initial cross-sectional results identified that three groups of persons with MS, differentiated on the basis of their level of depressive symptoms, were also differentiated by their level of negative attributional style. Negative attributional style was also positively associated with depressive symptoms across the whole sample and the proposition that negative life events would interact with negative attributional style to explain depressive symptoms, supported. Results of follow-up of the sample will be presented and comments on the clinical implications of the research made.
Impact of Multiple Sclerosis (MS) on Relationship and Sexuality: Implications for Clinical Psychologists
Multiple Sclerosis (MS) frequently results in increasing dependence on others for both social and practical support. The person who is called upon to provide this support is generally the partner of the person with MS. The level of support due to the illness is likely to impact on the relationships and sexuality of people with MS. This study was designed to determine differences between people with MS and those from the general population in their relationship and sexual functioning. The sample comprised 366 people with MS (142 males, 224 females) and 288 people from the general population (99 males, 189 females). Respondents completed questionnaire measures of relationship satisfaction, range of sexual experiences, sexual dysfunction, sexual satisfaction and coping style. The results demonstrated that people with MS (particularly males) were more likely to experience sexual dysfunction than people from the general population, although dysfunction levels were high for all respondents. People with MS also experienced lower levels of sexual activity, relationship satisfaction, and sexual satisfaction than respondents from the general population. Positive coping strategies were the strongest predictor of sexual satisfaction for both males and females with MS. Coping strategies were also important predictors of sexual dysfunction for MS females. A follow-up longitudinal investigation of the impact of coping style and illness related variables on sexual and relationship functioning among these respondents was conducted. Both men (n = 120) and women (n = 201) with MS and men (n = 79) and women (n = 160) from the general population participated in the study at two points in time, six months apart. Generally speaking, the time 1 levels of the health and coping variables explained little of the variance in the time 2 sexual and relationship variables. However, sexual activity at time 1 contributed significant unique variance to relationship satisfaction at time 2 for MS men, and coping strategies at time 1 contributed to relationship satisfaction among general population women at time 2. Further, for those respondents who had been diagnosed with MS for less than seven years, levels of sexual activity at time 2 were predicted by levels of sexual and relationship satisfaction, as well as levels of sexual activity at time 1. In contrast to the cross-sectional results, these results suggest that strategies used to cope with illness do not appear to play a major role in sexual and relationship satisfaction. The implications of these findings in terms of the development of strategies to improve the sexual and relationship functioning of both people with MS and their partners will be discussed.
Using Cognitive Models to Understand Reactions to Predictive Tests for Genetic Conditions
As technology improves, our ability to predict genetic disorders and conditions increases. Individuals and families experience a wide range of psychological reactions to increases in knowledge of their genetically determined future (for example discovering they are at high risk of developing some cancers, neurodegenerative disorders or heart disease). Research studies have so far not been able to predict peoples reactions to such knowledge any further than the finding that people who do not cope after they have had a genetic test for their family’s condition, are people who had emotional difficulties before their genetic test. This paper discusses the potential of cognitive-behavioural theory in understanding and foretelling peoples reactions to predictive genetic testing. Furthermore, the case is presented for cognitive behavioural therapy (CBT) as a way of helping people cope with increases in their own or their family’s genetic information. Case studies are presented to illustrate the value of cognitive behavioural thinking, with particular emphasis on formulation. For example, a case is presented of a lady with low mood and high anxiety one year after a positive predictive test result for Huntington’s disease. Formulation and intervention focused in particular on beliefs about abnormality and worthlessness that were triggered by the test result. BDI and BAI scores significantly reduced throughout therapy and this was maintained at 3 and 6 months post-treatment. In conclusion this presentation advocates the value of cognitive-behavioural models in explaining distress post-predictive genetic testing, a procedure that is rapidly becoming more common place for a number of conditions.
Who really does cognitive therapy? Factors associated with competence in Cognitive Therapists.
Cognitive therapy is apparently widely practised within the NHS, but it is not known whether it is generally carried out competently. This may have an impact on patient outcomes. The study aimed to examine therapist factors associated with competence. Attempts were made to recruit a wide variety of therapists; twenty-four eventually took part. Therapists provided information about their profession, training in cognitive therapy, years of experience, frequency of supervision, and whether they were accredited cognitive therapists. Therapists taped a mid-treatment clinical session and rated it on the cognitive therapy scale (CTS) to give a measure of self-evaluation. The tapes were rated on the CTS by an independent rater, blind to information about the therapist, to give the measure of competence. Five randomly selected tapes were rated by a second rater, also blind to therapist information. There was a high and significant inter-rater correlation. Therapists with advanced training in cognitive therapy showed significantly higher levels of competence than those without, despite the fact that all therapists in the latter group had a reasonable degree of cognitive therapy training. Psychologists showed significantly higher competence than Other Professions on one of the three CTS subscales (Interpersonal Effectiveness). There were no differences in competence attributable to years of experience, supervision frequency, or accreditation. Worryingly, some accredited cognitive therapists scored well below a cut-off competence score. Self-evaluation of competence correlated significantly with independent competence ratings in therapists of ‘high competence’ and in Psychologists, but not in ‘low competent’ or Other Profession groups.
How does personal experiential work impact on the skills of cognitive therapists?
Experiential training, and/or personal therapy have rich traditions in various therapies (e.g. gestalt, group, psychoanalysis) as strategies to enhance self-awareness and therapist skills. However, personal experiential work is not normally part of behavioural or cognitive therapy training. Recently, Bennett-Levy et al. (2001) developed a structured approach to practising cognitive therapy techniques on oneself within the training context, known as self-practice/self-reflection (SP/SR). They found that trainee cognitive therapists using SP/SR reported a ‘deeper sense of knowing’ of cognitive therapy practices, with enhanced therapeutic understandings and therapist self-concept (confidence, belief in cognitive therapy). The present research extends previous work by examining the self-reported impact of SP/SR on actual therapist skills in a group of professional CT practitioners. Follow-up of two small groups of practising therapists 1-5 months after SP/SR-based courses identified six areas of self-reported skill enhancement: Refinement of specific CT skills, Enriched communication of the conceptual framework of CT, Increased attention to the therapeutic foundations for change, Being where the client is at, Therapist self-reflection, and Therapeutic flexibility. The results suggest that SP/SR provides a unique perspective on the therapeutic process, and may enhance therapist competence.
You don’t learn to ride a bike by reading a book! Training in core Cognitive Behavioural Therapy skills.
Cognitive therapy has proven itself to be a treatment of choice for any number of emotional disorders. Furthermore, it is attractive to clinicians as the literature is often accessible and easily read. In addition, it is largely based on a “common sense” model to which people readily take. Hence, CBT is attractive and readily understood. Given that we know what treatment to use the next step is to effectively disseminate CBT skills. However, it is evident that there is a substantial skill component to CBT that is not necessarily addressed by reading literature or some training available. It is difficult to learn to ride a bike by reading a book about it and the same is true of CBT. This presentation describes the development, implementation and evaluation of a core skills in cognitive behavioural therapy training package. Consultation with providers of clinical services and trainers in cognitive therapy at a regional level identified that there was a requirement for various levels of training in cognitive therapy. These levels were identified as Foundation, Intermediate and Advanced training. Whilst advanced training via the Diploma in CBT was available locally it was recognised that there was a need to provide training that would be accessible and relevant to clinicians who may not require or desire diploma level training at this stage. Specifically, in our region training in the core skills was not widely or readily accessible. A program was designed that aimed to provide experience of core skills of Cognitive Therapy. Whilst different models of emotional disorders require different formulations and interventions there are still a great many components of CBT that are required regardless of the specific disorder with which a person is working. The Foundation course was designed to run over a five days. Each day followed a broadly standard format whereby, the participants were introduced to the new skill. Then the skill was demonstrated by the presenters and in turn practised by the participants. Then the participants would feedback the outcome of the experience in a consolidation period. This format lends itself to skills based learning and is based on Kolb’s model of learning. Over the five days, skill areas such as inductive questioning, socialisation, and a range of cognitive and behavioural techniques were taught. Two cohorts of trainees ( n= 14, and 18) have currently undergone the training and several more cohorts are scheduled for the near future in response to both general and specific service needs. The participants are from a variety of professional backgrounds and service settings. The course was evaluated in a number of ways and results of teaching assessments and confidence in skills assessments will be presented. The experience of running this training has been of value in providing training to local Clinical Psychology training courses, as well as other settings. However, what has also become apparent is the need for a variety of training measures that address knowledge, competence and confidence in skills and these are currently being developed here at the Centre.
Do We Do It Differently Downunder? A Preliminary Study Into CBT Training In New Zealand
CBT training has only recently been provided in New Zealand in a systematic way. The course at the University of Otago Wellington School of Medicine and Health Sciences provides postgraduate training for 14 students, halftime for one year. Students are experienced mental health professionals and include psychiatric nurses, consultant psychiatrists, social workers, and occupational therapists. On site individual supervision is provided by clinical psychologists experienced in CBT. Course content includes assessment, conceptualisation, and treatment of depression, anxiety disorders, substance abuse and psychotic disorders, and applications of CBT in a bicultural context. The Cognitive Therapy Scale-Revised (CTS-R; Blackburn, Milne & James, 1997; Milne, Blackburn & James, 1997) is used to provide specific feedback, together with lecturer, supervisor and student self-ratings of progress. This paper forms part of a wider and ongoing audit of the course and investigation of the development of competence in CBT. We present preliminary data on the development of knowledge as assessed by a modified version of the Behaviour Therapy Scale (Freiheit & Overholser, 1997), other-rated competence as measured by the CTS-R (Blackburn, et.al, 1997; Milne, et. al.1997) and supervisor and student evaluations of competence in particular CBT skill areas. Measures were taken at the beginning and at the end of the course. All students improved in specific CBT skills as a result of the training. The extent that students improved and variations around the other outcome measures, together with the limitations of this pilot study and suggestions for improvements for future investigations are discussed.
Issues in Clinical and Therapeutic Practice
An Integrated Framework for Working with Changing Dysfunctional Thoughts
Research shows that there is both a close relationship and specific interaction between thoughts and behaviours that help to maintain the dysfunctional thoughts. It is also commonly accepted that a high level of negative emotion will not only influence an individual’s course of action, but also perpetuate his/her dysfunctional thoughts. It is therefore crucial to acknowledge the affect, and to work on emotional change if one wants to be successful at changing the dysfunctional thought. Put simply, thought, affect and behaviour are in reality fused, and are reciprocally influencing each other. Cognitive change is about engaging the client to examine the logic of his/her thinking; developing objective and abstract thinking that the client can relate to his/her personal problems; and helping the client realise the consequences of holding on to his/her dysfunctional thinking and the potential benefits of changing. Behaviour change is to engage the client to undertake ‘data collection’ between therapeutic sessions to see if the balance of accumulated evidence supports or is against the dysfunctional thought; encourage the client to implement the practical skills in social and interpersonal situations; and reflect on their experiences (positive and negative) so as to refine and perfect their practical skills. Emotion change is about developing a habit of self-observation with regard to one’s own emotional conditions; effectively managing emotional manifestations as these arise; and developing a new set of values of such a kind that many of the circumstances that previously evoked the responses of fear, anger, guilt, shame diminish or are reduced in intensity. In order to facilitate clients’ emotional change, they need to know what they are trying to manage, and this knowledge (apart from its theoretical aspect) is the work of mindfulness. The work of mindfulness is to encourage the client to make detailed observation of all mental states in emotional outbursts. The purpose of the present paper is to discuss the conceptual and practical issues underpinning a therapeutic focus that reflects an integrated framework in working with changing dysfunctional thoughts, and examples will be given to illustrate how therapists and clients can achieve the change at the level of cognition, affect and behaviour. This integrated framework includes the assessment and disputation of the dysfunctional thoughts that are causal to emotional disturbance, and various strategies that facilitate the emotional and behavioural change.
Elaborating the problem or sketching the solution? How to lift hearts (and minds) by sharing ‘positive’ conceptualizations
Cognitive therapy trainees and supervisees often worry about how to share conceptualizations with clients. This may reflect potential dangers in the process of sharing conceptualizations focused entirely on clients’ problems. Recently, some authors have suggested that identifying beliefs at a schema level in a conceptualization may be ill-advised. This paper will review the background to alternative methods of presenting the conceptualization process, and will describe one approach that clients have experienced positively.
Preparing for Cognitive Work
This paper will discuss the issues that arise when people with learning disabilities are so disturbed that their ability to think in a structured and meaningful way is impaired. They need to address serious emotional and relationship problems before they can begin to see themselves as capable of ordered thinking. They present as regressed or as experiencing an arrested emotional development, which has left them not able to make sense of the external environment. Their behaviour is often described as manipulative and self-centred by direct carers who struggle to engage them in therapeutic work. Therapeutic interventions using one to one psychotherapy or a specific environmental provision are described, with a model for assessment and formulation of the underlying materiel. Some results are provided with evidence of increase in cognitive capacity and motivation to choose to take control of personal behaviour. The client group are people with severely challenging behaviour or learning disabled offenders who have become negative about human interaction. Most have had serious disruption of early childhood experiences involving single or multiple traumatic events, including abuse, early separation and sudden loss of carers. Successful intervention leads to a better developed sense of self, an increased ability to engage with other people, increases in logical thinking and the ability to use cognitive behavioural programmes with understanding.
The ‘Difficult Patient’: A Cognitive Analytic Therapy (CAT) Perspective
The ‘difficult’ patient is not a diagnostic entity and is described from different perspectives in a variety of ways (1). Characteristically, however, such patients, who may suffer from various psychological problems including notably, but by no means exclusively, personality disorders, cause major problems due to their ‘inability’ to engage in or be engaged in and remain in treatment. They characteristically also elicit extreme reactions from therapists or institutions attempting to work with them. These range from, for example, hostility and rejection through to over-involvement or protracted enmeshment. Traditional cognitive-behavioural approaches are recognised to have serious limitations in engaging with or working with such patients and in particular lack an adequate conceptual framework within which to approach them. This has limited the generalisability of otherwise useful techniques in a range of areas such as personality, psychosomatic or psychotic disorders. We suggest, on the basis of encouraging preliminary naturalistic evidence, that the application of the CAT model can be both theoretically enlightening and clinically helpful in working with such patients in a variety of settings. CAT is an increasingly popular integrative therapy with an expanding evidence base which has its roots in cognitive therapy, object relations theory and, more recently, Vygotskian activity theory (1). It is based upon a radically social model of the self in the context of which all mental and cognitive functions are seen to be rooted in and determined by the enactment of a repertoire of reciprocal role procedures (RRPs) the collaborative description and revision of which is a central focus of therapy. These are understood to be generated through the internalisation of early sign-mediated interpersonal experience, a process for which there is now increasing empirical validation from various strands of developmental psychology (2) (3). The CAT model can provide a means of describing and mapping the, often unconscious, role enactments underlying maladaptive and therapy-interfering behaviours. Importantly, these are always understood to involve the, often unwitting, reciprocation of others (including mental health professionals) in ways which may perpetuate or exacerbate presenting problems in a systemic manner. Initial work (1) with this heterogeneous group of patients suggests that a ‘contextual’ extension of the CAT techniques of verbal and diagrammatic reformulation of ‘identifying’ or ‘reciprocating’ enactments of RRPs can be extremely helpful both to patients and staff who often struggle to understand and to work with such patients. In some cases this may render redundant purely symptom-focussed approaches whilst in others it may enable engagement with the patient to occur and subsequent work to be undertaken using, for example, standard CBT techniques. This work will now require further extension on a more formal and controlled basis.
Ryle, A. & Kerr, I.B. (2002) Introducing Cognitive Analytic Therapy: Principles and Practice. John Wiley & Sons, Chichester.
Aitken, K.J. and Trevarthen, C. (1997) Self/other organization in human psychological development. Development and Psychopathology, 9,653-677.
Cox, B.D. and Lightfoot, C. (1997) Sociogenetic perspectives on internalisation. Mahwah, New Jersey, Lawrence Erlbaum
The Importance of Offender Type for Interventions With Domestic Violent Men.
Recent research suggests that spouse and child abusers are not a homogenous group. Holtzworh-Munroe and Stuart, (1994) propose three types of domestic violent men; Family Only, Generally Violent/Antisocial and Dysphoric/Borderline personality. These are said to differ in their propensity, frequency and severity of violence. A review of nine empirical research studies (Dixon and Browne, 2002) showed an average percent prevalence for the three types in the offender population as 50%, 30% and 20% of violent men, respectively. The overall effectiveness of offenders' treatment is not impressive. It would seem that effectiveness of intervention differs as a function of abuser type, with some varities of treatment proving ineffective for certain types of domestic violent men (Saunders, 1996). It is argued that Family Only perpetrators respond best to psychoeduactional programmes and in some cases family therapy. The Generally Violent/Antisocial offenders respond best to CBT anger management and those with Dysphoric/Borderline personalities to treatment involving psychodynamic approaches to personality pathology. As yet, there is little research utilising typologies for the purposes of assessment and treatment effectiveness.
Browne, K, Falshaw, L and Dixon L. (2002). ‘Treating domestic violent offenders’ In K. Browne, H. Hanks, P. Stratton and C. Hamilton (Eds). Early Prediction and Prevention of Child Abuse: A Handbook. Chichester: Wiley. pp.317-336.
Issues in Treatment
Group CBT For Anger Management In Inpatient Male Forensic Patients With Learning Disabilities
This presentation will examine the practical issues involved in providing CBT to male offenders with learning disabilities and present the short-term outcome data.
Location of treatment: Medium secure unit for learning disabled patients detained under the Mental Health Act 1983. Structure of treatment: Ten week modules; Participants could join at the beginning of a module; Four therapists, ensuring at least 2 would be present for each group; Homework supervised by psychology assistant between sessions.
Outcome: Quantitative change over baseline in STAXI results and frequency of challenging behaviour under analysis. Qualitative - In the judgement of the therapists there were marked improvements in the following areas: Cognitions; Problem solving; Introspect; Consideration of alternatives; Attention span; Time spent on task; Social skills; Communication; Listening; Discussion; Sharing; Disclosure.
Discussion: Whilst it is difficult to demonstrate a clear improvement in objective measures of state and trait anger in group participants, there was a clear improvement in their abilities to communicate and to use therapy constructively. Participants began to show an interest in the problems of others and demonstrated abilities to consider alternatives to aggression. Questions are raised about the teaching of basic skills [listening, turn taking, problem solving] before developmentally delayed individuals can benefit from group therapy.
Evaluation of Post-Conviction Treatment Program for non-Violent Drug-Related Offenders: A View from Western Australia
There has been considerable interest in the past ten years in diverting offenders whose offence is drug-related and non-violent from the judicial system and into treatment. In the United States and in Australia there has been considerable development of Drug Courts, evaluations of which are now becoming available. The Western Australian Court Diversion Service (CDS) is a post-conviction / pre-sentence program that aims to divert substance-using offenders from the prison system and into treatment programs. It has been in operation since 1988, though a formal evaluation has not been conducted. The present study evaluated the outcomes for offenders referred to the program in relation to program completion, sentencing and re-offending. It utilised a quasi-experimental within groups design using data from client files from January 1998 to June 1999. Offenders who had higher motivation, attended treatment regularly and had less than 20 prior convictions were more likely to complete the program. A custodial sentence was more likely if the offender was male, had committed a serious offence, had more than 30 prior convictions, had lower motivation and had not completed the CDS program. Predictors of re-offending included lower motivation and a previous custodial sentence. The offender’s level of motivation to change and number of prior convictions were significant predictors of all three outcomes: program completion, sentencing and re-offending. The paper concludes by discussing issues that these findings raise for therapists and managers involved in such diversion programs, two of which are of particular importance. First, offenders who are likely to successfully complete such programs should be included and those unlikely to successfully complete should be excluded and continue through normal judicial processes. This is important in light of anecdotal evidence that offenders who do not successfully complete such programs receive more severe sentences than if they had not engaged in diversion programs in the first place. The second issue is that motivation be included as a major focus of treatment offered to offenders engaged in such diversion programs.
Can Computerised CBT Treatments be Used as Teaching Tools? – Results of a Randomised Controlled Trial (RCT) and a Review of Computerised Teaching in Mental Health.
Is computer assisted learning a wasteful fashion trend or does it mark an important development in mental health teaching? The evidence from published reports is critically reviewed. In this context the following RCT attempts to explore the teaching potential of “Fearfighter” one of the computerised CBT packages currently under review by the National Institute of Clinical Excellence.
Objective: To compare the value of single session computer assisted instruction in exposure therapy for phobics with that of a single face-to-face small-group tutorial.
Design: Non-blind, randomised, controlled study.
Setting: King’s College Hospital Medical School, London.
Participants: 37 third-year medical students and 11 behaviour therapists.
Main Outcome Measures: 75 true/false multiple choice questions relating to b) below answered pre- and post-teaching by students and once by behaviour therapists to obtain “expert” scores; pre-teaching ratings of interest in behaviour therapy, teaching and study preferences, computer literacy and use; post-teaching ratings of educational and enjoyment value.
Educational Interventions: a) All students had a 20 minute lecture on basic concepts and historical aspects immediately before randomisation to: b) 90 minutes of computer or tutorial teaching. Computer instruction employed a reduced version of “Fearfighter” - a self-help computer system for phobics.
Results: In this format computer assisted instruction taught the principles of exposure therapy effectively but was marginally inferior to tutorial teaching of small groups which required 5 times more teacher time yet resulted in knowledge scores that did not differ significantly from those achieved by behaviour therapists. Students preferred face-to-face teaching. Rating the interactive teaching highly for educational value was the most powerful predictor of increase in multiple choice question score on an exploratory analysis. Rating the lecture highly was a negative predictor.
Conclusion: Computer assisted instruction may be most acceptable and effective when used to complement rather than replace conventional teaching.
Cognitive Behavioural Treatment of a 43–year-old with Obsessive-Compulsive Disorder
This study describes the treatment of severe obsessive-compulsive disorder in a 43-year-old female with a single case design. Onset of OCD was at age 8. She had been treated largely by medication only but had received 6 sessions of person-centred counselling approximately12 months prior to consultation. Almost all functions in her life was affected by OCD. An initial unsuccessful behavioural intervention that targeted praying was used as a springboard to understand her OCD. This enabled the change process to be formulated within a cognitive framework. Whilst successful behavioural interventions were later used in treatment initially several cognitive interventions enabled this the change process. There was a average 53% reduction in scores on standard measures post treatment.
Delivering an Arthritis Self-Management Course: The Training Experiences of Older Volunteer Lay-Leaders
Background: The untapped potential of older volunteers is increasingly being recognised. The importance of providing training for volunteers has been addressed in the literature, although few studies have examined volunteers’ training experience and needs in this respect.
Methods: The study was a pre-test post-test design with data collected before attending training, 6 weeks, and 6 months after training. Data were collected through a baseline questionnaire and interviews. The sample comprised 22 older people with arthritis. The majority of participants were women, with either osteoarthritis or rheumatoid arthritis.
Results: Volunteering to become a lay-leader was motivated by the need to fill the vocational void left by retirement, to feel a useful member of society by helping others and to find a peer group. Expectations included gaining a greater understanding of arthritis, peer support and the opportunity to meet similar people. At follow-up, identified training needs included team-working, presentation skills, and more time for personal discussion. The main benefits of training were social and skills based. The most disliked aspect of training was its intensity.
Conclusions: Through training, volunteers felt that they had acquired a purpose to their lives. The group training experience had enabled volunteers to draw social comparisons with their peers. Volunteers thrived on feeling ‘at home’ in a training environment reminiscent of their past working lives. Disappointment was expressed regarding the long gap between training and delivering a self-management course.
Non-Attendance on a Cognitive Behavioural Intervention for People with Chronic Disease
Background: The role of self-management in helping people with chronic diseases adapt to various psychosocial challenges is receiving growing recognition. Problems with participant recruitment and drop out once enrolled on the course have been identified in the US. Research evidence regarding reasons for non-attendance on self-management courses in the UK is currently lacking.
Objective: The purpose of this present study was to determine reasons for non-attendance on a community-based, cognitive-behavioural programme: Chronic Disease Self-Management Course (CDC).
Methods: The CDC comprised six two hourly sessions delivered by pairs of lay leaders. The course is designed to increase the individual’s ability to self-manage. Data were collected via self-completed questionnaires mailed to participants who, (1) did not attend any of the CDC sessions, (non-attenders, n=15) or (2) only attended one of the CDC sessions, (non-completers, n= 32). Participants were asked to indicate the reasons for their non-attendance.
Results: Of the 15 non-attenders, 6 felt the course venue was inconvenient, whereas 3 reported illness as the main reason for dropping out. Of the 32 non-completers, 12 cited illness. Thirteen non-completers also found the course venue to be inconvenient. Five reported that they did not like the course in terms of its timing and content and five non-completers reported tutors as the reason they dropped out.
Conclusion: This preliminary investigation of non-attendance and non-completion on the CDC when delivered in the UK suggests that non-attendance was motivated by two main reasons: course venue and illness. These findings are in accordance with those reported in the US. Recruitment strategy should consider ease of access to course venue.
Developmental Issues and Child Issues
The Way Forward for Child and Adolescent Cognitive Therapy: Issues, Controversies and Challenges.
Dr Jonquil Drinkwater, Consultant Clinical Psychologist, Head of Child and Adolescent Psychology, Oxfordshire Mental Healthcare NHS Trust
This is an exciting time for child and adolescent cognitive therapy. The field is starting to come of age and has a wealth of opportunities and potential for development. However, unless certain fundamental challenges are faced there is a risk that child and adolescent cognitive therapy will remain stuck at its current stage of development. The way forward involves addressing these challenges. One of the major issues is the controversy around the appropriateness of using adult theoretical models and techniques with children and adolescents. It will be argued that adult models are invaluable and discarding them could lead to an unhelpful separation between the adult and child cognitive therapy worlds. The interface between the two worlds is complex and interesting and the meeting of the two worlds could be the crucible in which we develop seamless theoretical models across the age range. Adult cognitive therapists are particularly advanced in developing maintenance models which identify the key cognitive abnormalities and the cognitive and behavioural maintaining factors. Cognitive therapists working with children are more advanced in identifying the factors which need to be included in developmental models of disorders. It is argued both would benefit from working together to develop more sophisticated models which include both development and maintenance. A second major issue is how to establish and develop child and adolescent cognitive therapy in the UK. The new BABCP Child and Adolescent branch was established in 2001 and is essential for the support and nurture of the field. Key issues that it can help address include research and training. Research is essential in order to develop and refine theoretical models for children and adolescents. This research would include fundamental issues such as the nature, content and specificity of cognition in different disorders and the evaluation of treatments. There is also a need to develop training courses. Challenges facing us include developing a shared definition of CBT for children and adolescents and defining the essential core components of training. Child and adolescent cognitive therapy is at a critical stage of development. The way forward involves facing and then addressing issues and controversies. There is tremendous enthusiasm and energy amongst cognitive therapists in the field and confidence that we can meet these challenges for the future.
Young People and Depression (provisional title)
[Text to follow]
The Development of Anxiety in Children
Convenors: Andy Field and Cathy Creswell
Discussant: Susan Spence
A Multivariate Genetic Analysis of Anxiety-Related Behaviours in 4-Year-Old Twins
Are anxiety-related behaviours in pre-schoolers manifestations of one underlying vulnerability, or are they distinct phenotypes? Behavioural genetics can shed light on this question by exploring the differential impact of genes and environment on several scales, and ascertaining the level of shared and specific genetic and environmental influences on related measures. The present study explored the genetic and environmental architecture of 5 mother-reported anxiety-related behaviour scales in a sample of over 4,500 4-year-old twin pairs. The scales assessed general emotional distress, fears, obsessive-compulsive behaviours, shyness and separation anxiety. Genetic influences were found on all 5 scales, but the pattern of influences differed considerably across the scales. Familial resemblance for general distress and fears was due to moderate heritability (43% and 44%), and modest shared environment (14% and 18%). For separation anxiety both genetic and shared environmental influences were moderate (39% and 36%), whilst for obsessive-compulsive and shyness scales genetic influences were substantial (65% and 70% respectively), with no shared environmental influence. Multivariate genetic analyses revealed a shared genetic factor that accounted for a large proportion of the correlations between these scales. In addition, there were genetic influences on both the obsessive-compulsive and shyness scales that were specific to these measures, indicating genetic differentiation of these phenotypes. Environmental influences were generally measure specific. These results illustrate that it is possible to differentiate between different anxiety-related behaviours in pre-schoolers, and that there are both shared and distinct aspects to their genetic and environmental aetiology.
“Beware the Jabberwock, My Son”: Do We Teach Children to be Scared?
Two experiments investigate the effect of fear information on the fear beliefs of children towards previously un-encountered animals. Unlike past research in which phobic patients report the importance of verbal information in the development of their phobia 10-20 years retrospectively, these studies use a prospective paradigm in children. In both experiments, children aged 6–8 had their normal fear levels assessed using the Fear Survey Schedule for Children before being shown pictures of three novel animals. The children were then told two stories, one in which an animal was portrayed as potentially harmful and one in which a different animal was portrayed as safe. As a control, no information was provided about the third animal. The type of information was counterbalanced across animals. Fear beliefs about each animal were measured before and after the information. In the second experiment behavioural inhibition was measured prior to the experiment. The results demonstrate that (1) negative information significantly increased fear beliefs about the animals compared to when positive or no information was given; and (2) children scoring high on self-reported behavioural inhibition generalized their negative fear beliefs to the animal about which they’d received no information. These experiments support past work (Field, Argyris and Knowles, 2001) that fear information can change children’s fear beliefs. This is the first step in understanding how normal childhood fears develop into adult phobias. The effects of fear information in children scoring high on behavioural inhibition may explain why this disposition is predictive of adult generalized anxiety disorder.
The Role of Family Environment in the Development of Cognitive Biases in Childhood Anxiety
Recent research suggests that parents of anxious children often exhibit a negative emotional parenting style, characterised as intrusive and overprotective, and showing high levels of criticism. The mechanism by which this style contributes to the development of anxiety disorders in childhood is unclear. Experimental studies using a number of different paradigms have shown that clinically anxious children or children high in trait anxiety have a cognitive style biased to the detection of threat in their environment. This project explores whether a parent-child emotional relationship characterised by parental over-involvement and parental criticism will heighten children’s sensitivity to threat detection and will be associated with higher levels of self-report anxiety in children. The study measures 50 families' emotional environments using Parent Expressed Emotion (EE). Parental EE is assessed using the Five Minute Speech Sample FMSS (Magana, Goldstein, Karno et al., 1986). Children are asked to complete self-report measurements of state and trait anxiety and depression. In addition, two experimental tasks aim to assess the relationship between anxiety and threat bias. The first serial search task aims to detect the presence of a cognitive bias to social threat, where angry faces depict threat. The second dot-probe task is designed to detect the presence of a cognitive bias to physical threat (e.g., a wasp, a girl with a broken arm). This research will serve to establish whether the origins of threat biases in childhood anxiety lies within families and stems from the emotional relationships children have with their parents.
The Role of Parents’ Cognitions and Behaviour in the Development of Childhood Anxiety
Anxiety disorders are the most frequent psychiatric disturbance experienced by children and adolescents. As well as causing disruption in many areas of the child’s life they also appear to follow a chronic course, highlighting the need for effective interventions for this group of young people. Risks for the development of childhood anxiety have been identified, and both environmental and genetic factors appear to play an etiological role. Risks that occur in the family environment, and may therefore be a focus of clinical attention, appear to include ‘overprotective’ parenting. The aims of the present study are to examine the etiological role of this form of parenting risk in childhood anxiety in a community sample of target children aged 10-11 years, a younger sibling, and their parent(s). Information on children’s symptoms was based on child, parent, and teacher report. Parents also reported on their own level of depressive and anxious symptoms. Questionnaires and interview measures of parenting risk, included over-protective parenting behaviour and parents’ cognitions relating to threat to the child. In addition, measures of school adjustment, social well being, and friendship quality were assessed using a combination of teacher, student, and objective reports.
The findings will be described with particular reference to associations between a) parent and child anxiety, b) parental anxiety, parenting behaviour and parents’ cognitions, c) parental measures and child symptoms and d) the mediating role of parents’ cognitions and parenting behaviour in the relationship between parent and child anxiety.
New Developments in Parenting.
Convenor & Chair: Dr Sam Cartwright-Hatton
Discussant: Dr Charlotte Wilson, Manchester University Division of Clinical Psychology
Coping Styles and Psychological Symptoms in Parents of Children With Obsessive Compulsive Disorder
This study examined the characteristics of parents of children aged 11 to 18 with obsessive compulsive disorder (OCD). OCD affects between 1 and 2% of children, has severe impacts on their development and, in about 50% of cases, persists into adulthood. The aetiology of childhood OCD appears to be multi-causal with complex interactions between biological vulnerability and environmental exposure (including family environment). The treatment of childhood OCD is based on methods developed and evaluated with adults. However, there is little direct evidence that such treatments are effective with children. One specific question is the extent to which parents and other family members should be included in treatment. 30 parents of children with OCD, 30 parents of children with other anxiety disorders and 62 parents of children with no mental health problems completed the McMaster Family Assessment Device (FAD; Epstein, Baldwin & Bishop), the Coping Resources Inventory (CRI: Moos, 1990) and the Brief Symptom Inventory (BSI; Derogatis, 1993). Diagnostic status of the clinical groups was confirmed using the Anxiety Disorders Schedule for Children and Parents (ADIS-C and ADIS-P; Silverman & Nelles, 1998) and OCD symptomatology was assessed using the Leyton Obsessional Inventory (Berg et al., 1988). The results will be discussed in relation to the development of treatment strategies for children with OCD. Implications for advancements in cognitive behaviour therapy for young people with OCD and future directions for research are also considered.
Parenting Skills Training: Can We Use This to Help Children with Internalising Symptoms?
A number of interventions are now thought to be effective for the treatment of older children with internalising symptoms. However, there is little research examining the efficacy of psychological interventions in treating their younger counterparts. There is good reason to believe that an intervention focussed on improving parenting might be effective in reducing these types of symptoms. The literature relating to the relationship between emotional symptoms and parenting will be introduced, followed by a summary of recent research carried out by the author and colleagues. In particular, two studies will be discussed. In the first study, parents of 43 children referred for help with behaviour problems took part in a parenting skills training programme. Their children’s externalising and internalising behaviours were measured before and after treatment and after a six-month period. As expected, externalising symptoms fell after treatment. Interestingly, however, internalising scores fell to an approximately equivalent degree. In the second study, the impact of comorbid emotional symptoms upon the efficacy of the behavioural intervention was examined. The results showed that parent training was equally effective in treating behavioural problems in those with and without comorbid emotional problems. Additionally, as shown in study one, the emotional symptoms of the children in this study fell significantly as a result of the intervention. Conclusions drawn from these results must be cautious. However, it seems that an intervention targeted towards parenting may be efficacious in the treatment of young children’s internalising symptoms.
Parent Based Therapies for Pre-School Attention Deficit/Hyperactivity Disorder: A Randomised Controlled Trial Within a Community Sample
Approximately five years ago, a parent-training therapy for AD/HD (Weeks et al., 1999) was empirically evaluated (Sonuga-Barke et al., 2001). Thirty parents received parent training (PT) in behavioural techniques to manage their child’s AD/HD behaviour. This consisted of one session per week, over a period of eight weeks. Two comparison groups were established, the first consisting of ‘parent counselling and support’ (PC&S), and the second a ‘waiting-list control’ (WLC) group. The PC&S group received the same amount of contact time as the PT group, however they did not receive any formal training in behaviour management, only the opportunity to reflect upon their experience of parenting in a non-threatening environment (Sonuga-Barke et al., 2001). The WLC group consisted of individuals who were on a waiting list to receive the PT intervention. All groups received a battery of baseline measures examining AD/HD symptomatology and maternal well-being. These were compared with measures taken immediately after intervention, and at 15-week follow-up. The study found that the PT group had demonstrated the most significant reductions at 15-week follow-up, in both clinical and observed measures of AD/HD behaviour, compared with PC&S and the WLC groups. The efficacy of the intervention 15 weeks after training is particularly interesting as there is little evidence to suggest that pharmacological interventions can maintain significant effects for this length of time (Sonuga-Barke et al., 2001). This paper outlines the intervention given to the PT group and discusses the findings of the research in relation to parental ADHD and expressed emotion in parenting.
The Design and Validation of a Questionnaire to Investigate Cognitions in Parents of Children with Behaviour Problems
Parent training has been demonstrated as one of the most effective interventions for behaviour problems in young children. Most models of parent training are largely behavioural in content and have been developed from social learning theory. However, up to a third of parents do not benefit from this approach. As with developments in treatments for adult disorders, it has been proposed that parent training implementation, engagement and resistance may be affected by parental cognitions (e.g., Johnson, 1996). There is now evidence that a more cognitive approach to parent training might be beneficial (White, McNally & Cartwright-Hatton, submitted). However, there is now a need for further investigation in to the role of parental cognitions. This study aimed to design a questionnaire to investigate cognitions in parents of children with behaviour problems. Four hundred and fifty parents of children with behaviour problems took part in this study and completed the newly designed parental cognitions questionnaire along with other validated measures. Factor analysis revealed six dimensions of cognition. This research is ongoing and the results will be presented more fully at the conference, along with discussion of clinical implications. The authors argue that obtaining a better understanding of parental cognitions is an important element in enhancing the efficacy of parent training.
How Do Maternal Expressed Emotion and Depression Influence Intervention for Child Behaviour Problems?
Many studies have shown links between maternal depression and child behaviour problems. There are indications that dimensions of parental Expressed Emotion (EE), particularly critical comments, hostility and warmth are associated with response to parenting interventions. A pair of studies looked at children referred to child clinical psychology and psychiatry services because of behaviour problems. Both studies were conducted in areas of NW England with high indices of deprivation and child poverty. In Study 1, 61 mothers were interviewed, prior to the first clinic appointment. Maternal depressed mood was found to be associated with higher levels of Expressed Emotion (EE). A striking finding was that higher levels of EE were associated with non-attendance for the first clinic appointment. Where families did attend, high levels of EE were associated with independent higher ratings of potential risk of emotional abusiveness made by the clinicians working with the family. In Study 2, a longitudinal design was used, and 75 mothers were seen at three time points in therapy, prior to the start of a parent management training group, at the end of the group and six months later. This study showed that maternal EE declined over the course of the group, as did maternal depression and ratings of child behaviour problems. However, for those mothers where depression remained high, there were elevated reports of continuing behaviour problems. In this study, the child's self perception was also assessed. Relationships to the main maternal variables will be discussed.
What Does the Older Adult Perspective Offer CBT?
Convenor: Georgina Charlesworth, University College London & North East London Mental Health Trust
Introduction to Symposium: What Does the Older Adult Perspective Offer CBT?
Working with older adults offers therapists the opportunity to benefit from the wisdom of people who have lived long lives. Such work forces us to create a cognitive behavioural therapy that: is able to handle multiple problems, including physical disabilities and adverse life circumstances; can be adapted for differing cognitive abilities; encompasses life review (including chronic problems and intervention history) and realistic fears for the future as well as 'here & now' concerns; allows for inter- and intra- personal issues, including an objective lack of agency to effect a desired change in ones own circumstances due to more powerful others; addresses long-standing beliefs incompatible with current circumstances, and self-limiting beliefs such as internalised ageism and 'cohort-characteristic' beliefs; and be holistic rather than mind-body dualistic. Hearing elders reflect on the impact of historical life events, their perception of societal belief change, and their formulation of the cause and maintenance of current difficulties, can lead us to question the practice of simply extrapolating theories and techniques devised by young people for young people. The aim of this symposium is to consider ways in which lessons from work with older adults may enrich CBT for people of all ages.
How Older People and Cognitive Therapy can stay Attached
Cognitive Therapy (CT) has become a well-established psychological intervention for mental health problems. However, rapid development of technique has led to accusations of CT ignoring relationship factors in therapy and of a naïve approach to complex psychological problems. Older people know all about the problems of living. On the whole they are poorer, in worse health and more socially isolated than the rest of the population. They also face the fundamental developmental task mediated by the outcome of the attachment process in childhood - negotiating how dependent to be on others. Changes in the nature and number of close personal relationships in old age may lead to great psychological challenges. There is loss and finitude, regret and resolution – maybe even “realistic depression”. The attachment issues that some older people may have put off for a lifetime return with a vengeance. Older people’s problems challenge the classical application of CT, forcing therapists to engage with attachment and existential issues. Adaptations of CT for work with older people are not a patronizing simplification of the model and its techniques, but a challenge that can produce mutual benefits for older people and the continued development of CT. This paper will highlight the perspective that old age offers on the existential issues of life, the lifespan effects of close relationship initiation and maintenance, and the implications for cognitive therapy.
Redefining Schemata Beyond Self-Referent Beliefs
Working with older people requires therapists to examine issues regarding information processing often not dealt with by therapists working with younger patients. It is suggested that therapists working with older people tend to have a better understanding of these processing issues, owing to their greater theoretical knowledge of memory (declarative, procedural, working, etc.) and neuropsychology. The present paper draws on this more holistic background, and presents a theory designed to facilitate therapy in general; particularly schema focused therapy for both the young and old. Employing knowledge and models routinely used in an older people’s setting, this paper redefines schemata in terms of networks of information and memories rather than viewing them solely as self-referent beliefs (eg. “I am worthless”; “I am inadequate”). This change in perspective allows us to see schemata more validly as elaborate structures, composed of many elements, including behavioural, emotional and visceral features. A rationale in support of this holistic perspective is outlined, together with a review of its implications in terms of schema assessment and change techniques.
The Impact of Training Community Dementia Nurses to Deliver Cognitive Behaviourally Based Family Intervention
Historically there has been very little specialised support for carers of people with dementia. Within health services the responsibility has rested predominantly with the community nurse allocated to the care of the person with dementia. However currently there appears to be no clear theoretical model used by nurses providing support for carers (Carradice 1999). This means that community mental health nurses are likely to be utilising any number of different approaches, potentially compromising the effectiveness of any intervention. In dementia care, cognitive behavioural interventions for carers have been shown to be effective when delivered by a psychologist (Marriott et al 2000). However, given that nurses have been trained to utilise this approach in psychosis, (Brooker et al 1994), coupled with a finite source of psychology provision, perhaps it is appropriate to widen the delivery to all members of the multi-disciplinary team in dementia care. This paper reports the findings of a pilot study that evaluated the effectiveness of training the nursing members of a community mental health team to deliver cognitive behaviourally based family intervention. Training was provided over a 6-month period and the evaluation utilised a pre and post-test design focusing on the impact of training on staff, carers and the individual with dementia. Outcome measures included psychological morbidity, met and unmet need, objective burden and strain. Interview data also highlighted staff perceptions of this model of care delivery. Issues in training nurses to deliver cognitive-behaviourally based interventions to meet complex needs are highlighted.
Health and Other Worries: Identifying and Addressing Unhelpful Cognitive Processes
It is not unusual for older people in therapy to cite ‘too much thinking time’ as an exacerbating factor for their difficulties. This is especially the case when physical disabilities result in a restriction of activity levels, and/or where loss of family members and close friends increases a person’s tendency to dwell on how things might have been different, or worry about what might happen in the future. In the face of chronic illness in themselves or others, bereavement and other adverse life circumstances, an older person’s negative automatic thoughts may be entirely realistic, thus presenting challenges for standard thought challenge techniques. This paper draws from Stirling Moorey’s work on cognitive therapy in adverse life circumstances, and Paul Gilbert’s use of the compassionate self to define techniques for targeting unhelpful cognitive processes such as anxious and depressive rumination. It is argued that a ‘meta-cognitive’ approach of encouraging clients to identify and reflect on their thinking patterns is more easily utilised than the traditional approach to challenging negative content. Case examples will be described.
Schemas Across the Lifespan Symposium
Chairpersons: Lusia Stopa & Jonquil Drinkwater
Schemata in Depressed Female Adolescents and Their Mothers
The investigation of schemata in adolescents is still at a very early stage. This paper will discuss the theoretical concepts and relevance of schemata in this age group, and present findings from a pilot study on depressed adolescents that uses the Young’s Schema Questionnaire (YSQ) to study the schemata of both adolescents and their mothers. The study indicates that the YSQ (adapted for adolescents) shows good psychometric properties and may be a useful tool for this population. Using the YSQ, depressed adolescents showed a higher total score than non-depressed adolescents and a greater number of clinically significant schemata. A regression analysis, with the adolescents’ depression scores as the dependent variable, indicated that the defectiveness/shame schema accounted for most of the variance. Mothers of these adolescents also showed a higher total score on the YSQ than mothers of adolescents without depression. The implications of these findings will be discussed.
Factor Structure of the Schema Questionnaire - Short Form (YSQ-S) in a Non-Clinical Adolescent Sample
The "schema" is a concept shared across many cognitive models of psychopathology, albeit with variations in definition. Hammen and Goodman-Brown (1990) suggest that high-risk children acquire negative perceptions of their worth and competence. These perceptions are thought to form the basis of highly accessible negative self-schema. Young (1990) proposes that these early maladaptive schemas are developed through a child's relationship with its significant caretakers, and that schemas provide the means for a child to comprehend and manage the environment. The Young Schema Questionnaire (YSQ; Young, 1994) was developed as a tool for identifying maladaptive schemas in adults, and a shortened version (YSQ-S; Young 1998) has now been developed, which measures 15 of the original 16 proposed schemata. There is a lack of empirical knowledge about the development of schemas in younger populations. This study aims to establish whether the YSQ-SI is a valid tool for use with adolescents (11-17 years) and how schemas relate to psychopathology, self-esteem and personality factors. The data is in the process of being factor analysed, but the initial findings appear to show a similar factor structure to previous research with adult populations. It is hoped that the YSQ-SI will prove to be a useful measure in identifying schemas in a population at a different developmental level.
Schematic Processing in Depression: An Analogue Study
Schemata are hypothetical constructs that have an important role in the development and maintenance of emotional disorders. Schemata are conceptualised as templates that both guide the interpretation of incoming information and shape the cognitive, affective, physiological and behavioural outputs in response. According to cognitive theories of psychopathology, schemata are developed early in life and are not available to consciousness in the same way as negative automatic thoughts. The study presented here investigates whether a non-clinical group of participants who score in the mild to moderate range or in the non-clinical range on the BDI show evidence of differences in schematic processing using both self-report measures and an implicit information processing task (the Extrinsic Affective Simon Task (EAST); de Houwer, 2001). Self-report measures assessed negative automatic thoughts, dysfunctional assumption, evaluative beliefs and early maladaptive schemas. The stimuli used in the EAST comprised schema words representing Young’s (Young & Brown, 1990) abandonment and defectiveness schemas; depressed mood descriptors; and a matched set of positive words. The study showed that the mild-moderate BDI group had higher scores on most of the cognitive self-report measures than the non-clinical BDI group and were also faster to respond to negative schema words when they were paired with the self showing evidence of a negative schematic bias on this task. The results are discussed in relation to the cognitive vulnerability to depression hypothesis and to issues around the best way to measure schematic processing when investigating the role of schemas in emotional disorders.
Schemas and Marital Satisfaction
Aim: Two questions were addressed. Firstly, is there a link between an individual's schemas and their relationship satisfaction? Secondly, is there a link between an individual's schemas and their partner's relationship satisfaction?
Method: To explore the nature of the effects of schemas on relationship satisfaction couples from the community completed the Depression-Happiness Scale (a measure of general psychiatric morbidity), the short version of Young's Schema Questionnaire (YSQ), the Depression-Happiness scale, the Golombok Rust Inventory of Marital State, and a modified version of the YSQ where self referential statements were replaced by "your partner." Twenty-four heterosexual, predominately European couples provided 48 between-partner observations.
Results: Two schemas (emotional deprivation and subjugation) significantly predicted individuals' relationship satisfaction on a linear regression model, accounting for 48.8% of the variance. General psychological morbidity mediated the association between subjugation schema and individual's relationship satisfaction, but not between emotional deprivation and relationship satisfaction. Individuals were less satisfied in their relationships if they thought that their partner had an emotional inhibition schema but this only accounted for 3.6% of the variance in the GRIMS. Variation in the individual's own schemas were not associated with their partner's relationship satisfaction. If the individual thought their partner had a subjugation or emotional inhibition schema, their partner was more likely to be dissatisfied in their relationship.
Discussion: Satisfaction with relationships is strongly determined by one's core beliefs, and this effect is mediated by levels of individual mood/happiness.
Schema Focussed Therapy With Older People
I report the result of schema-focussed therapy with a 74-year-old man. Treatment lasted fourteen months and was supervised as part of the training requirement for a diploma in Cognitive Behaviour Therapy for Severe Mental Health Problems through the University of Southampton. He presented with a 60+-year history of severe anxiety and interpersonal problems including mistrust/abuse, subjugation and self-sacrifice. He met the General Diagnostic Criteria for a Personality Disorder (DSM-IV-TR). The main outcome measure was Young’s Schema Questionnaire (YSQ). At the outset of therapy he scored significantly on nine out of sixteen early maladaptive schemas. After fourteen months of therapy he continued to score significantly on six schemas, however there was a reduction in schema strength in twelve out of sixteen schemas. Psychometric evidence of change was supported by a number of areas of behavioural change. The utility of the YSQ instrument as an outcome measure in schema-focussed therapy will be discussed. Finally I will discuss some more general issues raised by carrying out schema-focussed therapy with older people.
CBT Outcomes for Childhood Psychological Disorders Symposium
Convenors: Dr Sam Cartwright-Hatton and Dr Alice Farrington
Chair: Dr Sam Cartwright-Hatton
Discussant: Prof. Richard Harrington, Manchester University Department of Child and Adolescent Psychiatry.
CBT for Childhood and Adolescent Anxiety: A Systematic Review.
A number of trials now testify to the effectiveness of Cognitive Behaviour Therapy for the treatment of childhood anxiety disorders, and this approach is widely used in clinical settings. This paper reports a systematic review of this intervention. The review incorporated all available randomised controlled trials of cognitive behaviour therapy for childhood anxiety disorder (Post Traumatic Stress Disorder, Obsessive Compulsive Disorder and simple phobia were excluded). The authors conclude that Cognitive Behaviour Therapy for childhood anxiety disorders is significantly superior to no treatment, but that additional trials are needed to establish its validity further. In particular, we know very little about the comparative effectiveness of CBT versus other treatments, and the treatment of young anxious children. Further conclusions and suggestions for future treatment research will be presented at the conference.
Using Cognitive Behavioural Groups for Children With Anxiety and Their Parents in the UK
Current outcome literature indicates the efficacy of using cognitive behavioural therapy to treat anxiety in children. Recent evidence from both Australia and America indicates that treatment efficacy is enhanced by including parents in treatment protocols. Ronald Rapee and his team in Australia have developed a nine session CBT anxiety group programme which runs child and parent components consecutively in each session. Such groups have not been piloted and evaluated previously in the UK. The current study reports the results of two CBT anxiety groups with 8 to 11 year old children and their parents in Oxford. The first group closely followed Rapee's manual. In the second group, the cognitive component of the child and parent programme was changed to be more closely aligned with Beckian CBT. Quantitative and qualitative outcome data for parents and children who completed both groups are presented. It is argued that internationally developed group programmes are readily applicable to a UK setting, and that children as young as eight can benefit from a CBT approach. It is suggested that current treatment protocols for children may be enhanced through a greater emphasis on Beckian cognitive therapy techniques.
Randomised Controlled Trial of Group therapy for Repeated Deliberate Self-Harm in Adolescents
Repeated deliberate self-harm is an important problem among adolescents. It is strongly associated with recurrent psychosocial problems, such as sexual abuse and depression; it places considerable demands on both district and specialist Child & Adolescent Mental Health Services, there is some evidence that the problem is increasing and repeated self harm is an important risk factor for completed suicide. We compared group therapy with routine care in adolescents who had deliberately harmed themselves on at least two occasions within a year. We shall describe a single-blind pilot study with two randomized parallel groups that took place in Manchester between 1997 and 2001. 63 adolescent outpatients aged 12 to 16 years were randomly assigned to group therapy and routine care or routine care alone. Outcome data on suicide attempts were obtained without knowledge of treatment allocation on all randomized cases on average 29 weeks later. We shall outline our findings which suggest that group therapy shows promise as a treatment for adolescents who repeatedly self harm but that larger studies are needed to assess more accurately the efficacy of this intervention.
Randomised Controlled Trial of Fluoxetine and Cognitive-Behaviour Therapy Versus Fluoxetine Alone in Adolescents With Major Depression (Adapt Trial).
Background: Cognitive-behaviour therapy (CBT) and selective serotonin reuptake inhibitors (SSRI's) have both been shown to be effective in mild to moderate adolescent depression. However, up until recently, there have been no randomised controlled trials (RCT’s) of psychological treatments and medication in adolescent major depression. This study is a pragmatic trial of effectiveness within the NHS and aims to answer one central question – is combination treatment better than the cheapest treatment of proven benefit in persistent adolescent major depression (SSRI’s)?
Primary Hypothesis: The additional costs of CBT will be offset by improvements in patient outcomes and quality of life, and/or savings in the use of health or other services, when compared to fluoxetine alone.
Method: We are aiming to recruit a total of 230 adolescents with persistent major depression, i.e. approximately 100 adolescents in each group. Treatment is initially provided for 12 weeks, and if there is an improvement, continued to 28 weeks. Subjects are given weekly individual sessions for 12 weeks in the CBT arm, and then fortnightly maintenance sessions. The CBT sessions are based on a manual previously developed in Manchester. The primary outcome measure is the Health of the Nation Outcome Scale for Children and Adolescents. However, there are additional outcome measures encompassing multiple domains, including a health economics evaluation.
Results: The trial is still ongoing and results are not yet available. Over 100 adolescents have been recruited at this stage.
Child Basic Processes
Cognitive Appraisals in Young People with Obsessive Compulsive Disorder
This study examined the ability of measures of cognitive appraisals to differentiate young people aged between 11 and 18 years who have obsessive-compulsive disorder (OCD) from young people with other types of anxiety disorder and from a non-clinical group. Recently, a number of cognitive appraisals have been identified as important in the manifestation of OCD in adults but there have been few attempts to explore if these appraisals are also found in young people. Three questionnaires were used in this study to measure inflated responsibility (Responsibility Attitude Scale, Salkovskis et al., 2000), thought-action fusion (Thought Action Fusion Scale, Shafran et al., 1996) and perfectionism (Multidimensional Perfectionism Scale, Frost et al., 1990). Young people with OCD had significantly higher scores on inflated responsibility and thought-action fusion. There was no significant difference between overall perfectionism scores between the groups but the clinical groups did, however, differ on some dimensions of perfectionism. Some of the measures of cognitive appraisals were also predictive of the severity of OCD symptoms. The results of this study are discussed in relation to the continuity of OCD between childhood and adulthood. Implications for advancements in cognitive behaviour therapy for young people with OCD and future directions for research are also considered.
Attentional Biases and Childhood Anxiety and Depression: A Pilot Study
Objectives: Previous research has shown that adults with high social anxiety direct their attention away from faces with emotional expressions compared to those with neutral expressions, demonstrating avoidance of emotional information. We conducted a pilot study investigating this phenomenon in school aged-children.
Methods: Seventy-nine children aged 8- to 10-years from a south London primary school completed anxiety and depression self-report measures and a face dot-probe task. Bias scores were created from the face dot-probe in which positive scores indicate vigilance towards and negative scores indicate an avoidance of, the face type in question. The children were divided into three groups (low, moderate, high) based on the anxiety and depression scores.
Results: Group analyses indicated increasing avoidance of negative faces in negative versus neutral trials across the three groups from low to medium to high anxiety. Those in the high depression group also showed higher avoidance of negative faces than those with low depression scores. Correlational analyses confirm the direction of effects, with negative correlations between the negative face bias scores (from negative-neutral trials) and symptom measures. The strongest association was between the social anxiety sub-scale and avoidance of negative faces from negative-neutral trials.
Conclusions: These results provide preliminary evidence that anxiety is similarly associated with attentional biases in children as in adults. Notably, these data suggest this bias is specific to social anxiety, suggesting these children are avoiding negative emotional cues in a similar fashion to adults with high social anxiety.
Heart-beat Perception and Childhood Anxiety: A Pilot Study
One of the most common symptoms of panic attacks is heart pounding which is commonly interpreted as symptomatic of a heart attack and arouses high levels of fear. The superior ability of adults with panic disorder to perceive their own heart-beats is well-replicated, but this phenomenon has not been explored in children. We conducted a pilot study exploring the association between heart-beat perception and anxiety in 79 children aged 8- to 10-years. The children completed a battery of tasks including anxiety symptoms, anxiety sensitivity, and the heartbeat perception mental tracking paradigm. The children completed three trials lasting 35, 25, and 45 seconds. Percentage error scores were calculated as “raw error” as a proportion of actual heart-beats. Children with error rates of up to 20% were classified as accurate perceivers. The sample was divided into those with high, middle and low anxiety. Children classified as accurate had significantly higher CASI scores (M = 34.1 and 29.3 respectively, t = -2.16, p < .05), higher SCARED scores (M = 33.7 and 27.2 respectively, t = -1.17, p = ns), and were more likely to be in the high (16.7%) or moderate (9.1%) anxiety groups rather than the low anxiety group (3.1%, p < .10). Interestingly, when the sub-scales from the SCARED were considered, this association appeared to be specific to the panic/somatic scale. These results provide preliminary evidence that anxiety in children is related to similar biases in attention to those seen in adults.
Negative Schemas and Cognitions in Childhood Anxiety and Depression
Dysfunctional schemas and cognitions are associated with depression and anxiety in adults. Less is known about the relationships between depression and anxiety schemas and cognitions in children. This study investigated self-, peer and mother-schemas in 77 children aged 8-10 from a South London primary school. Children completed a number of task which examine children’s expectations of their mothers and peers, and also what children know and feel about themselves in relation to their peers (Rudolph et al, 1995). Depression and anxiety levels for children were assessed by self-reports on the Moods and Feelings (Angold et al, 1995) and the Screen for Child Anxiety Related Emotional Disorders (Birmaher et al, 1997) questionnaires respectively. Analyses revealed moderate correlations between negative expectations of mother and peers and anxiety and depression. Stronger correlations were found between negative perception of self in the context of peers and anxiety and depression.
The finding that increased anxiety and depression is associated with negative schemas and cognition is discussed and future work to assess this relationship longitudinally in a genetic framework is outlined.
Angold, A. et al. (1995). Int. J. Meth. Psych. Res., 5, 237-249.
Birmaher, B. et al. (1997). J. Am, Acad. Child. Adolesc. Psychiat., 36, 545-553.
Rudolph, K. et al. (1995). Child Dev., 66, 1385-1402.
Child General Issues
Obsessive Compulsive Features in Children and Adolescents with Anorexia Nervosa
BACKGROUND: Since the earliest descriptions of anorexia nervosa, the presence of obsessional features has been noted. However, it remains unclear whether such features are symptoms of obsessive-compulsive disorder (OCD) or are obsessive-compulsive personality traits (OCP). Substantial evidence exists to suggest an overlap between AN & OCD (Serpell et al, in press). However, some have suggested that these symptoms are primarily food-, weight- and shape focused and are therefore best considered within the anorectic spectrum. Additionally, evidence from sources such as Keys et al (1950) suggests that OC symptoms can be initiated purely through starvation, and will resolve upon weight restoration without the need for treatment. Personality traits observed in AN include perfectionism, tidiness, and stubbornness, implying a relationship between AN and OCPD, though few studies have evaluated this possibility.
AIM: To assess the presence of OCD and OCP symptoms in young adolescents with AN.
METHOD: 60 Consecutive referrals (13-18 year olds with AN) to two specialist eating disorder services will complete measures of OCD (Childrens Yale Brown Obsessive Compulsive Scale), OCP (International Personality Disorder Examination) and eating disorder symptoms (Eating Disorders Examination).
RESULTS: Data are still being collected. However, currently 55% of the sample (n=31) score within the moderately to severe range on the CYBOCS. Aggressive and contamination compulsions, and washing, checking and miscellaneous obsessions are the most frequently reported. Severity of OCD measured by CYBOCS score is significantly correlated with the restraint subscale of the EDE, indicating an association between the severity of OCD and the severity of AN. However, there is no correlation between low BMI and severity of OCD, giving no reason to support the view that OCD symptoms in AN are due to starvation. IPDE scores are generally low.
CONCLUSIONS: Rates of OCD appear to be markedly higher in this group than has been reported in other studies, whilst OC personality traits tend to be low. Results indicate a strong and complex relationship between OCD and AN. Further analyses are being conducted to assess a more detailed understanding of these relationships.
Keys, A., Brozek, J., Henschel, A., Mickelsen, O., & Taylor, H. L. (1950). The Biology of Human Starvation. Minneapolis: University of Minneapolis Press.
Serpell, L., Livingstone, A., Lask, B., & Neiderman, M. (in press). Anorexia nervosa: Obsessive compulsive disorder, obsessive compulsive personality or neither. Clinical Psychology Review.
The Prevention of Clinical Depression in Eight to Nine Year Old Children: A Nine Month Follow-Up
The aim of the current study was to demonstrate the prevention of clinical depression following a universal cognitive-behavioural intervention for young children. Four schools involving classes of eight to nine year old children were randomly assigned to either the intervention (72 children) or control conditions (48 children). Pre- and post assessments (immediate and nine month follow-up) involved measures of self-reported anxiety, depression and attribution style. Diagnoses were made with a computerised version of a standardised structured clinical interview (The DICA-IV, Child Version, Reich, Shayka & Taibleson, 1997). The intervention involved eight sessions of the Positive Thinking Programme and included training in awareness of thoughts and feelings, thinking more accurately, problems in peer and family situations and relaxation training. The sessions were run by Psychologists in classes of eight to twelve children to maximise participation. Results revealed that compared to the control group, a lower proportion of those in the intervention condition were in the clinical range of depression at nine month follow-up. In addition, compared to the control group, a greater proportion of children in the intervention condition who recovered from clinical depression at post-follow up were still in the healthy range nine months post intervention.
Effects of Parent Training on Parental Cognitions
Children’s behaviour problems are common, persistent, and have poor prognosis (Farrington, 1991; Kazdin, 1995a). In many areas they constitute the majority of referrals to child services, including health, social and education services. The cost to society of these problems is considerable. Current treatments are often based on behavioural models of children’s behaviour problems (Forehand & MacMahon, 1981; Patterson, et. al. 1982). For young children the intervention is usually parent training. These interventions are successful, but there are problems with parents dropping out of treatment, children showing poor generalisation to other settings and poor sustainability of gains (Brestan & Eyberg, 1998). It has been suggested that parental cognitions may play a role in the development and maintenance of children’s behaviour problems and therefore may be important when planning parent training (Bugental & Johnston, 2000). Parental cognitions may also interact with the process of intervention resulting in better or worse outcomes depending on the cognition. For example, Morrisey-Kane & Prinz (1999) have outlined a number of mechanisms by which parental cognitions may interfere with engagement. There are several studies showing that parental cognitions are associated with a variety of behaviour problems (Baden & Howe, 1992; Johnston & Freeman. 1997), however, fewer studies examine the developmental path of parental cognition, and how it changes over time. Kazdin (1995b) has suggested four criteria for determining a successful treatment:
Conceptualisation: a theoretical statement relating the mechanism(s) to clinical dysfunction.
Basic research: evidence showing that the mechanism can be assessed and relates to dysfunction, independently of treatment outcome studies.
Preliminary outcome evidence: evidence in analogue or clinical research showing that the approach leads to change on clinically relevant measures.
Process-outcome connection: evidence in outcome studies showing a relationship between the change in processes alleged to be operative and clinical outcome.
A role for parental cognition in the development of young children’s behaviour problems has been conceptualised (Bugental & Johnston, 2000; Dix, 1991; Milner, 1993), and the basic research does show associations with dysfunction (Baden & Howe, 1992; Johnston & Freeman 1997; Johnston et. al. 1998). However, there is little preliminary outcome evidence and process outcome connection evidence.
A number of studies suggest that changes in parental cognitions over time, and especially over the course of an intervention, are complex and not straightforward (Peters, 2001; Wilson, 1999). Both large and small scale studies are required to determine whether cognitions do change if the intervention is cognitive. The results at present are mixed. Results from a longitudinal study and two case series will be presented. Changes in parental cognitions, when they occur, appear to be associated with changes in other measures such as children’s behaviour problems. However, the direction of these changes is unpredictable and may need additional family context information to be interpretable. The implications for parent training interventions will be discussed.
"Self-Discovery": A Training Programme for Children with Learning Difficulties in Mainstream School: An Exploratory Study
Introduction: A Self-Discovery Programme (SDP) was developed by Cullen, Barlow & McCormack (2002) for children with learning and/or behavioural difficulties within a mainstream educational setting. The aim of the SDP is to provide children with a range of ‘self-management’ techniques that facilitate self-discovery, including touch therapy and relaxation.
Sample and Method: Twelve children (10 boys and 2 girls), age range 6 to 11 years and from Class Years 3 to 6 took part in the pilot study. Children were divided into two groups of 6 children. The SDP comprised 6 x 1-hour weekly sessions. Children were provided with ‘Work Books’ to accompany the Programme.
Results: Children responded well to the sessions and participated positively in the activities at each session. Some children did not like the lubricant used for touch therapy on their hands and found it quite a new experience. A few of the children showed a natural ability to do touch therapy. At the final session, 3 adult volunteers gave the children the opportunity to demonstrate the skills they had learned over the course of the SDP. During this time, children displayed their concentration skills and became almost transfixed in the activities.
Conclusion: The SDP appeared to be well received by the children and showed that it may enhance their concentration skills.
Case Formulation Based CBT with Children - Lessons from Research and Practice
This paper examines the evidence for the use and effectiveness of case formulation based work with children presenting severe behaviour problems in school settings. This group continues to occupy much public debate and few effective interventions. David will illustrate how combining individual CBT with systems based interventions, effective programmes can be achieved. The long term follow up data from this study (twenty years) will demonstrate that effective interventions do have long term benefits in reducing later criminal activity. The factors that predict response to interventions will be explored and elements of effective practice outlined. The data indicates that case formulation plays an important role as part of a set of interventions with this group. Recent studies by a group of practitioners working in the field will then be presented. This group have looked at effective services working with children with behaviour problems and the shared features within these services. Each of the services studied included a core model within a broader based provision. The research indicates the features that underpin effective work. This includes core counselling/therapeutic competences, issues of boundaries and partnership and the importance of the core model for preventing incoherence or chaos in provision. These services shared an emphasis on context led case formulation which extended across different theoretical models. The paper will form the basis for discussion of case formulation models in working with children and the key difference between these models and symptom focused assessment systems such as DSM. The shared elements of a case formulation model and its value across different theoretical perspectives in work with children will be discussed. A brief history of case formulation models in counselling and therapy will also be outlined as well as some of the helpful and unhelpful features of current practice that are emerging. The paper will provide an opportunity for practitioners to look at ways to incorporate a research orientation into their practice and the role of case formulation in that process.
Making Music: Measurable Effects on Brain Wave Activity
Given the generally low fast wave power of persons with Attention Deficit Disorder (AD/HD), and having observed during neurofeedback training that fast wave power increased with activities such as reading or drawing, we determined to measure the effect of making music. Fast wave activity is fundamental to both information processing and behavioural inhibition, both being critical to academic success. In the present intrasubject study, the subject acting as his own control, striking differences between baseline and music conditions were found in fast wave beta1 and smr magnitudes. There were differences amoung the music conditions, but they were more alike than different, compared with baseline. In all three music conditions, theta, alpha, beta1, and smr increased; in the music conditions however, increases in the fast waves were disproportionate relative to the slow and intermediate waves. The subject of this study was partial to his Highland bagpipe so we used the practice chanter for it. The intrasubject study comprised baseline and three music conditions, with only visual EEG feedback; there was neither aural EEG nor investigator feedback. Though we had anticipated a likely increase in fast wave magnitude, we were unprepared for it to increase by a factor of two, even three.
Recognition of Disgust in Children with Obsessive-Compulsive Disorder
Sprengelmeyer et al. (1998) proposed that disgust plays a role in the genesis of obsessive-compulsive disorder (OCD). In order to examine this proposal, Sprengelmeyer et al. tested the recognition of facial expressions of basic emotions amongst four groups including: adults with OCD, adults with Gilles de la Tourette’s Syndrome without obsessive-compulsive behaviours, adults with Gilles de la Tourette’s Syndrome with obsessive-compulsive behaviours, and adults with panic or generalized anxiety disorder. Recognition of disgust was found to be impaired in both groups suffering from symptoms of OCD relative to the other groups. Sprengelmeyer et al. argued that this impairment begins in early childhood when facial recognition is being learnt. In order to test this hypothesis, the current study attempted to replicate these findings with children diagnosed with OCD. Children with OCD were compared to children with other anxiety disorders and non-clinical children. Children in the two clinical groups were assessed for anxiety using the Anxiety Disorders Interview Schedule: Child Version for DSM-IV; non-clinical children were recruited from a local primary school and had never sought help from a mental health professional. Participants categorised emotional facial expressions as either disgust, anger, sadness, happiness, surprise or fear. Data collection is currently in progress; preliminary data indicates that comparison groups do not differ in their ability to categorise emotions, including disgust.
Index of Authors
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