Yorkk 2003 - BABCP Conference
York 2003
British Association for Behavioural and
Cognitive Psychotherapies
31st Annual Conference
Abstracts
York University
16th-19th July 2003
Copyright © British Association for Behavioural and Cognitive Psychotherapies, 2003
Published by the British Association for Behavioural and Cognitive
Psychotherapies
British Association for Behavioural and Cognitive Psychotherapies,
The Globe Centre, PO Box 9, Baxenden, Accrington BB5 0XB
ISBN 0-9542847-1-2
Table of Contents
Abstracts are grouped into topic areas, and then into categories (keynote addresses, symposia, open papers and posters). Within each category abstracts are presented in the order in which they occur during the conference.
Table of Contents ........................................................................................... 3
Recent Findings in the Experimental Psychopathology of Bipolar Affective Disorder ..... 6
New Developments in Theoretical Models of the Psychology of Bipolar Affective
New research into cognitive processes that maintain social phobia .............................. 13
Issues in Psychosis ..................................................................................... 24
Fowler: Trauma and Psychosis: Cause, Consequence, Common Processes and Clinical
Controversies and Growing Points in Early Intervention in Psychosis ........................... 27
New developments in cognition and psychosis: implications for therapy ....................... 30
Behavioural Medicine .................................................................................. 34
Morley: Issues and challenges for cognitive-behavioural treatment of chronic pain states
Basic Processes .......................................................................................... 42
Davey: Why do we worry? Can laboratory studies tell us anything about anxiety? ....... 42
The processing and regulation of emotion across different clinical conditions .............. 47
Intrusive imagery in psychopathology: Application of findings to treatment ................... 49
Clinical and Applied Issues ........................................................................ 55
CBT Self-help treatments: Delivery challenges for self-help in everyday practice. ........ 57
Psychological Disorders in People with Intellectual Disabilities: Recent Developments in
Prevention of Parasuicide by manual assisted cognitive behavioural therapy
(POPMACT): results of the study (presented on behalf of the POPMACT group) ......... 64
Application and effectiveness of CBT treatment programmes ....................................... 70
Children and Adolescents ........................................................................... 72
CBT for children and young people with autistic spectrum disorders ............................. 77
Adult Mental Health
Keynote Addresses
Disclosure, Language, and Health
James Pennebaker, University of Texas at Austin, USA
When individuals are asked to write about emotional upheavals in their lives, they often improve in their physical and mental health. Putting upsetting experiences into words helps people to organize and understand the events and, ultimately, move past them. A number of studies will be summarized that indicate how expressive writing can influence health, biological processes, a broad range of school- and work-related behaviours, and social processes.
The second half of the talk examines why expressive writing is so effective. Linguistic analyses of thousands of writing samples suggest that certain thinking and writing patterns are more likely to produce health improvements than others. For example, the ways pronouns are used
– which suggest perspective changes – are strongly correlated with changes in health. Other findings on markers of narrative, causal thinking, and use of emotions are also relevant to the effects of expressive writing.
The writing intervention offers a promising low-cost method that can help individuals deal with conflict and emotional upheavals. No single writing technique has evolved as being significantly superior to others. Suggestions for using expressive writing in therapy and research will be discussed.
Deliberate self-harm: current research and treatment
Keith Hawton, University of Oxford
Suicide prevention is a mental health priority and the publication of the National Suicide Prevention
Strategy for England has identified specific preventive approaches. The strong association between d eliberate self harm (DSH; ‘attempted suicide’) and suicide means that there is increasing focus on increasing our understanding of the causes of DSH and its prevention. Recent trends in suicide and
DSH, and the key elements in the National Suicide Prevention Strategy, will be reviewed. Factors associated with DSH will be discussed, with a specific focus on psychological characteristics associated with the behaviour and the motives or intentions that are involved. The potential influence of media portrayal of suicidal behaviour on risk of DSH and suicide will be highlighted. The results of one successful approach to prevention of DSH and suicide, namely reduction in availability of analgesics, will be presented. Problem-solving therapy is a pragmatic approach to treatment of DSH patients that is applicable in NHS settings. The rationale for this approach and its nature will be discussed, followed by presentation of results of meta-analyses of its effects on repetition of DSH and on depression, hopelessness and problem resolution.
Psychological Interventions for Bipolar Affective Disorder
Dominic Lam, Institute of Psychiatry, London
In this keynote address, psychosocial variables relevant to the course of bipolar disorder are presented.
These include expressed emotions, social-rhythm-disruption life events and coping with bipolar prodromes. These empirical findings led to the development of treatment packages specific for bipolar disorders.
The efficacy of the empirical based psychological interventions specifically for bipolar disorder is then critically reviewed. Questions are raised regarding the efficacy of treatment packages and the selection of bipolar patients suitable for psychological intervention. Based on empirical studies, moderators of the effects of cognitive therapy are also considered. A brief review of the common components of different treatment packages is presented. Given the cyclical nature of bipolar disorder, questions are also raised about the stage of the illness at which it is appropriate to consider psychological intervention.
Future directions such as the development of a psychological model for mania and how to engage bipolar patients who drop out of cognitive therapy prematurely are discussed.
Symposia
Recent Findings in the Experimental Psychopathology of Bipolar
Affective Disorder
Convenors: Jan Scott, Institute of Psychiatry, London, Warren Mansell,
Institute of Psychiatry, London and Steven Jones, University of Manchester
Chair: Steven Jones, University of Manchester
Mood Related Cognition in Remitted Bipolar Affective Disorder
Kim Wright & Dominic Lam, Institute of Psychiatry, London
Studies in the area of remitted unipolar depression have revealed a relationship between changes in mood at a subclinical level and changes in the expression of certain cognitions that are characteristic of clinical depression. This mood-cognition relationship has been interpreted as a vulnerability factor in the development of further depressive episodes. Cognitive patterns common to remitted bipolar and unipolar affective disorders - and those unique to remitted bipolar disorder - have been little studied.
Some findings suggest the possibility of a link between extreme goal-striving beliefs and over-positive self-image during remission, and bipolar illness. It is therefore of interest to investigate the possibility that distinctive cognitive patterns are present and activated by mood in remitted bipolar disorder. In this study a laboratory-induced change in mood provides the basis for a between-group comparison of change in dysfunctional attitudes and self-image in individuals with a history of bipolar illness, unipolar depression, or no affective illness. Evidence of certain mood-cognition relationships being specific to type of affective disorder, or common to both disorders, is presented.
Cognitive Processes in Remitted Bipolar Affective Disorder
Warren Mansell & Dominic Lam, Institute of Psychiatry, University of London
In contrast to unipolar depression, few studies have investigated cognitive processes in bipolar disorder.
It is particularly useful to investigate bipolar patients in remission because this may help us understand the processes that may contribute to the onset of an episode. For example, a rise in mood may have a specific effect on cognitive processing that further escalates the mood state. Research with patients with remitted bipolar disorder suggests they have an overgeneral style of memory retrieval compared to healthy controls (Scott, Stanton, Garland, & Ferrier, 2000), and that they report more dysfunctional attitudes relating to 'autonomous goal-attainment' than remitted unipolar patients (Lam, Wright, & Smith,
2003). We report the findings of a study of cognitive processing in patients with remitted bipolar disorder, patients with remitted unipolar depression and never depressed controls. Specifically, we investigated the effects of mood on social processing, the use of internal information to make positive evaluations about the self, and the nature, accessibility and content of autobiographical memory. A preliminary analysis demonstrated an overgeneral memory style for negative memories in the bipolar group, and a higher frequency of recollection of past negative memories in their everyday lives. Further results will be presented and discussed in the context of cognitive therapy and future research.
Vulnerability to Bipolar Disorder: Self-Esteem Fluctuation, Sleep, and Cognitive
Reactivity to Mood Induction.
Rebecca Knowles, Richard Bentall, Sara Tai, Steve Jones, Isabelle Blanchette,
University of Manchester
The present study is the 12 month follow-up phase of a behavioural high-risk analogue study in which a sample of undergraduate students were identified as being especially vulnerable to clinical bipolar symptoms based on their scores on measures of hypomanic personality and dysfunctional attitudes to self-evaluation. Their coping behaviours were found to be highly distinctive, characterised by a uniquely toxic combination of rumination and risk-taking. The present study reflects an attempt to further describe the psychological and cognitive profiles of these high-risk individuals with a view to drawing a direct comparison between the vulnerable students and a population of bipolar patients.
A total of 71 participants took part in the present follow-up, of which 26 fell into our high-risk group, 20 fell into a hypothetical mediumrisk group, and 26 were selected as controls. Following a ‘depressing’ or
‘elating’ mood induction, participants were requested to judge a series of ambiguous facial expressions for their affective quality to determine whether their judgements betray a strong mood-congruent bias.
Between the two sessions, participants kept a mood, self-esteem, event and sleep diary for seven consecutive days to enable us to measure fluctuations of self-esteem and mood, attributional styles for both positive and negative events, and sleep quality and regularity.
The results showed that nearly 80% of the hypothetical high-risk students met DSM criteria for a bipolar spectrum disorder within 12 months prior to the time of interview, and 50% fulfilled criteria for substance abuse. These proportions are significantly elevated above those observed in the control group. Further to this, the currently ‘symptomatic’ high-risk students also exhibited highly fluctuating self-esteem and irregular sleep relative to the healthy control students.
An investigation of sleep in bipolar disorder
Allison G. Harvey, Anne Schmidt, Anna Scarna, Christina Semler, & Guy Goodwin,
University of Oxford
.
Research has implicated sleep disturbance and circadian rhythms in bipolar disorder. The aims of the current investigation were threefold: (1) To investigate sleep in individuals with bipolar disorder when euthymic, when manic and when depressed, (2) To investigate the extent to which insomnia is a prodrome for manic and depressive episodes, and (3) To begin the process of empirically deriving a psychological intervention to treat/prevent insomnia in patients with bipolar disorder. A sample of patients with bipolar disorder who were euthymic at the time of the interview (n = 20) were compared with patients with primary insomnia (n = 20) and good sleepers (n = 20). Participants completed a semistructured interview that involved an assessment of sleep over the past week and sleep habits/schedules. For the bipolar group only, the interview included an assessment of sleep during, and prior to, manic episodes and episodes of depression. In addition, participants were asked to keep a sleep diary (subjective estimate of the sleep-wake cycle) and to wear an actigraph (objective estimate of the sleep-wake cycle) for 8 consecutive days. The results indicated that when euthymic, the sleep patterns reported by the bipolar group more closely resembled the insomnia group than the good sleeper group. An average of 6.5 days prior to the onset of a manic episode the majority of the bipolar group reported that their sleep became more disturbed. Sleep disturbance was a prodrome for depression for fewer patients, although 50% of the sample did report changes to their sleep prior to an episode of depression.
Selective attention and emotional processing in bipolar disorders
Natalie Kerr, and Mary Phillips, Institute of Psychiatry, London
Recent research reports deficits in selective attention and specific emotional biases in patients with bipolar disorder (BP). Using tasks that measure both direct and indirect levels of distractibility, we aimed to determine the extent of selective attentional impairments and emotional biases in BP.
Methods:
44 medicated DSM-IV bipolar 1 depressed (14), manic (15), remitted (15) patients and 17 MDD and 17 controls, aged between 18-65. All subjects were matched for age, sex and IQ. Subjects completed the
Golden (1978) version of the Stroop test, the Emotional Stroop test and the Fruit Distraction task. The
Stroop task assesses selective attention using the reading of colours and words in an allocated time span. The Fruit task total time is recorded. The Emotional Stroop assesses selective attention by the reading of colours of words that are positive or negative in theme alongside neutral words.
Results:
On the Stroop & Fruit Task, all patients were significantly slower than controls on all conditions, whilst manic and euthymic BP patients compared to controls, and all BP patients compared with MDD patients, demonstrated a significantly greater index of Stroop interference (p<.05). On the emotional
Stroop test, manic and euthymic BP patients demonstrated non-conservative biases.
Conclusion: We suggest that our findings support the presence of greater impairment in indirect measures of attention in BP patients than in MDD.
Cognition and Cognitive Therapy in Eating Disorders
Conveners: Myra Cooper & Hannah Turner, University of Oxford
Chairperson: Hannah Turner, University of Oxford
Discussant: Padmal de Silva, Institute of Psychiatry, London
Testing an intervention to reduce body shape concern: a randomised controlled trial
Clare Farrell, Roz Shafran, Christopher G Fairburn & Michelle Lee, University of
Oxford
A disturbance in body image is a diagnostic criterion for anorexia nervosa and bulimia nervosa. In addition, body dissatisfaction has been found to be a precursor of eating disorder psychopathology
(Stice & Agras, 1998), and high levels of shape concern at the end of treatment have been shown to predict relapse (Fairburn et al., 1993).
Current interventions for body image disturbance (Butters & Cash, 1987; Rosen, 1989; Stice et al.,
2000) are typically multi-session treatments and are difficult to integrate into evidence-based CBT for eating disorders. Furthermore, many studies lack appropriate comparison conditions. The current study tests a new intervention (“Mirror Retraining”) that is delivered in a single session enhanced by homework. This intervention has been designed so that it could be incorporated into evidence-based
CBT if there were empirical support for its effectiveness.
The key components of the new intervention and the results of a randomised controlled trial comparing its efficacy to a non-specific intervention (Progressive Muscle Relaxation) and a delayed treatment condition will be presented for 60 women with clinically significant levels of body shape concern.
Implications for the treatment of body shape concern in people with and without clinical eating disorders will be discussed.
Cognitions as predictors of eating disorder symptoms in16 – 19 year old school girls: a cross sectional study
Gillian Todd, Cambridge University, Myra Cooper, University of Oxford, Adrian
Wells, Manchester University, Tim Croudace & Ian Goodyer, Cambridge University
Epidemiological and experimental studies have suggested that several factors are important in the development and maintenance of eating disorders. However, the role of cognitions as predictors of eating disorder symptoms remains largely unexplored. Recently, a revised cognitive model of bulimia nervosa (Cooper, Wells & Todd, in press) has proposed that negative self-beliefs as well as eating, weight and shape related cognitions are important in the development and maintenance of eating disorder behaviour.
The current study investigated whether the negative self beliefs and eating, weight and shape related cognitions identified in this model predict eating disorder behaviours and symptoms. Participants were a cohort of 16 –19 year old schoolgirls. Cognitions were assessed using the EDBQ and items from the
EDE-Q, and eating disorder behaviour and symptoms were measured using the EAT, and EDE-Q behaviour items. A range of other factors identified in the literature as important in determining eating disorder behaviour and symptoms were also measured. The study was cross sectional in design and multiple regression was used to analyse the data. Four main questions were addressed in the analyses.
First, analysis determined whether cognitions, and other factors, predicted eating disorder behaviour and symptoms. Second, the two measures of cognition (EDBQ and items from the EDE-Q) were compared to see which measure best predicted eating disorder behaviour and symptoms. Third, the ability of the cognitive measures to capture unique variance in behaviour and symptoms was assessed.
Fourth, the sub-scales of the EDBQ and relevant EDE-Q items were investigated to determine the relationship between specific clusters of cognition and different eating disorder related behaviours.
The findings are considered in the light of recent developments in cognitive theory of eating disorders.
Implications for further research and for the treatment and prevention of eating disorders are discussed.
Qualitative interviews with women with anorexia nervosa: Beyond pros and cons
Lucy Serpell, Janet Treasure, Institute of Psychiatry, London & John Teasdale,
MRC Cognition & Brain Science Unit, Cambridge
This study used depth interviews (Ritchie, 1993) to examine the ‘pros’ and ‘cons’ of anorexia nervosa
(AN), as described by those with the disorder. Previous studies (Serpell, 2000, Serpell et al, 2002) have resulted in the development of a questionnaire, the P-CAN which appears to be a useful measure of the content of the positive and negative attitudes of individuals with AN towards their disorder. However the questionnaire is only able to measure pros and cons which fall into simple discrete categories and is unable to tell us anything about the processes whereby particular pros and cons may come to be important for an individual, how the individual deals with these attitudes, or how they may affect (or fail to affect) behaviour.
The study also aimed to explore anorexics’ perceptions of what other aspects of their illness might be preventing them from being able to change. It seems clear from previous studies that patients often endorse more cons than pros and may agree more strongly with cons of AN than with pros; however, we know from clinical experience and research studies that AN is commonly chronic and difficult to treat, hence it seems likely that something other than just pros are responsible for maintenance of the illness.
This being the case, it would be useful to ask patients with AN for their opinions on the blocks to successful behaviour change (i.e. increased food intake resulting in weight gain).
Results of the study will be presented as themes which emerged from the interviews which were analysed using Interpretative Phenomenological Analysis (Smith, 1996). The analysis suggests a complex relationship b etween pros and cons of the disorder. A further issue, that of ‘getting stuck’ in perseverant dieting behaviour emerged from the interviews and is deserving of further investigation.
Triggers of Vomiting in Bulimic Disorders: The Roles of Core Beliefs and Imagery Hendrik Hinrichsen,
St. George's Eating Disorders Service, London, Tamara Morrison, University College London, Glenn
Waller, St. George's Eating Disorders Service, London & Ulrike Schmidt, Institute of Psychiatry
Recent evidence has suggested a specific role for core beliefs in the triggering of bulimic behaviours.
However, less is known about the role of imagery in this link, despite its role in other disorders. The present study aimed to investigate the potential roles of core beliefs and imagery in the triggering of vomiting. Thirty bulimic women took part in a semi-structured interview focusing on their mental processes prior to vomiting, and completed self-report measures of core beliefs and trauma-related cognitions. The results showed that prior to vomiting the majority of bulimic patients reported thoughts relating to a Defectiveness/Shame core belief and associated feelings of shame and anxiety. Most patients perceived these feelings as triggers to their vomiting. The majority of bulimic patients also reported experiencing visual images prior to vomiting, and those images tended to be recurrent and linked to early traumatic memories. Those patients who experienced images prior to vomiting reported
higher levels of trauma-related thoughts and beliefs than those who did not. Overall, the findings suggest that negative automatic thoughts (relating to a Defectiveness/Shame core belief) and recurrent negative images (linked to early traumatic experiences), may play important roles in triggering vomiting in bulimic disorders.
Core beliefs and eating/weight-related cognitions in the eating disorders:
Impact on eating psychopathology
Glenn Waller, Michelle Hamill, Karen van Gerko, Laura Hughes & Becky
Lockwood, St. George's Eating Disorders Service, London
The eating disorders are characterised by both eating-related cognitions (usually conditional beliefs - e.g., "I am worthless unless I am thin") and core beliefs (unconditional, schema-level representations - e.g., "I am worthless"). However, it is not clear how these levels of cognition interact to predict the level of eating pathology. While it can be hypothesised that both eating-related cognitions and core beliefs are necessary to explain eating behaviours, this hypothesis and the mechanism of connection remain to be tested.
This study describes the use of measures of relevant cognitions (Young Schema Questionnaire - Short form; Eating Disorders Examination - Questionnaire) to determine the best explanatory model of the cognition-behaviour link in the eating disorders. In the first model, core beliefs and eating/shape-related cognitions are used as independent predictors of BMI and bulimic behaviours. In the second, eating/weight-related cognitions are used as potential mediators of the relationship between core beliefs and eating behaviours. In the final model, core beliefs are treated as potential moderators of the link between eating/weight-related attitudes and eating behaviours. The findings are used to suggest the best means of explaining the cognition-behaviour links that are present in the eating disorders.
The effects of using imagery to modify core beliefs in bulimia nervosa: an experimental pilot study
Myra Cooper, University of Oxford, Gillian Todd, Cambridge University & Hannah
Turner, University of Oxford
In an experimental paradigm an imagery modification strategy was administered to patients with bulimia nervosa. The study was a pilot study, and the aim was to change patients’ emotionally held negative self beliefs. Patient’s idiosyncratic beliefs were identified and belief ratings obtained. A single session imagery intervention, focussed on an early memory associated with these beliefs, was then conducted with the experimental group, while a control group received a control intervention. Significant changes were found in the experimental group, compared to the control group, in belief ratings for emotionally held negative self beliefs, and for deserves help and protection beliefs. There was also some suggestion that belief change was associated with mood and behaviour change, including decreased urge to binge and decreased urge to restrict. The shortcomings of the study are discussed and a theoretical explanation for the findings, drawing on the metacognitive S-REF model, is discussed.
New Developments in Theoretical Models of the Psychology of Bipolar
Affective Disorder
Convenors: Steven Jones, University of Manchester and Warren Mansell,
Institute of Psychiatry, London
Chair: Dominic Lam, Institute of Psychiatry, London,
A Model of Risk-Taking During Mania
Robert L. Leahy, Cornell University, and the American Institute for Cognitive
Therapy
Bipolar disorder represents a special challenge for the therapist in that many of the symptoms will reoccur during episodes of this chronic illness. Several studies have indicated the importance of psychosocial events in the precipitation of mood episodes (Hammen, Ellicott, & Gitlin, 1992; Johnson &
Roberts, 1995), the underlying cognitive vulnerabilities of bipolar patients (Alloy, Reilly-Harrington,
Fresco, Whitehouse, & Zechmeister, 1999; Lyon, Startup, & Bentall, 1999), and the utility of cognitivebehavioural treatment approaches for this disorder (Craighead, Miklowitz, Vajk, & Frank, 1998; Lam et al., 2000; Scott, 1999). Basco and Rush have provided an excellent treatment approach stressing the use of life charts, mood charts, behavioral and cognitive interventions (Basco, 2000; Basco & Rush,
1996). In the current presentation, I focus on specific cognitive distortions that give rise to high-risk behaviour during the manic phase. I develop a model of risk preference, based on a decision model, indicate some preliminary considerations in developing case conceptualization with the patient during the euthymic phase, and then examine how risk behaviour may be modified. These include the following
risky assumptions or areas: belief in unlimited financial resources, hypersexuality, impulsivity, belief in special physical powers, belief in special mental powers, aggression, inappropriate self-disclosure, flamboyant behaviour, over-extending commitments and poor time management.
The role of attributions for physiological changes in bipolar disorder: An empirical assessment of an adapted SPAARS model
Steven Jones, University of Manchester, Academic Division of Clinical Psychology and Pennine Care Trust
A model is described based on an adaptation of the SPAARS model of Power & Dalgleish (1997). In this model interpretations of physiological changes associated with circadian disruption are proposed to lead to symptoms of depression or mania. This model generates testable hypotheses which include : 1) differences in circadian stability (activity patterns and sleep) will be observed in remitted bipolar outpatients and normal subjects at high risk of bipolar disorder compared to controls and; 2) psychological interventions for bipolar disorder will be more powerful when provided earlier in the illness course.
Empirical studies relevant to this model are presented, which include: 1) A study of circadian functioning in bipolar versus control participants: 2) A study of sleep disturbance in a behavioural high risk sample:
3) Evidence regarding the extent to which high risk individuals make internal attributions for physiological experiences. Initial findings for a single case experimental study of cognitive therapy for first episode bipolar disorder are also presented.
The development of effective treatment requires clear models that encompass both physiological and psychological aspects of the disorder. The current approach provides one such model that can be readily tested.
The Processing of Meaning in Bipolar Disorder
Philip Barnard, MRC Cognition and Brain Sciences Unit Cambridge and Anne
Palmer, Hellesden Hospital, Norfolk Mental Health NHS Trust
Depression and mania differ markedly in their levels of activation and in the mental models that figure prominently in ideation. An account of Bipolar Disorder will be presented in which we extend the account of depression proposed by Teasdale & Barnard (1993). It is argued that the core symptoms of depressed and manic states arise when processing exchanges between two levels of meaning
(propositional and implicational) move to extremes of their “normal range” of operation. That range is determined by 4 sources of variability:
(1)Variation in mental representations of self-, others and the world;
(2)Variation in rates of change in the current contents of those mental representations;
(3)The extent to which the processing of meaning at different levels is synchronised; &
(4) The extent to which cognitive-affective processing is coordinated in one of two “modes.” In one mode processing is primarily coordinated by reference to specific “propositional” thoughts. In the other by reference to more generic meanings or “implicational senses.”
Depressed states are linked to “interlocked” exchanges between these two levels of meaning that continually regenerate the same thoughts and feelings. There is a low rate of change in (typically) negative schematic models, and processing is co-ordinated in propositional mode. Manic states are linked to “runaway” exchanges between the levels with high rates of change in schematic models
(positive or negative) and an implicational mode of co-ordination. We illustrate how these factors give rise to natural variation in signs and symptoms in depressed and manic states.
Acute and Long-term Reactions to Trauma
Convenors: Nick Grey and Michelle Moulds, Institute of Psychiatry, London
Chair: Nick Grey, Institute of Psychiatry, London
The differential prediction of PTSD, phobias and depression following road traffic accidents.
Thomas Ehring, Anke Ehlers, Institute of Psychiatry, London and Edward
Glucksman, Kings College Hospital, London
Past research into the psychological consequences of road traffic accidents (RTA) has largely focused on posttraumatic stress disorder (PTSD) and predictors for RTA-related PTSD have been identified in a number of studies. However, specific phobias and depression are also common following RTAs (e.g.
Mayou et al., 2001). Very few studies to date have looked at predictors for these disorders. Furthermore, it has rarely been tested whether factors that have been found to predict PTSD are specific of the disorder.
The present study aimed to identify potential differential predictors of PTSD, phobias and depression.
Candidate variables were mainly derived from recent cognitive models (e.g. Ehlers & Clark, 2000;
Teasdale & Barnard, 1993) and included measures of cognitive and emotional processing during the accident, characteristics of the accident memory, beliefs and cognitive and behavioural strategies.
Adult RTA survivors who had been treated at the Accident and Emergency Department of a South
London hospital following their accident took part in a research session between 3 and 12 months following their accident. They were interviewed with the Structured Clinical Interview for DSM-IV to diagnose PTSD, phobias and major depression.
Results will be presented and implications for theoretical models of the disorders will be discussed. The predictive power of the predictors identified in the study will be further tested in a parallel prospective longitudinal study.
Predictors of chronic PTSD in children and adolescents following road traffic accidents and physical assaults
Richard Meiser-Stedman, Patrick Smith, William Yule, Institute of Psychiatry,
London & Tim Dalgleish, MRC Cognition and Brain Sciences Unit, Cambridge
It has been demonstrated that children and adolescents can develop post-traumatic stress disorder
(PTSD) after traumatic events such as shipping disasters, road traffic accidents (RTAs), and war. In addition, recent research has indicated that PTSD in this population, if left untreated, can persist for several years. Attempts to understand the role of demographic and trauma-related factors in chronic
PTSD have been successful, but only account for a limited proportion of variability in PTSD outcome. A prospective study was therefore undertaken to investigate the role of psychological mechanisms, specifically cognitive processes, in the onset and maintenance of PTSD in children and adolescents.
Young people aged 1016 years who attended the Accident and Emergency department of King’s
College Hospital, London, following an RTA or non-sexual assault were invited to participate in the study. At 2-4 weeks and 6 months post-trauma children and their parent were interviewed to test for the presence of acute stress disorder (ASD) and PTSD. At each of these time points, and at 3 months posttrauma, children and their parent or caregiver completed self-report questionnaires relating to their levels of PTSD, depressive, and anxious symptomatology, and their cognitive styles, trauma appraisals, and trauma memory characteristics. Measures of children’s cognitive style, in particular the Childhood
Anxiety Sensitivity Index, and trauma memory characteristics were shown to be good predictors of
PTSD.
The implications of this research for cognitive-behavioural interventions with children and adolescents suffering from PTSD will be discussed.
CBT for Acute Stress Disorder: Enhancing the effectiveness of early intervention
Michelle Moulds, Institute of Psychiatry, London & Richard A. Bryant, University of
New South Wales, Sydney, Australia
The theoretical rationale for the inclusion of Acute Stress Disorder (ASD) in DSM-IV was to provide a diagnostic means by which to identify individuals at risk of developing long-term psychopathology subsequent to traumatic exposure. The majority of people who satisfy criteria for ASD go on to develop chronic posttraumatic stress disorder (PTSD). Although previous studies have reported the efficacy of cognitive behavioural interventions in reducing the development of PTSD, such trials are characterised by significant drop-out rates for participants treated with exposure-based therapy. This study aimed to increase the effectiveness of treating ASD by evaluating non-exposure-based treatment. Specifically,
ASD participants were randomly allocated to either: (a) prolonged exposure (PE), (b) cognitive restructuring (CR), or (c) wait-list control (WL) conditions. Treatment comprised five weekly sessions of individual therapy. PE comprised psychoeducation, prolonged imaginal exposure, in vivo exposure, and relapse prevention components. CR comprised psychoeducation, identification of cognitive errors, daily monitoring of thoughts and affective states, cognitive challenging and relapse prevention components.
Manualised treatments were strictly adhered to, and independent fidelity checks were conducted. Blind assessments were carried out post treatment and at 6-month follow-up. The study hypothesised that intent-to-treat analyses would indicate increased effectiveness for CR owing to a predicted reduction in drop-out rates in the CR relative to the PE conditions. Data is still being collected and 6-month follow-up data will be reported.
Characteristics of intrusions and rumination in post traumatic stress disorder
(PTSD)
Anne. Speckens, Institute of Psychiatry, London, Ann Hackmann, University of
Oxford, and Anke Ehlers, Institute of Psychiatry, London
Intrusive memories and rumination are a common feature of post traumatic stress disorder (PTSD). The aim of this study was to investigate the phenomenological characteristics of intrusions and rumination in
30 patients referred for cognitive behavioural therapy of PTSD following different kinds of traumatic events. PTSD and comorbid psychiatric disorders were assessed with the Structured Clinical Interview for DSM-IV axis I disorders. After their initial assessment, patients were interviewed with a semistructured interview about the frequency, qualities, meaning associated emotions, and coping with intrusions and rumination. Although intrusions and rumination were interlinked, they seemed to be different phenomena. Intrusions were characterised by sensory experiences, while rumination was more of a thought process. Intrusions were generally shorter than ruminations and they seemed to be associated with anxiety, whereas rumination was more associated with guilt and shame.
New research into cognitive processes that maintain social phobia
Convenors and Chairs: Colette Hirsch and Jen Wild, Institute of Psychiatry,
London
People with social phobia fear, and whenever possible avoid, social and performance situations. It is important to understand the nature of the cognitive processes that maintain social phobia in order to facilitate further therapeutic developments. This symposium will focus on new data relating to the cognitive mechanisms that maintain social phobia. The first paper presents data from a clinical study that examined the childhood speech and language difficulties of adult patients with social phobia and the potential link to negative beliefs. The second paper investigates the role of negative self-imagery in the development of social phobia. The third paper examines the role of safety behaviours in the maintenance of social phobia. The third paper presents findings from a semi-structured interview that investigates the nature of post-event processing in social phobia that has been posited to have a role in the maintenance of the disorder. The fourth paper presents an experimental study that manipulates post-event processing and examines its impact on performance and anxiety. The last paper presents data from the Netherlands on cognitive changes that may mediate recovery from social phobia.
Speech and language problems in childhood: The precursor to Social Phobia in adulthood?
Jen Wild, Institute of Psychiatry, London
Social phobia is an isolating anxiety disorder in which sufferers fear the possibility of appearing incompetent in social or performance situations. They fear saying or doing something that is embarrassing and this often includes a fear of stuttering, and/or not being able to express themselves.
Do these fears originate in real experiences of speech and language problems? Recent longitudinal data on children with speech and language problems have shown an association between early childhood speech and language disorders and adult Social Phobia (e.g. Beitchman, Wilson, Johnson et al, 2001). That is, children with speech and language problems have significantly higher rates of Social
Phobia in young adulthood compared with non-impaired children. This study examined the prevalence of reported childhood speech and language problems in adult Social Phobics compared to non-clinical controls. Results showed that individuals with Social Phobia reported significantly more problems with stuttering as children than non-clinical controls. Comparisons were then made with their current feared negative outcomes in social situations. These results will be discussed along with treatment implications for Social Phobics who have experienced early childhood speech and language problems and the subsequent impact on their social beliefs.
Anticipatory imagery and the development of social anxiety
Colette Hirsch, Institute of Psychiatry, London, David Clark, Institute of Psychiatry,
London, Andrew Mathews, MRC Cognition and Brain Sciences Unit, Cambridge,
Ruth Williams, Institute of Psychiatry, London, and Joanna Morrison, Institute of
Psychiatry, London
This experiments test the hypothesis that the negative self-images that are frequently reported by patients with social phobia (Hackmann, Surway & Clark, 1998; Wells, Clark & Ahmad, 1998) play a causal role in the development of social anxiety and negative beliefs about social performance. People with social phobia often generate these images prior to the social event in anticipation of how they may come across to others. In this study, low public speaking anxious volunteers (who do not normally hold negative images when presenting to an audience) were trained to generate a negative self-image, positive self-images or control (non public speaking relevant) image. Following the training, volunteers gave a speech, which was recorded on video camera. The volunteers then completed measures to assess anxiety, beliefs about their performance, their automatic thoughts and the extent to which they believed catastrophes occurred during the speech. As predicted the negative image training resulted in more anxiety, poorer performance, more negative thoughts and higher beliefs that overall bad things
happened. The independent rater also tended to observe poorer performance in participants who had been allocated to the negative image training condition.
An experimental investigation of the role of safety behaviours in social phobia
Freda McManus, University of Oxford, Catarina Sacadura, and David Clark,
Institute of Psychiatry, London
This paper describes two related studies carried out using an analogue population of high and low socially anxious participants. Study one used a semi-structured interview to assess the use of social anxiety related safety behaviours and their perceived effects. Results showed that the high social anxiety group reported using a greater number of different safety behaviours, more frequently and in a greater range of situations than low social anxiety group. Both the low and high social anxiety groups perceived their safety behaviours to be helpful, with the low social anxiety group perceiving their safety behaviours to be more helpful than the high social anxiety group on some variables. Study two involved experimentally manipulating the use of safety behaviours and self-focus in two five minute conversations to assess their impact on levels of anxiety, belief in negative predictions, perceived performance and actual performance. When carrying out safety behaviours and self-focussing, participants reported feeling more anxious, believing they appeared more anxious, feeling more self-focussed, believing their negative predictions to have occurred more, and perceived their overall performance to be poorer. They were also rated more negatively by a conversation partner. Results support the role of dropping safety behaviours and focussing externally as a therapeutic strategy in social anxiety.
If only I hadn’t said that… Post-event processing in social phobia
Louise Waddington, Institute of Psychiatry, London, Ann Hackmann, University of
Oxford, Kate Telford, Anke Ehlers & David. Clark, Institute of Psychiatry, London
Patients with social phobia frequently describe going over social situations in their mind after the event has finished. Clark and Wells (1995) suggested that this ‘post-event processing’ plays a crucial role in the maintenance of the disorder. Two studies have explored the phenomenon of post-event processing in student volunteers with high social anxiety (Lundh & Sperling 2002; Rachman, Gruter-Andrew &
Shafran, 2000). The present study uses a structured interview to explore post-event processing in patients with social phobia. The findings confirm that post-event processing is common, is experienced as unwanted and intrusive, can continue long after the event, and appears to play a role in maintaining the disorder. Some aspects of post-event processing are different from those emphasised in theoretical writings. Treatment implications of the findings are discussed.
Post-event processing and its role in the maintenance of social anxiety
Sophie Rushbrook & Lusia Stopa, University of Southampton
The Clark and Wells (1995) cognitive model of social phobia proposes that individuals with social phobia engage in post-event processing following a social-evaluative event. According to the model, this process is dominated by negative self-perceptions, which increase anxiety, promote the use of safety behaviours in future interactions, and perpetuates maladaptive beliefs about the self and about competence in social situations. The study presented here investigated the effects of post-event processing on anxiety and performance following a speech task, and on anticipated performance in a subsequent speech task in high and low socially anxious participants. 60 participants (30 high socially anxious, 30 low anxious) gave a speech. Following the speech, half of each group was assigned to a post-event processing condition and half to a distracter condition. The results provide partial support for the role of post-event processing in the Clark & Wells (1995) model. High socially anxious participants had more negative thoughts, believed their thoughts more, predicted worse performance, and recorded more negative and fewer positive thoughts in a ‘think aloud ‘test. However, contrary to prediction, the distracter condition had a greater impact on negative predictions of performance, frequency and belief in negative thoughts compared to the post-event processing condition. The implications of these results will be discussed.
Cognitive changes during treatment for social phobia
Marisol J. Voncken and Susan M. Bögels, University of Maastricht, The
Netherlands
Cognitive models of social phobia predict that reduction in social phobic complaints during therapy is mediated through changes in interpretation and judgmental bias. The work of Foa et al. (1996) and
McManus et al (2000) support this hypothesis. However, it is unclear whether other variables mediate reduction in social phobic complaints as well, like improvement in social skills, decreases in psychophysiological reactions, avoidance behaviour or self-focussed attention. The goal of this study
was to investigate whether reduction in social phobic complaints is mediated by changes in interpretation and judgmental bias rather than by changes in skills, physiology, avoidance or attention.
In this pilot study we assessed social phobic patients (n = 10) pre- and post treatment. The patients were randomly assigned to either cognitive therapy aiming at reducing interpretation and judgmental bias or mindfulness- and concentration training. The outcome measures were changes on the Social
Phobic Anxiety Inventory (SPAI) and anxiety during a behaviour test (5 minutes speech and 5 minutes interaction). As cognitive mediating factors we used changes on the Interpretation and Judgmental
Questionnaire (Voncken et al., in press) and on cognitions about performed social skills during the behaviour test. We assessed the following other mediating factors: observer-rated social skills, blushing, sweating and trembling, avoidance behaviour and self-focussed attention. We hypothesized that reduction in social phobic complaints is mediated predominantly by changes in interpretation and judgmental bias.
OCD: Cognitions and Confessions
Convenors: Roz Shafran, University of Oxford and Emily Holmes, MRC
Cognition and Brain Sciences Unit, Cambridge
Chair: Paul Salkovskis, Institute of Psychiatry, London
What Makes an Obsession So Upsetting?
Karen Rowa, Christine Purdon, University of Waterloo, Canada, Laura
Summerfeldt, & Martin Antony Trent University
Unwanted, intrusive thoughts commonly occur in the general population, and individuals often experience several different intrusive thoughts. Similarly, clinical observation suggests that people with obsessive compulsive disorder (OCD) are often bothered by multiple current obsessions, but tend to focus on one or two main themes as their most upsetting obsessions. The current studies were designed to examine some of the reasons why certain intrusive thoughts or obsessions are so much more upsetting than others. In the first study, 64 undergraduates were randomly assigned to report on their most upsetting intrusive thought ( n = 33) or their least upsetting intrusive thought ( n = 31). In the second study, 28 individuals with OCD were asked to report on their most and least upsetting current obsessions at two different sessions, counterbalanced for order. All participants answered questions in reference to their target thought (i.e., the participants with OCD answered all questions about both their most and least upsetting obsessions). Participants completed the Interpretation of Intrusions Inventory
(III), which asks how people appraise or evaluate their intrusive thoughts or obsessions. Participants also answered questions about the degree to which the target thought contradicts important or valued aspects of self, and whether their evaluation of the thought was related to concerns or issues in their lives when the thought first began. Results suggest that more upsetting thoughts are appraised in a more negative fashion than less upsetting thoughts, and more upsetting thoughts contradict valued aspects of self to a significantly greater degree than less upsetting thoughts. These results were consistent across the clinical and nonclinical samples. Responsibility appraisals were similarly strong for most upsetting obsessions and most upsetting intrusive thoughts, suggesting that responsibility appraisals may be especially important in understanding the distress associated with thoughts. There were no group differences in the relevance of life concerns or issues to the evaluation of the thoughts, with most participants reporting that what was going on in their lives was moderately related to both more and less upsetting thoughts. Finally, more and less upsetting thoughts or obsessions did not differ in thought content, with all groups showing a wide variety of thoughts. Results will be discussed in terms of understanding the development of obsessional thoughts and the phenomenology of OCD.
Client experiences of therapy for treatment-refractory OCD
Tracey Taylor and Blake Stobie, Centre for Anxiety Disorders & Trauma, The
Maudsley Hospital, London
The Centre for Anxiety Disorders and Trauma provides a national, specialist treatment service for people with obsessive-compulsive disorder, who have not responded to previous treatments. 57 respondents with treatment refractory OCD were administered self-report questionnaires examining the age of OCD onset, and course of diagnosis and treatment. Spinelli’s (2001) ‘dangerous proposal’ of listening to clients’ perceptions of their treatment was followed. The questionnaires revealed a wealth of qualitative information, and most respondents welcomed the opportunity to reflect on, and discuss, their previous experiences of therapy.
Particular attention was paid to what respondents recalled having done in therapy, and this was contrasted with their understanding of the therapist’s therapeutic orientation and the description of therapy which they had received. Although CBT is accepted as the treatment of choice for OCD, a significant proportion of respondents reported not having received CBT. The therapy experiences of the entire respondent group were analysed, before focusing on those respondents who had reported
receiving either behavioural or cognitive behavioural therapy. Emphasis was placed on the specific therapeutic techniques and strategies respondents reported having engaged in during the sessions, as well as the perceived helpfulness and unhelpfulness of the interventions.
The data yielded revealed a consistent pattern which has clear implications for the labelling of clients as
‘treatment refractory’, therapist beliefs regarding previous treatments, and the application of good quality
CBT to OCD. Wider implications for other ‘treatment refractory’ conditions are considered. Clinical implications, and ideas for future research, are discussed.
Group and individual cognitive therapy and exposure with response prevention for OCD: Immediate, short, and long-term follow-up results
Maureen L. Whittal, Dana S. Thordarson, & Peter D. McLean, Anxiety Disorders
Unit, University of British Columbia, Canada
In the largest treatment outcome study of OCD to date, 176 participants were randomised to Cognitive therapy (CT) or Exposure with Response Prevention (ERP). The first half of the participants were treated using a group format; the second half of the participants were treated individually. Treatment was 12 consecutive weeks in duration. Measurement time points include pre and post treatment, 3 and
24-month follow-up. Not surprisingly, for the 122 treatment completers, post-treatment scores on the
Yale-Brown Obsessive Compulsive Scale (YBOCS) were lower for those who received individual treatment. At 3-month follow-up, participants who received group CT had significantly higher YBOCS scores compared to individual CT, individual ERP and group ERP which did not differ from each other.
At post-treatment 67% of the participants in individual CT were clinically significantly improved and this increased to 76% at 3-month follow-up. Individual CT resulted in the largest effect size at 3-month follow-up at 2.71; group CT was the lowest at .88. Equal cognitive change was reported in CT and ERP treatment, but not surprisingly individual treatment produced greater change compared to group treatment. At two-year follow-up we obtained 69% of assessment data and 72% of interviewer YBOCS data. Results of this long-term follow-up will be addressed in the current talk and will be compared to the immediate and short-term follow-up.
Priorities in research and therapy of OCD
Paul Salkovskis, Institute of Psychiatry, London.
In research and clinical terms, Obsessive Compulsive Disorder (OCD) remains a strange mixture of understanding and misunderstanding. Sadly, the clinical misunderstanding means that many sufferers receive wholly inadequate or wholly inappropriate treatment, with only a minority receiving appropriate help and support. Current conflicting trends in research are discussed in an attempt to identify ways forward which will take us out of our present muddle. There may be some hope.
Roundtable Discussion
Learning from three cognitive behavioural therapies for depression:
Looking forward to a mindful, challenging and activating future
Convenor: Edward Watkins, Institute of Psychiatry, London
Speakers: Christopher Martell, University of Washington, USA and Mark
Williams, University of Oxford
Within the cognitive-behavioural framework, a number of exciting new approaches for the treatment of depression have recently been developed and tested in randomised controlled trials, most notably behavioural activation and mindfulness-based cognitive therapy. In Professor Williams and Prof Martell, this roundtable is exceptionally fortunate in having 2 world experts, who have been instrumental in the development and evaluation of, respectively, mindfulness-based cognitive therapy and behavioural activation. This roundtable will be a forum to discuss and compare these treatments with each other as well as with classical cognitive therapy for depression. It is hoped that this discussion will clarify which aspects of cognitive-behavioural therapy may be critical for successful treatment of depression and stimulate thinking about future therapy developments. The roundtable will concentrate on a question and answer format, providing an opportunity for all attendees to contribute to this discussion.
Open Papers
Issues in substance use and impulse control
Chair: John Taylor, Northumbria University and Northgate & Prudhoe NHS
Trust
Core beliefs and drinking behaviour in young adults: The moderating role of gender
Kirsty Gillings and Caroline Meyer, University of Warwick
Objective: This study examined the differential impact of core beliefs on alcohol consumption and situational drinking among men and women. Method: A cross-sectional design was used to compare 81 young men and 83 young women on their self-reported alcohol consumption, core beliefs and situational drinking. Findings: Men generally held more unhealthy core beliefs than women. Unhealthy core beliefs predicted negative situational drinking in both men and women, and increased alcohol consumption in men only. Dysfunctional mistrust/abuse beliefs had a significantly greater effect on negative situational drinking in women than in men, indicating that gender is a reliable moderator of the relationship between core beliefs and situational drinking. Conclusions: These findings highlight gender differences in the impact of core beliefs upon alcohol consumption and situational drinking. Although there is a need for replication within a clinical group, these findings provide preliminary support for the use of schemabased cognitive therapy with individuals presenting for alcohol treatment.
Drug-facilitated sexual assault: cognitive approaches to treating the trauma
Anna Keegan, Jeremy Gauntlett-Gilbert, Jenny Petrak , Infection and Immunity,
Barts and the London NHS Trust
Whilst the prevalence of drug-facilitated sexual assault (DFSA) is not known, this type of trauma is often seen in sexual health clinics and specialist sexual assault services. There are minimal data on the psychological consequences of this trauma. We present a review of our clinical experience of DFSA in an inner London sexual assault clinic. It seems that DFSA has some psychological consequences that are distinct from those seen in sexual assault without drug involvement. The survivor’s response to a fragmented or absent traumatic memory appears important. We suspect that specific characteristics of the assault (for example, obvious premeditation) may affect adjustment. Also, the involvement of alcohol, drugs and an incomplete memory in the survivor’s account may affect the levels of validation and social support received. We review the cognitive models of post-trauma reactions that are most useful in treating the consequences of DFSA. Typical cognitions and coping strategies seen after DFSA are summarised. Suggestions are made about addressing survivors’ attitudes to amnesic periods, and other cognitive treatment strategies that address the specific nature of this trauma are proposed.
Treating Violent Mentally Disordered Offenders; a cognitive behavioural approach.
Louise Braham & David Jones, Nottinghamshire Healthcare NHS Trust
The need for psychologically based treatment designed to address violent offending, has been repeatedly identified anecdotally, governmentally, and within academic literature. Research on treatment of violent offenders indicates the need for high intensity multi-modal treatment packages reflecting a cognitive-behavioural basis (McGuire, 2002).
The Violent Offender Treatment Programme for individual’s with mental illness (VOTPmi) is a treatment designed to assist mentally disordered offenders (MDOs) attend to &/or modify anti-social and violent behaviours. Delivered over a year within a group format, the VOTPmi utilises a variety of cognitive behavioural strategies focusing on criminogenic factors associated with violent offending. The initial phase centres on insight development & motivation emphasising personalised patterns of violence, ownership and goal setting. Subsequent modules focus on development of intra and interpersonal skills
(e.g. anger & anxiety management, problem solving, assertiveness) as well reframing thinking patterns and attitudes that trigger/maintain violent offending. The programme is delivered by the authors and 2 registered mental health nurses with an emphasis on personalised violent offending profiles. The
VOTP(mi) is currently being evaluated utilising pre & post assessment measures.
The VOTP(mi) consists of 12 manualised treatment modules (adapted for MDOs in maximum security) based on contemporary evidence-based treatment approaches within the psychological field. E.g. motivational interviewing (Emmons & Rollnick, 2001) anger management (Deffenbacher, 2001, 1995;
Novaco, 2000) learning theory (Bandura, 1973), cognitive behavioural theory for violent offending
(Dowden & Andrews, 2000; Wong & Gordon 1999; Andrews, 1990), anxiety management (Clark, 1989) substance misuse (Mattick & Heather, 1993) and relapse prevention (Marlatt & Gordon, 1985).
Open Papers
Chair: Michelle Lee, University of Oxford
Are the Principles of Cognitive Behaviour Therapy Able to Inform Behaviour
Change Interventions based on the Theory of Planned Behaviour?
Imogen C. A. Hobbis and Stephen R. Sutton, Behavioural Science Group, General
Practice and Primary Care Research Unit, Institute of Public Health, Cambridge
University.
Historically, models and interventions within the domains of clinical and health psychology have remained predominantly distinct. However, as increasingly research in both fields is focusing on the development of interventions for similar health-behaviour related conditions, encouraging assimilation between the two areas seems warranted.
The Theory of Planned Behaviour (TPB) is widely used in health psychology research to identify the predictors of health behaviours, and more recently, to inform behaviour change interventions. Although the TPB predicts intentions and, to some degree behaviours, specific guidance is not included on how to intervene to promote behaviour change. This has limited the success of the model in promoting health behaviour change. Other social cognition models, for example Social Cognitive Theory (SCT), have been more successful in supporting behaviour change, using primarily behavioural techniques. This suggests techniques routinely used with people with psychological difficulties may be applied to support behaviour change in wider contexts. It is proposed that Cognitive Behaviour Therapy (CBT), with its focus on the use of cognitive as well as behavioural techniques to support change, may provide the necessary strategies to promote and enhance behaviour change in interventions informed by the TPB.
Whether the underlying frameworks of the TPB and CBT share enough commonalities for CBT to be usefully applied to TPB-informed interventions will be discussed. Techniques used within CBT potentially suitable for this purpose will be explored, as will the issue of the cost-effectiveness of incorporating the individual, patient-focused CBT approach into what have been historically large-scale, population based TPB interventions.
Towards a cognitive model of chronic obesity
Jeremy Gauntlett-Gilbert, Royal London Hospital, London
Psychological treatments for obesity result in small weight losses that are poorly maintained. Data clearly show that weight regain occurs because positive behavioural changes are lost. However, there is no accepted understanding of why behavioural changes slip. Practitioners have recently begun to address the poor maintenance of weight loss by extending the duration of behavioural treatment.
However, efforts to improve maintenance may be aided by clearly-formulated models of the processes that maintain obesity. Clear cognitive models of disorders such as panic disorder or bulimia have been invaluable in this disseminating treatment strategies and generating research. Also, there is much existing research data that can be integrated in the service of a model of chronic obesity. It is clinically evident that many clients in an obesity clinic know how to lose weight, and have lost substantial amounts (usually more than the behaviour therapy average) without specialist help. However, they cannot sustain the loss. The model presented attempts to address the pattern of successful weight loss and subsequent regain in people with severe obesity. It incorporates existing data and some hypotheses derived from clinical work. It aims to integrate explanations of dietary failure, low-self-efficacy regarding weight, causal attributions for obesity and the impact of stigma. It is argued that binge eating is not a centrally important process in the maintenance of obesity. It is also argued that metacognitive processes are important in the failure of self-monitoring and behavioural change. Clinical experience indicates that obese people do not ‘suffer failures’ in self monitoring or restraint. Rather, they elect to avoid thinking about their eating due to a number of beliefs about the process of self-monitoring and attempted restraint. It is argued that understanding these beliefs may advance treatment. The strengths and weaknesses of this provisional model are assessed, and opportunities for empirical testing are presented.
The effects of labelling on clinical judgements in mental health professionals.
Danny C.K. Lam, Kingston University & St. George Medical School and Paul
Salkovskis, Institute of Psychiatry, London
Research suggests that mental health professionals are susceptible to labelling bias effects in their assessments of patients with psychological problems and that these effects may involve undue pessimism or even stigmatisation. An experimental study investigated the extent to which diagnostic information (related to borderline personality disorder) can influence mental health professionals’ attit udes towards a patient’s assessment and its implications for their treatment with cognitivebehavioural therapy (CBT). The mental health professionals (n = 289) who participated in the study were mental health nurses, mental health student nurses, psychiatric approved social workers, clinical and counselling psychologists, and psychiatrists. The experimental manipulation used involved changing the content of the written information given as background to a section of video (ten minutes) of a patient undergoing an actual assessment for CBT for panic disorder with agoraphobia. Participants were asked to base their ratings exclusively on the section of video which they watched. Participants
were randomly allocated to one of three background information conditions. Condition (a) was accurate information about the person’s background and family details, and clinical details of the panic disorder with agoraphobia. Condition (b) was as (a), but with brief mention that it had previously been noted that they experienced some more general disturbance at a time of stress. Condition (c) was as (b), but with the addition of information that it had previously been suggested that they might meet diagnostic criteria for borderline personality disorder (BPD). Note that condition (b) could also imply this diagnosis. Results suggest that the inclusion of both an account of a history of more general disturbance (consistent with a
BPD diagnosis) or the suggestion of the diagnosis itself are associated with mental health professionals making more negative judgements of the patient and the likely course of treatment and its outcome.
Some of these effects further interacted with professional group and level of experience. Implications for clinical practice and professional training are considered.
Posters
Adult Issues Posters
Post-event rumination and negative self-appraisal in social phobia before and after treatment.
Maree J. Abbott and Ronald M. Rapee, Macquarie University, Sydney, Australia
This study investigated the relationship between self-appraisals of performance, symptom severity and post-event rumination in social phobia, and evaluated the effect of treatment on these variables. A socially phobic group and a non-anxious control group performed an impromptu speech and were told that their performance would be evaluated. Participants appraised their performance immediately after the speech and one-week later and the frequency of post-event rumination during the week following the speech was assessed. The socially phobic group maintained the negative appraisals of their speech over the week, whereas the non-clinical group showed increased positivity about their performance.
The socially phobic group also engaged in more negative rumination than controls. Treatment improved perceptions of performance and reduced negative rumination. These results are discussed in the light of cognitive models of social phobia.
Effects of self-monitoring of nursing students on self-efficacy in practical training
Michiyo Ando, Gunma University, Japan
Introduction: Although nursing students can learn many things in practical training to adapt their fundamental knowledge to practice, they usually have much anxiety. And it is important for teachers to create a teaching method that will decrease their anxiety and increase the effects of education. Sasaki et al. (2002) showed that although general self-efficacy did not increase during maternal practical training, self-efficacy increases in p ractical training when a teacher promotes the students’ selfmonitoring as a special intervention, state anxiety decreases, and how students’ emotion change.
Method: Participants were 19 female students in the school of health sciences. They were in the second year, and this practical training was their first experience. Students completed the STAI
(Speilberger et al., 1970) to measure their state anxiety and ordinary efficacy scale (Sakano & Tojyo,
1986). They also wrote daily notes consisting of Events, Emotion, Thinking, Coping, then a teacher of practical training read the notes and gave advices to each student.
Results: Results showed that scores about self-efficacy increased (p<.01) and state-anxiety decreased
(p<.01) after practical training compared to those values before. Only Emotion in the note was analysed. Numbers of words about Emotion were counted and categorized. The practical training lasted for 2 weeks. In the first period, they have a “feeling of success in giving care”, “feeling of failure in giving care”, and “feeling of understanding by observation or giving care”. In the middle period, they have “feeling irritated by the facts of treatment” or “feeling of understanding by collecting information about patients from family”. Finally, in the last period, students have “high feelings of success”, “low feeling of failure”, and “a little feeling of loneliness after parting”.
Discussion: These results suggest that students’ self-monitoring with teacher assistance increases students’ self-efficacy and decreased state-anxiety, and although they had a low feeling of success about their own care, through trying to give care, they developed a high feeling of success by trying to provide care with ideas, understanding, and interacting with patients. These results are a little different from Sasaki et al. (2002), and suggest that self-monitoring by writing and collaborating may be effective in practical training.
The Application of Jeffrey Young’s Schema Mode Therapy to the Treatment of
‘Chronic Agoraphobia’: A Single case study
Martin Bamber, Bootham Park Hospital, York.
In the course of his clinical work Jeffrey Young found that some of his patients did not respond at all well to the traditional Beckian model of cognitive therapy ( Beck 1967;1976) , particularly patients with
‘characterological’ problems . To address this, he developed the ‘Schema Focused’ approach to therapy
(Young J.E.1994a). However, he soon found that even the schema focused approach itself was not sufficient to treat some of the most complex cases he encountered, who sometimes had as many as fourteen or fifteen of early maladaptive schemata present at the same time and this made working with the schema focused approach impractical. He thus developed the model further and introduced the concept of ‘Schema Modes’ and ‘Schema Mode Therapy’, which he initially applied to individuals with personality disorders (Young J.E. 2000; 2001). This paper provides an illustration of the innovative application of Youn g’s Schema Mode Model of therapy.
The case presented is of 47 year old man (Mr H) with a 30 year history of a severe and chronic agoraphobic condition. Prior to commencing this therapy Mr H. had undergone just about every other form of psychological therapy and psychiatric treatment available for this condition without success. At the commencement of therapy Mr H. was rigidly avoidant, severely disabled by his condition and very sceptical about any form of psychological therapy being of benefit to him.
Mr H. underwent a course of 30 sessions of schema mode therapy over an18 month period and this paper identifies six phases of therapy as applied to his chronic agoraphobic condition. He achieved some dramatic improvements in his condition and the success of clinical outcome exceeded anything anticipated by either the patient or the therapist. At the present time Mr H. is still in therapy and continues to make excellent progress.
References:
Beck A.T. (1967) ‘Depression: clinical, experimental and theoretical aspects’.
Harper Row, New York
Beck A.T. (1976) ‘ Cognitive therapy and the emotional disorders’. International Universities Press. New
York.
Young J.E. (1994a) ‘Cognitive therapy for personality disorders’. Professional Resource Press.
Young J.E. (2000) Wor kshop on Schema Mode therapy for Borderline personality Disorders’. Birkbeck
College University of London October 31 st 2000.
Young J.E. (2001) Workshop on Schema Mode Therapy for Narcissistic Personality Disorders.
University of Manchester 4 th October 2001.
Young J.E., Klosko J.E. and Weishaar E. ‘ Schema Therapy: A Practitioners Guide’. Published April
2003. Guilford Press.
Does the psychological management of depression in general practice match current recommendations?
Paul Blenkiron, Bootham Park Hospital, York
Background: Problem solving and cognitive behavioural therapy have proven efficacy in the management of depression. The Defeat Depression Campaign (1992-7) and UK consensus guidelines have recommended increased use of evidence-based psychological approaches in primary care.
Aims: To assess the extent to which general practitioners are currently using specific cognitivebehavioural techniques in their routine practice, and their confidence in such approaches.
Methods: Cross-sectional survey of 153 general practitioners (GP) principles. A questionnaire was constructed which incorporated points of good clinical management emphasised in the research literature since 1990, and posted to all GPs in the York area.
Results: The majority of GPs employed thought challenging, problem solving and collaborative approaches to their management of depressed patients. Only one quarter of GPs said that they routinely provided written information about depression, encouraged diary keeping or activity scheduling.
Respondents expressing a high degree of confidence in managing depression were less likely to agree care in collaboration with the patient (46/56, 82% v. 56/56, 100% of cases, p = 0.001), or to use problem solving (27/56, 48% v. 45/56, 80% of replies, p = 0.004). Female GPs more often used a diary keeping approach whereas male GPs were more likely to challenge automatic negative thoughts. Older doctors used all psychological methods less often.
Conclusions: Homework and written approaches are currently underused in primary care. Clinical confidence does not equate with clinical competence in the psychological management of depression.
Future educational initiatives should continue to emphasise basic cognitive-behavioural options, especially amongst well established general practitioners.
The use of a manual-based group cognitive therapy programme in community mental health settings
Joel Conrad & Laura Bocci, Avon & Wiltshire Mental Health Trust Partnership.
Three CMHTs each ran two cognitive therapy for depression groups. Group members were clients of the CMHTs. Twenty-six clients completed the treatment and provided a full set of data. Clients were more depressed at the start of treatment than in most studies of cognitive therapy for depression and a number had more complicated presentations, which would have excluded them from other studies. For three of the groups, a CNS-CBT was co-group therapist with a CMHT member while the other three groups were run by CMHT staff under the supervision of the CNS-CBT. The treatment followed the
GCT programme described in Cognitive Therapy in Groups: guidelines and resources for practice by M.
L. Free. The mean BDI II showed statistically significant improvement at the end of treatment and this was mostly maintained at 2-month follow-up. Mean DAS score showed a non-significant trend toward improvement. 40% of the completers demonstrated clinically significant improvement in levels of depression and this group had statistically significant improvements in DAS. There were no significant differences between the groups with a CNS-CBT and those without. Based on this pilot, three CMHTs have combined to develop a Group Cognitive Therapy Network that allows cross-team referrals to three groups a year. Referral guidelines and inclusion-exclusion criteria have been developed. The Free programme is used with modifications. Means of ongoing evaluation are in place, including use of the
Automatic Thought Questionnaire and 6-month follow-up.
Cognitive processes in relapse following medication withdrawal: A single case study
Paul Cromarty, Jaime Dixon, Steve Moorhead and Mark Freeston, Newcastle
Cognitive and Behavioural Therapies Centre
The efficacy of pharmacotherapy and cognitive therapy for depression and anxiety has been well established by randomised controlled trials and meta-analysis research. In contrast there is a relative lack of literature on addressing problems that may arise at the end of therapy such as factors in relapse on cessation of treatment and withdrawal from psychotropic medication. The notion of withdrawal symptoms and claims of addiction by users of non-habit forming dru gs such as SSRI’s has become a topical issue with frequent media attention. Amidst legal challenges pharmaceutical companies appear to be refuting claims as placebo effects that perhaps ironically point toward the presence of psychological processes. CBT has developed robust and effective treatment models based on psychological processes such as attentional focussing, sensitivity and scanning for symptoms as key features. Clear examples of these and associated safety behaviours that maintain disorders are seen in
CBT models of Panic and Hypochondriasis. CBT proposes that these are present at the outset of treatment whether this is pharmacological or psychological. Therefore these processes may warrant investigation at cessation and could especially apply during medication withdrawal. The current study uses an intensive single case AB style design to examine the role of psychological constructs such as interpretations, beliefs and attitudes that may influence relapse and lead to the resumption of medication following successful CBT. The participant is a twenty four year old woman who had received 18 sessions of CBT for longstanding depression and other problems. She had been on antidepressant medication for five years and most recently the SSRI paroxetine. The first part of the study naturalistically tracks changes as medication decreases; the second examines changes in these beliefs when a planned CBT intervention is introduced. Case-specific, daily self-monitoring diaries were used throughout all phases of the study to measure these target variables. Standardised questionnaires were used at baseline, mid-point and at post treatment up to six months follow up. Results show a series of changes in symptoms, appraisal of symptoms and beliefs about medication over the course of the study.
Therapeutic gains stabilised and the participant remained medications free at six months follow up. The pattern of change is discussed in terms of current approaches to medication cessation and the possible role of planned and focussed CBT during and immediately following withdrawal.
Group CBT for heterogeneous anxiety disorders: Preliminary evidence for effectiveness
David H. Erickson, Amy S. Janeck & Karen Tallman, Vancouver Hospital and
Health Sciences Centre & University of British Columbia; Vancouver, Canada
Evidence assessing the outcome of CBT for anxiety is based on protocols specifically tailored for individual disorders. To date, there is little published research that would assess a format designed for routine service delivery in typical clinical settings, i.e. group CBT for mixed groups of anxiety disorders.
Objective: To present preliminary results from a randomised wait-list controlled trial, assessing the immediate improvements following an 11-week heterogeneous Anxiety Disorders Treatment Group.
Methods: SCID-diagnosed participants (n=72) with one or more anxiety disorders were randomised to either immediate or delayed treatment. The treatment protocol consisted of eleven weekly 2-hour group sessions, a participant handbook, and daily homework tasks. Measures of symptom severity and anxiety sensitivity were completed at before and after the first group cycle. Hypotheses: Anxiety severity and sensitivity will show greater reductions among group participants, compared to wait-list controls. Results: An analysis of covariance, with post-group BAI and ASI scores as outcome
measures and the respective pre-group scores as covariates, will assess differences between treatment completers and wait-list controls. Discussion: Diagnosis-specific CBT group protocols are not practical for most mental health clinical settings. If these results replicate our earlier uncontrolled program evaluation (Erickson, 2003), which showed large and robust treatment effects, then this heterogeneous group format could have a direct and immediate impact in patient services. Our results, together with those from other heterogeneous-group trials (Barlow et al., 2003; Norton et al., 2003), may greatly spur the utilization of group CBT for anxiety disorders in general mental health settings.
Similarity in young women’s eating attitudes: Self-selected versus artificiallyconstructed groups.
Nicola Gilbert, University of Birmingham and Caroline Meyer, University of Warwick
Background: Evidence suggests that similarity in levels of binge-eating increase as friendships grow more cohesive (Crandall, 1988). In addition, similarity for body image concerns and dietary restraint is more similar within friendship cliques than between friendship cliques (Paxton, Schutz, Wertheim &
Muir, 1999). Preliminary findings suggest that socially valued eating-related attitudes become more similar over time amongst women who share accommodation (Meyer & Waller, 2001). However, to date no research has considered differences in eating attitude similarity between new and established groups. Objective: This study explored similarity (in terms of eating attitudes, depression and anxiety) among new versus established groups of young women. Methods: Three hundred and thirty two female students (living in 80 apartments) participated in the study. They were either living in a newly formed ‘no choice’ apartment or a ‘choice’ apartment where they had chosen their housemates. All participants completed the Eating Disorders Inventory and the Hospital Anxiety & Depression Scale. The groups were compared using similarity indices (showing attitude spread per apartment). Results: Consistent wi th our hypothesis, the ‘choice’ group held more similar eating-related attitudes and depression levels than the ‘no-choice’ group. Specifically, women who had chosen their fellow housemates were significantly more similar in their levels of ineffectiveness, interpersonal distrust and social insecurity.
Conclusions: The findings are interpreted within a social psychological framework, where pressures towards group uniformity are most prevalent in established groups of young women.
Group Cognitive Behavioural Psychotherapy for OCD in Dublin: Challenge and
Change
Yvonne Tone & Colette Kearns, Cognitive Behavioural Psychotherapy Department,
St Patrick’s Hospital, Dublin, Ireland
Individual Cognitive Behavioural Treatment has been proved as the treatment of choice for obsessive
Compulsive Disorder. However studies have focussed primarily on individual treatment. In recent years group treatment has been given more focus. There is conflicting evidence of its usefulness in OCD.
Locally Tone (1999, unpublished) used group treatment for OCD (n=15). There were significant statistical and clinical changes in measures of OCD symptoms.
In response to increased numbers of OCD referrals and an 11-month waiting time Tone & Kearns facilitated two further groups (n=10) with modifications to the treatment protocol.
This poster will present how this group was set up, content of the group and progress of clients within the group. There will be feedback from clients about their experience and usefulness of the group for them. Pre and post group questionnaires will be presented. The experience of the therapists will be described e.g. enhancement of skills and it being an enjoyable and different experience. There will also be comment on the cost effectiveness of this work in our service.
Our conclusions are that this has been a useful treatment: although numbers are small, there have been clinical improvements, it has been acceptable to clients and it has enhanced therapist skills. It has also been cost effective and reduced waiting times.
Our recommendations would be to view larger numbers and be clearer about whether clinical improvement is significant. Comparison to individual treatment would also be recommended.
Why is a normal result from a coronary angiography not always reassuring? :
An investigation of psychological variables in patients with unexplained chest pain
Anoushka Khan and John Weinman , Guy’s, King’s and St Thomas’ Medical
Schools, London
Patients that have undergone certain medical investigations, and that have received a normal test result, are often left without an explanation for their symptoms. Patients with chest pain referred for a coronary angiography, a medical investigation of heart functioning, may not be reassured by normal results from this procedure. Thus, medical reassurance, a process that can involve both receiving a normal result from the angiography and an explanation by the doctor of the benign nature or origin of the chest pain,
can be ineffective in reassuring these patients. This study investigates psychological variables (health anxiety, illness perceptions, anxiety and depression) previously found to be related to medically unexplained symptoms in patients who had received a result confirming normal coronary arteries following coronary angiography. We also investigated whether there is a relationship between these psychological factors and the failure of medical reassurance in patients receiving normal results. A prepost questionnaire design was used with 194 patients undergoing the coronary angiography test. Using non-parametric analyses, it was found that there was a higher level of health anxiety and general anxiety in patients later found to have normal coronary arteries, in comparison to patients later receiving an abnormal result. Patients not reassured by their normal results reported higher state anxiety after receiving their test results. Certain illness perceptions were found to be less strongly perceived in patients remaining unreassured, compared to those that felt reassured by their results. This study suggests that patients may not be reassured simply from a normal test result. They may need a chance to discuss the results and be allowed to have their concerns addressed, specifically in relation to their anxiety and illness perceptions around their chest pain.
A qualitative analysis of the phenomenology of clinical perfectionism
Caroline Riley and. Roz Shafran, University of Oxford
The nature of perfectionism is controversial. Although it was initially described as a unitary construct, more recent analyses in the 1990s broadened the conceptual basis of perfectionism and described it as a multidimensional construct. This multidimensional approach has been criticised for failing to capture the core clinical construct that is seen in therapeutic practice and which appears to interfere with treatment progress. In response to this a more specific construct, “clinical perfectionism” has been described (Shafran, Fairburn & Cooper, 2002) and the aim of this study was to determine its phenomenology in detail using qualitative and quantitative methods.
An open-ended, semi-structured interview was administered to 20 people including patients with Axis 1 disorders. These interviews were conducted on an individual basis and the data analysed using the
Grounded Theory approach (Strauss & Corbin, 1998). Theoretical sampling was carried out to ensure that the key issues that emerged from the analysis were examined in detail.
The poster presents the themes that emerged from the analysis including the relationship between clinical perfectionism and self-evaluation. Importantly, there appears to be an overlap in the domains in which clinical perfection ism was expressed and in the areas of patients’ Axis 1 disorders. The research highlights the dysfunctional nature of clinical perfectionism, and the implications of the results for the treatment of clinical perfectionism are presented.
The relationship between delusional ideation and temperament and character in college students
Syudo Yamasaki
1
, Yusuke Takahashi
1
Ando
3
, Shinji Yamagata
1
, Osamu Kobori
1
, Hiroko Maekawa
4
, Nobuhiko Kijima
, Yuko Hakamada
2
, Juko
3
, Motoko Matsuura
5 and Yoshihiko Tanno
1
1: Graduate school of Arts and Sciences, University of Tokyo, 2: Faculty of
Business and Commerce , Keio University, 3: Faculty of Letters, Keio University, 4:
Graduate school of Human Relations, Keio University, 5: Graduate school of
Letters, Waseda University
Objective: Delusional ideation in the general population has been investigated recently (Johns and van
Os, 2001). However, there were a few studies about the relationship between delusional ideation and personality in normal samples. Cloninger et al. (1994) developed Temperament and Character
Inventory (TCI). TCI was developed based on the psychobiological model of temperament and character (Cloninger et al. 1993). We examined the relationship between delusional ideation and
Cloninger ’s seven personality factors.
Method: The twenty one-item version of Peters et al. Delusions Inventory (Peters et al. 1999) and
Cloninger ’s 125-item TCI were administered to 470 college students (337 men and 133 women with mean age±SD of 18.9±0.9). TCI has four temperament scales (Novelty Seeking: NS, Harm Avoidance:
HA, Reward Dependence: RD, Persistence: P) and three character scales (Self-Directedness: SD,
Cooperativeness: C, Self Transcendence: ST).
Results: Correlations between PDI and TCI seven subscales were examined. In the four temperament scales, only TCI P scale showed a significant correlation between PDI. In contrast, there were significant correlations between PDI and all three-character scales.
Regression analysis with PDI as dependent variable and TCI subscales as independent variable was conducted. β coefficients of three-character scales were significant.
Conclusions: Correlation pattern and regression analysis revealed that delusional ideation has more relation to character than to temperament. Cloninger (1993) suggested that temperament was biological factor and character was psychological factor. The results of the present study suggested that
delusional ideation in the normal population had relation to psychological factor rather than biological factor.
Issues in Psychosis
Keynote Addresses
Trauma and Psychosis: Cause, Consequence, Common Processes and
Clinical Implications
Anthony Morrison, University of Manchester
This presentation examines potential links between trauma and psychosis. Research evidence suggests that psychosis can cause PTSD, traumatic events can cause psychosis, and psychosis and PTSD are part of a spectrum of responses to a traumatic event. Recent conceptualisations of PTSD and psychosis are used to inform the consideration of these different pathways. It is possible to identify several factors that contribute to the development and maintenance of both psychosis and PTSD. Evidence suggests that similar processes may mediate the development of psychosis and/or PTSD following a traumatic event. Both disorders are characterised by intrusions (and the subsequent interpretation of these, or the
‘search for meaning’) and avoidance or negative symptoms, and a common interpretation in both of these disorders is one of going mad. Other maintenance processes have been found to be common to both diagnostic groups, including selective attention, the use of safety behaviours and the use of dysfunctional thought control strategies. Recent conceptualisations of PTSD and psychosis, and data from several recent studies, are used to inform the consideration of these different pathways. Traumatic experiences contribute to the development of beliefs and responses that confer vulnerability to making culturally unacceptable (psychotic) interpretations of events. Such difficulties may be triggered by adult memories of childhood trauma, in addition to current trauma. The implications for theories of psychosis and the clinical implications for services for psychotic patients are discussed
Can fear turn into Psychosis? Trauma memories and the maintenance of psychotic symptoms: Studies in prevalence and processes and implications for the practice of CBT
David Fowler, University of East Anglia
Clinical observations clearly indicate that hallucinations and delusions can sometimes reflect the content of past traumas. However, at present it is unclear how common such threat reactions are; whether trauma related reactions form a subtype of psychosis; and what association trauma reactions have with maintenance of psychotic symptoms. This paper provides data on prevalence of trauma related psychotic symptoms in three samples: people with treatment resistant psychosis, relapse and first episode cases. Similarities and differences between cases with and without a trauma history are described.
A subgroup of cases with clear links between past trauma and the content of psychosis clearly occurs.
However, close analysis reveals that the content of psychotic symptoms only reflects the content of criterion A traumatic events in a minority of cases. Much more commonly the content of distressing psychotic symptoms reflects anomalous intrusions relating to day to day threatening events, fears worries and concerns. These observations raise important questions about the way in which trauma memories and the appraisal of trauma may lead to the maintenance of psychosis. Our cognitive model of psychosis (Fowler, 2000; Garety et al, 2002) suggests that the appraisal of anomalous experience as an external interpersonal threat may be critical in the maintenance of distressing psychotic symptoms.
Anomalous experience is assumed to occur either as a consequence of the products of cognitive confusion and/or emotional experience. In developing the model it may be worth considering how processes related to the occurrence of intrusive memories of threat and avoidance, normally associated with severe PTSD, might be involved in the maintenance of psychosis.
Symposia
Psychosis and Trauma I: Theoretical Perspectives
Convenors: Craig Steel, University College London and David Fowler,
University of East Anglia
Chair: Doug Turkington, University of Newcastle
Psychological protection from the trauma of early psychosis: is “sealing over”
an adaptive strategy?
Chris Jackson, University of Birmingham & Birmingham Early Intervention Centre
Approximately 1 in 3 people who experience a first episode of psychosis become so traumatised by it that they potentially fulfil the criteria for a diagnosis of PTSD (McGorry et al, 1991). Little is still known, however, about why some people maybe at more risk than others from such associated trauma and what are the psychological mechanisms that protect some individuals from the psychological impact of a first episode. In this paper it is argued that people who adopt a “sealing over” recovery style (i.e. a form of denial and emotional disinvestment in the recovery process) may, in the short term, be inadvertently using a psychologically adaptive strategy. In the long term, however, “sealing over” may lead to poorer global outcome. Data from some recent studies are presented which describe the ont ogony of “sealing over” and its relationship to PTSD type symptomatology and clinical outcome variables during the early and formative years of psychosis. The clinical and theoretical implications of the findings are discussed.
Trauma-Related Memories in Psychosis
Craig Steel, University College London and Emily Holmes, MRC Cognition and
Brain Science Unit, Cambridge.
There is growing evidence of phenomenological similarities within the intrusive mental experiences associated with both Posttraumatic Stress Disorder (PTSD) and psychosis. However, although there have been theoretical developments in our understanding of the psychological mechanisms which may be involved in the maintenance of such intrusions, there is currently little understanding of how such mental experiences may be formed within psychosis. An analogue study is reported which explored vulnerability factors, including measures of schizotypy and dissociation, which may predict the frequency of posttraumatic intrusive cognitions. Participants watched a short video containing traumatic scenes and subsequently recorded any intrusions of the video content, which occurred within the following week. The only independent predictor of intrusive experiences was high positive symptom schizotypy.
Results are discussed in relation to other psychological mechanisms which may contribute to the role of trauma-related intrusions occurring within psychotic symptoms.
Investigating Hallucinations in Psychosis in relation to Trauma History and
Post-Traumatic Stress Disorder
Amy Hardy, Institute of Psychiatry, London; David Fowler; University of East
Anglia; Daniel Freeman, Institute of Psychiatry, London; Ben Smith, Craig Steel,
University College London and Jane Evans, Institute of Psychiatry, London.
We propose that whilst previous research has established an association between traumatic events and hallucinations (e.g. Read et al, 2003; Reed and Argyle, 1999; Ross et al, 1994), the nature of this relationship is poorly understood from a psychological perspective. Elucidating the relationship between hallucinations, trauma history and PTSD is a pertinent issue for accurate diagnosis and treatment of individuals with severe mental illness. Preliminary work from the Psychological Prevention of Relapse in
Psychosis trial (the PRP trial) investigating these links is presented. From an initial cohort of patients we report, firstly, the types and phenomenology of hallucinations that relate to trauma history and PTSD diagnosis and, secondly, whether there are any content and thematic correspondences between traumatic events and hallucinations. A content correspondence refers to a literal correspondence between the content of a traumatic event and the content of hallucinations, such relationships may be indicative of situationally accessible memory (SAM) based intrusions (Brewin et al, 1996). A thematic correspondence refers to a correspondence between themes of the traumatic event and themes of hallucinations. Furthermore, the nature of traumatic events (e.g. event type) and hallucinations (e.g. modality) that may pertain to identified correspondences is considered.
Trauma exposure and PTSD in psychosis: Two sides of the same coin?
Aoiffe Kilcommons, University of Liverpool and Anthony Morrison, University of
Manchester
In recent years, there has been a call for greater awareness of a relationship between trauma and psychosis. This presentation will describe a study that examined the lifetime prevalence of trauma exposure and posttraumatic stress disorder (PTSD) in a sample of 32 people with a primary diagnosis of psychosis. It also investigated the associations between specific traumas and specific symptoms and the psychological factors that mediate the development of PTSD and psychosis, in an attempt to gain an insight into the way individuals process traumatic experiences and how outcome and symptomatology are determined. In particular, dissociation and cognitive factors such as metacognitive beliefs and posttrauma related beliefs were explored. The results revealed that 94% of the sample reported exposure to at least one traumatic event once over their lives. The prevalence of PTSD was 53%. Severity of
trauma was associated with severity of PTSD and psychotic symptomatology. However, lifetime physical abuse was only associated with positive psychotic symptoms in general, and lifetime sexual abuse was related to hallucinations in particular. Similar cognitive and dissociative processes appeared to mediate the relationship between trauma exposure and symptom presentation (psychosis and PTSD).
Furthermore, after controlling for the cumulative effect of trauma, negative beliefs about the self and depersonalisation significantly predicted hallucinations but not delusions, with depersonalisation emerging as the most important predictor of hallucinations. These findings will be presented and discussed.
Psychosis and Trauma II: Clinical Perspectives
Convenors: Anthony Morrison, University of Manchester and Craig Steel,
University College London
Chair: Max Birchwood, University of Birmingham
Trauma, psychosis and hotspots in memory: A case example of treating a delusional belief within a PTSD hotspots framework
Emily Holmes, MRC Cognition and Brain Sciences Unit, Cambridge and Kerry
Young, The Traumatic Stress Clinic, Camden & Islington Mental Health and Social
Care Trust, London
In the field of schizophrenia there has been increasing interest in the impact of trauma on certain symptoms of psychosis and their treatment. Conversely, in the posttraumatic stress disorder (PTSD) field, it can be important to consider the influence of psychosis in certain cases. Holmes and Steel
(2003) have argued that people with high positive schizotypy may be particularly susceptible to intrusions after trauma. Further, that such intrusions may be less clearly associated with the trauma.
Recent PTSD treatment emphasises the role of “hotspots” (Ehlers & Clark, 2000). Hotspots are moments of peak distress during trauma, and those points later associated with intrusions (e.g. Holmes,
Grey & Young, 2003). In PTSD the cognitive restructuring of hotspot cognitions, particularly within reliving therapy, can reduce intrusive re-experiencing (Grey, Young & Holmes, 2002).
We suggest focussing on “hotspots” may be useful in the treatment of people with psychosis and a specific trauma history. Conversely, certain clients with PTSD symptoms may also present with psychosis-like symptoms, such as unusual beliefs. For such clients, treatment strategies from psychosis, such as working with delusions can be incorporated within a trauma hotspots approach. This is illustrated in a case example of a client whose index trauma was an assault to her stomach during pregnancy. Afterwards she developed symptoms of PTSD and a delusional belief that the baby was dead.
Trauma and Psychosis: Conceptualisation and clinical application
Julia Renton, Bolton, Salford & Trafford Mental Health Partnership
There are clear links between traumatic events (particularly those occurring in childhood) and the experience of positive symptoms in psychosis. Such traumatic events can affect the content, form and appraisal of such symptoms. This presentation will use clinical material to provide examples of how the relationship between trauma and psychosis can be conceptualised. It will also look at some of the specific themes and challenges facing the therapeutic process and possible routes for overcoming these.
Developing awareness of traumatic experience and its effects: its role in CBT for psychosis
David Fowler, University of East Anglia
Cognitive behaviour therapy begins with an attempt to make sense of psychosis in collaboration with people. The aim is to help the person understand the occurrence of symptoms in the context of the persons life experience and vulnerabilities. Careful assessment can sometimes reveal that hallucinations and delusions directly or indirectly reflect the content of past traumatic events. In this paper we discuss specific features of working with such cases and illustrate this using case material.
There are several issues to highlight. The first is that there may need to be a considerable sensitivity in discussing traumatic events, people with psychosis may be highly sensitive to such events, may find the affect associated difficult to tolerate and indeed may be actively avoiding bringing memories of such events into awareness. The second is that with complex cases who have long histories it can often be difficult to define exactly what the true nature of the traumatic experience has been. The third is that people with psychosis tend to be unaware of the connection between trauma and their symptoms. The key is helping the person to develop awareness of traumatic experience and its consequences and the
way in which aspects of psychotic experience may reflect the sequellae of traumatic events.
Development of such awareness alone can be of significant benefit and may be a key target in itself. In some cases it can lead to more specific work targeting reactions to trauma.
Traumatic Psychosis: A Case Presentation.
Douglas Turkington, Department of Psychiatry, Royal Victoria Infirmary, Newcastleupon-Tyne
A typical case of traumatic psychosis is presented in which mood swings are accompanied by persistent derogatory auditory hallucinations and occasional visual hallucinations. Both the visual and auditory psychotic symptoms are abuse congruent. The process of therapy involved engaging, making links between abuse and symptoms and generating a case formulation and then focussing on linked schemas. Once schema level work had lead to improved psychological functioning the painful issue of reliving was tackled with a variety of pertinent techniques. The outcome was of reduced relapse, symptomatic improvement, reduced friction within the family and CMHT and improved self esteem.
Controversies and Growing Points in Early Intervention in Psychosis
Convenors: Chris Jackson and Max Birchwood, Early Intervention Service,
University of Birmingham
Chair: Max Birchwood, University of Birmingham
Cognitive therapy for people who are at high risk of developing psychosis: the results of a randomised control trial. A. Morrison. University of Manchester
Anthony Morrison, Richard Bentall, Paul French, Lara Walford, Aoiffe Kilcommons,
J Green, S Lomax, & S Lewis
Psychology Services, Bolton, Salford and Trafford Mental Health Partnership
Department of Psychology, University of Manchester
Department of Psychiatry, University of Manchester
There has been growing interest in the possibility of indicated prevention of psychosis. There is a strong case for using psychological approaches to prevent transition to psychosis in high-risk patients. This study aims to identify psychological indicators of risk that accurately predict transition to psychosis and to examine the effectiveness of a cognitive-behavioural intervention in reducing the rate of transition to psychosis in a high-risk group. This study therefore identifies an indicated high-risk group using criteria based on Yung et al.’s (1998) study, and randomly allocates participants to a psychological intervention
(Cognitive Therapy), or a monthly monitoring condition. This presentation will outline the design of this randomised, controlled trial and describe the cognitive theory and therapy that is employed. Data demonstrating a reduction in PANSS-defined transition at 12 months for those who received CT.
Positive symptomatology over the 12-month follow-up period was also significantly reduced in those people who received CT. The theoretical and clinical implications of these findings will be discussed.
Young people at high risk of developing psychosis – The new frontier?
Paul Patterson, Early Intervention Service, North Birmingham Mental Health NHS
Trust.
Whilst Early Intervention at the first episode of psychosis is now established procedure in the UK - working with young people who may be at 'ultra-high risk' of developing psychosis is not. Many questions are still the subject of hot debate: 'Can we accurately identify those at high-risk? Is it ethical to provide treatment or should we continue with research only? Who are these 'at-risk' individuals and where are they coming from? Is there a need for such a service? These questions are addressed in the context of developing and establishing a clinical service in Birmingham UK with a description of casestudy material.
Can we improve users’ adaptation to the onset of psychosis?
C Jackson, P Trower, I Reid, K Barton, J Jones, M Townend, J Smith, Max
Birchwood, L Newton, M Hall, L Newton and S Cox.
The Birmingham Early Intervention Service, Birmingham
Birmingham and Solihull Mental Health Trust
Worcester Mental Health Trust
Department of Clinical Psychology, Birmingham University
A first episode of psychosis can be a psychologically devastating event in the lives of young people. Comorbid problems such as trauma, depression and low self-esteem are common and suicide rates within the first five years are unacceptably high. This may be the direct result of poor adaptation to the onset of psychosis. Despite this very few interventions have been targeted at helping young people during this formative and critical period. In this paper an RCT of cognitive therapy to promote adaptation and personal recovery following a FEP is described. Preliminary findings and their implications are discussed.
Is emotional dysfunction ubiquitous in non-affective psychosis?
Max Birchwood, The Birmingham Early Intervention Service and University of
Birmingham.
Emotional dysfunction and schizophrenia have long been uncomfortable bedfellows. It was Bleuler who first argued that problems of affect lie at the heart of schizophrenia and that the symptoms we all focus on, the delusions and hallucinations, are merely ‘accessory’ and common to many forms of disorder.
This view gave way to the now familiar distinction between affective and non-affective psychosis. Yet, emotional dysfunction is pervasive in non-affective psychosis! Sometimes (and unhelpfully) referred to as ‘comorbidity’ these include: depression and suicidal thinking, social anxiety, problems in forming relationships and traumatic symptoms. There is also the distress attached to the experience of psychotic symptoms. In this paper I will argue that, in order to understand the development of emotional disorder in non-affective psychosis, we need to distinguish between three overlapping pathways including those which are: intrinsic to psychosis, those which are a psychological reaction to psychosis and patienthood, and those arising from the anomalies of childhood and adolescent development, triggered by an episode of psychosis, childhood trauma or both.
Evidence for these pathways will be presented and implications for CBT in psychosis
– in particular the problems of viewing CBT as a quasi-neuroleptic
– will be explored.
The PRP Trial. Testing a cognitive model of psychosis – studies of emotional and cognitive processes in the first 100 patients.
Convenor: Daniel Freeman, Institute of Psychiatry, London
Chair: Philippa Garety, GKT Medical School and the Institute of Psychiatry,
London
The Psychological Prevention of Relapse in Psychosis (PRP) Trial is a multi-centre randomised controlled trial of cognitive behaviour therapy and family intervention for psychosis. The research programme, funded by the Wellcome Trust, is designed to answer questions about clinical outcome, mediators of therapeutic change, and psychological processes associated with psychosis. A selection of findings will be presented - for the first time - from the baseline assessments of the first cohort of patients entering the trial. The trial is taking place in four NHS Trusts in London and East Anglia: the
South London and Maudsley NHS Trust; Norfolk Mental Health NHS Trust; Camden & Islington NHS
Trust; and North East London Mental Health NHS Trust.
EE studies and psychological processing in psychosis.
Elizabeth Kuipers, Institute of Psychiatry, Kings College, London.
It is well established that high levels of expressed emotion (EE) in carers of those with psychosis can affect outcome. However what is not well understood are the psychological processes involved.
Specifically, how do negative interactions with carers increase the risk of a subsequent relapse of psychosis?
One possible route is through affect. Our model (Garety, Kuipers, Fowler, Freeman & Bebbington, 2001) suggests that emotional changes may be part of the process involved in the recurrence of the positive symptoms of psychosis. We think that those in contact with high EE carers may react to these negative interactions affectively and that this may be a maintaining factor for positive symptoms of psychosis. We have therefore hypothesised that those in high EE family settings will have significantly higher levels of anxiety and depression than those with low EE carers. We also think that they will perceive this negative affect (criticism), and that this will feed into lower levels of self esteem for those with high EE carers than those in low EE settings.
We have other hypotheses abou t the meaning of high EE for carers, in terms of high levels of ‘burden’, depression, avoidant coping and cognitive inflexibility (need for closure questionnaire) in high EE carers compared to low EE carers.
Participants in PRP will have been assessed at baseline. We will present results from the first 50 participants with carers, in order to elucidate these factors.
Illness perceptions: explaining emotional responses in individuals with
psychosis
P.W.B. Watson1,Philippa Garety.1,2 & Elizabeth Kuipers1
1 Institute of Psychiatry, London
2 Guy’s, King’s and St. Thomas’ School of Medicine, London
The concept of illness perceptions and Leventhal's (1984) self-regulatory model of illness behaviour has recently attracted much attention. This model postulates that emotional and practical coping responses to illness can be predicted from five core illness constructs i.e. i) cause – the perceived aetiology of the illness; ii) timeline
– how long the illness is likely to last; iii) consequences
– the personal, social and financial implications of the illness; iv) cure/control – the extent to which the illness is controllable and v) identity
– the perceived level of symptomatology associated with the illness. Unlike social cognition models, Leventhal’s model postulates that cognitions change over the course of an illness and that a cyclical re-appraisal process occurs.
Since the development of the Illness Perceptions Questionnaire (IPQ) (Weinman et al, 1996), there have been numerous applications of Leventhal’s model in chronic physical conditions e.g. chronic fatigue syndrome (Moss-Morris et al,1996); cancer (Buick, 1997) and rheumatoid arthritis (Pimm &
Weinman, 1998). However, to date, no empirical research has been published applying self-regulation methodology to psychosis, with one notable exception (Barrowclough et al, 2001).
Therefore, one aim of our research programme was to test Leventhal’s model in its ability to predict emotional responses i.e. depression, anxiety and self-esteem, in individuals presenting with a second or subsequent episode of psychosis. Preliminary work from the Psychological Prevention of Relapse in
Psychosis (PRP) trial will be presented.
Illness representation and recovery attitudes in carers of individuals with psychosis
Juliana Onwumere, Elizabeth Kuipers: Institute of Psychiatry, London & Philippa
Garety: Institute of Psychiatry, Guys & St. Thomas Medical School, London
Evidence from studies of physical illness has shown that an individual’s explanatory model of illness
(Illness representation) can significantly affect adjustment to illness and outcome (Leventhal et al.,1984).
Illness representation has only recently been studied within the realm of severe mental illness
(Barrowclough et al., 2001). However, despite their central caring role, there is a paucity of data on illness representation amongst carers of individuals with psychosis. Thus, very little is known about the factors influencing the models of illness developed by carers. Similarly, very little data exists on the attitudes of carers towards recovery from psychosis. Using the Illness Perception Questionnaire (IPQ:
Weinman et al., 1996) with its subscales on cause, timeline, consequences and control/cure, the present study was designed to extend current thinking around illness representation in psychosis by exploring its relationship to recovery attitudes. Data will be presented on an initial cohort of carers of individuals with psychosis recruited from the Psychological Prevention of Relapse Clinical trial. Carers completed self-report questionnaires on illness representation and recovery attitudes. Measures of psychological distress, coping and social support were also included.
The process of CBT in relapse prevention: The relationship of patient characteristics, empathy and use of techniques.
Rebecca Rollinson, University of East Anglia, Norwich, & David Fowler, University of East Anglia, Norwich
A consistent finding from process research is that the therapeutic relationship, particularly the client’s appraisal of it, is strongly related to clinical outcome. The role of the therapeutic relationship in CBT for psychosis is particularly significant as it can often be difficult to establish and is usually the main area in which clinicians need to adapt traditional CBT approaches.
The initial set of PRP process studies examine the process of engagement in the early phase of therapy, its correspondence with client and therapist characteristics and therapy content. The second set looks more descriptively at the course of engagement throughout therapy, together with the characteristics of therapy itself over time, how these correspond with each other and with client characteristics. Finally, we plan to consider the correspondence between different ‘types’ of CBT for psychosis with different client presentations and clinical outcome. The preliminary analysis of the first of these three research areas, early engagement, will be presented.
This strand of research will be aiming to examine some of the following research questions: How do clients and therapists perceive initial engagement in CBT for psychosis? Are baseline levels of paranoia, and negative symptoms associated with levels of engagement? Are people with early psychosis harder to engage than those with a longer psychiatric history?
The findings will be directly relevant to clinical practice by providing information on the role of empathy in
CBT for psychosis and by identifying specific issues likely to cause engagement difficulties, together with their likely impact upon subsequent therapy.
The influence of self-esteem on the positive symptoms of psychosis: implications for theory and clinical practice of CBT.
Ben Smith, University College London, Daniel Freeman, and Hannah Bashforth,
Institute of Psychiatry, London.
Background: Garety et al (2001) propose an important role for negative schematic models and low selfesteem in their cognitive model of the positive symptoms of psychosis. These authors understand the development and impact of low self-esteem in psychosis as a normal emotional process. Barrowclough et al (2003) report empirical evidence indicating associations between negative self-evaluation and positive symptoms in Schizophrenia.
Objective: The focus of the current paper will be on the influence of self-esteem on the positive symptoms of psychosis. The first level of analysis will look at the relationship between global measures of positive symptoms and the measure of self-esteem. A second level of analysis will look at this relationship both by symptom dimensions and then multidimensionally. Importantly, relationships between depression, self-esteem and schematic models will be analysed.
Design: A cross sectional study of 100 PRP participants.
Results and Implications: Data analysis is ongoing at time of writing. Results of statistical analysis will be presented and related to theoretical conceptualisations of self-esteem in psychosis. The implications for a formulation driven CBT for psychosis emphasising negative schematic models and low self-esteem will be discussed and illustrated using clinical examples. It will be argued that self concept plays an important role in the development, maintenance and treatment of psychosis.
The psychology of persecutory ideation: using virtual reality to test a cognitive model.
Daniel Freeman, Institute of Psychiatry, London.
The PRP research programme includes a number of studies developing the theoretical understanding of the positive symptoms of psychosis. Improving the understanding of symptoms can lead to better formulation and outcome in therapy. We have begun to use virtual reality as an experimental method of testing the research team’s cognitive model of persecutory delusions (Freeman, Garety, Kuipers,
Fowler, & Bebbington, 2002, British Journal of Clinical Psychology). With virtual reality individuals can be presented with the same controlled event, which enables examination of psychological factors that lead to particular appraisals. The occurrence of (non-clinical) paranoia about virtual reality people is used to test our cognitive model. A pilot study will be briefly presented (Freeman, Slater, Bebbington,
Garety, Kuipers, Fowler, Met, Read, Jordan, & Vinayagamoorthy, in press, Journal of Nervous and
Mental Disease). Findings from a new study will then be outlined. The results provide support for the view that persecutory ideation arises from both emotional and psychotic processes.
New developments in cognition and psychosis: implications for therapy
Convenor and Chair: Christine Barrowclough, University of Manchester
The impact of beliefs about mental health problems and coping on outcome in schizophrenia
Fiona Lobban, University of Liverpool
In physical health research, a large number of social cognition models have been proposed to identify key beliefs associated with illness (see Connor & Norman, 1995). Overall, these models have shown that beliefs about illness can account for important variance in outcome and that these beliefs are amenable to change, thus offering important opportunities for clinical interventions.
In mental health, and particularly in psychosis, attention has recently been focused on developing psychopathology models of individual symptoms such as auditory hallucinations (e.g. Morrison, 2001) and delusional b eliefs (Kinderman & Bentall, 1996, 1997). Less attention has been paid to individuals’ overall appraisal of their mental health problems and the meaning that these experiences have. We have tested whether one social cognition model, The Self Regulation Model (SRM) (Leventhal et. al.,
1984), can help us to understand variation in outcome of people diagnosed with schizophrenia. The results showed that controlling for symptom severity, beliefs about the negative consequences of mental health problems were the strongest and most consistent predictors of outcome. Beliefs about greater controllability of symptoms were associated with a better perceived quality of life. Lack of a coherent understanding of mental health problems was associated with greater depression.
These results suggest that the SRM is a promising model for mental health problems. Important areas for development in clinical, and especially psychosocial interventions derived from the study will be discussed.
Exploring the effects of the interpretations of voices.
Sarah Nothard, Mental Health Services of Salford; Anthony Morrison, Department of Psychology, University of Manchester & Mental Health Services of Salford &
Adrian Wells, Department of Clinical Psychology, University of Manchester.
This paper consisted of 2 studies which explored the effects of beliefs about voices, based on the prediction of Morrison’s cognitive conceptualization of voices (1998) and Wells and Matthews’ metacognitive model of emotional dysfunction (S-REF, 1994). Study 1 examined the role of interpretation of voices in the maintenance of distress and negative beliefs. Study 2 explored the association between interpretations about voices and state anxiety; and dimensions of auditory hallucinations.
Method: Study 1 employed a semi-structured interview to collect information about catastrophic interpretations and safety behaviours. A within subjects crossover experimental paradigm was used to compare the effects of maintaining or dropping safety behaviours on negative beliefs and distress levels for 12 voice hearers with a diagnosis of psychosis. In Study 2 the Interpretation of Voices Inventory (IVI;
Morrison, Wells and Nothard, 2002), STAI
– State (Spielberger, 1974) were completed by voice hearers together with a semi-structured interview to assess clinical dimensions of voices.
Results: Study 1 showed that all the participants identified a feared outcome associated with the experience of hearing voices and all but one participant used safety behaviours to prevent the feared outcome. However, there was no significant difference in negative beliefs or distress rating between the maintain or drop safety behaviour conditions of the experimental paradigm. Case material illustrated interesting trends and the methodological limitations of the study. Study 2 found a significant positive correlation between beliefs about loss of control (IVI subscale) and state anxiety. Also, a significant negative correlation between positive beliefs about voices (IVI subscale) and state anxiety. Partial correlations showed that some of these associations remained significant when the physical dimensions of voice hearing were controlled for.
Conclusions: The theoretical and clinical implications of these findings are discussed.
An intervention model for psychosis and substance use
Ian Lowens, Salford Trafford & Bolton Mental Health NHS trust in association with the Manchester schizophrenia and substance misuse group.
Evidence indicates that people who experience psychotic symptoms may have a greater rate of substance use when compared to the general population: a state of co-morbidity presently referred to as
‘dual diagnosis’. Unfortunately, for the majority of people, the combination of psychosis and substance use tends to be associated with increased risk of poorer outcomes, such as relapse, number of hospital admissions, and suicide. Work carried out in Manchester has for some time focused upon adapting skills for working with this client group. A model has been developed that aims to connect the various factors thought to contribute to the maintenance of problems associated with dual diagnosis. The model indicates that psychological approaches in this area could be strengthened by initially conceptualising and intervening from a motivational interviewing approach. However, it also indicates that, with some clients, a motivational interviewing based intervention alone may be ineffective due to the severity of psychotic symptoms. Cognitive behaviour therapy interventions are frequently required in order to increase self efficacy by for example, combating debilitating affect. In pilot work, the model has been found to assist the selection of intervention focus and strategy by taking into account the influence of motivational factors, psychotic symptoms and client’s affect control strategies, within the context of the person’s social network. The presentation will highlight the clinical applications of the model, which will be illustrated with case material.
Cognitive-behavioural approaches in the understanding of psychosis, anger and aggression
Gillian Haddock, University of Manchester & Pennine Care NHS trust
There is an increasing body of evidence that cognitive-behavioural treatments can be effective for people with drug resistant psychosis. In addition, there is a growing literature on the investigation of the cognitive processes that underpin psychotic symptoms which have increased our understanding of these phenomena. However, there has been relatively little work carried out on our cognitivebehavioural understanding of psychosis when there are co-existing problems of violence and aggression. This paper will discuss the relationship between psychotic symptoms, anger and aggression and present a clinical model which is designed to inform therapeutic work with this group of
patients. Clinical observations from a current trial of a psychotherapeutic approach developed for treating anger and psychosis will be discussed.
Self esteem in schizophrenia: links to family attitudes and importance for symptoms
Christine Barrowclough, University of Manchester and Pennine Care NHS trust.
Although self esteem has been most closely associated with depression, recent psychological models of psychosis suggest it may play an important role in delusions and hallucinations. Negative content delusions and hallucinations are more likely to develop or be maintained when they are consistent with self critical beliefs about the self. If this is the case, then negative evaluation from the social environment may to some extent influence symptoms via self esteem. Recent results from a study investigating the relationships between self esteem, family attitudes and psychotic symptoms support this hypothesis.
These findings will be presented and it will be argued that they have considerable implications for new emphases in treatment and service provision.
Psychosis and Adolescence
Convenor and Chair: Chris Harrop, University of Birmingham
Traits of adolescence in psychosis and vice versa
Chris Harrop, University of Birmingham
As Early Intervention increases in popularity around the world, an increasing number of adolescents are encountering mental health services in one form or another; the psychological makeup of typical adolescents needs to be taken into account to ensure this contact is beneficial. Adolescence is an unusual time when empirical evidence suggests people are people have been shown to be typically
“slightly psychotic”, as shown by work on prodromes in normal adolescents, egocentricity, personal fables, and idealistic cognitions.
Empirical research is reported showing that people with a psychosis share with younger adolescents an idealising, black and white way of thinking (particularly about people in their lives), an egocentric perspective and also strongly moralistic beliefs about the content of their own thoughts. Cognitions about their own thoughts (metacognitions) have been mooted to be behind intrusive uncontrollable thoughts and splitting of ownership of thoughts seen in some psychosis symptoms such as voices.
Theoreticians have identified swapping attachments from parents to peers (perhaps in the form of romantic dyads) and working to construct an autonomous adult self to be particularly important tasks in adolescence. A study is reported in which it is illustrated that people with a psychosis struggle with such issues of attachment and autonomy, and it is argued that these issues have a great bearing on psychotic symptomatology. For example, some symptoms such as voices reflect a self-critical tendency which appears to be triggered by potential attachment losses. Other psychotic phenomena possibly reflect a way of coping with unmet attachment needs and social isolation.
We also report a therapeutic approach building on the normal psychological development of adolescence. This approach involves helping people change from self-focussed attention to otherfocussed, which increases empathy and understanding of others, deepens judgements away from black and white attributions and delivers other ‘soft’ social skills.
Model-driven psychological interventions to prevent the onset of psychosis.
Paul French, Early Detection and Intervention Team (EDIT), Mental Health
Services of Salford
Early interventions in psychosis have recently attracted a great deal of interest. This is predominantly because research findings have indicated the importance of duration of untreated psychosis (DUP) in influencing future prognosis. Most interventions have so far centred on the early identification of first episode cases in an attempt to minimize DUP. A further development in the early intervention paradigm has been to identify individuals at ultra high risk prior to the first episode of psychosis. Treatment of this high-risk group may hold the possibility of preventing or delaying the onset of psychosis. The Early
Detection and Intervention Evaluation (EDIE) study is a randomised controlled trial designed to test the effectiveness of a specific model driven psychological intervention to prevent the onset of psychosis.
The intervention is formulation based cognitive therapy, which utilises a specific cognitive model conceptualising the onset of psychosis. Case material will be utilised to demonstrate key aspects of the intervention with special reference to the adolescent population.
The Fragmented Self. Hidden Realms of the Psychotic Mind.
Phil Mollon, North Hertfordshire Clinical Psychology Services.
All human beings begin life in a potential state of psychobiological chaos
– Lacan’s ‘Primordial Discord’
– benign order being maintained only by the continual ministration of the caregiver. This order is established by means of the baby forming an interactional organisation with the caregiver, on the basis of an attachment relationship - the ‘selfobject’ described by Kohut. The threat of a resurgence of fragmentation, if the regulating relationship fails, may be a deep source of anxiety. However, if the formation of this regulating organisation is impeded, perhaps by a combination of neurobiological and environmental factors, then the child may resort to alternative internal ‘psychotic’ organisations. A psychotic part of the mind may exist hidden alongside the more overt non-psychotic mind. Years of experiences of social inadequacy and shame may precede the overt psychotic breakdown. In adolescence, under the developmental pressures requiring shifts in mental organisations, and in the face of anxiety, humiliation and despair regarding one’s potential fitness for adult life, there may be a retreat to the alternative world of the psychotic delusional organisation. Like military juntas, established in the face of political chaos, these psychotic mental organisations may have qualities of harshness and secrecy. Even when causing misery, they are difficult to relinquish since they may be experienced as like fundamental ‘skeletal’ structures of the mind, without which a terrifying disintegration is feared. A supportive and empathic psychotherapeutic stance may gradually allow the psychosis-prone person to find a sense of access to the human family.
Are there vulnerability factors for psychosis in adolescence?
Lara Walford, Salomons, Canterbury Christ Church University College; Anthony
Morrison, University of Manchester and Richard Bentall, University of Manchester.
It is reported that Psychosis often develops in late adulthood (Weinberger 1987). However, few studies have examined psychological explanations for this. It is possible that the numerous transitions faced in adolescence may not be successfully negotiated by some young people and that the failure to do this could lead to the development of psychotic symptoms.
This talk presents two studies attempting to explore this. Adolescents who had experienced a psychotic episode were interviewed about their experience of adolescence and a number of themes were ascertained. Following this a series of measures addressing adolescence specific issues were administered.
A number of themes were generated from the interviews including high levels of stress during adolescence, drifting away from peers, confusion, apathy, and a lack of communication with others.
There were also significant differences between adolescents with psychosis and a control group on measures of identity development and egocentrism. The two groups differed on the methods of coping used to deal with difficulties and adolescents with psychosis were more likely to have unusual experiences in this period of their lives and also to view themselves as different from others. These results and implications for the development of psychotic symptoms are discussed.
Open Papers
Issues in Psychosis
Chair: Matthias Schwannauer, University of Edinburgh
A latent growth model of the effects of a psychosocial intervention in bipolar disorders – the utilisation of latent variable growth models to investigate outcome in experimental clinical research
Matthias Schwannauer & Mick Power, University of Edinburgh.
We developed a psychosocial intervention for the purpose of a randomised control trial involving patients suffering from bipolar disorders. The treatment model included elements of cognitive therapy and interpersonal therapy in both a group and individual format.
The results of a sample of the patients (N=120) that completed follow up indicate the effectiveness of this intervention:
For the treatment group all measures of symptom severity decreased significantly; the number of emergency contacts and number and length of hospital admissions were significantly reduced; and the analysis of these results reveals that the changes in symptom scores appear to occur between beginning and end of treatment. This treatment effect is maintained following discharge from the service and without additional psychological interventions at follow up.
To establish the development of pathology, or the mediation of therapeutic change, an entire profile of developmental lines or pathways needs to be examined and compared to normal development for each line of functioning. Changes in developmental trajectories are likely to be determined by multiple factors, often from multiple system areas, which probably will not combine as simple additive linear functions. There have been remarkable and powerful advances in longitudinal data analysis. Such
methods for studying change over time include multiple group modelling, hierarchical linear modelling, exploratory growth modelling and latent variable growth modelling.
It is this latter method of latent variable growth modelling that will be applied to analyse the results of this trial highlighting the complex factor structure involved in the mediation of the main experimental effects.
Sleep disturbances in outpatients with bipolar disorders
Kate Evershed, Steven Jones, Dougal Hare, University of Manchester
Background: Previous studies have shown sleep disruptions in people with bipolar affective disorder
(Wehr, Sack, Rosenthal, Duncan and Gillan, 1983). These sleep abnormalities have been measured in different ways, e.g., self-report sleep diaries (Wehr, Sack, & Rosenthal, 1987). However, few published studies to date have used direct objective methods to measure sleep, particularly in outpatients with bipolar disorder.
Method: One method which seems to combine direct measurement of activity and sleep patterns with a non-invasive technology is the actiwatch (Cambridge Neurotechnology, 2001). The actiwatch is worn on the wrist, and is of similar size and appearance to a normal wrist watch. It uses a digitised acceleration sensor to detect physical movement which is stored digitally. This can then be downloaded for computer analysis. The present study used this technology to evaluate sleep patterns, among other variables, in 20 outpatients with bipolar disorder, in comparison to 20 age and gender matched controls.
Results: The results indicated that the bipolar disorder outpatients were exhibiting low levels of affective symptoms. Furthermore, the sleep patterns in this group did not appear to differ to age and gender matched controls, despite these two groups differing on circadian rhythm variables reported elsewhere.
However, there is some evidence that control participants identified by bipolar disorder participants, differ in terms of their sleep patterns, to controls identified and recruited by other means (i.e., by the researcher). In particular, mean fragmentation index scores are significantly higher in controls recruited by bipolar disorder participants (p < .05, one tailed). Furthermore, there is a clear trend towards bipolarrecruited participants to exhibit lower levels of sleep efficiency, in comparison to researcher-recruited controls (p = .06, one tailed).
Conclusion: Although tentative evidence, the current study suggests that it is possible that individuals with a diagnosis of bipolar affective disorder may further reinforce their disrupted activity and sleep patterns by choosing to associate with people that have equally disrupted sleep and circadian rhythms.
Further research is required to investigate this hypothesis in more detail.
Cognitive behavioural therapy for schizophrenia: The first outcome study in
Hong Kong
Frendi Li, and Peter W. H. Lee, The University of Hong Kong, Hong Kong
There has been promising evidence for the efficacy of CBT in the treatment of schizophrenia. To date, however, only a small number of schizophrenic patients in Hong Kong receive psychological treatment, and the nature and efficacy of such treatment have not been examined systematically. This study aimed to evaluate the outcome of a CBT treatment package for individuals with schizophrenia in Hong Kong.
The package consisted of standard CBT modules as well as optional skills training modules. The treatment lasted for 6 to 9 months, depending on whether the patients needed the extra training modules. Patients with a DSM-IV diagnosis of schizophrenia were recruited. All participants must agree to keep to their routine care regime, especially pharmacological treatment. They were then randomly assigned to either the CBT treatment group, or a waiting list control group which would start CBT 6 months later. Positive and negative symptoms of schizophrenia, depressive symptoms and role functioning were measured. Thirty-two patients completed treatment. Results showed that although the
2 groups started off with the same levels on the various measures, the treatment group, but not the waiting list control group, showed significant improvement by the 6 th month. After the control group had started CBT, their progress was comparable to that of the treatment group. Both groups showed significant improvement in positive and negative symptoms, and their depressive symptoms had reduced significantly. Their progress was maintained in the 15 th month follow up. These findings suggested that CBT was effective in reducing distress and schizophrenic symptoms for patients who were on medical treatment.
Behavioural Medicine
Keynote Addresses
Issues and challenges for cognitive-behavioural treatment of chronic pain states
Stephen Morley, University of Leeds
The first generation of randomised controlled trials has established good evidence that cognitive behavioural therapy (CBT) is effective. CBT has strong foundations in cognitive and behaviour theory that have been validated experimentally. In this presentation I consider seven issues that arise from the following question. WHO should be treated (issues 1-3), with WHAT treatment (4,5) with WHAT
EFFECT (6,7)? The answers will lead to the design of better trials, improvements in treatment, and the opportunity to extend CBT principles and practice to other problems. Issue 1 - Patients are not uniform:
The evidence suggests that medically valid diagnostic categories carry little information of psychological importance. Treatment could be made more effective by tailoring or customising it to particular subgroups of patients. I briefly outline three approaches to finding patient subgroups: symptom profiling, patient defined 'needs' and, psychological formulation (aetiology). I argue that the latter should be the focus of scientific and clinical endeavour. Issue 2 - Which patients? The possibility of developing brief
CBT interventions to be used in secondary prevention is already being explored and this area will continue to develop. In order to further this we need to develop a classification system that has very predictive ability, and treatments that are quick, focused and can be delivered by a range of health care workers in a quality assured manner. Issue 3 - Integrating CBT and medical approaches: Perhaps the biggest challenge facing pain psychology is to integrate CBT into every aspect of treatment. We have to work towards this aim for the sake of pain sufferers. Issue 4 - We need to refine treatment: Many RCTs and treatment programmes run treatments that incorporate multiple elements. I use the analogies of a
'shotgun' and 'supermarket trolley' to explore the implications of this. CBT also needs to develop approaches to assuring the quality of treatment (adherence and competence). Issues 5 - Developing psychological models of pain: The psychological model underlying CBT will be developed as a series of more precise models such as the fear-avoidance model and that the process of coping with continuous pain will require us to consider issues of personal identity. Issue 6 - Measurement of outcomes: I ask the question 'whose outcome is it?' At present researchers define many of the outcomes and they may, or may not, have utility and relevance for other stake holders. Not only do we need to consider which outcomes should be measured but I also argue that we need to use methods other than conventional pvalues to determine the impact of treatment. The concept of clinical significance in the context of chronic pain is briefly discussed. Issue 7 - Trial design: The majority of first generation trials deployed relatively small samples on single sites. There is evidence that recent trials are statistically more powerful. The opportunity for multi-site and cross-national trials should be explored. Issues of control group design will need to be further addressed in order to address the inherent inability to 'blind' psychological trials.
Symposia
Coping with Chronic Illness
Chair and Convenor: Stirling Moorey, Institute of Psychiatry, London
Expressive Writing and Chronic Disease
James Pennebaker The University of Texas at Austin, USA
Over the last decade, multiple labs have been exploring expressive writing and its effects on physical and mental health. Studies typically find that people who have been randomly assigned to write about emotional upheavals for 4 days, 20 minutes subsequently have better physical health than people assigned to write about superficial topics. Several researchers have extended these findings to patients dealing with cancer, heart disease, cystic fibrosis, asthma, arthritis, and other chronic health disorders.
In addition to summarizing these studies, this talk will explore the advantages and barriers to introducing a writing intervention with people suffering from chronic disease. Some of the underlying mechanisms to writing that may influence disease processes will be explored. Finally, a comparison between expressive writing and traditional cognitive therapy techniques will be discussed. What are the common mechanisms in the two interventions? Are there times when one strategy may be more effective than another?
Rheumatoid arthritis: factors associated with physical and psychological wellbeing
Tom Sensky1,2, Louise Sharpe 2,3, Stefan Büchi2,4, Clare Sidwell5, Lara
Mangelli2,6, Andrew MacLeod5, Diane Home2 and Simon Allard2
1Imperial College London, 2West Middlesex University Hospital, Isleworth,
Middlesex, 3University of Sydney, Australia 4University Hospital, Zürich, 5Royal
Holloway, University of London, 6Università degli Studi di Bologna, Bologna.
A series of studies will be outlined of cognitive factors in rheumatoid arthritis (RA). A randomised controlled trial of cognitive therapy (CBT) in a cohort of people with recent-onset RA, not selected for psychological vulnerability or the presence of affective disturbance, demonstrated significant benefits at
the end of treatment for depression and anxiety, which were sustained at 6-month follow-up, when the
CBT group also showed significant improvements over the standard treatment group in joint functioning.
Over longer follow-up, the CBT group showed less disability than the control group. Two studies focused on aspects of resilience in RA. These demonstrated that depression in rheumatology outpatients with RA was inversely associated with psychological well-being and with Sense of
Coherence, the latter also apparently moderating the relationship between depression and pain. As in previous research, depression scores in both these studies were independent of patient scores on
‘disease’ variables. In a further study involving a similar clinic sample, positive well-being was significantly reduced when compared with a general adult sample. In the RA sample, positive well-being was associated with the ability to find meaning from the illness experience or to experience positive growth.
Cognitive Behaviour Therapy in Advanced and Terminal Illness
Stirling Moorey, South London & Maudsley Trust and Institute of Psychiatry,
London. And Anne Garland, Nottingham Psychotherapy Unit, Nottinghamshire
Healthcare NHS Trust.
Cognitive behaviour therapy has proved effective as a treatment for emotional disorders in people with cancer, but most of the research has been done with early stage disease. Two challenges face clinicians and researchers in this area: to demonstrate the efficacy of CBT in advanced disease, and to develop packages of care that can be delivered by non-mental health professionals in oncology settings.
This presentation will describe schemes to train palliative care nurses in the use of CBT techniques as part of their everyday clinical practice. Some of the common emotional and adjustment difficulties experienced by people with terminal illness will be described and the application of CBT skills outlined.
Anne Garland will present some preliminary results from an evaluation of CBT training for palliative care professionals at the Marie Curie Centre, Newcastle. Stirling Moorey will describe a randomised controlled trial in progress at St Christopher's Hospice in which nurses treat symptoms of anxiety and depression in the patients' homes.
Enmeshment in chronic pain
Convenor and Chair: Stephen Morley, University of Leeds
Information Processing Biases Among Chronic Pain Patients and Ankylosing
Spondylitis Patients: The Impact of Diagnosis
Heather J Wells, Tamar Pincus and Elaine McWilliams, Royal Holloway, University of London
The aim of this research was to explore the impact that diagnostic status has on information processing biases among chronic pain (CP) and ankylosing spondylitis (AS) patients. AS patients, CP patients, and healthy hospital staff controls, completed a questionnaire and short computer task. During the computer task participants endorsed sensory, depression, illness, and neutral adjectives, following a cue question
(which facilitated encoding of the adjectives in relation to the self). They were then asked to recall the adjectives in a surprise memory task. Diagnosed CP patients demonstrated a recall bias away from depression related stimuli, whilst the non-diagnosed CP patients did not. The presence of a diagnosis among CP patients who are not currently depressed may protect or ‘buffer’ them against cognitive biasing towards classic depression related stimuli. The diagnosed AS group showed a bias towards sensory stimuli, indicating the presence of an enduring and over-riding pain schema. The non-pain control group also displayed a sensory bias, which was attributed to a frequency effect as a result of working in an environment where they were regularly exposed to sensory language. The results are discussed in relation to existing literature in this area and implications for clinical practice are provided.
Am I worthless? – Self-reference in depressed chronic pain patients
Zoë K Clyde, INPUT, Pain Management Unit, St Thomas Hospital, London
Characteristic of clinical depression are negative cognitions pertaining to the self, world and future.
Global self-denigratory beliefs are particularly predominant. The prevalence of depression in chronic pain populations is frequently reported but less is known about the nature of this relationship. This presentation focuses on the issue of self-reference in chronic pain, reviewing previous research and presenting the results of a study designed to take into account some of the methodological problems in this area. The results of a study using a self-referential encoding task did not indicate that depressed chronic pain patients show the same self-denigratory tendency as in clinically depressed populations.
The implications of these results for the nature of depression in chronic pain will be discussed in relation to the concept of enmeshment in chronic pain.
Cognitive bias in back pain patients attending osteopathy: testing the enmeshment model in reference to future thinking
Jessica Read, Southwark MHOA Psychology Service, Maudsley Hospital.
This presentation describes the findings of a study, which aimed to test the schema enmeshment model of pain with reference to future thinking. An information-processing paradigm compared endorsement and recall bias between depressed and non-depressed chronic low back pain patients and control participants. Twenty-five depressed, 35 non-depressed chronic low back pain patients and 25 control participants (student osteopaths) were recruited from an osteopathy practice. Participants were asked to endorse positive and negative ill health, depression-related, and neutral (control) adjectives, encoded in reference to either current or future time frame. Incidental recall of the adjectives was then tested.
While the expected hypothesis of a recall bias by depressed pain patients towards ill-health stimuli in the current condition was confirmed, the recall bias was not present in the future condition. Additionally, patterns of endorsement and recall bias differed. This data supports the SEMP in a different group of pain patients and extends understanding of future thinking in chronic pain. It suggests that, although this group of depressed pain patients appeared to have schema enmeshment in the present situation, their representations of the future differed, and were not characterised by pain, illness and hopelessness. Implications for the SEMP, and the relevance of current cognitive models of depression to distress in chronic pain, will be discussed.
“Future Possible Selves” conditionality and adjustment to chronic pain
Caitlin Davies, Salford Mental Health Services Trust, Salford.
This study explored the relationships between chronic pain patients’ constructions of the future and their current level of adjustment, indexed as depression, and their current ‘acceptance of pain’. We developed a measure of a person’s assessment of their future possible selves by combining two methodologies for examining the self We used the method to test a prediction from the self-enmeshment model of pain that depression would be associated with the degree to which a person viewed their future possible self as contingent on the future absence of pain. 89 chronic patients with various diagnoses were recruited from 2 pain clinics. Standard measures, Beck Depression Inventory, Chronic Pain
Acceptance Questionnaire, Trait Anxiety, Pain Disability Inventory, and Pain (VAS) were administered.
A new method for eliciting patients’ perspectives of their future possible selves was developed thought the combination of two established methods. A crucial addition was an assessment of the extent to which individual’s views of their future self was contingent on the absence (feared for self) or presence
(hoped for self) of pain. We also assessed the current, actual, self. The analysis showed that the response production methods used were independent of current depression and verbal fluency and therefore not subject to bias from these sources. On average the patients’ current self was nearer to their feared-for-future than their hoped-for-future. Current depression was predicted by both actualhoped discrepancies and the proportion hopes not contingent on pain removal. This was true after the influence of demographics, current pain and current levels of disability had been accounted for in a multiple regression analysis. Acceptance of pain was highly related to the proportion of hopes that were non-contingent on pain removal. The results were consistent with the predictions from self-enmeshment theory and provide the first prospective test of the theory. The methodology appears to be free of potentially important confounds and has the advantage that it is not dependent on endorsement. It therefore seems likely that the results are not attributable to method bias.
Role loss and self-organisation in adaptation to chronic pain.
Sam Harris, Lincolnshire Partnership NHS Trust
Chronic pain interrupts behaviour, interferes with functioning, and may affect a person's identity. We tested whether role loss or the associated change in self-differentiation, assessed by changes in personal attributes, better predicted depression. In this study 31 male and 40 female chronic pain patients with mixed diagnosis (mean duration 7 years) aged between 21 and 65 were recruited from a pain clinic. Measures: pain (MPQ), disability (PDI), depression and anxiety (BDI, HADS), role-attribute test (RAT) in which participants identify 4 social roles in 4 domains (friendship, occupation, leisure, family) and nominate 2 attributes in each role prior to pain onset and current. The RAT measures the number of roles, attributes and unique attributes - number of attributes occurring once or more: This is a measure of self-differentiation. Participants reported mean losses of 3.38 roles, 6.97 attributes & 4.72 unique attributes. Greater losses were observed in friendship, occupation and leisure domains compared with the family, which was well preserved. Multiple regression analyses revealed that after controlling for demographic and clinical differences e.g. pain duration, role and attribute loss predicted depression scores. The study provides supports the hypothesis that changes in self-identity are associated with adjustment (depression). One implication is that psychological interventions for chronic pain should focus on the maintenance and development of valued personal attributes in order to form a differentiated self-concept.
Understanding somatic complaints in children
Chair and Convenor and Discussant: Trudie Chalder, Guys, Kings and St.
Thomas’ School of Medicine, London
Psychological treatments for unexplained somatic symptoms in children and adolescents: a systematic review.
Kaneez Husain and Trudie Chalder , Guy’s, Kings and St Thomas’ School of
Medicine, London
Somatic symptoms for which no medical explanation can be found, such as headache, stomachache and fatigue (Garralda, 1999) are common in children and adolescents. We aimed to review the psychological treatment literature for such symptoms in this age group. The Electronic databases
Medline, PsychINFO, Embase, Cinahl, ISI Citation Indexes (Web of Science) and the Cochrane library were searched for suitable studies, as well as the reference lists of obtained studies. Controlled trials of psychological treatments for unexplained somatic symptoms in children up to 18 years of age, with outcomes assessing symptoms, distress or disability were included. 28 suitable studies were identified,
3 were on Recurrent Abdominal Pain (RAP) and the remaining studies were on headache disorders, specifically migraine, tension type headache and mixed headache. The most common interventions were relaxation, biofeedback, and cognitive behavioural interventions, which were effective in treating these disorders. The methodological quality of these studies and gaps in research are also discussed.
Parental expectations of intellectual ability in children with chronic fatigue syndrome: match or mismatch
Alice Coddington, and Trudie Chalder , Guy’s, King’s & St Thomas School of
Medicine, London.
Chronic fatigue syndrome is characterised by a sensation of persistent and debilitating fatigue of duration exceeding 6 months. This can result in a marked decline in the level of daily activity. In addition to physical symptoms patients report problems of attention, memory, learning and cognitive processing speed (Krilov, 1998). However research to date in adult samples has failed to find any significant impairment in IQ (Moss-Morris, 2000). Aetiology also remains unknown, and investigations have considered diverse possibilities. Research in adolescent samples is particularly limited despite growing prevalence in this group.
This cross-sectional pilot study focused on two hypotheses; firstly IQ will not be affected by CFS, and secondly that parental expectations of their child’s intelligence will be more unrealistic in CFS cases than healthy controls. The sample was 28 male and female CFS patients and 29 healthy controls aged
11-19 years and one parent of each subject. IQ was assessed using the AH4 group test of general intelligence and a self-ratings scale assessed perceived IQ. A battery of questionnaire measures controlled for possible confounding variables.
Results suggested that IQ was not affected by CFS. Furthermore it appears that parental expectations are significantly higher and more unrealistic for individuals with CFS that healthy controls. Additionally this relationship was strengthened when levels of fatigue, age and gender were controlled for.
Unrealistic parental expectations will therefore be discussed as a possible aetiological factor in CFS.
Illness Beliefs in Young People with Chronic Fatigue Syndrome
Sarah Lambert , St Bartholomew’s Hospital, London and Trudie Chalder, Guy’s,
Kings and St Thomas’ School of Medicine, London
Chronic fatigue syndrome (CFS) is a relatively rare condition in young people. Whilst the role of illness beliefs in adults with CFS has been investigated, very little is known about the beliefs of young people with CFS and the extent to which they influence fatigue, physical disability, or psychological adjustment.
This study employed a cross-sectional design to examine beliefs about illness and activity in a group of
38 young people with chronic fatigue syndrome. Mother’s beliefs about their child’s illness were also examined. A small number of specific child and maternal beliefs about the illness and about the harmfulness of activity were associated with self-reported levels of fatigue, physical impairment, and psychological distress. Maternal beliefs were found to contribute significantly to levels of child selfreported functional impairment. Contrary to expectation, maternal beliefs did not make a significant contribution, over and above that made by the children’s own beliefs, to fatigue or psychological adjustment.
Illness Cognitions and Coping Styles in Adolescents with Chronic Fatigue
Syndrome
Clare Henderson, Islington Primary Care Trust, London and Cathy Creswell,
University College London
People with Chronic Fatigue Syndrome (CFS) suffer from prolonged and debilitating fatigue with no identified organic pathology. There is a wide body of research investigating the condition in adults but few studies look at the illness in children and adolescents. In adults, research has identified a link between the beliefs sufferers have about their illness, the way they cope with it and their physical and psychological functioning. This study aimed to extend previous research by including an assessment of children's coping styles. Specifically this study investigated the association between illness beliefs, coping and functioning for adolescents with CFS. In addition, the relationship between the child and main carer’s beliefs about the child’s illness was also studied. 37 adolescents with CFS and their main carers completed questionnaires relating to illness beliefs, coping strategies and physical and psychological functioning. Results indicated that adolescents who thought negatively about the consequences of their illness tended to cope by focusing on their illness symptoms and reported more psychological impairment. The child and main carer illness cognitions were found to be moderately to highly correlated. These findings suggest that, as with adults with CFS, there may be a relationship between cognitions, coping and functioning for children with the same illness. Main carers and children seem to hold similar beliefs about the illness, and the role parents play in the formation and maintenance of illness cognitions should be investigated further.
Open Papers
Issues in Behavioural Medicine
Chair: Kate Rimes, Institute of Psychiatry, London
A comparative investigation into psychological and psychosocial risk factors in the management of chronic mental health problems (bipolar disorders) and chronic physical health difficulties (diabetes mellitus)
Matthias Schwannauer, University of Edinburgh
We aimed to investigate whether psychosocial, emotional and cognitive risk factors differ significantly between groups of patients suffering from bipolar disorder and a matched control group of patients suffering from a chronic physical illness (diabetes mellitus).
Over the course of this comparative study we recruited 71 subjects suffering from bipolar disorder who completed a course of psychological intervention and 57 patients suffering from diabetes mellitus.
The key outcome measures, patient quality of life, and measures of current psychiatric symptomatology, demonstrated significant improvement in the group which received a trial of psychological intervention compared to the control group.
We further found significant and systematic differences in the psychosocial needs profile and mediating cognitive factors btween the two patient groups of sufferers of bipolar disorder and diabetes mellitus.
Previous studies have shown the effectiveness of psychosocial interventions for people suffering from mental health difficulties, mainly within primary care settings. By targeting bipolar disorder, a disorder group that has traditionally been understood as having a predominantly biological and genetic basis and poor long term outcomes, we were able to show that people suffering form severe and enduring mental health difficulties can equally benefit from well targeted psychological intervention.
We further were able to demonstrate that similar psychosocial factors influence the treatment adherence and well being of sufferers of diabetes mellitus and that a similar intervention might prove highly beneficial for this group.
A cognitive behavioural therapy group for patients with chronic fatigue syndrome: a preliminary investigation
Wittkowski, A. Academic Division of Clinical Psychology, University of Manchester,
Toye, K. Manchester and Salford Pain Centre, Hope Hospital & Richards, H.L.
Department of Behavioural Medicine, Hope Hospital
Introduction:
A number of studies suggest that individual cognitive behavioural therapy (CBT) is beneficial to patients suffering from CFS compared to routine medical management or relaxation. However, in their review,
Price and Couper (2000) concluded that the evidence for the effectiveness of group CBT was unsatisfactory. This study developed out of an identified gap in the literature. It was predicted that participants would experience a reduction in their fatigue and a reduction in depression and anxiety following group CBT intervention.
Method:
Inclusion criteria included: a diagnosis of CFS; no primary psychiatric diagnosis and willingness to attend a group. Six patients were interviewed and agreed to participate. Assessments were completed at pre-, mid- and post-treatment as well as at a 3-month follow-up and included the Fatigue Scale
(Chalder et al, 1993), the Profile of Fatigue-Related Symptoms (PFRS; Ray et al, 1992) and the Hospital
Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983). Verbal and written feedback about the acceptability of the group format was also collected.
Treatment consisted of eight consecutive sessions. The content of each session was based on CBT principles and included individualised graded task assignments, activity scheduling and cognitive strategies, such as guided discovery and cognitive restructuring.
Results:
All six group members were female, with an age range of 25 to 52 years (median = 43 years). Symptom duration varied from 2 to 7 years (median = 3.8 years). Only one participant dropped out following the second session, citing transport difficulties.
The results suggested that group CBT led to reductions in physical and mental fatigue, with improvements largely being maintained at follow-up. Participants' degree of emotional distress appeared relatively stable throughout treatment. Significant reductions in cognitive difficulties on the PFRS were noted, which were supported by improvements in mental fatigue. Anecdotal evidence also suggested improvements in functional abilities. However, given the small sample size, these findings need to be viewed with caution.
Discussion:
The findings largely support the hypothesis that group CBT leads to improvements in physical and mental fatigue. However, given the small sample size, it is imposssible to comment on the statistical significance of these improvements. The hypothesis that group CBT would lead to reductions in anxiety and depression was not supported. Given the initial low levels of emotional distress in this sample and the stability of their mood, further improvements would have been difficult to achieve. Despite these encouraging findings, this study had a number of limitations. Due to an absence of CFS referrals during the study period, no adequate comparision group could be recruited. In addition, functional impairment was not formally assessed. However, participants reported to engage in a wider range of physical activities following group CBT. All five participants rated the group format, timing and content as highly acceptable.
“… but is it a cure?”: Evaluation of CBT group therapy for participants attending a tertiary outpatient CFS service
Amanda O’Donovan, Sarah Lambert and Jenny Petrak, Department of Clinical
Psychology, Infection and Immunity, Barts and the London NHS Trust.
Objectives
Chronic fatigue syndrome has high co-morbidity with depression and psychological distress. CBT has been shown to be an effective treatment for individuals with chronic fatigue syndrome. This study aimed to evaluate a six-week CBT group therapy programme attended by participants from a tertiary CFS service and to describe the psychological model adopted.
Design
The study has a longitudinal design and looks at pre- and post-intervention scores on a range of outcome variables.
Method
Participants were 20 adult outpatients at a tertiary CFS service in a London teaching hospital.
Participants were selected from the Clinical Psychology waiting list and individually assessed for their suitability for group CBT therapy. The programme consisted of six days of group CBT held over consecutive weeks, with four 45-minute sessions each day. Aspects of treatment included introduction to the CBT model, thought monitoring and challenging unhelpful thoughts and beliefs, with a particular focus on fatigue-related cognitions. Behavioural experiments to challenge thoughts related to exercise avoidance were also incorporated and conducted by physiotherapists. Other components included stress management, relaxation exercises, assertion training, communication skills, sleep management, goal setting and review of homework tasks.
A range of questionnaires was administered at assessment, end of group and at six-week, three-month and six-month follow-up including the CFS (Chalder Fatigue Scale) and the HADS (Hospital Anxiety and
Depression Scale).
Results
Preliminary analysis was conducted on 20 participants who had complete data sets at six-month followup. A significant reduction was seen at six-month follow-up on overall fatigue levels (t = 4.13, p =
0.001), physical fatigue (t = 3.64, p < 0.005) and mental fatigue (t = 3.07, p < 0.01). Participants selfrating of ‘making an improvement’ using a visual analogue scale, also increased significantly between pre-treatment and six-month follow-up (t = -3.254, p < 0.01).
There were no significant differences at pre-treatment and six-month follow up on levels of anxiety or levels of depression. Fatigue was not significantly correlated with anxiety or depression either at pretreatment or six-month follow-up.
Conclusions
Participants attending a six-week CBT programme for CFS reported significant reductions in levels of physical and mental fatigue and an increase in their self-rated improvement. Contrary to previous findings (Kroenke et. al., 1988) there was no significant correlation between anxiety and fatigue or depression and fatigue scores in this study. This is consistent with our finding of an improvement in fatigue levels but no improvement in levels of psychological distress and suggests that the CBT group programme may be effective in addressing the primary symptom of fatigue in this population.
Anxiety in patients who have had a myocardial infarction: The maintaining role of perceived physical sensations and causal attributions
Denise Ratcliffe and Andrew MacLeod, Department of Psychology, Royal
Holloway, University of London; Tom Sensky, Lakeside Mental Health Unit, West
Middlesex University Hospital, Middlesex. Denise Ratcliffe is now at Psychological
Medicine Unit, Chelsea & Westminster Hospital.
Anxiety is a common, persistent reaction following a myocardial infarction (MI). There is significant overlap between anxiety and cardiac symptoms, leaving ample scope for catastrophic misinterpretation of benign bodily sensations. This study used the cognitive model of health anxiety (Warwick &
Salkovskis,1990) to understand post-MI anxiety.
Fifty-one patients (22 anxious and 29 non-anxious), who had a MI 3-12 months before testing, participated. The groups were compared on self-report measures of risk perception, body vigilance, and illness perceptions. The type of causal attributions (somatic, normalising and psychological) generated for MI-congruent (cardiac and respiratory) and incongruent (gastrointestinal and cognitive dyscontrol) anxiety-related bodily sensations were compared.
Anxious, compared to non-anxious patients, perceived themselves to be at greater risk of a further MI, had higher levels of cardiac anxiety, bodily vigilance and more negative emotional and cognitive representations of their MI. There were significant group differences in the types of attributions generated for MI-congruent bodily sensations. Anxious individuals generated significantly more somatic attributions and fewer normalising attributions for cardiac sensations and significantly fewer normalising attributions for respiratory sensations. The groups did not differ in the type of attributions generated for gastrointestinal sensations. However, anxious individuals generated significantly more psychological attributions for symptoms of cognitive dyscontrol.
Our results are consistent with the cognitive model of health anxiety and the patterns of causal attributions for bodily sensations are similar to those generated by patients with health anxiety (MacLeod et al., 1998). These findings are relevant to health anxiety that follows other illnesses or conditions.
The impact of psychological and clinical factors on quality of life in individuals with atopic dermatitis
Wittkowski, A. Academic Division of Clinical Psychology, University of Manchester,
Richards, H.L. Department of Behavioural Medicine, Hope Hospital, Griffiths,
C.E.M. Dermatology Centre, University of Manchester & Main, C.J. Department of
Behavioural Medicine, Hope Hospital
Introduction: The psychological impact of skin conditions has been well documented in the literature, with some studies suggesting that patients with atopic dermatitis (AD) experience a greater degree of anger, depression and anxiety than control groups. In recent years, there has been a growing interest in identifying potential cognitive factors mediating the psychosocial impact of skin conditions on quality of life. The aim of the study was to assess the influence of psychological and clinical factors on quality of life in adults with atopic dermatitis (AD). It was hypothesised that quality of life would be predicted by clinical factors, such as disease severity, and psychological factors, such as perceptions of stigmatisation, depression, anxiety, fear of negative evaluation and self-esteem. The influence of psychological factors on AD-related quality of life would remain having controlled for clinical factors.
Method: A total of 125 adults recruited through the National Eczema Society of U.K. (NES) completed a number of psychological and dermatological questionnaires, including the Dermatology Life Quality
Index (DLQI), the Stigmatisation and Eczema Questionnaire (SEQ), the Hospital Anxiety and
Depression Scale (HADS), the Fear of Negative Evaluation Scale (FNE) and the Rosenberg Self-
Esteem Scale (RSE).
Results: Pearson’s correlational analyses suggested that perceptions of stigma were significantly associated with psychological factors as well as quality of life (P’s<0.01). An association was also found between perceived stigma and disease severity (-0.28, P<0.01). Almost 46% of participants were identified as having probable mood disorder. Regression analyses indicated that perceptions of stigma and depression accounted for 44.5% of the variance in quality of life in this sample (F (3,121)=34.18,
P<0.001) , when disease severity was controlled for.
Psychological factors predicted AD-related quality of life, when disease severity was controlled for.
Multiple stepwise regression analysis indicated that perceptions of stigma, disease severity and depression accounted for a significant amount (F (3,123)=55.45, P<0.001) of the variance in quality of life in this sample.
Conclusion: Psychological factors and disease severity were strong predictors of quality of life in adults with AD. AD-related perceptions of stigma were of particular importance in predicting AD-related quality of life over and above more general psychological factors, such as depression. These findings have important implications for the psychological and clinical management of AD. Psychological intervention should focus on reducing perceptions of stigma and associated social avoidance behaviours, when aiming at improving quality of life in adults with AD.
Basic Processes
Keynote Addresses
Why do we worry? Can laboratory studies tell us anything about anxiety?
Graham Davey, University of Sussex
Psychological research on worrying has only been undertaken in earnest over the last 10 years or so, and this is surprising given that chronic, uncontrollable worrying is now the cardinal diagnostic feature of generalized anxiety (GAD). Research on pathological worrying has to address a number of important issues, and these include (1) why worriers persist with bouts when nonworriers do not, (2) why pathological worriers perceive their worrying as uncontrollable, (3) why pathological worriers find the worry process emotionally distressing and uncomfortable, and (4) why a cognitive process that is supposed to address and resolve problematic issues often seems to make them worse rather than better (e.g. catastrophic worrying).
This paper will describe some of the laboratory studies on analogue populations that have enabled us to understand the cognitive processes that contribute to pathological worry. This research will, by necessity, require the description and understanding of cognitive processes occurring at a number of different levels, including basic information processing, the role of beliefs about the worry process, and an understanding of the mechanisms that contribute to perseveration of open-ended cognitive activities.
Symposia
Perseverative Thinking in Emotional Disorders
Convenors and Chairs: Costas Papageorgiou, University of Lancaster and
Christine Purdon, University of Waterloo, Canada
Discussant: Padmal de Silva, Institute of Psychiatry, London
Perseverative thinking is a central information-processing feature of emotional disorders, particularly major depressive disorder (MDD), obsessive-compulsive disorder (OCD), posttraumatic stress disorder
(PTSD), and generalized anxiety disorder (GAD). Research has shown that perseverative thinking is detrimental to both mood state and physiology, and elicits coping strategies that ultimately interfere with normal functioning. Several cognitive models have implicated perseverative thinking in the onset and maintenance of emotional disorders. Further investigation of the hypothesized mechanisms underlying perseverative thinking may contribute to our knowledge of the factors linked to emotional psychopathology, and inform the development of more effective, disorder-specific, cognitive-behavioural interventions (e.g., Papageorgiou & Purdon, 2001). This symposium offers a series of empirically based papers which examine the role and consequences of particular forms of perseverative thinking, such as rumination and worry, within the context of specific cognitive models of MDD, OCD, PTSD, and GAD. As a body, the papers offer new, exciting directions for research and treatment.
Understanding the persistence of worry in GAD
Graham Davey, University of Sussex
According to the most recent diagnostic categorization, the cardinal diagnostic feature of GAD is
“excessive anxiety and worry (apprehensive expectation)….which the individual finds difficult to control”
(DSM-IV-TR, APA, 2000, p476). One particular form in which uncontrollable worrying occurs in individuals suffering GAD is through processes of catastrophising. Catastrophising occurs when the individual persistently iterates the problematic features of their worry topic. However, rather than bringing the worry problem to satisfactory closure, catastrophising usually leads to the worrier perceiving
progressively worse outcomes to the worry topic and is often characterized as the worrier perseveratively posing internal, automatic questions of the “what if…?”. Recent studies have consistently found that worriers generate significantly more catastrophising steps than nonworriers, report a significant increase in subjective discomfort as catastrophising unfolds, and rate events in the catastrophising sequence as significantly more likely to occur than nonworriers. This paper will describe some of the laboratory studies that have contributed to our understanding of catastrophising, and will outline a cognitive model of perseverative worrying.
Rumination in Posttraumatic stress disorder
Thomas Ehring and Anke Ehlers, Department of Psychology, Institute of
Psychiatry, London, and Tanja Michael, Department of Psychology, University of
Basle, Switzerland
Theorists of posttraumatic stress disorder (PTSD) have recently highlighted rumination as a maintaining factor in PTSD (Ehlers & Clark, 2000; Joseph, Williams & Yule, 1997). The presentation will give an overview over a series of studies from our research group investigating rumination following a range of traumatic events.
Questionnaire reports of rumination correlated with PTSD severity both in cross-sectional and in prospective longitudinal studies (e.g., Clohessy & Ehlers, 1999; Murray et al., 2002). Compared to a range of other known predictors of PTSD, rumination explained a unique part of the variance of PTSD severity (e.g., Ehlers et al., 1998).
A cross-sectional and a prospective longitudinal study of assault survivors identified characteristics of rumination that distinguish between survivors with and without PTSD, and predict PTSD severity: feeling driven to continue dwelling on the trauma, having unproductive ruminative thoughts, feeling overwhelmed while dwelling, feeling worried after dwelling, and rumination stopping intrusive memories.
These variables explained 50% of the variance of subsequent PTSD severity (Michael, 2000).
A further study (Ehring & Ehlers, in prep.) investigated whether different aspects of rumination predict
PTSD and depression following trauma. Survivors of road traffic accidents filled in a rumination measure developed in previous PTSD research (Murray et al., 2002) and the widely used Ruminative Responses
Scale of the Response Styles Questionnaire (Nolen-Hoeksema & Morrow, 1991). Preliminary results indicate specificity in that the PTSD-related rumination measure was more closely correlated with PTSD severity than with depression, whereas the opposite was the case for the Response Styles
Questionnaire.
Theoretical and possible clinical implications of these results will be discussed.
Clohessy, S. & Ehlers, A. (1999). PTSD symptoms, response to intrusive memories, and coping in ambulance service workers. British Journal of Clinical Psychology, 38, 251-265.
Ehlers, A., & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour
Research and Therapy, 38, 319-345.
Ehlers, A., Mayou, R.A., & Bryant, B. (1998). Psychological predictors of chronic PTSD after motor vehicle accidents. Journal of Abnormal Psychology, 107, 508-519.
Joseph, S., Williams, R., & Yule, W. (1997). Understanding post-traumatic stress. A psychosocial perspective on PTSD and treatment. Chichester, UK: Wiley.
Michael, T. (2000). The nature of trauma memory and intrusive cognitions in posttraumatic stress disorder. D.Phil. thesis, University of Oxford, UK.
Murray, J., Ehlers, A. & Mayou, R.A. (2002). Dissociation and posttraumatic stress disorder: Two prospective studies of road traffic accident victims. British Journal of Psychiatry, 180, 363-368.
Nolen-Hoeksema, S. & Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social
Psychology, 61, 115-121.
Factors involved in the persistence of obsessions
Karen Rowa and Christine Purdon University of Waterloo, Canada, Laura J.
Summerfeldt Trent University, Canada and Martin M. Antony, McMaster University,
Canada
Cognitive theories of obsessions suggest that obsessions develop from commonly occurring intrusive thoughts that are appraised as important or meaningful (e.g.
, “This thought must mean I’m a terrible person” or “I will be responsible if anything bad happens”). Negative appraisals of the meaning of obsessional thoughts are also implicated in the persistence of obsessions, with obsessions thought to remit only when they are no longer the focus of negative appraisals. Another factor that may be important in the persistence of obsessions is the degree to which obsessions become linked with situational factors (e.g., where an obsession occurs or with whom it occurs) and what impact these factors have on the distress associated with the thought and appraisals of the thought. The purpose of the current study was to examine these factors in a group of individuals with obsessive-compulsive
disorder (OCD). Twenty-nine individuals with a primary diagnosis of OCD were asked to identify (1) the most upsetting and (2) the least upsetting current obsession they were having at the time of the study.
Over two sessions, each participant completed questionnaires assessing appraisals of both the most and least upsetting obsession identified, with the focus on most versus least upsetting obsession counterbalanced across participants. In between these sessions, all participants were asked to complete diaries on the situations in which their most upsetting obsession occurred. Participants were asked to complete 3 diaries a day for 7 days. Diary questions included the distress associated with the obsession at that moment, how often an obsession like their target occurred in a situation like the one reported on, the relevance of the situation to the content of the obsession, how much they felt the obsession could come true in that situation, the presence of others, etc. Results indicated that both types of obsessions were appraised negatively, with most upsetting obsessions appraised significantly more negatively than least upsetting obsessions. Participants completed a mean of 17 diaries over 7 days, and responses were averaged across completed diaries for each person. Participants indicated that their particular obsession often occurred in particular situations, supporting the idea that obsessions become linked with specific situations. Further, as the relevance of the situation increased in people’s eyes, so did its perceived ability to bring on the obsession and have the obsession actually come true. Similarly, the more participants rated the situation as triggering their obsessions, the more likely they felt the obsession could come true. In sum, results suggest that both appraisals and situational factors may help explain the persistence of intrusive thoughts. Implications will be discussed.
Metacognitive vulnerability and the persistence of rumination in depression
Costas Papageorgiou and Joanne Johnson, Institute for Health Research,
University of Lancaster
Perseverative negative thinking, in the form of rumination, is a key cognitive feature of dysphoria and
DSM-IV major depressive disorder. Several models have been advanced to account for the role of rumination in depression (Martin & Tesser, 1989; Nolen-Hoeskema, 1991; Teasdale & Barnard, 1993;
Wells & Matthews, 1994). Based on Wells and Matthews’ (1994) information processing framework,
Papageorgiou and Wells (2003) proposed a clinical metacognitive model of rumination and depression.
According to this model, positive metacognitive beliefs about the benefits and advantages of rumination are likely to motivate individuals to engage in sustained rumination. Once rumination is activated, individuals appraise this process as uncontrollable and harmful, and likely to lead to detrimental interpersonal and social consequences. The activation of negative metacognitive beliefs about rumination then contributes to the experience of depression. To date, several cross-sectional and prospective studies have supported the relationships between rumination, depression, and metacognitive beliefs. However, no studies have thus far investigated whether metacognitive beliefs about rumination are symptomatic of depression, and as such would abate when depression resolves, or persist as a vulnerability factor. This study set out to address this question. In order to do so, 15 currently depressed, 15 previously depressed, and 15 never depressed individuals were recruited in the study. All participants were screened using DSM-IV criteria. Following screening, participants completed relevant measures of positive and negative metacognitive beliefs about rumination and depressive symptomatology. The results of the comparison of measures across groups will be presented along with potential implications of these data for cognitive therapy of depression.
The nature and causes of worrying
Convenor and Chair: Graham Davey, University of Sussex
Discussant: Professor James Pennebaker University of Texas at Austin,
USA
An investigation of the mechanisms by which worry maintains chronic insomnia.
Allison G. Harvey, Julia Nelson, & Emmeline Greenall, University of Oxford
One of the most replicated findings in the insomnia literature is that people with chronic insomnia complain that they cannot get to sleep because of unpleasant intrusive thoughts and excessive and uncontrollable worry during the pre-sleep period. This paper will describe the results of three studies that aimed to delineate the mechanisms that maintain pre-sleep worry. The aim of Study 1 was to provide an empirical test of the proposal that catastrophic worry about the consequences of not sleeping is common among patients with primary insomnia and serves to maintain the sleep disturbance. A
'catastrophising interview was administered to 30 patients with primary insomnia and 30 good sleepers.
The insomnia patients generated more catastrophes about the consequences of not sleeping relative to good sleepers. For the insomnia group but not the good sleepers, catastrophising was associated with increased anxiety and discomfort. Study 2 investigated the role of beliefs about the utility of pre-sleep
worry. The Utility of Pre-sleep Worry Questionnaire (UPWQ) was administered to individuals with insomnia (N = 31) and good sleepers (N = 31). Patients with insomnia endorsed more positive belief statements compared to the good sleepers. Study 3 aimed to test the applicability of Borkovec, Ray and
Stober's (1998) theory of the maintenance of GAD to insomnia. Specifically, we indexed 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. They were then instructed to think about the speech and its implications in either images or verbal thought. 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. In summary, the results of these three studies highlight the potential importance of catastrophising, beliefs about worry, and imagery in the persistence of worry in chronic insomnia.
Comparisons between rumination and worry in a non-clinical population
Ed Watkins and Michelle Moulds Department of Psychology, Institute of Psychiatry,
London
Major depression is characterised by ruminative thinking whilst worry is considered central in
Generalised Anxiety Disorder (GAD). However, not only do these two forms of repetitive negative thinking regularly co-occur in the same individual but similarities between worry and rumination are apparent. Adapting a methodology developed by Langlois et al, 2000, this study directly compared worry and rumination in a non-clinical population across a series of variables drawn from current models
(appraisal, general descriptors and emotional reactions). Each of 234 volunteers, with a wide range of age and backgrounds, identified a ruminative thought and a worry and subsequently evaluated them using the Cognitive Intrusion Questionnaire. Significant within-subject differences were revealed on 10 variables: chronicity, unpleasantness and consequences of thought, reality of problem, future orientation, past orientation, interference with ability to work, need to prevent the situation, feelings of worry and feelings of insecurity. When using discriminant analysis, there was a low classification error rate when using 5 variables to categorize thoughts as worries or rumination, with chronicity of thought the main predictor. There were almost no differences found between worry and rumination on appraisals and strategies, consistent with accounts that propose that worry and rumination share the same processes but involve different content.
The use of ‘as many as can’ stop rules during worrying
Graham Davey, Helen M. Startup, C Benie. MacDonald, Deborah Jenkins & Kate
Patterson, University of Sussex
This paper will report the results of two studies that investigated the nature of the stop rules that worriers use in the context of their worrying. Study 1 found that the use of ‘as many as can’ stop rules was significantly related to measures of trait worry and beliefs about the positive and negative consequences of worrying, and Study 2 demonstrated that the reported use of ‘as many as can’ stop rules significantly predicted perseveration on behavioural measures of catastrophic worrying. Reported use of ‘feel like continuing’ stop rules was unrelated to any measures of worry in both studies. These results indicate that the use of ‘as many as can’ stop rules is a highly significant predictor of worry frequency and perseveration, and that beliefs about the positive and negative consequences of worry also independently predict the use of ‘as many as can’ stop rules. These findings are consistent with (1) the view that the stop rules used by worriers are closely associated with, or directly derived from, the more stable, global beliefs that worriers hold about the utility of the worry process, and (2) predictions from the mood-as-input model of catastrophic worrying (Startup & Davey, 2001). The processes by which worriers assess whether stop rule goals have been achieved or not, and the effect of these processes on worry perseveration, will be discussed.
Responsibility, Negative Mood and Catastrophic Worrying.
Helen Startup, Institute of Psychiatry, London
One particular form in which uncontrollable worrying occurs is through processes of catastrophising.
Catastrophising is the tendency of individuals to apply a “what if…?” questioning style to potential problematic features of their life. Rather than bringing their problem to a satisfactory close, however, this process usually leads the worriers to perceive progressively worse and worse outcomes to the worry topic. When asked to catastrophise a worry or iterate what is ‘good’ about a topic, pathological worriers iterate more steps than non-worriers. This paper describes a study which shows that this perseverative iterative style that worriers possess is linked to feelings of responsibility and negative mood. When involved in a task under conditions of high responsibility and an induced negative mood, individuals appear to use their negative emotional state as an indicator that the problem is not resolved
and so persevere further with such tasks. Issues of responsibility may thus mediate the relationship between negative mood and the perseverative iterative style typical of catastrophic worriers.
Overgeneralisation in depression and related disorders
Convenor Stephen Barton, University of Leeds and Edward Watkins,
Institute of Psychiatry, London
Chair: Stephen Morley, University of Leeds
Discussant: Mark Williams, University of Oxford
Autobiographical memory and the self-concept in adolescents at risk for depression
Willem Kuyken and Rachael Howell, University of Exeter
It is now a well-established phenomenon that people diagnosed with depression have difficulties retrieving specific autobiographical memories. Moreover, there is some evidence that that this retrieval style may be a trait marker for people at risk for depression. An early study suggested that a history of severe trauma (specifically childhood sexual abuse) was associated with overgeneral memory in adults diagnosed with depression (Kuyken & Brewin, 1995).
The transition to adulthood from mid-adolescence is considered to be a period of high risk for the onset of major depression (Reinhertz, Giaconia, Carmola Hauf, Wasserman & Silverman, 1999). A recent study suggests that adolescents diagnosed with depression report similarly overgeneral memory problems (Park, Goodyer, & Teasdale, 2002). Theoretical accounts of this phenomenon speculate that children who grow up in a chronically stressful environment may learn to avoid the recollection of specific memories, as their content is so negative (Williams, 1996).
This study looked at a sample of 30 adolescents at risk for depression to examine which risk factors predicted overgeneral autobiographical memory retrieval. We further hypothesised that over-generality would be associated with other problematic aspects of adolescent psychological development
(specifically a highly compartmentalised self-concept) that might confer risk for depression. Results of this work will be presented.
Effects of cognitive therapy on the specificity of autobiographical memories
Tim Lister, Calderdale NHS Trust, Stephen Morley, University of Leeds & Stephen
Barton, University of Leeds
People who are depressed find it difficult to retrieve specific autobiographical memories (Williams, 1996) and this is a good predictor of subsequent depression and poor problem solving (Brittlebank, Scott,
Willliams & Ferrier, 1993). After recovery, more specific memories can be accessed, but less than in people who have never been depressed. These findings suggest a scarring effect of a depressive episode, or perhaps a pre-existing cognitive vulnerability. This study investigated whether cognitive therapy for depression increases the specificity of personal memories compared with a pharmacological treatment. We hypothesised that memory variability in recovered depression would partly be a function of prior treatment, and that people recovered following cognitive therapy would be able to access more specific memories than those who had only received anti-depressant treatment.
Fifty-one people with a history of major depression were tested on the Autobiographical Memory Test
(Williams and Broadbent, 1986). Seventeen had recovered from depression with anti-depressants as the sole treatment (R-AD; mean BDI = 8.3), and 17 had recovered with cognitive therapy as the primary treatment (R-CT; mean BDI = 9.0). A further 17 participants met criterion for current Major Depression
(MD; mean BDI = 25). The three groups were compared on the specificity of their memories and also latency of retrieval. The R-CT group retrieved significantly more specific memories than the other groups, and there were no differences between the R-AD and MD groups. Contrary to prediction, the retrieval latency for specific memories in the R-CT group was slower than the other groups when memories were elicited by negative cues. This suggests cognitive therapy helps people to access specific memories, but via time-consuming conscious processes. Also contrary to expectations, the R-
CT group had greater levels of negative and dysfunctional thinking than the R-AD group, suggesting treatment effects on memory processes may be independent of cognitive change at the thought and belief levels. Overall, these results support a specific beneficial effect of cognitive therapy on autobiographical memory that is not observed following anti-depressant treatment. The results are consistent with the compensatory skill model of cognitive therapy.
Rumination and Overgeneral Thinking in Depression
Ed Watkins, Institute of Psychiatry, London
Rumination is recurrent thinking about self, mood, and negative events, with particular emphasis on the causes, consequences and meanings of these themes. Rumination is an important construct in depression because in prospective studies, rumination predicts the onset and maintenance of depression (Nolen-Hoeksema, 2000), whilst in experimental studies, compared to distraction,
(Lyubomirsky & Nolen-Hoeksema, 1995) rumination increases negative thinking and negative mood.
Another important construct in depression is overgeneral thinking, whether in the form of overgeneral memory recall or the cognitive distortion of overgeneralisation, the tendency to make global, characterological judgements in response to a failure or sad mood. Overgeneral memory resembles overgeneralisation in content. Furthermore, both forms of overgeneral thinking distinguish depression from anxiety, are found in recovered depressed patients and predict future depression (Carver &
Ganellen, 1983; Carver, 1988; Dent & Teasdale, 1988; Brittlebank et al., 1993; Mackinger et al., 2001).
Recent studies have demonstrated that compared to distraction, rumination can maintain overgeneral memory (Watkins, Teasdale & Williams, 2000). Furthermore, follow-up studies have suggested that an abstract-conceptual style of processing is the component of depressive rumination crucial to overgeneral memory (Watkins & Teasdale, 2001). Reducing abstract thinking reduced overgeneral memory in depressed patients.
The causal role played by the abstract-conceptual style of depressive rumination on overgeneral memory suggests the hypothesis that rumination might also be responsible for other forms of overgeneral thinking in depression, such as global negative self-devaluations (Teasdale & Cox, 2002) and overgeneralisations. This presentation will describe several studies that manipulated thinking style to test the hypothesis that an abstract style of thinking about self and mood is responsible for overgeneral thinking in depression. Findings will be presented, which although mixed, are broadly consistent with the hypothesis that abstract ruminative self-focus contributes to various forms of overgeneral thinking in depression.
Overgeneralisation in depression: some clinical and theoretical speculations
Stephen Barton, University of Leeds
There is a range of evidence in the memory, inference and reasoning literatures suggesting overgeneralisation is an important clinical feature of depression. There is also a range of techniques in cognitive therapy that counteract this thinking style. Notably, few if any attempts have been made to specify a cognitive model that bridges theory and practice in this area. This paper briefly reviews some of the main evidence, and outlines areas in which evidence is still absent. It speculates on the type of cognitive model that might account for overgeneralisation, relating it to strategic stasis, the notion that rather than suffering from motivational deficits, depressed people are disinvesting in their self and future to avoid further losses and disappointment. Stasis and disinvestment effectively close down self representations, rather than opening up new possibilities, and the closed self can become negative, global and undifferentiated. Arguably, it is undifferentiated cognitive processing that maintains negative overgeneralisation and depressed mood, and the paper ends with some speculations about how current cognitive and behavioural interventions counteract these processes, and how they may be further developed.
The processing and regulation of emotion across different clinical conditions
Convenor and chair: Tim Dalgleish, MRC Cognition and Brain Sciences
Unit, Cambridge
Discussant: Christine Purdon, Dept. of Psychology, University of Waterloo,
Canada.
Emotion regulation and psychopathology
Tim Dalgleish, MRC Cognition and Brain Sciences Unit, Cambridge
A brief overview of what we mean by emotion regulation, why it is potentially important in understanding psychopathology, and how it relates to current forms of psychotherapy.
Training of emotion regulation: Inducing Biases in the Interpretation of
Ambiguity
Jenny Yiend, and Andrew Mathews, MRC Cognition and Brain Sciences Unit,
Cambridge
Previous research has established that emotionally ambiguous information is often processed in a biased manner. Healthy individuals favour a positive alternative whereas, people prone to negative
emotional states tend to assume the more negative interpretation. A key unanswered question is whether biases in interpretation may cause vulnerability to negative emotional states.
To answer this, we have examined whether processing biases can be experimentally modified, and if so, with what emotional consequences. Specifically, we modified the processing of unselected individuals by controlling the interpretation placed upon ambiguous material. We repeatedly presented short scripts of ambiguous social situations, forcing participants into either a negative or positive interpretation using a disambiguating word completion. This manipulation influenced the interpretation of subsequently presented new descriptions in which the ambiguity was maintained. Changes in anxious mood in a direction consistent with the induced bias were also observed, consistent with the notion that negative cognitive biases render individuals vulnerable to mood disorders.
Subsequently we investigated the durability of these training effects over time spans of up to one day and found them to be robust. These data extend previous work on interpretative training (Mathews &
MacLeod, 2002) by demonstrating the persistence of the induced biases. The findings encourage us to believe that, firstly, induced biases may serve as a useful analogue to those observed clinically.
Secondly, they allow us to assess the direction of causality between anxiety disorder and cognitive bias.
Thirdly, the data raise the question of whether similar training techniques might be usefully developed as a treatment tool of the future.
Paradoxical effects of attempted emotion regulation on experienced emotion and autobiographical recall in depressed individuals
Tim Dalgleish & Jenny Yiend, MRC Cognition and Brain Sciences Unit, Cambridge.
Depressed states are characterised by persistent attempts to regulate negative emotions such as sadness, anxiety and anger as well as intrusive distressing thoughts and memories. In the first two studies reported here we asked depressed and healthy individuals to try to down-regulate their emotions to distressing film clips and to negative autobiographical scripts. The results revealed interesting differences in the effectiveness of down-regulation in the depressed group as a function of the autobiographical nature of the material, with attempted down-regulation of emotion to negative autobiographical information leading to a paradoxical increase in negative affect. In a third study we examined the downstream cognitive consequences of suppressing negative autobiographical memories in depressed and healthy participants. The results indicated that whilst both groups were relatively good at memor y suppression, there was a cognitive ‘cost’ of such suppression in the depressed individuals in the form of speeded access to other negative autobiographical material on a subsequent recall task.
These results are discussed in terms of current cognitive models of depression.
Dysregulation in the Processing Of Discrete Basic Emotions in Dysphoria and
Clinical Depression: Self-Report and Psychophysiology
Barnaby D Dunn, University College London, Andrew D Lawrence, Rhodri Cusack,
Alan Ogilvie, & Tim Dalgleish, MRC Cognition and Brain Sciences Unit, Cambridge
It is currently a matter of debate whether emotional experience in depression is characterised by attenuated positive emotions, elevated negative emotions, or a combination of these factors. Self-report and psychophysiological emotional responses to happy, fearful, sad and neutral images were examined in dysphoria and clinical depression to clarify emotional processing in the disorder. Study 1 compared
20 people with a BDI > 15 and 20 people with a BDI < 10. Study 2 compared 25 people diagnosed with
Major Depression and 25 non-depressed participants. The results revealed reliable differences in the processing of specific emotions in dysphoric and depressed individuals relative to controls that suggest that the main problem in depressed states is lack of responsiveness to positive material rather than excessive responsiveness to negative material. The data are discussed in terms of current theories of emotion processing in depression.
Emotion regulation in traumatised individuals with and without Post-Traumatic
Stress Disorder (PTSD)
Pieter Du Toit & Tim Dalgleish, MRC Cognition and Brain Sciences Unit,
Cambridge
PTSD is characterised both by difficulties in regulating emotions about the trauma and also by difficulties with affect regulation more generally (e.g. hyperarousal, emotional numbing). Data are presented from a series of studies in PTSD patients, traumatised individuals without PTSD, and never-traumatised controls. The studies looked at: 1) psychometric data on emotion regulation problems; 2) the effects of attempted emotion regulation to non-trauma-specific emotive material in an experimental context using self-report measures along with psychophysiology; and 3) the effects of attempted emotion regulation to autobiographical trauma scripts in an experimental context, again using self-report and
psychophysiology. The three studies revealed interesting differences in the emotion regulation profiles across the different participant groups and the data are discussed in terms of current theories of PTSD.
Intrusive imagery in psychopathology: Application of findings to treatment
Convenor and Chair: Ann Hackmann, University of Oxford
What I imagine does not reflect reality: re-scripting intrusive memories in social phobia
Jennifer Wild, Institute of Psychiatry, London
Most individuals with Social Phobia have intrusive images of early memories that are triggered in social situations. Like intrusive memories in Posttraumatic Stress Disorder (PTSD), they are recurrent in nature, distressing, and fail to be updated in light of new information. In Social Phobia, the recurrent images represent the distorted public image of the sufferer; they are linked to early unpleasant social experiences and usually involve the visual modality (Hackmann, Clark & McManus, 2000). However, they can also include other sensory modalities without a visual component, so that the sufferer experiences a ‘felt sense’ or impression of the earlier social experience. Despite the absence of negative feedback in social situations, the recurrent images fail to be updated. They adversely affect information processing and beliefs about the social self, influencing in-situation anxiety and behaviour.
This presentation will discuss the role of imagery in the maintenance of Social Phobia. A review of the current experimental literature in the field will be presented, in addition to therapeutic techniques for rescripting the images. These techniques draw on cognitive-behavioural therapy for PTSD and schemafocused therapy for personality disorders and will be illustrated with case examples.
Imagery and early traumatic memories in obsessive compulsive disorder
Anne Speckens, Anke Ehlers, Institute of Psychiatry, London and Ann Hackmann,
University Department of Psychiatry, Warneford Hospital, Oxford
This is an exploratory study of imagery and earlier traumatic memories in a consecutive series of patients with obsessive compulsive disorder (OCD) who were admitted to the Inpatient Cognitive
Behavioural Therapy Unit of the Bethlem Royal Hospital. Of the 34 (79%) patients who participated in the study, 24 (71%) reported having visual images when their OCD was really bad. In 8 (33%) of these patients, the visual images consisted of actual memories of aspects of a traumatic experience. When asked about their earliest recollection of having had similar sensations and feelings, all but one of the remaining patients could identify a particular traumatic experience that was linked to the visual image.
The perceived similarity between the visual image and the memory of the traumatic experience was very high, both in terms of sensory characteristics and in terms of interpersonal meanings. The study suggest that images are very common in patients with OCD and that in a substantial part of the patients they seem to be linked with memories of earlier traumatic experiences. Clinical examples of patients whose obsessive images were linked with traumatic events will be given and the application of these findings in clinical practice will be discussed.
Intrusive Images in Agoraphobia
Samantha Day, The Traumatic Stress Clinic, Camden & Islington Mental Health &
Social Care Trust, Emily Holmes, MRC Cognition and Brain Sciences Unit,
Cambridge and Ann Hackmann, Department of Psychiatry, University of Oxford
Intrusive images are noted common in anxiety disorders, and have been shown to be useful in uncovering key themes, and memories that occurred around the age of onset. This is the first study to investigate intrusions in agoraphobia and consider their thematic content and relation to past memories.
Twenty adults with agoraphobia and twenty matched controls were interviewed. They were asked to describe intrusive images experienced in agoraphobic situations, and any associated memories.
Strikingly, all agoraphobic but no control participants reported intrusive images. Agoraphobic images were viewed from a fluctuating field/observer perspective. Most participants linked an aversive memory to the image, but only 3/20 reported having thought about the content of the memory prior to the interview. 75% believed the image impacted on their anxiety in agoraphobic situations. The mean age at the time of the associated memory was 14. 3 years.
Themes present in the images and memories were qualitatively analysed. Links between the meanings the participant gave to the content of the images and the associated memories were compared. Themes of catastrophic danger and a negative view of self were prominent, such as the self intimidated, humiliated and misunderstood. The study raises questions about links between intrusive images, autobiographical memory and the sense of self in anxiety disorders.
Intrusive images and nightmares in PTSD: a case study.
Ann Hackmann, University Department of Psychiatry, Oxford.
Recent research suggests that intrusive images in posttraumatic stress disorder (PTSD) are sensory fragments of memory, carrying important meanings, and acting as ‘warning signals’ of current danger.
These meanings were often those given to events at the time of the trauma that have not subsequently been up-dated, even if they were grossly distorted. Nightmares are sometimes replicative, and also often echo the content of daytime intrusions. Several authors have suggested that to complete
‘emotional processing’ methods of inserting corrective information into the memory structure must be found, so that there is an emotional shift as well as intellectual change.
This case study will be used to illustrate methods used to achieve this aim using imagery techniques. A remarkable mirroring of changes in intrusive images and nightmares will be demonstrated. In addition the phenomenology will be closely examined, and obsessive-compulsive features will be highlighted and traced back to their origins in the memory structure.
Imagery for complex PTSD in child abuse
Sally Standart, Newcastle Cognitive and Behavioural Therapies Centre.
Imagery in complex PTSD reactions to child sex abuse gives a very rich and holistic representation of cognitions and core beliefs. Imagery distortions in the flashback content of the trauma can give a vehicle for transformations that occur in the “heart not in the head”. Imagery distortions that occur in the PTSD of child sex abuse appear to be highly idiosyncratic in content, but also appear to follow certain rules.
The author would like to describe two cases involving the imagery distortions of size and the transformations of the images. This caused change at the meaning level, PTSD measures and patient outcome.
Cognitive mechanisms in perseverative Psychopathology
Convenors: Graham Davey and Benie MacDonald, University of Sussex
Chair and Discussant: Graham Davey, University of Sussex
A number of prominent psychopathologies are characterized by the dysfunctional perseveration of certain thoughts, behaviours or activities. Examples include pathological worrying, which is the current cardinal diagnostic feature of Generalized Anxiety Disorder (GAD) (DSM, 4 th ed.; DSM-IV; American
Psychiatric Association, 1994); obsessive compulsive disorder (OCD) in which individuals indulge in perseverative bouts of activities such as checking, washing or obsessive thoughts; and rumination, which has been recognized as an important maintaining factor in depression. In almost all examples of these psychopathologies the perseveration is viewed as excessive, out of proportion to the functional purpose that it serves, and a source of emotional discomfort for the individual concerned.
Cognitive explanations of these perseverative psychopathologies have tended to be focused within individual disorders rather than addressing the possible common factors that might facilitate perseveration per se . Even though there is some evidence for co-morbidity across at least some of these perseverative disorders, suggesting the possibility of some common mechanisms operating across them, there have been few attempts to identify what these common mechanisms might be. This symposium consists of papers which discuss some of the mechanisms which may contribute to perseverative psychopathologies, and in particular, the symposium represents an attempt to define some of the mechanisms that may generate perseveration across a variety of different psychopathologies.
Mood-as-input and Catastrophic Worry
Helen Startup, Institute of Psychiatry, London
One particular form in which uncontrollable worrying occurs in individuals suffering GAD is through processes of catastrophising. Catastrophising occurs when the individual persistently iterates the problematic features of their worry topic. However, rather than bringing the worry problem to satisfactory closure, catastrophising usually leads to the worrier perceiving progressively worse outcomes to the worry topic and is often characterized as the worrier perseveratively posing internal, automatic questions of the “what if…?” kind. This paper describes three experiments investigating a
‘mood-as-input’ approach to understanding catastrophic worrying. Experiment 1 found that the number of items that worriers emitted in an iterative item generation task was dependent on the stop rules specified by the procedure; and Experiment 2 found that manipulating the stop rules for catastrophising had differential effects on worriers and nonworriers depending on the nature of the stop rules specified.
These results suggest that mood provides information about continuing or terminating the catastrophising process that is interpreted in the context of the stop rules for the task. It is argued that the mood-as-input hypothesis accounts for the facts of exacerbated catastrophising in worriers better
than explanations couched either in terms of mood-congruency effects or in terms of worriers possessing a generalized perseverative iterative style.
Rumination and mood-as-input
Ed Watkins, Institute of Psychiatry, London
Rumination has been recognized as an important maintaining factor in depression. Adapting the moodas-input theory to rumination, it was hypothesized that high ruminators have a default "as many as can" stop rule for determining when to stop analysing the causes and consequences of any problem, such that negative mood signals insufficient problem solving, leading to recurrent analysis and self-focus (i.e. rumination). To explore this hypothesis, sixty participants were randomly instructed to continue generating reasons for a recent depressed mood under three conditions: an "as many as you can" stoprule, an "as long as you feel like continuing" stop-rule, and a "no stop-rule" condition. Participants were split into high and low ruminators on a median split on Ruminative Response Scale scores. As predicted, the high ruminators in the "as many as you can" and "no stop rule" conditions produced significantly more reasons for their depressed mood (without significantly differing from each other), than either the high ruminators in the "feel like continuing" condition or the low ruminators in all conditions.
These results suggest that high ruminators adopt a default "as many as can" stop rule and that teaching high ruminators to use a "feel like continuing" rule may reduce rumination.
Mood-as-Input and obsessive checking
C Benie MacDonald & Graham Davey, University of Sussex
A common feature of many psychopathologies is perseveration (e.g. worrying, obsessive activities such as checking). These studies were designed to evaluate a model of task persistence, the mood-as-input hypothesis, which proposes that an individual uses mood as information about whether to continue a task in the context of the stop-rules for that task. Stop rules are the implicit questions individuals ask themselves: ‘Have I reached my goal’ (as many as can AMA) or ‘Do I feel like I want to continue with this task’ (feel like continuing’ FL). The aim was to assess mood-as-input predictions when applied to an analogue checking tasks that closely resembles that found in some forms of Obsessive Compulsive
Disorder. Using a between -subjects design, an experimental checking task required participants to proof read text. Both studies manipulated mood to produce positive or negative mood states and participants were required to execute the task under explicitly different stop rules. In study 1 results suggested that participants in negative mood given the AMA stop rule showed significantly greater task perseveration and mood improvement post checking than participants under other conditions (consistent with mood –as input predictions) In Study 2 a second mood induction (administered after checking had been completed) produced significant reduction of confidence for individuals in negative mood, suggesting that mood also influen ces an individual’s judgment of confidence in task completion. Study 3
(in progress) has used naturally occurring negative mood and will be presented at the conference.
These results are consistent with a mood-as-input model of perseveration and may help to identify the factors influencing obsessive checking.
Perseverative Thinking, Enough Rules, and Openness to Influence
Leonard L. Martin, University of Georgia, USA
Perseverative thinking occurs, in large part, because individuals feel frustrated in their goal pursuit
(Martin & Tesser, 1996). Specifically, goal frustration induces individuals to search for alternate ways to attain their goals. This is not surprising given that the individuals’ current strategies are not working (i.e., the individuals are not attaining their goals). Although the open, alternative mindset engendered by goal frustration may provide individuals with new ways to attain their goals, it may also make individuals more open to new ideas generally, even if these ideas are not particularly good. This hypothesis becomes even more plausible if we consider that perseverative thinking is especially likely among individuals who adopt an enough stop rule. With an enough rule, individuals look outside of themselves for evidence they have finished their task (e.g., Is my plate empty?), rather than inside of themselves toward their own feelings and knowledge (e.g., Am I full?). One implication of this difference in focus is that individuals following an enough rule may become especially susceptible to persuasion even when acceptance of the persuasive argument does not help them attain their goals. To test this hypothesis, we had participants adopt either an enjoy rule or an enough rule while performing a series of tasks. In one task, participants had to write a plausible scenario for a possible future event (e.g., How they could become a millionaire or go bankrupt). The writing of a plausible scenario can increase one’s belief that the scenario will in fact occur (the belief perseverance effect). We predicted, however, that this increase would be observed only among participants who wrote the scenario under an enough rule. The results were as predicted. The results suggest that individuals performing in accordance with an enough rule attend to external cues, rather than to their own feelings and knowledge. Being out of touch with their feelings and knowledge, they are unable to use this information to moderate their beliefs in the counterfactuals they have just generated. Consequently, they become more and more convinced that
the scenarios running through their heads reflect future reality (e.g., I will become a millionaire). As a result, they may pursue goals related to these scenarios, even if the goals are unrealistic. Then, they may not attain the goals, and they may experience greater perseverative thought as a result of the goal frustration. In this way, the adoption of enough rules and the attendant external focus of attention may contribute to the perseverative cycle.
The Role of Disgust in Obsessive Compulsive Washing
Sarah L. Marzillier & Graham Davey, University of Sussex
Obsessive washing is characterized by fears about dirt and contamination, and this has lead some theorists to propose that it may be a disgust- rather than an anxiety-based disorder (e.g. Power and
Dalgleish, 1997). Evidence for this conceptualization is relatively scarce thus far, and mainly centres on correlational studies, where a measure of disgust sensitivity is shown to be related to a measure of obsessive washing (Mancini, Gragnani and D’Olimpio, 2001; Muris, Merckelbach, Nedekoorn, Rassin,
Candel and Horselenberg, 2000; Ware, Jain, Burgess and Davey, 1994). However there are a number of problems with this methodology, for example it cannot clarify how disgust might be involved in obsessive washing. No previous research has investigated the causal effects of disgust mood on elements of obsessive washing.
Therefore, a series of five studies were conducted that investigated the effects of disgust mood on selfreported anxiety. Linguistic stimuli were selected to represent two disgust-relevant anxiety disorders
(obsessive washing and spider phobia), two disgust-irrelevant anxiety disorders (obsessive checking and claustrophobia) and controls. In each study, a non-clinical population rated anxiety to disgustrelevant, disgust irrelevant and control stimuli before and after a disgust or neutral mood induction. In the first study, an anxiety induction was also included to rule out possible effects of anxiety. Over all of the five studies, induced disgust mood significantly elevated self-reported anxiety to disgust-relevant stimuli, but not disgust-irrelevant stimuli. When all five studies were analysed together, it was found that disgust mood significantly inflated anxiety ratings to obsessive washing stimuli.
These five studies have all shown the same robust effect: disgust mood elevates anxiety to obsessive washing stimuli. This finding suggests that disgust mood is causally involved in fear towards obsessive washing stimuli. The implications for the both understanding and treating obsessive washing are discussed.
Iterative and perseverative thinking in social anxiety
Andy Field, University of Sussex
Objectives: Individuals with social anxiety often report Iterative and perseverative thinking following ambiguous social events (post-event processing). This talk looks at the relationship between these thought processes and social anxiety and the function that these thoughts might have.
Methods: This study was a cross-sectional questionnaire investigation of the relationships between social anxiety (SPAI), perseverative thought processes (rumination, worry, the obsessional beliefs questionnaire), interpretative biases and intrusive thoughts, imagery (visual imagery and absorption) and shame-related feelings (shame, guilt and disgust).
Results: The results indicated that social anxiety correlated with iterative and perseverative thought processes such as rumination and worry. As predicted, social anxiety was also associated with interpretative biases about external and social events, and with some aspects of shame. Interestingly, relationships were also found between social anxiety and all subscales of the obsessional beliefs questionnaire.
Conclusions: The results imply that socially anxious individuals engage in many iterative and perseverative thought processes.
Open Papers
Basic Process in anxiety and depression
Chair: Nick Hawkes, University of East London
Attentional bias in social anxiety: Manipulation of stimulus duration and selfevaluative anxiety
Margarita Ononaiye, Graham Turpin & John Reidy, University of Sheffield
Various theoretical accounts suggest that socially anxious people are either vigilant towards external anxiety cues or internal anxiety cues. A previous study by the authors has investigated the specificity of the attentional bias displayed by the socially anxious and found some evidence to support a cognitive bias towards internally cued stimuli. The current study sets out to replicate these findings and also to investigate whether such a bias operates at either the pre-attentive automatic processing or at the
strategic conscious processing stage, in high (n=40) and low (n=40) socially anxious participants, under conditions of high or low self-evaluative anxiety. A modified version of a visual dot probe detection task was employed incorporating four different threatening word groups, included to assess the specificity of the bias. Two of the word groups (somatic and negative evaluation) represented a more internally threatening source and two symbolised a more external threat (physical and situational). The stimuli were presented for 14ms (+ masking for 186ms) to detect automatic processing and 500 ms (no mask) to examine strategic processing. It was expected that the high socially anxious would automatically attend to all socially threatening stimuli in both experimental conditions. In the strategic stage of processing, however, they would only attend towards the negative evaluational words in the low-anxiety condition and the somatic words in the high anxiety condition. Reaction times and attentional bias scores for each word group were analysed using analysis of variance. The results were discussed in relation to previous findings and theoretical perspectives.
Why do patients neutralise their intrusive thoughts?
D. Keegan, University of Newcastle upon Tyne, M.H. Freeston, University of
Newcastle upon Tyne and D. Huey, North Tyneside Primary Care Trust
Introduction: Cognitive models of OCD differentiate between obsessions, appraisals and compulsive or neutralising attempts to deal with obsessions but differ in their definitions of neutralisation. Neutralisation may, therefore, have single or multiple forms or functions and may be differentiated from compulsions.
All definitions emphasise function over form but these functions have yet to be systematically described.
Cognitive models of OCD suggest various ways in which neutralisation may maintain the disorder. Such theorising suggests, for example, that those who neutralise to change the meaning of an obsession recall thematically-related information which may cue further obsessions. This also remains to be investigated.
Aim: This study aimed to (i) gain naturalistic descriptions of functions of neutralisation, to establish whether these are single, multiple and those theorised for neutralisation. It aimed to (ii) obtain preliminary understanding of ways in which neutralisation contributes to further obsessions, by investigating whether patients recalled thematically-related information whilst neutralising.
Method: 20 OCD patients described their neutralising strategies, the functions of these and their thoughts whilst neutralising, in a semi structured interview developed from methodology used in related studies (Freeston & Ladouceur, 1997).
Results: Evidence was found to support multiple functions for neutralising which reflected those theorised for this activity. Most participants recalled thematically related information whilst neutralising.
The recall of information was significantly greater among those who neutralised to change the meaning of obsessions.
Discussion: These findings are discussed in terms of current models of OCD and invite speculation about some of the potential mechanisms by which neutralising may play its apparent maintaining role.
Retrieval practice and forgetting in depression
Chris R. Brewin and Emma Waddington, University College London
Depressed individuals report being unable to prevent intrusive cognitions, primarily thoughts and episodic memories, frequently coming into their minds. Recent research suggests that excluding unwanted or inappropriate material from consciousness relies on a number of separate processes including deliberate thought suppression, inhibition of item representations in memory, and inhibition of the retrieval routes by which those items are accessed. All these processes have the potential to be disrupted by concurrent tasks, emotions or goals. Although several studies have shown that thought suppression is impaired in depression and may exacerbate the condition, there has been little investigation of whether the depressed fare poorly on tasks assessing the efficiency of inhibitory processes. No studies have investigated retrieval-induced forgetting in depression.
Retrieval-induced forgetting (RIF) is an example of a task where forgetting occurs for automatic rather than strategic reasons. In the learning phase, participants are presented with several word lists that each consist of a category and several of its members. In the retrieval practice phase they have to complete a set of category and word stems for half the members of the category (Rp+ items: retrieval practiced category, practiced item). The unpracticed members of the category are known as the Rp- items. In the recall phase, participants are asked for their free recall of words from both practiced and unpracticed categories. Recall of Rp- items is generally worse than recall of items from categories that have not been practiced at all (Nrp items), suggesting active inhibition of the Rp- items.
Twenty depressed patients and twenty matched nondepressed controls completed a retrieval-induced forgetting task in which they practiced retrieval of positive, negative, and neutral words from different categories. Recall was tested for practiced and unpracticed words from the practiced categories and compared with recall of words from unpracticed categories. Consistent with predictions, the usual retrieval-induced forgetting effect was present in the nondepressed group but absent in the depressed group. This effect was consistent across neutral and emotional material. To allow for the possibility that the depressed may have recalled more Rp- words than the controls because they failed to practice
retrieving the Rp+ words, we repeated the analysis controlling for the percentage of Rp+ words successfully practiced but this did not affect the results. Additional data were collected which demonstrated that the control participants' data were not a product of output interference. Taken together the data suggest that depression is associated with a general deficit in inhibitory processes.
Depression and social problem solving: A new method of assessment
Michelle Lee, University of Oxford and Andrew K. MacLeod, Royal Holloway,
University of London
Previous research has indicated that poorer social problem solving is associated with particular clinical disorders. The current study was designed to examine problem solving in adults with normal and elevated levels of depressive symptomology. A specific current problem was sought from all participants and indices of problem solving cognitions and behaviour were made using a self-reported questionnaire, and a newly developed technique which incorporated an initial and follow up interview and diary-keeping techniques to record problem solving thoughts, activities and problem outcome. Measures of problem solving cognitions and behaviours, and actual problem outcome were compared across two groups with normal and elevated levels of depressive symptoms. ‘Depressed’ individuals were found to differ from their ‘non-depressed’ counterparts in terms of their orientation to their current problem, expectations of resolution, and number of solutions generated and implemented. Specificity of goals and solutions were also found to differ across groups. Those with elevated levels of depression were also less likely to have resolved their current problem by the time of their follow up interview. The clinical implications of these findings are discussed along with potential clinical interventions.
Social problem solving and autobiographical memory in young adults with
Aspergers Syndrome
Lorna Goddard, Goldsmiths College, University of London, Dritschel, B, University of St. Andrews, Scotland and Howlin, P., St. Georges Hospital Medical School
Difficulties in social interaction are a central feature of Asperger Syndrome and have a pervasive impact on the day to day lives of individuals with this condition. Effective social interaction involves the ability to solve problems as they occur within an interpersonal setting. Previous research has shown that successful social problem solving is mediated by access to specific past experiences (e.g., Goddard,
Dritschel & Burton, 1996). The ability to retrieve specific autobiographical memories in Asperger syndrome is likely to be impaired: recent research has shown individuals with this condition to experience recollection (as assessed with word lists) with a reduced level of conscious awareness
(Bowler et al. 2000). In this study we examine autobiographical memory in a social problem solving context in individuals with Aspergers Syndrome and a control group matched for age, gender, IQ, and vocabulary. Social problem solving is assessed with the Means End Problem Solving task where participants are required to generate solutions to hypothetical problems. Solutions are scored using a variety of measures (e.g., effectiveness, detail, script violation, and diachronic thinking).
Autobiographical memory retrieval is assessed both in response to solution generation as well as on a standard word cueing task. Relations between retrieval style and quality of solutions are examined. In a second study we attempt to compare groups in the extent of their memory reconstruction by evaluating the similarity of memory reports of the same event, recalled on two separate occasions.
The Importance of Positive Cognitive Processes in Psychological Well-Being
R.F. Noad, M. J. Cooper, Warneford Hospital, Oxford & S. Stewart-Brown,
University of Oxford
Introduction
Clinical psychologists have traditionally focused on understanding and treating psychological distress, and psychological theories have rarely been applied to understand positive psychological well-being.
Despite developments in cognitive theory and therapy in the area of dysfunction there have been few studies examining how people who have “positive” psychological functioning think. One barrier to such research is the lack of appropriate measures of positive cognition.
Aims
The current study therefore had two main aims:
To develop psychometrically sound measures; one of positive core beliefs and one of positive assumptions.
To investigate the relationship between positive beliefs and psychological well-being.
Method
Semi-structured interviews were conducted with undergraduate students to investigate their cognitions when they were feeling “well”. During these interviews, cognitive therapy techniques (such as the
“Downward Arrow” technique) were employed to derive items for the creation of two measures, one of
Positive Core Beliefs and one of Positive Assumptions. These two measures were then administered to
a larger sample of students (N = 227), together with questionnaires examining other psychological variables (self-esteem, self-efficacy, levels of psychiatric morbidity, life-events, social support and extraversion) and levels of well-being.
Results
Semi-structured interviews highlighted that participants were able to identify and describe both positive core beliefs and assumptions. The Positive Core Beliefs Questionnaire (PCBQ) had high levels of inte rnal consistency (α = 0.96), test-retest reliability (p < 0.01, for total score) and convergent validity, when correlated with self-esteem, self-efficacy and psychiatric morbidity (all p<0.01). The Positive
Assumptions Questionnaire (PAQ) had high levels o f internal consistency (α = 0.94) and test-retest reliability (p < 0.01, for total score). Tests of convergent validity were either acceptable or good (selfesteem and self-efficacy, p<0.05, and psychiatric morbidity, p<0.01). Correlation analyses indicated a positive relationship between positive cognition and psychological well-being. Stepwise multiple regression analyses indicated that positive core-beliefs accounted for significantly more of the variance in psychological well-being than demographic variables, extraversion, life-events and self-efficacy, but for less of the variance than self esteem and social support. Importantly, positive core-beliefs (but not positive assumptions) had some unique predictive power, i.e. they were a significant predictor of wellbeing even when these other variables were accounted for.
Discussion
The findings provide support for the hypothesis that positive cognitions exist, can be reliably and validly measured, and are related to psychological well-being in a way that might be predicted by cognitive theory. The study also produced two psychometrically promising measures of positive cognition, which have the potential to be developed and used in future research. Methodological issues are discussed along with the implications of the findings for theory, clinical practice and future research.
Clinical and Applied Issues
Keynote Addresses
Cognitive Therapy: Past, present and future
Paul Gilbert, President BABCP & University of Derby
This presentation will look at the diversity of influences that have lead to the development of cognitive therapy. It will consider where we are now and the challenges to all therapies (including cognitive based ones) from research in both cognitive and neuroscience. New work is directing our attention to different affect processing systems and also complex sequences of safety beliefs and behaviours involved in personality difficulties. The conditioning and neurobiological substrates for fear learning will be considered, in terms of the automatic responding found across psychological disorders. The implications for the future directions of cognitive therapy, and it’s theory, will be proposed.
Empirical Work: Collaboration between clinicians and researchers to improve treatments and find common ground in cognitive and behavioural therapies
Christopher Martell, University of Washington, USA
A chasm exists between clinical researchers and clinical practitioners on several levels. Although many professionals occupy both roles, for most the emphasis rests more heavily on one or the other.
Clinicians often discount psychotherapy research findings on the basis that they are irrelevant to the populations with whom they work. For this reason a "top down" approach to treatment development and dissemination (from the research laboratory to the clinic) is subject to rejection by the general clinical community as irrelevant. A "bottom up" approach (from the clinic to the research laboratory) is often unappealing to the research community for fear of wasting time evaluating pop psychology ideas when reputations, tenure and scientific integrity is at stake. The ivory tower effect risks keeping researchers apart from the day to day issues clinicians face. In contrast to these approaches, the collaborative approach has potential for the most fruitful outcome, both in the improvement of existing therapies as well as in the clarification of theoretical understanding. This talk will focus on elements of this collaborative approach and will highlight ways of utilizing the skills the academician and the clinician, both of which are essential to developing theoretically sound, pragmatic, and teachable treatments.
Evidence-based practice in psychological therapies: A scientistpractitioner perspective
David Shapiro, Universities of Leeds and Sheffield
The scientist-practitioner model of clinical psychology, in at least two distinct and quite complex guises, has exercised a formative influence on the emergence and development of behavioural and cognitive psychotherapies. All genres of scientist-practitioner model value theory and strategy as highly as data.
Meanwhile, the relatively simple evidence-based practice (EBP) paradigm has risen to predominance in the wider multidisciplinary world of health care policy and practice. This predominance is currently reflected in the vogue for practice guidelines. This paper will review, from a scientist-practitioner perspective, the strengths, limitations and appropriateness of the EBP paradigm as applied to the psychological therapies. In relation to research, it will consider the relative contributions of a variety of investigative strategies to the continuing development of a robust and informative science of psychotherapy. Substantive issues arising from these will include the relative importance of technically specified versus common factors in the effectiveness of psychological therapy. Discussion of policy and practice will focus on the challenge to EBP posed by the limitations of the evidence base, for example in relation to complex cases. Some of these limitations are addressed by recent advocacy of a complementary paradigm of practice-based evidence. Others may in part reflect the downside of current arrangements for the funding and management of clinical research. Conclusions will highlight the continuing importance of the scientist-practitioner model to the future of psychological therapies of all orientations and as practised by all health professions
Symposia
Evidence-based treatments: Principles and Practicalities
Chair: David Shapiro, Universities of Leeds and Sheffield
It’s not what you know; it’s the way that you show it. – The role of research evidence in changing complex systems.
G. D. Parry, University of Sheffield
The enterprise of basing treatments on evidence in health service settings requires a multi-facetted approach, including processes of innovation, knowledge generation, professional consensus, research based guidelines, training, workforce policies and service evaluation. I shall review recent developments in NHS policy and summarise the use of evidence-based guidelines in psychological therapies. I shall argue that relying simply on guidelines fo r ‘empirically supported treatments’ is unwise and doomed to failure. Finally, I address evidence on what is needed to translate knowledge into practice in complex systems whilst avoiding unintended consequences.
Doing clinical psychology research: what is interesting is not always useful.
Graham Davey, University of Sussex.
For clinical psychology research to be useful for both understanding psychopathology and deriving useful treatments, we may have to change the way that clinical psychology research has come to be structured over the recent past. First, research needs to be carried out on the basis of relevant
‘psychological processes’ rather than diagnostic categories. This is because co-morbidity is the norm rather than the exception, and it is becoming increasingly clear that the psychological and cognitive processes that underlie psychopathology are usually not exclusive to individual diagnostic categories.
Secondly, clinical psychology researchers are becoming increasingly dependent on explanatory constructs derived from clinical experience. These ‘intuitively’ derived constructs can be misleading in that (1) they often simply re-describe the psychopathology rather than explain it, (2) they often appear to describe the consequences of the psychopathology rather than its causes, and (3) such constructs are rarely informative about relevant psychological and cognitive mechanisms.
Making a NICE Guideline: what place do psychological interventions have in the treatment of schizophrenia
T. Kendall, Co-Director, National Collaborating Centre for Mental Health, and
Community Health Sheffield.
In this paper Tim Kendall will describe the process of developing an evidence based guideline, drawing in particular on the work of the National Collaborating Centre for Mental Health which lead to the
National Institute for Clinical Excellence (NICE) clinical practice guideline for schizophrenia. He will describe the basic components involved with a particular emphasis on service user involvement. He will then present some of the key recommendation for psychosocial interventions and consider their interaction with other interventions.
Helping to develop and implement clinical practice guidelines
S. Pilling, Director of BPS Centre for Outcomes Research and Effectiveness
(CORE), Co-director of the National Collaborating Centre for Mental Health, and
University College, London.
In this paper Steve Pilling will identify to key challenges for psychological therapy researchers and practitioners in relation to guideline development. In doing this he will draw on the guideline development work so far undertaken by the National Collaborating Centre for Mental Health (NCCMH).
First, he will argue for the development of research which better address the key clinical questions that concern guideline developers (and users). For example, research often has little to say about the types of patients who may benefit or the factors associated with a positive response to treatment. Secondly he will raise questions about what contribution psychological therapy practitioners and researchers can make to improved uptake of guidelines.
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 diverse methods and settings for delivery. This symposium will review the current status of self-help delivery, summarise some current studies ongoing in the UK, and also describe the patient’s perspective to self-help delivery.
Does therapist guidance improve uptake and outcome of computerised CBT for bulimia nervosa? A quasi-experimental study.
Ulrike Schmidt1, Chris Williams2, Maria Guadelupe Pombo-Carril3, Miriam
Grover3, Katherine Murray3, Nuria Bara-Carril3, Janet Treasure4, Pat Harkin5 Sue
Aubin5.
1: Institute of Psychiatry; 2: University of Glasgow; 3: South London & Maudsley
NHS Trust; 4: GKT Medical School; 5: University of Leeds.
Purpose of the Study: We previously showed preliminary efficacy of an interactive CD-ROM based multi-media CBT package for BN (Williams et al., 1998) used as pure self-help without any therapist guidance (Bara-Carril et al., submitted). We wanted to know whether the addition of three brief guidance sessions with a therapist would improve uptake of and outcome from this treatment.
Methods: We used a quasi-experimental design and compared two consecutive cohorts of patients with bulimia nervosa or EDNOS referred to a catchment area based eating disorder service. Patients were offered the 8 session CD-ROM treatment, with the first cohort completing the package without any additional therapist input (pure self-help) and the second receiving three 20 minute sessions of therapist guidance at session 1, 3 and 8 (guided self-help). Results: 84 patients were offered participation in the study. There was no difference between groups in terms of treatment uptake or outcome at the end of treatment. Follow-up data are still being collected, but will be available at the time of presentation.
Conclusion: The implications of the findings will be discussed.
“Overcoming my depression.” A qualitative assessment of the patient’s perspective on using CBT based self-help in primary care.
Frances Cole Bradford Hospitals Trust, Wendy Iredale & Nigel King, University of
Huddersfield.
The aim of a training programme for primary care practitioners in the management of depression was to enable patients to manage their depression more effectively. To facilitate this process of patient empowerment, the use of “Overcoming Depression” CBT based patient self-help material was incorporated in this training. This study aimed to identify from the patient’s perspective what they valued about using self-help materials in managing their depression. Twelve patients recruited by their trained primary care practitioners were invited to participate in face-to-face semi-structured interviews. Analysis shows that patients value self-help workbook materials as it leads to improved understanding of themselves (thoughts, feelings, behaviours), their depression and the role of anti-depressants. It allows time to process their experiences with understandable structured materials and case history examples.
The materials provide a rationale for their experiences and reduced their perception of depression as an abnormality. The consequences were that it enabled them to regain control and in some cases develop confidence to cope with recurrent depression episodes. Access to a practitioner trained to facilitate their use was valued as this helped to maintain motivation in their use. Patient’s main barriers to the use of self-help were perceived lack of time, personal circumstances and personal dispositions.
Summary: This qualitative study of the patient’s perspective shows the value of self-help materials and adds further evidence to the role of CBT based materials in primary care.
Treating depression by CD Rom: a pilot study of Overcoming Depression on a psychology waiting list.
Graeme Whitfield, Robert Hinshelwood, Adele Pashley, Linda Campsie (Greater
Glasgow Primary Care Trust) and Chris Williams, University of Glasgow.
A part-time self-help support nurse is supporting the use of computerised CBT (CCBT) delivered to all patients on the clinical psychology waiting list at the Lansdowne Clinic, Glasgow who are referred with mild to moderate depression or depression and anxiety. The Overcoming Depression: Five Areas
Approach self-help CD Rom contains 6 sessions of treatment and includes video, sound, and text to teach the user key information about depression and also skills of self-management. The purpose of the study is to allow rapid access to CBT using this approach.
We are recording mood (BDI-II), social functioning (SASS scale), use of services (with the self-help support nurse) and satisfaction with the approach. This is a pilot study that we hope will move towards an application for a larger Randomised Controlled study. Provisional data on take-up/drop-out, and impact on mood will be presented.
Developing a guided self-help package for panic disorder
Tom Ricketts 1,2, Julie Forrest1, and Glenys Parry2.
1Community Health Sheffield NHS Trust, 2University of Sheffield
Panic disorder with or without agoraphobia is estimated to affect between 1.5% and 3.5% of the population, with sufferers making heavy demands on primary care and specialist mental health services.
Cognitive behavioural psychotherapy is identified by the Department of Health (2001) as the first-line psychological treatment for panic disorder.
Despite this there is continuing concern regarding the accessibility of effective treatments for panic disorder. One strategy to meet this gap is the extension of the use of self-help strategies. This paper will report upon the process of development of a self-help manual for use in guided self-help for panic disorder with or without agoraphobia.
The manual was developed by the research team and then evaluated within a structured process by a group of cognitive behavioural psychotherapists and then a group of mental health service users. The details and benefits of this process will be outlined and discussed.
SPIRIT: Training practitioners in CBT self-help: the first 214 practitioners.
Christopher Williams, Rebecca Dafters, Margret Watson, Yvonne McNeill,
University of Glasgow
Access to CBT is limited by the numbers of trained and accredited practitioners. The MAPLE paper has suggested that we need to think about delivering CBT services at three different levels of access – selfhelp, focused interventions and expert-delivered CBT (Lovell and Richards, 2000). Each level has a supporting evidence base, however few accredited CBT practitioners have been trained in the use of
(level 1) CBT self-help materials (Keeley et al, 2002).
We describe here the development and delivery of a large city-wide training programme that trains practitioners in level 1 and partially in level 2 CBT delivery. The SPIRIT (Structured Psychosocial
Interventions in Teams) course trains adult and elderly mental health teams to use structured CBT selfhelp workbooks. The course is offered to teams rather than individuals to encourage sustained adoption of the approach. Training is multidisciplinary and multi-agency and provides skills-based training to both inpatient and community staff. Eight trainers are co-opted to the project and a training co-ordinator and two researchers are evaluating outcomes.
The 10 main sessions (3 hours) address clinical assessment, problem solving, using self-help, identifying and challenging extreme and unhelpful thinking, overcoming reduced activity and unhelpful behaviours. They are supported by additional clinical supervisions sessions. Over 200 staff members have been trained in the programme and we present an overview of learning gains for the project and initial findings on the impact on team functioning.
Building the evidence base for computerised CBT: A progress report on
Beating the Blues
David A Shapiro, University of Leeds and University of Sheffield, Judy Proudfoot,
Jeffrey Gray, Clash Ryden, Paul McCrone, Martin Knapp, & David Goldberg
Institute of Psychiatry, London, Kate Cavanagh & Susan van den Berg Ultrasis plc,
Jeremy Dawson Aston University
We present an overview of completed and ongoing research on Beating the Blues (BtB), an 8-session computerised CBT programme for anxiety and depression. This work fulfils many of the research requirements specified by the October 2002 Guidance on computerised CBT from the National Institute for Clinical Excellence (NICE). Two randomised, controlled trials (RCTs) in primary care have demonstrated the clinical efficacy of BtB. Economic analysis of data pooled across theses two trials have shown BtB to be cost neutral in terms of healthcare costs, whilst delivering significant gains in terms of lost employment. Alongside its clinical superiority, these results indicate that BtB is costeffective. Predictor analysis indicates that BtB is effective for a wide variety of patients. In addition, a multi-site open trial has shown substantial clinical effectiveness in routine primary and secondary care, and charted the course of changes in anxiety and depression over the 8 sessions of the package. We close with a discussion of practical issues in the implementation of BtB in NHS settings, based on a survey of the experiences of services that have used the programme for substantial periods of time.
Taken together, our findings support the use of computerised CBT as a significant contribution to meeting the challenge of making evidence-based psychological treatment available to the vast numbers of patients needing it
A pilot study of a fast access self-help clinic for anxiety and depression in primary care.
Karina Lovell, David Richards & Peter Bower, University of Manchester
The fast access self-help clinic for anxiety and depression is a new and innovative service which delivers effective mental health care to between 3-5 times as many people as would normally be seen in a traditional primary care mental health service.
The clinic underwent a 16-month pilot phase. The clinic offers fast access for people with anxiety and depression and offers facilitated self-help (usually via self-help manuals). Users of the service were seen for 30-minute assessment and offered 15-minute follow-up appointments. The CORE (Clinical outcomes in routine evaluation) evaluated the clinic at pre intervention, 3 and 6-month follow-up. A brief satisfaction questionnaire and indepth qualitative interviews with a sample of people collected user’s evaluation of the clinic. In the pilot phase 159 patients were assessed and offered facilitated self-help.
Results found that facilitated self-help led to clinically significant and reliable change in a proportion of people.
Psychological Disorders in People with Intellectual Disabilities: Recent
Developments in Assessment and Treatment
Convenor: John Taylor, Northumbria University and Northgate & Prudhoe
NHS Trust
Family environment links to patient anger and aggression effects of volatile parents
Raymond W. Novaco, University of California, Irvine, USA and John L. Taylor,
Northumbria University and Northgate & Prudhoe NHS Trust
Children’s exposure to inter-parental anger aggression has been shown in many studies to have longterm adverse effects on a child’s development, psycho-social adjustment, and well-being. Exposure to domestic violence has been found to contribute to children's delinquency and clinical dysfunction, to predict child conduct disorders and personality disorders, and to lead to childhood symptoms of posttraumatic stress disorder.
The present study concerned 110 male hospitalised forensic patients with intellectual disabilities. The relationship between patient anger and aggressive behaviour (assessed by multiple self-report, staffrated, and archival measures) and their childhood experiences of parental anger, parental fighting, and abusive victimization was examined. Patient anger and assaultiveness in the hospital was found to be significantly related in convergent analyses to parental anger and aggression and to physical and sexual abuse victimization. In hierarchical multiple regression analyses, parental anger and aggression was highly predictive of patient anger, controlling for both parental and patient alcohol and drug abuse and for patient physical and sexual abuse victimization. The results are discussed with regard to social learning theory, threat sensing anger schemas, and aggressive scripts.
Life events and psychiatric symptoms in adults with intellectual disabilities
Richard Hastings, and Dawn Owen, University of Wales, Bangor
Background: Previous research has indicated that children and adults with intellectual disabilities may respond to traumatic and other life events in a similar way to the general population. Thus, there is evidence of increased exposure to life events in the recent past of those with depressive illness, and increased risk of psychological problems especially affective disorder contiguous with bereavement.
However, few studies have charted the extent of exposure to life events in samples of adults with intellectual disabilities and the association of such exposure with general psychiatric problems. The results of two studies will be described.
Method: In Study 1, adults with intellectual disabilities (N = 1174) in community and residential services in the north east of England were assessed using the Psychiatric Assessment for Adults with
Developmental Disabilities (PAS-ADD Checklist) and a checklist of recent life events. In Study 2, adults with intellectual disabilities (N = 101) in a residential hospital in North Wales participated. Measures of life events, behaviour problems, mental health, adaptive behaviour and quality of life were taken. In both studies, data were provided by carers who knew the target individual well.
Results: Within the twelve months prior to data collection, the five most frequently experienced life events reported in Study 1 were: moving residence (15.3% of sample), serious illness of close relative or friend (8.9%), serious problem with close friend, neighbour or relative (8.7%), serious illness or injury to self (8.3%), and death of close family friend or other relative (8.2%). Overall, 45.7% had experienced one or more significant life events in the previous 12 months and 17.2% had experienced two or more. A series of logistic regression analyses were performed with caseness on the PAS-ADD sub-scales as the dependent variables. These revealed that the presence of one or more life events in the previous 12 months added significantly to the classification of psychiatric caseness predicted by demographic variables (age, sex, residence in community or hospital) on the PAS-ADD Affective Disorder scale but not the Organic Disorder or Psychotic scales. Overall, the odds ratio for affective disorder given exposure to one or more life events was 2.23 (95% CI = 1.56
– 3.18). In Study 2, exposure to recent life events was associated with increased challenging behaviour, increased affective and organic psychiatric symptoms, and poorer quality of life.
Discussion: Small, but potentially significant relationships were found between life events exposure and psychiatric problems, behaviour problems, and quality of life in adults with intellectual disabilities.
Further research is needed to explore the causal direction of this relationship and also to develop more sensitive measures of life events relevant to the situation of adults in residential and community service environments.
Screening for psychiatric symptoms in adults with intellectual disabilities using the psychiatric assessment schedule for adults with development disabilities (PAS-ADD) Checklist
J. L. Taylor, Northumbria University and Northgate & Prudhoe NHS Trust, UK and
C. Hatton, Institute for Health Research, Lancaster University, UK
Objective: The PAS-ADD Checklist is a screening instrument designed to help care staff recognise likely mental health problems in people with ID and to make informed referral decisions. To date the PAS-
ADD Checklist has not been applied to a general population of people with ID, and consequently no published normative data is available for this instrument.
Method: Informants with good levels of knowledge of participants completed the PAS-ADD Checklist on
1155 adults with ID living in community, residential care and hospital settings in a county district in the
North East of England.
Results: Normative data are presented for the PAS-ADD Checklist for the study population with reference to gender, age, and type of residence. The overall prevalence of mental health was 20.1%, and the rates for affective/neurotic, organic and psychotic disorders were 14%, 3.9% and 10.2% respectively. Significant differences in the rates for particular types of disorder were found across gender, age and residence type.
Conclusions: The rates of mental disorders found in the study population were consistent with previous studies of general populations of people with ID that used over-inclusive screening instruments. The
PAS-ADD Checklist appears to be an easy to use and sensitive tool for identifying mental health cases in ID populations, but further investigation is required concerning the specificity of the instrument.
Cognitive behaviour therapy with people with intellectual disabilities and mental health problems: The state of the evidence
Chris Hatton, Lancaster University
Evidence-based practice is becoming increasingly important in selecting mental health interventions.
The evidence-base on psychosocial interventions for a range of mental health problems is rapidly increasing, including a number of relatively large-scale randomised controlled trials evaluating cognitivebehaviour therapy.
This presentation will focus on the published evidence-base concerning cognitive-behaviour therapy for people with intellectual disabilities and mental health problems. The presentation will argue that the evidence-base in this area is at a very early stage of development. Research designs typically employed are towards the bottom of traditional evidence-based practice hierarchies, and the state of the evidence is such that meaningful systematic reviews are not possible in most areas.
In terms of increasing the evidence-base concerning cognitive-behaviour therapy with people with intellectual disabilities and mental health problems, current major funders are largely concerned with activities where there is already substantial evidence, such as randomised controlled trials and systematic reviews. There is a danger that areas with little current evidence will be further marginalized in terms of research funding.
The presentation will conclude by discussing potential strategies for the production of evidence concerning cognitive-behaviour therapy for people with intellectual disabilities and mental health problems, in the absence of substantial research funding.
Beyond the evidence-base: CBT for complex cases
Chair: Christopher Fairburn, University of Oxford
Moving beyond the evidence base: a case example
Gillian Butler, Warneford Hospital, Oxford, and Oxford Cognitive Therapy Centre.
Abstract: Dilemmas have always faced clinicians when they try to relate theory to practice
– whether or not they are working with complex cases. Recently, research into the effectiveness of CBT, together with political and economic considerations, has added to the pressure on the clinician. There are more available ‘protocols’, and there is more pressure to provide them. However, the dilemmas remain. This paper will focus on questions of identity that arise when working with people whose early experience has had long-term damaging effects. It will be argued that some of these effects make it particularly difficult for these people to make use of cognitive therapy as delivered according to accepted conventions. They also make it difficult for clinicians to keep their work theoretically well-grounded, and require of them a degree of creativity that can be hard to locate precisely when it is needed. Some of the problems in practice will be described, together with sources of solutions to them. Case material will be used to illustrate the points made throughout. The main aim is to think about how clinicians can maintain a balance between theoretical coherence and flexibility, especially when working at the limits of the knowledge currently available to them.
CBT for a client with bipolar affective disorder: The role of interpersonal anxiety.
Warren Mansell and Dominic Lam, Institute of Psychiatry, London
The case is described of a client with a diagnosis of bipolar affective disorder, who was currently in an episode of major depression. The client identified several goals for therapy. Although he was happy to follow a standard protocol for CBT for bipolar affective disorder, initially he wanted to work on a different goal which he perceived to be at the root of his difficulties: his fear of other people. The fear manifested itself both as social phobia and post-traumatic stress disorder. First, he reported always being extremely anxious about other people's evaluations of him in social, academic and work situations. This fear led him to adopt a range of safety behaviours such as avoiding attention from others, excessive drinking and drug-taking, and 'trying to be someone else'. Second, following several previous assaults, he was particularly fearful of being assaulted by young males in pubs, shops, streets and on public transport.
This fear would lead him to either avoid going to these places or to suffer them with extreme distress.
We carried out CBT for anxiety disorders (Clark, 1999) before tackling the depression and working on techniques to help prevent future relapse into mania (Lam et al., 1999). After 20 sessions of weekly therapy, the depressive symptoms remitted, the client returned to work and he remained symptom-free at ten-month follow-up. This case underlies the importance of listening to a client's concerns, identifying the known role of anxiety in many cases of serious mental illness and having access to a range of cognitive models.
Beyond the evidence-base: Psychological debriefing for overseas aid workers
Debbie Lovell-Hawker, University of Oxford
Many overseas aid workers experience traumatic incidents and high levels of stress while carrying out their duties (for example in Iraq, Afghanistan, Kosovo or Rwanda). When they return home, it is common for aid workers or the organisations they represent to request that they receive psychological debriefing to help them process their experiences and cope with stress-related symptoms, and to promote normal recovery.
Some clinicians and organisations refuse to offer such debriefing, as they believe the evidence-base recommends against it. The Cochrane review of psychological debriefing states: ‘There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traum atic incidents. Compulsory debriefing of victims of trauma should cease’(Rose,
Bisson & Wessely, 2003).
This Cochrane review is based on eleven trials, and the reviewers accept that the trials were of poor quality. This raises the question of whether reviews based on a few poor quality trials should be
accepted as an adequate ‘evidence-base’ from which to make recommendations. The population studied (involving mainly people who had suffered recent miscarriages; complications giving birth; road traffic accidents; dog bites; burns; violent crime, or were relatives of trauma victims) is also very different to the population of overseas aid workers. Clinicians working with aid workers need to look beyond the existing evidence base (see British Psychological Society, 2002).
Preliminary research on the psychological debriefing of overseas aid workers will be presented (Lovell-
Hawker 2002a, 2002b). The problem of accepting ‘evidence-based recommendations’ without question will be discussed.
British Psychological Society (2002). Psychological Debriefing: Professional Practice Board Working
Party. BPS: Leicester.
Lovell-Hawker, D. (2002). Effective Debriefing Handbook. People in Aid: London.
Lovell-Hawker, D. (2002). Guidelines for crisis and routine debriefing. In K. O’Donnell (Ed.) Doing
Member Care Well: Perspectives from around the world. William Carey Library: Pasadena.
Rose, S., Bisson, J. & Wessely, S. (2003). Psychological debriefing for preventing post traumatic stress disorder (PTSD). (Cochrane review). In The Cochrane Library, Issue 1, 2003. Oxford: Update Sortware.
Empirically grounded clinical interventions: cognitive behavioural therapy progresses through a multi-dimensional approach to clinical science
Paul M. Salkovskis, Institute of Psychiatry, London.
The current emphasis on Evidence Based Medicine (EBM) is both welcome as a bid to improve the empirical foundations of clinical practice and a cause for concern because it has the potential to distort the scientific approach that has underpinned the development of cognitive-behavioural approaches. It is suggested that EBM needs to be seen in context; that is, as an approach that almost exclusively focuses on just one of the dimensions that have been and are crucial to the further development of
Cognitive-Behavioural Treatments (CBT). EBM is particularly well suited to the development of
Biological approaches to treatment, where treatments (and treatment development) are largely atheoretical. However, different considerations apply to CBT, where validated theory and linked research studies are key factors. It is suggested that relationship to evidence in CBT is best conceptualised in terms of Empirically Grounded Clinical Interventions. The parameters of such an approach are considered in relation to the Scientist-Practitioner model that is prevalent in the field.
Emotional Processing Using Writing Therapy
Convenor: Roz Shafran, University of Oxford
Chair: Chris R. Brewin, University College London.
What is emotional processing and how do we measure it?
J. Pennebaker, University of Texas at Austin, USA
There is general consensus that emotional processing is necessary for therapeutic gains to occur. A longstanding difficulty has been in defining and measuring the processing of emotional information.
Recent attempts to understand emotional processing in narratives, stories, and expressive writing will be discussed. One strategy suggests that it may be more helpful to think about the nature of emotional events than about emotional responses per se. Emotions provide valuable information about the impact of an event but are not the central problem on their own. Research from expressive writing narratives, then, indicate that we should focus on emotional event processing rather than emotional processing.
Another strategy is to explore the ways people use language when working through upsetting experiences. Using a relatively new text analysis method, we are finding that the ways people use pronouns, cognitive words, and, to a lesser extent, emotion words, can predict therapeutic gains as measure by health improvements. Implications of these approaches for therapy will be discussed.
Can a cognitive-behavioural framework help understand the mechanisms by which writing therapy may work?
Lynne Battersby, University of Leicester
A review of available studies indicates a positive effect of the writing task on a range of variables assessing physical and psychological health (Smyth, 1998). This has led to therapeutic writing being described as a “hot topic” on both sides of the Atlantic with the focus in the UK tending to be on descriptive accounts and somewhat speculative psychodynamic explanations for subjective improvements on these variables (Greenhalgh, 1999). However, it is possible that cognitive-behavioural theories could be used to account for the efficacy of writing therapy on physical health and psychological functioning. This paper will explore whether cognitive-behavioural theories can help understand the mechanisms by which therapeutic writing may be improving psychological problems. The advantages
and disadvantages of viewing writing therapy within a cognitive-behavioural framework will be discussed. The paper will conclude by examining the possibility that some cognitive-behavioural treatments may be improved by the addition of a therapeutic writing component
Greenhalgh T. (1999). Writing as therapy. Effects on immune mediated illness need substantiation in independent studies. BMJ Jul 31;319(7205):270-1
Smyth JM (1998). Written emotional expression: effect sizes, outcome types, and moderating variables
J Consult Clin Psychol 66(1):174-84
Journal writing as an adjunct to counselling in the context of primary care
Kate Thompson, Newham Psychology & Counselling Service, London
Journal therapy is the purposeful and intentional use of personal and reflective process writing to facilitate healing and further therapeutic goals. An increasing body of literature confirms that journal writing can be an effective tool in psychological healing both within a therapeutic framework and as part of personal development. Journal writing can be used as a means of developing intimacy with the self and enhancing self-knowledge; it can also be used to confront trauma in the past and prepare for the future. This presentation will explore the use of journal writing with clients in the context of time-limited counselling and consider how it can extend the benefit of brief interventions for clients. A range of techniques will be discussed.
Expressive and Reflective Writing in Time-limited Workplace Therapy
Jeannie Wright, University of Derby
The efficacy of writing therapy has been established. Whether by logging positive data, writing unsent letters, keeping an emotional diary or in autobiographical writing, the benefits of writing about events and experiences and the thoughts and feelings associated with them have been demonstrated both in laboratory and naturalistic settings (Pennebaker, 1995; Lepore & Smyth, 2002; Bolton et al, in press).
Based on brief, workplace therapy contracts, themes from evaluative interviews with female clients who used writing therapy will be presented. An integrative, transtheoretical approach was used in the brief therapy. Narrative (Etherington, 2001; Pennebaker & Seagal, 1999) and feminist (Ussher, 1999; Lather,
1991) approaches to research have been influential in the design and methodology of the study.
Bolton, G., Howlett, S, Lago, C., Wright, J.K. (co-editor.) (in press) The Writing Connection: An
Introductory Handbook of Writing in Counselling and Therapy . London: Brunner-Routledge.
Etherington, K. (2001) Writing qualitative research
– a gathering of selves.
Counselling and
Psychotherapy Research, 1(2): 119-126.
Lather, P. (1991) Getting Smart: Feminist Research and Pedagogy with/in the Post-modern. New York:
Routledge.
Lepore, S.J. & Smyth, J.M. (2002) (Eds.) The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-Being . Washington,DC: American Psychological Association.
Pennebaker, J.W. (ed.) (1995). Emotion, Disclosure and Health. Washington, DC: American
Psychological Association.
Pennebaker, J.W.& Seagal, J.D. (1999). Forming a story: The health benefits of narrative. Journal of
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Ussher, J. (1999) Feminist Approaches to Qualitative Health Research, in M. Murray & K.Chamberlain
(1999) Qualitative Health Psychology: Theories and Methods.
London: Sage.
The Therapist Relationship in Cognitive Therapy
Convenor: Paul Gilbert, University of Derby
Welcome: Some key issues in the therapeutic relationship in cognitive therapy
Paul Gilbert, University of Derby
This brief introduction will introduce the symposium raise the issue that CBT are often thought to be neglectful of the therapeutic relationship. However, although it has a specific view of the therapeutic relationship based on guided discovery, collaboration this should not be seen to invalidate the need for other key therapy building skills.
Micro-CBT: The integration of specific interpersonal skills
Chris Gillespie, Derbyshire Mental Health Services Trust
It is suggested that although current cognitive models are supported by impressive techniques and evidence of effectiveness, there has been a perceived neglect of basic interpersonal skills common to
the therapeutic process. The skilled and experienced cognitive therapist will be able to develop a strong alliance, and work through barriers of resistance, by the systematic use of a range of interpersonal
‘micro-skills’. In this paper each micro-skill will be described and classified with clinical examples. It will be suggested that CBT training may be compromised if it assumes that people have these skills before they begin training. Micro-CBT facilitates the experience of guided discovery, collaboration and guards against being overly prescriptive.
Emotional and interpersonal schemas in the therapeutic relationship
Robert Leahy, Cornell University Medical College, New York Hospital. Director,
American Institute for Cognitive Therapy, USA
The therapeutic relationship is viewed by all modalities as essential in assuring improved outcome.
However, cognitive therapy has generally ignored the important role of the therapeutic relationship because of its emphasis on information processing. In this presentation we will examine how patients' emotional schemas and interpersonal schemas (of abandonment, helplessness and autonomy) affect the therapeutic relationship and how these schemas can assist the therapist in modifying underlying assumptions, emotional processing and interpersonal functioning.
A Review and Critical Analysis of Studies Assessing the Nature and Quality of
Patient-Therapist Interactions in the Treatment of Patients with Mental Health
Problems.
Gillian Hardy, Kate Bonsall, Kanan Pandya, Michael Barkham, Jane Cahill, Kerry
Audin, Simon Gilbody, Dave Richards, Peter Bower, Clive Adams, & Linda Gask.
University of Leeds.
The establishment of a good relationship appears to be necessary early in therapy, and this relationship is usually called the alliance. This presentation outlines a map of patient -therapist Interactions (TPI) developed through a systematic review of the literature. The aim is provide a tool which could be helpful in training and supervision of mental health staff. The quality of TPI is not just a by-product of therapeutic success, but is the most consistently reported predictor of successful outcome. Contextual factors and an understanding of therapy roles moderate the quality of the alliance. As therapy continues, the relationship becomes an arena in which therapeutic activity is carried out. These relational interventions lead to a deepening of the therapist
–patient relationship, but may also lead to misunderstandings and negative reactions. Maintaining the quality of the relationship then involves therapists making therapeutic use of countertransference materials, ensuring appropriate responsiveness, and repair of ruptures in the relationship.
The Professional Development of British Behavioural and Cognitive
Psychotherapists.
T. Schröder, P. Gilbert, D. Orlinsky, and H. Rönnestad. Department of
Psychotherapy, Derbyshire Mental Health Services Trust
Much of current psychotherapy research is focussed on the evaluation of therapeutic techniques. Apart from the work of a recent APA task force on ‘empirically supported relationships’, little attention has been paid to investigating the qualities of helpful relationships let alone the characteristics of therapists engaging in them. We lack basic descriptive data about the attributes and experiences of psychological therapists and how these may change over the course of an individual’s career.
This situation has been addressed over the past decade by a group of clinician-researchers forming themselves into a collaborative research network to undertake an international study on the professional development of psychotherapists in which more than 5000 therapists worldwide have participated so far.
As part of the UK component of this study, all BABCP registered therapists and a random sample of non-registered BABCP members have been invited to take part in the study. This presentation reports on the characteristics of BABCP therapists from both samples and compares the results with findings from the international database.
Prevention of Parasuicide by manual assisted cognitive behavioural therapy (POPMACT): results of the study (presented on behalf of the
POPMACT group)
Convenors: Kate Davidson Glasgow Institute of Psychosocial Interventions
(GIPSI) Greater Glasgow Primary Care Trust
Prevention of parasuicide by manual-assisted cognitive-behaviour therapy
(POPMACT): results of a randomised controlled trial of 480 patients with recurrent self-harm
Peter Tyrer (on behalf of the POPMACT Group), Imperial College, London.
480 patients with a history of recurrent deliberate self-harm were randomised to a brief psychological intervention linked to bibliotherapy (manual-assisted cognitive behaviour therapy (MACT) or treatment as usual (TAU) and followed up over 1 year. Those allocated to MACT received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to 5 plus 2 booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months (Tyrer et al, 2003). 60% of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those having a repetition of deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (odds ratio
0.78, 95% CI 0.53 to 1.14, P=0.20). There were no significant differences between MACT and treatment as usual on any of the secondary measures but health costs were significantly less (£890 per patient) in MACT patients after 6 months and this saving was maintained at one year.
Tyrer, P., Jones, V., Thompson, S., Catalan, J., Schmidt, U., Davidson, K., Knapp, M, Ukoumunne, O.
(on behalf of the POPMACT group)(2003). Service variation in baseline variables and prediction of risk in a randomised controlled trial of psychological treatment in repeated parasuicide : the POPMACT study. International Journal of Social Psychiatry, 49, 58-69.
The MACT Manual and Treatment Model
Ulrike Schmidt, Institute of Psychiatry, London
Suicidal individuals have been characterised as being sensitive to 'signals of defeat', perceiving 'no escape' from adverse circumstances (due to deficient problem solving capacities based on impaired memory functions) and perceiving 'no rescue' related to a reduced capability to generate positive events in the future leading to feelings of hopelessness. This paper will present the rationale for and the contents development of the MACT approach and manual in light of recent cognitive models of parasuicide and clinical approaches to parasuicidal behaviour.
Therapist competence and clinical outcomes in the POPMACT trial
Kate Davidson, Glasgow Institute of Psychosocial Interventions, University of
Glasgow
The level of therapist competence and clinical outcomes of patients with recurrent self-harm in the
POPMACT trial was examined. Twenty-one (57%) therapists provided tapes of POPMACT therapy sessions with clients. An 11 –item MACT rating Scale was developed to measure three aspects of competence: skill in applying techniques, interpersonal effectiveness and general adherence to the
MACT model. A total of 49 tapes were selected at random from the therapists providing tapes.
Satisfactory agreement between two raters on scores on the rating scale was achieved. An average therapist competence score was calculated for each therapist and these scores were further divided into three groups reflecting the range of competence in delivering MACT. Difference scores between baseline and 6-month data showed no differences between the competence groups expect on observer rated depression. However, difference scores between baseline and 12-month follow-up showed significant differences between the competence groups on observer rated measures of depression, anxiety, GAF social and GAF symptoms. Patients with recurrent self-harm treated by the most competent therapists show significant clinical improvement but this benefit in not evident until 12-month follow-up.
Positive and negative future thinking in suicidal behaviour: Findings from the
POPMACT study
Andrew MacLeod. Royal Holloway, University of London
How a person thinks about the future is an important aspect of suicidal behaviour. A lack of positive future thinking can be distinguished from increased negative future thinking and both can be further broken down into different components, for example number of anticipated events, perceived likelihood of their occurrence and their affective value. Results from the POPMACT study will be presented that address the relationship of different aspects of positive and negative future thinking to hopelessness, depression, anxiety and personality disturbance. Changes in positive and negative future thinking over time will also be described and their relationship to treatment, repetition and risk factors discussed. In
addition, the content of future thinking will be described to show how different themes relate to different aspects of suicidality and how themes change over time in the process of recovery.
Panel Discussion
Getting research off the ground: Ask the experts
Chair and Convenor: Allison Harvey, University of Oxford
The bedrock of CBT is research. The commitment (1) to discovering the mechanisms that cause and perpetuate psychological and health-related problems, (2) to translating these findings into treatments, and (3) to demonstrating the effectiveness of CBT treatments has established CBT as the frontline treatment for a diverse and growing range of problems. The aim of this symposium is to stimulate research. Specifically, it recognised that research is crucial to the further development of CBT, yet many
CBT therapists feel under-equipped to setup and complete their own research. Accordingly, we have decided to bring together research experts who will each give a short presentation on one or more aspects of ‘getting research off the ground’. We will ensure that there is ample time to discuss the issues raised by each panelist and for discussion of specific problems that individuals in the audience are having in getting research studies completed.
In Part 1 of the symposium (before the coffee break), we will address basic research methods. Graham
Turpin (University of Sheffield) will briefly overview of quantitative methods including questionnaire studies, case series, and experimental studies. Philippa Garety (Institute of Psychiatry) will talk about the joys and pitfalls of randomised controlled trials. Then Nancy Pistrang (University College, London) will discuss qualitative research methods.
In Part 2 (after the coffee break), Nick Tarrier (University of Manchester) will talk about formulating research questions and getting funded. Paul Salkovskis (Institute of Psychiatry) will talk about writing up research papers and getting published (Paul is the editor of Behavioural and Cognitive Psychotherapy).
Finally, Graham Davey (University of Sussex) will highlight areas where clinical researchers can go wrong.
Open Papers
Models of Training and Supervision
Chair: James Bennett-Levy, Oxford Cognitive Therapy Centre
Cognitive Therapy from the Inside: Reaching the Parts Other Training
Strategies Cannot Reach?
James Bennett-Levy, Oxford Cognitive Therapy Centre
Several leading cognitive therapists (e.g. J. Beck, Padesky) have suggested that practising cognitive therapy techniques on oneself can make a valuable, and perhaps unique, contribution to the training of cognitive therapists. However, until recently, there have been no data to suggest what this impact might be. The present paper reviews several studies by the author and colleagues, which map the impact of a training strategy known as self-practice/self-reflection (SP/SR). Self-report data from cognitive therapy trainees suggest that SP/SR impacts on a range of therapist skills, knowledge, and attributes. In particular, there may be specific areas of therapist skill development to which SP/SR, as a training strategy, makes a unique contribution. It is suggested that these may include enhanced perceptual skills, relational skills, therapist attitude, and reflective practice. Overall, SP/SR appears to infuse the application of cognitive therapy principles and t echniques with “professional artistry”.
Supervisor training: What have we learnt to date and what do we need to develop?
Peter Armstrong1, Mark H. Freeston1,2, Vivien Twaddle1,2, Jamie Dixon1, Katie
Froom1
1Newcastle Cognitive and Behavioural Therapies Centre, Newcastle, North
Tyneside and Northumberland Mental Health NHS Trust, 2University of Newcastle
In 2001-2002 staff at NCBTC started development of supervision training based on an emerging conceptual framework drawing on the experience of supervisors mostly associated with the Newcastle
Cognitive Therapy Course. We have now run five training events of different types based on this framework and have been using it to shape supervision on the Newcastle course and guide supervision of supervision. This presentation provides an update on our developing understanding of supervision, the training that flows from this understanding, and how it is shaping our supervision practice both
collectively and individually. First, the major points of the framework will be briefly summarised, concentrating on issues that have emerged more recently. Second, data will be presented from the evaluation of the training events to date. Third, we will discuss some of the major changes in the way that we organise, think about and deliver supervision at the Centre and will highlight a number of unresolved issues. Finally, we will address possible future directions for supervision training and research, identifying gaps in current knowledge.
What can supervisors tell us about supervision? Mapping supervisor attributes to a conceptual model.
Vivien Twaddle1,2, Mark H. Freeston1,2, Peter Armstrong1, Jamie Dixon1, Katie
Froom1
1Newcastle Cognitive and Behavioural Therapies Centre, Newcastle,
Northumberland and North Tyneside Mental Health NHS Trust, 2University of
Newcastle.
Over the last two years, NCBTC staff and collaborators have initiated a research, development and training programme addressing CBT clinical supervision. As a follow on from previous work that has utilised supervisee feedback to map on to an emergent conceptual model of supervision (Freeston,
Fennell, Dixon and Froom 2002), this study has collected data from over 60 supervisors participating in supervision training workshops. Before the workshops, they identified attitudes and skills they believed significantly contribute to their supervisory activity. These data have been categorized and mapped on to the conceptual framework that has developed through our programme, so that we have been able to specify in greater detail some components of this framework. Examples will be used to show how these naturalistically obtained characteristics would be likely to facilitate certain types of supervisory activity that we believe to be important to successful supervision. Discussion will include 1) ongoing data collection to gather complementary information that may elucidate other components of the framework, and 2) discussion of the advantages and limits of this type of naturalistic data collection.
Improving access to psychological therapies – The Praxis distance learning solution
Pamela Myles, Roger Paxton, Newcastle, North Tyneside and Northumberland
Mental Health NHS Trust. Mark Freeston, Newcastle Cognitive Therapy Centre.
Derek Milne, Douglas Turkington, Newcastle University. Alison Brabban, County
Durham and Darlington Priority Services NHS Trust. Bernie Morrison, Northumbria
University. Stephen Williams, The Garth Surgery, Guisborough. Sheila Cleugh,
INPUT, North Tyneside. Lisa Purvis, Christine Green, Michael Lavelle, User
Representatives, Newcastle, North Tyneside and Northumberland Mental Health
NHS Trust.
There is a clear need to improve access to evidence-based treatments for people with common mental health problems. Based on an evaluated brief course in Cognitive Behavioural Therapy (CBT), a distance-learning system has been developed. The system is designed to be widely applicable and has been particularly designed for primary care staff and community mental health practitioners. The training system centres on an interactive CD-ROM, and includes support for local clinical supervision and organisational development to ensure that the training leads to changes in clinical practice. The system will be available from the beginning of April 2003.
This system is distinctive firstly in being closely based on an existing evaluated training course; secondly in being skills-based rather than disorder-based; thirdly the system offers appropriate supervision to accompany the training including a training package and support system for supervisors; fourthly, the training system incorporates a maintenance programme to encourage retention of skills; lastly, the learning system allows trainees throughout the country to communicate with each other and tutors through internet forums incorporated within the training system.
Benefits of the system will include reducing the training costs often accrued by sending staff on training courses away from the workplace and allow the whole team to be trained at a low cost. A needs assessment is used to offer appropriate help and advice to ensure no dilution of the quality of the training. Identified supervisors are provided with a one-day training package from the Newcastle
Cognitive Behaviour Therapy Centre. In addition, supervisors receive a supervision manual and support throughout the training period. The system is educationally sound, centred on problem-based learning using case studies with video and audio clips to emphasise important points.
Evaluation of the system is planned to commence in June 2003 using a controlled before-after study, which will investigate p articipants’ learning and client outcomes. The aims are to assess changes in participant knowledge and skills, and client functioning and symptoms. A minimum of 40 participants
(relevant staff) will be allocated to each group (n ≥ 80 total). Four neighbouring Trusts are to take part in
the study. Participants will be community mental health professionals (e.g. nurses, occupational therapists and social workers) with a relevant professional qualification (e.g. RMN) and direct clinical contact with clients with common mental health problems.
The project is compatible with government initiatives such as the NHS Plan and the Mental Health NSF aiming to improve access to appropriate psychological therapies for people with common mental health problems.
Assessment studies of training and supervision
Chair: Ken Gordon, University of Southampton
The development of a new measure of knowledge to evaluate training in
Cognitive Behavioural Therapy: the contributions of an expert panel.
Pamela Myles, Newcastle, North Tyneside & Northumberland Mental Health NHS
Trust; Mark Latham, University of York; Tom Ricketts, University of Sheffield.
The National Service Framework for Mental Health (DoH 1999) has set standards to ensure service users with common mental health problems are offered appropriate evidence-based treatment. As a result of growing demand for effective therapies, the need for short training programmes in Cognitive
Behavioural Therapy (CBT) has also increased. As the number of training programmes grow, so evaluation becomes increasingly important to ensure appropriate standards are achieved. At present, appropriate instruments to measure knowledge acquired during training are lacking. A new multiplechoice questionnaire, the Cognitive Behavioural Therapy Knowledge Questionnaire (CBT-KQ), has been developed to fill this gap
Nine experts were asked to comment on 40 items developed by the authors with a view to their inclusion in the CBT-KQ. The feedback from the panel resulted in significant changes to the questionnaire. This paper presents the data from the expert panel, which informed the development of the CBT-KQ.
Development of a Multiple Choice Questionnaire to measure changes in knowledge during CBT training
Mark Latham, University of York, Pamela J. Myles, Newcastle, North Tyneside &
Northumberland Mental Health NHS Trust, and Tom Ricketts, University of
Sheffield
Recent years have seen an unprecedented rise in the UK in both the use of Cognitive Behavioural
Therapy (CBT) as a psychotherapeutic approach and in the demand for CBT training courses. Some attempts have been made to measure their effectiveness (e.g. Shaw & Wilson-Smith 1988, Williams et al 1991, & Freiheit & Overholser 1997). Generally, however, there is a paucity of research evidence available, especially regarding valid and reliable measuring tools.
This paper reports the development of a Multiple Choice Questionnaire (MCQ) designed to measure the acquisition of CBT knowledge during training. A bank of 30 questions was devised and piloted on 58 members across three CBT training courses. As a result of the pilot, 10 questions were retained in largely unmodified form, 10 were altered substantially, and 10 were discarded. Twenty new questions were constructed, resulting in a revised MCQ of 40 questions. This revised version was then submitted to a panel of nine CBT “experts” with extensive experience in CBT training. Following feedback from this panel, the MCQ was reduced to 22 items and was piloted on 104 trainees on six different courses, ranging from short introductory CBT courses to one-year intermediate level CBT training. The process involved in devising the MCQ is discussed, data from the pilot are presented, and details of further developments and modifications to the MCQ are outlined.
References:
Freiheit SR & Overholser JC (1997). Training issues in cognitive-behavioural psychotherapy. Journal of
Behaviour Therapy & Experimental Psychiatry, Vol.28, pp.79-86.
Shaw BF & Wilson-Smith D (1988). Training therapists in cognitive-behaviour therapy. In C Perris & IM
Blackburn (Eds.) Cognitive Therapy in Practice . Heidelberg: Springer Verlag.
Williams RM, Moorey S, & Cobb J (1991). Training in Cognitive-behaviour Therapy: Pilot Evaluation of a
Training Course Using the Cognitive Therapy Scale. Behavioural Psychotherapy, Vol.19
, pp.373-376.
A naturalistic study of cognitive therapy supervision activity
Sandy Waite and Ken Gordon, University of Southampton
As the need for good clinical supervision becomes recognised through accreditation and clinical governance systems, it has become apparent that the research base for psychotherapy supervision is inadequate, and even within an explicitly evidence-based approach such as cognitive-behavioural therapy (CBT), we can show little proof that supervision impacts on client outcome, or is consistently applied. Whilst models of good practice exist (e.g. Liese & Beck, 1997), it is unclear how often these
are followed. This study therefore used a naturalistic format to observe supervisor activity during routine
CBT supervision.
Twenty experienced CBT supervisors working in southern England agreed to submit an audiotape of a routine supervision session. Three tapes were used as a pilot phase, being rated by one of the researchers, and an independent second rater, using categories derived from Liese and Beck (1997).
Their structure identifies 9 types of supervision activity, which largely parallel the format of therapy. It was possible to operationally define and rate each of these reliably (agreement 75.3
– 81%), but as most time (73%) was devoted to “prioritisation and discussion of agenda items”, this category was expanded to three sub-categories for the main study, namely: information giving and case conceptualisation, direct instruction, and reflective learning.
10 tapes were received within the timescale of the main study and coded at 30 second intervals, using the revised, 12-item categorisation. In addition, supervisors completed a brief demographic questionnaire, and supervisees were also asked to rate the helpfulness of each category.
Across the group of tapes, most time was spent on information giving and case conceptualisation (32
%). Supervisor activity commonly involved direct instruction (16%), summaries (13%), and reflective learning methods (21%). However, the only form of reflective learning used was guided discovery, with no tape showing any use of live supervision methods. Less than 1% of supervisor time was spent setting and reviewing homework, or bridging from the previous session. There was also considerable variation between supervisors. Finally, activities that supervisees rated as helpful on their questionnaire did not correspond closely with the time actually spent on that activity.
The results suggest that supervisors do not adhere closely to the structure suggested by Liese and Beck
(1997) as a model for effective CBT supervision. This was a small-scale study, and some of the findings may be attributable to variations such as the experience level of supervisees (who included both trainees and qualified colleagues). Nevertheless, taken together with recent survey data (Townend,
Iannetta & Freeston, 2002), it would appear that improved training and closer monitoring of CBT supervisor activity might enhance its value as part of safe and effective practice.
References:
Liese, B.S., & Beck, J.S. (1997). Cognitive Therapy Supervision. In C. Watkins (Ed.), Handbook of
Psychotherapy Supervision (pp. 114-131). New York: Wiley & Son.
Townend, M., Iannetta, L. & Freeston, M. (2002) Clinical supervision in practice: a survey of cognitive behavioural psychotherapists accredited by the BABCP. Behavioural Psychotherapy, 30(4), 485-500.
The impact of supervisee experience level on the conduct of cognitive therapy supervision sessions.
Ken Gordon, University of Southampton
Recent research suggests that the practice of cognitive-behavioural therapy (CBT) supervision in the
U.K. deviates substantially from recommended models. In particular, 'live' supervision methods
(observation, audiotapes of therapy sessions, and role play work) are relatively rarely used within supervision. Live methods are an important way of enhancing skills, and have a particular place within the cognitive-behavioural approach, where supervision is seen as broadly following the same structure as therapy. It is therefore important to investigate why they are infrequently used. Supervisee experience is expected to influence the style of supervision, according to Padesky’s developmental model (Padesky, 1996). This study therefore sought to assess whether supervisee experience is one factor that determines the methods used within supervision meetings.
Fifty supervisors who attended an advanced training event on supervision skills were later contacted by post, with a request to complete a questionnaire, which included ratings of the frequency of use of 11 structural elements and 12 content areas within their supervision practice. Questions were repeated for
(a) supervision of trainees in CBT and (b) supervision of experienced practitioners. Replies were received from 22 supervisors (44%), who had a mean of 10.2 years experience of CBT and had all acted as supervisors (to a mean of 17.6 supervisees).
The survey confirmed previous findings, showing that both live supervision methods, and homework setting and review are infrequently used. However, these elements are significantly more likely to be used in supervision of trainees than in sessions with qualified colleagues. When working with trainees, supervisors also give more direct instruction, and more often discuss CBT skills and protocols, assessment of the supervisee and standards of work. There are no differences between the groups on many other elements (e.g. agenda setting, guided discovery, feedback, discussion of therapist reactions and therapeutic relationship).
There is some evidence from this small-scale survey that supervision style changes as the supervisee becomes more skilled, but this seems to happen in a different way from the process envisaged by
Padesky (1996). Rather than moving on to more complex issues for discussion, the topics covered remain relatively similar, whilst key structural elements such as taped observation and role-play decline.
The paper will discuss possible reasons why this occurs.
References:
Padesky, C.A. (1996). Developing cognitive therapist competency: teaching and supervision models. In
P.M. Salkovskis (Ed.), Frontiers of Cognitive Therapy (pp.267-292). New York: Guilford Press.
Application and effectiveness of CBT treatment programmes
Chair:
Increasing the effectiveness of large-group format CBT in Primary Care through the application of practice-based evidence
Stephen Kellett, David Newman, Linda Matthews & Ann Swift, Barnsley NHS
Primary Care Trust
Within Primary Care, clients presenting with mental health problems are most likely to report the presence of an anxiety disorder. Subsequent referrals to mental health services can result in waiting times due to the sheer scale of clients referred and the domination of individual models of psychological intervention. A recent service delivery innovation has been Jim White’s ‘Stresspac’ approach, which is a group-based six-session psychoeducational CBT intervention. The service philosophy driving the approach is that the provision of such groups liberates clinicians time to provide the necessary individual provision for clients with complex presentations. The current project compared two groups of clients treated with the ‘Stresspac’ approach, the second of which was selected using a locally derived practicebased evidence (PBE) criterion. PBE is gathered using experimental designs that do not meet the stringent parameters of efficacy type research, but have high external validity due to factors such as naturalistic settings. Both groups completed the BSI, BDI-II, IIP-32 and GHQ-12 prior to and following the ‘Stresspac’ intervention. Both groups also completed a satisfaction questionnaire at the termination of the group. The first group (n=16) displayed limited effectiveness and the conclusion was reached that high levels of depression may be interfering with clients abilities to utilise and assimilate the information offered. A selection criterion of a BDI-II score of less than 29 was set for the selection of clients for the second group (n=18). The selection criterion was based on the locally derived PBE, that 29 represents the mean score on the BDI-II for the Primary Care referrals in the district. Analysis of the second group’s data revealed a marked increase in effectiveness across the BSI, BDI and GHQ. Both groups appeared ineffective in terms of the IIP-32 results, but with clients being generally satisfied with the group-based format. The results indicate that active application of PBE in terms of selection of clients may be a means by which the effectiveness of CBT interventions may be increased.
The cost-effectiveness of CBT for Anxiety Disorders
Andrew J. Baillie, Ronald M. Rapee, Maree Abbott, Jonathan Gaston, and Craig
MacMillan, Macquarie University, Sydney, Australia
With increasing pressure on health service budgets there has been an increase in interest in the economic analysis of health care technology. Existing research into the cost effectiveness of CBT for anxiety disorders has employed estimates of direct treatment costs or more recently measured a narrow set of direct treatment costs in a specialist settings. Analyses of the cost burden of anxiety disorders have found that while health service use costs are high they are not as large as the economic effect of days off work or reduced efficiency work days. These disorders also place a burden on family members and carers which can be quantified in economic terms. Thus direct treatment costs are likely to be a small part of the impact of anxiety disorders on our communities. Because of the magnitude of these effects it is important to consider whether intervention reduces these broader costs. Indeed guidelines for the evaluation of the cost-effectiveness of health programs recommend the broadest possible or societal perspective in the selection of costs. Using data from a completed study of the costeffectiveness of brief CBT for panic attacks and an ongoing study of CBT for social phobia we will illustrate some of the difficulties and considerations in the cost-effectiveness of CBT for anxiety disorders. In particular time taken to practice skills and techniques may be considered a cost, because it may reduce time for other valued activities such as childcare, housework, and leisure time. Giving up some of these activities may place an additional burden on family members but may also be considered as an investment by the client. Because homework is important for the effectiveness of CBT valuing the time taken to carry it out is important for economic analyses. Costs associated with time taken to carry out anti-anxiety procedures were high in the study of brief CBT for panic attacks but importantly clients were not using this time for optimal evidence based procedures such as exposure. There will be some opportunity to discuss issues relating to the cost-effectiveness of CBT.
An Investigation of the effectiveness and acceptability of a computer-based treatment for anxiety and depression.
Deborah Mairs, Laura Kildea, Brian McCrum, & Micheal Gallagher, Homefirst
Community Trust. Northern Ireland.
Background: The effectiveness of Cognitive Behaviour Therapy (CBT) in the treatment of many psychological problems is well supported by evidence from randomised controlled trials. There is a high level of demand for face to face therapy but not the staff resource to meet the demands.
Aim: To explore the effectiveness and acceptability of cognitive behavioural therapy provided by a computer-based intervention.
Method: Opportunity sampling was used. Participants in the project were selected from psychology waiting lists and from referrals by mental health professionals. Suitability for inclusion was based on responses to a structured interview, standardised inventories and questionnaires (the Beck Depression
Inventory, the Beck Anxiety Inventory and the Clinical Outcome in Routine Evaluation). Anyone who was currently suicidal, engaging in self-harm or involved in alcohol or other substance abuse was excluded from the project. The computer therapy package selected for use was “Beating the Blues”.
Results: Differences between pre- and post-treatment scores indicated a statistically significant improvement in depressed mood (as measured by the Beck Depression Inventory), and in anxiety (as measured by the Beck Anxiety Inventory), and across all subscales to the Clinical Outcome Routine
Evaluation. Participants reported that their involvement in this intervention promoted their selfempowerment, and the facility to progress at their own pace contributed considerably to the benefit they experienced from the programme.
Conclusion: Early results f rom this study indicate the value of the “Beating the Blues” computer-based therapy as part of a wider range of therapeutic intervention in the treatment of depression and anxiety.
Results of a Computer-Aided Self-Help Service for Anxiety and Depression in
Primary Care
Mark Kenwright, Ealing Cognitive Behavioural Therapy Service
The recent appraisal by NICE of computerised CBT for (CCBT) depression and anxiety concluded that evidence for effectiveness is at present limited, with a need for further research that includes patients with co-morbidities routinely treated in primary care settings. In order to provide the kind of guide to outcome in daily practice that cannot be well demonstrated by randomised controlled trials, a computeraided self-help clinic was set up to offer broad-spectrum CCBT in primary care. Four CCBT systems, employing several modes of access, were available for sufferers of a variety of anxiety and depressive disorders. It operated for 15 months as a pragmatic evaluation project within the West London Mental
Health Trust and the Charing Cross Campus of Imperial College. The service dealt with 355 patients over one year. Results of clinical outcome, patient satisfaction, resource implications and the effect on a local GP practice will be presented. Issues for future service models will be explored.
Internet-based cognitive behaviour therapy to treat panic disorder: How effective is it?
Jeffrey C Richards, Britt Klein, & Marlies E Alvarenga, Monash University,
Melbourne, Australia
The internet is increasingly being used as a source of mental health information as well as structured treatment programs for people with mental health concerns or difficulties, who choose not to seek or who have limited access to face-to-face specialised treatment. This paper discusses the evaluation of our internet-based treatment for panic disorder, one of the more common and, with agoraphobia, disabling anxiety disorders. Our treatment intervention consists of a detailed and structured cognitive behaviour therapy (CBT) program for panic disorder and agoraphobia, together with email assistance from clinical psychology graduate students. From three studies over four years with 100 people with panic disorder, this paper presents results showing that our internet-based CBT intervention is superior to internet-based information about panic and anxiety alone, and superior to the use of a therapistassisted self-help written manual based on CBT principles. Our studies show that use of the internetbased CBT program is associated with reductions in fear of ambiguous bodily sensations and that its effects are greatly enhanced when basic stress management information and advice is added to the panic control program. Our internet-based CBT program produces changes in panic-related variables and measures of end-state functioning that are statistically and clinically significant. Moreover, the effect sizes generated in the comparative trials of our internet-based CBT program range from medium to very large. Attrition rates are comparable to those found in face-to-face CBT, and therapeutic change from use of the internetbased program is not related to participants’ educational levels.
Pragmatic evaluation of computer-aided self help for anxiety and depression
Isaac M. Marks, David Mataix-Cols, Mark Kenwright, Rachel Cameron, Steven
Hirsch, Lina Gega, Imperial College School of Medicine
Background: Many sufferers with anxiety and depressive disorders find it hard to access effective treatment. This study aimed at a pragmatic evaluation of a free clinic giving immediate access to
cognitive behaviour therapy for anxiety and depression via broad-spectrum computer-aided self-help plus brief advice from a therapist.
Methods: Outcome and satisfaction were measured of a year's referrals who sent a Screening
Questionnaire and did computer-aided self-help with one of 4 systems, for non-suicidal depression, phobia/panic, general anxiety, or obsessive-compulsive disorder.
Results: The equivalent of one full-time clinician dealt with 355 referrals over a year, of whom 266 had a
Screening Interview, of whom 79% were suitable. Pre-treatment features were similar among the 108 suitable patients who completed computer-aided self-help and gave post-treatment data (51%), or refused such self-help (20%), or gave no post-treatment data (29%) - all 3 groups had very chronic moderately-severe problems. Completers of computer-aided self-help had a mean total of an hour's live support with a therapist over 12 weeks; they improved both significantly and clinically meaningfully with
3 of the 4 self-help systems and rated themselves as fairly satisfied. Improvement was similar to that in controlled and other trials of computer-aided cognitive behaviour therapy.
Conclusions: Broad-spectrum computer-aided self-help enabled clinicians to greatly cut their per-patient time and raise their throughput of anxious/depressed patients having cognitive behaviour therapy without impairing effectiveness
Children and Adolescents
Keynote Addresses
The role of parenting interventions in the prevention of childhood psychopathology
Matthew Sanders, University of Queensland, Australia
Family conflict and poor parenting are generic risk factors associated with a wide variety of adverse developmental outcomes in children including increasing risk for conduct problems, drug abuse, delinquency and academic underachievement. This paper makes the case for the importance of a population perspective in addressing parenting and family risk factors related to the development of child psychopathology. A comprehensive multilevel model of parenting and family support is presented.
Empirical evidence concerning the efficacy and effectiveness of media, primary care within a brief consultation format, and more intensive family intervention programs are discussed. Predictors of differential response to different levels of intervention are highlighted. The evidence reviewed shows significant effects across several trials on both child and parent mental health outcomes (particularly depression and marital conflict). Challenges in disseminating empirically supported interventions and future possible directions for family intervention research are discussed.
Can young children do CBT?
Shirley Reynolds, University of East Anglia
The treatment of mental health problems amongst children lags behind treatments for adults. There is great interest and enthusiasm for adapting CBT for children but limited knowledge about the applicability of cognitive models to children and the extent to which children can engage in the cognitive aspects of
CBT. Basic knowledge about children’s cognitive development is scant and little of this has been disseminated to or conducted by clinicians. The aim of this presentation is to highlight some recent developmental research on children’s cognitive and meta-cognitive development and to link this with the development of CBT for children.
Raising the game in CBT intervention studies for children: from developmental theory to clinical practice and back again
Stephen Scott, Institute of Psychiatry, London
In this presentation I will discuss two kinds of evidence. First, to what extent can cognitive models of disorder be applied to children? Second, what cognitive skills do young children possess, and how do these relate to childr en’s ability to take an active part in cognitive behaviour therapy.
Developmental science tells us that child and adolescent mental problems have multifactorial causes
– for example David Farrington identifies 26 separate factors that contribute to teenage antisocial behaviour. Yet clinicians in everyday practice often tend to offer only one main treatment modality, ranging from CBT with the young person to parent counselling. Many of the best evidence-based intervention packages address one risk only. Thus there have been over 400 trials of parenting programmes for antisocial behaviour, but far fewer addressing the other 25 risk factors. It is as if there are two parallel universes, that of the jobbing clinician and that of the research psychologist. I will argue that closer collaboration will have benefits for both sides. Not only can treatment outcomes get better if
we can find cost-effective ways to address several risk factors, but interventionists can in their turn help elucidate mechanisms. This is because cross-sectional and longitudinal studies are inevitably prone to confounding errors, whereas experimental/intervention designs hold them constant. Thus some recent behavioural genetic studies suggest that parenting has little or no effect on child outcomes. Yet intervention trials demonstrate that within individuals, changing parenting makes a large difference on child outcomes, and further that when mediating mechanisms are measured, it is proximal parenting behaviour rather than depression or critical comments that are the active ingredient. In conclusion, the researcher can enrich the life of the interventionist, and the interventionist can enrich the life of the researcher: the question is how to make it happen?
Symposia
Parenting: from individual to universal interventions: 1
Convenors: Rachel Calam, University of Manchester and Cathy Creswell,
University College London
Chair: Cathy Creswell, University College London
Lessons from Naturalistic Studies of Parenting and their Implications for
Intervention Research
Thomas O’Connor, Institute of Psychiatry, London
Research findings reported in recent years have both advanced and entrenched debates on basic issues in the study of parentchild relationships and children’s psychological well-being. Several findings, particularly from behavioural genetics investigations, are worth highlighting: a) parent-child relationship quality is partly mediated by genetically-mediated characteristics of the child, b) children growing up in the same family resemble one another for genetic reasons rather than because of
“shared” environmental experiences, c) studies of biologically related families are unable to address even rudimentary questions concerning the environmental mediation of parent-child relationships on child psychological outcomes. There are, in addition, a number of methodological questions that have yet to be answered, such as how best to study parent-child interactions (e.g., behaviours versus cognitions) and how best to gather this information (e.g., observation, interview, questionnaire).
The current presentation will review the general state of play of parenting research from the perspective of naturalistic and quasi-experimental studies and discern some of the major conceptual and methodological lessons from these studies. This information will then be used to point to the kinds of intervention studies that would be most useful for tackling lingering questions in the field.
The Parent Child Game: a single case
Rachel Calam, University of Manchester and Helen Carlton Smith, Booth Hall
Children's Hospital, Manchester
The Parent Child Game was originally developed by Forehand and McMahon and subsequently developed in the UK context by Jenner. It is an individual programme of intensive work with parents and children which teaches parenting skills "online" through direct feedback and advice while the parent is interacting with the child. Advice is given via a bug in the ear by a trained professional who is watching parent and child together either through a videolink or one-way mirror. Usually, a team runs the clinic, with different staff taking responsibility for face-to-face work and observation and consultation. In common with other parent skills training interventions, techniques aim to enhance positive interaction between the parent and child and to provide help with specific techniques for managing difficult behaviour, for example systematic ignoring and "time out". Systematic questionnaire and observational data are collected at specified points in the clinical intervention. The approach is established as good clinical practice. There have been a number of studies which indicate that it leads to improvements in child behaviour and other associated improvements in family functioning. Because this kind of work is very labour intensive, and runs over an extended period, it tends to be reserved for families who have already attempted other therapeutic approaches. A single case will be presented, with videotaped examples to illustrate both the techniques and the level of change that can be achieved with this approach.
Development of Early Intervention Services in Manchester
Caroline White , Booth Hall Children’s Hospital, Manchester
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. This paper will outline the citywide service developments
across Manchester using the Webster-Stratton model of parent training, as an effective early intervention strategy. In particular, two multi-agency parenting initiatives will be discussed: one provides early intervention parent training to parents of pre-school children and the other provides a training resource to workers to enable them to run effective parenting courses within their own services & communities. The early intervention strategy presented is a model for successful partnership working between health, education, social services and the voluntary sector; funded from a number of sources, including NHS Modernisation Fund, Children’s Fund, Surestart, Neighbourhood Renewal Fund. The pathways to successful service delivery will be explored and parental outcomes will be presented.
Effectiveness of a school-based parenting programme that targets both
antisocial behaviour and literacy
Stephen Scott, Institute of Psychiatry, London and Kathy Sylva, University of
Oxford
Introduction Prevention programmes for social exclusion starting in childhood suffer from small effect sizes and poor takeup rates, or else are so expensive they are unrepeatable. The SPOKES (Supporting
Parents on Kids Education) project aimed to tackle some of these difficulties by offering a programme that would interest all parents concerned to maximise their child’s potential.
Method Strengths and Difficulties Questionnaires (SDQs) were completed on 1033 grade 1 and 2 children by teachers in 8 schools (99.5%). Parents of 633 (61%) returned SDQs. Those above the 10 th percentile nationally for antisocial behaviour were invited to take part, n = 134. They were a typical inner-city, multi-ethnic disadvantaged population, and were randomised to the intervention or an advice helpline. The intervention had 3 parts: the 12 week Incredible Years program (Webster-Stratton), a 10 week parent-led child literacy program, and 6 weeks of the Incredible Years problem-solving program .
Results 110/134 invited parents took part. Mean attendance was 14/26 sessions. One year after starting intervention, antisocial behaviour reduced by an effect size 0.51 standard deviations on semi-structured interview, ADHD symptoms by es 0.43; reading age increased by 7 months, es 0.41.
Conclusion Parents in the community are prepared to take up this type of program in large numbers. It is effective in ameliorating four risk factors for poor long-term outcome, namely antisocial behaviour,
ADHD, poor reading, and poor parenting. The long-term cost savings are likely to be very large. It makes economic and humanitarian sense to implement such programs widely.
Parenting: from individual to universal interventions: 2
Convenors: Rachel Calam, University of Manchester and Cathy Creswell,
University College London
Chair: Rachel Calam, University of Manchester
Teen Triple P: Outcomes and Issues in a clinical sample
Charlotte Wilson, Cambridgeshire and Peterborough Mental Health Trust
Emotional and behavioural problems in adolescence are relatively common. These can be particularly difficult for parents and families to manage and cope with, given the extra challenges of negotiating increasing independence and autonomy for the teenager. Approaches such as Cognitive Behaviour
Therapy may be more effective and acceptable for teenagers with emotional and behavioural problems, and so parents of teenagers may not be offered as much input or involvement as they would if their child was younger. There may also be fewer informal support systems for these parents.
Teen Triple P is based on social learning principles that have been extensively researched. It aims to give parents of teenagers a range of developmentally appropriate strategies to help promote positive development and manage difficult and risky behaviours in their teenager. Triple P emphasises selfregulation as a central skill, and encourages development of support systems within the group.
Early results from a transition to high school project in Brisbane are extremely encouraging. However, few groups have been run in the U.K., or for parents of teenagers already involved in specialist mental health services. Results from the first three groups run in a specialist child and family mental health service will be presented. Outcomes reported on will include teenagers’ behaviour, parents’ parenting styles and attitudes, pa rents’ own mental health and relationship quality. Satisfaction with the service will be reported on and some of the issues arising from the groups will be discussed.
Reducing risk factors for behavioural and emotional problems in adolescents with an early intervention parenting programme (Teen Triple P): Engagement, delivery and outcome
Alan Ralph, Matthew R. Sanders, & Helen Stallman, School of Psychology, The
University of Queensland, Australia
The engagement of parents and identifying optimal options for delivering effective parenting advice and support to parents of adolescent and pre-adolescent children poses significant difficulties. Teen Triple P is multi-level system of intervention that is designed to provide parents with specific strategies to manage the behaviour of their teenage children as they make the transition into high school and through puberty. The program is based on a combination of education about the developmental needs of adolescents, skills training to improve communication and problem-solving skills, plus specific modules to deal with common problems encountered by parents and adolescents that can escalate into major conflict and violence. Analysis of the effectiveness of a group parenting delivery modality with parents of first-year high school students revealed significant improvements in parenting efficacy and style, reductions in conflict between parent and teenager, and reductions in parental depression and stress. In addition, a family-based self-directed delivery modality, which included a self-directed workbook and video, was compared with an enhanced program which included weekly telephone consultations.
Significant improvements were reported for those parents who completed the telephone-assisted program relative to those parents who participated in the unassisted version of the program. Implications of the findings for parent engagement and implementation of population-based early intervention parenting programs to reduce behavioural and emotional problems in adolescents will be discussed.
Triple P as a whole school approach in primary schools – developing a genuinely joined up project which “does what it says on the tin”.
Claire Halsey, North Staffordshire Combined Healthcare NHS Trust
This paper presents an innovative use of Triple P as an agent for change in five Primary Schools in
Stoke on Trent. Schools represent a universal service to children and parents and as such have strong untapped potential to support families. Our use of Triple P capitalises on this access to parents and responds to teacher’s pleas for parent support. By training all school staff in Universal Triple P and developing a full Triple P service targeting each school we hope to enhance home
– school support and improve children’s behaviour and emotional well-being. This presentation covers the establishment of a service co-led by Health and North Staffs MIND, closely involving education and financed by the
Children’s Fund. Our strategy is to increase the supportive role of all school staff, including those not traditionally in receipt of parent support information, e.g., secretaries, and lollipop people. We are evaluating our work at both a whole school and individual level. We will present our large scale pre –test measure, The Whole School Behaviour Review, incorporating feedback from staff, children and parents on school life. Outcomes for Triple P services in each school will be presented including early work in a school serving children with moderate learning difficulties. Links between our service and Boxall Nurture groups will be touched upon. The issues of mainstreaming and exit strategy will be discussed including early data on delivery of Triple P services by other agencies and disciplines across Stoke on Trent.
Parenting Education in Context
Michael Killoran Ross and Linda de Caestecker, Greater Glasgow NHS Board
There is significant national interest in parenting education among both politicians and parents themselves. However, there is concern that the provision of parenting education can stigmatise rather than support parents and the context within which parenting education is provided is of increasing concern. The Starting Well Health Demonstration Project ensures that participating parents are universally offered parenting education as a component part of a broad range of family support services.
This paper will describe the Starting Well Project, will specifically focus on the delivery of a parenting education programme as part of the Project and will explore issues in the provision of community based parenting education.
The Starting Well Project aims to demonstrate that child health can be improved by a programme of activities that both supports families and provides them with access to enhanced community-based resources. The Project is implemented through a programme of intensive home-based health visiting, lay worker support and community development. Implemented in two areas of socio-economic deprivation in Glasgow, it is important to recognise that the Project is based on a concept of a
“vulnerable community” as opposed to the concept of vulnerable families.
The implementation of the Project and the development of the parenting education activities within the
Project have led to certain conclusions regarding community based parenting education. These conclusions include observations on the particular demands placed on service (both health and nonhealth based) infrastructures. These issues will be explored in detail in this presentation.
Remote application of CBT with children and adolescents
Convenor: Cathy Creswell, University College London
Chairs: Chris Williams, University of Glasgow and Cathy Creswell,
University College London
Potential for computer aided self-help for adolescents with phobia/panic or
OCD
Isaac Marks, Imperial College London
Computer-aided CBT (CCBT) self-help together with brief helpline support from a therapist proved effective in open studies and in randomised controlled trials for both phobic/panic and obsessivecompulsive disorder (OCD). These trials mainly involved adults but did include some adolescents who posed no special problems. A few young adolescents needed help from parents to complete their selfhelp program. The main self-help systems were 1) FearFighter for phobia/panic, which patients can now access at home on the web, and 2) BTSteps for OCD, an interactive voice response system which patients accessed by phone from home after receiving a manual to guide them through the system.
CCBT reduced both distress and disability. CCBT enabled therapists to treat 4 times more patients than was possible without it by delegating routine aspects of therapy to the computer. Some modifications of the self-help systems might be desirable for them to become optimal for young adolescents. CCBT currently requires users to have initial screening by a clinician and brief subsequent advice from a clinician, all of which can be done by phone while users self-treat at home. CCBT is a clinician extender, not clinician replacer.'
Multimedia information for young people with Obsessive compulsive disorder
(OCD)
Isobel Heyman and James Woolley, Institute of Psychiatry, London
Cognitive behaviour therapy (CBT) protocols for the treatment of obsessive compulsive disorder in young people emphasise the importance of psychoeducation. Evidence from other chronic disorders suggests that access to, and assimilation of, high quality health information, facilitates recovery and maintenance of remission. We will present the development and use of a CD-ROM information pack on
OCD for young people with this condition. Surveys of its utility will be summarised, with feedback from both health professionals and service users, their friends and families. A study designed to measure the impact/efficacy of psychoeducation will be discussed. A web site version of the CD is under development, with help and advice from young people, and we will present the prototype of the site, with examples of the input from users and some of the methods available for evaluating the impact of websites. We will also use the opportunity to discuss benefits and risks of web-based mental health resources.
Treatment of Child Anxiety in Rural Australia using Therapist Supported -
Parent Led CBT.
Heidi J. Lyneham & Ronald. M. Rapee, Macquarie University, Sydney, Australia
Research has indicated that anxiety disorders in childhood can be successfully treated using CBT.
However current programs rely on direct contact between a therapist and family which indirectly excludes some children because of geographic isolation from services. In response to this service gap a standard therapist-administered CBT program was developed into a home-based treatment programme.
A parent, using written materials as a guide, implements the programme with the ongoing support of a psychologist based at the clinic in Sydney. The targeted children live in regional and rural areas of
Australia, are 6-12 years and have been diagnosed with an anxiety disorder as their main presenting problem. The home-based programme is being evaluated in a randomised treatment outcome study that compares scheduled telephone sessions, scheduled emails, and family initiated contact with a waitlist control. Approximately 100 children have completed to the post treatment assessment and 1 year follow up data is currently being collected. Results indicate that the home based programme is an efficacious way of treating childhood anxiety, with better outcomes being achieved when the programme is supplemented by scheduled telephone sessions than when used with email or ad-hoc contact. Initial findings will be presented along with comment on the unique characteristics of conducting therapy with families at a distance.
Development and evaluation of a new computer intervention to teach people with autistic spectrum disorders how to recognise and predict emotions in others.
Miriam Silver, Northampton General Hospital
The Emotion Trainer computer program was designed to help people on the autistic spectrum learn to recognise and predict emotions in others. It is a multi-media CD ROM intervention, for use in home, school or clinical environments, for people with a reading age over 7.
The content of the computer program was designed according to current research findings about social skills training, use of computers and emotional understanding in this population. It is designed to be an
errorless learning experience, presenting only relevant information and free from social demands. It engages users in an enjoyable interactive learning experience, progressing at their pace and providing consistent and predictable responses, which can be repeated indefinitely without fatigue.
The program was evaluated using a randomised controlled trial. Two groups of eleven children (age 12-
18) with autism or Asperger's syndrome from two special schools participated. Individuals in one group used the computer program for 10 half-hour sessions over two weeks. Students were assessed pre and post intervention using facial expression photographs, cartoons depicting emotion-laden situations, and non-literal stories.
Scores were not related to age or verbal ability. The experimental group made gains relative to the control group on all measures, reaching significance on the cartoons and stories, despite the small sample size. Gains correlated significantly with the number of times the computer program was used.
Results suggest positive effects of using the program, and encouraging signs of generalisation. Further research could assess whether these gains i mproved "real life" skills or “Theory of Mind" measures.
CBT for children and young people with autistic spectrum disorders
Convenor and Chair: Maria Callias, Child Mental Health Learning Disability
Service, St George’s Hospital, London
Cognitive BT for anger control in Pervasive Developmental Disorder: Cognitive
Self Statements according to 'Bart'
Kathryn E. Greenwood (1) and Maria Callias (2)
(1) Department of Psychology, Institute of Psychiatry, London and (2) Child Mental
Health Learning Disabilities Service, St Georges Hospital, London.
Autistic Spectrum disorders are associated with high levels of behavioural and emotional disturbances.
A case is presented of bullying and catastrophic fears concerning loss of control in a 13-year old boy with Pervasive Developmental Disorder (PDD). Predisposing factors included his immature speech and motor control which encouraged teasing; poor social skills, impulse control and paucity of alternative actions which led to sudden tempers; and rigid catastrophic views concerning the consequences of rule breaks. Triggers included a recent school move, teasing and forced rule-breaks, which escalated his emotional responses and subsequent bullying.
Therapy included discussion of incidents to promote social problem solving; behavioural strategies and relaxation to encourage rage control; and cognitive techniques to evaluate and create alternative cognitions and self-statements, and alleviate distress. Adaptations for PDD included the use of concrete examples, role plays and role models to aid development of self-statements; the use of pictorial images to represent tension, emotion, responsibility and cognitions and to capitalise on artistic strengths; and the use of a parent as a co-therapist to enable modelling of approaches. Bullying incidents, tension and the client's reactivity to teasing decreased and he became more aware of his own role in escalating incidents. Of particular importance, he used pictorial self-statements and responsibility pie charts to promote self-confidence and personal control, to construct alternative beliefs and to reduce anger and anxiety.
This study demonstrates the effectiveness of a cognitive intervention, with specific adaptations for cognitive strengths and deficits, in a child with PDD.
Behaviour problems in children with autistic spectrum disorders: management at a distance by telephone and email.
Tim I. Williams, G. Oliver, M.J. Stroud, L. Mason & E. Pullen, CHASAC team,
Berkshire Healthcare NHS Trust
The aim of this work was to demonstrate the feasibility of providing advice on managing behaviour by telecommunications. The study described is a two phase evaluation of a service provided for parents of children with autistic spectrum disorders aged between 2 and 19 years of age in a total population of about 500,000 people. The service collates the information using specialist computer software
(Challenge, www.antam.co.uk) to generate hypotheses regarding the function of behaviour, which in turn leads to intervention strategies. The functions identified by this process are then used to design non-aversive behavioural management strategies. In the first phase we attempted to implement a telecommunications only strategy. Other professionals referred parents because they were having problems managing the behaviour of their children. Twenty families were contacted by the service, but only three took up the offer of help. The second phase of the study involved starting the intervention with a home visit to explain the purpose of the service. A further fifty families were recruited to this phase.
The majority of these families returned enough information for the team to design interventions. 40% of the behaviour problems were maintained by attention. The interventions are then monitored remotely by the service. The ability to use telecommunications to provide interventions has reduced the need for home visiting and has increased efficiency of the team. Difficulties with the service are also described
and consideration is given to the nature of the service required by parents of children with autistic spectrum disorders and difficult behaviour. Particular attention is paid to the effects of parenting a child with communication problems.
Cognitive-behavioural intervention with young adults with Asperger's syndrome
Dougal Julian Hare, University of Manchester
Concomitant with an increase in the recognition of Asperger's syndrome in both children and young adults, there has been a demand for appropriate psychotherapeutic input for the difficulties which many people with this diagnosis experience. In particular, people with a diagnosis of Asperger's syndrome seem vulnerable to developing severe anxiety and delusional beliefs in adolescence. This paper will discuss, from a cognitive-behavioural perspective, (1) the engagement of people with Asperger's syndrome in therapeutic work and (2) the conceptualisation of delusional belief and its clinical implications.
Issues for CBT interventions with individuals with Autistic Spectrum Disorders
Maria Callias , South West London and St. George’s Mental Health NHS Trust
The papers presented illustrate developments in some of the ways CBT therapeutic approaches have played an important role in ameliorating or managing the psychological and developmental problems of individuals with ASD. They also raise issues for future work and the role that CBT can play in the overall management and education of individuals with ASD.
Among the issues that need to be addressed more explicitly are: the relevance of age and cognitive development of individuals to CBT interventions; ways of working - directly with individuals, with ASD, and /or through parents (and other significant adults, such as teachers); use of CBT to address specific difficulties and incorporation of CBT into broader educational programmes and social skills training; and the limitations as well as the major positive contributions of CBT for individuals with ASD.
PTSD in children and adolescents
Convenors & Chairs: Paul Stallard, Royal United Hospital, Bath and Cathy
Creswell, University College London
Intrusive post-traumatic stress symptoms and coping processes in a nonclinical child and adolescent population.
Richard Meiser-Stedman, Patrick Smith, William Yule, Institute of Psychiatry,
London & Tim Dalgleish, MRC Cognition and Brain Sciences Unit, Cambridge
Cognitive models of PTSD in adults have stressed the importance of intrusive post-traumatic stress symptoms, and how individuals cope with such symptoms, in the aetiology of the disorder. Intrusive memories of a traumatic event are thought to arise from laying down poorly structured and sensory focused memories of the event. Other processes, such as the negative interpretation of intrusive symptoms and thought suppression, are hypothesised to maintain the occurrence of these symptoms. A study examining the applicability to children and adolescents of this theory was undertaken. A nonclinical sample of 11-17 year olds, recruited from two English secondary schools, completed self-report questionnaires concerning the most frightening event to have happened to them in the previous two months. The questionnaire battery assessed 1) each child/adolescent’s affect at the time of the event, 2) how frequently they had intrusive memories of the event, 3) the affect associated with having intrusive memories of the event, 4) the quality (e.g. structure, sensory versus verbal form, etc.) of the child/adolescent’s memories of the event, 5) how the child/adolescent typically copes with unpleasant and unwanted thoughts and memories, and 6) the child/adolescent’s PTSD and depressive symptomatology (using the Revised Child’s Impact of Event Scale and the Birleson Depression Self-
Rating Scale). The results of this study will be presented and discussed with regards to cognitivebehavioural interventions for children and adolescents suffering from PTSD.
Post-traumatic stress symptoms in London school children following terrorist attacks on September 11th 2001: Predictors and stability of symptoms
C. Creswell, University College London, E. A. Holmes, MRC Cognition and Brain
Sciences Unit, Cambridge & T. O’Connor, Institute of Psychiatry, London
A number of recent studies have described the emergence of symptoms of post-traumatic stress in children after remote witnessing of a traumatic event via the media. The aim of the current study was to replicate these findings and investigate possible predictors of an enduring stress reaction. Specifically,
cognitions at the time of the trauma (peri-traumatic) have recently been cited as a primary predictor of the subsequent development of PTSD in adults and children. This study investigated whether the same held true for events that were witnessed remotely. The event occurred on September 11 th 2001 when the USA was subjected to terrorist attacks. These events were widely and extensively reported through television coverage, radio, and photographs in the print media
London school children (n=76) who saw the events on television completed self-report measures of post-traumatic stress reactions relating to the terrorist attacks and potential predictors of distress 2 and
6 months after September 11 th 2001. 14.5% of children reported stress reactions consistent with PTSD two months after the attack; as did 9.2% of children 6 months after. Self-reported post-traumatic stress symptoms at both assessments were predicted by the child’s subjective feelings during the attack and subsequently perceiving the world as a more dangerous place. Sense of personal danger at the time of the event was associated with PTSD symptoms at 6 months, after controlling for symptom stability.
These results suggest 'psychological distance', rather than 'geographical distance' may be of primary importance with regards the development of post-trauma symptomatology. Implications for the identification and treatment of at-risk children following media coverage of traumatic events, such as warfare that has ensued since 9/11will be discussed.
Post-traumatic stress symptoms in London school children following terrorist attacks on September 11th 2001: Intrusive mental images
E. A. Holmes, MRC Cognition and Brain Sciences Unit, Cambridge & The
Traumatic Stress Clinic, London C. Creswell, University College London T.
O’Connor, Institute of Psychiatry, London and A. Saunders, University College
London
A key response to trauma can be intrusive re-experiencing. We investigated whether London school children experienced intrusive mental images following media coverage of the traumatic events of
September 11 th 2001. The contents of any intrusive images were assessed via a checklist of prevalent
TV images (such as the planes flying into the twin towers) and free report of any additional images.
We found that a significant minority of children reported experiencing intrusive images of the attacks at both 2 and 6 months, and stability over time is considered. Levels of PTSD-like symptoms were predicted by the presence of images of the traumatic events. This relationship held even when the reexperiencing subscale of the PTSD questionnaire was removed. Qualitative inspection of free report images indicated that children had also incorporated personally relevant figures into images, for example, an image of an uncle jumping from the twin towers. These findings are limited by lack of a clinical interview. However, they provide indication that a significant minority of children experience considerable distress after media coverage of remote traumatic events. Furthermore, the findings indicate the importance of assessing for traumatic intrusive imagery in children, and are relevant to the treatment of children’s reactions to remote-trauma.
School-based CBT Group Intervention for Refugee Children who have experienced War-Related Trauma
Kimberly A. Ehntholt, Patrick Smith and William Yule, South London and Maudsley
NHS Trust & Department of Psychology, Institute of Psychiatry, London
Approximately 10 million of all refugees and displaced people worldwide are children, who have been forced to flee due to wars, ethnic cleansing campaigns and political unrest (UNHCR, 2001). PTSD symptoms are common amongst children who have been exposed to war. An estimated 40% of young refugees in Britain may have mental health difficulties, including PTSD, depression and anxiety (Hodes,
1998). As numerous barriers prevent refugee children from accessing mainstream mental health services, innovative methods of providing treatment are required. School-based interventions have the potential to provide non-stigmatising, easy access to mental health care for large numbers of refugee children.
This study evaluated the effectiveness of a school-based group intervention designed for children who have experienced trauma. Twenty-six children (aged 11 to 15 years) who were refugees or asylum seekers from war-affected countries participated. The manual-based intervention consisted of CBT techniques and was implemented within London schools. The treatment group (n=15) received six sessions of group CBT over a six week period, while the control group (n=11) were placed on a waiting list for six weeks and then invited to enter treatment. Children in the CBT group showed significant improvements following the intervention with decreases in overall severity of post-traumatic stress symptoms and symptoms of intrusion. Significant improvements were also found in overall behavioural difficulties and emotional symptoms. The findings from this study and the implications for group interventions with refugee children experiencing PTSD symptoms will be discussed.
A randomised controlled trial to determine the effectiveness of an early
intervention with child trauma victims.
Paul Stallard1, Richard Velleman1, Emma Salter1, Imogen Howse1, William Yule ²,
Gordon Taylor ³ and Willm Mistral1
1 Avon and Wiltshire Mental Health Partnership NHS Trust and University of Bath
2 Department of Psychology, Institute of Psychiatry
3 Research and Development Support Unit, University of Bath/Royal United
Hospital Bath.
Road traffic accidents (RTAs) are a significant public health issue that each year affect a large number of children. Official statistics identified 72,674 children under the age of 18 as being involved in a RTA in
2001(Transport Statistics Great Britain 2002). The psychological consequences arising from such accidents have been documented and suggest that six weeks after an accident approximately 30% of children will present with significant adverse reactions (Mirza, Bhadrinath, Goodyer & Gilmour 1998;
Stallard, Velleman & Baldwin 1998). There is therefore a need to determine whether early interventions with child trauma victims are effective in reducing subsequent adverse psychological reactions.
This is the first randomised-controlled trail to examine the effectiveness of an early intervention for child trauma victims. A total of 158 children aged 7-18 were randomly allocated, four weeks after their accident, to an intervention (facilitated trauma discussion) or a control (discussion about neutral events) condition. The facilitated trauma discussion was designed to help the child achieve a coherent narrative of their accident, to understand their cognitions and emotional reactions and to normalise any subsequent psychological changes. A diagnostic PTSD interview and a battery of self and parent completed assessments were completed before the children were assigned to their study group. The assessments were repeated approximately 8.5 months post-accident with 131 (82.9%) of the cohort being successfully re-assessed.
The results of this study will be presented and the implications for early interventions with child trauma victims will be highlighted.
Panel Debate
ADHD: The drugs don’t work
Convenors: Veira Bailey, The Maudsley Hospital, London
Chair: Stephen Scott, Institute of Psychiatry, London
Many people have strongly expressed views about the use of medication for children and particularly the use of stimulant medication for children with ADHD.
The debate will be an opportunity to hear from leading experts in the field who will explore the issues and review the evidence for what works for whom.
Open Papers
Child and Family Issues
Chair: Alice Farrington, Oxfordshire Mental Health Care Trust
Gender differences in the links between maternal core beliefs and children’s feeding problems
Caroline Meyer, University of Warwick, Jackie Blissett, University of Birmingham,
Rachel Bryant-Waugh & Dasha Nicholls, Institute of Child Health & Great Ormond
Street Hospital, London
Objective: Whilst maternal mental health problems have been implicated in the exacerbation of childhood feeding difficulties, little research has assessed the contribution of broader maternal cognitions to these problems. This study examined gender differences in the relationships between mothers’ core beliefs and children’s feeding problems. Method: One hundred and three mothers of girls and ninety-three mothers of boys (all aged between 7 and 64 months) completed the Young Schema
Questionnaire (Young, 1997) and the Child Feeding Assessment Questionnaire (Harris & Booth, 1992).
Results: Whilst controlling for child age, a clear link between maternal core beliefs and perceived feeding difficulties emerged for mothers of girls. In particular, abandonment, failure to achieve, dependence & incompetence, enmeshment and defectiveness & shame beliefs were associated with increased reports of feeding problems in their daughters. In contrast, Emotional deprivation and subjugation beliefs were associated with food fussiness and food refusal in boys. Discussion: There
appears to be a clear role for maternal core beliefs in the reporting of feeding difficulties in children, and the specificity of these links differ depending on the gender of the child.
Social Information Processing in Oppositional Defiant and Conduct Disordered
Children- Do treatments for their behavioural difficulties also improve their social problem solving abilities?
Marita T Brack and Pauline Howie, The University of Sydney, NSW, Australia
Whilst there has been much research focus on treatments for children with oppositional defiant disorder
(ODD) and conduct disorder (CD), the role that cognitions play in the development and maintenance of conduct problems has been less well studied. One theory that can possibly shed light on the role that cognitions play for conduct problem children is the theory of Social Information Processing (SIP) put forward by Crick and Dodge (1990, 1994). Although this theory has been well researched on ‘normal’ children, only a handful of studies have focused on the SIP abilities of ODD and CD children, and these studies have found these children to exhibit significant deficits in this domain. Interestingly, despite these studies highlighting the poor SIP skill of ODD and CD children, there has been virtually no examination of whether the SIP abilities of these children are altered through treatment programs aimed at targeting their behavioural difficulties. This paper will present the results of a study examining the SIP abilities of a group of conduct problem children who took part in a combined parent management training and child social skills/anger management treatment program. Comparisons between the clinical group and a control (non-clinical) group will also be presented.
Depression and Self Harming in Homeless Young People - An investigation into mediators and underlying psychological mechanisms
Matthias Schwannauer & Emily Taylor, University of Edinburgh.
A drop-in clinical service was designed for single young homeless in Edinburgh who were suffering from significant emotional distress and/ or engaged in self-harming behaviours.
We further carried out a comprehensive psychosocial needs assessment not only to determine the prevalence and severity of significant emotional distress in this group, but further to investigate the psychological and social factors most closely associated with the level of distress and to design a tailored psychological intervention for this high risk population.
Utilising structural equation modelling techniques a model of complex interaction emerged between significant negative life experiences and how the individual is affected by those and the quality of their social network and the way in which individuals process and conceptualise their experiences. A better understanding of these interactions and factors will facilitate the development of better ways of preventing and alleviating the extraordinarily high levels of clinically significant emotional distress and maladaptive coping strategies in this highly vulnerable group of young people.
These preliminary results suggest that there is a complex interaction between significant negative life experiences and how the individual is affected by those and the quality of their social network and the way in which individuals process and conceptualise their experiences. A better understanding of these interactions and factors will facilitate the development of better ways of preventing and alleviating the extraordinarily high levels of clinically significant emotional distress and maladaptive coping strategies in this highly vulnerable group of young people.
Attributions for marital break-up and the post-divorce parental relationship
Helena Afonso, University of Lisbon, Portugal
Past marital issues have an important emotional impact during divorce transition and are usually at the root of most child custody disputes between former spouses. Until both partners perceive and accept their roles in marital break-up, the marital relationship will remain the focal point of their lives, retarding their emotional growth and affecting their relationship as parents.
The purposes of the present exploratory study are: 1- Identify issues of past marital dissatisfaction
(perceived causes of marital separation; attribution of responsibility for the marital break-up; degree of control over the decision to divorce); 2 - Explore the relation between these three past marital issues and variables of the marital separation process (difficulty in reaching agreements on custody, visitation, and child support; negative feelings towards the former spouse; quality of the relationship between parents). Data were obtained through individual, face-to-face interviews with a sample of 108 divorced mothers living with their children. The results suggest that some causal explanations for marital separation, personal contribution to marital break-up, and degree of participation in the decision to divorce are related to the emotional climate and the quality of the current relationship between parents.
Based upon these findings, it seems important that professionals working with divorcing parents take into account and deal with issues of blame and control, allowing room for expression and resolution of feelings involved. This can be a way to reduce the contamination of the parental relationship by marital past issues and conflicts.
Posters
Child and Learning Disabilities Issues
Health needs of children 6-12 years in foster care
Lisa Anderson, University of Leicester, Panos Vostanis, University of Leicester, and
Nick Spencer, University of Warwick
It is well established that looked after children have high levels of health needs, which are not usually met by existing services. The aim of this study was to establish the perceptions of health needs among children aged 6-12 years and their foster carers. Fifty-six children and their carers from two Local
Authorities completed a health checklist, the Health of the Nation Outcome Scales for Children and
Adolescents, and the Strengths and Difficulties Questionnaire. Despite their young age, children were broadly aware of what constitutes and promotes good health. In contrast, children gave a range of definitions of mental illness. Children were reported to be registered with general practitioners and be up to date with immunisations, while their contacts with primary and specialist health services were related to a variety of relatively minor problems. High levels of mental health problems were established among this group, which were significantly associated with recent admission in public care and short-term placements. The findings are discussed in the context of guidelines on the health assessment of looked after children, and the need for development of accessible and designated mental health services.
Developmental issues in the study of adolescent’s psychological well-being
Luisa Bizarro, University of Lisbon, Portugal
Adolescence is a period of unique developmental transitions and adaptation demands. Until now, research with this population has provided contradictory results in what concerns psychological wellbeing: some studies point to the existence of periods of great disturbance with lower levels of psychological well-being, while other conclude that there is no significant alteration of this domain.
The first aim of this study is to analyse the developmental trajectory of psychological well-being during adolescence and to identify periods of potential major changes. The secondary aim is to analyse the relation of adolescent’s demographic (age, gender) and social context factors (socio-economic status and family structure) to their psychological well-being.
The study was conducted with a longitudinal design. Three groups of adolescents with 12, 14 and 16 years were assessed during two years.
Results show significant changes of psychological well-being on specific periods through adolescence: there is an increase during early adolescent years (12 to 13 years) followed by a major decrease in middle adolescence (15 years) and again a slight decrease near late adolescence (17 years). Results also show a strong relationship between psychological well-being and gender (girls have significant lower levels), socio-economic status (adolescents from upper levels have higher psychological wellbeing when compared to adolescents from lower socio-economic levels) and family structure
(adolescents living with remarried families have lower levels of psychological well-being when compared to adolescents living with intact and single parent families).
Meeting the psychosocial needs of children experiencing failure at school
Poppy Nash, and Margaret Snowling, University of York
The paper looks at how children experience failure at school, and the psychosocial implications of these experiences. For example, a child with persistent communication difficulties or dyslexia, may feel inadequate, incompetent and different to their peers. The impact of these experiences is often carried into the playground, where the child can continue to feel stigmatised, socially excluded by peers and be the target of school bullying.
Thus, the child's experience of school is not only coloured by anxiety surrounding the classroom, but also by a sense that they are failing in the playground too. This may be seen in concomitant behaviour problems. Without appropriate intervention, these negative self-perceptions can develop into a cycle of disadvantage, and affect the child's whole attitude towards school and motivation to learn.
Nash and her colleagues have recently published an intervention programme (Nash et al., 2002), which addresses the psychosocial needs of children with persistent communication difficulties. The team is currently developing a battery of measures for assessing the effectiveness of the programme.
The paper examines the relevance of the intervention programme for other groups of children who are underachieving and experiencing failure at school. It also discusses the interface b etween the child’s experiences in the classroom and the playground.
Reference
Nash, P., Stengelhofen, J., Brown, J. and Toombs, L. (2002)
Improving children's communication, Managing Persistent Communication Difficulties. Whurr: London.
Children’s inner resources for school achievement: a developmental analysis of the impact of parental support
Isabel Sá, University of Lisbon, Portugal
This study examines a process model of relations between children’s perceptions of their parents’ support (involvement and control) concerning schoolwork and three inner resources for school achievement: control understanding, perceived competence and perceived autonomy. These variables were assessed in a sample of 526 children, 5th to 9th grades, between 10 to 14 years of age.
Path analysis revealed that perceived parental support and involvement were positively associated with perceived competence, control understanding, and perceived autonomy, while perceived parental control was negatively associated with the three motivational variables at 7th to 9th grades but not before that grade. For younger children parent support and control don’t seem to affect control understanding.
The results are discussed in terms of their importance not only for assessing the need for therapy but also in the application of different cognitive techniques to children at different developmental levels in control understanding.
Can people with learning disabilities engage in cognitive components of CBT?
Kathryn Sams, Suzanne Collins, and Shirley Reynolds, University of East Anglia
There is increasing interest in applying CBT for use with people who have learning disabilities.
Fifty-nine adults with learning disabilities (IQ of 50-72) completed 3 tasks that reflected CBT tasks.
These were, i) identifying emotions, ii) distinguishing thoughts from feelings and from behaviours, and the impact of visual cues on performance, and iii) the ability to link thoughts to feelings and thoughts to behaviours.
The results indicated that adults with learning disabilities were able to demonstrate these skills, though not always at the more complex level. Visual cues did not improve performance on the distinguishing thoughts, feelings and behaviour task. Receptive vocabulary was a good predictor of performance on all 3 tasks, IQ was only related to distinguishing thoughts, feelings and behaviours.
CBT may be an appropriate form of treatment for some adults with learning disabilities especially if they have good language abilities. The findings will be discussed in relation to theoretical, clinical and research implications.
Staff attributions toward client with mild learning disabilities who self-injure
Elizabeth Snow, Peter E Langdon, Shirley Reynolds, University of East Anglia
The aim of this study was threefold, 1) to examine the types of causal attributions care staff make about self-injurious behaviour amongst people with mild learning disabilities, 2) to investigate the relationship between the attributions made and staff burnout, and 3) to explore the relationship between staff characteristics, their level of burnout and their attributions.
Participants were forty-one staff members from a range of service contexts. All participants were working with clients with mild learning disabilities who self-injure. Participants completed the Maslach
Burnout Inventory, a demographic questionnaire, and took part in a semi-structured interview which was coded using the Leeds Attributional Coding System (LACS). The results will be discussed within the context of a cognitive-behavioural model along with the implications for services.
Challenging behaviour and learning disabilities: The relationship between expressed emotion and staff attributions
Luise Weigel, Suzanne Collins, Peter E Langdon & Yvonne O'Brien, University of
East Anglia
Expressed emotion (EE) and attributions toward challenging behaviour (CB) were explored amongst a group of staff working within a residential and day service placement for people with learning disabilities.
Fifteen staff members completed the attributional questionnaire and the five-minute speech sample
(FMSS) to allow for EE ratings concerning staff relationships with two clients. One client exhibited CB, while the other did not, giving two groups. Attributional and EE ratings for each group were compared.
Staff working with a client with learning disabilities and CB attributed the CB as internal to the client and controllable by the client. Staff reported high levels of EE and made more critical comments toward the client with CB as compared to the client without CB. Furthermore, staff who reported high EE attributed
CB as internal to the client, external to the staff, personal to the client, controllable by the client and uncontrollable by the staff.
This study replicated the findings of Cottle et al., (1995). Additionally, staff working with a client with challenging behaviour appeared to be making the “fundamental attribution error”. The relationship between expressed emotion and attribution theory is discussed. Attribution theory is hypothesised as providing some explanation for the development of high EE. These results and their implications for our understanding of attribution theory within a cognitive-behavioural framework within the context of working with challenging behaviour is discussed
Index of Authors
Abbott, M ........................ 20, 73
Adams, C .............................. 66
Afonso, H .............................. 84
Allard, S ................................ 37
Alvarenga, M ........................ 74
Anderson, L .......................... 85
Ando, J ................................. 24
Ando, M ................................ 20
Antony, M ....................... 15, 45
Armstrong, P ......................... 69
Aubin, S ................................ 59
Audin, K ................................ 66
Bailey, V ............................... 83
Baillie, A ............................... 73
Bamber, M ............................ 20
Bara-Carril, N ........................ 59
Barkham, M .......................... 66
Barnard, P ............................ 11
Barrowclough, C ............. 31, 33
Barton, K .............................. 29
Barton, S .................. 47, 48, 49
Bashforth, H.......................... 31
Battersby, L .......................... 65
Bennett-Levy, J ..................... 68
Bentall, R .................... 7, 28, 34
Birchwood, M ............ 27, 28, 29
Bizarro, L .............................. 85
Blanchette, I............................ 7
Blenkiron, P .......................... 21
Blissett, J .............................. 83
Bocci, L ................................. 21
Bögels, S .............................. 15
Bonsall, K ............................. 66
Bower, P ......................... 61, 66
Brabban, A ........................... 69
Brack, M ............................... 84
Braham, L ............................. 18
Brewin, C ........................ 55, 64
Bryant, R .............................. 13
Bryant-Waugh, R .................. 83
Büchi, S ................................ 37
Butler, G ............................... 63
Cahill, J ................................. 66
Calam, R .................. 75, 76, 77
Callias, M .................. 79, 80, 81
Cameron, R .......................... 74
Campsie, L ........................... 60
Carlton Smith, H ................... 76
Cavanagh, K ......................... 61
Chalder, T ....................... 39, 40
Clark, D ................................ 14
Cleugh, S .............................. 69
Clyde, Z ................................ 38
Coddington, A ....................... 39
Cole, F .................................. 59
Collins, S .............................. 86
Conrad, J .............................. 21
Cooper, M ............... 8, 9, 10, 56
Cox, S................................... 29
Creswell, C ... 40, 75, 77, 78, 81,
82
Cromarty, P .......................... 22
Croudace, T ............................ 9
Cusack, R ............................. 50
Dafters, R ............................. 60
Dalgleish, T......... 12, 49, 50, 81
Davey, G 43, 44, 46, 47, 52, 53,
58, 68
Davidson, K .......................... 67
Davies, C .............................. 38
Dawson, J ............................. 61
Day, S................................... 51 de Caestecker, L................... 78 de Silva, P ........................ 8, 44
Dixon, J .......................... 22, 69
Dritschel, B ........................... 56
Du Toit, P.............................. 50
Dunn, B ................................ 50
Ehlers, A ........ 12, 13, 14, 44, 51
Ehntholt, K ............................ 82
Ehring, T ......................... 12, 44
Erickson, D ........................... 22
Evans, J ................................ 26
Evershed, K .......................... 35
Fairburn, C ........................ 8, 63
Farrington, A ......................... 83
Field, A ................................. 54
Forrest, J .............................. 60
Fowler, D ............ 25, 26, 27, 30
Freeman, D ............... 26, 29, 31
Freeston, M .............. 22, 55, 69
French, P ........................ 28, 34
Froom, K ............................... 69
Gallagher, M ......................... 73
Garety, P .................. 29, 30, 68
Garland, A ............................ 37
Gask, L ................................. 66
Gaston, J .............................. 73
Gauntlett-Gilbert, J .......... 17, 19
Gega, L ................................. 74
Gilbert, N .............................. 22
Gilbert, P ........................ 57, 66
Gilbody, S ............................. 66
Gillespie, C ........................... 66
Gillings, K ............................. 17
Glucksman, E ....................... 12
Goddard, L............................ 56
Goldberg, D .......................... 61
Goodwin, G ............................. 8
Goodyer, I ............................... 9
Gordon, K ....................... 70, 71
Gray, J .................................. 61
Green, C ............................... 70
Green, J ................................ 28
Greenall, E............................ 46
Greenwood, K ....................... 80
Grey, N ................................. 12
Griffiths, C.E.M ..................... 43
Grover, M.............................. 59
Hackmann, A ...... 13, 14, 50, 51
Haddock, G ........................... 33
Hakamada, Y ........................ 24
Hall, M .................................. 29
Halsey, C .............................. 77
Hamill, M .............................. 10
Hardy, A ............................... 26
Hardy, G ............................... 66
Hare, D ........................... 35, 80
Harkin, P ............................... 59
Harris, S ............................... 39
Harrop, C .............................. 33
Harvey, A .................... 8, 46, 68
Hastings, R ........................... 62
Hatton, C ........................ 62, 63
Hawkes, N ............................ 54
Hawton, K ............................... 6
Henderson, C ....................... 40
Heyman, I ............................. 78
Hinshelwood, R..................... 60
Hirsch, C ......................... 13, 14
Hirsch, S ............................... 74
Hobbis, I ............................... 18
Holmes, E 15, 26, 27, 51, 81, 82
Home, D ............................... 37
Howell, R .............................. 47
Howie, P ............................... 84
Howlin, P. ............................. 56
Howse, I ............................... 82
Huey, D ................................ 55
Hughes, L ............................. 10
Husain, K .............................. 39
Iredale, W ............................. 59
Jackson, C ................ 25, 28, 29
Janeck, A .............................. 22
Jenkins, D ............................. 47
Johnson, J ............................ 45
Jones, D ............................... 18
Jones, J ................................ 29
Jones, S ..................... 7, 11, 35
Kearns, C.............................. 23
Keegan, A ............................. 17
Keegan, D............................. 55
Kellett, S ............................... 72
Kendall, T ............................. 58
Kenwright, M ................... 73, 74
Kerr, N .................................... 8
Khan, A ................................. 23
Kijima, N ............................... 24
Kilcommons, A ................ 26, 28
Kildea, L ............................... 73
Killoran Ross, M .................... 78
King, N .................................. 59
Klein, B ................................. 74
Knapp, M .............................. 61
Knowles, R ............................. 7
Kobori, O .............................. 24
Kuipers, E ....................... 29, 30
Kuyken, W ............................ 47
Lam, D .................... 6, 7, 11, 63
Lam, D.C.K ........................... 19
Lambert, S ...................... 40, 42
Langdon, P ........................... 86
Latham, M............................. 70
Lavelle, M ............................. 70
Lawrence, A .......................... 50
Leahy, R ......................... 11, 66
Lee, M ........................ 8, 18, 56
Lee, P ................................... 35
Lewis, S ................................ 28
Li, F ...................................... 35
Lister, T ................................ 48
Lobban, F ............................. 32
Lockwood, B ......................... 10
Lomax, S .............................. 28
Lovell, K ................................ 61
Lovell-Hawker, D .................. 64
Lowens, I .............................. 32
Lyneham, H .......................... 79
MacDonald, CB......... 47, 52, 53
MacLeod, A ........ 37, 42, 56, 68
MacMillan, C ......................... 73
Maekawa, H .......................... 24
Main, C.J .............................. 43
Mairs, D ................................ 73
Mangelli, L ............................ 37
Mansell, W .................. 7, 11, 63
Marks, I ........................... 74, 78
Martell, C ........................ 17, 57
Martin, L ............................... 53
Marzillier, S ........................... 53
Mason, L ............................... 80
Mataix-Cols, D ...................... 74
Mathews, A ..................... 14, 49
Matsuura, M .......................... 24
Matthews, L .......................... 72
McCrone, P ........................... 61
McCrum, B ............................ 73
McLean, P ............................ 16
McManus, F .......................... 14
McNeill, Y ............................. 60
McWilliams, E ....................... 38
Meiser-Stedman, R ......... 12, 81
Meyer, C ................... 17, 22, 83
Michael, T ............................. 44
Milne, D ................................ 69
Mistral, W ............................. 82
Mollon, P .............................. 34
Moorey, S ....................... 36, 37
Moorhead, S ......................... 22
Morley, S ............ 36, 37, 47, 48
Morrison, A ... 24, 26, 27, 28, 32,
34
Morrison, B ........................... 69
Morrison, J ............................ 14
Moulds, M ................. 12, 13, 46
Murray, K .............................. 59
Myles, P .......................... 69, 70
Nash, P ................................. 85
Nelson, J .............................. 46
Newman, D ........................... 72
Newton, L ............................. 29
Nicholls, D ............................ 83
Noad, R ................................ 56
Nothard, S ............................ 32
Novaco, R ............................. 61
O’Connor, T .............. 75, 81, 82
O’Donovan, A ....................... 42
O'Brien, Y ............................. 86
Ogilvie, A .............................. 50
Oliver, G ............................... 80
Ononaiye, M ......................... 54
Onwumere, J ........................ 30
Orlinsky, D ............................ 66
Owen, D ............................... 62
Palmer, A .............................. 11
Pandya, K ............................. 66
Papageorgiou, C ............. 44, 45
Parry, G .......................... 58, 60
Pashley, A ............................ 60
Patterson, K .......................... 47
Patterson, P .......................... 28
Paxton, R .............................. 69
Pennebaker, J ...... 6, 37, 46, 64
Petrak, J ......................... 17, 42
Phillips, M ............................... 8
Pilling, S ............................... 59
Pincus, T .............................. 38
Pombo-Carril, M.................... 59
Power, M .............................. 35
Proudfoot, J .......................... 61
Pullen, E ............................... 80
Purdon, C ........... 15, 44, 45, 49
Purvis, L ............................... 69
Ralph, A ................................ 77
Rapee, R .................. 20, 73, 79
Ratcliffe, D ............................ 42
Read, J ................................. 38
Reid, I ................................... 29
Reidy, J ................................ 54
Renton, J .............................. 27
Reynolds, S .................... 75, 86
Richards, D ..................... 61, 66
Richards, H.L .................. 41, 43
Richards, J ............................ 74
Ricketts, T....................... 60, 70
Riley, C ................................. 24
Rimes, K ............................... 40
Rollinson, R .......................... 30
Rönnestad, H ........................ 66
Rowa, K .......................... 15, 45
Rushbrook, S ........................ 15
Ryden, C .............................. 61
Sá, I ...................................... 86
Sacadura, C .......................... 14
Salkovskis, P . 15, 17, 19, 64, 68
Salter, E ................................ 82
Sams, K ................................ 86
Sanders, M ..................... 74, 77
Saunders, A .......................... 82
Scarna, A ................................ 8
Schmidt, A .............................. 8
Schmidt, U ................ 10, 59, 67
Schröder, T ........................... 66
Schwannauer, M . 34, 35, 40, 84
Scott, J ................................... 7
Scott, S ..................... 75, 76, 83
Semler, C................................ 8
Sensky, T........................ 37, 42
Serpell, L ................................ 9
Shafran, R ............ 8, 15, 24, 64
Shapiro, D................. 57, 58, 61
Sharpe, L .............................. 37
Sidwell, C.............................. 37
Silver, M ............................... 79
Smith, B .......................... 26, 31
Smith, J ................................ 29
Smith, P .................... 12, 81, 82
Snow, E ................................ 86
Snowling, M .......................... 85
Speckens, A ......................... 13
Spencer, N............................ 85
Stallard, P ....................... 81, 82
Stallman, H ........................... 77
Standart, S............................ 52
Startup, H ....................... 47, 52
Steel, C ..................... 25, 26, 27
Stewart-Brown, S .................. 56
Stobie, B ............................... 16
Stopa, L ................................ 15
Stroud, M .............................. 80
Summerfeldt, L ............... 15, 45
Sutton, S ............................... 18
Swift, A ................................. 72
Sylva, K ................................ 76
Tai, S ...................................... 7
Takahashi, Y ......................... 24
Tallman, K ............................ 22
Tanno, Y ............................... 24
Taylor, E ............................... 84
Taylor, G ............................... 82
Taylor, J .................... 17, 61, 62
Taylor, T ............................... 16
Teasdale, J ............................. 9
Telford, K .............................. 14
Thompson, K ........................ 65
Thordarson, D ....................... 16
Todd, G ............................ 9, 10
Tone, Y ................................. 23
Townend, M .......................... 29
Toye, K ................................. 41
Treasure, J ....................... 9, 59
Trower, P .............................. 29
Turkington, D ............ 25, 28, 69
Turner, H .......................... 8, 10
Turpin, G ........................ 54, 68
Twaddle, V............................ 69
Tyrer, P ................................. 67 van den Berg, S .................... 61 van Gerko, K ......................... 10
Velleman, R .......................... 82
Voncken, M ........................... 15
Vostanis, P ........................... 85
Waddington, E ...................... 55
Waddington, L ...................... 14
Waite, S ................................ 71
Walford, L ....................... 28, 34
Waller, G .............................. 10
Watkins, E ..... 17, 46, 47, 48, 52
Watson, M ............................ 60
Watson, P.W.B. .................... 30
Weigel, L .............................. 86
Weinman, J ........................... 23
Wells, A ............................ 9, 32
Wells, H ................................ 38
White, C ................................ 76
Whitfield, G ........................... 60
Whittal, M.............................. 16
Wild, J ............................. 13, 50
Williams, C ................ 59, 60, 78
Williams, M ..................... 17, 47
Williams, R ............................ 14
Williams, S ............................ 69
Williams, T ............................ 80
Wilson, C .............................. 77
Wittkowski, A .................. 41, 43
Woolley, J ............................. 78
Wright, J ............................... 65
Wright, K ................................. 7
Yamagata, S ......................... 24
Yamasaki, S ......................... 24
Yiend, J ................................ 49
Young, K ............................... 27
Yule, W ..................... 12, 81, 82
