Paradoxical Intention (PI) is a cognitive treatment approach for sleep-onset insomnia. It is thought to operate by eliminating voluntary sleep effort, thereby ameliorating sleep performance anxiety, an aroused state incompatible with sleep. However, this remains untested. Moreover, few PI studies have employed objective sleep measures. The present study therefore examined the effect of PI on sleep effort, sleep anxiety and both objective and subjective sleep. Following a seven-night baseline, 34 sleep-onset insomniacs were randomly allocated to 14 nights of PI, or to a control (no PI) condition. Consistent with the performance anxiety model, participants allocated to PI, relative to controls, showed a significant reduction in sleep effort, and sleep performance anxiety. Sleep-onset latency (SOL) differences between PI participants and controls using an objective sleep measure were not observed, although an underlying trend for significantly lowered subjective SOL amongst PI participants was demonstrated. This may relate to actigraphic insensitivity, or more probably confirms recent suggestions that insomniacs readily overestimate sleep deficit, due to excessive anxiety about sleep. Together, results help determine putative mechanisms underlying PI, have important implications for the clinical application of PI, and emphasize the need for further PI research within an experimental cognitive framework.

Interpersonal therapy (IPT) was developed in the late 1960s, but has only recently gained real prominence. The interest in this approach has grown further following the positive findings obtained in the NIMH study (Elkin et al., 1989). In this extensive, multi-site US study it was found to be as effective as CBT and, in some methods of analyses, more effective. There is a growing literature on IPT's use with older people (Miller and Reynolds, 2002), but very few articles, with the exception of Bauer's (1997) work, have examined its use with people with cognitive impairment. The present paper describes the use of IPT to treat a man (Mr M) with dementia suffering from depression. The case is presented chiefly as a vehicle to explore the applicability of the conceptual framework, although details regarding treatment are discussed.

Early interventions for psychosis have recently received a great deal of interest. This is because research findings have indicated the importance of duration of untreated psychosis (DUP) in influencing future prognosis. Most interventions have so far centered around the early identification of first episode cases in an attempt to minimize the DUP. A further development of the early intervention strategy aims to identify high-risk cases prior to the onset of psychosis. Treatment of this at risk group could potentially prevent the onset of psychosis. In this paper we describe three cases from a randomized controlled trial designed to test the feasibility of a cognitive therapy intervention, to prevent the onset of psychosis. These are presented with formulations based on a recent cognitive model conceptualizing the onset of psychosis. Implications of this approach for future research and clinical practice are also discussed.

Delivery of cognitive behavioural therapy (CBT) is limited by a scarcity of resource. In England and Wales, there are not enough practitioners appropriately trained in CBT to meet the needs of those who might benefit from treatment. In addition, there are reasons to believe that available therapists are inequitably distributed across the country. We investigated the distribution of British Association of Behavioural and Cognitive Psychotherapies (BABCP) members, accredited CBT practitioners, and BABCP members who are nurses or clinical psychologists in England and Wales by postal code. This analysis demonstrated a 20-fold discrepancy in availability of accredited CBT practitioners between the best and least well-served population deciles. Despite limitations, these findings are highly indicative of “postcode availability” of the best qualified CBT practitioners. We discuss possible strategies to remedy this inequity, which further challenges the ability of conventional methods of CBT delivery to meet public health requirements.

The importance of clinical supervision is increasingly recognized, as is the need to demonstrate that the work we do in the NHS is effective. However, observational analyses of supervision or evidence bearing out the effectiveness of supervision are rare and narrow in focus. To contribute to the evidence base, the present N=1 content and outcome evaluation describes and then assesses the effectiveness of cognitive behaviour therapy supervision, in terms of its observed impacts on a supervisee and her patient. The supervisee was a trainee therapist participating in a diploma course in cognitive therapy. The study utilized a qualitative and quantitative content analysis methodology, based on the intensive coding of a series of 10 longitudinal, video-recorded supervision sessions, linked to the subsequent 10 therapy sessions. Based on this method, 14 supervisory themes were extracted, which served to describe the change methods employed in the supervision. The predicted transfer (generalization) of those themes from supervision to therapy was observed to occur to a surprisingly marked extent, indicating that the supervision was effective. Implications are drawn for developing supervision and related research.

Hoarding has been recognized as a frequent sub-component of obsessive-compulsive disorder that can occur at lesser frequency in a primary form. The theoretical and empirical literature on hoarding is still in its infancy. The current paper attempts to expand and refine CBT theory via the identification of the specific cognitive distortion of object-affect fusion (OAF) relating to problematic emotional attachment to objects. The concept of OAF is defined and then related to sentimental saving. Two case examples are detailed in which OAF represented the main focus of the CBT intervention. The case examples illustrate how OAF recognition can be integrated into and supplement existing CBT approaches to hoarding. Future theoretical and empirical developmental tasks in relation to OAF are identified and discussed.

There is still a lack of indicated prevention programs for couples who, although subjectively concerned about their relationship, do not seek marital therapy. In a previous randomized controlled study, the efficacy of a cognitive-behavioural psychoeducational program delivered on a weekend by two trainers for groups of four couples was established. The program consists of communication and problem-solving training, couples' discussions to clarify their relationship expectations, and exercises to enhance their sensual/sexual relationship. In the current study, the effectiveness of adding two booster sessions with each couple individually one and three months after the weekend training program was investigated. Sixty-two couples were recruited by newspaper announcements. At post assessment, couples emitted significantly more positive and less negative verbal and nonverbal communication behaviours during a conflict discussion task than at pre-assessment, thus replicating the previous findings. At the 1-year follow-up, couples with booster sessions reported significant higher marital satisfaction ratings and fewer problem areas than couples receiving the weekend program only. Booster sessions seem to be effective in enhancing the long-term effectiveness of preventive interventions.

Patients referred with anger problems often do not attend for treatment. The aim of this study was to determine if group Cognitive Behaviour Therapy (CBT) was feasible. Patients referred for help with their anger were assessed, given 6 sessions of group CBT and re-assessed. Of 119 patients referred, 49 (41%) did not attend the initial appointment. Patients who attended for interview were invited to participate in the group CBT. Only 11 patients (9%) of those referred for therapy attended for the full course of CBT. Thirty-four patients (29%) were exposed to at least one session of CBT, while 66 patients (56%) did not attend for any therapy. Patients who attended for some or all of the CBT treatment reported reductions in the frequency and intensity of their anger outbursts. There was also a significant reduction in measures of their anger traits. It could be concluded that group CBT is an appropriate way to deliver this therapy to patients with anger problems, but it is clear that many of those referred are ambivalent about therapy and will not attend. Figures are given that will allow the planning of a randomized controlled trial to evaluate the difference between individual and group based CBT for patients with anger problems.

A retrospective analysis was undertaken to determine whether the Ehlers and Clark (2000) model of posttraumatic stress disorder explained PTSD in children involved in road traffic accidents. Children were assessed 6 weeks after their accident and items related to subjective trauma severity, sequelae appraisal, trauma memory, behavioural avoidance and cognitive strategies were examined. Ten of the 14 items, from four of the five areas, were significantly associated with the onset of PTSD. Data from the remaining area, trauma memory, approached statistical significance. These data provide preliminary support for the applicability of the Ehlers and Clark (2000) model to children.

Developing staff competence in evidence-based interventions for people with a severe mental illnesses is now a government priority. However, evidence concerning the nature and effectiveness of the training programmes that are designed to develop competence is decidedly limited. The purpose of the present study was, therefore, to evaluate systematically a manualized and evidence-based staff training programme. This programme was delivered over a 17-day period, in a modular and experiential workshop format. Staff (mostly mental health nurses) were allocated to either an experimental group (N = 18) who received the training or to a waiting-list, control group condition (N = 7). Multi-dimensional process and outcome evaluations indicated that the staff training was delivered competently, followed an experiential learning approach, and led to significant improvement in the participants' targeted knowledge and skills. The staff were also satisfied with the acceptability and delivery of the training. Generalization to the participants' clients was reported to be very good, which was congruent with evidence of a supportive work environment, the organizational evaluation aspect of this study. While these learning outcomes are typical of such training, the degree of generalization is exceptional. Possible reasons for this favourable outcome are discussed, and conclusions are drawn for developing staff competence in ways that maximize the delivery of evidence-based practice.

The assessment and treatment of an unsuaul pre-sleep ritual are described. The patient had unusual ideas about the probability and consequences of self-harming behaviour in sleep, and averted such behaviour through a ritual with possibly dangerous consequences. The origin and maintaining factors of the ritual are described; a cognitive-behavioural approach was used to treat the ritual, with successful results.

The accounts of five subjects who survived life threatening experiences without the development of PTSD were examined, focusing on the coping strategies and cognitions described in these situations. The study aimed to determine whether there was a common pattern of response amongst subjects in these situations similar to the cognitive patterns described by the senior author of the previous case study (Ness & Macaskill, 2000) who survived a near drowning experience without the development of PTSD. In the search for common coping strategies all five respondents in the study completed the Locus of Control Scale (Rotter, 1966) and the Self-Control Schedule (Fisher & Reason, 1988). All five respondents demonstrated the use of problem solving as their main cognitive strategy, utilizing specific information from their previous experience relevant to their life-threatening situation. Respondents did not appear to rely on coping strategies aimed at the management of acute anxiety symptomatology. There was no common pattern among respondents in profiles on the Self-Control Schedule or the Locus of Control Scale. The possible implications of this case series study are discussed in relation to opportunities for the prevention of PTSD, the use of debriefing and the treatment of post-traumatic stress.

Psychological measures have little sensitivity in the prediction of postnatal depression. We report the development of a questionnaire of beliefs about pregnancy and motherhood. Information from a literature review, staff working with women with postnatal depression and interviews with recently ill patients was used to develop a questionnaire called the PRBQ. The PRBQ was piloted on 42 pregnant women and achieved a Cronbach alpha of 0.85. Scores significantly correlated with scores on the Dysfunctional Attitude Scale (DAS), Beck Depression Inventory (BDI) and the Cognitive Adaptation to Stressful Events questionnaire (CASE), measuring adaptation to pregnancy. DAS and CASE scores did not correlate. The PRBQ and the CASE differentiated between those with (n = 5) and those without moderate depression. The PRBQ has been validated against established psychological measures. It may be a helpful tool contributing to the identification of women specifically at risk of postnatal depression. Further basic research is required.

There is widespread support for training in Cognitive Behavioural Psychotherapy (CBP) amongst psychiatrists and from the Royal College of Psychiatrists. One possible way to gain such training is to undertake a diploma or certificate course, a growing number of which exist in the United Kingdom. We report on a postal questionnaire survey of psychiatrists who have completed a CBP diploma course. Psychiatrists described the course as altering their clinical practice and found the skills learned, the format of multidisciplinary learning and of supervision all useful and helpful. However, individuals who undertook a CBP diploma were concerned about their ability to apply these skills and undergo further training, given the time constraints within busy consultant jobs.

Despite a marked expansion in the methods and applications of cognitive therapy, few specific models exist that delineate the process and means of psychotherapeutic change within cognitive therapy. In the present model, three core conceptual components of change are suggested: interpersonal conscious appraisal, response procedures and therapeutic communication. The subsequent circumplex developed from the core components enables the classification and description of 16 identifiable assessment profiles. Specific hypotheses drawn from the cognitive circumplex are stated concerning levels of functioning, client/problem complexity and typical client interactions. The circumplex is offered as a means of assessing, tracking and evaluating change during cognitive therapy. The structure of the model is consistent with the goals, rationale and expectations of cognitive therapy.

Parent training is 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. As with developments in treatments for adult disorders, it is proposed that parent training implementation and parental engagement may be improved by the introduction of a cognitive component. In particular, the use of the “thoughts, feelings, behaviour cycle” throughout parent training is proposed as a tool for challenging parental beliefs and attributions regarding children's behaviour and increasing parental uptake of the behavioural strategies that are taught. Preliminary findings are discussed with reference to clinical implications and future research.

Stimulus preference assessment (SPA) methods have been used to identify stimuli that might function as reinforcers. These methods typically assess social stimuli, such as hugs and verbal praise, tangible stimuli, such as toys and edibles, and high-frequency activities. Individual preferences for staff personnel, however, have not been assessed. In this study, the paired-stimulus assessment method was adapted to assess consumer preferences for different staff. Four adults with intellectual disabilities, two children with autistic-spectrum disorders, and one child with emotional difficulties participated in the present study. The results showed that preferences for different staff were identified for five of the seven consumers. These results provide support for the use of this procedure for identifying preferences for different staff. Directions for future research are discussed in terms of systematizing the assessment procedure, validation of results, and practical considerations regarding the assessment of preferences for staff personnel.

The present study illustrates the use of brief functional analysis probe conditions to verify the results of a descriptive assessment. An initial descriptive assessment of the disruptive behaviour of an 8-year-old student with severe developmental disabilities showed that levels of disruptive behaviour (screaming and throwing equipment) were higher in some lessons than others and suggested that the behaviour might be maintained by escape from task demands. An intervention in which work demands were alternated with 5-minute periods of free activity reduced levels of screaming to under 50%, and of throwing to under 25%, of baseline levels. Brief experimental variations of demand level in some lessons confirmed that levels of disruption were generally higher under high demand conditions. We conclude that brief probes provide a method by which experimental analyses can be conducted in the client's natural environment, reducing the problem of non-occurrence of the target behaviour that can pose problems for analogue assessments and facilitating ongoing assessment during initial intervention. We note also, however, that the consequent reduction in control over establishing operations may reduce the precision of the analysis and that ethical considerations limit the range of behaviours for which the method is appropriate.

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

A pilot RCT of cognitive therapy (CT; based on Fowler, Garety, and Kuipers, 1995) for early psychosis adjunctive to treatment as usual (TAU) compared to TAU alone is presented. Recruitment is problematic and numbers are small. Levels of symptomatology are low at baseline; and both CT (n = 12) and TAU (n = 9) groups improve, with few significant group differences and high levels of individual variation. This pattern is common to other studies (Jackson et al., 1998; Lewis et al., 2002). The body of evidence to date seems to suggest that CT for early psychosis is not strongly indicated as an adjunctive treatment for all people with early psychosis, but should perhaps focus on the sub-group of patients whose recovery is incomplete.