adult mental health 9 - babcp · 2012-08-09 · factors influencing psychological adjustment in...

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Table of Contents Abstracts are grouped into topic areas, and then into categories (keynote addresses, symposia, panel

discussions, clinical roundtables and posters)

Adult Mental Health ...................................................................................... 9

Keynote Addresses ........................................................................................................ 9

A kinder, gentler CBT for anxiety disorders: The potential for safety behaviour use in treatment9

Third Wave Behaviour Therapies: Efficacy in Treating Clinical Depression .................................... 9

Performing in the mind’s eye: Imagery use in sport ....................................................................... 9

Building a Unified Model for Cognitive Behavior Therapy: The New Clinical Science of

Mindfulness and Values .................................................................................................................. 9

From Soup to Nuts: From Inception and Research through Dissemination of Cognitive

Processing Therapy ......................................................................................................................... 9

A better understanding of how the world works? An integrated perspective on how

psychological treatment is effective with particular reference to the current status of

understanding and treatment of OCD .......................................................................................... 10

Emotional Schemas and Emotional Intelligence ........................................................................... 10

Time bombs and tidal waves: What has been the impact of the wars in Iraq and Afghanistan

other health of UK service personnel and what can we expect in the future? ............................ 10

Symposia .................................................................................................................... 10

Recent Investigations into the Roles of Safety Behaviour in the Treatment of Anxiety Disorders

...................................................................................................................................................... 10

Working with 'Others' in the Treatment of Anxiety ..................................................................... 11

Working with Complexity .............................................................................................................. 12

Body Dysmorphic Disorder and Body Image Problems ................................................................ 13

CBT for Treatment Resistant Depression: Results From the COBALT Trial ................................... 13

Increasing the Efficiency and Impact of Cognitive Therapy for Chronic and Recurrent Depression:

The CLAHRC Depression Project ................................................................................................... 15

Trauma Work with Military Veterans ........................................................................................... 16

Formulation and Treatment in Complex Obsessive Compulsive Disorder ................................... 17

Re-visiting the Role of Re-living and Re-Scripting For the Treatment of PTSD ............................. 18

Trauma and Conflict ...................................................................................................................... 18

Skills Classes ............................................................................................................... 20

Enhancing Self-Inquiry and Flexible Responding: A Novel Skills-Based Approach for Refractory

Depression .................................................................................................................................... 20

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Clinical Roundtable ..................................................................................................... 20

The Future of Couples Therapy From a CBT Perspective .............................................................. 20

Posters........................................................................................................................ 21

MBSR - 2 years and counting ........................................................................................................ 21

CBT skills of Student Nurses .......................................................................................................... 21

Factors influencing psychological adjustment in military personnel following a Tour of Duty .... 21

Image rescripting with people who hear voices: A case series .................................................... 22

Psychometric properties of the Japanese version of the mental pollution questionnaire .......... 22

Psychosis, Cannabis and Context. An Experimental Study .......................................................... 22

The effectiveness of components of cognitive-behavioral therapy for obsessive-compulsive

disorder ......................................................................................................................................... 22

Integrated psychological therapy for people with bipolar disorder (BD) and co-morbid alcohol

use: a feasibility randomised trial ................................................................................................. 23

An exploration of telephone screening for Recruitment: The Staying Well after Depression Trial

...................................................................................................................................................... 23

An Evaluation of the Methods used for Recruitment in Randomised Controlled Trials: The

Staying Well after Depression Trial ............................................................................................... 23

Treatment resistant Obsessive Compulsive Disorder (OCD): A Multidisciplinary Team Approach

...................................................................................................................................................... 24

Basic Processes and New Developments ...................................................... 25

Keynote Addresses ...................................................................................................... 25

Recent developments in the etiology and treatment of PTSD ..................................................... 25

Wrong turnings down memory lane: the nature and treatment of maladaptive and distressing

patterns of autobiographical remembrance in emotional disorders ........................................... 25

Symposia .................................................................................................................... 25

Autobiographical Memory and Psychological Disorders .............................................................. 25

Training A New Perspective: Can Direct Modification of Interpretations and Appraisals Reduce

Anxiety and Depression? .............................................................................................................. 26

From Basic Science to Innovative Treatments: Using Cognitive Bias Modification to Understand

and Develop Psychological Interventions ..................................................................................... 27

Mental Imagery: Investigation and Clinical Application of Mental Images in Cognitive Therapy 28

New Developments in CBT (A Sheffield perspective) ................................................................... 30

How Does Acceptance and Commitment Therapy (ACT) Work? Examining the Processes

Underlying Change ........................................................................................................................ 31

Attentional Bias Modification in Affective Disorder: Promises and Pitfalls .................................. 32

How Does CBT Work? Exploring Multiple Factors ........................................................................ 33

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New Developments in Treatment ................................................................................................. 34

Maximising Treatment Outcomes ................................................................................................ 35

Cognitive Processes in Obsessional Disorders .............................................................................. 37

Cognitions in Suicidality, Psychosis and Cancer ............................................................................ 38

Panel Discussion ......................................................................................................... 40

How Does CBT Work? Mechanisms of Change 'Across the Waves’ ............................................. 40

Posters........................................................................................................................ 40

Validation of the Behavioural Activation for Depression Scale in a clinically depressed primary

care sample ................................................................................................................................... 40

The bi-directionality hypothesis: Are clinical constructs both causes and effects of symptoms? 41

The availability and specificity of autobiographical memory recall in bipolar disorder ............... 41

Individualised Recovery Focused Care Packages within an Anxiety Disorders Program .............. 41

Behavioural Medicine .................................................................................. 42


Chronic Pain: A Learning Theory Perspective ............................................................................... 42

Emotional Processing in the Context of Chronic Fatigue Syndrome and Implications for

Treatment ..................................................................................................................................... 42

Symposia .................................................................................................................... 42

Long-Term Conditions: Investigation of CBT Approaches ............................................................ 42

Working with the Unfamiliar: Latest Perspectives on Medically Unexplained Syndrome ........... 44

Non Pain Focussed Treatment for Individuals with Chronic Pain: Science and Practice .............. 45

Cognitive Behavioural Therapy for Menopausal Symptoms ........................................................ 46

Skills Classes ............................................................................................................... 47

Adapting Clinical Approaches for People with Long Term Conditions ......................................... 47

Posters........................................................................................................................ 48

General beliefs, response expectancies and attentional bias: impact on treatment related

symptoms and quality of life in breast cancer patients having chemotherapy............................ 48

Child and Adolescent Mental Health ............................................................ 49


Working through families to increase the efficiency and impact of CBT: application to childhood

anxiety disorders ........................................................................................................................... 49

Widening parenting programmes to promote attachment security, prevent antisocial

personality and be more accessible .............................................................................................. 49

Symposia .................................................................................................................... 49

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Improving our Understanding of Adolescent Mental Health ....................................................... 49

Using Community Day-Long Workshops to Offer CBT to Adults and Adolescents Who May Not

Otherwise Access Services ............................................................................................................ 50

Issues in Parental Mental Health .................................................................................................. 52

Treatment of Obsessive-Compulsive Disorder in Children and Young People: New National

Clinical Research ........................................................................................................................... 53

Intolerance of Uncertainty, Worry, and Generalized Anxiety Disorder Among Young People .... 54

Perinatal, Child and Adolescent Issues ......................................................................................... 55

Panel Discussion ......................................................................................................... 57

An Innovative Approach in CAMHS to First Episode Psychosis using Parents as Co-Therapists .. 57

Posters........................................................................................................................ 58

A Service Evaluation: Service User Satisfaction in Attending a Dialectical Behaviour Therapy

Course ........................................................................................................................................... 58

The Moderating Role of Child Callous Unemotional Traits in an Internet-based Parent

Management Training Program .................................................................................................... 58

Acceptability of telephone versus face-to-face cognitive behaviour therapy for obsessive

compulsive disorder in youth: the views of parents and young people ....................................... 58

Eating Disorders and Impulse Control .......................................................... 59

Keynote Address ......................................................................................................... 59

Is obesity a problem that simply does not yield to psychological methods of treatment? ......... 59

Symposia .................................................................................................................... 59

Implementing CBT for the eating disorders: how do we ensure the delivery of good quality care?

An opportunity to discuss and reflect upon common service dilemmas ..................................... 59

What goes on in the Eating Disorders Clinic? Clinicians’ and patients’ perspectives on treatment,

the working alliance, and recovery ............................................................................................... 60

Emotions in the eating disorders .................................................................................................. 61

Advances in Cognitive-Behavioural Therapy for Problem and Pathological Gambling ................ 62

IAPT and Primary Care ................................................................................. 63


IAPT Progress Report .................................................................................................................... 63

Symposia .................................................................................................................... 63

Extending the Scope of the IAPT Programme to Other Client Groups: Workforce Implications

and Impact on Education and Training ......................................................................................... 63

Low Intensity Interventions in IAPT: Improving Efficacy by Group Based Formats ...................... 64

IAPT in Routine Clinical Practice: Challenges, Innovations and Outcomes ................................... 65

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Doing a Lot More in Low Intensity: The STEPS Service ................................................................. 66

Defining Effective Therapists and Therapies in IAPT Services ...................................................... 67

Second Generation Low Intensity Interventions for Complex Health Problems .......................... 68

IAPT Treatment & Delivery ........................................................................................................... 69

Increasing Access and Effectiveness of Treatments ..................................................................... 71

Low Intensity Interventions .......................................................................................................... 72

Skills Classes ............................................................................................................... 74

How to Deliver Brilliant Therapy Using 7 Sheets of Paper ............................................................ 74

Posters........................................................................................................................ 74

Using low intensity interventions to treat depression and anxiety in people with long term

health conditions (LTC) ................................................................................................................. 74

Evaluation of a CBT group for anger regulation problems delivered in an open group format ... 74

Community Wellbeing Champions ............................................................................................... 75

CBT group for diabetes and co-morbid depression ...................................................................... 75

Therapist effects in routine low-intensity psychological therapy: evidence from the Improving

Access to Psychological Therapies (IAPT) programme ................................................................. 75

CBT workshops for GPs and practice staff .................................................................................... 76

Auditing the key support and resources required to deliver high quality CBT. Using the RAISE

audit tool as part of a systematic approach to measuring and improving the quality and

efficiency of CBT within and across services ................................................................................. 76

Intellectual and Developmental Disabilities ................................................. 76


Learning to listen: what aspects of CBT work for people with intellectual disabilities? .............. 77

Symposia .................................................................................................................... 77

Developing Cognitive-Behavioural Interventions for People with Autism ................................... 77

Posters........................................................................................................................ 78

Measuring Anxiety in Autism Spectrum Disorders: Parent-child agreement ............................... 78

Older Adults ................................................................................................. 78


Sex, lies and video tapes: The use of CBT and schemas across the lifespan ................................ 79

Symposia .................................................................................................................... 79

CBT for Anxiety in People with Mild Cognitive Impairment or Dementia .................................... 79

Severe and Enduring Problems .................................................................... 80


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Translating Cognitive Research Findings into Effective and Accessible CBT for Psychosis ........... 81

Think Effectively About Mood Swings (TEAMS): Can we integrate the past, present and future

'waves' within CBT for bipolar disorders? ..................................................................................... 81

Symposia .................................................................................................................... 81

Too Much of a Good Thing? Theory and Research investigating the Emotionally Over-Controlled

Personality Proto-Type ................................................................................................................. 81

New Trajectories in Bipolar Disorder Research ............................................................................ 83

New Developments and Interventions for Bipolar Disorder ........................................................ 84

Recent Developments in CBT for Psychosis: What Can We Learn From the Social Anxiety

Literature? ..................................................................................................................................... 85

Cognitive Behavioural Therapy for Auditory Verbal Hallucinations ('Hearing Voices'): From

Causes to Effects in Clinical Practice ............................................................................................. 86

Dissociation in the Real World ...................................................................................................... 87

Dissociation Past, Present and Future: Cognitive Insights ............................................................ 88

Learning From and Alongside Service Users: The Recovery Programme .................................... 89

Psychosis: Basic Processes ............................................................................................................ 90

Treatment of Psychosis ................................................................................................................. 92

Skills Classes ............................................................................................................... 93

Running Acceptance and Commitment Therapy (ACT) Groups for Psychosis .............................. 93

Posters........................................................................................................................ 93

The role of nursing staff in transforming problems with borderline personality disorder

inpatient admissions into opportunities: Incorporating dialectical behaviour therapy skills into

acute psychiatric inpatient units ................................................................................................... 93

How acceptable is Acceptance and Commitment Therapy to keyworker staff working with

individuals with substance misuse difficulties? An exploratory pilot study ................................ 94

Decreasing Anxiety and Increasing Cognitive Flexibility in a Young Girl With Asperger Syndrome

...................................................................................................................................................... 95

Description of North East Traumatic Stress Centre ...................................................................... 95

Therapeutic Techniques ............................................................................... 95

Skills Classes ............................................................................................................... 96

Imagery-focused CBT for traumatic bereavement ....................................................................... 96

Seeing the Difference: The Application of Cognitive and Motivational Imagery to Athletes and

Exercisers ...................................................................................................................................... 96

How to integrate Compassion Focused Therapy within Familiar CBT Approaches ...................... 96

Using CBT to Help People Cope With Unemployment ................................................................. 97

How to Enhance the Therapeutic Value of the Therapeutic Relationship ................................... 97

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Using Imagery in CBT Treatment of Long-term Conditions .......................................................... 98

Making CBT Memorable: How to Use Story and Analogy in Daily Practice .................................. 98

Developing Change Methods to Engage with the Disengaged in Military Trauma ...................... 99

Posters........................................................................................................................ 99

A case study of a client with 'shy bladder syndrome’ ................................................................... 99

A study of the perceptions and practice of physicians on the use of cognitive behavioural

therapy (CBT) .............................................................................................................................. 100

Classification of Metaphors in Cognitive Behavioural Therapy .................................................. 100

Assessment of Integrated Therapeutic Approaches (AITS) (for caring systems) ........................ 101

Training and Professional Issues ................................................................ 102

Symposia .................................................................................................................. 102

What Can the NHS Learn From the Third Sector in the Delivery of CBT? ................................... 102

CBT Skills Training: Supporting Clinical Competency Development ........................................... 102

Cognitive Therapy in Context ...................................................................................................... 104

Using Cognitive Formulations With Staff Teams: Examining the Clinical and Organisational Value

of Differing Consultation Approaches ......................................................................................... 106

Utilising New Technologies in Training and Therapy .................................................................. 107

Skills Classes ............................................................................................................. 108

Culturally Adapted Cognitive Behaviour Therapy for Mental Illness .......................................... 108

Clinical Roundtable ................................................................................................... 109

Delivering Acceptance and Commitment Therapy in Groups .................................................... 109

Posters...................................................................................................................... 109

A qualitative analysis of experts’ experiences of how CBT competence is conceptualised and

assessed ...................................................................................................................................... 109

Adaptation and psychometric testing of the CTS-R for use in chronic low back pain ................ 109

Do Psychotherapists use research to enhance their clinical practice? ....................................... 110

The impact of supervision in the delivery of a CBT based intervention ..................................... 110

40th Anniversary Founder Celebrations ..................................................... 111

Symposia .................................................................................................................. 111

Celebrating 40 years of BABCP: A Symposium in Honour of Andrew Mathews - A Founder

Member ...................................................................................................................................... 111

Celebrating 40 Years of BABCP: A Symposium in Honour of William Yule – A Founder Member

.................................................................................................................................................... 112

Celebrating 40 Years of BABCP: A Symposium in Honour of Isaac Marks - A Founder Member 113

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Panel Discussions ...................................................................................................... 114

Celebrating 40 Years of BABCP: A Panel Discussion in Honour of Ivy Blackburn – A Founder

Member ...................................................................................................................................... 114

Celebrating 40 Years of BABCP: A Panel Discussion in Honour of Joan Kirk - A Founder Member

.................................................................................................................................................... 114

Mixed Categories ....................................................................................... 114

Symposia .................................................................................................................. 115

New innovations. Putting the IA in C+A IAPT .............................................................................. 115

Increasing Access to Talking Therapies for People with Severe Mental Health Conditions: Can we

Start a Revolution? ...................................................................................................................... 116

London IAPT Training: Recent Developments in IAPT Evaluation and Expansion: Evidence Based

Training for Evidence Based Choices, Improving Mental Health to Meet the Needs of All ....... 117

Clinical Roundtable ................................................................................................... 118

IAPT for Psychosis: A large step in the right direction? .............................................................. 118

Panel Discussions ...................................................................................................... 118

Transforming Mental Health Services for Children and Adolescents ......................................... 118

CYP-IAPT Parent Training: Making It Happen! ............................................................................ 118

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Adult Mental Health

Keynote Addresses

A kinder, gentler CBT for anxiety disorders: The potential for safety behaviour use in treatment Adam S. Radomsky, Concordia University, Canada Our roots are in the history of learning and behaviour change. Iconic individuals such as Ivan Pavlov and Joseph Wolpe have provided us with an evidence-based approach, as well as sound theoretical and technical frameworks on which to base our use of CBT in the clinic. Some highly experienced (and even many inexperienced) therapists apply the techniques of CBT for anxiety disorders with both empathy and compassion; although, some existing techniques (e.g., exposure) can be challenging for clients nonetheless. Anecdotal and now, emerging empirical evidence suggests that challenging exposure exercises can be a source of client concern and may well lead them to refuse and/or discontinue the treatment. Though this is clearly not always the case, CBT for anxiety disorders is sadly often associated with markedly and unacceptably high rates of treatment discontinuation and refusal. This presentation will review past and current research work designed to re-consider the role of safety behaviour in the treatment of anxiety disorders. Specifically, studies which show that judicious safety behaviour use during treatment can enhance the acceptability of CBT, without necessarily interfering with outcome will be described in the context of developing a highly effective, but kinder and gentler approach to CBT for anxiety disorders.

Third Wave Behaviour Therapies: Efficacy in Treating Clinical Depression Derek Hopko, University of Tennessee Behavioural and cognitive behavioural therapies have a lengthy history as effective and efficacious treatments for depression. In the past few decades, increasing emphasis has been placed on third-wave behaviour therapies that have fundamentally different philosophies on depressive psychopathology and corresponding intervention components. This address will present a historical perspective on cognitive-behavioural treatments for depression, highlight the most current literature on third-wave behaviour therapies for depression, address their efficacy and methodological strengths and weaknesses, and provide commentary on future directions toward improving psychotherapy outcomes for depressed patients.

Performing in the mind’s eye: Imagery use in sport Jennifer Cumming, School of Sport and Exercise Sciences, University of Birmingham Imagery is a dynamic and complex mental activity that is fundamental to learning and performance. The extensive and systematic use of imagery is a characteristic of the most successful sport performers and there is growing evidence in support of this technique as a supplement to regular physical practice. How effective this imagery will be, however, depends on the athlete’s ability to easily and vividly create and control images. There is evidence that imagery ability can be modified with training, however, progress in establishing the efficacy of such improvements has been limited due to lack of appropriate measurements. The development of the Sport Imagery Ability Questionnaire (SIAQ; Williams & Cumming, 2011) has now made it possible to assess athletes’ ability to generate cognitive and motivational images. This instrument can be used to screen athletes prior to an intervention and monitor their progress throughout. Furthermore, the revised applied model of deliberate imagery use (Cumming & Williams, in press) can help to ensure that such interventions are designed with the specific goals of the athlete in mind. In this key note address, Dr Cumming will review research in support of the model and outline the practical methods for improving imagery ability. Dr Cumming will also recommend how this evidence-based model can be translated to training techniques for a variety of individuals.

Building a Unified Model for Cognitive Behavior Therapy: The New Clinical Science of Mindfulness and Values Kelly G. Wilson, University of Mississippi Cognitive behavior therapy (CBT) has experienced extraordinary growth in recent decades and has led the way in evidence-based clinical psychology. CBT encompasses a diverse group of science-based treatments that has evolved from its earliest roots in the behavior therapies of 1950’s and 60’s to its current dominant form that includes a variety of cognitive interventions. The CBT movement remains dynamic and evolving. Some CBT strategies such as cognitive disputation strategies are giving way to more acceptance and mindfulness-oriented approaches. In addition, the role of values has begun to receive increased attention. Although these approaches may appear to diverge from traditional CBT, they emerge from the same commitment to science-based treatments. In this address, I will describe a unified model for CBT called the Psychological Flexibility Model. The model is most closely connected with Acceptance and Commitment Therapy, but has much broader implications for applied psychology. The model has been applied with good benefits to a wide variety of psychological difficulties, including psychosis, depression, anxiety, and substance abuse, to multi-problem Axis-II clients, to a variety of physical health problems, as well as to educational and workplace concerns. Evidence from basic psychological science, experimental psychopathology, and clinical trials will be presented in support of the model. Finally, suggestions will be made for the ongoing development of psychological models that move beyond current diagnostic and treatment systems.

From Soup to Nuts: From Inception and Research through Dissemination of Cognitive Processing Therapy Patricia A. Resick, National Center for PTSD, VA Boston Healthcare System and Boston University Cognitive Processing Therapy (CPT) was developed in 1988 as a group treatment for PTSD for rape victims. In the intervening years, CPT has been the subject of randomized controlled trials with a range of traumas as well as effectiveness studies. The purpose of this talk will be to describe the research supporting CPT including a recent long term follow-up that was conducted on average six years post-treatment with 74% of the original 171 participants in the original intent to treat sample. The results of a group trial with active military will be presented. Ongoing studies and future directions will also be described. Aside from research results, Dr. Resick will describe the dissemination project that has been underway since 2006 to teach CPT to therapists at 160 Veterans hospitals, the components of the program and some of the results.

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A better understanding of how the world works? An integrated perspective on how psychological treatment is effective with particular reference to the current status of understanding and treatment of OCD Paul Salkovskis, Department of Psychology, University of Bath The last decade has seen parallel development and integration of highly effective disorder specific and trans-diagnostic approaches to mental health problems. In this presentation, factors underpinning the success of these approaches will be considered. Key factors identified are the development of clear and understandable relationships between theory, descriptive and experimental research and outcome research, leading to empirical grounding of treatment itself. In addition, the importance of an increasing emphasis on linking meaning, behaviour and symptoms a part of a shared understanding (in which service users feel understood) is considered. Involving people with personal experience of mental health problems is a further exciting and highly promising development. These factors will be illustrated with reference to clinical research and treatment, particularly the presenters’ work on obsessional problems.

Emotional Schemas and Emotional Intelligence Robert L. Leahy, American Institute for Cognitive Therapy Emotional intelligence is comprised of multiple components--- recognition, differentiation, labelling, emotional regulation, display of emotion, and the ability to regulate the emotions of others. In this keynote I will outline a social-cognitive model of emotional schemas and illustrate the relationship between emotional schemas, individual differences in psychopathology, and emotion regulation strategies. Emotional schemas represent beliefs about the durability, comprehensibility, control, danger, shame, normality, and legitimacy of emotion in self and other. These conceptualizations and evaluations may result in problematic strategies of emotion regulation, such as rumination, blaming, bingeing, substance abuse, and self-injury. I will review research on emotional schemas and their relationship to personality disorders, PTSD, depression, anxiety, worry, and substance abuse. We will also examine the relative contribution of emotional schemas, dispositional mindfulness and psychological flexibility to psychopathology. In addition, we will review research on how interpersonal emotional schemas are related to relationship satisfaction.

Time bombs and tidal waves: What has been the impact of the wars in Iraq and Afghanistan other health of UK service personnel and what can we expect in the future? Simon Wessely, Institute of Psychiatry, King’s College London No abstract

Symposia

Recent Investigations into the Roles of Safety Behaviour in the Treatment of Anxiety Disorders Convenor: Irena Milosevic, St. Joseph’s Healthcare Hamilton Discussant: Mark Freeston, Newcastle University

Does commitment to future exposures reduce negative effects of safety behaviours? Juliane Reininghaus, Utrecht University; Diederik Stap, Utrecht University; Marcel van den Hout, Utrecht University Safety behaviours are widely held to counteract the positive effects of exposure treatments. Recent analogue studies have suggested, however, that safety behaviours (i.e., washing one’s hands after repeated contaminations) do not reduce the positive effects of repeated exposures (Rachman et al, 2011; van den Hout et al., 2011). A possible explanation for these findings is that participants in the safety behaviour condition implicitly committed themselves to engage in new future contamination, rendering safety behaviours futile. This hypothesis was tested in the current study. Three groups of healthy participants (N=48, divided equally across groups; 65% women) engaged in a series of 20 contamination trials, during which they had to touch a dirty item. Participants were asked to provide ratings of contamination, disgust, fear, and perceived danger in response to six contaminating items before and after the trials. In the first group, no safety behaviours were included (no SB). In the second group, safety behaviours (usage of a hand disinfectant) were allowed, but it was stressed to participants that they can stop any time they wanted and that there was no need to carry out all exposure trials (SB without commitment). In the third group, explicit commitment to finish the entire series of exposures was obtained (SB + commitment). The results demonstrated that all groups displayed substantial reductions in ratings on all measures. There was a significant Time X Group interaction for contamination, with the SB + commitment group showing greater reduction in scores than the no SB group. The SB without commitment group’s reduction in contamination lay in between the other two groups and did not differ significantly from either. Results will be critically discussed. Safety Behaviour Enhances the Acceptability of Exposure Therapy Adam S. Radomsky, Concordia University, Canada; Hannah C. Levy, Concordia University, Canada Compulsive washing and contamination fear are among the most common symptoms of obsessive-compulsive disorder (OCD). Research suggests that exposure and response prevention (ERP) is effective for OCD; however, ERP is prone to dropouts and refusals, and a substantial proportion of patients do not receive the care they need. A proposed solution involves the judicious use of safety behaviour in the early stages of treatment to enhance its acceptability and tolerability. The current study tested the impact of this proposed solution. Participants were 70 undergraduate students who completed two exposure-based treatment sessions for contamination fear, one with safety behaviour and one without. Following each trial, participants rated the acceptability and tolerability of the treatment in which they had just engaged. Results indicated that exposure with safety behaviour (ESB) was rated as significantly more acceptable than ERP. Furthermore, subjective fear ratings were significantly lower and behavioural approach to a series of contaminants was significantly greater in the ESB condition. These findings support the notion that safety behaviour may increase the acceptability of cognitive behavioural therapy (CBT). Results will be discussed in terms of the conceptualization of safety behaviour as a maintaining factor of anxiety symptomatology and of the potential benefit of the judicious use of safety behaviour in CBT.

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The Role of Safety Behaviour in Attributions for Fear Change Irena Milosevic, St. Joseph's Healthcare Hamilton; Jeff Renaud, Concordia University, Canada; Adam S. Radomsky, Concordia University, Canada According to cognitive-behavioural theories of anxiety disorders, anxious individuals’ use of safety behaviour hinders their acquisition of fear-disconfirming information, as they are likely to conclude that their own actions (i.e., the safety behaviour) are responsible for preventing feared outcomes (Salkovskis, 1991). While there has been increasing interest in the impact of safety behaviour on fear and belief change in the context of cognitive-behavioural interventions, with evidence of both detrimental and facilitative effects of safety behaviour use (Rachman, Radomsky, & Shafran, 2008), there has been surprisingly little focus on the role of safety behaviour in participants’ attributions for treatment change. This study thus investigated whether attributions for fear change following a brief behavioural experiment were affected by participants’ use of safety behaviour during the session. Highly spider-fearful participants (N=126) were randomized to one of two conditions, in which they either used or did not use safety gear (e.g., gloves, goggles, head covers) during a 20-minute session with a live spider. During this session, participants were instructed to acquire information to disconfirm a target negative belief related to their spider fear. Measures of fear were administered before and after the session (without safety gear in both groups). Participants were also asked to provide attributions for fear change after the session, which were coded by two independent raters along the following eight categories: belief disconfirmation/information acquisition, habituation, increase in self-efficacy, increase in perceived control, laboratory (controlled) environment, atypical spider, safety gear, and experimenter’s presence. Participants in both groups experienced significant pre- to post-session reductions in fear based on a self-report measure, a behavioural index, and ratings of subjective distress. Proportional attribution scores were calculated for each of the attribution response categories and subjected to one-way ANOVAs. No significant differences between the groups were observed for any of the eight categories. Participants who used and who did not use safety gear provided similar attributions for their fear change, with the most frequently reported attribution by both groups being belief disconfirmation/new information. The use of safety gear was reported as a reason for fear change by only 3% of participants in the safety gear group. Results will be discussed in terms of cognitive-behavioural and exposure-based treatments and the role of safety behaviour in the treatment of anxiety disorders. Safety Behaviours and Adaptive Coping: The Same or Different? Lynn E. Alden, University of British Columbia; Heather Baker, University of British Columbia; Leili Plasencia, University of British Columbia; Melisa Robichaud, University of British Columbia; Thwaites and Freeston (2005) described a series of conceptual and clinical difficulties that arise when attempting to distinguish between safety behaviours and adaptive coping strategies. To explore this issue, we conducted two studies that assessed: a) potential overlap between established measures of the two constructs and b) the effects of safety behaviour use on social interactions. In Study 1, 168 undergraduate participants completed measures of Social Anxiety Disorder (SAD) symptoms (Social Interaction Anxiety Scale, SIAS) and Generalized Anxiety Disorder (GAD) symptoms (Penn State Worry Questionnaire, PSWQ), along with two measures of safety behaviours (the Social Behaviour Questionnaire (SBQ), Clark et al, 1995 and the GAD Safety Behaviour Scale, G-SBS). They also completed two versions of the Brief Ways of Coping Scale (BWOC), one focused on strategies for coping with situations that cause social anxiety and the second focused on strategies for coping with situations that cause uncontrollable worry. We conducted two hierarchical multiple regression analyses, one to predict the SIAS and the other to predict the PSWQ. The relevant coping measure was entered in step one and the two safety behaviour scales in step two. Results indicated that coping was not associated with anxiety symptoms in step 1. In contrast, each safety behaviour scale displayed a significant and specific relationship with its corresponding symptom measure, i.e., the SBQ was uniquely associated with the SIAS and the G-SBS with the PSWQ. These findings suggest that safety behaviours and adaptive coping, at least as assessed by established instruments, can be reliably distinguished. Study 2 examined whether different types of safety behaviours may be more or less debilitating in social situations. Treatment-seeking individuals diagnosed with SAD were randomly assigned to either a safety behaviour reduction or a control condition and participated in two laboratory social interactions. Findings revealed that avoidance safety behaviours (e.g., avoiding eye contact and self-disclosure) resulted in negative social outcomes whereas safety behaviours focused on impression-management (e.g., rehearsal, feigned friendliness) did not. The clinical implications of the two studies will be discussed.

Working with 'Others' in the Treatment of Anxiety Convenor: Stephanie Fitzgerald, Charlie Waller Institute, University of Reading

The Treatment of Child Anxiety Disorders via Guided CBT Self-Help Delivered to Parents: A Randomised Controlled Trial Kerstin Thirlwall, University of Reading; Catherine Creswell, University of Reading; Peter Cooper, University of Reading Anxiety is the most common form of mental health difficulty in childhood and often leads to future psychological difficulties. One form of treatment shown to be effective is Cognitive Behaviour Therapy (CBT). However, CBT is a specialist treatment which is expensive and not widely available. As such there is a need to provide effective and deliverable forms of CBT. One way of doing this is via a CBT self-help manual. Such manuals have been shown to be effective in helping treat other problems and could increase the availability of CBT to children with anxiety. A guided CBT self-help programme delivered via parents has been developed based on the principles outlined in a published manual entitled ‘Overcoming Your Child’s Fear and Worries- a self-help guide using Cognitive Behavioural Techniques’ (Creswell and Willetts, 2006). The programme is aimed at children aged 7-12 with a range of anxiety disorders and is carried out with parents alone. Following a feasibility study, a randomised controlled trial was conducted in order to further investigate the efficacy of this approach. Parents of anxious children were either assigned to a waitlist control condition, a ‘full’ treatment condition (four face-to-face sessions and four telephone sessions) or a truncated version of the treatment (two face-to-face sessions and two telephone session). Outcomes were assessed using standardised interview measures and questionnaires. The findings and implications of this study will be presented.

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Living with Obsessive-Compulsive Disorder: An Exploration of Partners’ Experiences Using Grounded Theory Analysis Stephanie Fitzgerald, Charlie Waller Institute, University of Reading; Blake Stobie, Institute of Psychiatry; Sue Thorpe, Newcastle University; Obsessive Compulsive Disorder (OCD) affects all those who come into contact with it. Existing research examining the impact of Obsessive-Compulsive Disorder has tended to focus on the impact of OCD on the individual with the diagnosis. However, there is increasing recognition that OCD also impacts heavily on those around the individual with the diagnosis. Previous research into this area has focused on ‘family members and carers’, a term which has grouped families and partners together. The presented research focuses on partners’ experiences of living with someone with OCD. A grounded theory approach was used to interview and analyse data from nine participants all of whom were partners of someone with a diagnosis of OCD. The results highlight the various impacts on partners of living with someone with OCD, including detrimental impacts on their personal life, work-life, social-life and mental health and well-being. Also partners appeared to be inadvertently engaging in behaviours that were maintaining their partner’s OCD symptoms. This research highlights the extensive impact of living with someone with OCD, and the necessity of providing support and including partners in the therapeutic process. This holds implications for clinical practice and future research in this area. Adding Compassion to Groups for Carers of People with Dementia Ian Scott, Berkshire Healthcare NHS Foundation Trust; Anxiety and stress brought on by the role of caring for someone with dementia is commonplace. We have tailored our group intervention to incorporate aspects of Paul Gilbert's work on Compassion. Building up skills from challenging critical thinking, we have gone further, teaching service users how to balance negativae thinking with compassionate thinking. Service users report this additional technique enables them to cope with aspects of caring that are most demanding.

Working with Complexity Convenor: Stirling Moorey, South London and Maudsley NHS Foundation Trust

Discussant: Florisn Ruths, South London and Maudsley NHS Foundation Trust

Conceptualising complex cases Suzanne Byrne, Institute of Psychiatry Kings College London CBT practice continues to develop and expand and there are promising results with a variety of presentations and populations. The reality for many CBT therapists is that they work with a number of clients with differing presentations ranging from one or two main focal problems that can be easily identified and targeted through to clients who have diffuse problems with multiple co-morbidities. Developing an integrative conceptualisation has many benefits and can be containing for therapist and client alike. It can help to guide treatment planning by predicting roadblocks and suggesting the focus of interventions. This presentation is clinically based and illustrative cases will be presented including integrated case conceptualisation and treatment outline for alcohol misuse and depression and substance misuse and social phobia. Complexity in Anxiety Disorders - with illustrative cases of OCD Tracey Taylor, Centre for Anxiety Disorders & Trauma, South London & Maudsley NHS Trust The evidence base for the efficacy of CBT for wide range of anxiety disorders is large, and growing. There is increasing interest in issues of complexity, how these impact on therapy and ways in which, as clinicians, we can tailor our therapy programmes to maximise therapy outcomes, and reduce levels of distress and suffering within this population. Along with the refinement of new techniques and strategies; including imagery work, time-intensive therapy and some excellent single case report studies there are also reminders to stick with the evidence base, and not be pulled off course too early, particularly in the face of complexity. This talk is clinically based, and focusses on factors that can be helpful when working with this client group, with illustrative case material. Transference and countertransference in CBT Stirling Moorey, Sout London and Maudsley NHS Foundation Trust CBT has tended to avoid the term transference because of its association with psychoanalysis, yet many of the patients we work with have strong reactions to us that seem to arise from beliefs, emotions and behavioural patterns that were learned in childhood. These patients can evoke responses in us that are equally strong and different from our usual professional style and behaviour. A model of conceptualisation will be presented that allows the therapist to understand how beliefs and interpersonal compensatory strategies may affect the therapy process. Some common transference and countertransference reactions and the schemas that give rise to them will be described together with methods for managing them. ‘Schema-Informed CBT’: Integrating Schema Therapy Concepts and Techniques into CBT Anna Lavender, South London and Maudsley NHS Foundation Trust Schema therapy has a significant and growing evidence base for the treatment of individuals with complex presentations and personality disorders. While the limitations of shorter-term, ‘lite’, versions of Schema Therapy are acknowledged, we have found that integrating some of Schema Therapy’s key concepts and techniques into CBT treatments of 12-30 sessions can be a useful addition to the treatment of individuals with complex presentations. This is a clinical presentation of our group’s ideas about and experiences of providing Schema-informed CBT to individuals within an NHS clinical setting. We propose a stepped, goal-oriented model for the integration of Schema Therapy with CBT. Within this, we will discuss methods of integrating key concepts, avoiding potential difficulties, and maintaining theoretically coherence.

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Body Dysmorphic Disorder and Body Image Problems Convenor: David Veale, Instiute of Psychiatry, King’s College London

The role of self focussed attention and mood induction in miror gazing Martin Anson, Instiute of Psychiatry; David Veale, Institute of Psychiatry, KCL; Emma Baldock, Institute of Psychiatry, KCL We investigated the role of self-focussed attention and mood induction in mirror gazing in an analogue population of female students. 93 particpants were randomly allocated to either (a) instructions to be externally focussed in front of a mirror (b) instructions to be self-focussed in front of a mirror or (c) have a depressed mood induction by watching a short film and then instructions to be self-focusssed in a mirror. Measures were taken before and after mirror gazing for 2 minutes. We will report on the effects of group and time on appearance related distress, degree of preoccupation with appearance, degree of certainity about appearance, focus of attention (internal or external), focus on the whole face or specific features, urge to look into the mirror. The findings may provide experimental evidence for some of the maintenance factors in body dysmorphic disorder. Characteristics and outcome of women seeking labiaplasty Ertimiss Eshkevari, Institue of Psychiatry, KCL; David Veale, Institute of Psychiatry, KCL Little is known about the characteristics and prevalence of psychiatric disorder in women seeking labiaplasty. We report on a matched case control design in which we compared women seeking labiaplasty against women having a general gynaecological procedure. The groups are matched according to age and the same degree of protrusion of the labia minora. We will compare the prevalence of Body Dysmorphic Disorder (BDD) as well as their attitudes towards their genitalia, sexual functioning, quality of life, their disgust sensitivity and whether there is any history of teasing or childhood abuse. We will discuss how to develop Cognitive Behaviour Therapy for identifying and engaging clients with concerns about the size of their labia in settings where they are most likely to present. We will also report on the outcome of women having labiaplasty. Our primary outcome measure at 3 months is the Genital Appearance Satisfaction Questionnaire. Our secondary outcomes are Sexual Functioning, Hospital Anxiety And Depression scales, Body Image Quality of Life scales. Characteristics of men worried by the size of their penis Julie Read, Institue of Psychiatry, KCL; David Veale, Institue of Psychiatry, KCL; Andrea Troglia, Institue of Psychiatry, KCL; Gordon Muir, King's College Hospital NHS Foundation Trust The aim of this study is to determine the characteristics of men worried by the size of their penis (but have a normal size), known as Small Penis Syndrome (SPS); the prevalence of body dysmorphic disorder and other psychiatric disorders in men with SPS. Such men seek penile extenders, pills and surgical solutions which are not scientfically evaluated for the effect on size or psychosexual function. Men will be matched according to their age and the size of their penis. We will comapre them on their beliefs about penis size, their safety seeking and avoidance behaviours, level of anxiety and depression, sexual functioning, social anxiety and experience of past teasing and trauma. Knowledge about their beliefs and behaviours will contribute to developing CBT for men with SPS that can be evaluated in future trials. A randomised controlled trial of cognitive behaviour therapy v anxiety management David Veale, Institute of Psychiatry, KCL; Martin Anson, Institute of Psychiatry, London The evidence base for cognitive behaviour therapy (CBT) for treating body dysmorphic disorder (BDD) is small with ony two randomised controlled trials that have compared CBT v waiting list. We are investigating whether CBT is more effective than anxiety management over 12 weeks. Anxiety management is designed to control for time, therapist attention and relationship, a formulation and homework. We will test the credibility of both treamtents. The main outcome measure is the Yale Brown Obsessive Compuslive Scale for BDD which is done blind at 12 weeks. There are various secondary measures including depression, anxiety, and body image quality of life. The CBT continues until week 16 and follow up occurs at 6 and 12 months.

CBT for Treatment Resistant Depression: Results From the COBALT Trial Convenor: Nicola Wiles, University of Bristol

Clinical effectiveness of CBT as an adjunct to pharmacotherapy for treatment resistant depression in primary care Nicola Wiles, University of Bristol Only one-third of patients with depression respond fully to treatment with antidepressant medication (Trivedi et al, 2006). Depression guidelines recommend reviewing treatment options if a patient experiences little or no improvement after 6 weeks treatment with antidepressants. However, there is no consensus as to the best ‘next step’. Combined pharmacological and psychological treatment of depression has been shown to be effective (Pampallona et al, 2004; Friedman et al, 2004), but there is no evidence specific to those who have not responded to antidepressants, the group for whom cognitive behavioural therapy (CBT) is often reserved. The COBALT study is a HTA-funded multi-centre (Bristol, Exeter and Glasgow) pragmatic randomised controlled trial (RCT) of CBT given as an adjunct to pharmacotherapy for primary care patients with treatment resistant depression (defined as those who have significant depressive symptoms following at least 6 weeks treatment with antidepressants at an adequate dose).The aim is to determine the effectiveness of CBT (in addition to pharmacotherapy) in reducing depressive symptoms and improving quality of life over 12 months (compared to usual care alone) and (ii) to determine the cost-effectiveness of this intervention. Eligible patients were those: (i) aged 18-75 years; (ii) who were currently taking antidepressants (≥6 weeks at an adequate dose); (iii) who scored ≥ 14 on the Beck Depression Inventory (BDI-II); (iv) who had adhered to their medication; and (v) who met ICD-10 depression criteria. Those who gave written informed consent were randomised to one of two treatment groups: usual care or usual care plus CBT. The primary outcome was depressive symptoms assessed using the BDI-II at 6 months. Secondary outcomes measured at 6 and 12 months included quality of life, antidepressant use and health care utilisation.

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469 patients were randomised to either continue with usual care (including antidepressants) or to receive 12-18 sessions of CBT in addition to usual care. 90% (n = 422) of participants were followed up at 6-months (primary outcome) and 84% (n = 396) at 12-months. 95 participants (46.1%) in the intervention group met criteria for ‘response’ (≥50% reduction in depressive symptoms compared to baseline) at 6 months compared to 46 participants (21.6%) in the usual care group (odds ratio (OR): 3.26 (95%CI: 2.10, 5.06) p<0.001). Those randomised to the intervention group were more likely to experience ‘remission’ (BDI score<10) at 6 months (OR: 2.30 (95%CI: 1.39, 3.81) p=0.001). In repeated measures analyses using data from 6 and 12 months, the corresponding ORs for ‘response’ and ‘remission’ were: 2.89 (2.03, 4.10) p <0.001 and 2.74 (1.82, 4.13) p<0.001. Amongst patients who have not responded to antidepressants, CBT when given in addition to pharmacotherapy is effective in reducing depressive symptoms and these effects are maintained over 12 months. It will be important to evaluate the effectiveness of this intervention over the long-term. Funding: This research was funded by the NIHR HTA programme (06/404/02). The views expressed in this publication are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS, or the Department of Health. Cost-effectiveness of CBT as an adjunct to pharmacotherapy for treatment resistant depression in primary care: economic evaluation of the COBALT trial Sandra Hollinghurst, University of Bristol The aim of the economic evaluation was to assess the cost-effectiveness of the COBALT intervention compared with usual care. This was carried out from the perspectives of: (i) the health and social care providers (the National Health Service) and personal social services (PSS); (ii) participants; and (iii) wider society. Two types of analysis are presented: a cost-consequences framework is used to compare cost from each perspective with a range of primary and secondary outcomes and a cost-utility analysis is used to compare NHS and PSS costs with quality adjusted life years (QALYs). Both analyses are based on the costs incurred and the benefits obtained over the 12 months following randomisation into each group. The cost of the intervention was estimated using data on the number of CBT sessions received by each participant, the length of the sessions and the grade of the staff member. An additional cost was included to allow for supervision, and DNA (did not attend) sessions were costed at 50% of the full rate. Other NHS and PSS costs include: primary care appointments by health care profession and location; prescribed medication; hospital outpatient appointments; in-patient stays; use of social services; and disability payments received. Participant costs include: travel; over-the-counter medication and therapies; use of private therapies and health care; loss of earnings; and additional childcare and domestic help. Societal costs include: the value of time off work; and services provided by the voluntary sector. QALYs were estimated from responses to the EQ-5D obtained at baseline, 6 and 12 months. Complete cost and QALY data were available for 368 (78%) participants: 186 (79%) intervention and 182 (77%) control. The mean number of sessions received by these participants was 11.24 with 0.67 DNAs; the mean cost was £1,020 (sd £407). Provisional estimates of NHS service costs per participant are: CBT group £731 (sd £935); usual care group £745 (sd £714). Adjusted QALYs over the 12 months for the CBT group were 0.614 (sd 0.243) and 0.559 (sd 0.245) for the usual care group. QALY gain was 0.055 (95% CI: 0.008 to 0.102). Our provisional estimate of incremental cost per QALY gain is £18,300. This is likely to be conservative because of bias introduced by missing data. Further analyses planned include the estimation of participant and societal costs. We will also report the results of imputing missing data and sensitivity analyses of assumptions, notably around the cost of the intervention. Patients’ experiences of CBT and usual care for treatment resistant depression Katrina Turner, University of Bristol The COBALT trial included a nested qualitative study that entailed conducting in-depth interviews with trial participants. These interviews aimed to: (i) explore patients’ views and experiences of CBT; (ii) identify patients’ reasons for completing or not completing therapy; and (iii) describe ‘usual care’ for this patient group. The data gathered provided another standpoint from which to evaluate the intervention and highlighted possible reasons for the trial’s quantitative findings. The interviews were held with patients who had completed their 6 month primary outcome measures for the trial. Patients were purposefully sampled to ensure interviews were held with individuals in both arms of the trial. Within this sampling approach we aimed for maximum variation in relation to study site (Glasgow, Bristol and Exeter), patients’ age, gender, socio-economic background and whether or not their BDI score had improved by 6 months post-randomisation. When sampling patients from the intervention arm, we also aimed to sample those who varied in their levels of treatment adherence, i.e. had or had not completed therapy. The interviews were conducted in patients’ own homes or in their own GP surgery. A topic guide was used to ensure consistency across the interviews. Most interviews lasted about an hour. With patient consent, they were audio taped and fully transcribed. Data were then analysed thematically. The software package ATLAS.ti was used to aid analysis. Data collected ended when data saturation had been reached, i.e. no new themes emerged from the analysis. Forty patients were interviewed in total. 17 had completed therapy, 9 had not and 14 were interviewed having been randomised to the usual care arm. It was apparent that patients in intervention arm felt they had benefitted from receiving CBT. These benefits related to having had someone they felt able to talk to and who they viewed as non-judgemental and skilled in providing appropriate advice and support; learning to question their negative thoughts; feeling more able to manage their depression and communicate with others; and feeling more motivated to do things, such as exercise, which could also improve their mood. However, patients also described how they had found CBT a challenging and difficult process at times, and had struggled to complete homework tasks for both emotional and practical reasons. These difficulties were reasons why some patients had not completed their course of CBT. Other reasons for not completing were the need to prioritise other commitments and feeling too depressed to talk to someone about their feelings. Data gathered on patients’ experiences of usual care indicated that this mainly entailed taking antidepressants, although many of the patients interviewed also talked about having had counselling in the past. These data also highlighted that some patients had received invaluable support from family and friends, and had developed strategies/skills to help them cope, for example, avoiding certain situations and learning how to meditate.

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Conditional beliefs in patients with treatment resistant depression Alex Burrage, University of Bristol The COBALT trial used a CBT approach as described by Beck et al. (1979) with elaborations from Moore & Garland (2003) which were specifically designed to overcome the avoidance and resistance often found in patients with treatment resistant depression. CBT postulates three levels of cognition: unconditional core beliefs; conditional beliefs; and negative automatic thoughts. It has been suggested that in order to treat treatment resistant depression using CBT, it is helpful to work at the intermediate level of conditional beliefs (Mooney & Padesky, 2000; Moore & Garland, 2003) in order to effect longer-lasting change. Conditional beliefs are also known as ‘underlying assumptions’ or ‘rules for living’, and usually stated in an “If…then…” format. They drive behaviour and may therefore maintain negative core beliefs and influence engagement in therapy. This qualitative study reviewed the conditional beliefs recorded in the therapist notes of a random sample of 50 trial participants (stratified by age and gender) across the 3 study sites (Bristol, Exeter and Glasgow). The aim of the study was to explore and describe the types of conditional beliefs found amongst patients with treatment resistant depression, and identify if there were any prominent themes. The final sample consisted of 29 women (mean age: 50 years) and 21 men (mean age: 49 years). 284 conditional beliefs were extracted from the clinical notes and framework analysis (Ritchie & Spencer, 1994) was used to provide a systematic method of organising the data to identify key themes. The researchers extracted the data together, then worked independently to organise the beliefs according to themes. Any differences in themes were identified and discussed. Themes were then cross-referenced to determine agreement between the researchers. A third, independent researcher reviewed the data and resolved discrepancies. Preliminary findings and clinical implications will be presented. It is hoped that the results will both improve clinical understanding of this client group, and provide useful clinical information to facilitate the complex process of developing collaborative longitudinal formulations with patients with treatment resistant depression.

Increasing the Efficiency and Impact of Cognitive Therapy for Chronic and Recurrent Depression: The CLAHRC Depression Project Convenor: Anne Garland, Nottinghamshire Healthcare NHS Trust Chair: Richard Moore, Cambridgeshire and Peterborough Foundation Trust

A Service User’s Experience of Seeking and Engaging in Treatment for Chronic and Recurrent Depression Gail Hopkins, Service User representative, University of Nottingham In this presentation, treatment for chronic and recurrent depression will be discussed from a service user’s perspective. Gail will talk about her own experiences with talking therapies and pharmacological interventions. She will highlight issues that she has experienced with coordination of care and will present her views on the importance of people with chronic and recurrent depression being treated in secondary care. Gail will also highlight her own role within the CLAHRC mood disorders project and discuss her views regarding what should be provided by a service for treating users with depression. The CLAHRC-NDL Depression Service: A pragmatic randomised controlled trial Anne Garland, Nurse Consultant in Psychological Therapies, Nottinghamshire Healthcare NHS Trust The CLAHRC Depression Project is a 5 year randomised controlled trial comparing the efficacy and cost effectiveness of a specialist depression service delivered in secondary care, offering NICE recommended pharmacological and psychological (CBT) treatments for people suffering with severe, chronic and recurrent depression with treatment as usual. This presentation will define the philosophy and purpose of the CLAHRC programme, which represents the Department of Health’s new model for allocating research funding. It will go on to outline the service delivery model for the depression service which incorporates a collaborative care approach. There will be a discussion of the role a collaborative care model can play in increasing the efficiency and impact of CBT in a severe and complex clinical population. Implementing NICE recommended pharmacological and CBT treatments in a real world setting: a tale from the front line Tim Sweeney, Cognitive Behavioural Psychotherapist, Nottinghamshire, Healthcare NHS Trust This paper will begin by describing the NICE recommended pharmacological and CBT treatments offered in the CLAHRC depression project. A rationale will be given for their inclusion alongside discussion of those currently not offered within the service. There will be a description of the typical clinical profile of patients recruited to the project and discussion of the challenges of applying NICE recommended treatments given the complexity and severity of the population recruited. Consideration will also be given to current commissioning strategies which seek to deliver CBT treatments for this group within IAPT services and the presentation will give consideration to the potential limitations of such a strategy in terms of engagement in and delivery of effective pharmacological and psychological treatment. The Barriers and Drivers to the Development of a Mood Disorder Service: The Application of an Implementation Framework. Nicola Wright, Research Fellow, Univeristy of Nottingham; Catherine Kaylor-Hughes, Research Fellow, Univeristy of Nottingham; Markus Barker, Research Associate, Univeristy of Nottingham Background: The CLAHRC-NDL Mood Disorder project is a RCT comparing the utility and cost effectiveness of a specialised depression service to treatment as usual for people with chronic, recurrent depression. To bridge the second gap in translation from research to clinical practice, an implementation framework was applied to systematically identify the important barriers and drivers to the establishment of the service in a clinical setting. Methods: A two stage consensus activity was conducted with members of the team involved in establishing the service in healthcare settings. Stage one involved participants using the Bate et al (2008) framework to list barriers and drivers they had encountered. A consensus meeting and thematic analysis of responses refined these to ten core themes. The second stage was an online survey where participants rated each item for importance as both a barrier and driver to the implementation of the mood disorder service. Results: Project management theme was identified as the most important driver to ensuring the successful implementation of the mood disorder service. Service model, professional culture, organisational structure, education and boundary

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spanning were also considered to be important drivers. There was no consensus amongst the respondents regarding which themes acted as barriers to implementation, demonstrating the socio-contextual and fluid nature of implementation. Implications: Implementation frameworks such as the Bate et al (2008) model can structure the identification of barriers and drivers to implementation. However, participants expressed difficulties at using the model; the language had little resonance with their experiences. To facilitate the process, similar frameworks need to be more engaging for clinicians. Adapting Beckian Cognitive Therapy to address persistence in depression Richard Moore, Clinical Psychologist, Cambridgeshire and Peterborough NHS Foundation Trust Despite the development and implementation of evidence based “effective” treatments, rates of persistence and relapse of depressive symptoms remain alarmingly high. A number of novel therapies have been proposed to address chronicity, which address a variety of factors claimed to prevent sustained recovery. There is as yet little evidence for the enhanced effectiveness of these approaches. The way in which the model of Cognitive Therapy can be expanded to provide an integrative framework for understanding and treating persistence of depression will be illustrated. Factors that need to be included in a model of persistent depression will be described. Ways that treatment needs to be adapted will then be outlined. It will be argued that conventional psychotherapeutic approaches need to be expanded to incorporate not only technical developments, but also organisational, interdisciplinary and relational changes.

Trauma Work with Military Veterans Convenor: Imogen Sturgeon-Clegg, Combat Stress

Chair: Suzanna Rose, NHS South of England

How is combat-related trauma currently understood and made sense of by British Army Veterans. Pamela Reeves, Combat Stress; Laura Simonds, University of Surrey Background: The literature on combat-related trauma suggests varied conceptualisations of individual vulnerability and acceptance within the army across time. Current literature presents seeming contradictions between acceptance of trauma and actual rates of disclosure by soldiers. The literature suggests strong disincentives to help-seeking within the army and evidence of under-reporting of difficulties. Consequently, civilian mental health practitioners are likely to encounter discharged soldiers seeking help for unmanaged traumatic reactions. Current study: The current study attempts to understand the meaning of combat-related trauma within the context of a group of British army veterans. Methods: Two focus groups were conducted; one group comprising four male officer veterans and the other group comprising four male non-officer veterans. Each focus group was recorded, transcribed verbatim, and subjected to thematic analysis. Findings: An overarching theme of ‘Resisting the idea of trauma’ was developed with three sub-themes, namely: ‘Dissonant representations of trauma’, ‘Trauma interferes with operational imperatives’ and ‘’ambivalence regarding self disclosure’. Veterans understood that the army was encouraging people to seek help, but believed this would result in discrimination and exclusion. Furthermore the culture encouraged them to transform distress into more acceptable narratives, further removing the possibility of developing a language by which to express suffering. Conclusions: It is argued that the army is in a dilemmatic position: the need to maintain cohesion amongst troops to ensure operational success conflicts with the recognition and care of traumatised soldiers. The study findings provide insight for civilian clinicians attempting to achieve ‘cultural competence’ with a veteran population. The Relational Theatre of Stress: The Experience of Stress in Contemporary Counter-insurgency Warfare for UK Veterans with a Diagnosis of PTSD Vanessa Lewis, Combat Stress This present study sets out to explore the experience of stress in a contemporary counter-insurgency warfare context for veterans who have been diagnosed with Post-Traumatic Stress Disorder. Concious of the limited research on UK veterans and the lack of qualitative exploration within this new contemporary war context, an existential/phenomenological perspective to their experience of stress was taken and semi-structured interviews with 6 British male veterans who were registered with Combat Stress were analysed using IPA. The analysis yielded four major themes: i) 'The Relational Given of Human Existence', ii) 'Living with Constant Instability', iii) 'The Absurdity and Contradictions of Being', iv) 'Aftermath: Unknown Territory'. The themes in this research position the experience of stress as a relational and existential phenomenon, thus bringing the experience of stress in this context into a new focus. The knowledge produced in this thesis and its implication for therapeutic practise with this client group were discussed, offering a perspective of combat-related stress translated within existential phenomena in addition to ways of weaving this perspective into other more main stream therapeutic appraoches used with individuals with this diagnosis. Preliminary Outcomes of a Six Week Residential Post-Traumatic Stress Disorder Treatment Programme for Military Veterans Imogen Sturgeon-Clegg, Combat Stress; Nicola Sorfleet, Combat Stress In September 2011, Combat Stress began a National Specialist Commissioned Department of Health six week residential Post-Traumatic Stress Disorder (PTSD) treatment programme for military veterans. The programme is designed to treat veterans who have had multiple exposures to traumatic events (not limited to combat) with co-morbid difficulties such as depression and historic substance abuse. The treatment programme we offer is based on programmes developed by the Australian Veterans Mental Health Services, which have an evidence base of over 10 years, relating to approximately four thousand veterans with similar clinical presentations. The treatment programme itself consists of three elements; group psychoeducation, group skills training and a minimum of sixteen hours of Trauma-Focused Cognitive-Behavioural Therapy and/or Eye Movement Desensitisation and Reprocessing. Psychometric data is collected from veterans attending the treatment programme at seven points; initial assessment, start of treatment, mid-treatment, end of treatment, six week follow-up, six month follow-up and one year follow-up. A combination of self-report and clinician administered are utilised including; Impact of Events Scale-Revised, the General Health Questionnaire-28, the Hospital Anxiety and Depression Scale, the NOVACO Anger Scale, Global Assessment of Function and the PTSD Symptom Scale Interview.

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The evidence from the Australian Veterans Mental Health Services Treatment programmes on which are programme is based, is that one third of veterans who complete the programme will do well and need a little help after the programme; one third do well but need more help; and one third do not so well, but still need less help than they did before joining the programme. A preliminary analysis of the psychometric data collected during the first six months of operation of our treatment programme will be presented and discussed. What does a NHS Clinical Champion for Veterans Mental Health and Wellbeing do? Suzanna Rose, NHS South of England In 2010 there were various government drivers to improve the mental health of serving military and military veterans. This has resulted in the funding and development of new NHS services working jointly with charities such as Combat Stress. This enhanced joint working includes promoting evidential based treatments. This presentation will outline the background and current and future work undertaken by a Clinical Champion.

Formulation and Treatment in Complex Obsessive Compulsive Disorder Convenor: Alison Roberts

Chair: Lauren Callaghan, Anxiety Disorders Residential Unit, Bethlem Royal Hospital

Treatment Resistant OCD Alison Roberts, Centre for Anxiety Disorders and Trauma OCD can be a severe and debilitating condition. Treatment response in OCD can be variable and some people do not appear to make significant improvements with treatment. As an introduction to this group of talks about formulation and treatment of complex OCD Dr Alison Roberts will present descriptive and outcome data from the National Specialist Commissioning Group outpatient OCD service based at the Centre for Anxiety Disorders and Trauma. This is a national service for people who have not achieved or maintained treatment gains despite having at least two sets of adequate OCD focused CBT and access to appropriate medication (as outlined in the NICE guidelines). The talk will outline some of the key clinical issues and process which we feel impact on people’s ability to engage with OCD focused CBT, the difficulties clinicians experience in using this engagement to develop appropriate formulations and the difficulties in using these formulations to plan treatment which results in significant and long lasting change. Following on from this I will introduce four colleagues to give more detailed descriptions of the formulation and treatment of particularly challenging OCD presentations and the common stumbling blocks encountered in these type of cases. Mental Rituals and Rumination in OCD Blake Stobie, Centre for Anxiety Disorders and Trauma OCD characterised predominantly by obsessions and rumination (which is often misleadingly referred to as “Pure O” on service user fora and support groups) has a reputation as being especially difficult to treat. This presentation will make use of case examples to illustrate how routine CBT approaches to “standard OCD” can usefully be modified to help therapists to respond effectively to clients who present with predominantly covert compulsions including rumination. The reasons for early stage therapeutic techniques (including formulation and theory A/B) possibly being less effective for these clients will be considered, along with suggestions for modifications to these techniques. CBT techniques borrowed from other areas such as generalised anxiety disorder, and their application to compulsive rumination, will be discussed in the context of the treatment of clients with OCD who have not responded to previous treatments. Integrating ideas from compassion-focused therapy in the treatment of OCD Asmita Patel, Anxiety Disorders Residential Unit, Bethlem Royal Hospital When individuals with OCD have not improved despite receiving adequate CBT and when our usual treatment approach leaves us feeling stuck as therapists, this may indicate a need to adapt our usual approach to formulation and treatment. Integrating ideas from Compassion-Focused Therapy can offer a way forward with cases where the standard treatment approach has not worked, for example, where an obsessional problem is maintained by feelings of shame or guilt related to past events. This talk will discuss alternative approaches to formulation, based on Gilbert’s compassion-focused approach, and how this may be meaningfully integrated into our usual evidence-based treatment for OCD. There will also be a discussion of how this may indicate interventions that go beyond exposure and response prevention, including compassionate imagery and compassionate letter-writing, particularly where the formulation indicates that tackling self-criticism, cultivating self-acceptance and letting go of guilt is key to the individual’s recovery. When intrusions are unwanted and shameful sexual intrusions Fiona Challacombe, Institute of Psychiatry, Kings College London Many people with OCD experience unwanted sexual obsessions including doubts regarding sexual orientation, unacceptable sexual thoughts in a religious context and thoughts of sexual violence against adults and children. Understandably, obsessions of this nature are often associated with intense feelings of shame and guilt and consequent secrecy. As with other forms of OCD, but often acutely so, the problem can distort the person’s sense of self, leading to compromised interpersonal relationships and altered life goals. The lag to treatment-seeking can be considerable. This talk will cover commonly found maintaining factors and issues in eliciting a detailed formulation for sexual obsessions. I will then discuss moving from formulation to presenting a credible and testable alternative explanation for the person’s experiences. The talk will draw on a specific case in which the key feature was distressing intrusive thoughts about paedophilia related to the person’s own child. When the subject of intrusions is not obviously OCD such as 'relationship OCD' Lauren Callaghan, Anxiety Disorders Residential Unit, Bethlem Royal Hospital 'Relationship OCD' is a hot topic on online OCD advice fora but features little in research/academic literature. We would define 'relationship OCD' as OCD where the intrusions concern certainty of choice of partner, fear of making a mistake in this choice, doubts about compatability, sexual orientation, fidelity, attractiveness etc. We would view 'relationship OCD' as a problem to formulate like any other manifestation of OCD but this can be problematic. People with intrusions about their

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relationship often engage in compulsions, reassurance seeking and safety seeking behaviours which are not obviously 'OCD behaviour' compared to excessive hand washing for example. Their doubts are often validated by significant others. People often don't seek treatment for this problem alone but we have experience of treating people for OCD where these issues come up and can be successfully resolved using an OCD formulation. This talk will use clinical data to explore the common difficultes in collaboratively formulating the problems, discuss using the formulation to plan treatment including cognitive restructuring, behavioural experiments and couple sessions.

Re-visiting the Role of Re-living and Re-Scripting For the Treatment of PTSD Convenor: Harry O'Hayon, University of Reading

Revisiting, Rescripting and Reliving in treating PTSD Nick Grey, Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Foundation Trust Within traumatic memories people with PTSD usually have a few most distressing moments. Various authors have referred to these as hotspots. Identifying the meanings associated with hotspots allows the patient and therapist to ‘update’ the memory in a variety of ways. This is thought to help with the emotional processing of trauma memories. This talk briefly outlines ways in which hotspots might be identified and the evidence that less than 50% of hotspots are associated with the diagnostic emotions of fear, helplessness and horror. This talk focuses on two ways to rescript trauma memories: verbal updating and bodily updating. A further way of working with traumatic memories within Ehlers and Clark’s CT for PTSD, stimulus discrimination, is described. This breaks the associative links made with various stimuli at the time of the trauma, and thus helps to reduce the triggering of trauma memories. Questions remain as to exactly how effective such techniques are, which ones to use when with which people, and how we can further improve treatments. Working with intrusive memories in PTSD: reflections from The Ehlers and Clark research group. Ann Hackmann, Oxford Cognitive Therapy Centre; Ehlers, A., Clark, D., Speckens, A. and Hackmann, A. In this presentation the Ehlers and Clark model of PTSD is briefly presented, together with research findings from the group on the phenomenology of intrusive memories in this disorder. This will be followed by a discussion of possible methods of dealing with intrusive memories within this framework . Clinical examples will be provided. Within these case examples formulation led interventions will be described. The presentation will end with a discussion of the methods of processing intrusive memories in PTSD. These include reliving, verbal updating of memories, imagery rescripting techniques, site-visits and behavioural experiments. Possible mechanisms of change will also be discussed. These potentially include development of a coherent account, updating and contextualising memory fragments and their meanings, working with earlier memories that coloured the meaning of the trauma, the expression of emotions not expressed at the time, and imagining carrying out actions clients wished they had taken. Such interventions may challenge distorted appraisals of the event and its significance. Metacognitive beliefs may also be affected.

CPT or CPT-C? That is the Question Patricia Resick, National Center for PTSD, VA Boston Healthcare System and Boston University, USA; Michael Suvak, National Center for PTSD, VA Boston Healthcare System and Suffolk University Cognitive Processing Therapy (CPT) was originally developed in 1988 as a 12-session therapy with two written accounts between sessions 3-5 and the remainder consisting of systematic cognitive therapy. Resick et al. (2008) completed a dismantling study to compare the full protocol with the two constitute components as the other conditions. Cognitive therapy only (CPT-C) was exactly the same as CPT minus the written accounts. The written account condition (WA), after a check-in, consisted of an hour of writing about the worst account along with SUDS ratings during the session and then the patient read back the account to the therapist and they did non-cognitive therapy processing of the writing assignment. The results of the dismantling study were that CPT-C was more effective than WA but no different than CPT. However, CPT-C resulted in quicker clinical improvement. Subsequently, we have examined these data considering whether participants had a history of childhood sexual or physical abuse and considering their level of dissociation at pretreatment (Resick et al. in press). The results of these analyses were different from each other and provide indications which version of CPT may be most appropriate given the trauma history or level of dissociation of the patients.

Trauma and Conflict Chair: Suzanna Rose, Academic Lead Berkshire Healthcare NHS Foundation Trust

A New Emotion Processing Therapy for Post Traumatic Stress Disorder Roger Baker, Bournemouth University; Lisa Gale, Dorset HealthCare University NHS Foundation Trust The evidence base for the use of exposure therapy in treatment for Post Traumatic Stress Disorder (PTSD) is strong. The National Institute of Clinical Excellence signposts prolonged exposure as the ‘gold standard’ of treatment for PTSD (NICE, 2005). However, individuals with PTSD often find it too distressing to confront memories, and studies indicate that therapists may not be entirely comfortable using the therapy (Boudewyns & Shipley, 1983). Furthermore, studies have shown that 25-45% of PTSD patients still meet diagnostic criteria after treatment suggesting that exposure may lead to improvement, but not always recovery. The rationale for an emotion processing approach to prolonged exposure is presented. Emotional Processing Therapy for PTSD (Baker, 2010) contains everything involved in prolonged exposure. However, a more emotional approach to exposure leads to a different understanding as to what is happening in therapy. Through exploring the individual’s ‘emotional processing style’, previously learned and unhelpful styles can be addressed and the addition of an ‘emotional preparation’ phase helps them understand why it is important to face emotionally distressing memories before exposure sessions begin. Emotional Processing Therapy is intuitive and makes sense to those affected by PTSD. It is framed in an emotional context and is presented as part of a lifestyle change that may reduce the likelihood of psychological problems developing in the future. Advantages of Emotional Processing Therapy are illustrated through case histories and show it is more acceptable to both patients and therapists, more simple and understandable, and it resonates with cultural attitudes in the west about the importance of ‘letting your feelings out’ and the danger of ‘bottling them up’. The individual practises a more open style of sharing feelings prior to exposure, and the approach is presented as part of a lifestyle change rather than a ‘difficult therapeutic procedure’. A research study has been designed

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to explore the possible psychological mechanisms by which emotional processing therapy operates. Emotional Processing Therapy incorporates nearly all the same procedures and elements as prolonged exposure with the addition of an intensive emotional preparation phase prior to exposure exercises and a more emotion-based rationale. It could be regarded as an adjunct to an already successful approach and thus could be relatively easily accommodated within prolonged exposure practice.

The perils and pitfalls of setting up a new veterans psychological trauma service Matthew Cole, York Stress & Trauma Centre; Matthew Cole, York Stress & Trauma Centre Through the presentation of this paper the presenter will describe the development of a new service in York, North Yorkshire, from inception to the first client walking through the door. Deleopment of a best practice model of psychotherapy for veterans with a diagnosis of PTSD Although setting up the new service has been challenging we have set up a service that is efficient, effective and of value to the veterans population A record of the process of setting up a new mental health service and the perils and pitfalls that have been encountered along the way and how a vision can be turned into a reality. We are developing a best practice model for the effective psycholigical treatment of Veterans with a diagnosis of PTSD, we hope to encourage national use of this model of working

Trauma-Related Guilt and Posttraumatic Stress among Journalists Tess Browne, Department of Psychology, Royal Holloway, University of London; Michael Evangeli, Department of Psychology, Royal Holloway, University of London; Neil Greenberg, Academic Centre for Defence Mental Health, King’s College London, University of London There is growing recognition that journalists routinely cover traumatising events which may leave them at risk of work-related psychopathology. It was hypothesised that unique aspects of their role (e.g. to observe and not intervene) and job-specific factors (e.g. the requirement to sensationalise an event) may make them particularly vulnerable to guilt in the aftermath of a work-related traumatic event. This study investigated the relationship between trauma-related guilt and symptoms of work-related post-traumatic stress disorder (PTSD), and the role of guilt in mediating the effect of work-related traumatic events on PTSD symptoms. Fifty journalists, recently exposed to work-related trauma, completed an online questionnaire that explored their work-related experiences of trauma, PTSD symptoms, and guilt cognitions. The association between guilt cognitions and PTSD symptoms indicated that trauma-specific cognitions might be significant in understanding the impact of work-related trauma on the mental health of journalists. Furthermore, since guilt cognitions partially mediated the relationship between exposure and PTSD symptoms, the findings provide tentative support for PTSD models that focus on posttrauma appraisals, in addition to the impact of peritraumatic fear on memory. Higher levels of exposure to work-related trauma were significantly associated with higher levels of PTSD symptoms and guilt cognitions. Guilt cognitions were significantly positively associated with PTSD symptoms, and were found to partially mediate the relationship between exposure to work-related trauma and PTSD symptoms. The study provides preliminary evidence of a relationship between guilt cognitions and PTSD symptoms among journalists exposed to work-related trauma. It implies there may be specific factors that increase vulnerability to guilt among certain occupational groups. The findings highlight the need for CBT therapists to be aware that journalists who have PTSD to work-related traumatic incidents may experience guilt in relation to the event, and that guilt cognitions may perpetuate their symptoms. One goal of treatment should be to help clients achieve an objective and undistorted appraisal of their role in the trauma. It may be important to identify and treat distorted appraisals in advance of exposure therapy as guilt may disrupt the therapeutic effects of exposure.

Rest and Recuperation in the Armed Forces: Developing our Understanding of Recovery Olga Luzon, Royal Holloway, University of London; Laura Parsloe, Barnet, Enfield & Haringey Mental Health Trust; Neil Greenberg, Academic Centre for Defence Mental Health; Norman Jones, Academic Centre for Defence Mental Health; Mohammed Furtout, Academic Centre for Defence Mental Health There is evidence from epidemiological studies of recent armed conflicts that the ability to recover from adversity might be common amongst Service personnel (Fear et al., 2010; Hotopf et al., 2006). Despite this, recovery has yet to be directly assessed within U.K. military. Recovery has been associated with a range of beneficial physical and mental health outcomes (Hahn, Binnewies, Sonnentag, & Mojza, 2011; Sonnentag, 2003; Tucker et al., 2008). However, full recovery may not always be possible and this may potentially lead to long-term difficulties, such as exhaustion, psychosomatic complaints and mental health problems (Eden, 2001; Zijlstra & Sonnentag, 2006). Developing an understanding of recovery-promoting factors will potentially have implications for the clinical work of psychological therapists working with this client group. The military policy of Rest and Recuperation (R&R) is thought to play an important role in promoting recovery and wellbeing; however, as yet there is no empirical evidence to support its effectiveness. The current study had three main aims: firstly to develop a measure of experiences of and satisfaction with R&R (R&R-RQ); secondly to explore for associations between recovery from deployment on R&R and psychological wellbeing; and finally, to investigate the relationship between exposure to potentially traumatic events (PTEs) and wellbeing after a period of R&R. The current study had three main aims: firstly to develop a measure of experiences of and satisfaction with R&R (R&R-RQ); secondly to explore for associations between recovery from deployment on R&R and psychological wellbeing; and finally, to investigate the relationship between exposure to potentially traumatic events (PTEs) and wellbeing after a period of R&R. A total of 97 participants were recruited who completed self-report measures of mental health and exposure to PTEs, as well as the new measure of R&R-RQ. The findings provide information that furthers our understanding of the role of R&R and its capacity to promote recovery and wellbeing amongst Service personnel. The results have potential implications for the military, in terms of encouraging specific recovery activities and experiences whilst on R&R. Statistical analysis indicated that R&R-RQ was a reliable measure within the current sample. Recovery following R&R was associated with fewer symptoms of mental health difficulties. Furthermore, exposure to PTEs was associated with associated with feeling less recovered at the end of R&R. In the discussion, suggestions are made on how psychological therapists can facilitate recovery and promote mental wellbeing for military personnel within a CBT framework. For example encouraging personnel to engage more in social support and activities; running workshops aimed at increasing participation in activities associated with recovery; providing interventions aimed at skills training and cognitive restructuring with regards to perceptions of social support; and paying attention to the physical health of personnel as this was strongly associated with mental wellbeing.

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Examing the effectiveness a self-help guide for traumatised university students in Iraq Rachel Sabin-Farrell, Univeristy of Nottingham; Saad Jaber, University of Baghdad; Nigel Hunt, Univeristy of Nottingham; Abdulgaffar Al-Qaysi, University of Baghdad Iraqi people have been experiencing traumatic events continually for several decades . Consequently, high prevalence rates of trauma-related symptoms have been documented. In contrast, there is a clear lack in mental health services available for traumatised people. This study aimed to screen for PTSD, depression, and anxiety, assess related variables (e.g. coping strategies, posttraumatic cognitions, and social support), and develop a self-help guide (SHG) for traumatised university students. The SHG was developed. Its effectiveness was examined in a sample of participants who reported symptoms that fully met PTSD criteria. The sample included 125 participants: 65 in the experimental group (used the guide for six weeks) and 60 in the control group. Baseline tests were conducted in both groups before conducting the experiment and post tests afterward. Using the SHG enhanced coping strategies and reduced negative cognitions about self. This led to a reduction in PTSD and depression. There were significant increases in the tendency to use active and seeking support coping and significant decreases in non problem-focused coping, negative cognitions about self and the total negative cognitions. There was a significant reduction in levels of PTSD. This reduction related to re-experiencing and avoidance symptoms but not hyperarousal. The level of depression was also reduced. Anxiety was not reduced. This guide can be an adjunct tool for people with PTSD symptoms, also, it can used for those with mild PTSD symptoms to prevent them to be severe or chronic.

Skills Classes

Enhancing Self-Inquiry and Flexible Responding: A Novel Skills-Based Approach for Refractory Depression Tom Lynch, University of Southampton Self-control—inhibiting acting on urges, impulses, and desires—is highly valued in most societies, and failures in self-control characterize many of the personal and social problems afflicting modern civilization. However, too much self-control can be equally problematic. Emotional over-control (EOC) is beginning to be recognized as an important factor associated with social isolation, poor interpersonal functioning, and the development of severe and difficult-to-treat mental health problems, in particular refractory depression. Based on 17 years of research and an ongoing MRC funded multi-centre RCT the aim of this Skills Class is to provide an opportunity for participants to learn several of the skills that are part of a new adaptation of Dialectical Behaviour Therapy (DBT) for refractory depression and EOC. Implications: Four novel skills specifically targeting deficits common in refractory depression and EOC will be reviewed. First, participants will learn behavioural methods to up or down regulate neuroregulatory deficits associated with EOC, thereby increasing flexible interactions and reducing social ostracism. Second, participants will learn new skills related to going opposite action to emotions of envy and bitterness. Third, participants will learn new skills designed to enhance intimate relationships that are informed by research showing “open expression increases social connectedness”. Finally, participants will learn a novel skills-based approach for an empirically informed protocol designed to increase mood states associated with social-safety—via a loving-kindness meditation practice. Objectives: By the end of the class, participants will be able to: 1. Describe strategies designed to facilitate pro-social behaviours via “bottom-up” processes. 2. Describe the opposite action skills needed to change ineffective envy and bitterness. 3. Describe a novel hypothesized mechanism of change “open expression=social connectedness” and strategies designed to enhance intimate relationships. 4. Understand the theoretical and empirical basis for loving-kindness meditation and how this type of practice can be incorporated within individual therapy. Professor Lynch is a Professor of Clinical Psychology and Director of the Emotion and Personality Biobehavioural Laboratory in the School of Psychology at the University of Southampton. He a world-leading researcher and senior trainer of DBT and directs a laboratory focused on understanding personality/mood disorders and their interface with basis emotion processes. He has been the principal investigator on multiple large research grants. He is a recipient of the John M. Rhoades Psychotherapy Research Endowment and a Beck Institute Scholar. His book outlining a new DBT adaptation, entitled Dialectical Behaviour Therapy for Treatment Resistant Depression; Targeting Emotional Over-Control is forthcoming. References Lynch, T. R., & Cheavens, J. S. (2008). Dialectical behavior therapy for comorbid personality disorders. Journal of Clinical Psychology, 64(2), 154-167. Lynch, T. R., Hempel, R. J., & Clark, L. A. (in press). From self-control to self-regulation: Emotion based strategies for over-controlled personality disorder. In W. J. Livesley, G. Dimaggio, & J.Clarkin (Eds.). Integrated Treatment for Personality Disorder. Carson, J. W., Keefe, F. J., Lynch, T. R. et al. (2005). Loving-kindness meditation for chronic low back pain: Results from a pilot trial. Journal of Holistic Nursing, 23, 287-304.

Clinical Roundtable The Future of Couples Therapy From a CBT Perspective Convenor: Thaddeus Birchard, The Marylebone Centre Speakers: Pavlo Kanellakis, KCA; Frank Burbach, Somerset Partnership NHS Foundation Trust; Dan Kolubinski, Efficacy In 2009, the NICE guidelines for depression recommended Behavioural Couples Therapy as a treatment for ‘people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit’. The introduction of couples work as a clinical treatment has provided the UK with a shift in thought in how we view psychopathology within a systemic framework. Cognitive-Behavioural Couples Therapy has demonstrated an effect size similar to individual CBT for depression, with a far superior impact on the couple’s relationship satisfaction. In the spirit of transition and new beginnings, this discussion will explore basic methods in which partners have been incorporated into treatment plans. We will differentiate between Couples Therapy, where the primary goal is to reduce relationship distress, Couples-Assisted Interventions, where a partner is brought in to therapy to learn how to assist with treatment for individual psychopathology, and Diagnosis-Specific Interventions, where systemic factors that enable or reinforce the client’s psychopathology is targeted. This discussion is

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aimed at those with little to no experience in working with couples and will focus on sharing experiences and alleviating fears and concerns that the average therapist might have in regards to using any Couples-Based Intervention. Implications: As recent research provides support for the efficacy of including partners in an individual's treatment, this new frontier is one that is still misunderstood by many clinicians. This session could serve as a first step towards educating clinicians in the benefits of thinking beyond the standard client-therapist dyad to include the client's partner in a number of different ways. We hope that by addressing concerns and providing clarity on a number of issues, we will be able to increase both awareness of the topic and interest in learning more about how to utilise a Behavioural Couples Therapy framework.

Posters MBSR - 2 years and counting Matthew Cole, NCMC; Robert Broughton, NCMC At the NCMC we have been running the 8 week MBSR course for 2 years. Over this time we have gathered data from all our particants using validated questionnaires. In this poster we will be presenting our findings looking at the impact our MBSR course has had on the lives of our particpants and the follow up data. Quantitative data analysis from the validated questionnaires and qualitative data from particpants comments Our MBSR course's over the past 2 years have helped to change the lives of our participants, we have followed up the particpants and our interim (12-24m) findings demonstrate the effectivness of MBSR well after the course finishes. We will present the results from our 2 year research project looking at the effectivness of our MBSR course's with a 12 month follow up Reinforcing the evidence base for the medium to long term effectinvcess of MBSR courses and encouraging the use of this effective group process CBT skills of Student Nurses Rick Fothergill, University of Central Lancashire The mental health workforce is facing considerable demands. CBT has shown great effectiveness in meeting the therapeutic needs of people with anxiety and depression and many CBT training opportunities exist for qualified mental health practitioners. However such training opportunities are rarely available for pre-registration students. This study is novel in being one of the first to examine the delivery of CBT training to an undergraduate mental health workforce. A quasi experiment was performed to investigate if pre-registration mental health nurses’ (N=16) knowledge gains would increase following attendance at a thirty hour foundation level module delivered as part of their course curriculum. Two validated questionnaires measured their learning, within a pre-post research design. The findings may indicate that with the correct support, student nurses could make a valid contribution in the treatment of clients in line with relevant NHS priorities and their more experienced colleagues. However, the small sample and other limitations do reduce the generalisability of these findings. Scores achieved showed that student nurses’ knowledge improved significantly. These positive findings indicate that pre-registration student mental health nurses can effectively be taught foundation level CBT whilst still in their initial training phase. Improving the CBT skills that student nurses acquire during their initial training may prepare them to use CBT skills in every day practice, or at least prepare them well for further CBT in depth training at a later date, allowing them to impact upon tackling the huge burden of psychiatric morbidity. Such a development may have significant positive clinical and cost implications. Factors influencing psychological adjustment in military personnel following a Tour of Duty Elizabeth Banwell, Insitute of Psychiatry; Neil Greenberg, King's College London; Patrick Smith, Insitute of Psychiatry; Norman Jones, King's College London; Mohammed Fertout, King's College London Introduction: Deployed individuals, in comparison to non-deployed individuals have been shown to be at higher risk of developing any DSM-IV diagnosis (30.8% vs. 21.1%) (Ikin et al., 2004). Iversen et al. (2009) found that 28.9% of deployed personnel had a common mental disorder. The MoD has introduced a number of initiatives to help identify and treat psychological disturbance, such as the peer-led Trauma Risk Management (TRiM) program. The current research had two main aims; firstly, to identify what factors identified at Third Location Decompression (TLD) immediately after a tour of duty predict psychological adjustment at follow up three-to-six months later; secondly, what factors identified at follow up are associated with concurrent psychological adjustment? Method: A two stage procedure was carried out. All participants completed baseline measures. Half of participants were followed up from three weeks to three months after homecoming. The remaining participants were followed up between four and seven months after homecoming. These formed two follow up groups for analyses. 2580 personnel completed the baseline questionnaire at TLD in the Sovereign Base Area (SBA) in Cyprus. TLD provides a structured programme which typically runs from 24-36 hours and includes structured debriefing sessions and recreational activities (Castro, Greenberg & Vigneulle, 2009). TLD also facilitates identification and monitoring of vulnerable individuals and a subsequent mental health referral if necessary (Hacker-Hughes et al., 2008). Baseline mental health outcomes were completed, these were: sleep; common mental disorders; post traumatic stress symptoms; functional impairment; anxiety; depression; stigma and barriers to care. 516 baseline participants consented to follow up, of which 296 provided data for one of the two follow up stages. The baseline questionnaire contained measures of common mental disorders, depression, anxiety or PTSD. The follow up questionnaire included the aforementioned baseline measures as well as: transition; support of deployment unit; childhood trauma; alcohol use; and combat exposure. Follow up participants formed two groups: responses gathered three weeks-to-three months post homecoming; or responses from four-to-seven months post homecoming. Discussion: The rates of mental health outcomes in relation to predictors of adjustment and potential correlates shall be examined. This shall be discussed in relation to current initiatives to support deployed and returning personnel e.g. TRiM, and whether the need for additional support at certain time points/in relation to certain groups is indicated from the current analyses. Results: Two sets of analyses will be run. In longitudinal analyses, baseline predictors of adjustment between the first and second follow up groups will be examined. In cross sectional analyses, associations between potential correlates and adjustment at follow up will be examined. Highlighting when mental illness or symptomatology is more likely to occur in returning personnel and what factors influence recovery or development of symptoms will help to indicate at what point psychological treatment such as CBT may be best introduced and which groups may be most in need of receiving treatment.

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Image rescripting with people who hear voices: A case series Rebecca Ison, Institute of Psychiatry, Kings College London; Elizabeth Kuipers, Institute of Psychiatry, Kings College London; Gino Medoro, South London and Maudsley NHS Trust; Nadine Keen, South London and Maudsley NHS Trust Approximately 74% of people with psychosis also experience recurrent intrusive imagery (Morrison, 2002). Evidence indicates that image rescripting can be helpful in reducing the distress associated with intrusive images or memories across a range of disorders (Holmes and Mathews, 2010). There is currently no research exploring the use of imagery rescripting with people hear voices. This case series aimed to explore the use of image rescripting with this population. This study used a one off image rescripting session, using an A-B design with 4 participants who hear voices. The image rescripting procedure was based on methods described by Arntz and Weertman (1999) The study indicates that image rescripting work is an effective treatment approach to be used with people who experience intrusive imagery in the context of hearing voices. Future research is needed to further explore the use and efficacy of imagery work as an integrated component of CBT for psychosis. Reductions in distress, negative affect and reduced conviction in the beliefs associated with the imagery were reported at one week follow-up and maintained for three of the four participants at one month follow up. Results indicate that there may be benefits to using image rescripting with people who are hearing voices and experiencing negative recurrent intrusive imagery. More research is needed to explore how to integrate these techniques into standard CBT for psychosis. Psychometric properties of the Japanese version of the mental pollution questionnaire Ryotaro Ishikawa, Research Centre for Child Mental Development, Graduate School of Medicine, Chiba University; Sawako Nagaoka, Research Centre for Child Mental Development, Graduate School of Medicine, Chiba University; Osamu Kobori, Centre for Forensic Mental Health, Chiba University; Eiji Shimizu, Research Centre for Child Mental Development, Graduate School of Medicine, Chiba University Mental contamination is the sense of being contaminated and it involves an internal, emotional feeling of dirtiness that may be evoked by simply imagining negative events. Cougle, Lee, Horowitz, Wolitzky–Taylor, and Telch (2008) developed the Mental Pollution Questionnaire (MPQ) which measures mental contamination. Ishikawa, Nagaoka, Kobori, and Shimizu (2012) developed the Japanese version of the MPQ (MPQ-J), and the factorial validity and internal consistency of the MPQ–J were verified (Ishikawa et al., 2012). This study aims to confirm the psychometric properties of the MPQ–J: we test the hypothesis that MPQ–J would be associated with OCD symptoms (i.e., obsessive washing), depression, anxiety, and cognition linked to OCD (i.e., responsibility attitude). Two hundred and thirty–six Japanese undergraduates (68.64% female) enrolled in Japanese universities participated in this study (age range: 18–43; Mean = 20.81, SD = 4.42). MPQ–J has nine items and two subscales (MPQ–ideation and MPQ–washing). MPQ–ideation assess an ideational form of mental pollution (e.g., ‘When I recall certain memories it leaves me feeling dirty’), while the MPQ–washing assesses impulsive washing for mental pollution (e.g., ‘I wash my hands after doing something I feel is morally wrong’). In addition to this, all participants completed BDI–II–J (Kojima et al, 2002), BAI (Beck et al., 1988), OCI–washing scale (Foa et al., 1998), and RAS (Salkovskis et al., 2000). We concluded that psychometric properties of the MPQ–J were verified. MPQ–J is psychometrically robust and can be used to assess symptoms of mental contamination for Japanese people. In addition, there was no significant difference between females and males for the mean scores of MPQ–J and both subscales. These results would support the notion of Rachman (2010) that feeling of mental contamination is found in males, as well as females. There was no significant difference between female and male participants for the mean score of the MPQ–J (t (234) = 1.39, p = .17). In the correlation analyses, consistent with our predictions, MPQ–J total score was significantly correlated with MPQ–ideation, MPQ–washing, BAI, BDI, OCI–washing scale and RAS (p < .01). Then, MPQ–ideation and MPQ–washing were significantly correlated with BAI, BDI, OCI–washing scale and RAS (p < .01). Addressing cognition of responsibility, perhaps through established methods (Clark, 2004; Freeston et al., 1997; Rachman, 2003; Wilhelm & Steketee, 2006) would have a strong effect on reducing feelings of mental contamination. Psychosis, Cannabis and Context. An Experimental Study Fergus Kane, Institute of Psychiatry; Steven Dakin, Institute of Opthamology; Oliver Sundermann, Institute of Psychiatry; Paul Morrison, Institute of Psychiatry; David Hemsley, Institute of Psychiatry; Suzanne Jolley, Institute of Psychiatry Cognitive models of psychosis highlight the role of underlying differences in cognitive function and information processing. As a result there is now an interest in directly addressing cognitive function in psychosis treatment. It has been suggested that aberrant processing of context may play an important role in these differences. Recent work has suggested that this may be reflected in differential processing of visual illusions. Further, it has been suggested that, in addition to being risk factors for psychosis, psychoactive substances such as cannabis may provide a useful model for psychosis. The current study thus investigates: A, the cognitive consequences of cannabis use and B, visual processing differences in first episode psychosis. Part A: A randomised groups, repeated measures design (group n=25) investigating the effect of two key cannabinoids (cannabidiol (CBD) and ?9-THC) on performance of the Chubb illusion.Part B: A case-control study (group n=20) comparing performance on the Chubb illusion in a group of patients with first episode psychosis to a control group. The results suggest that the psychotomimetic effects of cannabis do not work on the same system as the Chubb illusion, which has been implicated in psychosis. This is in contrast to evidence for another illusion, the Binocular Depth Inversion Illusion (BD-II), performance on which has been related to psychosis and cannabis use. It is possible that the two illusions tap into different stages of the visual system and that cannabis interacts further downstream in this system. Part A: The study found no effect of either CBD or ?9-THC on perfomance on the Chubb Illusion. Furthermore, there was no association between performance and schizotypy. Part B: Data collection for part b is not yet complete. The current study is part of a broader effort to understand how cognitive vulnerabilities may lead to experiencing of psychotic symptoms. An improved understanding of these processes may facilitate the development of more effective psychological interventions for psychosis. Furthermore, an improved understanding of how cannabis causes psychotic-like symptoms may have relevance in developing evidence based public health and substance use policy. The effectiveness of components of cognitive-behavioral therapy for obsessive-compulsive disorder Mehmet Hakan Turkcapar, Ankara DYB Research and Training Hospital; Mehmet Emrah Karadere, Ankara DYB Research and Training Hospital; Yasir Safak, Ankara DYB Research and Training Hospital; Turkan Dogan, Ankara DYB Research and Training Hospital; Bengu Yucens, Ankara DYB Research and Training Hospital; Mehmet Hakan Turkcapar, Ankara DYB Research and Training Hospital; Sibel Orsel, Ankara DYB Research and Training Hospital

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Cognitive-behavioral therapy (CBT) have proven effective in reducing symptoms of obsessive-compulsive disorder (OCD). CBT techniques are commonly used in OCD psychoeducation, cognitive intervention and exposure-response prevention. There is no consensus about which of these components of treatment is more effective. The aim of the study was to compare the effectiveness of these components (CBT) for obsessive compulsive disorder (OCD). Thirty-seven patients meeting DSM-IV criteria for OCD were randomly assigned to one of the four CBT group for 14 weekly Cognitive-behavioral group therapy (CBGT) sessions. Organic brain disease, bipolar, psychotic and severe personality disorders, substance-related disorders were excluded. Treatment Protocol of Group CBT of OCD included psychoeducation, cognitive intervention, exposure-response prevention, relaps prevention. Efficacy of treatment component was rated according to the reduction in scores on the Yale-Brown Obsessive Compulsive Scale (YBOCS) Beck-Anxiety Inventory (BAI), Beck-Depression Inventory (BDI) and the Clinical Global Impression Scale (CGI). The trial was performed in four successive periods from August 2011 to January 2012. This result suggest that CBGT is effective in reducing OCD symptoms and all of CBT components are effective for OCD treatment. We found effective outcome in CBGT groups. There was a significant reduction in YBOCS for all treatment components. The reduction rates were found statistically significant according to initial with sample-dependent t-test and Wilcoxon signed ranks; for psychoeducation (z= -3.78, p= 0.001), for only cognitive intervention (z= -4.87, p= 0.001), for cognitive intervention with exposure-response prevention (z= -4.74, p= 0.001), for other exposure-response prevention (z= -4.47, p= 0.001). Further there was significantly reduction for BAI, BDI and CGI scores. In our clinical practice CBT is an effective treatment for OCD Integrated psychological therapy for people with bipolar disorder (BD) and co-morbid alcohol use: a feasibility randomised trial Lucy Bateman, The University of Manchester; Steven Jones, Lancaster University; Christine Barrowclough, The University of Manchester; Rosalyn Hartwell, The University of Manchester; Lisa Riste, The University of Manchester; Lucy Bateman, The University of Manchester; Emma Weymouth, The University of Manchester BD is characterised by high rates of substance misuse, with studies reporting rates of 48-70% (Miller et al, 1989; Bernadt and Murray, 1986), lifetime prevalence 3-6 times more likely than the general population (Reigier et al, 1990) and a greater proportion of substance users than any other axis 1 psychiatric disorder. Such substance misuse can have profound effects on mood and behaviour which worsen the course, outcome and morbidity of BD (Salloum and Thase, 2000). Intervention research for substance use in BD is at an early stage and whilst promising, results from the few studies conducted have been confounded by their use of motivated individuals or individuals using various substances. This study seeks to address these issues by evaluating the feasibility and acceptability of an ‘Integrated Psychological Therapy’ for individuals with BD and a co-morbid alcohol use disorder. Therapy will employ motivational interviewing to facilitate engagement and explore the role of alcohol misuse in worsening symptoms. Information collected will be used to create an individualized formulation identifying links between alcohol use and destabilisation which will form the basis of a CBT intervention focused on changing alcohol consumption and developing a comprehensive relapse prevention plan. A small rater-blind randomised trial is currently recruiting 48 participants to be randomised to either receive MI-CBT and standard care, or standard care alone. Primary outcome measures will examine time to next bipolar relapse, average weekly symptom score (SCID-LIFE) and frequency and severity of alcohol use. Treatment effects will be estimated using the intention-to-treat principle. It is hoped the planned intervention will enhance engagement, and the integrative approach of the therapy will further emphasise the importance of integrated mental health and substance misuse work as detailed in NICE guidelines. An exploration of telephone screening for Recruitment: The Staying Well after Depression Trial Isabelle Rudolf von Rohr, University of Oxford; Adele Krusche, University of Oxford; Kate Muse, University of Oxford; Catherine Crane, University of Oxford; Danielle Duggan, University of Oxford; Mark Williams, University of Oxford Participants taking part in Randomised Controlled Trials (RCTs) must fulfil a number of pre-determined eligibility criteria to ensure that the intervention is delivered to an appropriate study population (e.g. the presence of a specified disorder and absence of contraindications). Often, brief telephone screening interviews are conducted prior to face-to-face assessments to determine preliminary eligibility and prevent inviting ineligible participants for a time-consuming and costly assessment. The utility of implementing telephone screening procedures has yet to be examined. The current study will examine the effectiveness of a telephone screening protocol implemented within a large-scale RCT investigating the efficacy of a relapse prevention treatment for depression. The screening procedure under investigation was utilized within the context of the Staying Well After Depression randomised controlled trial. The screening tool was designed to determine the participants’ eligibility regarding the main trial criteria. The differences found in exclusion at the varying time points will be outlined, especially whether phone screening is an efficient use of resources for recruitment. This poster will discuss the effectiveness of the screening tool by exploring the reasons for exclusion at different time points during recruitment and comparing the reasons for exclusion at phone screening and at initial assessment. Results from this study will increase current understanding of cost-effective and efficient strategies for determining whether participants meet eligibility criteria for inclusion within RCTs. Identification of effective screening procedures may also be applied within routine clinical practice settings where lengthy face-to-face assessments may not be feasible. An Evaluation of the Methods used for Recruitment in Randomised Controlled Trials: The Staying Well after Depression Trial Adele Krusche, University of Oxford; Isabelle Rudolf von Rohr, University of Oxford; Kate Muse, University of Oxford; Catherine Crane, University of Oxford; Danielle Duggan, University of Oxford; Mark Williams, University of Oxford The Randomised Controlled Trial (RCT) is widely regarded as the gold standard for investigating the efficacy of psychological interventions. However, researchers conducting RCTs commonly report difficulties recruiting an adequate sample within planned timescales and research investigating the effectiveness of recruitment strategies is limited. This paper will evaluate the effectiveness of the recruitment strategies utilised for recruiting a sample of participants with a history of recurrent depression. Participants were recruited to the Staying Well after Depression trial in Oxford investigating the efficacy of Mindfulness-Based Cognitive Therapy (MBCT) in preventing relapse to depression. Each recruitment source was evaluated for effectiveness regarding the number of participants contacting the research team and subsequently randomised and the cost of each strategy, including financial and human resources. Strategies which seem expensive can actually be the most cost-effective when considering other resources utilised to implement them and the number of contacts received. Future research should evaluate the effectiveness of recruitment strategies for other samples to contribute to a comprehensive base of knowledge for future RCTs. The most effective method of recruitment utilised was online advertising as this was inexpensive and generated a large number of responses.

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Radio advertising was the most expensive method of recruiting participants but was also one of the quickest and most efficient. Other methods utilised such as GP referrals, posters and newspaper advertising were time consuming and expensive. Many studies fail because they are underpowered. Refining research methodology is crucial to developing evidence-based practice to advance therapeutic interventions. Treatment resistant Obsessive Compulsive Disorder (OCD): A Multidisciplinary Team Approach Debbie van Tonder, St Patricks' University Hospital Longstanding OCD: Primary Obsessional Slowness Primary Obsessional Slowness (POS) is a rare OCD variant, and differs from typical OCD in that it is less ego-dystonic with acceptance of the rituals rather than resistance. There is usually little evidence of specific cognitive biases, obsessions and most importantly sufferers don’t seem to perform their compulsions to reduce or avoid anxiety(1). On assessment of the present case it became clear that obsessional slowness was secondary to meticulous rituals attempting to neutralise obsessions regarding harm and responsibility as described by Veale (2). The subject had been unresponsive to standard treatment before presenting to the Anxiety Disorders Service (ADS) Team at SPUH. The multi-disciplinary team (MDT) followed a staged approach of recurrent in-patient cycles with a CBT centred, recovery focused package of care. The staged approach contributed to building trust in the therapeutic relationship which enabled the MDT to increase the intensity of the work in a graded and humanistic manner. MDT inputs were added at different stages to enable effective and efficient use of team resources. Standard multi-time point outcome measures will be presented to illustrate the therapeutic impact of each component of the treatment (YBOCS, BAI, BDI, Fear Questionnaire and Life Adjustment). Well-focused CBT formulation and strong alliance between MDT members ensured that every treatment stage was continuous with the last with specific work focusing on. psycho-education, a supportive therapeutic milieu and accompanied behavioural tasks. Other elements included Veale’s approach of pacing, prompting and modelling(2), cognitive restructuring and focused behaviour experiments applying Salkovskis’ Cognitive model for OCD(3) combined with compassionate mind work. Evidence that Obsessional slowness can be treated succesfully by a carefully well-timed package of care focusing on unraveling obsessional slowness by working through layers of shame and guilt towards building a trusting therapeutic alliance and holisitc recovery.

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Basic Processes and New Developments

Keynote Addresses

Recent developments in the etiology and treatment of PTSD Iris Engelhard, Professor of Clinical and Health Psychology, Utrecht University, Netherlands The aim of this presentation is to cover recent key developments in the etiology and treatment of posttraumatic stress disorder (PTSD). With respect to etiology, results will be presented from various prospective studies, including research of soldiers deployed to Iraq or Afghanistan. Topics will include: prevalence/ measurement issues; malleability of traumatic memories; and the role of neuroticism, intelligence, and extinction learning before trauma. With respect to treatment, results will be presented from well-controlled laboratory studies and clinical research about the working mechanism of EMDR. Topics will include working memory theory; the effect of horizontal eye movements during recall of a negative emotional memory, compared to recall alone; the effect of other dual-tasks (e.g., vertical eye movements, bilateral tones, mental arithmetic); and future-oriented images about potential catastrophe (flashforwards). Potentially important clinical implications will be discussed.

Wrong turnings down memory lane: the nature and treatment of maladaptive and distressing patterns of autobiographical remembrance in emotional disorders Tim Dalgleish, MRC Cognition and Brain Sciences Unit, Cambridge Our past and the ways in which we represent and recollect it critically define who we are. We access memories of previous events to facilitate future planning, as a tool for social discourse, for problem-solving, and to manage our mental health. Memories also intrude unbidden into awareness, driving our emotions and patterns of thinking. Depression is characterised by biases and irregularities across all of these facets of autobiographical memory from the way the past is constructed in memory to how it intrudes on current cognition. This paper outlines our translational programme that seeks to elucidate patterns of dysfunctional autobiographical memory in depression and to use those insights to generate novel mnemonic interventions. Data will be presented from across the programme including studies on the structure of the life story, on reduced memory specificity and Memory Specificity Training (MeST) to ameliorate it, on enhancing access to elaborated positive memories and maintaining access using historically ancient imagery-based mnemonic techniques, and on the effects of a perspective broadening intervention. The integration into clinical practice of such intervention elements translated from basic science will be discussed.

Symposia

Autobiographical Memory and Psychological Disorders Convenor: Laura Jobson, University of East Anglia and Medical Research Council Cognition and Brain Sciences Unit, Cambridge & Martin Conway, City University London Chair: Martin Conway, City University London Discussant: Emily Holmes, University of Oxford

The relationship between social problem-solving and depression: Insights from autobiographical memory functioning Barbara Dritschel, University of St. Andrews Autobiographical memory has a complex relationship with social problem-solving. There is clear evidence of a positive relationship between performance on the autobiographical memory cueing task and solving hypothetical social problems. Further manipulations or training to facilitate that retrieval of specific autobiographical memories is also associated with facilitated performance on these tasks for both clinically depressed and non-depressed samples. Explanations for this relationship are discussed. However Autobiographical memories are also spontaneously retrieved during the social problem-solving process itself . For clinically depressed participants greater spontaneous categoric retrieval has been found to be negatively associated with problem-solving performance. Further the characteristics of memories retrieved during social problem-solving are qualitatively different for clinically depressed and dysphoric participants as opposed to non-depressed individuals. Finally intrusive autobiographical memory retrieval also appears to be negatively associated with social problem-solving performance in depression. The implications of these complex findings are discussed Autobiographical Specificity in Psychological Illnesses: A Review Martin Conway, Department of Psychology, City University London; Jefferson Singer, Department of Psychology, Connecticut College, USA; Colin McKay, Department of Psychology, Connecticut College, USA We review evidence on the specificity of memories and general affective content of autobiographical memories across a range of illnesses and also consider increased rates of contamination sequences. Contamination occurs when a memory initially featuring positive action and emotion shifts to and terminates in a negative outcome. We propose that in a healthy autobiographical memory, memories are used to gain insight into one’s experiences, guide future behaviour in beneficial and purposeful ways, and broadly to facilitate meaning-making. When memory specificity is compromised and contamination sequences increase then meaning-making becomes attenuated and psychological illness is present.

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The influence of culture on the autobiographical remembering of trauma: Implications for posttraumatic stress disorder Laura Jobson, University of East Anglia, and Medical Research Council Cognition and Brain Sciences Unit; AliReza Moradi, Tarbiat Modares University, Iran Current models of posttraumatic stress disorder (PTSD) emphasise the role of autobiographical memory in the aetiology, maintenance and treatment of PTSD. However, these models have been developed independently of recent findings indicating cultural differences in the autobiographical remembering of everyday events. To date very little research has investigated the influence of culture on the autobiographical remembering of trauma and implications for PTSD. This presentation will provide an overview of some of our current research which has investigated the influence of culture and PTSD on the autobiographical remembering of trauma using both cross-country and within-country designs. Our findings indicate that cultural differences are evident in the memory content variables and phenomenological properties of general autobiographical remembering of everyday events. However, for the trauma memory the expected cultural differences were less evident, especially for those with PTSD. Overall, those with PTSD, regardless of cultural background, were found to have lower levels of autonomous orientation, social interactions and specificity in their autobiographical remembering. Their trauma memories were rated as having greater sensory details and fragmentation and their identity, regardless of culture, was more likely to be trauma-defined than trauma survivors without PTSD. Therefore, across these studies the findings indicate that the cultural differences evident in everyday memories are less evident in the trauma memories of those with PTSD suggesting there is something unique about the processes (and disruptions) in how those with PTSD remember trauma which may transcend one’s cultural background and override cultural influences on these processes. These findings are discussed in terms of PTSD models and current treatment.

Training A New Perspective: Can Direct Modification of Interpretations and Appraisals Reduce Anxiety and Depression? Convenor: Laura Hoppitt, University of East Anglia

Cognitive Bias Modification for Interpretation: Duration of effects in a healthy sample Emily Hammond, Cambridgeshire & Peterborough NHS Foundation Trust; Laura Hoppitt, University of East Anglia; Bundy Mackintosh, University of East Anglia & MRC Cognition & Brain Sciences Unit, Cambridge; Cognitive biases favouring threatening or negative interpretations of ambiguous situations have been causally implicated in vulnerability to, and the maintenance of, anxiety disorders. This has led to the development of cognitive training techniques that aim to redress these biases, termed Cognitive Bias Modification for Interpretation (CBM-I). To maximise the clinical efficacy and efficiency of CBM-I, it is important to establish how frequently training sessions need to be delivered to maintain therapeutic benefits whilst minimising the time commitment required of service users. Previous research has shown that healthy volunteers trained to interpret ambiguous vignettes in either consistently negative or positive ways acquire training-congruent interpretation biases that influence emotional reactivity to a stressor task 24 hours later (Mackintosh et al., 2006). Yet it remains unclear whether these effects stem from negative interpretation training, positive training, or both and furthermore, what the maximum duration of the effects might be. Given that therapeutic CBM-I entails purely positive training, the present investigation explored how the cognitive and emotional effects of a single session of positive CBM-I wax and wane over the course of two weeks. Two studies were conducted with CBM-I training (positive; control) manipulated between participants: Study One assessed the impact of CBM-I after a training-to-test interval of one week and Study Two extended the interval to two weeks. Thirty-four healthy volunteers participated in each study and were randomly assigned to positive or control CBM-I. The interpretation training paradigm developed by Mathews and Mackintosh (2000) was used, in which participants are exposed to a series of initially ambiguous scenarios. In the positive CBM-I the final word of each scenario resolves the ambiguity in a positive or benign way whereas in the control training the final word preserves the initial ambiguity, leaving the outcome of the situation open to interpretation. The cognitive and emotional effects of the training were probed using a recognition test and a mild stressor task that entailed watching a short film clip depicting accident scenes. In the recognition test participants were presented with novel ambiguous scenarios and afterwards, unexpectedly asked to rate how similar four summarising sentences were to how they remembered each scenario. Emotional reactivity to the film was assessed using self-report measures of anxiety and mood before and after viewing. In the recognition test, participants receiving positive CBM-I training reliably remembered the ambiguous scenarios as more positive than participants in the control condition following both one- and two-week intervals. Training-congruent effects on emotional reactivity were observed at one week post training: the positive CBM-I group reported attenuated anxiety and mood-lowering responses to the accident film relative to the control group. This difference was not observed after two weeks however. These results suggest that whilst the cognitive impact of CBM-I training endured in the relevant context for at least two weeks, the beneficial impact on emotional reactivity to stress persisted for between one and two weeks only. The implications of these findings for the therapeutic application of CBM-I will be considered. Effects of Implicit and Explicit Cognitive Bias Modification and Computer-aided Cognitive-Behaviour Therapy on Modifying Cognitive Biases in Social Anxiety Sirous Mobini, University of East Anglia; Bundy Mackintosh, University of East Anglia; Laura Hoppitt, University of East Anglia; Joanna Illingworth, University of East Anglia High socially-anxious individuals are more likely to attend to social threat information and interpret ambiguous social information in a negative manner. This study aimed to examine the effects of a single session of implicit and explicit cognitive bias modification for interpretation bias (CBM-I) and an analogue of computer-aided CBT (C-CBT) task on modifying interpretative and attentional biases in non-clinical social anxiety. Volunteers with a high score on the Fear of Negative Evaluation (FNE) scale were randomly assigned into one of the four conditions: implicit CBM-I, explicit CBM-I, C-CBT, Control. To test these research hypotheses, a single session of CBM-I training was developed to train socially-anxious participants to resolve ambiguous social scenarios in a positive manner. The training materials were identical in both CBM programmes, except that unlike the CBM-imp condition, in the CBM-exp condition participants were given explicit instructions about the intention of the training. An analogue single session of the computer-aided CBT (C-CBT) was also developed to train participants about the thinking and behavioural processes involved in social anxiety and how modifications of negative thoughts and behavioural exposure can reduce social anxiety. Participants completed the recognition test and dot-probe

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task at pre- and post-training and at 1 week follow-up as measures of interpretative and attentional biases, respectively. Following training, they also completed an imagined social stress task and the social anxiety measure (FNE). The results showed that after training participants who were trained to access benign interpretations, either implicitly or explicitly, generally produced less negative interpretations, and more positive interpretations, of the new ambiguous social scenarios than those in the control condition at both post-training and 1 week follow-up. Also, computer-aided CBT reduced negative interpretative biases at post-training and 1 week follow-up. Larger effect sizes were found for the explicit CBM-I condition suggesting instructions enhanced the emotional transfer of training. The results also showed that the explicit CBM-I training reduced attentional bias towards threat (both social and physical sensation) words, whereas the implicit CBM-I only reduced attentional bias towards social threat words. No training effects were observed on anticipatory social anxiety and social anxiety symptoms measured by FNE. A comparison of interpretation bias modification and computerised cognitive behaviour therapy for social anxiety Jennifer Bowler, University of East Anglia; Bundy Mackintosh, University of East Anglia; Barnaby Dunn, Medical Research Council Cognition and Brain Sciences Unit, Cambridge; Andrew Mathews, University of California, Davis; Laura Hoppitt, University of East Anglia Research has demonstrated that computerised cognitive behavioural therapy (cCBT) and cognitive bias modification for interpretation (CBM-I) can each alleviate social anxiety, yet how they compare to each other has not been examined. The present study aimed to test the hypothesis that whilst both interventions would lower anxiety levels, CBM-I would be better at reducing threat related interpretive bias in the presence of cognitive load. Sixty-three participants self-reporting high social anxiety were randomly allocated to three groups: CBM-I (n = 21); cCBT (n = 21); and a no intervention control group (n = 21). The interventions each comprised four laboratory sessions over two weeks, with control participants only attending pre and post sessions. Self-report measures of anxiety, depression, perceived attentional control and threat-related interpretive bias were administered at baseline and post intervention. Interpretive bias with and without concurrent mental load was measured using a scrambled sentences test. Results indicated that both CBM-I and cCBT groups had significantly reduced levels of social anxiety, trait anxiety, depression and improved perceived attentional control at post intervention, relative to the control group. While both interventions reduced threat related interpretive bias on the scrambled sentences test when concurrent mental load was imposed, the effect was significantly greater in the CBM-I group. Findings suggest that while CBM-I and cCBT both provide effective approaches to tackling anxiety, they may differ in the residence of their effects when cognitive load is high. Perspective Broadening Training for Major Depressive Disorder: A Pilot Trial of Decentering and Reframing Emma Hill, MRC Cognition and Brain Sciences Unit; Tim Dalgleish, MRC Cognition and Brain Sciences Unit; Barney Dunn, MRC Cognition and Brain Sciences Unit A key characteristic of emotional disorders is that the individuals often have distorted and maladaptive ways of interpreting the world (Matthews & MacLeod, 2005). In individuals suffering from Major Depressive Disorder (MDD) we think this may be due to problems in perspective, and that two related things are likely to be happening; a loss of sight of the bigger picture, and black and white thinking. Our research is looking at ways of challenging these two aspects of depressive thinking. First, by helping individuals to learn to step back from situations in order to see the bigger picture – what we call perspective broadening through mental imagery. And, second, by helping individuals to use that wider perspective to see situations in terms of shades of grey so that everything isn’t simply all good or all bad – what we call perspective broadening through reframing or training new reappraisals. We know from past research that it is possible for sub-clinical groups to apply new perspective broadening rules to situations and memories (Schartau, Dalgleish & Dunn, 2009), so the next step was to find out whether individuals who suffered from MDD were able to do the same. In this talk we will be presenting the data from a pilot trial of this novel perspective broadening training programme. The three week study was conducted with twenty-four MDD individuals in remission, half of the participants were given the perspective broadening training (Training group), whereas the other half were only exposed to the training stimuli and given no training (Control group) . The training was administered through scenario tasks, their autobiographical memories and their everyday life events (diary task). The outcome measures were Beck Depression Inventory scores as a measure of residual symptoms (a proxy for depressive relapse), autobiographical memories (distress, avoidance and intrusion ratings), emotional thinking scores in relation to scenarios, and scores on a set of study-specific emotion regulation questions. The results will be presented and their clinical implications will be discussed, along with what they might tell us about Mindfulness Based Cognitive Therapy and directions for future research into perspectives in depression. References: Matthews, A., & MacLeod, C. (2005). Cognitive Vulnerability to Emotional Disorders. Annual Review of Clinical Psychology, 1, 167-195. Schartau, P.E.S., Dalgleish, T., & Dunn, B.D. (2009). Seeing the Bigger Picture: Training in Perspective Broadening Reduces Self-reported Affect and Psychophysiological Response to Distressing Films and Autobiographical Memories. Journal of Abnormal Psychology, 118, 15-27.

From Basic Science to Innovative Treatments: Using Cognitive Bias Modification to Understand and Develop Psychological Interventions Convenor: Simon Blackwell, University of Oxford

Using Attentional Bias Modification as a Cognitive Vaccine Against Depression Michael Browning, University of Oxford; Emily Holmes, University of Oxford; Matthew Charles, Univeristy of Oxford; Phillip Cowen, University of Oxford; Catherine Harmer, University of Oxford Background: Negative attentional biases are thought to increase the risk of relapse in depression suggesting that reduction of such biases may be a plausible strategy in the secondary prevention of the illness. However, no previous study has tested whether reducing negative attentional bias causally impacts on risk factors for depressive relapse. The current experimental medicine study reports the effects of a computerized attentional bias modification (ABM) procedure on intermediate measures of the risk of depressive relapse (residual depressive symptoms and the cortisol awakening response) in patients with recurrent depression. Methods: 61 patients with at least two previous episodes of depression who were currently in remission were randomized to receive either an active (positive) or placebo computer based ABM regime. The ABM regime presented either pictures of faces or words. Residual depressive symptoms, measured using the Beck Depression Inventory (BDI) and the Cortisol

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Awakening Response (CAR) were measured immediately before and after completion of the bias training and then again after four weeks follow-up. Results: Positive, face-based ABM reduced both measures of relapse risk (BDI and CAR). This effect occurred during the month following completion of the bias training. Word-based training did not influence the outcome measures. Conclusions: Positive face-based ABM was able to reduce intermediate measures of relapse risk in previously depressed patients. These results suggest that ABM may provide a “cognitive vaccine” against depression and offer a useful strategy in the secondary prevention of the illness. Using Functional Brain Imaging to Measure Effects by Internet-Delivered Cognitive Behaviour Therapy and Cognitive Bias Modification in Social Anxiety Disorder - an RCT Kristoffer NT Månsson, Department of Behavioural Sciences and Learning, Psychology, Linköping University, Sweden Per Carlbring, Department of Psychology, Umeå University, Sweden; Owe Bodlund, Department of Clinical Sciences, Division of Psychiatry, Umeå University, Sweden; Carl-Johan Olsson, Umeå Centre for Functional Brain Imaging (UFBI), Umeå University, Sweden; Tomas Furmark, Department of Psychology, Uppsala University, Sweden; Gerhard Andersson, Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden Introduction: Randomized clinical trials (RCT) have yielded promising results for both internet-delivered Cognitive Behaviour Therapy (iCBT) and Cognitive Bias Modification (CBM). The aim of this study was to compare effects by these treatments using functional Magnetic Resonance Imaging (fMRI). Method: A total of 26 persons diagnosed with SAD were randomized to one of the two conditions: iCBT or CBM. The CBM was conducted 8 times during a 4 week period. This dot probe task involved 160 trials of disgust or neutral facial expressions during 500 msec. iCBT was delivered over a period of 9 weeks, and consisted by standard CBT interventions as cognitive restructuring, behavioural experiment, exposure and shifting attention. An experimental paradigm known as the Hariri emotional face task, matching different expressions as anger, fear, surprised and neutral faces, was used in brain image acquisition. Activations in fear related networks, such as amygdalae, insular, anterior cingulate cortex and prefrontal cortex has been reported by this paradigm. Hyperactivity in related networks has been reported in patients with social anxiety disorder. Results: Brain imaging data were collected pre and post treatment, using a GE 3.0T (T2* weighted), with a 32-channel head coil. A repeated measure with a flexible factorial design is presented. Analyzing primary and secondary outcome measures was completed by March 2012. Discussion: Brain imaging and behavioural data will be discussed. Conclusion: This is the first study exploring change in brain mechanism by two interesting internet-delivered treatments in social anxiety disorder. Examining the cognitive basis for change in anxiety vulnerability over time: Readiness to acquire an attentional bias as a predictor of treatment response Patrick Clarke, University of Western Australia; Nigel Chen, University of Sydney; Adam Guastella, University of Sydney; Colin MacLeod, University of Western Australia While it is known that individuals will differ in the extent to which they reduce anxiety vulnerability in response to a therapeutic intervention, the cognitive basis for such individual difference is still poorly understood. This presentation will describe clinically-relevant findings regarding the prediction of treatment response using measures of change in biased attention and will also touch on recent research examining the underpinnings of this cognitive mechanism. Within a clinical sample of individuals undergoing cognitive-behaviour group therapy for Social Anxiety Disorder study we examined whether individual differences in the readiness to adopt selective attentional processing in response to an experimental contingency will predict the magnitude of change in a range of anxiety vulnerability measures across treatment. Findings support the hypothesis that those who show greater readiness to acquire an attentional bias, as indexed by the adoption a pattern of attentional processing encouraged by an experimental contingency at the beginning of therapy, also show the greatest reductions in measures of anxiety vulnerability from pre to post-treatment. These findings will be discussed in relation to their implications for mechanisms of change in anxiety vulnerability and for predicting treatment response for a range of clinical interventions, including Cognitive Bias Modification. Understanding and enhancing the clinical impact of cognitive bias modification for depression using mental imagery Simon Blackwell, University of Oxford; Two clinical studies have provided preliminary evidence that “Cognitive Bias Modification” (CBM) designed to train positive interpretation and imagery can have a significant impact on symptoms of depression (Blackwell & Holmes, 2010; Lang, Blackwell, Harmer, Davison, & Holmes, 2012). In addition to the promising outcome data, these studies also provide insights into how the clinical benefits of engaging in this CBM may come about in a “real world” application. These and other recent studies investigating mental imagery are drawn upon to inform how we can understand the potential mechanisms by which imagery and interpretation-focussed CBM may reduce symptoms of depression, and how we may be able to enhance this clinical impact. Current developments in taking the paradigm forwards from experimental investigation to clinical application are presented.

Mental Imagery: Investigation and Clinical Application of Mental Images in Cognitive Therapy Convenor: Susie Hales, University of Oxford Chair: Lusia Stopa, University of Southampton

Phenomenology of imagery in patients with burn injuries Soljana Çili, University of Southampton; Elaine Cockerham, Salisbury NHS Foundation Trust; Lusia Stopa, University of Southampton Trauma symptoms and posttraumatic stress disorder (PTSD) are common reactions following a burn injury (e.g., Patterson, Carrigan, Robinson, & Questad, 1990; Perry, Cella, Falkenberg, Heidrich, & Goodwin, 1987). These reactions are known to be positively correlated with factors such as the body surface area affected by the burn, female gender, and duration of hospitalisation (Patterson et al., 1996). Despite this evidence, however, the risk factors for developing PTSD and the

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maintaining factors for patients who do not recover with time are not well understood. In particular, it is not known whether intrusive injury-related images patients experience play a role in the development and maintenance of PTSD and other psychological disorders. A consistent body of research shows that intrusive images related to memories of past aversive experiences are an important feature of several psychological disorders (see Brewin, Gregory, Lipton, & Burgess, 2010). They tend to be recurrent, vivid, and distressing. They are often associated with negative emotions and core beliefs about the self and others and are involved both in the onset and in the maintenance of disorders. In PTSD, in particular, images consisting of brief sensory fragments of the trauma intrude into consciousness and make patients relive the trauma with all its emotions and sensory impressions (e.g., Hackmann, Ehlers, Speckens, & Clark, 2004). They thus contribute to a sense of impending threat which may be related to the fact that cognitions experienced during the worst moments of the trauma revolve around two main themes: threat to one’s physical integrity (e.g., injury) and threat to one’s sense of self (e.g., blame) (e.g., Grey & Holmes, 2008). In the long run, according to Ehlers and Clark (2000), the sense of impending threat helps maintain patients’ PTSD symptoms. Given this evidence on the importance of imagery in PTSD, the current study aimed to investigate the presence of injury-related imagery in patients with burn injuries and the relationship between this imagery and patients’ psychological well-being. Twenty-one patients who had suffered moderate burn injuries were administered a series of questionnaires focusing on psychological well-being (e.g., PTSD, depression, anxiety) and a semi-structured interview exploring the nature of the images related to their injury (e.g., their frequency, sensory modalities, associated emotions and thoughts). Data analysis for this study is still going on. Results are expected to show that the presence of intrusions is associated with the cognitions and emotions experienced at the time the injury occurred. In addition, they are expected to show that the characteristics of these images (e.g., frequency, distress) are negatively related to patients’ psychological well-being. If the results support our hypotheses, they will be in line with existing evidence on imagery and PTSD and will highlight the importance of addressing imagery in patients with burn injuries in the aftermath of the injury. Anxiety and incontinence-preoccupation: mental imagery associated with visceral distress Sunjeev Kamboj, Research Department of Clinical, Educational and Health Psychology, University College London & Rosanna Pajak, Research Department of Clinical, Educational and Health Psychology, University College London Anxiety symptoms often include distressing visceral sensations located in the bowels and bladder. These sensations can be accompanied by specific concerns about losing control of the bowels and/or bladder in public. Here we examine the expression – in mental imagery - of this feared ‘social catastrophe’ among participants from a community sample who self-reported a fear of incontinence. Images were assessed using a semi-structured imagery interview and thematically analysed. Images were generally of feared (future) catastrophes, rather memories. However, content was linked to a distressing previous experience of incontinence or ‘near miss.’ The majority of participants experienced this imagery from a field perspective with high levels of vividness. Super-ordinate imagery themes included the sense of being ‘shrunken or diminished,’ both physically (a diminutive self, huddled, crouching and childlike) and socially (seen by others as incompetent and losing social status). The self was also experienced as ‘totally exposed’ and as a rejected object of disgust and ridicule. A lack of volition was conveyed : being trapped or paralysed; lacking control. A minority of participants reported images of the inside workings of their bodies, denoting illness or dysfunction. Imagery often occurred in the context of panic attacks, with additional predominant feelings of shame. Although the themes reported here may overlap with those found in other psychological disorders, images associated with gastrointestinal distress and fear of incontinence may also have distinct characteristics. This knowledge should help clinicians develop more effective imagery-based CBT procedures for individuals with this specific concern. Mental imagery in bipolar affective disorder versus unipolar depression: Investigating cognitions at times of 'positive' mood Annabel Ivins, University of Oxford; Emily Holmes, Department of Psychiatry, University of Oxford; Helen Close, Oxford Health NHS Foundation Trust; Guy Goodwin, Department of Psychiatry, University of Oxford Mental imagery has been implicated in the amplification of mood states (Holmes et al., 2008). A better understanding of the phenomenology of mental imagery in mood disorders is thus warranted. Bipolar disorder is characterised by episodes of mania or hypomania alternating with periods of depression. Existing studies on mental imagery among individuals with bipolar disorder report on the presence of vivid affect-laden imagery related to depressive states and suicidality (Mansell & Lam, 2004; Tzemou & Birchwood, 2007; Hales et al., 2011). In contrast, little is known about the frequency, content and qualities of images experienced during periods of elevated mood. To date, one published study has investigated mental imagery during hypomania (Gregory et al., 2010); sixty-six percent of participants reported imagery characterised by vivid, enjoyable images of future events. The current study aimed to extend this novel finding in three ways; the addition of a psychiatric control group; probing both mental imagery and verbal thoughts; using a definition of positive mood of more ‘everyday’ severity. Adults with bipolar disorder (n=26) or unipolar depression (n=26) completed a semi-structured interview investigating their experience of mental imagery and verbal thoughts during their last period of positive mood. Participants rated qualities of their mental imagery and verbal thoughts including compellingness and realness, and were asked to describe their most significant image in detail. All 52 participants reported experiencing spontaneous mental imagery when positive in mood. A wide range of image content, consequent affect and behaviour was described by both groups. Similarities and differences between the groups in their imagery ratings and descriptions shall be discussed during the talk. This is the first study to show that both bipolar and unipolar participants experience spontaneous mental imagery during positive mood. As current psychological treatments are limited in bipolar disorder, further research into mental imagery could inspire new approaches to working with this population. The effects of repeated imagery practice on self-concept, anxiety and performance in socially anxious participants Lusia Stopa, School of Psychology, University of Southampton; Mike Brown, School of Psychology, University of Southampton; Colette Hirsch, King’s College London, Institute of Psychiatry, and University of Western Australia Current cognitive models of social phobia, all stress the importance of negative self-perceptions in mainlining social anxiety (Moscovitch, 2009, Hofmann, 2007; Rapee & Heimberg, 1997; Clark & Wells, 1995). In some models, (Clark & Wells, 1995) negative self-perceptions are embodied in the form of a visual image. In this study, 58 socially anxious participants were assigned to either a positive (n =19) or a negative (n =19) self-imagery condition and we tested the impact of repeated

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imagery practice on self-concept (self-esteem and self-concept clarity), and on anxiety and performance in a conversation with a stooge. Participants in each condition group practised holding either a positive or a negative self-image in mind over eight days while at the same time imagining themselves in a series of increasingly challenging social situations. After the final imagery practice, participants took part in a conversation with a stooge. We hypothesised that repeated practice with a positive image would produce higher levels of self-esteem, more self-concept clarity, and would lead to less anxiety and better ratings of performance than holding a negative image. The hypotheses were partially supported. Positive self- imagery practice led to higher self-esteem ratings and higher self-concept clarity on a computerised measure of self-concept clarity, but not on a self-report measure. Positive self-imagery practice also produced better performance ratings in the social test (in both subjective and objective assessments of performance) and a trend towards reduced anxiety. The results are discussed in relation to Conway and Pleydell-Pearce’s (2000) self-memory model and the clinical implications are considered. The Oxford Mood Action Psychology Program (OxMAPP): targeting mood instability in bipolar disorder using a novel, imagery-based approach Susie Hales, Department of Psychiatry, University of Oxford; Emily Holmes, Department of Psychiatry, University of Oxford; Simon Blackwell, Department of Psychiatry, University of Oxford Bipolar disorder is a recurrent, severe, complex mental health disorder characterised by episodes of (hypo)mania and depression. It has a significant impact on life chances and relationships with family and friends, is associated with high levels of psychiatric and physical co-morbidities, and confers the highest risk of suicide of all the psychiatric disorders. It has been proposed that mental imagery may act as an ‘emotional amplifier’ in bipolar disorder (Holmes et al, 2008). In a range of laboratory studies, imagery has been shown to have a greater impact on emotional states than verbal thoughts. Patients with bipolar disorder have been found to have high levels of some types of mental imagery compared with both healthy controls (Holmes et al, 2011) and other psychiatric populations (Hales et al,2011). To date, cognitive behaviour therapy (CBT) has a limited evidence-base in bipolar disorder. Though the importance of image-based cognitions was highlighted by the developers of CBT, there has been a tendency for CBT practitioners to focus largely on modification of dysfunctional verbal thoughts. Mental imagery may be a neglected psychological treatment target in bipolar disorder. The Oxford Mood Action Psychology Program (OxMAPP) is a treatment innovation program which aims to develop and evaluate a novel imagery-based approach to target mood instability in bipolar disorder. The theoretical rationale of the OxMAPP intervention approach is discussed, and case studies are presented to illustrate the imagery techniques used and their impact on individual outcome data. Implications for psychological treatment innovation with patients with bipolar disorder are emphasised, and attention is drawn to the challenges of conducting research in this area.

New Developments in CBT (A Sheffield perspective) Convenor: Joe Curran, Sheffield Health and Social Care NHS Foundation Trust

Cognitive behavioural therapy for dental anxiety: improving access to therapy and the effective reduction of sedation John Davies, Sheffield Health and Social Care NHS Foundation Trust The paper demonstrates how CBT can have a long lasting effect on the reduction of sedation in dental anxiety for patients previously reliant on its use to manage their symptoms. Initial findings describing how access to CBT has been widened for Sheffield patients, adapting an established approach and developing an innovative mode of delivery in dentistry, will be presented. IQuESTS: Identifying priorities for improving the recovery orientation of psychological therapy services for people with longer-term depression Tom Ricketts, Sheffield Health and Social Care NHS Foundation Trust; Glenys Parry, Rebecca Hutten, Jo Cooke, Sarah Cook, Eleni Chambers, University of Sheffield Research trials into psychological therapies for people experiencing depression tend to reinforce a treatment model of the passive patient receiving care from expert therapists. In contrast NHS policy increasingly emphasises the role of patient choice, partnership between an active, expert patient and a user-centred professional, and endorses the value of self-management and recovery principles (DH, 2011). Recovery principles (Davidson 2005, Deegan 1996) involve people making sense of their experience of mental illness in ways that allow them to preserve or reconstruct a sense of personal efficacy and control, and to re-establish meaningful connections with others. Many psychosocial therapies intrinsically value self-efficacy, patient empowerment and psychoeducation, and ‘self-management’ as a key principle. However there has been a dearth of research to test the capacity of these treatment programmes to facilitate recovery as defined by service users, and to help them develop expertise in managing their own condition. Very few research trials incorporate qualitative research on the patients’ own experience in their own terms, despite evidence that the views of patients differ from those of professional care providers and give important insights into how to customise and improve services (Hodgetts & Wright, 2007). Our long-standing collaboration between therapists and researchers, including service user researchers, has shown the need for, and feasibility of, translational research in this area. This aims to address systematically the gap between clinical trials and routine service provision, and the lack of evidence on which to take forward implementation of recovery oriented, effective psychological and psychosocial treatments. This paper will present the results of a research process that has included three workshops and a survey to identify priorities for service improvement within secondary care psychological therapy services for people experiencing longer-term depression. The process has brought together a diverse group of stakeholders including service users, clinicians, managers and commissioners of services, and health service researchers, to make decisions about priorities for change. The process and outcomes will be described, together with plans to implement the identified changes within a research clinic. There will be an opportunity to consider how this approach could be applied to other areas of decision-making within mental health services.

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Evaluation of an Acceptance and Mindfulness-based training course for clinicians Jennifer Darling, Sheffield Health and Social Care NHS Foundation Trust & Joe Curran, Sheffield Health and Social Care NHS Foundation Trust; Nic Wilkinson, Sheffield Teaching Hospitals Acceptance and Mindfulness-based approaches to psychotherapy (ACT, MBSR, MBCT) are increasingly adopted by health and social care professionals in their clinical work. The availability of training in these approaches is limited to short workshops. This paper reports the process and outcome of a 12-day postgraduate module for psychotherapists that aims to increase participants’ knowledge and skill in the application of these approaches to their clinical work and/or their own personal experience. The evaluation aims to provide data on these outcomes and to report on participants’ experiences of engaging with the learning processes of the module. Specific consideration will be given to the issues that arise when attempting to integrate acceptance and mindfulness approaches into a single training package. Can we increase the availability of CBT for schizophrenia by reconceptualising the disorder? Joanna Priddy, Sheffield Health and Social Care NHS Foundation Trust Although NICE guidelines recommend that CBT is offered to all people with schizophrenia (NICE 2010), the availability of therapy is limited. One way of increasing the availability of therapy may involve a reconceptualisation of the phenomenology of schizophrenia, based on our existing understanding of anxiety and affective disorders. Such a reconceptualisation should enable clinicians experienced in delivering CBT to work effectively with the component problems of people who present with schizophrenia and related disorders. This paper reviews what is being treated in current research studies and discusses how we can extend treatment to people who are traditionally neglected by evidence-based psychological therapy, but potentially very likely to respond. Findings from a case study are presented to illustrate the clinical application of the work presented, and the local implementation of a related service improvement project considered.

How Does Acceptance and Commitment Therapy (ACT) Work? Examining the Processes Underlying Change Convenor: Jo Lloyd, Goldsmiths, University of London Discussant: Kelly Wilson, University of Mississippi, USA

ACT for distressed voice hearers: a multiple-baseline study Eric Morris, South London & Maudsley NHS Foundation Trust We will present an evaluation of an ACT intervention for people hearing distressing auditory hallucinations, using a multiple baseline design with repeated measures of distress, functioning, quality of life, non-judgemental awareness and acceptance of voice hearing. Distressed voice hearers (N=8) residing in inner-city London, from a range of ethnic and social backgrounds, were engaged in a 10 session ACT intervention that focused on valued living and active acceptance of voices and other private experiences. In addition to interview and self-report ratings participants also completed a repeated implicit relational assessment procedure (IRAP) on non-acceptance/ acceptance of voices. The results of this study will be discussed in terms of process and outcome measurement, and treatment acceptability. An adherence measure developed for the study will be described. The role of ACT processes in Trauma Symptoms in anAdult Clinical Population Penelope Noel, Centre for Child Health, NHS Tayside Posttraumatic stress disorder (PTSD) is a complex disorder and no one theory can fully explain the development and maintenance of PTSD symptoms. According to Acceptance and Commitment Therapy (ACT) one way of conceptualising such a disorder is that symptoms develop and persist as a result of underlying psychological inflexibility. The ACT model of psychological inflexibility describes ways of responding to contextual cues, two of which, namely experiential avoidance (EA) and cognitive fusion (CF) may be particularly relevant to a disorder such as PTSD which is characterised by re-experiencing, avoidance and hyperarousal symptoms. The current study aimed to examine the role of EA and CF processes in posttraumatic stress symptoms and living consistently with values (valued action) in a clinical sample. Eighty two patients attending an adult psychological therapies service completed the following measures; Cognitive Fusion Questionnaire (CFQ 13), Acceptance and Action Questionnaire (AAQ II), Valued Living Questionnaire (VLQ) and Posttraumatic Stress Diagnostic Scale (PDS). Results indicated that CF and EA were positively correlated with trauma symptom severity and negatively correlated with valued action. Both CF and EA mediated the relationship between number of traumatic events and trauma symptom severity in a simple mediation model. However, a multiple mediation analysis demonstrated that EA over and above CF explained 33 per cent of the variance. In addition, CF and EA jointly had a significant indirect effect on the relationship between trauma history and valued action. The implications of the findings and further directions are discussed. Assessing the effectiveness of two brief Acceptance and Commitment Therapy (ACT) Interventions in Higher Education Vasiliki Christodoulou, Lambeth Early Onset (LEO) Services, South London & Maudsley NHS Foundation Trust Objectives: Two studies examined the impact of a brief, Acceptance and Commitment Therapy (ACT) group training for university students. The studies explored if significant changes on psychological wellbeing were mediated by ACT mechanisms of change (e.g., mindfulness, goal-directed action, psychological flexibility). Design: Both studies adopted a repeated-measures randomised controlled trial design. Method: In Study 1, 65 students were randomly assigned to one of two conditions: 1) an ACT training day (5 hours); 2) a waitlist control group. Participants completed outcome and mediation measures at baseline, at one month and two months post. Study 2 utilised similar methodology. Seventy-one students were randomly assigned to receive ACT training or to a waitlist control group. Measures were completed at identical time-points as in Study 1. Results: Study 1 significantly improved students’ reported stress, anxiety and depression at one month. The ACT group also experienced increased goal-directed action and reductions in negative thought believability at one month. Reduced thought believability partially mediated between-group differences on stress and anxiety. Study 2 benefitted students’ psychological well-being, stress and anxiety at two months. Improvements in participants’ psychological wellbeing were fully mediated by increases in psychological flexibility and mindfulness. Reductions in stress were partially mediated by increases in mindfulness and psychological flexibility.

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Conclusions: Brief ACT preventative interventions can be beneficial when delivered in Higher Education although benefits maybe more apparent during exam periods. The outcomes validate ACT’s theoretical assertions albeit difficult to statistically separate the mediational contribution of different process variables. A Randomized Controlled Evaluation of Mindfulness-Based Training in the Workplace: Outcomes and Mediators of Change Jo Lloyd, Goldsmiths, University of London; Paul Flaxman, City University London In this article we propose that the field of worksite stress management training (SMT) can be advanced by adopting the mindfulness-based theories and intervention technologies that have recently expanded the cognitive behavior therapy (CBT) tradition. To test this proposition, we conducted a randomized controlled evaluation of a worksite training program based on the principles of acceptance and commitment therapy (ACT). A total of 154 employees were randomly assigned to receive three half-day sessions of ACT-based training (n = 71) or to a waitlist control group (n = 83). Results indicated that the training was effective in reducing psychological distress and improving affective well-being and life satisfaction over a five month evaluation period. Consistent with ACT’s underlying model, bootstrapped mediation analyses revealed that the beneficial effect of the training on employees’ mental health was mediated by an increase in mindfulness skills (particularly experiential acceptance) and, to a lesser extent, an increase in goal-directed action. Findings further indicated that the cultivation of mindfulness during the training enhanced employees’ propensity to engage in goal-directed behavior. Implications for worksite SMT theory, research, and practice are discussed.

Attentional Bias Modification in Affective Disorder: Promises and Pitfalls Convenor: Willem Van der Does, Leiden University, Netherlands

Chair: Peter Putman, Leiden University, Netherlands

Fewer intrusions of analogue trauma after an Attentional Bias Modification Training Ineke Wessel, University of Groningen; Johan Verwoerd, University of Groningen; Peter J De Jong, University of Groningen Most people who have experienced a traumatic event initially suffer from involuntary intrusive memories of that event. Yet, only a minority shows persistent re-experiencing. A gradual decrease of intrusions may be supported by a well-developed ability to direct attention away from trauma-related environmental stimuli. If so, enhancing attentional disengagement from such trauma-reminders should reduce intrusive re-experiencing. The present analogue experiment used an attention training to examine this idea. After exposure to a trauma film, participants in a training group (n = 22) completed a modified exogenic cueing task (ECT), in which invalid trials always contained trauma-film stills and valid trials always consisted of neutral stimuli. Control participants (n = 23) performed a similar task without such a contingency. Post-training processing bias was assessed with a single target Rapid Serial Visual Presentation (RSVP) task, in which trauma-film reminders served as task-irrelevant distracters preceding a neutral target. Consistent with predictions, participants who received attention training showed less interference from film distracters than controls. Moreover, they recorded fewer film-related intrusions in a three-day take-home diary. A Multiple Case Series Analysis of Six Variants of Attentional Bias Modification for Dysphoria Anne-Wil Kruijt, Leiden University; Peter Putman, Leiden University; Willem Van der Does, Leiden University Background: Attention Bias Modification (ABM) is a new treatment that has been investigated mainly in anxiety disorders. Two studies have tested ABM in dysphoria or depression with varying results. The working mechanism of ABM has not yet been convincingly demonstrated and little is known about the influence of design parameters. We compared six different versions of ABM for dysphoria in a multiple case series design. Methods: Thirty students with mild to moderate symptoms of depression underwent four sessions of ABM within one week. Two training directions and three stimulus durations were combined into six ABM variants. Attentional bias was assessed over the course of each training session. Generalization of effects to untrained stimuli and awareness of training were assessed. Results: Attentional training had no consistent effects on attentional bias. No relationships were observed between attentional bias changes for trained and untrained stimuli. Awareness of receiving training correlated with bias change for untrained stimuli but not with bias change during the training. Conclusions: Our study does not support the proposed working mechanism of ABM. Attentional Bias Modification in Posttraumatic Stress Disorder: A Randomized Controlled Trial Maartje Schoorl, PsyQ and Leiden University; Peter Putman, Leiden University; Willem Van der Does, Leiden University Background: Attentional Bias Modification (ABM) is a new treatment for anxiety disorders. Three randomized controlled clinical trials have shown positive effects of ABM in social anxiety disorder and generalized anxiety disorder. This study investigated the efficacy of ABM in outpatients with chronic posttraumatic stress disorder (PTSD). Methods: Randomized controlled double-blind trial (N = 102). ABM and control treatment consisted of eight 20-minute sessions over the course of three weeks. Symptoms and attentional bias were assessed pre- and post-treatment and at three-week follow up. Results: ABM and the control treatment were equally effective in reducing the symptoms of PTSD. The effect sizes of the improvement (pre-post) were 0.66 for ABM and 0.46 for the control treatment, which is comparable to the effect sizes of pill-placebos in pharmacotherapy trials of chronic PTSD. Both treatments did not affect attentional bias. The acceptability and tolerability of ABM were moderate. Conclusions: This version of ABM does not seem to be an effective treatment of PTSD. Mutual Interference When Attentional Bias Modification and Antidepressant Medication Are Combined Michael Browning, University of Oxford; Maud Grol, University of Oxford; Verena Ly, University of Oxford; Guy Goodwin, University of Oxford; Emily Holmes, University of Oxford; Catherine Harmer, University of Oxford Background: The efficacy of the treatments for anxiety and depression is disappointing. One method which is sometimes used to improve response when a particular intervention has failed is to combine different forms of treatment—such as antidepressant medication and psychological therapy. Meta-analyses suggest that combining pharmacological and

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psychological treatments provides a modest improvement in efficacy over the individually administered interventions, although the reported benefit is somewhat inconsistent, particularly for the anxiety disorders. Cognitive models of both anxiety and depression predict that symptoms of the illnesses may be caused and maintained by negative cognitive processing biases. This causal relationship is most clearly demonstrated in recent reports that bias modification procedures (simple computerised tasks that train affective processing biases) can be used to ameliorate symptoms in clinical groups. However, there is also evidence that antidepressant medications are able to induce positive processing biases suggesting that bias modification may be a common mechanism for both psychological and pharmacological treatments. Given the evidence for a common cognitive mechanism underlying both forms of treatment, the current study examined the effect of combining antidepressant medication and an attentional bias modification procedure. The key question addressed in the study was: do the two forms of intervention interact to produce a synergistic effect on cognitive and emotional function or do they interfere with each other? Methods: 62 non-clinical participants were randomly assigned to receive 7 days of the SSRI medication citalopram (20mg) or a placebo capsule, while also completing 7 days of a positive or control attentional bias modification (ABM) task. A factorial study design was used to assess the influence of each active intervention administered on its own as well as the combination treatment. The critical outcomes were 1) behavioural measures of cognitive bias (emotional memory and categorisation) and 2) subjectively reported mood in response to a negative mood induction task. These were measured immediately after completion of the treatment week. Results Participants who received both citalopram and the active ABM task showed a smaller alteration in emotional memory and categorisation bias than did those who received either active intervention singly. Citalopram protected participants against the effect of the negative mood induction, with the effects of the medication on the cognitive outcomes predicting this protective effect. The addition of positive ABM to citalopram tended to reduce this protection. Conclusion: These results suggest that co-administration of an SSRI and ABM can reduce the effectiveness of either intervention alone in terms of anxiety- and depression-relevant emotional processing. More generally, the findings suggest that pinpointing the cognitive actions of treatments may inform the future development of combination strategies in mental health.

How Does CBT Work? Exploring Multiple Factors Convenor: Rob Dudley, Newcastle University Discussant: Mark Freeston, Newcastle University and Northumberland Tyne and Wear NHS Foundation Trust

Effective elements of CBT for Psychosis Philippa Garety, Institute of Psychiatry, King’s College, London; G. Dunn, D. Fowler, R. Rollinson, D. Freeman, E. Kuipers, B. Smith, C. Steel, J. Onwumere, S. Jolley and P. Bebbington This talk will explore recent research evidence concerning what works most effectively in CBT for Psychosis. Findings from the PRP (Psychological Prevention of Relapse in Psychosis) trial will be presented, which examined effective elements of CBT in a large multi-centre trial, using novel statistical approaches to the analysis of post-randomisation sub-group data, such as the delivery of therapy, while retaining the benefits of randomisation. In this trial, 133 people were allocated to receive CBT, and therapist competence and the elements of CBTp which were actually delivered were assessed. In 102 cases, for whom extensive data were available (drawn from over 1000 audio-taped sessions, plus other therapy records), we were able to allocate the therapy to one of three categories: No, Partial or Full therapy, based upon both the number and content of therapy delivered. Forty-two participants had full therapy, and 39 partial therapy. A further 21 participants had less than five sessions of therapy, thus falling into our no-therapy group. There were highly significant differences in outcome between these groups, with those in receipt of full therapy achieving significantly better outcomes than the partial and no therapy groups: for example the full therapy group achieved 8 additional months in remission, over period of 24 month. Treatment was effective if, and only if, clients received full therapy. Factors which predicted membership of these groups included treatment centre and client factors but not therapist competence. What constituted full and partial therapy, the role of client factors, and implications of these findings for future strategies to enhance the effectiveness of CBTp, will be discussed. Examining the effects of thought records and behavioral experiments in instigating belief change Freda McManus, Course Director and Clinical Research Fellow, Oxford Cognitive Therapy Centre and Oxford University; K. Van Doorn, Oxfordshire & Buckinghamshire Mental Health NHS Foundation Trust; J. Yiend, Institute of Psychiatry, King's College London Objective: While the efficacy and effectiveness of CBT protocols is well established, much less is known about the comparative contribution of the different techniques within CBT. Or whether different techniques are differentially suited to different patients. The present study examined the relative efficacy, in comparison to a control condition, of two central techniques in CBT: thought records (TRs) and behavioral experiments (BEs). A post-hoc analysis was used to examine whether the intervention (TR or BE) was differentially effective according to whether it was either ‘matched’ or ‘mismatched’ to the individual’s learning style. Method: A mixed within and between participants design was used to compare the efficacy of a single session TR and a single session BE intervention with a control intervention, in a non-clinical sample (N = 91). Results: While direct comparisons of the TR and BE conditions failed to reach significance, the overall pattern of results suggests both TR and BE had a therapeutic impact on belief ratings in comparison to the control condition, and that there may be an advantage of the BE intervention over the TR intervention in reducing anxiety related belief ratings and behavior. Results from the post hoc analysis suggest that greater belief change may be achieved when the intervention technique is matched to the participant’s learning style, than when the intervention technique is mismatched to learning style. Conclusions: The findings confirm the utility of both TR and BE interventions and point to BE’s as more useful in effecting belief change in that change in the BE condition occurred sooner and generalized further. Furthermore, the impact of either BE or TR interventions may be attenuated by the participant’s learning style. Limitations: Conclusions are limited by the limited dose of the intervention and the non -clinical sample, as well as the retrospective nature of the learning styles / matching analysis. Further investigation using prospective designs with clinical samples and higher dose interventions is warranted.

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Using the Therapeutic Relationship for Change: A Focus on How Things Work Timothy Carey, Flinders University & Charles Darwin University Evidence clearly suggests that the therapeutic relationship is important to successful outcomes in psychotherapy. It is less clear as to why this might be the case. My contention in this presentation is that the way in which the therapeutic relationship works to produce good therapy outcomes needs to be understood in the context of how therapy, in general, works to help alleviate psychological distress. To begin with, therefore, I provide a model of psychological change based on the concept of reorganizing networks of goal achieving systems. While this is an inherently internal model of change, the process can be encouraged and promoted externally by someone familiar with the model. Apart from understanding the change process it might also be helpful for therapists to conceptualise the therapeutic relationship in terms of two people each seeking to achieve certain goals. Diagrams are presented that represent a way of mapping the therapeutic interaction. It is suggested that understanding the relationship from the perspective of goal attainment provides a helpful way of considering issues such as ruptures, resistance, and disengagement. With this model of the therapeutic relationship, some strategies to promote the change process are provided. By understanding how to use the therapeutic relationship to best facilitate the change process psychotherapy might be provided as efficiently and effectively as possible. Is the devil in the detail? Therapeutic benefits of focusing on the specific details of emotional experience Tim Dalgleish, MRC Cognition and Brain Sciences Unit, Cambridge This paper collates data and theoretical work from a number of sources to consider whether therapeutic benefit can accrue from a focus on the specific details of both positive and negative emotional experiences. The theoretical background will cover construal theory alongside models of rumination and autobiographical memory specificity. Findings in the literature on concreteness training, emotion regulation and exposure therapy for PTSD will be drawn upon, and new data on memory specificity training (MEST) for depression will be presented.

New Developments in Treatment Chair: Hayley Dare, West London Mental Health NHS Trust

Evaluation of a pilot acceptance and commitment therapy group in an NHS adult mental health psychological therapies team Rachel MacLeod, NHS Lanarkshire; Louise Tansey, NHS Lanarkshire; David Gillanders, University of Edinburgh Acceptance and commitment therapy continues to emerge as a promising third wave therapeutic model. Built on a transdiagnostic philosophy which rejects the common agenda of omitting psychological suffering, the approach has been evidenced as an effective intervention for a range of anxiety and mood-based presentations (Powers et al., 2009). Initial findings indicate that employment of the model in a group format provides an effective intervention for multiple presentations including OCD, social phobia, health anxiety and depression (e.g. Zettle et al., 2011; Ossman et al., 2006). The current climate in NHS Psychological Therapy services demands the development and evaluation of new treatment options. An eight-session ACT group, aimed at individuals referred with anxiety-based difficulties, has been implemented within an Adult Psychological Therapies team in a Scottish Health Board. The treatment protocol is summarised and discussed. The ACT group model and pilot data will be discussed in relation to the development of ACT in the context of the current climate surrounding psychological therapies in the NHS. Preliminary data comparing participants’ pre- and post- treatment scores on CORE (Evans et al., 1998), the Cognitive Fusion Questionnaire (Dempster et al., 2009) and the Valuing Questionnaire (Smout et al.) are reported. This represents initial developments of the application of third wave CBT approaches in a group setting. Outcomes will allow for tentative conclusions to be drawn around the potential for an ACT Group approach to be appiled in clinical practice, and may point to refinements to the intervention that may lead to improvements in its clinical application.

The efficacy of CBT on a group based intervention for problematic internet-enabled Sexual behaviour Manpreet Dhuffar, Buckinghamshire New University The proposed study addressed the effectiveness of CBT for internet-enabled/related sexual behaviour (as defined by Griffiths, 1998) in men and women. Though CBT is based upon much empirical evidence, there is very little documented around the efficacy among the treatment of problematic internet enabled sexual behaviour. In addition to a lack of conceptual consensus, there has only been one report of a controlled study documenting the short or long term effectiveness of any psychotherapeutic model for treating problematic Internet related sexual behaviours. Collation of baseline and follow-up measures of the efficacy of CBT on internet enabled sexual addicted clients, but also to co-facilitate a rolling closed group one of which starts in December 2011 and runs for 12 consecutive weeks. In process will be completed by February.

Developing a CBT manual for adult inpatient secure services: exploring patients’ and mental health practitioners’ views on CBT for psychosis in secure services Gurmit Dhillon, University of Southampton and Central and Northwest London NHS Trust; David Kingdon, University of Southampton; Mary Gobbi, University of Southampton Patients remanded to forensic secure hospitals often experience high levels of psychotic symptoms and the realisation of their legal situation may worsen their condition. Individual cognitive behaviour psychotherapy is often not used with this population due to a generally high level of impairment, lack of resources, staff training, and an absence of a structured approach. It is necessary to have an understanding of what patients themselves view as being effective within their treatment. This may help to determine risk management plans that perhaps have more ecological validity as they are grounded in the patients’ experiences (Laithwaith 2009 & Greenwood 2009). This paper generates new understandings of the perspective of patients and mental health practitioners regarding the place of CBT in secure services. It highlights key themes with clinical implications to inform the development of a customized CBT manual for this patient group. This qualitative research study used semi structured interviews with 17 patients across 3 secure settings. Focus groups were conducted in 3 secure setting sites involving 25 health care practitioners. The analysis employed a grounded theory approach (Strauss & Corbin, 1990) with integration of thematic analysis. First, the emergent themes were analysed according to the participants (professionals and patients). Second the participants themes were then compared with each to elicit areas of commonality and difference. This study highlights those concepts that are jointly experienced, albeit from different perspectives, by both practitioners and patients. It clearly identifies those issues that patients and professionals find useful

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and other non specific aspects that influence therapy process. The analysis produced 14 themes from both participants groups which were clustered into two higher orders concepts. Professionals spoke about their experiences of employing a multimodal approach and essential components in CBTp. Their data identified the important concepts of a ‘multimodal approach and solution focused therapy’. Patients narrated their experiences of living in secure services and ‘what works’ in therapy. Patient analysis revealed the importance of a ‘place of healing’ and the issue of ‘containment’. This study emphasises the patients’ perceptions of their care which can help staff to assess, engage and understand the covert processes which are not normally reported and may affect staff and patients relationship. Staff will also be able to reflect on their therapy work and style to deliver better treatment for this population.

The role of nursing staff in transforming problems with borderline personality disorder inpatient admissions into opportunities: Incorporating dialectical behaviour therapy skills into acute psychiatric inpatient units Jayne Fitches, The Logos Centre; Christopher Rae, The Logos Centre Borderline personality disorder (BPD) is a complex and enduring psychological condition. To manage associated risks, especially self-harming and suicidal behaviours, inpatient admissions frequently occur but this poses problems in maintaining continuity of community based psychological treatment. Patients with BPD are admitted to inpatient units more frequently than patients with other disorders and represent up to 20% of psychiatric admissions Dialectical behaviour therapy (DBT) is one of the third wave developments of CBT. Training inpatient nursing staff in skills from DBT, an evidence based treatment for BPD, can help to maximise the continuity of therapeutic input and promote patient’s functional and effective behaviours during admissions.The most immediately relevant skills for inpatient staff to be focussing on teaching and reinforcing to patients are the distress tolerance and emotional regulation skills. These are likely to have most impact on the behaviours which have prompted or prolonged the admission. Patients who are part of a community DBT treatment programme will have been taught mindfulness as it is the first set of skills to be covered; they may not have yet been taught other skills prior to admission therefore training for inpatient staff on mindfulness is not such a priority - but they must have an understanding to prompt and remind patients to use mindfulness. Whilst BPD remains a complex and challenging condition to treat there is mounting evidence that DBT is an effective intervention. Given the propensity for BPD patients to be admitted to inpatient units, training all levels of nursing staff in appropriate DBT skills is an advantageous step to maintaining the continuity and therapeutic input for patients during a time when utilising functional and effective skills and behaviours is most required. Though there are barriers to achieving this milieu, maximising effective coping strategies and skilful behaviours are key aspects of helping patients reduce inpatient admissions and develop a life worth living. One of the key potential benefits of staff utilising DBT skills is the opportunity to address problems caused by the interruption of therapy which can contribute to protracted admissions and set backs in therapeutic progress. These periods of reduced DBT therapy, particularly in the early stages of therapy, caused by admissions often contribute to the de-skilling of patients which means when they return to community services and therapy work often has to focus on reviewing and rehearsing previously learned skills which have been under practiced or forgotten. If inpatient staff were to continue the teaching and practicing of skills with the patient whilst admitted then the momentum of effective skills utilisation would more likely be maintained. Clinical implications: • Maintain therapeutic continuity of treatment plan from community to inpatient settings • Developing and empowering inpatient nursing staff to utilise cognitive and behavioural interventions • Provide patients with skills to use in crisis situations • To move towards a more successful and faster discharge Rising to the Challenge of Suicide Prevention in Prisons Daniel Pratt, University of Manchester; Patricia Gooding, University of Manchester; Nicholas Tarrier, King's College London Suicide is the leading cause of preventable death in prisons with a suicide rate up to five times greater than for the community. Despite the dearth of interventions routinely available for this vulnerable group, psychological therapists working in forensic settings are well placed to play an important role in the prevention of future suicides. Firstly, a brief overview of the prevalence of suicidal behaviour by prisoners and a summary of the factors shown to be associated with increased risk of suicide will be presented. Then, the remainder of this paper will briefly review the extant literature on psychological interventions for suicidal prisoners before providing a practical focus upon key contextual and individual factors affecting implementation in a prison setting. This paper concludes with a summary of the key contextual and individual-level issues and challenges facing the psychological therapist responsible for implementing suicide prevention interventions in a feasible and acceptable manner for both prison staff and the prisoners. Prisoners are identified as a high-risk group but there are no evidence-based suicide prevention interventions routinely available. The need for further investigation of psychological approaches to the prevention of prisoner suicide is proposed. Despite numerous individual and contextual issues making therapeutic work with prisoners difficult and challenging, there remains a desperate need to develop psychological interventions specifically targeting distress associated with suicidality experienced by prisoners. Indeed, the development and evaluation of structured, theory-driven, psychological interventions may be the first step towards larger scale research on the effectiveness of preventative treatments for suicidal prisoners.

Maximising Treatment Outcomes Chair: Nick Hawkes, Barnet, Enfield and Haringey Mental Health NHS Trust

Efficacy of cognitive behavioural therapy in the treatment of mood and anxiety disorders in adults - Review Magnus Blondahl Sighvatsson, Landspitali-The National University Hospital, Iceland; Hafrun Kristjansdottir, Landspitali-The National University Hospital, Iceland; Engilbert Sigurdsson, Landspitali-The National University Hospital, Iceland; Jon Fridrik Sigurdsson, Landspitali-The National University Hospital, Iceland; Paul M Salkovskis, University of Bath, United Kingdom Cognitive behavioural therapy (CBT) represents the form of psychotherapy which has the most research data to build on in the treatment of mental disorders for adults. In this review we will introduce CBT and present the results of pertinent outcome research for mood and anxiety disorders. Efficacy at the end of the treatment will be discussed, as well as long term effectiveness and the efficacy of combined treatment with medication and CBT. CBT is an effective treatment for common mental disorders. Side effects are almost never a problem and long-term success is a good. Further research is though needed on combined treatment. The results show that CBT is an effective treatment for; depression, GAD, panic disorder, social phobia, OCD, PTSD and specific phobia but results for dysthymia are inconclusive. Results of follow-up studies show that the efficacy of CBT lasts for a considerable time after the termination of treatment. CBT is more effective

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than other forms of psychotherapy except for behaviour activation and interpersonal therapy in treatment for depression and EMDR in treatment for PTSD. When CBT is compared with anti depressive medication results reveals that CBT is as effective or more effective than drug treatment, especially when the long-term effects are considered. This is true except for the treatment of dysthymia. Results are contradictory regarding whether medication improves or reduces the efficacy of CBT, especially in the treatment of anxiety disorders.

In defence of “reinventing the wheel”: practice-based evidence from 10 years of CBT-based groups for Binge Eating Disorder Kate Allsopp, Barnet, Enfield and Haringey Mental Health NHS Trust; Kate Allsopp, Barnet, Enfield and Haringey Mental Health NHS Trust; Emma Friddin, Barnet, Enfield and Haringey Mental Health NHS Trust; Nick Hawkes, Barnet, Enfield and Haringey Mental Health NHS Trust The NICE guideline for eating disorders (2004) recommends guided self-help (GSH), cognitive behavioural therapy (CBT), and modified dialectical behaviour therapy (DBT) for Binge Eating Disorder (BED), but how much flexibility can clinicians employ in their approach? Various outcome measures were compared for a range of CBT-based group interventions at an eating disorders service, spanning a 10 year period. Since 2002, the groups have evolved in their structures and content. A stand-alone 18-session CBT group developed into a stepped care model of varying formats; 12 sessions GSH followed by 18 sessions CBT, 8 sessions GSH with 18 sessions CBT, and finally 8 sessions GSH with 15 sessions CBT. GSH groups were CBT based and relatively high input, therefore follow-on CBT groups were made more similar to modified DBT. Changes in structure were made iteratively, following reflection and planning during a multidisciplinary “BED meeting”, in response to changes in staffing, referral rates, and waiting times. Guided self-help always used ‘Overcoming Binge Eating’ (Fairburn, 1995), and there were changes in emphasis to CBT group protocols depending on emerging literature, and staff experience with different CBT approaches (for instance, metacognitive, DBT, compassion focused). The research aimed to compare outcomes of groups varying in structure and content. Routine pre-treatment and post-treatment outcome evaluation data was collected over the past 10 years using various questionnaires, including the Hospital Anxiety and Depression Scale (HADS), the Bulimic Investigatory Test Edinburgh (BITE) and the Eating Disorder Examination Questionnaire (EDE-Q). Data was available from 7 GSH and 7 CBT groups. Pre-treatment measures were collected at the start of the first group, and post-treatment measures at the final session attended in the BED treatment pathway (i.e. pre-GSH and post CBT for those following both steps). Data were compared using descriptive statistics and paired sample t-tests. Data are not directly comparable due to changes in routine outcome evaluation. Follow-up data would have allowed longer-term effects to be considered, and it would have been interesting to see how dropout rates have changed. Nevertheless, the research suggests that post-treatment outcomes were similar in spite of changes to the group style and format. There is suggestive evidence of improvement in efficiency. Post-treatment outcomes for each of the groups were approximately equivalent, showing improvements in binge frequency, global EDE-Q score, BITE symptom and severity, HADS anxiety and depression, compared with pre-group scores. Dropout rates for recent groups are presented. Two years after the first of the shortened 8-session GSH groups, the mean waiting time between assessment and offer of a place in the group has decreased by approximately half. The research suggests that a range of styles and formats of CBT-based intervention, including GSH, can be used with Binge Eating Disorder to good effect. The different outline group session plans, plus other changes, such as weekly/fortnightly, approach to self-monitoring (including weighing) and homework tasks, and choice of outcome measure will be presented along with their rationales, to enable comparison of routine practises within our services and across services.

What does complex mean? Therapist’s descriptions of the factors contributing to complexity in clinical presentations in CBT Thomas Reeves, Northumberland, Tyne and Wear NHS Foundation Trust; Thomas Reeves, Northumberland, Tyne and Wear NHS Foundation Trust “Complex” is a term often used in clinical practice when describing individual cases and clinical populations who may pose a challenge in therapy. There would appear to be a remarkable lack of research into the concept of complexity, yet if asked most clinicians would be able to list factors which contribute to complexity. This study aimed to do just this. This study utilised a Delphi Method with a small group (n =12) of highly experienced CBT researchers, trainers, writers and practitioners. Three rounds of questionnaires were completed by participants via a web based survey tool. The first round questionnaire asked the participants to identify in a way in which they felt most appropriate an initial list of factors. Thematic analysis was employed in order to develop an initial list of factors identified by participants. This list was refined / modified by the participants in the subsequent two rounds with the aim of working toward a consensus. This study whilst not providing a definitive description of factors associated with complexity does identify a number of disorder specific and transdiagnostic factors which were consistently endorsed by the majority of participants in the study. This information with further refinement may provide a valuable resource of information for developing greater clarity and shared understandings of complexity. With further research and refinement it may also help in service development, in terms of clarity of referral criteria, better access for patients i.e. the right treatment at the right time and the better recruitment and training staff. Over the course of the study the factors were refined and several were consistently endorsed by the participants, however no factor received 100% endorsement. There were 10 factors identified and endorsed by a majority of participants in the final round.

How can psychological therapy help young people with complex mental health difficulties improve their well-being and sense of self? A study of the clients’ views. Sara Melo, The University of Birmingham; Michael Larkin, The University of Birmingham Objectives: To understand how helpful young people find psychological therapy, and the impact that therapy may have on how they see themselves and the future. Design: Studies investigating the Self-Determination Theory (SDT) have found that when people identify goals which are in line with their self values and interests, they are also more likely to strive towards attaining them, and to experience higher well-being (Sheldon & Elliot, 1999). It has further been suggested (Sheldon et al., 2001; Epstein, 1973) that individuals experiencing a mental health problem will have their fundamental needs unmet. Thus, it seems pertinent to investigate whether young people who have been in receipt of psychological treatment are aware of having any self-motivated goals, and how meeting these goals may relate to their wellbeing (Sheldon & Elliot, 1999). However, all of the existing studies in this field have employed a quantitative method of analysis, and so lack insight into the personal significance of the theory. A

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qualitative method was therefore chosen in the present study, based on the underlying aims, whereby the experience and perspective of young clients is being investigated. Methods: 7 service-users (aged 16-19 years old) who were in receipt of psychological therapy from Birmingham services took part in an interview about their experiences of therapy. The data was transcribed and analysed using the Interpretative Phenomenological Analysis (IPA). Data analysis is still underway. However, our preliminary findings seem to highlight common themes regarding the difficult engagement of young people with complex mental health difficulties with mental health services and the importance of tailoring clinical practice to their individual psychological needs. Results: Data analysis is still underway. Several themes have been extracted from the interviews, with some service provision recommendations being put forward. Being a client-centred project, our findings will shed some light into how young people with complex mental health difficulties experience CBT therapy and other types of therapy. It will highlight some common difficulties in the engagement and in the active involvement of these young clients into therapy, as well as provide some insights into what has been experienced as helpful ways of addressing such difficulties.

Cognitive Processes in Obsessional Disorders Chair: Adam Radomsky, Concordia University, Canada

An Experimental Study of Self-Focused Attention and Appearance Related Comparisons in Body Dysmorphic Disorder Mark Turner, Institute of Psychiatry; Martin Anson, Institute of Psychiatry; David Veale, Institute of Psychiatry Body Dysmorphic Disorder (BDD). BDD is defined as a preoccupation with an imagined or slight defect in appearance, resulting in significant distress and impairment in daily functioning (American Psychiatric Association [APA], 2000). People with BDD report that they frequently compare their appearance to others and it can become a time consuming behaviour (e.g. Phillips 2005; Phillips & Diaz, 1997). Theories of body image disturbance propose that appearance comparison is a core factor in the development and maintenance of distorted body image (e.g. Stormer and Thompson, 1996; Cash, 1997). There is currently no research on the function (i.e. why) people with BDD engage in appearance-related comparing. People without BDD, when comparing, rate their own appearance more favourably and that of others less favourably under conditions of self-focused attention (Schwinghammer, Stapel, & Blanton 2006). This finding suggests the presence of a self-serving appearance-related comparing bias in people without BDD. Data will be presented from research conducted with individuals with BDD and healthy controls that had two clear aims. The first aim was to investigate the hypothesis that people with BDD do not hold the self-serving appearance-related comparing bias that is seen in the general population. This was addressed using an experimental design including appearance-related information (pictures of faces) with a manipulation of self-focused attention. The second aim was to investigate the functions of making appearance-related comparisons in people with and without BDD. This was addressed using a newly-designed measure of the functions of appearance-related comparing. TBC unknown (05/03/12) Treatment implications will be discussed with a focus on maintenance factors of distress in BDD.

A qualitative study of the investigation of reassurance seeking in obsessive–compulsive disorder Osamu Kobori, Chiba University; Paul Salkovskis, University of Bath; Julie Read, King' College London, Institute of Psychiatry; Naima Lounes, Salomons, Canterbury Christ Church University; Vivien Wong, University College London Reassurance seeking is a common problem in clinically anxious populations, and is particularly obvious in obsessive-compulsive disorder (OCD). This study seeks to examine the way individuals with OCD try to seek reassurance and the perceived consequences of such reassurance seeking using a qualitative analysis of the perspectives of individuals with OCD who seek reassurance from other people. A semi-structured interview was employed to ask individuals with OCD to reflect on occasions when they sought reassurance, and its impact on themselves and others. Ten interviews were conducted, transcribed and analysed in detail using thematic analysis. Main results suggest that the reduction of uncertainty is a key perceived motivation for reassurance seeking in OCD. Sufferers attempt to ensure the validity of reassurance whilst they frequently seek to minimise the negative impact of reassurance seeking and the linked interpersonal problems. Four overarching themes were identified in terms of reassurance seeking; interrogating feelings to achieve a sense of certainty, ceaseless and careful effort, reluctance to seek reassurance, and interpersonal concern. A thematic map was produced to understand the relationship between themes and sub-themes. This study enables us to understand why and how individuals with OCD seek reassurance, and the consequences of reassurance seeking both to the sufferers and carers.

The Use of 'Mental Shields' to Protect from Mental Contamination in OCD Anna Coughtrey, Reading University; Roz Shafran, Reading University; Jack Rachman, University of British Columbia Patients with Obsessive Compulsive Disorder (OCD) often decribe a fear of contamination that arises in the absence of physical contact with a contaminant. This experience of mental contamination leads to intense feeligns of internal dirtiness and results in a number of compulsive behaviours including washing to neutralise the negative feelings and prevent future contamination. This presentation will describe a case of mental contamination in a young woman with OCD who developed a 'mental shield' to protect herself from future harm. It will focus on the features of this mental shield in the presenting problems and the impact on cognitive behavioural therapy (CBT) for OCD. The implications of these findings for examining safety behaviours in OCD will be discussed. In particular, future research is needed to explore the use of mental shields in other cases of mental contamination. Treatment involved 12 sessions of CBT following which the woman no longer met the diagnostic criteria for mental contamination or any mental health problem. These gains were maintained at 3 and 6 month follow up.

Investigating the Three Pathways Theory: Inducing Contamination Fears Eva Zysk, University of Reading; Prof. Roz Shafran; Dr. Tim Williams Extensive evidence supports the influence of Rachman’s (1977) learning pathways in the acquisition of fears and phobias, but their role has been largely overlooked in the context of contamination fears. This prospective study investigates whether, and to what extent, contamination fears can be induced following a direct negative, vicarious, or learning experience. Participants from a community sample (N = 75) reported their fear cognitions after being shown an unspecified dark liquid and being told the study would involve touching the substance. A behavioural approach task (BAT) was used to determine how close participants could get to the substance. Each participant was randomly assigned to one of three conditions. Those in the direct condition were asked to open the jar and look at the substance which exposed them to an offensive smell. The vicarious condition involved participants observing the researcher acting fearfully towards and using antiseptic wipes

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following handling the substance. Participants in the informational condition read that the substance was an agar growth medium for bacteria which was only to be handled with precaution by trained lab personnel in accordance with biohazard procedures. Fear cognition measures and a BAT were repeated to examine the influence of each of the proposed pathways in inducing fear and avoidance towards the substance. Findings lend support to the role of the learning pathways in the acquisition of contamination fears.

Cognitions in Suicidality, Psychosis and Cancer Chair: Catherine Crane, Oxford Mindfulness Centre, University of Oxford

Dynamics of self-esteem in ‘Poor-me’ and ‘Bad-me’ paranoia Alisa Udachina, University of Sheffield; Filippo Varese, University of Manchester; Richard Bentall, University of Liverpool; Margreet Oorschot, University of Maastricht; Inez Myin-Germeys, University of Maastricht The study investigated (i) stability of beliefs about deservedness or persecution in paranoid patients and (ii) dynamics of self-esteem and paranoia in subgroups of paranoid patients and in healthy controls. Forty-one patients with past or current paranoia and 23 healthy controls completed a battery of questionnaires and the Experience Sampling Method – a structured diary technique which allows the assessment of symptoms, mood and behaviour in the context of daily life. For some analyses, patients were further divided into 3 groups: (i) individuals who believed that persecution is underserved (‘Poor-me’; PM), (ii) individuals who believed that persecution is justified (‘Bad-me’; BM) and (iii) remitted patients. Our results suggest that paranoia can serve a defensive function in some circumstances. It is likely that previous inconsistencies in psychological research in relation to paranoia might be explained by failure to account for deservedness of persecution and disregard for the dynamic nature of paranoid process. Most patients initially classified as PM and BM tended to maintain this position over the study period (6 days), although a few changed their stance. PM, and especially BM patients, had highly unstable psychological profiles. BM beliefs were associated with low self-esteem and depression. Measured concurrently, paranoia predicted lower self-esteem in the BM patients. Prospectively, paranoia predicted lower subsequent self-esteem in BM patients but higher subsequent self-esteem in PM patients. The results highlight the importance of assessment of deservedness beliefs in clinical practice and suggest that both BM and PM patients may benefit from interventions aimed at improving self-esteem.

Suicide Schemas in Non-Affective Psychosis Daniel Pratt, University of Manchester; Patricia Gooding, University of Manchester; Kate Sheehy, University of Manchester; Nicholas Tarrier, King's College London Suicide is the leading cause of premature death among individuals experiencing psychosis. The risk of suicide is proposed to increase with a greater potential for activation of suicide related schemas. Empirical representations of suicide schemas were compared between individuals experiencing non-affective psychosis, with and without a history of suicidal behaviour. Employing a cross-sectional between-groups comparison design, 84 participants, previously diagnosed with a non-affective psychotic disorder, were recruited from community mental health services. Participants completed a demographic questionnaire and clinical measures of psychopathology. To assess participants’ suicide schemas, a series of direct and indirect cognitive tasks were designed and administered. Pathfinder analysis enabled the construction of empirically derived representations of the groups’ suicide schemas based on responses to the cognitive tasks. Findings are discussed in relation to current models of suicide, and clinical and theoretical implications of the study are addressed, particularly pertaining to the therapeutic potential for preventing suicidal behaviour amongst individuals experiencing psychosis. The suicide group achieved significantly greater scores on measures of anxiety, depression, hopelessness and suicidality than the non-suicide group, but not on measures indicative of the severity of psychosis. The suicide schema for the suicide group was more elaborate and extensive than for the non-suicide group, even when clinical measures were taken into account. To be able to develop viable, specific psychological treatments for suicidality, a better understanding is required of the key psychological processes underlying suicidal behaviour. The current study highlights the Schematic Appraisal Model of Suicide to show considerable promise, both theoretically and clinically.

Trajectories of Suicidality in the Course of Major Depression Dhruvi Shah, Oxford Mindfulness Centre, University of Oxford The Differential Activation Theory of suicide suggests that once suicidality has occurred during one episode of depression it is highly likely to recur, when depression recurs. However, paradoxically, although depression recurs, for some people their suicidality may stop. Few studies have addressed the psychological factors associated with resolution or persistence of suicidality within recurrent depression but some research has shown pre-adult onset of depression and suicidality can have particularly toxic consequences. For this thesis, baseline data was obtained from the assessments of a large randomised clinical trial in major depression and in particular a novel method of using timeline data was used to explore each individual’s life history. This data was examined for the presence of sub-groups within those who have been previously depressed based on their history of suicidality. The overall aims of this thesis were to investigate whether distinct suicidal groups, characterised by different patterns of recurrence of suicidality, could be identified within a sample of participants who all had recurrent major depression. If these specific groups existed within our sample, then a further aim was to compare the socio-demographic and clinical characteristics of each group to those who had never been suicidal. The trajectories of onset of depression and suicidality in adolescence were also explored. Results showed that although it was possible to identify resolved and unresolved groups, differences between the groups were limited. The unresolved group reported experiencing more intrusive suicidal thoughts and found suicidal thoughts more comforting. In regards to age of onset, more than half of the sample had an onset of depression during their adolescence. Those with an onset of suicidality in adolescence experienced a greater number of subsequent suicidal episodes. The presence of suicidality within the first episode of depression rendered individuals more vulnerable to experiencing further suicidal episodes in the future. Intervention, prevention and assessment of suicidality should take into consideration onset of depression and suicidality as well as whether suicidality was present in initial depressive episodes, levels of comfort obtained from suicidal thoughts and how intrusive suicidal thought are.

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Cognitive pathways to depression: the role of reflection and modes of processing Kate Brennan, Oxford Mindfulness Centre, University of Oxford; Crane, C., Duggan, D., Barnhofer, T., & Williams, J. M. G. Ruminative thinking is strongly implicated in the onset, persistence and severity of depressive symptoms (Just and Alloy, 1997; Nolen-Hoeksema and Morrow, 1991). However other, less evaluative, forms of self-focused thinking that involve active problem-solving aimed at understanding or overcoming one’s problems are generally considered less maladaptive. Consistent with this, research has indicated that the reflective pondering subscale of the Response Style Scale is associated with adaptive forms of coping, is unrelated to cognitive biases, and is less consistently associated with concurrent and longitudinal depressive symptoms when compared with other forms of rumination (Burwell and Shirk, 2007; Joorman et al., 2006; Treynor et al., 2003). However, more recent theories of self-focused attention and processing modes suggest that cognitive problem-solving of this sort may have negative outcomes for some individuals – motivated by this research, and recent studies indicating an association between reflection and suicidal ideation, the aim of this study was to investigate the psychological conditions under which reflection may be an adaptive, constructive process or a maladaptive response style associated with more depression. Levels of mindfulness and memory specificity were proposed as potential moderators of the relationship between reflective thinking and depressive symptoms and the study set out to investigate whether there was an effect of these variables on this relationship. Cross-sectional data was collected from 276 participants, consisting of previously depressed individuals recruited as part of the Staying Well after Depression randomized trial. Participant’s levels of reflective rumination were measured using the Ruminative Response Scale of the Response Style Questionnaire (RRS; Treynor et al., 2003), dispositional mindfulness was measured using the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006) and the Autobiographical Memory Test (AMT; Williams and Broadbent, 1986) was administered to assess participant’s ability to recall specific memories of events in their lives. Depressive symptoms were recorded using the Beck Depression Inventory (BDI-II; Beck et al., 1987) Regression analyses were conducted to explore the relationship between reflection and depression across levels of memory specificity (AMT) and mindfulness (FFMQ), examining the conditions under which reflection might predict higher levels of depressive symptoms. Results indicated that for a particular group - those participants low in both mindfulness and memory specificity - higher levels of reflection are related to more depressive symptoms. This suggests perhaps that, unlike other forms of rumination which are inherently negative, reflection may represent a response to depressed mood that is susceptible to the effect of individual state or trait processing. The cognitive problem-solving aspect of reflection may be hampered under conditions of unspecific, abstract processing and a mind tending toward self-judgment and reactivity. The findings suggest that reflection cannot be assumed to be a benign or helpful process. While supporting the idea that reflective techniques, in the context of the psychotherapeutic process for example, can be a useful tool for generating solutions or insight this study highlights the importance of the ways in which they are employed. If an individual is supported to be concrete and specific in the creation of solutions, while mindful of their reactions to the thoughts and emotions being reflected on, this study would suggest that there would be no increase symptoms among individuals engaging in such a process. However for vulnerable individuals– perhaps those already showing symptoms of depression–this may be an unconstructive means of attempting to resolve the low mood. Exploring the cognitions and behaviours associated with vasomotor symptoms (hot flushes and night sweats) in men with prostate cancer undergoing hormone treatment Chinea Eziefula, Institute of Psychiatry, King's College London; Myra Hunter, Institute of Psychiatry, King's College London Prostate cancer has the highest diagnostic incidence of all cancers in males in the United Kingdom (Cancer Research UK, 2010) and in wider Europe. Standard treatments for prostate cancer include radical treatments such as radical prostatectomy (surgical removal of the prostate), radical radiotherapy and hormone therapy. Current hormone therapies reduce androgenic activity, principally testosterone, via interference with the cycle of androgen production. Hormone treatments have been found to be associated with reduction in disease progression and increases in survival advantage however, they are associated with extreme side effects. Hot flushes are one of the main reported symptoms of hormone treatment; some men treated for prostate cancer report that hot flushes are the most distressing side effect of treatment and some have been found to discontinue their hormone treatments due to frequent hot flushes that are judged to be debilitating. The experiences of hot flushes and night sweats (HF/NS) in healthy women going through the menopause and women with cancer are well-documented. Psychological measures such as the Hot Flush Belief Scale (Rendall et al., 2008) and the Hot Flush Behaviour Scale (Hunter et al., in press) have been developed along with psychological interventions, such as Cognitive-Behavioural Therapy (CBT) derived from a cognitive model for menopausal hot flushes (Hunter and Mann, 2010), which are viable alternatives or adjunctive treatments to pharmacological methods for managing these symptoms. There is currently little research considering the experiences of men with prostate cancer who have these symptoms. Thus, this study involves a preliminary qualitative exploration of HF/NS cognitive appraisals and behavioural reactions reported by a sample of these men using semi-structured, in-depth interviews that draw upon existing experiences as reported by women and the lesser documented experiences reported by men. There are cultural differences in the incidence of prostate cancer, with preponderance towards Afro-Caribbean men, whereby knowledge of the disease in this group differs to that of Caucasian men. Disease knowledge is associated with perceptions of risk and subsequent help-seeking behaviours in prostate cancer, thus, an area for further research is an exploration of whether or not these differences in this population of men with prostate cancer have an effect on the reporting, perceptions and experiences of HF/NS. Therefore this study includes men of African and Caribbean descent as well as Caucasian men in order to consider any differences that may exist in male experiences when considering ethnicity and to add strength to the range of experiences generated. On the basis of the cognitive-behavioural experiences generated from this qualitative exploration, a list of cognitive-behavioural items was generated which will be used in later research to construct questionnaire measures of HF/NS in men with prostate cancer and inform cognitive-behavioural interventions in these men. No such measures or interventions for HF/NS exist for this population. A qualitative research methodology was undertaken to explore men's cognitive appraisals and behavioural reactions to HF/NS. This study includes in-depth interviews, lasting for approximately 60-minutes, with 19 men with prostate cancer (age range: 45-84) who were undergoing hormone treatment at the time of interview. The sample includes 15 Caucasian men and 3 Afro-Caribbean men and interviews followed a semi-structured format, guided by an interview schedule adapted from Rendall et al. (2008). The schedule consisted of open-ended questions framing the topics to be discussed around a flexible structure that was responsive to emergent issues that were relevant and important to participants. All interviews were audio-recorded and then transcribed in verbatim. Analysis for cognitive-behavioural themes was conducted using framework analysis (Ritchie and Spencer, 1994), an analytic approach originally designed for applied social policy research which has a systematic and well-defined procedure for organising and categorising material according to relevant themes. The cognitive appraisals and behavioural reactions reported by men with prostate cancer who

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experience HF/NS as a result of the side effects of hormone treatments to treat their cancer fall into cognitive-behavioural themes that are similar to that of women, however there are clear distinctions that are associated with beliefs that HF/NS are commonly associated with women rather than men and beliefs about the effects of the hormone treatment their masculinity. Men from different ethnic backgrounds reported similar experiences and possible pathways were identified between particular categories of cognitions (e.g. control cognitions) and what could be considered more or less "helpful" behavioural reactions, as well as the perceived severity of HF/NS. Thus, in this preliminary investigation of the cognitions and behaviours reported in this population, it seems that there are common cognitive-behavioural themes; the data from this study could be used to devise a questionnaire-measure to explore and possibly standardise these thematic categories in a larger sample of men with prostate cancer who have HF/NS as a result of hormone treatment. Emergent cognitive-behavioural themes showed some similarities but clear distinctions from that of women with HF/NS. Men with prostate cancer reported experiences of shame and embarrassment, whereby these feelings were associated with beliefs about being perceived as ill, unwell or weak. They had beliefs about HF/NS being more commonly associated with women and beliefs about the impact of the hormone treatment on their masculinity and traditional gender roles; this was also in relation to other side effects of the hormone treatment (e.g. fluctuations in mood, loss of libido). Men also had control beliefs related to HF/NS that were associated with the fatal consequences of not continuing with the treatment. Control beliefs had either negative or positive effects on subsequent behavioural strategies for coping with flushes, i.e. acceptance of flushes as part of life, leading to coping strategies such as relaxing and allowing flushes to pass, versus frustration and resignation leading to reactions such as avoidance of daily activities and social withdrawal. Acceptance was associated with less problematic flushes, whereas frustration and resignation was associated with more problematic flushes. There was variability among men in the use of behavioural strategies that are associated with help-seeking and in their knowledge about the causes of their hot flushes; the experiences of Afro-Caribbean and Caucasian men fell into similar cognitive-behavioural categories. This preliminary study is illustrative of the way in which a cognitive-behavioural framework that informs cognitive-behavioural treatment in one population could be extended to encompass another population with similar difficulties. The cognitive-behavioural themes generated from this study illustrate that men with HF/NS demonstrate associations between affect, cognitions and behaviours; for those men who have particularly problematic HF/NS, such associations could be addressed with the cognitive-behavioural interventions that are currently used in women with such symptoms.

Panel Discussion

How Does CBT Work? Mechanisms of Change 'Across the Waves’ Convenor: Warren Mansell, University of Manchester Chair: Adam Radomsky, Concordia University, Canada Speakers: Tim Carey, Flinders University, Australia; Kelly Wilson, University of Mississippi, USA; Paul Salkovskis, University of

Bath; Iris Engelhard, Utrecht University, Netherlands

Several decades of evidence indicate that CBT is associated with significant improvements in clinical and functional outcomes that persist over several years in a large proportion of clients. Controlled trials indicated that CBT is typically superior to medication and ‘non-bona’ fide placebo therapies. However, the relative efficacy of CBT is inconsistent when compared to a wide variety bona-fide therapies and seems to depend on a variety of factors such as the disorder presentation, outcome measure and service context. Moreover, findings are mixed when comparing the efficacy of different forms of CBT - behaviour therapy, cognitive therapy and ‘third-wave’ therapies. None is clearly superior across all contexts. These findings make it increasingly important to explain and justify the mechanism of change in CBT, especially in an increasingly competitive environment for commissioners of psychological interventions. Is the mechanism of change specific to CBT? Or does CBT target change mechanisms that overlap across the different forms of CBT and in common with other effective therapies? What is this mechanism? Can we enhance it more efficiently in the future? In order to address the above question, we are convening a range of international experts on the mechanisms of action in CBT, taken from diverse theoretical backgrounds. Adam Radomsky (Concordia University, Canada) whose recent innovative work on the judicious use if safety behaviours in CBT has challenged recent assumptions, will be chairing the discussion. Iris Engelhard (Utrecht University, Netherlands) will be proposing that behavioural conditioning can account for change in CBT. Kelly Wilson (University of Mississipi, USA) will present a ‘third-wave’ behavioural account based on functional contextualism. Paul Salkovskis (University of Bath, UK) will propose a cognitive account of the change mechanism. Tim Carey (Centre for Remote Health; Darwin & Flinders University, Australia) will present an account of change based on a self-regulatory framework known as perceptual control theory.The panel discussion will have several aims. First, each speaker will provide a brief overview and justification for their proposed mechanism of change. Second, the speakers will debate with one another on the relative merits and shortcomings of the different accounts. Third, the discussion will open up to the audience for their contribution, questions and comments. Fourth, we will raise the question of whether any of the accounts can be integrated with one another. Finally, the audience will be asked to express their preference for the different (potentially modified or integrated by this point) accounts by a show of hands. Ultimately, we hope that the discussion provides thought-provoking ideas for the audience that they can apply to clinical practice, training, service organisation, research and future technical developments in CBT.

Posters Validation of the Behavioural Activation for Depression Scale in a clinically depressed primary care sample Helen Mander, University of Hull Behavioural Activation (BA)theory proposes that depression is maintained through high levels of avoidance and low levels of reinforcing activity. Recent developments in BA have emphasised the importance of defining behaviour within a functional context (Martell et al, 2001). The Behavioural Activation for Depression Scale (BADS, Kanter et al, 2009) assesses functionally defined categories of behaviour. The BADS has not yet been validated with a clinically depressed, help-seeking sample. Thirty adults with depression were recruited through primary care. Participants (age: 46.03 yrs, 67% female) completed the BADS, along with measures of depressive symptoms, cognitive and behavioural variables. The current study provides support for a pattern of behaviour consistent with behavioural activation theory in a clinically depressed, primary care sample. Elevated levels of avoidance and impairment and lower levels of activity were observed in comparison to

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previous findings in a non-clinical sample (Kanter et al, 2009). A high level of internal consistency was observed within BADS subscales (alpha =0.69 – 0.88). Score on BADS was negatively associated with depressive severity (r=-.56, p<0.01), with frequency of negative automatic thoughts (r=-.75, p<0.01), with rumination (RSQ, r= -.42, p<0.05) and with mental wellbeing (r=.71, p<0.01) and positively associated with metacognitive awareness (r=.54, p<0.01) and with acceptance (r=.68, p<0.01). Only metacognitive awareness significantly predicted later depression severity (r=.60, p<0.5), accounting for 36% of the variance. The BADS may provide a useful measure of BA as potential target for treatment in depression. Further research is necessary in order to determine its re-test reliability and sensitivity to change. The bi-directionality hypothesis: Are clinical constructs both causes and effects of symptoms? Frances Meeten, Graham Davey, Frances Meeten, Georgina Barnes, Suzanne Dash, University of Sussex Clinical constructs provide a way of conceptualising and understanding clusters of patient reported symptoms and clinical observations; they are often used to infer a particular psychological state or specific cognitive pattern. Examples of commonly used psychological constructs in the area of anxiety disorders include intolerance of uncertainty (Dugas, Gagnon, Ladouceur, & Freeston, 1998) and inflated responsibility (Salkovskis, 1985), and these constructs allow a shared understanding of psychopathology symptoms and are often the basis for developing interventions. Displaying a particular cognitive style (or clinical construct) is often causally associated with subsequent symptoms – and this causality has been demonstrated in experimental studies that have manipulated constructs and looked at this effect on anxiety-based symptoms (e.g. Ladouceur, Gosselin, & Dugas, 2000; Startup & Davey, 2003). However, because constructs might cause symptoms in experimental studies does not necessarily mean that they explain them, especially when studies have only rarely investigated causal relationships in the opposite direction (e.g. checking influencing doubting (Randomsky & Alcolado, 2010; van den Hout & Kint, 2003) and worrying influencing negative affect (Buhr & Dugas, 2009; Johnston & Davey, 1997). The present studies sought to examine the possibility of a bi-directional relationship between symptoms and constructs relating to obsessive compulsive disorder. Both study 1 & 2 used an analogue population and manipulated obsessive thinking by asking participants to read and write obsessive or neutral statements. . In study 2 the high and low obsession groups were split into self-referent and non-referent conditions, where participants in the self-referent group had to imagine the obsessive thought relating directly to themselves. We conclude that many clinical constructs may simply be convenient redescriptions of symptoms rather than causal explanations of them. . In study 1 those in the high obsession group reported a significantly greater increase on construct measures of responsibility and thought action fusion as compared to the low obsession group. In study 2 those in the high obsession self-referent group reported significantly higher ratings on OCD relevant constructs as compared to the high obsession non self-referent group. This research indicates that the manipulation of clinical constructs will affect psychopathology symptoms. CBT may usefully target construct manipulation to decrease, for example, feelings of responsibility or intolerance of uncertainty, to further target symptom reduction. The availability and specificity of autobiographical memory recall in bipolar disorder Robert Dempsey, and Robert Dempsey, University of Bradford; Patricia Gooding, University of Manchester, Steven Jones, Spectrum Centre for Mental Health Research, Lancaster University Tendencies to recall generalised descriptions of autobiographical memories have been associated with the experience of major depressive disorder and suicidality, and have been highlighted as a marker of poorer health outcomes in clinical samples. Whilst preliminary research has suggested that individuals with bipolar disorders may possess a similar overgeneral bias, many of these studies have been associated with methodological issues in their assessment of autobiographical memory. A sample of 18 individuals in remission from bipolar disorder, and 18 age and gender-matched non-bipolar participants, completed the cued-memory Autobiographical Memory Test and a series of self-report measures, with the specificity and speed of memory recall compared between groups. Although bipolar disorder may be associated with an overgeneral recall bias, the fast recall of specifically detailed negative memories may result from more direct automatic retrieval processes which are unavoidable and not subject to emotional suppression. This ready access to specific negative memories would be important to target clinically, particularly as specific negative memories are associated with the recall of sensory-perceptual information and may prime dysfunctional emotion regulation and coping strategies which may contribute to mood lability and increases in mood symptoms. Although this research supports the notion of an overgeneral recall bias in bipolar disorder, there is also a clear need for further refinement of psychological theories of bipolar affective illness. Whilst individuals in remission from with bipolar disorder demonstrated more extreme overgenerality on the AMT, the bipolar participants were also significantly faster to retrieve specifically detailed negative autobiographical memories compared to the controls. This talk highlights two issues: (i) a lack of research into the basic processes underlying bipolar affective illness, such as autobiographical memory, and (ii) the relative lack of adequate psychological models for bipolar disorder relating to the underlying psychology of bipolar disorder and the processes implicated in symptom exacerbation. Research into autobiographical memory has the potential to inform better designed and targeted psychotherapies, particularly as there is evidence that overgeneral memory recall is associated with poorer health outcomes in depressed patient samples, that the severity overgeneral memory is predictive of poorer responses to medication and ECT, and that overgenerality can be modified through cognitive behavioural therapies. Individualised Recovery Focused Care Packages within an Anxiety Disorders Program Debbie van Tonder, Martha Ryan, Judy Moran, Michael McDonough, St Patricks' University Hospital This poster aims to communicate the complex interaction and synergy between the CBT Scientist Practitioner (SP) and the Recovery model (1) applied to an Individual Service User’s (ISU) journey on the Anxiety Disorders Program (ADP) at SPUH according to the Mental Health Commission’s Quality Framework standards(2) and Mental Health Act statutory requirements. The mission of the program is to deliver a CBT evidence based program to a complex group in a compassionate environment. Introduction of a structured, systematic three tier assessment process after initial referral. Comprehensive end treatment report of therapeutic process issued to service user and consultant indicating stage of recovery and recommendations for future recovery pathways. The therapeutic journey through the program of a sample patient is plotted in relation to the spectrum and illustrates how individualized CBT centred care packages are designed, measured and evaluated within a group environment that are recovery focused. Capturing routine outcomes measures and disorder specific measures at three stages. Collaborative weekly review of case conceptualisation(3) with service user linking with recovery process, Qualitative feedback and Routine outcomes measures available for auditing and analysis of efficacy of the program and needs for development. Evidence that there is real synergy between the CBT scientist practitioner and the philosophy of recovery, that the two elements are cohesive. Having a three tier assessment process adds value to the client's group experience as well as to the evidence base of the effectiveness of group CBT.

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Behavioural Medicine

Keynote Addresses

Chronic Pain: A Learning Theory Perspective Johan W.S. Vlaeyen, Research Group Health Psychology Katholieke Universiteit Leuven, Belgium and Department of Clinical Psychological Science Maastricht University, Maastricht, Netherlands Pain is a biologically relevant and vital signal of bodily threat, which urges the individual to protect him/herself (Eccleston and Crombez, 1999). Immediate protective responses to pain include increased arousal, attention to the sources of threat, and various safety-seeking behaviors including avoidance and escape. Despite this biologically hard-wired system, there are individual differences in how pain is interpreted as threat, and the expression of pain usually is dependent on social context variables and current goals (e.g. Vlaeyen et al., 2009). Also, learning takes place rapidly. In order to reduce the impact of pain, and to facilitate early and effective protection against bodily threat, previously neutral stimuli (interoceptive, proprioceptive or exteroceptieve) that somehow are causally related to the threat of pain can receive the propensity to elicit similar defensive responses as well (e.g. De Peuter et al., 2009). For example, a previously benign movement that was followed by severe shooting pain will now be avoided (Leeuw et al., 2007; Vlaeyen and Linton, 2000). Chronic disability may develop when the individual subsequently over generalizes the 'movement threat' knowledge, and starts to avoid various movements and activities, despite medical reassurance about rather innocent causes and the transient character of the pain. Three pathways exist through which such 'threat knowledge' and associated protective responses can develop: observation, verbal instruction, and direct experience. Once acquired, these knowledge representations remain stored in memory, and the extinction of protective responses can only occur through inhibitory processes. In this presentation, the underlying mechanisms of both the acquisition of pain-related fear responses, as well as the available cognitive-behavioral interventions to extinguish these fears will be reviewed. This will be done from an affective-motivational perspective.

Emotional Processing in the Context of Chronic Fatigue Syndrome and Implications for Treatment Trudie Chalder Department of Psychological Medicine, King’s College London Chronic fatigue syndrome (CFS) is characterised by severe fatigue and is associated with profound disability. Up to 75% of people with CFS have co-morbid psychological distress. We have shown that despite this overlap many patients hold the belief that it is unacceptable to either experience or express emotions (Rimes & Chalder 2010). Other researchers have shown that CFS patients are more likely than controls to report childhood trauma (Heim et al 2009). It seems highly likely that these strands of research are linked. The purpose of this lecture is to describe our ongoing research into emotional processing and to make some suggestions as to how these emotional difficulties may be addressed. These suggestions may be useful for a range of disorders.

Symposia

Long-Term Conditions: Investigation of CBT Approaches Convenor: Kate Rimes, Department of Psychology, University of Bath

The role of psychological processes in depression and distress in Parkinson's disease Camille Julien, Barts and The London NHS Trust and Institute of Psychiatry, King's College London; Katherine Rimes, University of Bath; Richard Brown, Institute of Psychiatry, King's College London Background: Rates of reported depressive symptoms in Parkinson’s disease (PD) are elevated compared to those in the general population. The contribution of psychological factors to depression and distress in PD remains unclear. Several Randomized Clinical Trials of CBT for depression in PD are underway but to date little research has investigated whether the psychological processes underpinning cognitive models of depression apply in patients with PD. Aims: To test the hypothesis that a range of core psychological factors related to cognitive and health psychology models of depression are significantly associated with reported rates of current depressive symptoms and distress and significantly predict rates of depression and distress at four months follow-up, over and above the contribution of functional disability. Method: At baseline assessment, 104 participants with PD completed validated questionnaires that measured their mood, level of functional disability and a range of psychological variables, including dysfunctional assumptions, rumination, cognitive behavioural avoidance, illness representations and cognitive behavioural responses to symptoms. Seventy-three participants also completed the same measures at four months follow-up. Results: Regression analyses revealed that psychological factors account for a large amount of variance in both depression and distress, over and above that explained by functional disability. PD participants who reported high levels of rumination, cognitive-behavioural avoidance, symptom focusing and avoidance/resting in response to their PD symptoms experienced more severe depressive symptoms and were more likely to report syndromal depression. Rumination and perception of PD as having serious consequences emerged as significant cross-sectional predictors of PD specific distress. Psychological factors failed to significantly predict longitudinal change in depression severity when baseline rates of depression were taken into account. By contrast, rumination significantly predicted change in the severity of PD specific distress at four-month follow-up, even when baseline distress was accounted for. Discussion: Cognitive and behavioural processes including rumination, avoidance and symptom focusing play a significant role in depression and distress in PD. The findings hold important implications for psychological models of depression in PD and enable further development of cognitive-behavioural interventions that are tailored to patients’ needs.

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A Multivariate Study to explore the involvement of Cognitive and Behavioural factors in Cancer-related Fatigue Sahil Suleman, Guy's & St Thomas' NHS Foundation Trust; Trudie Chalder, Institute of Psychiatry, King's College London; Kate Rimes, Department of Psychology, University of Bath Background & Aims: Fatigue is a highly prevalent and debilitating problem in women with breast cancer undergoing chemotherapy. It is becoming evident that psychological factors are more important than illness-related and treatment-related factors when seeking to understand the development and maintenance of cancer-related fatigue. This study investigated the cognitive behavioural, social and affective responses associated with cancer-related fatigue and related functional impairment. Method: 100 women diagnosed with breast cancer completed a range of measures. Correlational and multiple regression analyses were used to explore associations between fatigue severity, social adjustment, physical functioning and a range of psychological, social demographic and clinical variables. 33 patients completed measures prior to chemotherapy and were followed up prospectively to examine the relationship between psychosocial variables and fatigue and functional impairment as measured after three cycles of chemotherapy. Results: A range of cognitive, behavioural and affective variables were associated with increased fatigue severity, poorer social adjustment and increased physical impairment. Key cognitive behavioural correlates included increased embarrassment avoidance (cancer-related) cognitions, all-or-nothing behaviour, avoidance behaviour, health anxiety, unhelpful beliefs about negative emotions and perceptions of punishing responses from their significant other. Furthermore, exploratory analyses suggested that increased presence of maladaptive behaviours and unhelpful cognitions prior to chemotherapy predicted the presence of fatigue and functional impairment after three cycles of chemotherapy.Conclusions: In line with our hypotheses, endorsement of the majority of cognitive, behavioural and affective variables was associated with increased fatigue and functional impairment. Some of these variables also continued to predict fatigue and functional impairment over time. These findings make a significant contribution to a cognitive behavioural understanding of cancer-related fatigue and also point to particular factors that are amenable to change within the context of cognitive behavioural therapy approaches. Is health anxiety linked to disease-related disability in rheumatoid arthritis (RA)? Claire Goodchild, Institute of Psychiatry, King's College London; Nicole Tang, Arthritis Research UK Primary Care Centre, Keele University; Paul Salkovskis, Department of Psychology, University of Bath Background: The impact of RA on quality of life arises in large part from flares of pain, stiffness and fatigue and the interaction of these physical factors with psychological characteristics. Health anxiety is one such psychological factor that may play an important role in RA given the unpredictable nature of the disease. Health anxiety can be defined as the propensity to negatively interpret ambiguous bodily sensations that is associated with fear or excessive worry about illness. Health anxiety is yet to be investigated in RA, but recent research conducted with other chronic pain populations has identified health anxiety as a prevalent characteristic that is associated with pain interference, catastrophic thinking and sleep disturbance. The aim of this study was to assess the presence of health anxiety in RA and examine its relationship with a selection of disability-related variables. Method: Participants were 150 adults (aged 18-65 years) with established RA (diagnosis of >2 years). Participants’ perceptions of health anxiety were assessed using the Short Health Anxiety Inventory (SHAI, Salkovskis, Rime, Warwick, Clark, 2002). Disease-related measures included the Health Assessment Questionnaire (Kirwan & Reeback, 1986), International Physical Activity Questionnaire (IPAQ; Booth, 2000), Insomnia severity Index (ISI; Bastien, Vallières, Morin, 2001), Brief Pain Inventory (Cleeland, 1989), Profile of Fatigue (Bowman, Booth, Platts, 2004) and Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983). Findings: There were significant positive correlations between health anxiety and all measures of pain, interference, fatigue and distress. Participants were allocated to either the high or low health anxiety group according to their scores on the SHAI. Participants with high health anxiety reported significantly greater pain, interference, physical disability, fatigue, depression, anxiety and sleep disturbance than those with low health anxiety Discussion: The findings suggest that health anxiety may be involved in the development and maintenance of disability associated with RA. Targeting negative interpretations of symptoms during treatment may potentially alleviate disability and improve quality of life for those struggling to manage RA. Health anxiety, Multiple Sclerosis and perceived impairment Aimee Hayter, King's College London; Paul Salkovskis, University of Bath Multiple Sclerosis (MS) is a neurological condition with a variable disease course and disability prognosis. Neurological, psychological and sociological factors may contribute to the development of a range of co-morbid mental health difficulties such as depression and anxiety. The rate of anxiety in patients with MS is higher than the general population; however, there is a paucity of research into the prevalence of specific anxiety diagnoses, as well as cognitive factors maintaining anxiety in the MS population. Health anxiety remains one such anxiety disorder, with only one study reporting its point prevalence at 25 %. This study aimed to measure the rate of health anxiety in patients with Relapsing Remitting MS, as well as testing if level of health anxiety impacts patients’ quality of life, even when functional impairment (disability) is taken into account. It also aimed to identify two possible factors in the maintenance of health anxiety in patients with MS, according to the cognitive model of health anxiety: amplified perception of normal changes in body sensations, cognition and fatigue and the misattribution of bodily sensations, cognition and fatigue due to MS. Approximately 29 % of 84 patients sampled had high levels of health anxiety (pMS1, score 18 and above on the Health Anxiety Inventory (HAI). From this sample, pMS1 (n=21) reported lower quality of life than patients with low health anxiety (pMS2, n=21, HAI score of 10 and below), even when level of disability was held as a covariate of no interest. pMS1 were found to “amplify” bodily sensations and attribute common bodily sensations to somatic (MS) causes more than pMS2 and healthy control participants (HC). pMS1 also perceived their average performance on two cognitive tasks, and a hand grip task (endurance/fatigue measure) as worse and attributed their performance to MS more than pMS2. It was concluded that given the prevalence of health anxiety and its effect on quality of life, it may be important to offer therapy to MS patients with high levels of health anxiety which focuses on lowering amplification of benign changes and shifting causal attribution away from MS to more benign causes.

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Working with the Unfamiliar: Latest Perspectives on Medically Unexplained Syndrome Convenor: Nicole Tang, Keele University

The “good old days” bias and its correlates for adults with persistent postconcussional symptoms Seb Potter, South London & Maudsley NHS Foundation Trust; Lucie Herrmann, NHS Greater Glasgow and Clyde; Kate Rimes, University of Bath Persistent post-concussional symptoms (PCS) can be associated with significant ongoing difficulties for a minority of individuals after mild and moderate traumatic brain injury (TBI). Whilst early direct effects of brain injury on cognition are significant, they are typically expected to resolve by themselves: conversely, psychological variables have been proposed as playing a significant role where symptoms do persist (Lishman, 1988). However, specification and examination of these factors remains relatively under-developed. Research into potential psychological variables has identified the existence of a “good old days” bias: when individuals with persistent symptoms are asked to retrospectively estimate any similar symptoms that they had before an injury, they tend to report lower levels compared with the current symptom reports healthy adult controls (Mittenberg et al, 1992; Gunstad & Suhr, 2004). Early expectations and beliefs about injury and recovery may also influence improvement: scores on the Consequences and Timeline scales on the Revised Illness Perception Questionnaire (IPQ-R: Moss-Morris et al, 2002) at 1-3 weeks after injury predicted the presence of persistent symptoms after three months (Whittaker et al, 2007). The current study sought to explore the relationships between the “good old days” bias and these areas, alongside a number of other possible (psychological) variables of interest such as symptoms of depression and anxiety, aspects of perfectionism, litigation status, and dysfunctional beliefs about emotions (in particular, the unacceptability of experiencing or expressing negative emotions). 28 adults with persistent PCS (mean length of time since injury = 33 months) after mild-moderate TBI and 43 control participants completed a range of measures including both current and retrospective ratings of symptoms and other variables (where applicable). Whilst the control group also showed an attenuated “good old days” bias, the effect was more marked in the PCS group and present relative to both controls’ current and retrospective reports. There was no relationship between the PCS group’s retrospective PCS-like symptom ratings to current depression, anxiety or PTSD symptoms, suggesting that the “good old days” bias is not simply a function of more conventional, comorbid psychiatric symptoms. The only variable to correlate significantly with pre-injury symptom ratings was the Consequences scale from IPQ-R (r = 0.40). Correlations between the IPQ-R and current PCS were weaker, although significant relationships were noted between the IPQ-R and PCS-related psychosocial disability. Finally, scores on a measure of dysfunctional beliefs about emotions, the Beliefs about Emotions Scale (BES: Rimes & Chalder, 2010), originally developed for adults with Chronic Fatigue Syndrome, were elevated in the PCS group for both current and retrospective ratings, identifying it as a possible trait risk factor for persistent symptoms. These and other findings from the study will be discussed in terms of cognitive-behavioural approaches to managing and treating persistent PCS. From minor head injury to Post Concussion Syndrome: Does the Cognitive Behavioural Model provide the map? Rona Moss-Morris, Institute of Psychiatry, King's College London; Ruihua Hou, Robert Peveler, Antonio Belli, Brendan Bradley, Karin Mogg, University of Southampton Objective: A significant proportion (15-30%) of people presenting with a mild traumatic brain injury (MTBI) develop postconcussional syndrome (PCS). The aim of this study was to investigate the contributions of cognitive, emotional and behavioural factors to the development of PCS and identify early predictors, based on a proposed cognitive-behavioural model. Methods: In a prospective study, 126 MTBI patients completed baseline questionnaires within 2 weeks after injury assessing cognitive, behavioural and emotional responses to the acute MTBI. 107 of these patients completed follow-up assessments at 3 and 6 months. The primary outcome was the ICD-10 diagnosis for PCS. Individual and multivariate logistic regression analyses were used to detect early predictors of PCS. Results: 107 MTBI patients 24 (23%) met the criteria for PCS at 3 months, and 23 (22%) at 6 months. Individual logistic regression analysis indicated that negative perceptions of the MTBI, perceived stress, anxiety, depression, and all-or-nothing behaviour were associated with the onset of PCS. Multiple regression analysis revealed that all-or-nothing behaviour was the independent predictor for the onset of PCS at 3 months, while head injury perceptions predicted PCS at 6 months after injury. Discussion: In accordance with similar studies predicting the onset of chronic fatigue and irritable bowel syndrome post infection, cognitive, behavioural and emotional factors appear to be good predictors of PCS. These findings will discussed in terms of treatment models and early prevention targeting patients’ perceptions of their head injury and their behavioural responses to symptoms. Working with the unfamiliar in primary care: A qualitative study of GP trainees’ educational and clinical experience of medically unexplained symptoms Mary Howman, UCL; Marta Buszewicz, UCL; Kate Walters, UCL; Joe Rosenthal, UCL Introduction: Much of a GP’s workload consists of managing patients with medically unexplained symptoms (MUS). Competent management of such presentations can be complex, requiring clinical acumen and adept consultation skills to avoid unnecessary and potentially damaging investigation or referral. The focus of teaching at medical school is on medically explainable symptoms. There has been no qualitative work looking at the views of GP trainees on any prior teaching they have received about MUS or exploring their views on managing such presentations. Their experiences are key, as they are often taking responsibility for looking after people with MUS for the first time and so are ideally placed to reflect on this and the preparation they have had for it. Method: An interactive training session on MUS using video and case discussion was devised and delivered to four London GP vocational training schemes. The trainees were purposively sampled and invited to take part in in-depth interviews. Topics covered included: discussing the teaching they had previously had in this area, their experiences and attitudes towards managing MUS and their views on how the topic should be taught, including evaluation of the teaching session they received. Interviews were analysed using the framework approach. Results: Fifteen interviews were carried out with trainees at different stages of their vocational training. Trainees felt poorly prepared for managing MUS, receiving little teaching on the topic. They saw patients with MUS frequently and often discussed them with their trainers. Most participants described struggling to manage the uncertainty

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inherent in such consultations, feeling that they over-investigated or referred due to their lack of experience. Managing such presentations often engendered anxiety, frustration or a sense of being over-whelmed. Trainees were keen for more opportunities to discuss MUS and felt that more teaching on the topic was needed, although when this should occur was contentious. Conclusion: Managing MUS accounts for a large proportion of GP trainees’ workload and results in a disproportionate amount of anxiety. Their training needs to better reflect their clinical experience and so more teaching about MUS is needed. Working with the unfamiliar in secondary care: A qualitative study of how hospital doctors approach patients with medically unexplained symptoms and their views on training Alex Warner, Primary Care Mental Health Research Group, University College London; Marta Buszewicz, University College London; Kate Walters, University College London; Kethakie Sumathipala, University College London Introduction: Medically unexplained symptoms (MUS) are common and a cause of significant morbidity and high levels of service use in both primary and secondary care. Little is known about the attitudes of hospital specialists towards such patients, the strategies they may use in their management, or what training if any they may have received in this topic. Method: In-depth interviews have been conducted with 20 hospital consultants and doctors in training, purposively selected from physicians working at two hospitals in north London. Physicians working in cardiology, gastroenterology, neurology and rheumatology were approached, as there is evidence that many patients they see may not receive a clear organic diagnosis. Data were analysed via the framework approach to identify key issues, concepts and themes. Results: Key themes will be presented, focussing on two main areas: 1) Views of hospital specialists about patients presenting with MUS, their attitudes towards and experience of managing such patients, and their thoughts about working across the primary-secondary care interface in such cases. 2) Ways in which hospital specialists may influence medical students and postgraduate doctors in training as regards patients presenting with MUS, and their attitudes towards having further training themselves in this topic. Conclusions: We aim to increase the understanding of ways in which doctors working in secondary care approach patients with MUS and how their attitudes may impact on such patients referred from primary care. We will also discuss ways of improving communication about such patients across the primary-secondary care interface and the importance of appropriate training at all levels.

Non Pain Focussed Treatment for Individuals with Chronic Pain: Science and Practice Convenor: Nicole Tang, Keele University

Hybrid cognitive-behaviour therapy for insomnia and chronic pain: A pilot randomised controlled trial Nicole Tang, Keele University; Claire Goodchild, King's College London; Paul Salkovskis, University of Bath Objective: Insomnia is a debilitating comorbidity of chronic pain. The current pilot trialtested the utility of a brief intervention that simultaneously targets insomnia and pain-related interference. Methods: Chronic pain patients with concomitant insomnia were randomly allocated to either (i) receive 4 weekly sessions of hybrid treatment (Hybrid CBT Group; n=10) or (ii) keep a pain and sleep diary for 4 weeks, before crossing over to receive the hybrid treatment (Symptom Monitoring Group; n=10). All participants were assessed at the beginning and end of this 4-week treatment period, and at 1-month and 6-month post-treatment. Primary outcomes were insomnia severity and pain interference. Secondary outcomes were self- reported fatigue, anxiety, depression and pain intensity. Results: Compared to symptom monitoring, the hybrid CBT was associated with greater improvements in sleep at post-treatment. Although pain intensity remained the same in both conditions after the 4-week period, participants who received the hybrid CBT reported greater reductions in pain-related interference, fatigue and depression than those who performed symptom monitoring. Overall, the treatment-associated gains were maintained at 1-month and 6-month post-treatment. Conclusion: The hybrid CBT appeared to be an efficient and effective treatment for chronic pain patients with insomnia. It may be a viable alternative to conventional treatments that target either of the diagnoses. The acquisition, exptinction and generalization of movement-related fear of pain: An experimental analysis Johan Vlaeyen, University of Leuven, Belgium; Ann Meulders, University of Leuven, Belgium Fear-Avoidance models consider fear of pain as a key factor in the development and maintenance of chronic pain disability. Although it is generally assumed that associative learning is involved in the acquisition of movement-related fear of pain, experimental evidence on this topic is scant. Therefore we conducted a series of experimental studies in healthy participants using a novel voluntary movement conditioning paradigm with joystick movements as conditioned stimuli (CSs) and a painful electrocutaneous stimuli as unconditioned stimuli (USs). We examined the acquisition of movement-related fear of pain, its extinction when individuals were exposed to unreinforced movements, and we tested whether this particular form of pain-related fear also generalized to similar movements that were never reinforced by pain. In the experimental condition pain was predictable, while pain stimuli were presented unpredictably in the control condition.During acquisition, participants moved a joystick to the left/right (Predictable Condition, PC), and upwards/downwards (Unpredictable Condition, UC). In the PC, the left movement (CS+), but not the right movement (CS-), was followed by pain. In the UC, painful stimuli were delivered during the inter-trial interval (ITI) and never after the upward/downward movements. Both fear ratings and eyeblink startle measures showed more pain-related fear to the CS+ than CS-, whereas no differences occurred between both unpredictable CSs. When CS+ movements were not followed by pain anymore, fear ratings and startle measures decreased. Results further show that –at least in the verbal ratings– pain-related fear generalized more to the movements having a common feature with the original CS+ than to the movements having a feature in common with the original CS-. These data support this novel pain-relevant fear conditioning paradigm as a promising tool to study learning of (un)predictable PRF. Clinical implications for the management of pain-related fear in patients with chronic pain will be discussed. Cognitive behaviour therapy, exercise or both for chronic widespread pain John McBeth, Keele University; Karina Lovell, Manchester University; Gordon Prescott, Aberdeen University; Phil Hannaford, Aberdeen University; Deborah Symmons, Manchester University; Gary Macfarlane, Aberdeen University Chronic widespread pain (CWP), the cardinal feature of fibromyalgia , is associated with lost work productivity, mental ill health and reduced quality of life. There is a need to develop clinical- and cost-effective, acceptable interventions at a

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primary care level that could potentially be available to a large number of patients. Current guidelines recommend pharmacological, physical and psychological therapies, although the importance attributed to individual therapies is inconsistent. Systematic reviews show that while no individual management modality is effective in relieving symptoms physical exercise and cognitive behavioural therapy (CBT) are promising. We conducted a 2x2 factorial randomized controlled trial to determine whether exercise and/or telephone delivered CBT (TCBT) would improve outcome. 442 patients with CWP (1990 American College of Rheumatology criteria) were recruited from 8 primary-care practices in the United Kingdom and individually randomised to intervention arms. Interventions were TCBT, an individually tailored exercise programme, or both (Combined). Interventions were of six months duration and were compared to treatment as usual (TAU). The main outcome measure was a 7-point patient global assessment scale of change in health since trial enrolment (range: very much worse to very much better), assessed at baseline, 6 (intervention end) and 9 months post-randomisation. A positive outcome was defined as “much better” or “very much better”. After adjustment for age, sex, centre, and baseline predictors of outcome, active interventions improved outcome compared to TAU: TCBT (6 months: Odds ratio 5.0 95% confidence interval (2.0, 12.5); 9 months 5.4 (2.3, 12.8)), exercise (6.1 (2.5, 15.1); 3.6 (1.5, 8.5)), and combined (7.1 (2.9, 17.2); 6.2 (2.7, 14.4)). At 6 and 9 months TCBT was associated with improvements in bodily pain, social function, and mental component subscales of the SF36. Conclusions on cost-effectiveness were sensitive to missing data. This trial demonstrates short (6 month) to medium term (9 month) improvements across multiple outcomes in patients with CWP receiving TCBT. These data provide encouragement that short-term improvement is possible in a substantial proportion of patients with CWP. Problem solving when the problem that can't be solved Stephen Morley, University of Leeds, Caroline Wells, University of Leeds & Lauwerier Emelien, University of Gent; Stephen Donaldson, University of Leeds People with chronic pain spend considerable time and resources in attempting to solve the unsolvable problem of pain. Eccleston and Crombez have called this misdirected problem solving. There are general measures of problem solving not specifically related to pain and one questionnaire measure that appears to measure attitudes towards the problem of pain. This presentation describes recent attempts to develop a problem solving task using a vignette task. The Means End Problem Solving(MEPS) for Pain was based on Platt and Spivack's 1975 MEPS procedure but the structure of the pain problems was informed by Carver and Scheier's distinction between principles and procedures in goal attainment and the scoring system by Rothermund and Brandstadter's distinctions between assimilative and accommodative coping strategies. This presentation describes the development of the items and reports relevant data on the procedure in UK and Belgian samples (approximately 180 patients with chronic pain). Initial data suggest that responses can be reliably coded and that the psychometrics are satisfactory. We have also test the conjecture that assimilative problem solving is associate with proximity to the feared-for self and may therefore represent attempts to avoid many of the feared outcomes that pain patients report.

Cognitive Behavioural Therapy for Menopausal Symptoms Convenor: Beverley Ayers, King’s College London

Chair: Myra Hunter, Kings College London

Cognitive Behaviour Therapy (CBT) for women with problematic menopausal hot flushes - a four stage cognitive model and intervention Melanie Smith, Kings College London; Eleanor Mann, Kings College London; Myra Hunter, Kings College London Hot flushes and night sweats (HF/NS) are commonly experienced by mid-aged women during the menopause transition. They affect approximately 70% of women but are regarded as problematic for 15–20% largely due to physical discomfort, distress, social embarrassment, and sleep disturbance. HF/NS are an example of a physiological process embedded within, and moderated by, psychological processes, as evidenced by discrepancies between subjective experiences and physiologically measured symptoms. A four stage cognitive model of menopausal hot flushes has been developed that draws on symptom perception theory, self-regulation theory and cognitive behavioural theories. The model can be used to identify the variables to target in psychological interventions for HF/NS and to aid understanding of possible mediating factors. Cognitive behavioural treatment which links the bio-psycho-social processes specified in the model to components of the intervention will be described. This intervention helps women to understand physiological and psychosocial factors that influence hot flushes, as well as helping them to identify and implement individual cognitive and behavioural strategies to manage HF/NS and disrupted sleep and hence the impact that HF/NS have on quality of life. The treatment has been developed and evaluated in both group and self help formats. The model and corresponding intervention will be outlined and discussed. MENOS 2: A randomised controlled trial of Group and Guided Self-Help Cognitive Behaviour Therapy (CBT) for women with problematic menopausal hot flushes Beverley Ayers, Melanie Smith, Kings College London; Jennifer Hellier, Mental Health and Neuroscience Clinical Trials Unit, Kings College London; Eleanor Mann, Kings College London; Myra Hunter, Kings College London Background: Hot flushes and night sweats (HF/NS) are problematic for approximately 20-25% of menopausal women. Hormone-replacement therapy (HT) is an effective treatment, but the results of recent prospective trials linking potential health risks with HT use have led to some women reducing or discontinuing HT and seeking alternatives. However, many alternatives lack rigorous research evidence to support their efficacy, or have been associated with significant side effects, leaving a large number of women with limited treatment options. Previous exploratory work using four or six sessions of individual or group Cognitive Behaviour Therapy (CBT) suggests that CBT may be an acceptable and effective treatment. Methods: In this randomised controlled trial 140 menopausal women with at least 10 HF/NS a week for at least a month were randomly allocated to four sessions of Group CBT or Guided Self-Help CBT or a no treatment control group. Questionnaire measures of HF/NS frequency, problem rating, quality of life and mood were taken at baseline, 6 weeks and 26 weeks post randomisation along with physiological HF/NS. Results: Group and Guided self-help CBT significantly reduced HF/NS problem rating and night sweat frequency at 6 and 26 weeks. There were also significant improvements in mood and quality of life at 6 weeks and improved emotional and physical functioning for Group CBT at 26 weeks.

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Conclusions: These results suggest that CBT delivered in group or self-help format is an effective treatment option for women during with problematic HF/NS. A randomised controlled trial of a cognitive behavioural intervention for women who have menopausal symptoms following breast cancer treatment (MENOS 1) Myra Hunter, Kings College London; Eleanor Mann, Kings College London; Melanie Smith, Kings College London; Janet Balabanovic, Kings College London; Hisham Hamed, Guy's and St Thomas' NHS Foundation Trust; Elizabeth Grunfeld, University of Birmingham Background Hot flushes and night sweats (HF/NS) affect 65-85% of women following breast cancer treatment. Hormone replacement therapy is often either undesirable or contraindicated. Safe, effective non-hormonal treatments are needed. This randomised controlled trial investigated whether cognitive behavioural therapy (CBT) can help breast cancer survivors to effectively manage HF/NS. Methods 96 women who were experiencing problematic HF/NS following breast cancer treatment were recruited from breast clinics in London, UK. They were stratified by age (under 50 years, 50 years or over), to receive Usual Care or usual care plus Group CBT. Assessments were conducted at baseline, nine and 26 weeks post-randomisation. The primary outcome was the intention to treat adjusted mean difference in HF/NS Problem-Rating (1-10) between CBT and usual care arms at 9 weeks post randomisation. Secondary outcomes included HF/NS frequency, measured subjectively and physiologically, mood and health-related quality of life. Results. Group CBT significantly reduced HF/NS Problem-Rating at 9 weeks post-randomisation compared to usual care and improvements were maintained at 26 weeks. There were significant improvements in mood, sleep, and quality of life for Group CBT compared to Usual Care. There were no CBT-related adverse events. Discussion/Conclusion. Group CBT appears to be a safe and effective treatment for women who have problematic HF/NS following breast cancer treatment. The treatment could be incorporated into breast cancer survivorship programmes and delivered by trained breast cancer nurses. We are currently adapting this intervention for men who have HF/NS following prostate cancer treatment. How do women experience CBT for menopausal symptoms? A qualitative analysis using IPA Janet Balabanovic, Kings College London; Beverley Ayers, Kings College London; Myra Hunter, Kings College London Introduction. This is a qualitative study of women’s experience of participating in two RCTs of CBT for hot flushes and night sweats (HF/NS). The findings of both studies will be described, drawing attention to differences between groups (breast cancer patients and well women) and the two forms of the intervention. Methods. Thirty in-depth semi-structured interviews were conducted at the end of the two trials. Twenty women had received Group CBT (ten breast cancer patients and ten well women) and ten well women had received the self-help intervention. The interviews explored women’s experiences of the treatment. The resulting data were analysed using Interpretative Phenomenological Analysis. Results. Two superordinate themes were evident for both breast cancer patients and well women and both forms of the intervention: making sense of symptom change and new ways of coping and regaining control. For breast cancer patients additional themes were: tailoring the treatment to meet individual needs and resources; and valuing the group context, social support and social comparisons, and for well women: acknowledging and challenging the menopause taboo, and social interaction and support versus individual learning. Discussion. Participants reported that CBT improved their ability to cope with their HF/NS, and increased awareness of the role of psychological factors in their symptom experience. They developed a more accepting stance to their symptoms, as well as gaining a ‘sense of control’. Conclusion. The results of this qualitative study were consistent with the main trial outcomes, and provided insights into women’s experience of the intervention and possible mechanisms of change.

Skills Classes Adapting Clinical Approaches for People with Long Term Conditions Chris Dickens, Institute of Health Service Research, Peninsula College of Medicine and Dentistry Up to one third of the general population of the UK suffer from long term conditions (LTCs), such as coronary heart disease, diabetes and chronic lung diseases. People with such LTCs are at greatly increased risk of developing common mental disorders, with depression alone affecting about 20% of such individuals, (4 times the prevalence usually seen in the general population). Research has shown that when people with LTCs also suffer from depression, they are more likely to suffer adverse consequences from their physical health problems, such as greater mortality, morbidity and worse health related quality of life. Recent health policy (QoF) has incentivised the screening of LTCs sufferers for depression and NICE guidance has directed delivery of evidence based treatments, though it is recognised that appropriate treatments for depression are frequently not delivered to people with LTCs. Barriers to successfully delivering such treatments have been identified within patients and healthcare professionals; both have difficulty recognising the symptoms of depression in the context of LTCs, both are reluctant to use stigmatising psychological labels and both sometimes resist acceptance that depression is deserving of treatment in its own right. In February 2011, the Department of Health released the report “Talking Therapies: a 4 year plan of action”, which outlined its intentions to extend the roles of the IaPT services to improve access to psychological treatment for depression for people with LTCs. Additional training is planned to provide the workers responsible with the necessary skills to deliver treatments to this new group of patients. These workers frequently report concerns and a lack confidence in taking on this new role, however. Objectives: This skills class will address the gaps in knowledge and experience often reported by people who deliver psychological treatment when dealing with patients with LTCs. The class will use workshop format to i) generate a list of common problems and concerns when faced with patients with LTCs, ii) identify the additional skills and adaptations to treatments required and iii) practice key skills under the guidance of a clinician with 15 years experience in dealing with these clinical problems.

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Chris Dickens is Professor of Psychological Medicine at Peninsula College of Medicine and Dentistry and Honorary Consultant in Liaison Psychiatry at the Devon Partnership Trust. His research and clinical interests focus on the development and evaluation of psychological treatments for people with chronic physical health problems. References Talking about depression: a qualitative study of barriers to managing depression in people with long term conditions in primary care. Coventry PA, Hays R, Dickens C, Bundy C, Garrett C, Cherrington A, Chew-Graham C. BMC Fam Pract. 2011

Posters General beliefs, response expectancies and attentional bias: impact on treatment related symptoms and quality of life in breast cancer patients having chemotherapy Oana Cobeanu, Babes-Bolyai University, Department of Clinical Psychology and Psychotherapy; Daniel David, Babes-Bolyai University, Department of Clinical Psychology and Psychotherapy Little is known about the impact of cognitive factors, in particular general beliefs (e.g. catastrophizing), response expectancies and attentional bias, on symptoms intensity and quality of life among breast cancer patients undergoing chemotherapy. The aim of this study is to investigate the relationships between general beliefs, response expectancies and attentional bias with respect to perceptions of self-reported secondary symptoms (e.g. nausea, vomiting, fatigue, pain) and quality of life during chemotherapy. We use a predictive correlational design. One hundred breast cancer patients, recruited from the Oncological Institute in Cluj Napoca and an oncological private clinic, completed self-administered questionnaires and the dot-probe task (for the cognitive assessment of attentional bias towards symptom related linguistic stimuli), prior to their first and second sessions of chemotherapy. Correlational and regression analyses will be performed. This study reports on the development and initial application of a dot-probe task assessing attentional bias towards secondary symptoms to chemotherapy in breast cancer patients. Furthermore, we investigate the interaction between general beliefs, response expectancies (that have been shown to impact on symptoms intensity in cancer patients undergoing treatment) and attentional bias, with respect to patients’ chemotherapy response and quality of life. Our results are relevant for further development and investigation of psychological interventions addressing both attentional biases (through the use of attentional retraining) and maladaptative general beliefs, specific to the breast cancer population. Preliminary results suggest positive correlations between response expectancies and attentional bias. These variables are expected to mediate the effect of general beliefs on i) the self-reported intensity of secondary symptoms to chemotherapy and ii) quality of life. Moreover, they will be significant predictors of the criteria. We believe that by adding the cognitive bias modification procedure in a CBT protocol, we can enhance the efficacy of CBT, by addressing both explicit and implicit cognitive processes.

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Child and Adolescent Mental Health

Keynote Addresses

Working through families to increase the efficiency and impact of CBT: application to childhood anxiety disorders Cathy Creswell, University of Reading CBT is an effective treatment for childhood anxiety disorders, however many children do not access treatment, and of those who do, a significant proportion do not benefit. Working through families can be an efficient approach to treatment, and can also provide opportunities to improve therapeutic impact by targeting particular factors, such as ones in the child’s family environment. This talk will report on the findings from two recently completed randomised controlled trials that aimed to enhance the efficiency and impact of treatment of childhood anxiety disorders. One of the most consistent predictors of poor treatment outcome for child anxiety disorder is parental psychopathology, particularly maternal anxiety. Where parents are not highly anxious, it is possible that brief treatments for child anxiety may be effective. The first trial to be presented (the Overcoming trial) addressed this issue. Two guided CBT self-help treatments (varying in intensity – i.e. 5 hrs and 2.5 hrs therapist input), delivered via parents, and were compared to a waitlist control condition. The second trial (the MaCh trial) addressed the issue of improving outcomes for those children with a relatively poor prognosis by virtue of their mother) having a current anxiety disorder. It is unclear from previous research whether treating parental anxiety improves child outcomes, and this needs to be clarified. Further, it has been suggested that it is necessary to focus on the cognitive and behavioural parent-child interaction processes that maintain childhood anxiety, and this too requires empirical examination. This trial therefore compared two adjunctive treatments to standard CBT delivered to children (CCBT): one treatment targeted maternal anxiety disorders, and the other targeted the cognitions and behaviours that characterise highly anxious parents when interacting with an anxious child. Both of these conditions were compared with a control group where children received the same CCBT as in the other two conditions, with their mothers receiving certain control conditions. The findings of these two studies will inform the development of a stepped care approach to the treatment of childhood anxiety disorders, in order to maximise efficiency and impact of CBT in this context.

Widening parenting programmes to promote attachment security, prevent antisocial personality and be more accessible Stephen Scott, Professor of Child Health and Behaviour, Institute of Psychiatry, and Director, National Academy for Parenting Research Improving parenting can lead to enormous improvements in child development, and there is considerable enthusiasm amongst policy makers for its role in early intervention. However, parenting programmes have mostly been researched using one theoretical paradigm - social learning theory - on antisocial children in birth families, with only short-term follow-up, and their availability is limited. This lecture will cover three ways our team has addressed these issues, and includes video clips. (1) What is the potential for a parenting programme to improve attachment security in older abused children taken into foster-care? This is the first study to examine if attachment security can be improved in adolescence. (2) What is the long-term effectiveness of parenting programmes for antisocial children at risk of developing antisocial personality? Two contrasting early-childhood prevention strategies, indicated and selective, are compared in a ten year follow-up study into adolescence of two trials with young children. (3) What steps have been taken to get effective approaches more widely available? Good quality programmes are far from universally available, whereas some non- evidence-based programmes are widely promoted. Three steps have addressed this (a) the development of the “Commissioning Toolkit”, a “Which?”-style guide to the quality of the 150 or so programmes available in England; (b) lessons from the National Academy for Parenting Practitioners’ training of over 4,000 practitioners in evidence-based approaches, and (c) the aims of the half of the Children and Young Person’s Increasing Access to Psychological Therapies (CY-IAPT) programme dealing with parent training for conduct problems.

Symposia

Improving our Understanding of Adolescent Mental Health Convenor : Polly Waite, University of Reading

Understanding Parent-Child Interactions in Anxious Adolescents: A Systematic Review Polly Waite, University of Reading Approximately 5% of British 12-15 year olds meet diagnostic criteria for an anxiety disorder (Ford et al., 2003). Indeed, anxiety disorders are more common among adolescents than in younger age groups and symptoms are likely to be more severe, with higher levels of co-morbidity with other anxiety disorders, depression, conduct disorder, and substance abuse (Essau, 2008; Costello et al., 2003; Clark et al., 1994). The majority of anxiety disorders persist into adulthood, and lead to poorer life course outcomes (Pine et al., 1998; Last et al., 1997). There is a body of research with younger children demonstrating that parents of anxious children are more controlling and less autonomy granting, and model more avoidant behaviour than those of children without anxiety (McLeod et al., 2007; Rapee, 1997; Murray et al., 2008) and that this is associated with increased impairment in anxiety disorders (Manassis & Hood, 1998), and predicts poorer treatment outcome (Crawford & Manassis, 2001). Typically adolescence is a period during which the young person develops independence and

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spends less time with their family. Nevertheless, evidence suggests that parents continue to exert significant influence throughout this developmental stage and face the challenge of providing increasing levels of autonomy to their adolescent (Liddle et al., 2010). There is some preliminary evidence to suggest that parental overinvolvement may be a significant factor in relation to anxiety among adolescents (Hudson & Rapee, 2001) and contribute to a poorer outcome from CBT (Garcia-Lopez et al., 2009). This presentation will discuss the findings of a systematic review of the literature on parent-child interactions in anxious adolescents and consider the implications and future research directions. Autonomy granting parental behaviour and adolescent anxiety: the effects of age and child temperament Lauren Whittington, University of Oxford; Catharine Creswell, University of Reading Research has demonstrated a significant relationship between parental behaviours that restrict child autonomy and childhood anxiety. Furthermore, recent experimental studies have provided evidence consistent with a causal or maintaining role of these parental behaviours, particularly among children with elevated trait anxiety. Most studies however, have focussed upon younger children or have included young people from a broad age range. This assumes that as children develop the relationship between these factors remains the same however this is not necessarily the case. As children get older developmental tasks associated with adolescence e.g. development of autonomy, may mean that parental behaviours that restrict autonomy could have a different effect to that seen in younger children. Also when children reach adolescence research suggests that other people apart from parents, such as peers and teachers, begin to have more of an influence on behaviour and well-being. This study uses a repeated measures experimental design, in which parents were instructed to behave in an over-controlling or autonomy granting way while helping their child prepare to give a speech to a stranger. The impact of parental behaviours on observed child anxiety, rated by blind observers, will be compared for children aged 7-8 and 13-14 years, as will the interactive effects of children’s trait anxiety levels and parental behaviours. Implications for understanding of the development of anxiety, prevention and treatment with children and young people of different ages will be discussed. Eating disorders in adolescence - translating research findings into clinical practice Anne Stewart, Oxford Health and University of Oxford Eating disorders are common in adolescence and can have a huge impact on the individual’s life. Research studies of CBT in adult eating disorders have shown efficacy for cognitive behavioural approaches, however, there has been very little research on CBT in adolescent eating disorders. Family-based treatment for anorexia nervosa is considered the treatment of choice but even using this approach a significant proportion of young people do not fully recover with treatment. Alongside research on interventions there is considerable interest in understanding the processes involved in development and maintenance of eating disorders. This paper will focus mainly on anorexia nervosa, firstly summarising the current evidence base for treatment including cognitive behavioural approaches. Recent studies which have illuminated our understanding of adolescent eating disorders will then be described, including a qualitative study on patients’ experience of their eating disorder and treatment. This qualitative study highlights the impact of anorexia nervosa on thinking styles, the role of emotional states in anorexia nervosa and the importance of the therapeutic context. Finally, the paper will draw together the evidence and consider how to translate research findings into the real world, maximising the efficacy of treatment in adolescent eating disorders. Online support in caring for an adolescent with anorexia nervosa: A case study of one mother's experience Carrie-Anne McClay, University of Glasgow; Louise Ewan, University of Dundee; Chris Williams, University of Glasgow The majority of individuals who suffer from anorexia nervosa are female and the disorder tends to develop during early adolescence. NICE recommends that the majority of those with AN be managed on an outpatient basis, therefore placing family members at the forefront of care. This can potentially place considerable strain on family functioning. Parents of children with an eating disorder report poorer relationship bonds with the sufferer and also with their spouse and other children. Parents of children with AN experience high levels of distress, burden and psychological morbidity with supporters often reporting symptoms of anxiety and depression. It is evident therefore that parents and the wider family unit have significant needs which need to be met in order to improve their own self-care as well as to enable effective care giving. Addressing carers’ needs may potentially reduce carer distress and better allow the family to serve as an important resource in treatment, which in turn may help reduce relapse. Skills-based interventions, such as online educational packages, may constructively alter parental reactions to reduce unhelpful responses that maintain their loved one’s illness, such as high levels of expressed emotion or age-inappropriate levels of care. Such a package has recently been created; Overcoming Anorexia Online (OAO). This web-based intervention helps supporters change the ways in which they offer support to individuals with AN using a formulation-based “systemic” cognitive-behavioural approach based on the five areas CBT model. The in-depth case study discussed as part of our on-going research into the area of parents who are caring for an adolescent child with AN will describe the journey that one mother has been on in caring for her daughter with anorexia nervosa. Through information collected from interviews with carers, support sessions whilst using the carer support package, questionnaire based measures and informal discussions we will describe the mother’s experience of trying to care for her child with anorexia nervosa from when her symptoms started until the present. Furthermore we will discuss her use of the Overcoming Anorexia Online package, how she engaged with the package and her thoughts and feelings regarding the OAO carer support package. Implications for supporting parents who have a child with AN and the impact which this may have on the individual with AN are discussed. Using Community Day-Long Workshops to Offer CBT to Adults and Adolescents Who May Not Otherwise Access Services Convenor: June Brown, Institute of Psychiatry, King’s College London

Might self-confidence workshops help the implementation of the NICE Guidelines for depression? Linda Horrell, Institute of Psychiatry, Kings College London; Kimberley Goldsmith, Institute of Psychiatry, Kings College London; Jennifer Beecham, London School of Economics; Andre Tylee, Institute of Psychiatry, Kings College London; Ulrike Schmidt, Institute of Psychiatry, Kings College London; June Brown, Institute of Psychiatry, Kings College London

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The NICE Guidelines for Depression (2004) recommend that psychological treatments are offered as part of a stepped care model. However, psychology services are limited and can be difficult to access. There is also global reluctance for people with depression to seek help, so that depression remains undertreated. The IAPT programme has offered funding for delivering high and low intensity psychological treatments, but low intensity treatments are under-researched. A new accessible low intensity intervention – community day-long CBT workshops – was found to be effective for stress (Brown et al 2000) and for depression in a small pilot study (Brown et al 2004). To see whether these Self-confidence workshops, which could each take up to 30 people, were clinically effective at reducing depressive symptoms and generalisable outside one London borough, we ran a randomised controlled study of workshops in 8 south London sites. Participants were invited to self-refer to the Self-confidence workshops. Outcomes were measured by self-report using the BDI, GAD-7 and Rosenberg Self-esteem Scale. We recruited 459 participants to the study. The results showed that the one-day workshops, which used CBT techniques, were effective in improving levels of depression, anxiety and self-esteem. Compared to the ethnicity proportions in the local populations, the proportion of BME groups in the self-referral population was much higher in 5 of 8 boroughs. This suggests that the innovative format of the intervention is attractive to a population who are traditionally hard to reach for psychological services and provides a feasible alternative. In addition, the workshops appealed to many people who had never contacted their GP before for psychological treatment, indicating this accessible format can help the public overcome their reluctance to seek help for depression. Community day-long workshops for insomnia: an RCT evaluating effectiveness, accessibility and acceptability June Brown, Institute of Psychiatry, Kings College London; Naomi Swift, Cardiff University; Robert Stewart, Institute of Psychiatry, Kings College London; Anna Smith, South London and Maudsley NHS Trust; Colin Espie, Glasgow University Insomnia is a very common and disabling symptom. Evidence for the efficacy of cognitive behavioural therapy for people diagnosed with insomnia (CBT-I) is very strong, with 70-80% benefitting, with sustained effects. Not only does CBT-I show longer term benefits than pharmacotherapy, it has no physical side effects and is preferred by patients. CBT-I is also effective in improving insomnia secondary to other physical and mental disorders as well as co-morbid symptoms such as depression. However, few people seek help and not many services offer CBT-I. Reasons for non-help-seeking include a tendency to trivialise sleep problems as well as not knowing what is available. More recently, less intensive adaptations of CBT-I have been shown to be valuable, including small groups, telephone consultations, 2 session individual CBT-I, and an internet adapation of CBT-I. Given the size of the problem and low rates of help-seeking, an accessible intervention with a large capacity is needed, which members of the public can utilise. Day-long CBT-I psycho-educational workshops (each for up to 30 people), to which members of the public with insomnia symptoms could self-refer, have been developed. This randomised controlled trial aimed to evaluate the effectiveness of these workshops. Measures included the Insomnia Severity Index (ISI), sleep diaries and the BDI. Baseline measures were taken from 151 participants, who were then randomised to experimental or waiting list control groups. Scores of the experimental group and the control group were compared three months after baseline. Insomnia scores decreased significantly in the experimental group, but not in the control group. Promising results were also found on sleep diary measures. Access to the workshops was good, with 50% of participants having never previously sought help for sleep difficulties from their GP. CBT-I workshops proved to be both accessible and effective in reducing insomnia symptoms in the medium term. They may represent a feasible brief intervention with the potential to address unmet treatment needs of adults with insomnia. Are day-long psycho-educational workshops cost-effective? Jennifer Beecham, London School of Economics; Eva Bonin, London School of Economics; Linda Horrell, Institute of Psychiatry, Kings College London; June Brown, Institute of Psychiatry, Kings College London Depression and related problems are associated with high costs to society, related to high rates of hospital admissions, increased use of other health and community services as well as medications. There are also wider costs arising from high rates of absenteeism and reduced work productivity. Cognitive behaviour therapy (CBT) can be delivered in a workshop format and has been shown to be effective for improving depression and sleep difficulties; however, the evidence base for the cost-effectiveness of psychological treatments is small. Here we present the results of the economic evaluation of day-long CBT workshops for a) insomnia (N=111) and b) self-confidence problems (N=380) that were run in 2 studies run between 2008 and 2011. Service use data and outcome measures were collected at baseline and 3-month follow-up. Participants completed a specially adapted version of the Client Service Receipt Inventory (CSRI) to record contacts with primary care, hospital services, specialist mental health services, social work, other community services as well as medication use. The cost of each participant’s “care package” was calculated by attaching unit costs to the reported service use. The unit costs of the CBT workshops were calculated based on information provided by the research team and includes salaries and on-costs, and the costs of travel, volunteer time, workshop materials and capital costs (e.g. room rental). We will describe service use and service costs at baseline and follow-up for the two studies. Cost-effectiveness and cost-utility analyses were performed using cost-effectiveness acceptability curves, which indicate the likelihood that each intervention is cost-effective in terms of an improvement in Beck Depression Inventory (BDI), Insomnia Severity Index (ISI) or Rosenberg Self Esteem Scale (RSES) and quality adjusted life years (QALYs) gained at different levels of societal willingness to pay (WTP) for this improvement. In both study cohorts, participants were in contact with a wide range of services, but most services were used by only few people. In both studies, the most well used services were GPs, outpatient services and alternative therapy. Additionally, counsellors and psychologists were used by participants in the self-confidence group. The largest contributors to service costs were hospital services, followed by mental health and counselling services. There were no significant differences in costs at baseline or follow-up in either group. The insomnia workshops resulted in a significant reduction in ISI for the intervention group, relative to the control group, while the self-confidence workshops significantly improved general symptoms of depression (BDI). Detailed figures for the probabilities of the workshops being cost-effective will be presented at the symposium. Our analysis suggests that psycho-educational workshops have a high probability of being cost-effective for people with sleep or self-confidence problems as well as more general symptoms of depression. This makes them a promising low-intensity option to include within the range of interventions that are encouraged within the UK policy of increasing access to psychological therapies.

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Day-long CBT workshops in Southwark IAPT service Seon Lynch, South London and Maudsley NHS Trust; Jack Cahill, South London and Maudsley NHS Trust; June Brown, Institute of Psychiatry Day-long CBT workshops with different programmes have been run in the Southwark IAPT service since 2008. The series of workshops is called the Southwark Wellbeing Workshops. These day-long workshops are held in a local library and offered free to residents of Southwark. A non mental health setting was chosen in order to reduce the possibility that fear of being labelled with a mental health problem could affect attendance, given that stigmatization can affect people's help seeking behaviours (Hayward and Bright 1997). The venue was also chosen for its location within the borough and proximity to local transport links. Each workshop held at the library can take up to 25 participants. Workshops are held on Saturdays with the aim of improving accessibility for those with work or commitments during the week. The workshops are publicized in the 8 weeks prior to the month in which each workshop takes place. Publicity material in the form of letters and fliers are sent out to GP practice managers, counsellors, council offices, libraries and leisure centres. Email publicity is sent to general practitioners and counsellors in the borough, and the workshops are also publicized in local newsletters. This publicity invites the public to self refer by telephoning or emailing the workshop team co-ordinator. Four programmes are currently being run, all using a CBT approach. The workshops are: Stress workshop, Self confidence workshop, Sleep workshop and Anger workshops. The main measures used to assess the effectiveness of the workshops are the Patient Health Questionnaire 9 (PHQ-9) for depression and the Generalized Anxiety Disorder 7-item questionnaire (GAD-7). The characteristics and clinical outcome of participants self-referring and attending over the last 3 years will be reported at the symposium. DISCOVER Adolescent wellbeing workshops Irene Sclare, South London and Maudsley NHS Trust; Fay Coster, South London and Maudsley NHS Trust; Elizabeth Malpass, South London and Maudsley NHS Trust In 2010, to meet the mental health needs of 16-18s with anxiety and low mood symptoms who do not access CAMHS, we set up the Adolescent Wellbeing workshop project. Its aims were to develop, pilot and evaluate an adapted and ‘teenfriendly’ version of the Wellbeing workshop approach (Brown et al 2000. 2004). The adolescent workshop model was developed with Teenage Advisors from a range of backgrounds. Using a self referral approach to recruitment, the workshops were designed to be held in youth appropriate community settings, and were run in Spring 2011. Two workshop interventions were planned, the first for anxiety, the second for low mood. Initial clinical outcomes for the workshop designed to tackle anxiety symptoms are very positive, but participant recruitment was slower than anticipated in the community sites, despite intensive publicity. We shifted to delivering the second workshop, for low mood, within several sixth forms in local schools in autumn 2011, increasing accessibility, and workshop numbers improved. We are in the process of analysing clinical and wellbeing outcomes for around 60 young people who have attended the pilot workshops and will report these at the symposium, alongside a summary of service user perspectives on the nature of the service provided, its acceptability and accessibility. We will also discuss the potential of this approach to deliver CBT intervention to troubled youth, plans for further dissemination, and the interagency planning with youth agencies and with mainstream CAMHS that underpinned the workshop approach. Issues in Parental Mental Health

Covenor: Sam Cartwright-Hatton, University of Sussex

Preliminary findings from effective interventions using MCT and Baby Triple P in women with postnatal mood disorders Anja Wittkowski, University of Manchester This presentation will outline the importance of early psychological and parenting interventions with infants and their parents, particularly their mothers. Mothers who experience postpartum mood disorders including Postnatal Depression (PND) have been found to be less responsive, stimulating, contingent and attuned to their infants, which can impact on their psychological development. The benefits of two types of interventions will be discussed. First of all, the findings from a multiple-baseline study of the effects associated with metacognitive therapy in the treatment of postnatal depression will be presented. Maternal mood improved significantly alongside maternal ratings of their bond with their babies. As this type of intervention did not specifically address the mother-infant relationship, the audience will also be introduced to preliminary findings from a pilot RCT investigating the efficacy of the Baby Triple P (Positive Parenting) Programme a) in women with PND and b) women admitted to an inpatient Mother and Baby Unit. Can a Web Based Positive Parenting Intervention Help Bipolar Parents of Young Children Steve Jones, University of Lancaster Background: Children of bipolar parents are at elevated risk for psychiatric disorders including bipolar disorder. Helping bipolar parents to optimise parenting skills may improve their children’s outcomes for. Clear evidence exists for benefits of behavioural parenting programmes, including for depressed mothers. The aim of this research was to conduct a pilot study of a web-based parenting intervention based on the Triple P Positive Parenting Programme. Method: Thirty-nine self-diagnosed bipolar parents were randomly allocated to the web-based intervention or a waiting list control condition. Parents reported on their index child (entry criterion age 4-10 years old). Perceived parenting behaviour and child behaviour problems (internalising and externalising) were assessed at inception and 10 weeks later (at course completion). Fifteen participants did not provide follow-up data. Results: Levels of child behaviour problems (parent rated; Strengths and Difficulties Questionnaire) were above clinical thresholds at baseline and problematic perceived parenting (self-rated; Parenting Scale) was at similar levels to those in previous studies of children with clinically significant emotional and behavioural problems. Parents who received the intervention reported significant improvements in child behaviour problems and problematic perceived parenting compared to controls based on random effects models with random intercept.Conclusions: A web-based positive parenting intervention may have benefits for bipolar parents and their children. Initial results support improvement in child behaviour and perceived parenting, although there were issues with retention to follow-up. Lessons learnt from this work are informing an MRC treatment development study which is ongoing.

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The treatment of mother-child interaction within the context of child and maternal anxiety disorder Lucy Willetts, University of Reading; Cathy Creswell, University of Reading; Peter Cooper, University of Reading A randomised controlled trial of the treatment of child anxiety in the context of maternal anxiety disorder, involving child directed CBT, mother directed CBT, and mother-child interaction treatment has recently been completed at the Berkshire Child Anxiety Clinic. 210 families were recruited to the trial. The design of the trial will be outlined and the context in which the mother-child interaction treatment was delivered will be described. The mother child interaction treatment (MCI) involved teaching mothers of anxious children the principles of CBT to use with their child, alongside the use of videoed interactions of the mother and child and subsequent video feedback to address maternal cognitions and behaviours. The overall aim of the treatment sessions was to increase autonomy granting behaviour by the mothers in their interactions with their child. A brief summary of the findings will be presented and case studies will be presented to illustrate the treatment content. Parents with OCD – effects on children, parenting and parental perceptions. Fiona Challacombe, King’s College London OCD has been termed relatively uncommon but particularly severe (Torres, 2006). The symptoms of OCD can permeate all aspects of life including home life, with routines and relationships and aspirations frequently compromised. The problem can have a significant impact on sufferers and those around them including children. In addition, people with OCD often worry about the potential effects on children and their ability to parent effectively. Data will be presented from three studies exploring the effects of parental OCD on children and parenting, and parents' own perceptions of the impact of the disorder. These studies highlight the difficulties experienced by some parents in managing the demands of the disorder and those of parenting, particularly where they conflict. Parents frequently perceive a significant impact on their abilities to parent. However the large variances in scores indicate that many are able to maintain considerable skill and warmth as a parent. Specific difficulties can form a useful set of treatment goals.

Treatment of Obsessive-Compulsive Disorder in Children and Young People: New National Clinical Research Convenor: Cynthia Turner, Institute of Psychiatry, King's College London

A randomised controlled trial of telephone CBT versus face-to-face CBT in the treatment of OCD in young people Cynthia Turner, Kings College London, Institute of Psychiatry; David Mataix-Cols, Kings College London, Institute of Psychiatry; Karina Lovell, University of Manchester; Georgina Krebs, South London and Maudsley NHS Trust; Katie Lang, South London and Maudsley NHS Trust; Isobel Heyman, South London and Maudsley NHS Trust Telephone CBT represents a means by which CBT can be made more readily available to young people who need it. This paper will present the methods and results of a randomised controlled trial comparing telephone CBT with face-to-face CBT in the treatment of obsessive-compulsive disorder in young people. N = 72 young people were randomly allocated to one of the two treatment conditions, which were identical except in the method of delivery offered. Post-treatment and three month follow-up results will be presented and discussed. Who needs the Full Monty? Comparing predictors of success in brief and longer duration treatments for children with OCD Tim Williams, University of Reading; Derek Bolton, Kings College London, institute of Psychiatry; Sean Perrin, Kings College London, Institute of Psychiatry; Paul Salkovskis, University of Bath The data from a trial comparing short and standard OCD treatment protocols for young people with OCD were reanalysed to investigate the importance of different predictors. Overall severity of OCD was a predictor of post treatment OCD ratings. The severity of OCD was a predictor of change in CYBOCS score. Self report measures of other emotional disorders were not predictive of change in CYBOCS score. Similalry most of the cognitive measures (magical thinking, thought action fusion and responsibility intrusions and beliefs) only responsibility cognitions predicted change in OCD symptoms. No aspects of parental behaviour or mood were preictive of change in CYBOCS score. The results will be discussed in relation to other trials of child emotional disorders. The ROCKY Trial: Preliminary outcomes of an RCT to compare family enhanced versus individual CBT in young people with OCD. Shirley Reynolds, University of East Anglia; Sarah Clark, University of East Anglia, Norfolk and Waveney Mental Health Trust; Harriet McIlwham, University of East Anglia, Norfolk and Waveney Mental Health Trust; Gemma Bowers, University of East Anglia, Norfolk and Waveney Mental Health Trust The ROCKY trial is a randomised controlled trial of family enhanced CBT versus individual CBT for young people with Obsessive Compulsive Disorder (OCD). Although NICE recommend CBT with family involvement, this is not based on any evidence and this trial was designed to provide direct evidence related to the recommendation. Fifty young people, aged 12 to 17 years, who were diagnosed with OCD using the ADIS, were randomised to receive 14 sessions of CBT either alone or with their parent(s). Severity of OCD was assessed on the CY-BOCS by a blinded researcher before treatment, at the end of treatment, and at 6 month follow-up. In addition, young people completed measures of responsibility appraisals, depression and anxiety symptoms and parental mental health was assessed using the SCL-90. In this presentation we will report the primary outcomes of treatment at the end of treatment and at 6 month follow up. A randomised controlled pilot study of CBT with d-cycloserine or pill placebo in the treatment of OCD in young people. Benedetta Monzani, Institute of Psychiatry, King’s College London; Cynthia Turner, Kings College London, Institute of Psychiatry; Benedetta Monzani, Kings College London, Institute of Psychiatry; Georgina Krebs, South London and Maudsley NHS Trust; Isobel Heyman, Kings College London, Institute of Psychiatry, and South London and Maudsley NHS Trust; D-Cycloserine (DCS) is a partial N-Methyl-D-Aspartate agonist that facilitates fear extinction when given before or shortly after exposure to feared stimuli. This trial tested whether DCS augments exposure and ritual prevention (ERP) therapy for Obsessive-Compulsive Disorder (OCD) administered immediately after each of 10 ERP sessions. Twenty-seven adolescents

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with OCD were randomised to 50mg DCS or placebo; 25 patients completed the study. The talk will present the preliminary findings and discuss avenues of future research in the field. International Standard Randomised Controlled Trial Number (ISRCTN): 70977225.

Intolerance of Uncertainty, Worry, and Generalized Anxiety Disorder Among Young People Convenor: Mark Freeston, Newcastle University

Intolerance of Uncertainty: Its relevance to Autism Spectrum Disorder Jacqui Rodgers, Newcastle University; Mark Freeston, Newcastle University; Mikle South, Brigham Young University, USA; Laura Gray, Newcastle University; Sarah Wigham, Newcastle University; Christina Boulter, Newcastle University Anxiety is a significant problem for many individuals with an Autism Spectrum Disorder (ASD), with prevalence rates estimated at between 30 - 81%. Despite growing awareness of the need to tackle the psychological, social and economic impact of childhood anxiety in ASD there are no well validated theoretical models to guide the development of targeted and developmentally sensitive assessment and intervention techniques for this population. This talk will explore the relevance of the Intolerance of Uncertainty model of worry to ASD. It will begin by considering the construct of IoU in relation to core features of ASD, especially insistence on sameness. Using what we have learnt from this model we will then consider some of the potential neurocognitive correlates of IoU in adolescence and how they relate to neurocognitive characteristics of autism. We will then take a preliminary look at some pilot data exploring the relationship between IoU and anxiety in ASD. Despite early indications that the IoU model of anxiety has utility in understanding anxiety in ASD it is unlikely due to the complex and pervasive nature of ASD that models of anxiety that have utility in typically developing populations can be applied directly to young people with ASD without adaptations. Therefore the talk will end with an exploration of a novel, integrated cognitive model of anxiety for ASD based on the IoU framework. This theoretically framed individual differences approach we hope will make an important contribution to the development of ASD specific treatment programmes. An examination of construct of Intolerance of Uncertainty with groups of typically developing young people of different ages Gioia Bottesi, University of Padova; Mark Freeston, Newcastle University Introduction: The Intolerance of Uncertainty Scale (IUS) was originally developed on the basis of clinical observations of patients affected by GAD. Since then, a number of studies have been conducted to examine its latent structure to better understand the nature of IU and so improve conceptualization of both etiological and therapeutic models of GAD. Results from factor analyses are variable, but two factors have been consistently identified among adult samples, labeled respectively “desire for predictability” and “uncertainty paralysis”. On the contrary, exploratory factor analyses detected only one global factor among child samples and there is no test of IU latent structure in adolescents. A more parsimonious 12-item version of the scale has been recently proposed (Carleton et al., 2007) and has been adapted for children (IUS-C). Preliminary results support its validity among both adult and child samples. Objectives and Methodology: The aim of the present study was to further analyze the IUS-12 structure across groups of typically developing young people of different ages, through a series of Confirmatory Factor Analyses (CFAs). Eight groups were analyzed separately. Children aged 6-8 (N = 183) and 9-11 (N = 129), two groups of adolescents aged 12-14 (N = 300 and N = 156) and 101 British undergraduates completed the 12 item IUS with items modified to increase reading ease. Two groups of British undergraduates (N = 199 and N = 268) and one group of Spanish undergraduates (N = 323) completed the original IUS, CFA was conducted on the 12 items retained by Carleton et al. (2007). Both the one- and two- factor models were tested among all samples on both the Pearson and polychoric correlation matrixes. Results: Overall, the two-factor solution resulted as the best option in all samples. This was particularly true among the undergraduates, whereas in the younger groups the two-factor model was only slightly better than the one-factor model. In all the tested models, however, at least one criterion of goodness of fit did not meet the desired value. Generally equivalent results were found for both Pearson and polychoric correlation matrices; however, the IUS-12 in the undergraduate sample showed much better indexes of goodness of fit for the polychoric matrix. Discussion and conclusion: These results confirm those previously emerged from EFA studies for adults but do show that conceptualizing IU as a two-component construct is also appropriate among children aged between 6 and 11. Thus, our findings further support the notion of IU as consisting of two main aspects, defining approach (i.e. “desire for predictability”) and avoidance (i.e. “uncertainty paralysis”) strategies and processes when facing uncertain situations. Nonetheless, the goodness of fit is still not optimal; future studies on larger non clinical groups of different ages and among anxious individuals are required. Moderate-high correlations between the factors suggest that not everyone scores equally on both, so differential profiles may exist. Thus approach to uncertain situations and behavioural responses to them need to be further investigated, both in the laboratory and in the clinic. Hypothetical uncertain situations, intolerance of uncertainty and worry among adolescents Michelle Ford, Northumberland Tyne and Wear NHS Foundation Trust; Mark Freeston, Newcastle University and NTW NHS Foundation Trust; Caroline Pickering, Newcastle University; Catherine March, Newcastle University; Jakki Fortune, Newcastle University; Jacqui Rodgers, Newcastle University Although well established as construct of interest among adults, there are relatively few studies of Intolerance of Uncertainty (IoU) amongst adolescents. Ford et al. (2011) used a semi-idiographic approach to measure appraisal of personally salient uncertain situations and to relate these to IoU (measured by the Intolerance of Uncertainty Scales among 215 adolescents typically developing aged 12-14. They found that the best predictor of IoU was appraisals of arousal rather than appraisals of the situation or affect. These data suggest that uncertainty may be found threating in part because of internal experience which is seen in a negative way as intense, unpleasant, lasting, dangerous, etc. This study extends these findings by first considering whether these appraisals make an independent contribution to worry variance over and above IoU, it then examines whether the appraisals mediate the relationship between IoU and worry, then finally whether IoU acts as a moderator on any mediational paths. Method: Adolescents aged 12-14 (N = 215) completed measures of worry, intolerance of uncertainty and then chose a personally salient hypothetical uncertain situation (i.e. a future event that could have positive, neutral, or negative outcomes, but the outcome is as yet unknown). They then rated the situations and internal experiences related to those situations (affect and arousal) on a number of dimensions.

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Results: The appraisals and intolerance of uncertainty both accounted for similar amounts of worry variance when entered first or last. Using PROCESS (Hayes, 2012) mediation models were tested and showed a strong indirect effect of IoU on worry through the appraisals, with the strongest indirect path through appraisal of affect. Finally, there is evidence that IoU moderates the indirect effect. That is the indirect effect through appraisals of affect is stronger at higher levels of IoU. Discussion: Results are consistent with a model where IoU leads people to react to uncertain situations using internal information from their affective state and that this then leads people to worry. Moreover, high levels of IoU strengthen this indirect path to worry. These data start to move our understanding from a trait-like understanding to a process level understanding of IoU. Plans for the next wave of research are discussed together with early ideas about treatment implications. Applicability of a cognitive model and treatment to worry in children and adolescents Sean Perrin, Lund University & King’s College London; Derek Bolton, King's College London; Laura Fialko, East London Mental Health Trust; Susanna Payne, South London & Maudsley NHS Foundation Trust Studies have found that the cognitive model of worry developed by Dugas, Gagnon, Ladouceur and Freeston (1998) involving Intolerance of Uncertainly (IU), Cognitive Avoidance (CA), Positive Beliefs about Worry (PB), and Negative Problem Orientation (NPO) accounts for approximately 40-50% of the variance in worry frequency in adults. A recent trial of the treatment based on this model (Dugas, Brillon, Savard et al., 2010) found it to be superior to no treatment and marginally superior to applied relaxation in adults with Generalized Anxiety Disorder (GAD). In this presentation the authors discuss the results of two studies testing the applicability of this cognitive model to children and adolescents. In the first study measures of IU, CA, PB, worry and anxiety were administered to 515 British primary and secondary school students (aged 7-19 years). A path analysis was undertaken to test whether IU acted as a higher order variable for CA and PB and whether the relationship between IU/CA/PB and anxiety was mediated by worry frequency. Significant (bivariate) correlations were observed between the measures of IU, PB, CA, worry and anxiety across the age range. However separate path models had to be fitted for children (aged 7-12 years) and adolescents (aged 13-19) with PB being dropped from the child model. CA was related to anxiety only through worry in children while IU showed direct paths to worry and anxiety in both children and adolescents. In the second study we present results from a case series where a modified version of the treatment based on the Dugas et al (1998) led to an 80% reduction in GAD diagnoses in 16 youth (aged 7-17 years) clinically referred for anxiety. Further testing and refinement of this cognitive model and its treatment may lead to further improvements in our understanding of worry in youth and its treatment. Possible modifications and refinements are discussed. Intolerance of uncertainty, worry, and Generalized Anxiety Disorder among young people Mark Freeston, Newcastle University and NTW Foundation NHS Trust The Intolerance of Uncertainty model of worry and GAD developed at Université Laval (Dugas et al. 1998) has proved a useful avenue for the development of effective treatments for adults and has resulted in a series of trials and broad dissemination. There has been relatively less attention to young people with few studies examining the models and even fewer testing the treatments that follow. This symposium brings together recent and on-going research in the area covering studies examining the construct of intolerance of uncertainty itself, treatment based on the model, and some early research on intolerance of uncertainty among young people with autism spectrum disorders (ASD). First, Sean Perrin (Institute of Psychiatry) will report on a recent open trial of treatment of 16 young people aged 7-17 with GAD using an adapted version of the Laval treatment. Second, Gioia Bottesi (University of Padua) and Mark Freeston (Newcastle University) will present an examination of the construct of Intolerance of Uncertainty with groups of typically developing young people of different ages. Third, Michelle Ford (Northumberland Tyne and Wear NHS Foundation Trust) and Mark Freeston will present an investigation of intolerance of uncertainty using situational measures with initial data from 12-14 year olds. Finally, Jacqui Rodgers (Newcastle University) will present initial findings on intolerance of uncertainty among samples of young people with ASD from the UK and the US.

Perinatal, Child and Adolescent Issues Chair: Polly Waite, University of Reading

Findings from a pilot randomised controlled trial investigating the efficacy of the Baby Positive Parenting Programme in women with Postnatal Depression Zoe Tsivos, University of Manchester; Anja Wittkowski, University of Manchester; Rachel Calam, University of Manchester; Matthew Sanders, University of Queensland Postnatal depression (PND) has wide and negative effects on maternal wellbeing as well as implications for the mother-infant relationship, subsequent infant development and more generally, family functioning. Postnatal depression (PND) impacts on a mother’s ability to be a sensitive and responsive caregiver. Furthermore parenting is thought to be a mediator for poor developmental outcomes. The Baby Positive Parenting Programme (a new variant of Triple P Positive Parenting Programme) has been designed to support new parents learn how to settle their baby, help their baby sleep, how to develop a positive relationship with their baby and how to look after themselves as well as after the relationship with their partner. This is a randomised controlled trial comparing the efficacy of Baby Positive Parenting Programme in addition to Treatment as usual (TAU) with TAU only in women with Postnatal Depression. Based on initial case observation Baby Positive Parenting appears to be a highly acceptable and promising intervention for women coping with Postnatal Depression. Preliminary case observations suggest that Baby Positive Parenting is associated with improvements in maternal mood and increased confidence in parenting. Baby Positive Parenting was rated highly acceptable to the treatment group. We hope to present group data. Findings from our research may help to inform the implementation of CBT within perinatal populations who are experiencing difficulties with parenting.

“Is it scary mummy?” Vicarious Learning as a Pathway for Fear Acquisition and Reduction in Children and the Relative Effectiveness of a Mother or a Stranger as Model Guler Dunne, Kingston University; Guler Dunne, Kingston University; Chris Askew, Kingston University; Young infants (12-20 months) show greater fear and avoidance of a stimulus after mothers respond negatively to it (Gerull & Rapee, 2002; Dubi, Rapee, Emerton & Schniering, 2008). Learning of this fear response is inhibited following positive modelling by mothers (Egliston & Rapee, 2007). The current study compared modelling by mothers and strangers, and

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examined whether children’s vicariously acquired fear beliefs for animals can be unlearned (‘counter-conditioning’) by positive modelling.Sixty children (29 boys, 31 girls), 6-10 years (M = 8.72 years, SD = 1.28) were shown images of novel animals (CS) together with images of mothers or strangers (US) displaying negative (‘scared-paired’) or positive (‘happy-paired’) facial expressions. Fear Beliefs Questionnaire (FBQ: Field & Lawson, 2003) The FBQ consists of 7 questions for each animal designed to measure fear beliefs, carried out: before, and after vicarious learning, and post counter-conditioning vicarious learning. Nature Reserve Task (Field & Storksen-Coulson, 2007). A triangular wooden board designed as an indirect measure of children’s avoidance/preference of the animals, carried out: after vicarious learning and counter-conditioning. Findings indicate children’s fear beliefs and avoidance of animals increased following fear-related vicarious learning and decreased following positive vicarious learning. Following positive vicarious counter-conditioning (unlearning), fear beliefs that had increased due to fear-related vicarious learning returned to pre-experiment levels. Similarly, decreases in fear beliefs due to positive vicarious learning, were reversed in subsequent fear-related vicarious learning. Children's fear beliefs increase for an animal if they see it with scared faces. However, presenting animals with happy faces before scared faces can prevent fear beliefs increasing above baseline levels. Similarly, seeing the animal with happy faces after seeing it with scared faces can return fear beliefs to baseline levels. The effect is the same whether the face is a stranger or the child's mother. Fear belief scores A three-way 3(Time: baseline, post-learning 1, and post-learning 2) x 3(Pairing type: scared, happy and none) x 4(Modelling group: MM, MS, SS,SM) mixed ANOVA was performed on fear belief scores (see Figure 1). The time x pairing type interaction was significant, F(3.13, 175.05) = 18.54, p < .001, indicating vicarious learning led to changes in fear beliefs dependent on the type of face presented. Planned comparisons showed a significant increase in fear beliefs after scared-pairing, F(1, 56) = 21.58, p < .001, r = .53, and decrease after happy-pairing, F(1, 56) = 10.12, p < .01, r = .39, returning to baseline levels after counter-conditioning. The group x pairing type x time interaction, F(9.38, 175.05) = 1.04, p > .05, was not significant indicating that there was no difference between mother and stranger modelling. Nature Reserve Task A three-way 2(Time: post-learning 1 vs. post-learning 2) x 3(Pairing-type: scared, happy, and none) x 4(Modelling type: MM, MS, SS, SM) mixed ANOVA was performed on NRT scores (see Figure 2). The main effect of pairing type was significant, F(2, 112) = 10.30, p <.001, as was the pairing type x time interaction, F(1.71, 95.63) = 26.45, p <.001, indicating that vicarious learning affected how far away from animals children placed themselves on the board depending on the type of face seen with an animal. Planned comparisons showed that the effect of pairing type differed over time for both scared and happy paired animals compared to the control condition. There was no significant main effect or interaction with group. The results of the current study showed that positive parental information demonstrated a significant decrease in children’s fear beliefs. Therefore, from a therapeutic point of view, parents could be taught, on the basis of the findings of this and other similar studies to actively provide positive instruction to their children when they are faced with uncertain or unfamiliar situations or stimuli in order to immunize their children from developing fears. Vicarious learning of social anxiety in children Chris Askew, Kingston University; Anna Hagel, Kingston University Evidence suggests that children can acquire fears for certain stimuli via vicarious (observational) learning (e.g. Askew & Field, 2007; 2008; Gerull & Rapee, 2002). However, little is currently known about the transmission of social fears vicariously and there are few experimental studies in this area. The current study aimed to investigate whether children’s social fear beliefs and cognitions are influenced by watching a model performing in a social situation with a negative outcome. Two groups of children (8 – 11 years, N = 64) watched animated films - one neutral, one negative (control) - of a stick figure playing basketball while being watched by a panel of judges. In the negative film the boy performs badly and expresses shame and embarrassment. Children’s social fear beliefs for the situation were measured before and after watching the film as well as their general levels of social anxiety. In addition, they completed an Emotional Stroop Task. Findings indicated that children can acquire social fear-related beliefs and processing biases after observing someone else’s embarrassment in a negative performance situation. Children’s social fear beliefs for the performance situation increased after children watched the negative animation compared to the neutral animation. In addition, children took longer to name the colour of social anxiety- relevant words compared to situation-relevant and neutral words in the Emotional Stroop Task. These effects were present after children’s general social anxiety levels were controlled for. Understanding how children’s fears develop can lead to the development of better treatment.

Anxiety in Autism: An Intergenerational Phenomenon? Katy Hopkins, University of Reading; Fiona Knott, University of Reading; Lucy Willetts, University of Reading Children with Autism Spectrum Disorder (ASD) have elevated rates of anxiety in comparison to their non-ASD peers. Non-ASD children with anxiety disorders often have anxious mothers and maternal anxiety may act as an impediment to treatment. It is unknown whether this is the same in ASD; this study aimed to measure maternal anxiety in a cohort of anxious children with ASD. Anxiety was measured using semi-structured interviews (ADIS; ADIS-C) and questionnaires (DASS-21; SCAS). Possible explanations and clinical implications of these findings and directions for future research are discussed. 85% of children in the sample were found to have an anxiety disorder using the combined parent-child ADIS and of these 35% had clinically anxious mothers. No correlation was found between maternal and child anxiety severity ratings either on the ADIS(C) or on the child-report version of the SCAS, although a significant correlation was found between maternal anxiety and parent-reported child anxiety on the SCAS. Interestingly, maternal stress, as measured by the stress subscale of the DASS-21 correlated with both parent- and child-reported child anxiety on the SCAS but not on the ADIS. The parenting stress index (PSI), a more detailed measure of stress, showed the same result. Treatment for child anxiety has better outcomes when parents are involved, particularly for the subgroup of anxious children with anxious mothers. If a relationship exists between maternal affective disorder and child anxiety in ASD, this is likely to have implications for the treatment of child anxiety in this population.

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Evaluation of an MBCT course adapted for 14-18 year olds with anxiety and depression Brenda Davis, Brighton & Hove tier 3 CAMHS, SPFT; Lana Jackson, Brighton & Hove tier 3 CAMHS, SPFT There exists a strong evidence base for MBCT for adults with anxiety and depression (Teasdale et al, 200), (Ma & Teasdale, 2004), now extended for use with other disorders. The emerging evidence base for mindfulness approaches with adolescents is mostly with non-clinical, school based samples (Huppert and Johnson, 2010), but increasingly also with clinical populations (Bogels et al, 2008), (Biegal et al, 2009). We were interested in adapting MBCT for adolescents presenting to CAMHS with anxiety and depression. Aims for treatment were reduced levels of anxiety and low mood and an increase in coping skills for both, maintained at 3 and 6 month follow up, plus achievement of individual treatment goals. We are delivering a termly 6 week programme of 1 ¼ hour sessions with shorter, more varied practices to groups of 8-10 adolescents between 14-18 years. MFQ (depression) and SCARED (anxiety) are used pre and post group with adolescents and parents, and at 3 and 6 month follow up. CAMM, an adolescent mindfulness measure, and the CORC goal based measure are also used pre and post- group. Feedback is obtained post-group via interview with young people and their parents, which has informed modifications made to the group programme to assess and improve effectiveness. Data available from two groups run in Summer and Autumn 2011 showed 50% to 75% improvements in anxiety and 50% to 83% in low mood and 60% to 100% gains in problem resolution/goal attainment, as well as 50-60% gains in mindfulness skills post-group. We are awaiting 3 and 6 month follow-up data and results from our group finishing in March 2012. The greater improvement on mood than anxiety in the second group and vice versa may be the result of earlier introduction of being with difficult thoughts/feelings in the second group. Also there were higher initial levels of anxiety in the first group (exam stress), and in low mood in the second, so the degree of overall change was likely to be greater respectively. This treatment, if proved effective, could provide a way of reaching a larger number of young people in CAMHS with anxiety and depression, delivered pre-discharge, to help prevent relapse.

Panel Discussion An Innovative Approach in CAMHS to First Episode Psychosis using Parents as Co-Therapists Convenor: Faramarz Hashempour, Betsi Cadwalader University Health Board Speakers: Faramarz Hashempour, Betsi Cadwalader University Health Board; Sylvia Rawlings, Parent of Service User; Tracy O'Farral, Parent of Service User; Katherine O’Farral, Service User; Sarah Clarke, Betsi Cadwalader University Health Board

Cognitive Behavioural Therapy (CBT) for Psychosis was introduced by Beck in 1952 (Beck, 1952), and since this has further developed to a more adaptive and flexible approach in treatment of First Episode Psychosis and its features. Therefore in line with National Institute of Clinical Excellence (NICE) directives, early intervention to Psychosis within Flintshire CAMHS has been pro-actively addressed by developing a skills group for parents/carers in conjunction with individualised CBT or other modality based intervention. Parenting any child is difficult, however parenting a child/young person with mental health difficulties can be extremely challenging. There are many validated parenting programmes available for families of children with difficulties such as Eating Disorders (Zucker et.al., 2005), Phobias (Cartwright-Hatton et.al., 2011) and Attention Deficit Hyperactivity Disorder (ADHD) (Jones et.al., 2007). Similarly NICE has provided guidance for treatment in First Episode Psychosis and Early Intervention (NICE, 2002). However, Early Intervention Services (EIS) and family support intervention programmes for families of children/young people experiencing symptoms of Psychosis seem to be lacking. This is not only evident in Wales but throughout the UK. This deficit has been highlighted by a number of service providers namely, the Betsi Cadwalader University Health Board (BCUHB) and has extensively been discussed by the First Episode Psychosis Steering group at both county and country (Wales) level to develop intelligent targets within the ‘1000 lives’ Welsh Assembly Government initiative. In addition Flintshire CAMHS endeavours to develop engaging and active therapeutic approaches with families, children, and young people. This has been recognised by the Royal College of Psychiatry award for CAMHS provider of the Year 2010. Programme Development A small team was developed to carry out a pilot project to provide such a service for four families. Children/young people were identified by clinicians along with a brief description of current presentation. The child/young person was then approached for consent to contact their parent/carer and offer them a place on the programme. We had a range of parents of young people at different levels of functioning from newly assessed to hospital admissions. The programme was developed to educate parents, resulting in a better understanding of Psychosis. This was provided in a safe environment and to present them with skills to become the Co-Therapist within their family unit, assisting in the recovery process of their child/young person. The elements which were covered over the eight weeks included: An Introduction to Psychosis; Symptoms and Presentation of Psychosis; Introduction to CBT; Impact on Family Life; Safekeeping; Types of Intervention, Treatments and Stigma; Relapse and Relapse Prevention. The programme was delivered via theoretical teaching and practical exercises which prompted group discussion which all parents and facilitators found beneficial. Upon concluding the programme, parents were positive about the effects that the information had had on the way they parent their child/young person. Parental Endorsements ‘An excellent course that provides the support, information and guidance required to help your child’. (Parent, attendee) ‘Very informative and supportive – helped immensely. Theoretical information and practical sessions were a good balance’. Implications: To promote active involvement and engagement with families utilising CBT as a core mode of intervention. This in turn would further involve families in delivering an appropriate framework of treatment. Furthermore, implications for future research in this area and future provisions could be highlighted and shortfalls could be addressed from the panel discussion.

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Posters A Service Evaluation: Service User Satisfaction in Attending a Dialectical Behaviour Therapy Course Hannah Lisa Butler, University of Manchester The National Service Framework for Children, Young People and Maternity Services state that a part of developing a “comprehensive CAMHS” is through encouraging the participation of service users and their families in all operational aspects of services (standard nine; DoH, 2004; Garland et al, 2000). In line with this and in consideration of the current economic climate inflicting pressuring on NHS Services to demonstrate “value for money”, it is becoming progressively important for services to evaluate and evidence satisfaction in conjunction with highlighting efficient and (cost-)effective services (Walker et al, 2010). Dialectical Behavioural Therapy (DBT), originally developed for chronically suicidal adults, has both expanded and adapted its scope and target treatment population (DoH, 2004; Scheel, 2000). DBT courses are now being recognised for providing young people with effective techniques and skills to improve psychological well-being and lifestyle (James et al, 2011). A local Child and Adolescent Mental Health Service regularly offer DBT courses across 3 localities within the North West. Historically the Service has used quantitative outcome measures to gain insight into course member perspectives. Unfortunately low response rate has resulting in a lack of sufficient data to conduct meaningful analysis. With this in mind, the Service were keen to explore children and young people’s satisfaction with recently attended Service run DBT courses through the use of qualitative methodology. Five participants were interviewed and their data explored utilising thematic analysis guided by Braun & Clarke (2006). Findings suggest satisfaction with the DBT course and benefits post-course indicating an efficient and (cost-)effective intervention and therefore supporting the continuous provision of DBT courses within this setting. Negative aspects tended to reflect future recommendations with necessary Service consideration within these areas. Methodological limitations of the service evaluation are discussed within the report. Four key themes (DBT course-positive talk, DBT course-negative talk, post-course benefits and future recommendations) and 11 sub-themes emerged from the data. With the lack of global literature detailing service user satisfaction with DBT courses (especially young people) and the increasing need and pressure to evidence clinically-effective provision, this service evaluation is timely. The data collected provides valuable insight about the experiences and satisfaction of young people who attended a DBT course, suggests feasible adaptations for future DBT groups and arguably highlights considerations for everyday clinical practice. The Moderating Role of Child Callous Unemotional Traits in an Internet-based Parent Management Training Program Jens Högström, Karolinska Institute, Department of Clinical Neuroscience; Pia Enebrink, Karolinska Institute, Department of Clinical Neuroscience; Ata Ghaderi, Uppsala University, Department of Psychology Although parent management training (PMT) is generally considered the treatment-of-choice for children with conduct problems, there are differences in how well different subgroups of parents and children benefit from these interventions. The aim of this study was to examine the influence of child callous-unemotional traits (CU traits) on the outcome of an internet-based PMT-program for parents of non-referred children with conduct problems (n = 57; mean age 6.65). This was a randomized controlled trial where children assigned to the intervention group were categorized as either “High CU” or “Low CU”. Group affiliation was decided through a cut-off score on the CU subscale of the Antisocial Process Screening Device. Analyses of baseline- and treatment outcome differences between the groups were conducted. Elevated levels of callous-unemotional traits in children seem to predict an inferior treatment response in parent management training. These findings call for more attention on empathy and emotional patterns in the assessment of children with conduct problems. CU traits in children were associated with more severe conduct problems at baseline, as well as more hyperactivity and peer related problems. Treatment outcome, in terms of conduct problem reduction, was poor in the High CU group compared to the low CU group, despite the fact that parents in both groups improved equally in parenting skills. Today, several efficacious prevention and treatment programs with a behavioural orientation exist for children with conduct problems. While these and other evidence-based programs show good effects for many families, there is still a need to enhance treatment effectiveness for families and children not adequately supported by the available interventions. As the present findings indicate, children with CU traits and conduct problems may be a subgroup in need of other treatment components for improved outcome. In order to provide children and parents with the best available interventions, assessment of CU traits, in a standardized manner, may need to be conducted on a more regular basis. Acceptability of telephone versus face-to-face cognitive behaviour therapy for obsessive compulsive disorder in youth: the views of parents and young people Katie Lang, National & Specialist Obsessive Compulsive Disorder and Related Disorders Clinic for Young People, South London & Maudsley (SLaM) NHS Foundation Trust; Karina Lovell, University of Manchester; Georgina Krebs, National & Specialist Obsessive Compulsive Disorder and Related Disorders Clinic for Young People; South London & Maudsley (SLaM) NHS Foundation Trust; Isobel Heyman, National & Specialist Obsessive Compulsive Disorder and Related Disorders Clinic for Young People; South London & Maudsley (SLaM) NHS Foundation Trust; Cynthia Turner, National & Specialist Obsessive Compulsive Disorder and Related Disorders Clinic for Young People. South London & Maudsley (SLaM) NHS Foundation Trust Cognitive Behaviour Therapy (CBT) is the first line recommended treatment for obsessive compulsive disorder (OCD) in young people. However, face-to-face CBT may not be a viable option for some patients for a number of reasons. Telephone CBT (TCBT) has a number of potential advantages including overcoming geographical barriers and increasing convenience for families, thereby improving access to CBT. This poster presents a study looking at the satisfaction levels reported from families, who had their treatment as part of a randomised controlled trial comparing TCBT with face-face CBT. Young people within the UK were randomly assigned to receive CBT either face-to-face or via the telephone. All families completed a treatment satisfaction questionnaire developed for the purpose of the study, the widely used Experience of Service Questionnaire (ESQ), and the Therapeutic Alliance Questionnaire. Comparisons were made between the acceptability of TCBT versus face-to-face CBT, with respect to both parents and young people’s opinions. The discussion will consider the findings and implications of the results. The results of this study will be presented. Demonstrating that TCBT is a well accepted form of treatment has important implications regarding the accessibility of CBT. Delivering CBT via the telephone could increase access to CBT for families where geographical location is problematic. It could also prove to be a more convenient and cost-effective method of delivery.

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Eating Disorders and Impulse Control

Keynote Address

Is obesity a problem that simply does not yield to psychological methods of treatment? Andrew Hill, Academic Unit of Psychiatry & Behavioural Sciences, University of Leeds School of Medicine The title of this presentation is a conclusion offered by Kelly Brownell, Professor of Psychology at Yale School of Public Health, reflecting on 45 years of behavioural treatment for obesity. It was prompted by publication of a trial documenting the failure of a new cognitive behavioural treatment directed at maintenance of weight loss (Cooper et al, 2010). A variety of issues cascade from the paper and associated commentaries, several of which that challenge this rather bleak assertion. Foremost is that our conceptualization of obesity and understanding of its causes have altered. Psychological research in the 1960s and 70s focused on differences between the obese and non-obese in the ways they responded to and consumed food. The formulation that underpinned behavioural treatment was of deficits in self-control skills. This view has been perpetuated, in part for reasons of political expediency, by portraying obesity as a lifestyle disorder: something that merely requires a self-motivated change in behaviour(s) to resolve obesity. The shift to an environmental perspective, that of an obesogenic environment, alters the formulation. It accepts that the environment is especially toxic for susceptible people and includes the possibility that obesity itself increases vulnerability to obesity risk factors. This new understanding also argues for behavioural justice; not repeatedly blaming the obese for failing to treat their obesity in the face of such forces. Accordingly, many clinicians and researchers now regard obesity as a chronic condition requiring long-term supportive management, akin to diabetes and hypertension. With this change in conceptualisation come changes in approach. One is to separate treatments for weight loss from those that maintain loss once achieved. Behavioural treatments are effective in weight loss although mostly embedded within complex interventions. Maintenance of treatment gains requires treatment continuation, possibly including different strategies such as motivational interviewing. Another approach is to recognise the opportunities offered in the current environment. These range from exploiting the different reinforcement opportunities (e.g. financial) to alterations in social networks and ways in which children and adults interact. Finally, psychological approaches can offer kind and compassionate help to manage the distress associated with being fat in an overweight intolerant society, as in third wave and compassion-based therapies.

Symposia Implementing CBT for the eating disorders: how do we ensure the delivery of good quality care? An opportunity to discuss and reflect upon common service dilemmas Convenor: Hannah Turner, Southern Health NHS Foundation Trust

Waiting list management in treatment for the eating disorders Madeleine Tatham, Cambridgeshire & Peterborough NHS Foundation Trust Guidelines for the treatment and management of eating disorders recommend that those seeking help for their eating disorder “should be assessed and receive treatment at the earliest opportunity” (NICE, 2004). However demand for services often exceeds healthcare resources and a common consequence is the development of waiting lists for assessment and/or treatment. Whilst this has a cost in itself relating to the time and resources required to manage the list, it also raises questions regarding how patients are prioritised for treatment; are decisions based on clinical risk, on the patient’s potential to benefit from therapy or other factors? Pressure to reduce waiting times also has implications for therapist workload; how many patients should a therapist be expected to see? This discussion will focus on addressing some of these questions. Running an evidence-based service for the eating disorders in real-life clinical settings Hannah Turner, Southern Health NHS Foundation Trust Alongside intervening at the earliest opportunity, it is also recommended that patients should be able to access evidence-based treatment interventions (NICE, 2004). Adherence to treatment protocols is closely monitored within research settings, but how can we ensure that patients are getting evidence-based treatment in routine clinical settings? Addressing this question requires us to consider a number of areas including training and supervision, as well as assessment of clinical competencies and outcomes. Should therapists in routine clinical settings use outcome measures to regularly monitor progress and if so what measures should be used and when? What do we do if we don’t see clinical change? Alongside thinking about what to measure and when, consideration also needs to be given to how such procedures can be integrated into routine clinical care. This in turn connects to a need to build a team culture that values the assessment of clinical competencies and outcomes. This talk will focus on addressing some of the issues connected to how we might best ensure that patients get good quality therapy, and how we might get our clinical colleague on board with this aim. The complexities of offering good quality care for children and adolescents with eating disorders Rachel Bryant-Waugh, Great Ormond Street Hospital for Children NHS Trust Implementing evidence-based practice in relation to eating disorders in child and adolescent settings raises particular challenges. The evidence base generally in this population is small, leading to appropriately cautious phrasing of current guidance. This can result in variable interpretation and lack of clarity for the clinician about optimal intervention strategies. The extent to which it is appropriate to extrapolate from research with adults remains unclear and guidance around effective ‘treatment packages’ is absent in this age group. In addition, it is well recognised that the presentation of clinically significant eating disturbances in this younger population presents diagnostic challenges, in turn raising problems for clinicians in relation to the delivery of evidence based care. These and other issues related to offering good quality, cost effective care in a child and adolescent population will be discussed.

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What should we do with severe and enduring cases of the eating disorders? Nicky Boughton, Oxford Health NHS Foundation Trust Whilst a significant percentage of patients will make positive progress in their recovery, a small percentage will present with a severe and enduring course. Approaches to managing this clinical group are likely to vary across services and may include discharge back to primary care if physically stable, long-term contact with out-patient specialist teams and/or repeated hospital admissions without clear progress in recovery or sustained improvement in quality of life. The question as to how best to manage the needs of this group is complex: should patients be managed in a separate part of the service? Should there be a limit on number of admissions? Is there ever a case to consider palliative care? This talk aims to facilitate discussion of some of these important clinical and ethical dilemmas. What goes on in the Eating Disorders Clinic? Clinicians’ and patients’ perspectives on treatment, the working alliance, and recovery

Convenor: Glenn Waller, CNWL NHS Foundation Trust and King's College London

What do CBT therapists do when they say they are doing cognitive-behavioural therapy for the eating disorders? Glenn Waller, CNWL NHS Foundation Trust & King's College London; Hannah Stringer, Caroline Meyer, Loughborough University Objective: Clinicians commonly ‘drift’ away from using proven therapeutic techniques. This study examined the degree to which such ‘drift’ occurs among CBT clinicians working with a specific clinical population – adults with eating disorders. Method: The participants were 80 qualified clinicians (69 female, 11 male; mean age = 39.2 years, range = 23 – 62), who routinely offered what they described as CBT to adults with eating disorders. Each detailed whether/how often they used different cognitive-behavioural techniques when delivering CBT to such patients, and completed the anxiety scale of the Brief Symptom Inventory. Results: Implementation of specific CBT techniques was far lower than protocols would suggest, particularly for clinicians who were anxious, older, or more experienced in working with the eating disorders. The use of treatment manuals was associated with greater use of recommended CBT techniques. Cluster analysis showed that clinicians fell into three types – behaviour-, motivation- and mindfulness-oriented. Conclusions: These findings need to be extended to other therapies and other disorders, but they indicate the need for stronger training and closer supervision if clinicians are to give patients the best chance of recovery. They demonstrate that clinicians’ use of the label ‘CBT’ is not a reliable indicator of the therapy that is being offered. Do patient factors influence the development of an early effective therapeutic alliance in cognitive-behavioural therapy for the eating disorders? Jane Evans, CNWL NHS Foundation Trust The therapeutic alliance is not an issue that is ignored either in CBT in general (e.g., Gilbert & Leahy, 2007) or in CBT for the eating disorders (e.g., Fairburn, 2008; Waller, Cordery, Corstorphine, Hinrichsen, Lawson, Mountford & Russell, 2007), however, it is more often assumed than discussed in this field. The following paper explores patient factors that influence an early effective therapeutic alliance in CBT for the eating disorders. The findings shall be presented alongside a discussion of clinical implications, including how to establish an effective working alliance utilising a “judicious blend of empathy and firmness” (Wilson, Fairburn & Agras, 1997). Objective: This study examined the strength of the therapeutic alliance in the early stages of cognitive-behavioural therapy (CBT) for the eating disorders, and whether the strength of that alliance is associated with early eating characteristics, comorbid axis 1 features and axis 2 features. Method: Forty-four eating-disordered patients completed measures of eating and axis 1 and 2 characteristics at the start of therapy, and measures of the therapeutic alliance and eating characteristics at the sixth session of CBT. Results: The therapeutic alliance was strong, including in the domain of attachment. It was unrelated to initial eating pathology and early changes in eating cognitions and behaviours. However, there were links between initial emotional and interpersonal features and therapeutic alliance by the sixth session. Discussion: The findings counter suggestions that CBT for eating disorders is characterised by a poor therapeutic relationship. The therapeutic alliance is likely to be enhanced by addressing high levels of emotional distress and difficulties in interpersonal function where appropriate. This research needs to be extended to other therapies, other domains of function and different time points in therapy, to build a fuller picture of the role of the therapeutic relationship in working with the eating disorders. Therapeutic alliance and early behavioural change in cognitive behavioural therapy for anorexia nervosa Amy Brown, Royal Holloway, University of London Objective: The current study examines the role of two processes in cognitive behavioural therapy (CBT) for anorexia nervosa: therapeutic alliance and early behavioural change. Specifically, their effects on treatment outcomes and the temporal relationship between the two processes are explored. Method: A longitudinal analysis was conducted on a case series of referrals (n=62) who were assessed and offered individual outpatient CBT for anorexia nervosa at a specialist clinic for eating disorders. Therapeutic alliance was measured using the client rated Working Alliance Inventory-Revised-Short Form (WAI-SR). Early behavioural change was measured by change in weight in the early part of treatment (session one to six). Two outcomes were considered: treatment retention and weight gain in the later part of treatment. Results: Neither early weight gain nor early therapeutic alliance were significantly associated with the likelihood of completing treatment (although there was a trend for treatment completers to gain more weight than non-completers in the early part of treatment). Higher scores on the WAI-SR-Bond subscale in the early part of treatment was associated with significantly less weight gain in the remaining treatment. Early weight gain was significantly associated with less later weight gain. Temporal correlations revealed that early weight gain is positively associated later therapeutic alliance, but not vice versa. Conclusions: Therapeutic alliance is widely considered important in psychological treatment response (e.g. Horvath & Symonds, 1991); this study does not support that association in CBT for anorexia. In addition, while there is fairly robust evidence that early behavioural change is associated with good outcome in therapy for other eating disorders; this study

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raises questions about the applicability to anorexia nervosa. The sequential relationship described between therapeutic alliance and weight gain is in support of the argument that it is successful change in therapy that drives therapeutic alliance. Recovery from eating disorders: Sufferers’ and clinicians’ perspectives Francesca Emanuelli, Azienda Ospedaliera San Paolo, Milano, Italy; Glenn Waller, CNWL NHS Foundation Trust and King's College London Objectives: Disagreement exists on how to define recovery from eating disorders. Definitions include physical, cognitive, emotional, psychological and social factors. However, none provides a multidimensional model of recovery, addressing and comparing sufferers’ and clinicians’ viewpoints. This study investigates those perspectives on recovery. Method: Two-hundred and thirty-eight participants (individuals with eating difficulties and clinicians working in the field) completed a recovery checklist, rating the importance of 53 somatic, cognitive. emotional, social, eating-related, and body experience-related recovery criteria. Results: Recovery criteria fell into five meaningful factors (Psycho-emotional-social, Weight-controlling behaviours, Non-life threatening features, Life-threatening features, Evaluation of one’s own appearance). Sufferers and clinicians agreed on the ranking of importance of these five factors, but sufferers considered the ‘Psycho-emotional-social’ and ‘Evaluation of one’s own appearance’ criteria as more important to recovery than clinicians did. Conclusion: Findings are discussed in relation to existing research, together with study limitations and future research. Clinical implications are outlined, focusing on the facilitation of recovery.

Emotions in the eating disorders Convenor: John Fox, University of Manchester and Priory Hospital Cheadle Royal

Eating disorders and multi-level models of emotion: the SPAARS-ED model of eating pathology John Fox, University of Manchester and Priory Hospital Cheadle Royal This presentation will outline a new model of eating disorders - the SPAARS-ED, which that is based upon the SPAARS model of emotion functioning (Power and Dalgleish, 2008). This new model is supported by data from five innovative studies that have highlighted the potential role of coupled emotions in both anorexia nervosa and bulimia nervosa. The first two studies found that anger and disgust were potentially ‘coupled’ within individuals with symptoms of bulimia nervosa and anorexia nervosa. In one of these studies, the anger induction led to an increase in the perception of their body size (for anorexia nervosa), when compared to controls. One of the other studies was a qualitative study that investigated perceptions of the basic emotions and the developmental histories of emotions within people with severe anorexia nervosa. The analyses revealed themes that centred upon difficulties to express either sadness or anger, with a number of beliefs about the threat or lack of entitlement in expressing emotion. In keeping with other research on emotions in eating disorders, all the participants discussed these difficulties with their management of their emotions, and this was termed ‘poor meta-emotional skills’. All of these data support the new SPAARS-ED model. Shame, self-criticism and self-compassion in eating disorders Hannah Andrews, Coventry Eating Disorder Service This presentation will explore the role of shame, self-criticism and self- compassion in eating disordered population, including Anorexia and Bulimia Nervosa, ENDOS, Binge Eating Disorder and adults who are obese and seeking treatment for weight loss. Shame and self-criticism are very high across these populations. A model for understanding how this may impact on the aetiology, maintenance and treatment will be introduced, and data exploring these emotions in eating disorders will be presented. The development of self-compassion as a way of addressing shame and self-criticism, and supporting patients though the process of therapeutic change during recovery from an eating disorder, will be discussed. Data regarding treatment outcome for a group therapy that targets the development of self-compassion (Compassion Focused Therapy for Eating Disorders) will presented. Shame and pride in eating disorders Anita Holtom-Viesel, Coventry Eating Disorder Service Although much attention has been recently paid to the impact of “negative” emotions in the aetiology and maintenance of eating disorders, relatively little is known about the impact of “positive emotions”. This presentation will present a model in which the positive affect of pride is seen as an important factor which may need to be addressed during treatment. Data from research based on the development of new measure of shame and pride in eating disorders will be outlined . Finally there will be a discussion of the clinical implications of the high levels of pride in eating disorder behaviours associated with feelings of attractiveness and being in control that was found in clinical samples. The perception of threat from basic emotions and binge eating behaviours in people who are obese and seeking treatment for their weight John Fox, University of Manchester/Priory Hospital Cheadle Royal; Emily Suter, Rachel Msetfi, Richard Johnson, University of Manchester Obesity is a current priority for governments in developed countries. Due to the heterogeneity of obesity, increased focus has been placed on subgroups of people who are obese, such as those who binge eat. It has been suggested that some people binge eat in response to distressing emotions. This study was designed to test some of the theoretical pointers from the eating disorders (ED) literature that emotions are seen as threatening and this leads to an increase in ED symptomatology. Consequently, it was hypothesised that perceptions of threat from the basic emotions (e.g. sadness, anger, fear) would predict binge eating. In addition, it was hypothesised that emotional expressiveness and emotional eating would significantly contribute to the additional variance in this group. This study had fifty-one participants who were obese who were recruited from weight management services in the North of England. Following on from a regression analysis, results showed that the perception of threat from sadness directly predicted binge eating, whilst the perception of threat from fear, via reduced emotion expressiveness, also predicted increases in binge eating. This study’s findings strongly suggest how it is important to consider individual emotions in treating binge eating and this may be a fruitful way forward in the treatment of this condition.

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Advances in Cognitive-Behavioural Therapy for Problem and Pathological Gambling Convenor: Neil Smith, National Problem Gambling Clinic

The present and future of CBT for problem gambling Neil Smith, National Problem Gambling Clinic Problem and pathological gambling is the most widely recognised and established behavioural-type addiction, with cognitive-behavioural therapy the recommended intervention for treatment. Since the 1980’s researchers have been establishing the evidence base for the treatment of problem gambling with CBT. Studies looking into individual and group CBT have displayed the efficacy of this type of treatment and compared it favourably with more commonly known treatment approaches for gambling, such as the 12-step programme of Gambler’s Anonymous. A meta-analysis has also established good effect sizes for the treatment of problem gambling with CBT. However, the current treatment models and manuals available for problem gambling have their roots in ‘second-wave’ CBT treatment programmes. This talk will summarise the area of problem gambling and the current evidence for CBT approaches. To date, there have been few studies investigating the effectiveness of the newer innovative forms of CBT. This talk will also detail the available literature on third-wave CBT approaches for the treatment of problem gambling and speculate on innovative approaches that could be taken with the cognitive and behavioural treatment of problem gambling, drawing on the mental health and substance misuse research literature. Neuropsychological mechanisms of distorted cognition in problem gambling Luke Clark, University of Cambridge Gambling is a classic risky behaviour, and despite widespread acceptance that ‘the house always wins’, gambling remains a popular and expanding form of entertainment, which also becomes dysfunctional in a small but significant minority. This presentation will review recent developments in understanding the cognitive and neural mechanisms that underlie gambling decisions, focussing on the cognitive distortions that occur during play. In ongoing work at the National Problem Gambling Clinic, we are using a combination of self-report questionnaires and neurocognitive testing to elicit and quantify these distortions, and explore their relationship with facets of impulsivity. In a comparison of 30 pathological gamblers (PG) and 30 controls, the PG group displayed elevated self-reported impulsivity on several UPPS-P subscales, with strongest effect sizes on mood-related impulsivity (‘Urgency’; positive urgency, Cohen’s d=1.427, negative urgency d=1.784). Impulsive choice was observed on a state measure of delay discounting, and discounting tendencies were highly predictive of the level of gambling distortions (on the Gambling Related Cognitions Scale). Several distinct distortions have been identified, which can also be elicited in the laboratory in healthy participants. In sequential predictions, the Gambler’s Fallacy occurs when a run of one outcome (e.g. heads in a coin-flipping task) generates a conviction that the other outcome (tails) is somehow ‘due’. Other distortions pertain to mistaken appraisals of skill (the ‘illusion of control’). We have been particularly interested in the processing of ‘near-miss’ events (losses that are somehow close to a win), which enhance motivations to gamble despite their objective status as losses. Psychophysiological and functional MRI studies provide some clues about the motivational basis of these effect, which may also operate through false appraisals of skill acquisition. Online CBT Interventions for Problem Gamblers – Opportunities and Dilemmas Sharon Kalsy, Gamcare Emerging technologies over the last twenty years have meant that conventional therapies can now be delivered in a variety of different ways. Intuitively, given the prolific use of the internet, it might appear that making therapy available via online media is a necessary advancement in the field of psychological treatment as a means, if nothing else, of improving access into treatment services. However, what opportunities are afforded by online services and what might be the pitfalls? During this session, Dr Kalsy will discuss how CBT treatments may be adapted for delivery online, how clinical formulations might emerge when clients and clinicians are rendered invisible by this medium of treatment and the safeguards that should be in place to protect the integrity of the treatment itself. Consideration will be given to the dispelling of common misconceptions about delivering treatment online, the opportunities for developments in online psychological treatments for individuals, couples and groups and the vulnerabilities faced when using technology to deliver clinical services. Questions and comments will be gratefully received to help further expand thinking around this fascinating area of clinical work. Metacognitions and Problem Gambling Annika Lindberg, National Problem Gambling Clinic; Bruce Fernie, CASCAID; Marcantonio Spada, London South Bank Univeristy Problem gambling is heterogeneous in nature, ranging in severity from occasional but problematic gambling episodes, to extreme, impulsive and pervasive gambling behaviour. Problem gambling may be accompanied by a sense of impaired control and can give rise to financial, interpersonal, legal and vocational costs for the sufferer, their families and society. This study investigated the relationship among metacognitions, anxiety, depression and gambling in a sample of problem gamblers. A total of 91 individuals attending gambling treatment services completed a battery of self-report instruments that consisted of the Metacognitions Questionnaire 30 (MCQ-30), the Hospital Anxiety and Depression Scale (HADS) and the South Oaks Gambling Scale (SOGS). Correlation analyses showed that anxiety, depression and metacognitions were positively and significantly correlated with both gambling consequences and behaviour. Hierarchical regression analyses indicated that two metacognitive constructs (negative beliefs about thoughts concerning uncontrollability and danger and beliefs about the need to control thoughts) predicted gambling behaviour independently of anxiety and depression. These findings are consistent with the hypothesis that metacognitions play a role in problem gambling. The results of the study will be discussed and links will be made to our clinical work and how it can further inform our practice.

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IAPT and Primary Care

Keynote Addresses

IAPT Progress Report Kevin Mullins, National IAPT Director, Department of Health This keynote address will give an update on the first 3 years’ implementation of the main ambitions of the IAPT programme to roll out access to psychological therapies across all health communities in England. Additionally, it will provide an update on the extended programme aims set out in “Talking Therapies: A four year plan of action”.

Symposia

Extending the Scope of the IAPT Programme to Other Client Groups: Workforce Implications and Impact on Education and Training Convenor: Graham Turpin, National Advisor IAPT Education and Training

Where we are with the current IAPT workforce and education and training Roslyn Hope, IAPT National Workforce Advisor The IAPT programme started in 2008 and since then has developed a new workforce of over 3600 to deliver evidence based interventions for adults with anxiety and depression. The first phase ended in 2011, having focussed on training new and existing staff in CBT interventions through an ‘earn and learn’ process, but building choice through the development of IPT, Couple Therapy, Counselling and Brief Psychodynamic Psychotherapy (‘the four modalities’). The second phase from 2011- 2015 has been funded to complete the roll out to this group in all geographic areas and to extend access to psychological therapies by other groups including children and young people, older people, those with long term conditions and medically unexplained symptoms and to people with severe mental ill health. Commissioning of training in CBT and the four modalities is continuing although the demand and the process varies across Strategic Health Authorities, influenced by financial pressures, local service commissioning priorities and history; nevertheless IAPT is clearly identified as a priority in the national Operating Framework. Considerable interest is being shown in the extensions to other client groups and local services and universities are already organising their own training for these groups. It is important at the outset to be clear how far the current IAPT model of stepped care, low and high intensity interventions, competences and bespoke training curricula, and outcome measurement are applicable to these new groups. The ‘earn and learn’ model of funding new posts is not directly applicable and therefore service and workforce redesign is an important new focus, already clear in terms of the children and young people national sites. The same is likely to be true of the other client groups, but this is a developing picture as these programmes of work take shape. Which workforce becomes an important area for clarity, whether it is CAMHS teams, primary care teams, secondary care providers in NHS Trusts and staff in the voluntary and private sectors. The principles of outcome measurement and competence based workforce development will continue but their form may change. This symposium is intended to explore current thinking and practice as it develops. Ensuring that IAPT services encompass the needs of older people and their carers Cath Burley, PSIGE Chair & Division of Clinical Psychology, Faculty of the Psychology of Older People Over 10 million people in the UK are aged 65 years and above, making up almost 18% of the total UK population and 21% of the adult population. There are over 6 million carers supporting long-term sick and infirm relatives at home, the majority of whom are in their later years themselves. However, Glover et al’s (2010) review of the data from the first wave IAPT implementation sites showed that only 4% of referrals were from this age group. Therefore, it is incumbent upon the IAPT Programme to ensure that services are designed to meet the needs of this age group. This presentation will report on the progress of the PSIGE/IAPT working group which is developing IAPT operational standards to provide an effective model for creating equal access for older people. Workforce planning proposals for ensuring that IAPT staff have appropriate competences for working with this age group will lead to the development of specific additional elements to the curricula for HI and PWP training programmes and to top-up training for existing IAPT staff. Consideration is given to the specific needs of people with dementia and their carers and to those with long term conditions. IAPT and services for people with long-term conditions and/or medically unexplained symptoms Rona Moss-Morris, National Advisor IAPT for LTC/MUS Increasing access to psychological therapies for people with long term conditions (LTCs) and and/or medically unexplained symptoms (MUS) is one of the new IAPT work streams. Long term conditions are physical illnesses which can be managed but not cured by current medical treatments and/or lifestyle changes. MUS is an umbrella term currently used to describe symptoms or syndromes where the level of disability and symptoms experienced by the patient appear disproportionate to the underlying medical pathology and includes conditions such as irritable bowel syndrome and fibromyalgia. In this presentation I will provide an evidenced based argument for conceptualising MUS as biopsychosocial conditions rather than medically unexplained conditions. I will present our working model for providing psychological support to people with LTC’s and MUS which includes a stepped care approach and the importance of collaborative multidisciplinary care. The advantages of incorporating psychological treatment within current medical services rather than proving treatment through parallel mental health or liaison services will be debated. Discussion will focus on how psychological interventions for these groups may differ to interventions for people with primary mental health problems, the need to provide specialist IAPT training in this area and the overlap between MUS and LTCs.

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IAPT and services for people with severe mental illness Alison Brabban, National IAPT Advisor & Alex Stirzaker, National IAPT Advisor Since 2008 the IAPT programme has focussed its development upon adults suffering from anxiety and depression. Whilst access to psychological therapies for this population has become more readily available, the case remains that many people suffering from more severe and complex difficulties lack the same opportunity, despite the fact that psychological therapies are recommended in NICE guidance for these groups. In the last 12 months the IAPT programme has expanded to include a work stream to improve access to psychological therapy for those diagnosed with psychosis, bipolar disorder and personality disorders. This presentation aims to outline the plans for how this is to be achieved, including some of the challenges that need to be tackled to make the goals a reality. What are the overall implications for the IAPT workforce and the commissioning of education and training? Graham Turpin, National IAPT Advisor Education and Training From its inception the IAPT Programme has had a very prescriptive model for the development of education and training which has included the development of competency frameworks based upon NICE guidance, the agreement of national curricula and quality standards for training, together with IAPT accreditation processes agreed with professional bodies. However, the future extensions to IAPT are likely to demonstrate greater flexibility. Already the C&YP IAPT is stressing service transformation and redesign focused around the existing workforce, together with routine outcome measurement, as being distinctive features of these new services. For Older people, LTC/MUS and SMI, it is also likely that the focus will be around the existing workforce rather than developing a new workforce as in the case of the original programme. So the key issues for designing education and training will be which workforce are we considering (IAPT vs primary care vs specialist physical or secondary care staff?), what is the nature of the clinical problems (anxiety/depression or more specific problems such as somatic symptoms or psychosis), what are the range of interventions indicated by NICE and to be employed etc? Indeed, we will also need to address quite fundamental questions about the service model and whether constructs such as Stepped Care and Low Intensity Interventions are appropriate for these conditions. Irrespective of the outcome of these discussions, it is likely for each of the new areas of development, we will need to identify relevant NICE indicated interventions, competency frameworks, curricula which address the additional training requirements for existing IAPT staff, new CPD curricula both for specialist IAPT staff but also for non-IAPT staff wanting to become familiar with a more psychological informed IAPT approach. We expect that several common frameworks and models will emerge across the on-going development work for each of these very distinct client groups.

Low Intensity Interventions in IAPT: Improving Efficacy by Group Based Formats Convenor: Madhi Ghomi, Sutton & Merton IAPT

Chair: Helen Curr, Sutton & Merton IAPT

Introduction & Summary Mahdi Ghomi, Sutton & Merton IAPT In October 2009 Sutton & Merton Psychological Therapies in Primary Care made a successful application to become an IAPT service, as part of the second wave IAPT national initiative. Our local service agreement was to dramatically increase the numbers of patients entering treatment to 5000 patients in the first year, and 5500 patients in the second year. Thus the challenge the service was facing was to manage waiting lists, while offering NICE guideline compliant treatments to all referred patients in the most cost effective way. Any possible solution would need to offer an intervention with a minimum amount of training that could be consistently delivered to large numbers of patients, while ensuring reliable treatment outcomes. It was agreed that a workable plan would be to offer group based CBT at the low intensity level. We hoped to base these interventions as closely as possible on the ongoing cognitive and behavioural models being developed for the treatment of Depression, Generalized Anxiety Disorder, Panic Disorder, Panic with Agoraphobia, and Specific Phobia. This symposiums aims to outline how the manuals for three different groups; Depression; General Anxiety Disorder; and Panic Disorder & Specific Phobia, were developed; how the staff were trained in facilitating these groups, and the outcome of each individual group treatments thus far. We will also present an innovative approach to group treatment for people living with Long Term Conditions, and finally how we have increased service user involvement at every stage of the service development, culminating in our IAPT Community Engagement (ICE) project. We hope that this clinical symposium will provide detail on how these groups can be set up and delivered in the fast paced environment of an IAPT service, with a particular focus on how to deliver high quality interventions through low intensity staff, and to adapt these approaches to ensure that individual needs are genuinely met. Presenting the Mood Management (Depression) course Alan Underwood, University College London Depression is associated with high economic cost to both individuals and the wider society (Layard, 2006) yet only 10% of those suffering are currently accessing talking therapy. The IAPT model identifies significant levels of mild to moderate depression and recommends the delivery of low intensity interventions (Sobell & Sobell, 2000). Several studies have reported that gCBT can be as effective as individual treatment (Hollon & Shaw, 1979, Morrison, 2001, Ghaderi, 2006), however there is now a need to grow practice based evidence for what works in an IAPT setting. The present study trained IAPT low-intensity clinicians to deliver a manualised group CBT based intervention to treat people with mild to moderate levels of depression. 238 patients entering the service over a 10 month period were offered a CBT based 6 session manualised group treatment for depression (max 10 patients in a group). PHQ9, GAD7 and W&SAS were collected at each contact (self-reported). The treatment protocol drew significantly from Martell et al. (2010) Behavioural activation treatment manual for depression, but also addressed cognitive aspects of depression as well as relapse prevention, and followed a structured plan to ensure consistent delivery. Patients were expected to attend a minimum of four sessions to have successfully completed the course. The intervention was delivered by step 2 clinicians who had received specialist training from manual authors. Each group was facilitated by a single step 2 clinician. Numbers of patients meeting IAPT caseness for both depression and anxiety fell significantly post treatment, and the implications of this are discussed.

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Presenting Anxiety specific groups Anna Hall, Sutton & Merton IAPT With the advent of low intensity IAPT work our service, like many, developed generic ‘anxiety management’ programs, aimed to support people presenting with mild to moderate anxiety problems, which might include presentations of phobias, panic, generalised anxiety and overlap with depressive episodes. Having delivered group based ‘anxiety management’ programs, the service received clear service user feedback indicating a need for a longer treatment intervention, to ensure a wider range of topics were covered, and feedback from clinicians questioning the efficacy of generic interventions, when cognitive models of anxiety disorders were based on very different maintenance cycles. Our approach therefore has been to separate anxiety management into two treatment approaches, which target ‘panic & phobias’ in one cluster and excessive worrying in another cluster. The panic and phobias course provides psycho-education about the physical symptoms of panic, graded exposure, and specific behavioural experiments challenging the catastrophic misinterpretations present in these disorders. Thus the treatment protocol also drew heavily from David Clark treatment protocol for panic disorder. The stress and worry course, recently renamed ‘overcoming worry’, was designed to focus on people whose difficulties may hold more similarities with generalised anxiety disorder (although they may not always meet clinical threshold for this diagnosis), and was based on the Dugas & Robichaud (2006) treatment protocol for General Anxiety Disorder. This presentation will report initial outcome data using both the IAPT minimum data set, and disorder specific measures (including the Panic Disorder Severity Scale and the Penn State Worry Questionnaire). Pilot data suggests significant improvements found at end of treatment which are maintained at 3 month follow up. Presenting the Long Term Condition approach Helen Curr, Sutton & Merton IAPT People living with long term physical health problems are three to four times higher risk of developing mental health difficulties, and about one quarter of people living with a physical illness do develop a mental health condition as a result. The impact of these co-morbid difficulties include poorer physical health outcomes, poorer engagement with physical health care and rehabilitation services, and increased risk of suicide. It is estimated that the population of Sutton and Merton will have risen by 15-20% by 2020 and projections suggest that by 2015 there will be nearly 12,500 people in Sutton and 11,500 people in Merton over 65 years living with long term physical health conditions. There is growing evidence that cognitive behavioural therapy (CBT) techniques, can improve both the mental and physical health of people living with long term physical health conditions. NICE guidelines recommend individual and group CBT for people with chronic physical health conditions. In April 2010 the service began a program of development to offer adapted CBT to meet the needs of people living with long term physical health conditions (LTC). Given the service demands, we have created a group based approach to work specifically with this population. This presentation will describe the rationale behind the ‘Living Well’ group delivered locally, and the necessary service developments required to incorporate this into the standard IAPT service framework. This includes considering how and why a condition generic approach can function, the development of the clinical content of the group, and the selection of measurement tools for the outcome analysis. The presentation will then outline the content of group material, before considering the training requirements for low intensity staff and supervisors to ensure quality practice. Marketing of this approach in order to facilitate more integrated pathways across physical and mental health services are also discussed, and the operational lessons learned considered. Outcome data from the group based approach will be presented and new developments considered. Presenting the ICE Project Alexia Trafford, Sutton & Merton IAPT; Elaine Potter, Ex-Service User This section of the symposium will first take the opportunity to hear about the lived experience of a group program, from a service user who attended Mood Management. We hope this will give clinicians a first hand account of the group environment and treatment process. We will then go on to present the decision to pilot ex-service user co-facilitators through a project called the IAPT Community Empowerment (ICE) project. Developed in 2011, this trial aims to allow ex-service users to bring their unique knowledge and skills to the treatment environment. Having been provided with basic counselling training, and a comprehensive introduction to the concepts and delivery of the Mood Management Manual, a small cohort of ex-service users became qualified to work as co-facilitators salaried on a pro-rata basis. We believe that this approach holds significant value in spreading knowledge and skills beyond the IAPT staff base, and provide the potential to reach out to hard to reach communities. We also believe that this will enhance treatment for current service users, who have the benefit of hearing about the treatment process from someone who has been able to make use of the intervention themselves. We will conclude this presentation hearing again from one of our service user co-facilitators.

IAPT in Routine Clinical Practice: Challenges, Innovations and Outcomes Convenor: Paul Bliss, Sheffield Health and Social Care NHS Foundation Trust

Pathways of Stepped Care – history of an IAPT service including initial set up, challenges and development Paul Bliss, Sheffield Health and Social Care NHS Foundation Trust This symposium will present the means by which an IAPT service has dealt with the challenge of increasing access, implementing stepped care and ensuring quality of clinical and supervisory practices. The first presentation will focus on pathways of stepped care, in particular balancing the tensions between implementing NICE guidelines and managing ever increasing demands and expectations in the most efficient way possible during a period of fundamental organizational change. This presentation will look at the history and development of the Sheffield IAPT service, including a) the strategic decisions made at the outset to closely align the service with GPs, b) the problems of variation that this creates across the 100 GP practices in Sheffield and the challenge of establishing and maintaining positive relationships with GPs and practice teams, c) the decision, in the face of high demand and smaller resource, whether to centralize the service or to make the existing system more efficient, and d) the bottom-up systems approach that the service took to resolving this issue. How this service has tried to avoid the problems associated with gatekeeping and has enabled patient inclusion and choice on an industrial scale will be addressed.

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Innovations in enabling access and addressing waiting times in an IAPT service Jodie Millington, Sheffield Health and Social Care NHS Foundation Trust Historically long waiting lists have been the biggest cause of complaint from patients and GPs. Treatment has more chance of success the quicker people are seen. Waiting is not a psychological intervention! The aim of this presentation is to describe innovations made in addressing waiting times by an IAPT service and the plans to address the future challenges of improving access. In particular the presentation will focus on how technology can inform waiting list management. Most of the clinical work of the Sheffield IAPT service is undertaken in GP practices. A mini IAPT team of PWP, CBT therapist and counsellor works into each practice. This presentation will feature the role of the IAPT worker in these settings and the application of the stepped care model. It will include the challenges for communication within the mini teams and with the GPs and administration staff. The difficulties in addressing these issues will be discussed. For instance Sheffield IAPT has identified that there is no relationship between our service capacity, the number of referrals received and the amount of time a patient had to wait to access therapy. A case study will be described showing how a positive change was instigated in a GP practice with poor communication pathways and long waiting lists. Implementing a direct booking system and self referral has been paramount in enabling changes in systems and processes and lessons from this will be addressed. Finally the long term sustainability of low waiting times for the service will be discussed. Developments in psychological interventions within a stepped care model in an IAPT service Gill Donohoe, Sheffield Health and Social Care NHS Foundation Trust How might a large psychological therapies service provide a range of interventions which are applied effectively and efficiently and also encourages individual patient choice through the least intrusive method? This presentation aims to describe the breadth of psychological interventions provided by Sheffield IAPT, the key principles which underpin them, implementation processes and evaluation data. At Step One, a guided self help approach has been developed which is designed for brief consultations by GPs, using materials created by the SHARP Project, based on the Williams ‘Overcoming’ series. At Step Two, patients can choose from computerised CBT programmes (‘Fearfighter’ or ‘Beating the Blues’) with telephone support from IAPT workers. If they prefer an educational format then they can self-refer onto Stress Control courses, run by Psychological Wellbeing Practitioners, or one day localised Healthy Living Workshops. Other patients can see a Psychological Wellbeing Practitioner for guided self help in their own GP Practice. Overlapping Steps Two and Three are city wide Behavioural Activation for Depression Groups which are facilitated by IAPT CBT therapists. At Step Three, patients can access Cognitive Behavioural Therapy or Counselling in their own GP Practice. Outcome data for each of these interventions will be presented. Overcoming the past and future challenges in their implementation across the service will be discussed. Advances in clinical governance and organisational development in an IAPT service Annie Mason, Sheffield Health and Social Care NHS Foundation Trust Safeguarding and maintaining high standards of care in a large, diverse psychological therapies workforce presents challenges. This presentation will focus on the means by which a city wide IAPT service has dealt with the challenges of ensuring quality of clinical and supervisory practices as well as continuing professional development for all staff. It will detail advances in clinical governance and organisational development in terms of a) clinical leadership, b) the structure and delivery of clinical supervision, c) the use of technology to enhance clinical supervision and therapist performance, and d) the continuing professional development of staff. Learning from these developments and future challenges will be discussed. Examples will be given throughout the presentation.

Doing a Lot More in Low Intensity: The STEPS Service Convenor: Jim White, Greater Glasgow and Clyde NHS

STEPS: the model Jim White, Greater Glasgow and Clyde The STEPS primary care mental health team in south Glasgow provides one of the most comprehensive matched-care mental health services in Britain. Working in a deprived, multi-cultural area, we have developed a multi-level, multi-purpose service that attempts to meet some of the major challenges in low-intensity work. These include providing immediate help to very large numbers of people with common mental health problems; improving outcomes, attendance and completion rates, offering GPs an alternative to prescribing, designing services that are relevant to the psychosocial and cultural needs of our population; offering genuine choice to service users; working alongside other organisations, developing preventative or, at least, early intervention approaches, working with GPs to help increase detection rates of, e.g. depression and, a major challenge, trying to reach the ‘hard to reach’ – those individuals who do not self-refer (or accept referral from a GP), who are not ‘psychologically-minded’, greatly motivated and who often have significant social issues to deal with, i.e. the people who do not feature in research trials. This takes us from being a reactive service, i.e. waiting for people to come to us, to developing a more assertive outreach/community psychology approach. STEPS works at six levels: individual therapy; classes/groups; single contacts; non-face-to-face approaches; working with others and population-level work. This first talk will outline the philosophy behind the model. Accessing service: lowering barriers Vicky Manson, Greater Glasgow and Clyde NHS This talk looks at the various ways to access the service – what we have learned about attracting people to the service and what have been our successes and failures. Until 2008, access to individual therapy was by GP-referral only while access to all other services was self-referral. The first part of the talk will look at whether moving all services to self-referral for individual therapy improved outcomes. Users have the choice between opting for therapist assessment or by-passing assessment and going straight into services. The second part will look at how many opt for each and if we can determine the profile of who opts for what. The third part will look at the performance of the two therapist-assessment options – the (face-to-face) Advice Clinic and the ‘Call-back’ phone assessment and, again, whether the two services attract different service users. Finally the talk will focus on attempts to advertise services directly to communities.

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Classes, groups and workshops Carol Richards, Greater Glasgow and Clyde NHS The talk looks at the performance of our classes, groups and workshops. ‘Stress Control’ is a six session didactic CBT evening or afternoon class (never ‘group therapy’) with a strong evidence base. With well over 100 attending each evening class, this is our most popular service. Research evidence (from STEPS and elsewhere) will be presented including a recent user satisfaction evaluation. ‘Mood Matters’ is a newer depression group developed to be relevant in an area of deprivation. Evidence will be presented comparing 6 or 8 session, CBT or behavioural activation versions. The talk will also look at the exercise class and anger and self-esteem workshops. The First Steps peer-supporter-led open-ended group offers long-term contact with the service and seems most appropriate for a population we regard as being best defined as having common and enduring mental health problems and for whom ‘cure’ models are not appropriate. The talk will consider whether other groups/classes are necessary and what we have learned from evaluation of the existing classes. Getting the best out of limited resources Simon Stuart, Greater Glasgow and Clyde NHS The NHS will always struggle to cope with demand especially in a time of significant financial strain and where all services are likely to have to cope with budget cuts. This talk will look at achieving the best compromise between effectiveness - providing the best service for the individual service user and efficiency - providing a service to as many people as possible. The talk will look at, e.g. working with others and using non-face-to-face options, e,g. media – print, DVDs, internet, social media. Working at the population level Michael Ross, Greater Glasgow and Clyde NHS The ‘Usual Suspects’ will always find and use services. The ‘Hard to Reach’ are well-named. So, if people will not come to us, we need to go to them and, especially for those living in difficult circumstances, perhaps lower our expectations. We believe that keeping heads above water may be more realistic than curing in many communities. Thus STEPS is happy to be ‘better than nothing’ in such circumstances. This talk will look at engaging with the ‘Hard to Reach’ and, once found, designing services that they may engage with. The talk will look at how well the different approaches we have tried have worked. In general, traditional therapy service approaches found been tested and found wanting. So, it is not simply about ‘more of the same’ especially in deprived communities. The role of STEPS workers in such circumstances is to be ‘more than just therapists’. This talk will look at a range of population-level approaches. What have we learned and where do we go from here? Jim White, Greater Glasgow and Clyde NHS This talk attempts to make sense of the last eight years – what should we be proud of and what should we be embarrassed by? How can we use this learning to further develop the service, particularly in economically-straightened times? And, if, as we suspect, the model will move further away from more traditional service provision, what skills would a good primary care mental health worker need to have to flourish in such a service?

Defining Effective Therapists and Therapies in IAPT Services Convenor: Stephen Kellett, University of Sheffield Chair: Katherine Berry, University of Manchester

Discussant: Tom Ayers, Sheffield IAPT service

What’s helpful in using computerised cognitive behavioural therapy (CCBT) for depression: What do service users say? Kate Doran, University of Sheffield This paper presents findings from two qualitative studies on the experience of service users in using a cCBT programme (“Beating the Blues”) supported by Psychological Wellbeing Practitioners (PWPs). The first study is a retrospective in-depth qualitative study, using a 2x2 (clinical outcome x completion status) sampling frame to represent a range of client experiences. The second study is a prospective qualitative study exploring the experience of three women aged 43-59 years who were interviewed at six sampling points as they progressed through and beyond ‘Beating the Blues.’ The final interview took place 4 months post-completion of the programme. Data from the first study was analysed using Framework Analysis; data from the second study were analysed using interpretative phenomenological analysis. Similarities and differences in results across the two data sets will be discussed and then reflected upon. Defining the characteristics and practices of clinically effective Psychological Well-being Practitioners; a mixed methods approach. Helen Green, RDASH NHS Foundation Trust; Kellett Stephen, University of Sheffield; Barkham Micheal, University of Sheffield; Dave Saxon, University of Sheffield The key purpose of this research was to examine whether 'therapist effects' (i.e. differences in the effectiveness of individual practitioners) are apparent in a sample Psychological Wellbeing Practitioners (PWPs) delivering guided self-help interventions in IAPT clinical services and then to examine factors that define effective PWP practice. Using outcome data (PHQ-9 and GAD-7; N = 1, 112) gathered in routine practice, the clinical effectiveness of 21 PWPS across 9 IAPT services was examined using multi-level modelling. PWPs and their clinical supervisors were also interviewed and completed measures of ego strength, intuition and resilience. A therapist effect was found whereby PWPs accounted for almost 9 per cent of the variance in patient outcomes. Computed PWP ranks identified clusters of the most and least effective PWPs. More effective PWPs were more resilient, organised, knowledgeable and confident and less effective PWPs more affect-driven in cognitive style. Resilience appears to play a role in effective PWP practice and future studies should aim to explore this further. Study weaknesses are identified and methodological considerations for future therapist effects studies are provided.

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Sudden gains, sudden losses and clinical outcome in patients treated IAPT services Gillian Hardy, University of Sheffield; Michael Barkham, University of Sheffield; Dave Saxon, University of Sheffield; Stephen Kellett, University of Sheffield This study utilises the routinely collected outcome data from an IAPT service to consider what factors predict treatment outcome during high intensity psychological interventions. During psychotherapy some patients can experience a large between-session positive or negative changes in their symptoms and distress, known as ‘sudden gains’ and ‘sudden reversals.’ The aim of this study was to (1) to explore and evidence the rate of sudden gains and reversals across the stepped care model in an IAPT clinical service and (2) to test whether those who experience a sudden gain had better treatment outcomes than those who do not. Predictors of sudden gain and good or poor treatment outcome will also be investigated. The results will be discussed in term of methodological shortcomings and clinical implications. Translating knowledge into performance: some specific dilemmas for IAPT high intensity and PWP trainees Rebecca Hutton, University of Sheffield This paper presents findings from an ethnographic research study on the experience of IAPT trainees - both PWP and High Intensity Therapists. Trainees were observed at regular intervals over a 10-month period, during their University based teaching and a small sample were interviewed using an in-depth qualitative approach, mid-way through the course, upon completion of the course and at six follow-up. Results indicate specific dilemmas encountered by trainees in translating knowledge accrued from the courses into performance at work in the clinical role. These dilemmas relate to (1) negotiating the boundaries of the role, (2) engaging and maintaining patients in treatment and (3) acting on the idea that patients with complex problems may not always need complex solutions. The paper will reflect on how these dilemmas play out in practice for individuals from each trainee training group.

Second Generation Low Intensity Interventions for Complex Health Problems Convenor: Chris Williams, University of Glasgow

Discussant: Paul Farrand, University of Exeter

Online self-help for bulimic type disorders: A randomised controlled study recruiting from community settings Carrie-Anne McClay, University of Glasgow; Louise Ewan, University of Dundee; Ulrike Schmidt, Institute of Psychiatry; Chris Williams, University of Glasgow Eating disorders such as bulimia nervosa are potentially fatal illnesses which affect many young women and men. Many individuals access services only when their condition becomes chronic and therefore miss the opportunity for early intervention. The reasons for this can be varied, including the perceived stigma of eating disorders and a lack of knowledge regarding their symptoms and / or the resources available to help. There is a lack of provision of specialist eating disorder services within the UK with significant waiting lists for such services, leaving many mild and moderate sufferers without access to specialist treatment. One resolution to this problem is self-help. Self-help books, CD-ROMS and internet packages have shown the potential to significantly reduce symptoms of bulimia nervosa. Self-help delivered as part of a Stepped Care Treatment Model could bridge the gap between the onset of illness and specialist individual therapy and has been recommended in the NICE 2004 eating disorder guidelines for the treatment of eating disorders. An online package has recently been created which focuses on helping individuals with bulimia nervosa and EDNOS. Overcoming Bulimia Online (OBO) aims to help individuals to change their thoughts, feelings and behaviours with regard to food using the principles of cognitive behavioural therapy. This paper will describe the results of a community based randomized controlled trial (RCT) of OBO. The results of this study show significant improvements on a number of eating disorder symptoms at the follow up points and build upon the evidence base for the use of cCBT for the treatment of bulimic type problems. The findings of studies such as these support the view that low intensity CBT, delivered in convenient and accessible ways, is an effective way to increase access to psychological therapies and reduce waiting times for evidence based treatment. Medically Unexplained Neurological Symptoms - Can 90 minutes make a difference? Catriona Kent, NHS Greater Glasgow & Clyde; Michael Sharpe, University of Oxford; Alan Carson, NHS Lothian; Walker Jane, University of Edinburgh; Chris Williams, University of Glasgow Functional or medically unexplained neurological symptoms are disabling and distressing to those experiencing them. They are a common presentation in neurology clinics, GP surgeries and elsewhere in the NHS. Previous trials have shown that Cognitive-behavioral therapy (CBT) can be an effective treatment. Despite this, in practice there is often a lack of availability of a CBT based intervention. CBT-based guided self-help was used in a Medical Research Council (MRC) funded randomised control trial in 2 NHS Regional Neurology Centres. CBT based guided self help was compared to the usual care received by patients. In the CBT guided self-help arm, participants were offered a maximum of 4 half-hour sessions of guided self-help along with a specifically designed workbook, which had previously been piloted on a similar population. The primary outcome was self-rated health on a 5-point clinical global improvement scale (CGI) at 3 months. Secondary outcomes were measured at 3 and 6 months. Results: In this trial, 127 participants were enrolled, and primary outcome data were collected for 125. Participants allocated to guided self-help reported greater improvement on the primary outcome. Conclusions: CBT-based guided self-help improves self-reported general health, as measured by the CGI, in patients with Medically Unexplained Neurological symptoms. Assessing the efficacy and feasibility of a web-based cognitive-behavioural package for carers of individuals with anorexia nervosa Louise Ewan, University of Dundee Anorexia nervosa is a disorder which affects many individuals and also has a great impact on families and friends. Due to a lack of availability of specialist eating disorder services within the UK, waiting lists for such services are significant and are often forced to only treat individuals whose condition is severe and life threatening, leaving sufferers with mild or moderate illness without specialist treatment. This leaves individuals being supported by relatives, friends etc. who often have limited knowledge and skills as to how to help the person with the disorder.

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Carers (e.g. friends, parents, or partners) of people with anorexia nervosa are usually highly motivated to contribute to their loved one’s treatment but feel ill-equipped to do so. This often leads to carers becoming highly distressed and they can suffer from increased levels of anxiety and depression. Such reactions to their loved ones illness may inadvertently lead to unhelpful responses which may act to maintain the illness. For example high levels of over-involvement (wrapping the person in cotton wool) and criticism (also known as expressed emotion) are such responses. This study aimed to evaluate the efficacy and feasibility of a web-based cognitive-behavioural intervention (Overcoming Anorexia Online) for carers of individuals with anorexia nervosa, designed to help supporters offer effective support, identify problematic responses and better self-manage how they cope. Carers of people with anorexia nervosa (n=60) were recruited from community based sources such as carer support groups, and via Google advertisements, in order to try and provide support as early as possible and to the widest network of individuals. The study was un-randomised with all individuals being offered access to the online package with limited supportive guidance (by email or phone) from a trained support worker. Carer outcomes were assessed at baseline, post-intervention (10 weeks) and follow-up (16 weeks). Results showed that using the web-based cognitive-behavioural intervention led to a significant reduction in carers’ anxiety (primary outcome) and expressed emotion, in addition to an increase in their mental health literacy at post-intervention. These improvements were maintained at follow up. No change was seen in a number of other outcome measures. Interviews with a sub-sample of carers also showed that carers found the package extremely beneficial and felt it had given them back some control; reaffirming their caring abilities. However, carers also commented that the package would have been most useful at the start of their caregiving journey. Computerised delivery for complex disorders such as eating disorders Chris Williams, University of Glasgow; Miriam Grover, King’s College London, Institute of Psychiatry; Ulrike Schmidt, King’s College London, Institute of Psychiatry; Varinia Sanchez-Ortiz, King’s College London, Institute of Psychiatry; Calum Munro, Cullen Centyre, Edinburgh; Ulrike Naumann, King’s College London, Institute of Psychiatry Two recently published studies are reported. Firstly the study by Sanchez Ortiz et al (2010) excamines the use of the Overcoming bulimia online package. Bulimic eating disorders are common among female students, yet the majority do not access effective treatment. Internet-based cognitive-behavioural therapy (iCBT) may be able to bridge this gap. Method. Seventy-six students with bulimia nervosa (BN) or eating disorder not otherwise specified (EDNOS) were randomly assigned to immediate iCBT with e-mail support over 3 months or to a 3-month waiting list followed by iCBT [waiting list/delayed treatment control (WL/DTC)]. ED outcomes were assessed with the Eating Disorder Examination (EDE) at baseline, 3 months and 6 months. Other outcomes included depression, anxiety and quality of life. Results. Students who had immediate iCBT showed significantly greater improvements at 3 and 6 months than those receiving WL/DTC in ED and other symptoms. Conclusions. iCBT with e-mail support is efficacious in students with bulimic disorders and has lasting effects. The second study (Grover et al 2011), examines Overcoming anorexia online- an online resource produced to support carers of those with anorexia. Anorexia nervosa (AN) poses a major burden on families. Carers (e.g. parents or partners) of people with AN are often highly distressed and may inadvertently respond in ways that can contribute to the maintenance of the disorder, e.g. through high levels of over-involvement and criticism [also known as expressed emotion (EE)]. This study aimed to evaluate the efficacy of a novel web-based systemic cognitive-behavioural (CBT) intervention for carers of people with AN, designed to reduce carer distress and teach skills in how to offer effective support. Method. Carers of people with AN (n=64) were randomly allocated to either the web-intervention, overcoming anorexia online, with limited clinician supportive guidance (by email or phone), or to ad-hoc usual support from the UK patient and carer organization Beat. Carer outcomes were assessed at post-treatment (4 months) and follow-up (6 months). Results. Compared with the control intervention, web-based treatment significantly reduced carers’ anxiety and depression (primary outcome) at post-treatment, with a similar trend in carers’ EE. Other secondary outcomes did not favour the online intervention. Gains were maintained at follow-up. This is the first ever study to use an online CBT program to successfully reduce carer distress and improve carers’ ability to support the person with AN.

IAPT Treatment & Delivery Chair: Kevin Mullins, National IAPT Director, Department of Health

From Service Users to Associates: Challenges and benefits of involving service users in a London IAPT service Jocelyne Kenny, Bromley Mind; Sinead Brennan, Bromley Mind; Frances Westerman, Bromley Mind Involving patients in public health services came onto the NHS agenda in 1999 through the publication of Patient and Public Involvement in the new NHS. This paper recognised that “involving patients leads to more responsive services and better outcomes of care” (Department of Health, 1999). More recently the NHS Act 2006 states that both patients and the public must be consulted about and in the planning of and provision of services (Department of Health, 2006). Research suggests there are measurable benefits from involving patients in mental health services (Simpson & House, 2002). These have been understood both as improvements to services (Lester & Gask, 2009; Crawford et al., 2002) and how patients can benefit from meaningful involvement programmes (Sainsbury Centre for Mental Health, 2010). The difficulties of establishing meaningful service user involvement in IAPT services have been documented (Stuart, Hunter & Ross, 2012). Low intensity interventions encourage independence through enabling people to manage their own wellbeing through self-help materials. Patients have brief support from PWPs making their relationship with the individual PWP as opposed to the service. Additionally, many clients are in employment, or seeking employment, so have little time or inclination to become involved. We have developed an Associate role within Bromley’s IAPT service. This role goes beyond traditional service user models to meet the challenges posed by involving patients in primary care. People discharged from the service are invited to become paid Associates involved in developing the service. We will discuss future qualitative research opportunities within the area. We will present the challenges, benefits and developments which have arisen as a result of the work of the Associates and plans to develop the Associate role. This case study highlights potential changes to clinical practices and service management which have arisen as a result of the Associates programme. It aims to answer some questions which have emerged in previous research papers about how service user involvement can be applied to IAPT services.

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Does symptomatic improvement to a sub clinical level predict client satisfaction as measured by the Improving Access to Psychological Therapies (IAPT) Patient Choice and Experience Questionnaire (PEQ)? Sonia Malik, University of Manchester; Sonia Malik, University of Manchester; Matthew Kemsley, Bury Primary Care Mental Health Service Treatment satisfaction is associated with treatment success, treatment adherence and service commissioning (McCracken, Evon, & Karapas, 2002; Haas 1999, Spear 2003; Hansen, Hoogduin, Schaap & de Haan 1992; Bower & Rowland 2006). The Improving Access to Psychological Therapies (IAPT) Patient Choice and Experience Questionnaire (PEQ) is currently used to assess treatment satisfaction within IAPT services. Plans to use the Quality Outcomes Framework referenced in the Equity and Excellence liberating the NHS’ White paper (July 2010) render the exploration of factors affecting treatment satisfaction imperative for primary care services. Outcome data was routinely collected for those completing treatment at Bury Primary Care Mental Health Service. The data was coded dichotomously according to cases reaching ‘recovery’ according to IAPT’s recovery key performance indicator and entered into a binary logistic regression model as a predictor for treatment satisfaction. A separate hierarchical logistic regression model examined post-treatment scores on outcome measures whilst controlling for pre-treatment scores, therapist satisfaction was then added to this model as a predictor. This data therefore indicates that treatment satisfaction as measured by the IAPT PEQ is not acquired through a reduction in symptomatology, rather it is acquired through satisfaction with individual therapists. This has implications for the use of satisfaction measures in services and the use of indicators of treatment satisfaction within commissioning. Null hypotheses were confirmed, symptomatic improvement was not a predictor of client treatment satisfaction, regardless of caseness post-treatment. Therapist satisfaction is a predictor for treatment satisfaction, whilst symptomatic improvement effects were not significant in the regression model. The outcome of this research questions the use of measures of treatment satisfaction within services, and the appropriate delivery of such measures within routine clinical practice. The data suggests an influence of therapist satisfaction on overall client treament satisfaction, regardless of symptomatic improvement, which suggests the effective use of CBT as measured by IAPT key performance indicators, is not associated with client treatment satisfaction.

‘Let’s just have a few more sessions’: Audit of outcomes for clients offered more than 20 sessions of CBT in an IAPT service. Charlotte Cox, Institute of Psychiatry, King's College London; Charlotte Cox, Institute of Psychiatry, King's College London; Nicholas McNulty, Lambeth IAPT; Charandeep Khera, Lambeth IAPT The NICE guidelines for cognitive behaviour therapy for common mental health problems recommend treatment durations within a range of 6 to 20 sessions. Although efficiency targets put pressure on services to work within these guidelines, some clients are seen for more than 20 sessions. This paper outlines the results of a service audit investigating the profiles of these clients and the impact of extended treatment on their outcomes. The audit looked at the data on all clients (n=99) who were seen for more than 20 sessions by high intensity therapists in one IAPT service. Outcome measures were the weekly anxiety and depression questionnaires completed by clients (the GAD-7 and the PHQ-9) and questionnaires completed by therapists. Not surprisingly, this group emerged as particularly hard to treat; recovery rates were low and the differences in depression and anxiety scores between session 20 and the final session were not clinically significant. Nevertheless, in most cases clinicians reported that extending treatment was worthwhile. Positive impacts other than a change in questionnaire scores are discussed. Further detail is also provided on the cases for which therapists felt extending therapy made no difference. The mean differences between scores on the GAD-7 and the PHQ-9 between session 20 and the final session were 2.0 and 2.4 respectively. Criteria for recovery were fulfilled in 32.7% of cases. Therapists indicated that they believed extending beyond 20 sessions had made a slight or significant positive difference in 73.8% of cases, and no difference in 26.3% of cases. There are valuable reasons for extending therapy even when it will make no difference to outcomes on questionnaire measure. These include slow but important progress in difficult cases, consolidating improvements in therapy, and effective management of risk. Supervision could usefully focus on helping therapists identify cases where persisting in therapy is unhelpful and in supporting therapists to consider alternatives for clients who are not responding to treatment. Further, where a client’s attachment to a therapist makes ending unhelpful therapy difficult, supervisors may need to offer additional support to therapists.

A benchmarking method for mental health services using PHQ-9 and GAD-7 Jaime Delgadillo, Leeds Community Healthcare NHS Trust; Dean McMillan, Hull York Medical School and Department of Health Sciences, University of York; Chris Leach, South West Yorkshire Partnership NHS Foundation Trust and University of Huddersfield; Mike Lucock, South West Yorkshire Partnership NHS Foundation Trust and University of Huddersfield; Simon Gilbody, Hull York Medical School and Department of Health Sciences, University of York; Nick Wood, Leeds Community Healthcare NHS Trust The emphasis on session-by-session data collection is one of the defining features of the IAPT programme, offering the possibility of benchmarking clinical outcomes against national standards in a way that has not been possible previously for psychological services in the UK. However, despite the existence of several reports on the performance of these services, various methods of evaluating and quantifying effectiveness have been used, some of which have considerable limitations. This review proposes a consistent and straightforward method for benchmarking the performance of routine services using PHQ-9 and GAD-7. High, average and poor performance benchmarks were calculated using published data from services working under the Improving Access to Psychological Therapies (IAPT) Programme in England, UK. Pre-post treatment effect sizes and confidence intervals were estimated to develop a ranking system to enable services to assess routine clinical outcomes. The main contribution of this report is to propose a standard and consistent method of data analysis and routine outcomes evaluation, together with simple visual plots to enable IAPT services to compare their performance easily with national benchmarks. This method is a methodologically robust alternative to the conventional league table approach that uses arbitrary percentile and quartile rankings of comparable services. Some limitations concerned heterogeneity among sites, wide variations in effect sizes and data completeness. High, average and poor performance effect sizes for routine IAPT services were estimated to be 0.91, 0.73 and 0.46 for PHQ-9 and 1.02, 0.78 and 0.52 for GAD-7. Other secondary outcomes were also calculated. Data from a specific treatment service in West Yorkshire exemplify how to evaluate and contextualise routine clinical effectiveness against these benchmarks. This paper proposes a methodologically robust alternative way of defining and measuring the performance of routine psychological care. The method can be expanded and refined to assist individual therapists in evaluating their own performance against that of their wider service and of clinical trials.

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IAPT, Linking Training and Patient Outcome Amanda Branson, University of Reading and Pam Myles, University of Reading IAPT is a Government initiative to train therapists to deliver evidence based psychological therapies (typically cognitive behavioural therapy) for patients presenting with anxiety and/or depression. A substantial part of the government investment of £400 million is to train new therapists, yet little is known about the efficacy of such training programmes (Keen and Freeston 2008). The current investigation aimed to investigate the relationship between training and patient outcomes. Patient outcome data were collected from five IAPT services for patients treated by Psychological Wellbeing Practitioners (n=46) and High Intensity Therapists (n=36) between 2008 and 2011. Preliminary correlational analyses suggest that assessments of clinical skill (such as the Cognitive Therapy Scale Revised and Observed Structured Clinical Examination) on the University Training Programmes were significantly and positively associated with the number of patients recovering from anxiety and depression at Step 2 (PWP: r=.35, p=.02) and Step 3 (HI: r=.37, p=.03). Conversely there was limited association between academic assessments such as case reports and essays, and patient outcome. Examinations, undertaken by Psychological Wellbeing Practitioners were however significantly and positively associated with the number of patients recovering from depression and anxiety (r=.62, p=0.002). The implications of these findings and future lines of research will be discussed.

The development and evaluation of CBT ‘Emotional Wellbeing’ groups within IAPT: An Exploratory Study looking at who attends and who benefits. Kirsty James, University of Bath; Alison Sedgwick-Taylor, 2gether NHS Foundation Trust; Jo Daniels, University of Bath; Joanne Myers, 2gether NHS Foundation Trust IAPT services in Gloucestershire are developing innovative solutions to meet the needs of the significant proportion of the population experiencing anxiety and depression, while also maintaining high quality services. This study describes the development and preliminary evaluation of an Emotional Wellbeing manual, written with and for all communities across Gloucestershire. The manual draws together cognitive behaviour therapy (CBT; Beck, 2005) skills to cover five steps of emotional wellbeing, with the development method facilitating both ownership from communities and dissemination. CBT psycho-educational groups constitute a low intensity intervention which may have use initially within a stepped care model. Groups provide a cost-effective service to reach a larger proportion of the target population, including those who have historically not been forthcoming in accessing services. Further, it offers an innovative method for socialising patients to the CBT model prior to engaging in individual therapy. Six ‘Emotional Wellbeing’ groups ran for five weeks within routine practice and included participants (n = 243) referred as a result of experiencing transdiagnostic difficulties with anxiety and depression. No other inclusion or exclusion criteria were applied. Following the minimal dataset, participants completed the PHQ-9, GAD-7, and WSAS at each session. The implications of this pilot trial for service delivery and the dissemination of psychological interventions across IAPT and other communities (including deaf, prison and perinatal) are discussed. The development methodology and dissemination potential will be explored. The results of this pilot study are discussed in relation to participants who attended and benefitted from the groups. This research demonstrates the feasibility and effectiveness of CBT Emotional Wellbeing psycho-education groups within routine clinical practice and the implications for extending the work of the IAPT service across ‘hard to reach’ groups. This has implications for service delivery within IAPT and stepped care services by providing an accessible transdiagnostic first line intervention. Furthermore, the approach may be adapted for use with under-represented populations in IAPT services and developed with communities to increase accessibility.

Increasing Access and Effectiveness of Treatments Chair: Faramarz Hashempour, Betsi Cadwalader University Health Board

Sakoon, a Pilot Anxiety Management Group for South Asian Men Saquib Ahmad, 5 Boroughs Partnership Care Trust South Asian (SA) men have historically been difficult to engage within primary care mental health services; due to stigma and inappropriateness of services (Ali et al., 2007). Sakoon is a primary care mental health initiative which looks to provide culturally sensitive approaches in a group setting using a CBT framework. Referrals were generated through traditional pathways as well as through the use of the media and specific targeting of mosques and community centres. The programme consisted of 13 sessions which included a 4 week follow-up. Session included interventions at a step 2 & 3 level, and were facilitated by myself, a PWP and a CBT therapist. Sakoon highlights the effectiveness of adapting mental health provision and pathway referrals to the cultural needs of BME communities due to the barriers present within conventional pathways (Gilligan and Akhtar, 2005). Outcome measures highlight the effectiveness of using a psychoeducational group in the treatment of anxiety. The intervention was successful for those suffering from social anxiety, panic and specific phobias, but less effective for the treatment of GAD and OCD. Patient feedback highlighted the benefits of a culturally sensitive approach, and those who showed only minor improvements were stepped up to 1:1 therapy under the stepped care model. Sakoon offers an alternative to 1-on-1 working and encourages collaboration in treating anxiety effectively. Sakoon meets the recommendations of Delivering Race Equality and is also IAPT compliant therefore has the potential to be rolled out across IAPT sites nationally.

A service evaluation of a CBT-based psycho-education course targeted to a student population. Dominic Mossa, Talking Changes - IAPT County Durham & Darlington; Dominic Mossa, Talking Changes - IAPT County Durham & Darlington; Lisa Boyd, Talking Changes - IAPT County Durham & Darlington CBT-based psycho-education courses are an effective intervention for common mental health problems in primary care settings when delivered as part of a stepped care framework (White 2000a, 2000b, DOH May 2007). Student populations report a higher than average prevalence of CMHP, however often experience barriers in accessing evidence based interventions (Gallagher 2008 ,McCall et al 2001) due to their transient living conditions and service design. Preventative educational work to raise students awareness about the causes, identification and management of health problems, has been advocated (Royal College of Psychiatrists 2011) however limited literature exists to guide the clinician in the design and delivery of such interventions. In this presentation we report the development, delivery and results of an innovative psycho-education course targeted to a university population in the North East of England. A psycho-education course was developed and delivered to a targeted group of Higher Education (HE) students. Recruitment for the workshops was largely

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done through two avenues. 1) Promotional outreach e.g. holding a stall at the University during ‘Freshers’ week, advertising on the University intranet etc. 2) Directing ‘standard’ referrals (i.e. previously unaware of course) of the local Talking Changes IAPT service toward the workshops. The IAPT ‘minimum data set’ was used for clinical evaluation. Student satisfaction with access, structure and delivery of the course was evaluated via a specific questionnaire designed for purpose. When considering the broad notion of student wellbeing and the challenges faced in achieving this, the fundamental approach of this project may be a useful tool in combating mental ill health in the HE population. Evidence is provided to suggest that HE students may benefit from this psycho-educational approach as this potentially increases accessibility, whilst at the same time reducing stigma. Additional research is required with larger samples to explore these findings further. This presentation reports issues identified in the design and delivery of this innovative approach in meeting the demands of a student population and provide discussion regarding lessons for IAPT service providers with this group. After screening 27 initial students entered the course, (10 male, 17 female) with 21 (77%) attending 3 or more of the 4 sessions. The mean score of the group pre course was 12.64 sd 5.37 on the PHQ9 and 10.45 sd 5.59 on the GAD7. Of those attending all 4 sessions: 43% achieved clinical improvement on the PHQ9 and/or the GAD 7; with 68.8% of those students whose scores indicated ‘caseness’ at the commencement moving to recovery. Students appeared very satisfied with the course were satisfied with the course design and delivery. Many young people who are studying at a HE institute experience very similar and extensive psychosocial stressors. This habitually leads to an influx in the number of referrals for mental health support during the academic term time, resulting in local and University mental health services struggling to provide adequate and timely treatment (RCP 2011). This can in turn leads to long waiting lists, further mental distress and ultimately the failed care of what is a highly vulnerable group. This project may aid services in the high volume delivery of an evidence-based intervention, specifically targeting and relieving mental distress in the student population.

Culture and Therapist Self-Disclosure Peter Phiri, University of Southampton; Shanaya Rathod, Southern Health NHS Foundation Trust; Mary Gobbi, University of Southampton; David Kingdon, University of Southampton This paper critically discusses the extent to which therapist self-disclosure impacts upon the early stages of therapeutic relationship. Particular reference is made to the importance of self-disclosure with Black and Asian minority ethnic groups. Our group recently conducted a qualitative study aimed at developing culturally sensitive cognitive behavioural therapy for psychosis for ethnic minority patients by exploration and incorporation of service users and health professionals’ views and opinions, funded by the Delivering Race Equality (DRE). This two centre study consisted of individual in-depth face to face interviews and focus groups on a total data set of 114 participants comprising of service users with schizophrenia, therapists and mental health practitioners and lay member participants from the minority ethnic groups in the UK. In conclusion, client initiated self-disclosure by the therapist has significant relevance to multi-cultural psychological practice today. It requires therapists’ cognizance and sensitive response to nurture trust and promote rapport. Further investigation in this area is recommended. The results had face validity that CBT would be acceptable if culturally adapted. Several themes emerged relating to the need for therapist awareness of culturally derived behaviours, beliefs and attitudes that can influence client response and participation in therapy. Therapist self-disclosure is one such theme. This issue is contentious and has challenged previous thinking regarding disclosure of personal issues. Implications for clinical practice and practical guidance are discussed.

Behavioural Activation in the Treatment of Depression: A Control Theory Perspective Phil McEvoy, Six Degrees Social Enterprise; Kelly Hylton, Six Degrees Social Enterprise; Abigail Law, Six Degrees Social Enterprise; Rachel Bates, Six Degrees Social Enterprise; Warren Mansell, University of Manchester Although behavioural activation is a treatment that has proven efficacy in treating depression, there is still significant scope for increasing its efficiency and effectiveness (Dimidjian et al., 2011; Kanter et al, 2010). This paper examines how the application of control theory may enhance the application of behavioural activation in practice. Control theory focuses upon the problems can arise when we find ourselves being pulled in opposite directions by goals that are incompatible with each other. It suggests that problems are maintained by rigid and inflexible control processes, which prevent us from resolving conflicts in satisfactory ways. (Carey, 2006; Mansell et al., 2009; Powers, 1973). The basic principles that underpin the application of control theory are explained, together with the rationale for applying the control theory to behavioural activation. The approach is illustrated using two case studies which combine the use of control theory with established strategies such as activity monitoring, event scheduling and problem solving. The difference between control theory based approaches and more orthodox behavioural and cognitive approaches are highlighted and the implications of these differences are discussed. The case studies provide anecdotal evidence which supports the view that effective treatment crucially depends upon clients being able to retain or regain the sense of control that they value. Flexible approaches towards the implementation of behavioural activation that are based upon the application of control theory, may offer a useful alternative to more established approaches in the treatment of depression.

Low Intensity Interventions Chair: Chris Williams, University of Glasgow

A PWP clinical competence model in the delivery of therapeutic interventions Jo Fear, Gloucestershire 2gether NHS Foundation Trust; Jo Fear, Gloucestershire 2gether NHS Foundation Trust Clinical competence is central and specific to the provision of effective and efficient patient care within NHS (Roth and Pilling 2008). Clinical competence is the therapist’s capability to apply knowledge, understanding and skill, to organisational standards (Milne et al 2001). Therefore, competences play an important role in the provision of NICE approved, therapeutic interventions, for treating people with anxiety and depression disorders (DoH 2011). The aim of this paper is to define a psychological well being practitioner (PWP) competence model I compiled for my master’s dissertation. The function of the competence model is to assist in adherence to, PWP treatment protocols to use in clinical supervision and everyday clinical practice. To date, there has been a focus on learning outcomes at a local and National level (Richards and Whyte 2008). Thus, highlighting an opportunity for development, whilst building on the successes of the IAPT initiative (NICE 2011). The PWP workforce provides short term, specific, psychological interventions and manage a large caseload of clients, referred to the local IAPT services. PWP’s constitute a large percentage of the IAPT workforce and are often the first point of contact for a client (Richards and Whyte 2008). Thus the PWP role is fundamental to National IAPT service provision. The objectives

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of this paper are to discuss specific competencies, that measure adherence to PWP treatment protocols and thus maintain efficacy as part of IAPT service provision (Richards and Suckling 2009). Overall, such a competency model is pertinent to the IAPT workforce, including supervisors and management.

Supervising the Psychological Wellbeing Practitioner - “Throw down the gauntlet!” Elaine Davies, 2gether Trust NHS There is a plethora of literature recognising that CBT supervision is an ethical requirement, it facilitates model fidelity and helps to develop the practitioner. (Branch 2012, Milne 2011, Bennett-Levy 2010, Grant 2005, Townend 2002) Supervision is held to be important by most every therapeutic tradition (Branch 2012, vanOoijen 2003) it is mostly true to say that supervision reflects therapy itself; it is this position that interests the writer of this paper. Supervising the PWP in an IAPT Primary Care Service with a high volume of client turnover comes with rewards but more often than not challenges. Permission was sought from the Supervisors of PWP’s and from PWP’s themselves to use data collected from Supervision of Supervision and from open-ended informal conversations (Patton, 1990) with the supervisors of PWP’s to discuss the challenges that supervisor’s face during supervision. The model of clinical case management supervision and clinical skills practice is important and the writer agrees that for a high volume turnover of clients it is an essential requirement. However, this existing model needs to evolve further to incorporate other tasks into supervision. There is agreement that PWP’s should also receive appropriate management supervision, regular appraisals and advice regarding their CPD. However, this needs to be included into the existing supervision through a new model developed to help both the supervisor and PWP. This paper is an open invitation to supervisors of PWP’s to share their challenges of supervision asking the questions what is not working well, what can we do for the future of PWP supervision in an IAPT Service and how can a new model be achieved. Weekly clinical supervision comes with challenges when the supervisor takes annual leave (entitlement 4 weeks) leaving the supervisee (PWP) without supervision and carrying over a high number of clients for discussion. When the supervisor goes ‘sick’ how do Service’s support PWP’s when other supervisors are already committed to a workload and Services are often under-resourced. The alliance between supervisor and PWP is as important as with any other form of supervision. When the existing model is applied without any flexibility there is little time to develop the relationship, nor the time to give extra support for personal or professional issues, disciplinary or complaints. Finally, clients do impact personally on PWP’s and there is little scope for exploration of these triggers in order for the PWP to make sense of their own conceptualisation in the rigid confines of clinical case management and skills practice supervision. CBT supervision tends to consider relational dynamics which links to the theory. If there is no time and space for this to develop in the supervision of PWP’s then the potential implication would be cold administration of skills and techniques. This then in turn would give no opportunity for personal and professional growth and potentially have an effect on client work.

Examining uptake, adherence, attrition and maintenance in self-help for depression and anxiety: A meta-analysis Katie Hanson, University of Sheffield; Katie Hanson, University of Sheffield; Thomas Webb, University of Sheffield; Paschal Sheeran, University of Sheffield; Graham Turpin, University of Sheffield A number of reviews suggest that self-help can be a cost-effective way to reduce the burden of depression and anxiety (see Bower, Richards & Lovell, (2001). However, relatively little attention has been paid to other aspects of self-help such as, clients willingness use self-help materials (uptake), compliance with self-help techniques and exercises (adherence) and drop out during the treatment period (attrition). The present research used meta-analysis to investigate uptake, adherence, attrition, and efficacy of self-help treatments for depression, anxiety & posttraumatic stress disorder. Randomised controlled trials that used symptom measures and included self-help interventions were included. Self-help was defined as a therapeutic intervention for self-treatment administered through either group meetings (self-help groups), books (bibliotherapy) or electronically (including self-help web sites and computerized self-help packages). The self-help intervention may be undertaken independently without the help from professionals (pure self-help) or the self-help treatment may be overseen by a professional (guided self-help), who may meet with the user to discuss progress or contact them periodically (including phone or email contact). 103 suitable studies were identified via current published reviews of the self-help literature and a computerized search of scientific databases. The rate of uptake, adherence and attrition to self-help programs have not been analysed in a meta-analysis before, as to date research has focused on efficacy and cost-effectiveness. By understanding these issues we hope to further enhance self-help treatments for depression, anxiety and PTSD. Initial analyses suggest that levels of uptake for self-help treatments are around 40%, while levels of attrition are around 22%. Levels of adherence to the self-help treatments is currently being calculated. CBT techniques are often delivered in a self-help format, so to better understand the uptake, adherence, attrition and maintenance of self-help treatments would be beneficial for clinical practices which use self-help techniques. If we can understand:1. Why a client choses to undertake a program of self-help, 2. why a client sticks with the self-help program, while others give in,3. How the client interact with self-help treatments and uses the materials, and 4. Whether the client continues to use the self-help techniques learned, then we can better understand how self-help works and the process clients go through when under going self-help treatments. This can only lead to the enhancement of self-help treatments and lead to a better patient experience.

A Community Based Pilot Study of Life Skills Classes for Individuals with Low Mood and Depression: Quantitative and Qualitative Findings Carrie-Anne McClay, University of Glasgow; Katrina Collins, AWARE Defeat Depression; Pat Lynch, AWARE Defeat Depression; Michelle Affleck, University of Glasgow; Chris Williams, University of Glasgow Our project draws on current NICE guidelines for the treatment of depression and offers the possibility of rapid access and larger throughput of numbers coupled with delivery by non-specialist trainers using guided group CBT self-help classes. The self-help classes were delivered by voluntary sector workers with a non-NHS label (Action on Depression and AWARE Defeat Depression) in order to appeal to a wide range of people including those currently attending the NHS as well as those who were not. The aim of the pilot study was to assess the feasibility of delivering a guided group CBT self help (SH) intervention in a community setting in partnership with voluntary sector organisations. 51 participants were recruited using a novel community based strategy in a combined 6 week period across two sites (Glasgow and Londonderry). The main outcomes of interest were: the number of participants who attended at least one class following baseline measures, the number of sessions attended by participants, PHQ9 and GAD7 scores at the 3 and 6 month follow-up points and acceptability of the intervention as measured by the CSQ8. The findings of this pilot study will give information regarding the feasibility, acceptability and efficacy of this approach and will be used inform the future large RCT of this study. ANCOVAs will be used

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to compare the two groups whilst adjusting for baseline differences. Paired t-tests will be carried out in order to assess improvements within the two separate groups. Descriptive data outlining the take-up of the intervention and adherence levels will be presented and comparisons will be made across the two study sites. These analyses will be complete in April 2012. If the subsequent planned RCT demonstrates that the intervention is effective and cost effective then the approach could be confidently rolled out as a flexible low intensity group intervention to deliver CBT both within and outside the NHS. If the LLTTF community based course is shown to be effective it may help to alleviate the problem of fewer than 50% receiving appropriate treatment for depression.

Skills Classes

How to Deliver Brilliant Therapy Using 7 Sheets of Paper Chris Williams, University of Glasgow

This half day skills-based workshop teaches attendees how to engage and support patients in improving how they feel by using seven key pieces of paper. Each sheet concisely summarises key elements of the CBT approach, and helps guide patients and practitioners alike in applying the model in a focused and structured way. Learn how to complete a whole-person formulation, identify unhelpful thinking styles, conduct a thought review, challenge thoughts (2 sheets) and fix problems (2 sheets). Each sheet provides a simple to apply approach which is fully shared with the patient and uses everyday language. Together you teach the person skills to both self-assess, and then better self-manage some of the most common problems faced in everyday life. References These sheets make up a subset of a series of worksheets which have been found to be effective in delivery of CBT based interventions by non-specialists (Reference Morrell, J. et al (2009) Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care. BMJ Jan 15;338:a3045. doi: 10.1136/bmj.a3045. Professor Chris Williams is a Past-President of BABCP, and is a well known CBT trainer and researcher. His CBT self-help approach is amongst the most widely used in the world.

Posters Using low intensity interventions to treat depression and anxiety in people with long term health conditions (LTC) Helen Curr, Sutton and Merton IAPT; Harriet Barkes, Sutton and Merton IAPT; Rebecca Dale, Sutton and Merton IAPT Statistics show that people living with long term health conditions (LTC) are more likely to additionally suffer from mental health problems. The NICE guidelines (2010) recommend cognitive behavioral therapy (CBT) for the treatment of depression and/or anxiety. The Department of Health (2008) suggests that CBT may be delivered effectively by IAPT services. This study aimed to test the efficacy of low intensity interventions specifically targeted at people with LTC, within the IAPT model. Data was collected from a sample of patients referred to Sutton & Merton IAPT who were deemed suitable at assessment for a low intensity intervention (N = 195). Patients were offered either a six week course of group-based CBT, or four to six sessions of individual guided CBT and then a three month follow up. Clinicians followed a manual devised by the service Health and Wellbeing Lead. Scores on the PHQ-9 and GAD-7 were collected at each point of clinical contact. The present study suggests that CBT for people suffering from LTC delivered within the IAPT model is effective in treating mild to moderate depression and/or anxiety. The study also demonstrated that there is a high drop out rate (47%) within this client group which needs to be explored. Scores for those completing treatment (N = 103) were compared pre- (initial assessment) and post-treatment (final session) using paired t-tests. Scores on both the PHQ-9 (t = 9.35, df = 102, p < .001) and the GAD-7 (t = 8.81, df = 102, p < .001) significantly reduced. Improvements were maintained at three-month follow up. • Patients moved from moderate to mild depression scores after a course of low intensity treatment (CBT based groups and guided self-help) highlighting the efficacy of the treatment received. • In light of these findings these manuals may be suitable for use among the wider IAPT community. • Through further research we need to better understand the high drop-out rate (47%) associated with these interventions and consider how this can be overcome within the constraints of IAPT services. Evaluation of a CBT group for anger regulation problems delivered in an open group format John Owen, Bolton Primary Care Psychological Therapy Service / School of Psychological Sciences, University of Manchester Difficulty in regulating the experience and expression of anger can lead to a range of psychosocial problems, thus motivating individuals to seek help and treatment. This is reflected in the consistent demand from general practitioners in the UK for 'anger management' interventions for patients. However, whilst demand is high, significant drop out rates from anger interventions are often reported. Bolton Primary Care Psychological Therapy Service (PCPTS) has continuously provided a weekly CBT group for anger regulation problems for the past six years, initially delivered in a typical 12-week closed group format. Clinical audit showed the group to have a high non-completion rate. In order to reduce the clinical and service-level impact of this, the intervention was changed from a closed to an open group format. Additional changes included (i) the introduction of an ex-service user as co-facilitator (ii) the group becoming male-only. This poster will present an evaluation of the clinical effectiveness of the open CBT group, based upon analysis of pre- and post-intervention self-report measures for 15 consecutive treatment completers. The following measures were used: The Novaco Anger Scale and Provocation Inventory, (Novaco, 2003) the State-Trait Anger Expression Inventory-2 (Spielberger, 1999), the Patient Health Questionnaire-9 depression scale (Kroenke, Spitzer & Williams, 2001) and the Generalised Anxiety Disorder-7 scale (Spiter et al, 2001). The salient clinical and service-level implications of delivering CBT for anger regulation problems in this novel open group format, in comparison with closed group and 1-1 interventions, will be highlighted. Outcome data is still being collected, however, preliminary analysis indicates clinically significant improvements in anger regulation. These improvement appear equivalent to those found in the earlier closed format group. Clinically significant reductions in depressive and anxiety symptoms have also been found. In addition to such broad outcome data, change in the experience anger (as measured by the Dimensions of Anger Reactions II; Novaco, 2004) each week over the course of the intervention will be displayed for a subset of clients.

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Community Wellbeing Champions Janine Ward, DHUFT; Sarah Khan, Southampton PCT IAPT has been tasked with engaging many individuals in the hard to reach groups in society (Doh, 2007; IAPT 2010). This has included providing accessible care pathways, care and culterally appropriate services as per the equality act (2010). Therefore to meet this need and replicating some best practice examples from around the country (Sheffield and Scotland) Southampton steps to wellbeing (SSTW) applied for a QUIPP grant to train individuals from hard to reach groups in mental health and wellbeing. The purpose of this was to increase awareness, referrals and accessible care pathways of SSTW. An additional advantage of which was to establish understanding of cultural differences in need. 15 individuals volunteering with or in paid employement with BME, Older adults, ex offenders and carer organisations, were invited to attend 3 training days on mental health and wellbeing. 2 days were spent in training in Mental Health First Aid and one in the Art of Living, based on WRAP (Copeland, 2005). They were encouraged to deliver the information formally to their target groups by delivering the information in any groups they were involved with. The hope being that referrals from these groups would increase and a wellbeing preventative agenda would be encouraged. Although there was a noted increase in referrals from the areas involved, it would have been of more benefit to capture the information delivered to the target areas in a quantatative way. A benefit from this project was the links established with key volunteers in target areas which has helped to form more cohensive care pathways. Although the champions were unable to record any quantitative data of how many people they delivered their knowledge to, it was noted that referrals slightly increased from the target areas. However more importantly the 15 wellbeing champions reported qualitative feedback of a greater understanding of mental health and wellbeing. In addition the champions reported a lowered level of stigma and discrimination around mental health which they felt had encouraged positive engagement with a number of their clients. A greater understanding of culterally appropriate IAPT services and a 'bottom up' approach to mental health awareness. CBT group for diabetes and co-morbid depression Deniz Kemal, KCA (UK); Pavlo Kanellakis, KCA (UK) Living with a long term health condition can be further distressing for an individual when there is co-morbidity with depression and/or anxiety. Depression in these individuals is known to be associated with poor compliance to diabetes control (Gonzalez et al. 2010), increased risk of complications from diabetes and is known to be mainly treated with pharmacological intervention. The long term conditions positive practice guide published by IAPT (2008) highlights the importance of better links between IAPT services and physical health services in order to reduce the suffering experienced by the individual and also to reduce costs of additional health services from those experiencing co-morbid depression and/or anxiety. The aim of this study is to determine the efficacy and appropriateness of offering a group intervention tailored for those with diabetes within a Step 3 IAPT service compared to a waiting list control group. A 12 session weekly CBT based depression group was developed with a specific focus on diabetes control. Participants: Participants were recruited from the current waiting list and local diabetes service. Measures: For those recruited to the group, the IAPT minimum data set was used at each session, including the PHQ-9 as a measure of depressive symptoms, GAD-7 as a measure of anxiety symptoms. For those on the waiting list, measures were taken at the start and end. Outcomes will be taken again 3 and 6 months after treatment. Measures of glycemic control were requested from the GP at the beginning, end and at follow up where possible. Intervention: Based on the NICE guidelines for depression in adults with a chronic (2009) a structured CBT group-based intervention was developed with a focus on diabetes psycho-education and management. The group met for 12 meetings of eight to ten participants, including a follow up. Long term health conditions are an increased focus of IAPT services. This study aimed to investigate the effectiveness of using a group-based CBT intervention for those with diabetes and co-morbid depression. Previous research had shown individual CBT to be effective in improving the symptoms of depression in participants with co-morbid diabetes and depression but had received mixed results on improving diabetes management (Gonzalez et al. (2010), Khalida et al. (2004)). Therefore, this study aimed to investigate the effectiveness of a group based approach. These preliminary results may provide evidence for the acceptability, feasibility and potential utility of CBT groups for diabetes and other long term conditions within IAPT services. The results of the study will be discussed further upon completion of the study. This study is currently in progress and therefore, it is not currently possible to conclude any results. The first group will be completed by the Conference and therefore initial results can be presented. It is anticipated that if the group based intervention is showed to be effective for co-morbid depression and diabetes then it is possible that further studies can be conducted and/or randomised controlled trials set up to investigate the efficacy further. Furthermore, a group based intervention is likely to be utilised within IAPT services and physical health services as a way of treating higher numbers of those awaiting therapy and also as a way of driving forward specific interventions for long term conditions. Therapist effects in routine low-intensity psychological therapy: evidence from the Improving Access to Psychological Therapies (IAPT) programme Shehzad Ali, University of York; Liz Littlewood, University of York; Jaime Delgadillo, Leeds Community Healthcare NHS Trust; Simon Gilbody, University of York; Dean McMillan, University of York; Alfonso Miranda, Institute of Education Therapist effects, i.e. the variance in patient-level outcomes that is attributable to therapists, can inflate estimates of treatment effectiveness (1). In the literature, analyses of therapist effects have produced mixed results, ranging from 0% to almost 50% (1). Factors influencing therapist effect sizes include adherence to treatment manuals and heterogeneity of patient diagnosis (2). This study aimed to estimate therapist effects for low-intensity psychological therapy delivered in routine primary care mental health services as part of the IAPT programme (3). Routinely collected session-by-session data was available for 2,030 patients treated by 39 therapists across 5 IAPT teams in Leeds. Patient scores on the Patient Health Questionnaire (PHQ-9) were used in three-level hierarchical mixed effects models to evaluate the estimated proportion of total variance explained by therapists. Sensitivity analysis was conducted on a sub-sample of 1,316 patients who scored ?10 on PHQ-9 at baseline. We found that across these low-intensity IAPT teams, therapist effects were small. This may partly be because the treatments delivered were largely standardised, using a prescribed set of workbooks, therapy manuals and self-help materials. One limitation of the study is the relatively small number of therapists. The results showed that therapists

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accounted for 0.82% of the total variance in PHQ-9 scores, with even smaller therapist effects found for the depressed sub-sample (0.62%). The therapist effects further reduced when controlling for age, gender, baseline PHQ9 score and the length of treatment (0.25% for the whole sample, 0.11% for the depressed sub-sample). However, the estimated therapist-level variance was statistically significant. Efforts to standardise practice may result in small variance between therapists; such variance may be sizeable in more heterogeneous groups of practitioners and clinical settings. CBT workshops for GPs and practice staff Judith Seagrave, University of Hull; Marie Acton, Humber NHS; Helen Mander, University of Hull GPs and primary care staff have an important role in diagnosing and managing common mental health problems (www.nice.org.uk/nicemedia/live/13476/54520/54520.pdf). GPs often feel under-confident with dealing in this area (www.ncbi.nlm.nih.gov/pubmed/9054902) Participants were recruited through a local GP trainer. 6 attended (4 GPs and 2 practice nurses) Three, 3hour sessions focused on an introduction to CBT, CBT for depression and panic, using a variety of teaching methods. Confidence was measured in a variety of areas using a pre and post course questionnaire, and a visual analogue scale. Goals were measured using the Goal attainment scale (GAS) Participants felt more confident in understanding CBT and how to explain what it would involve to patients Results: Participant goals were to develop a greater understanding of the role of CBT and when CBT is indicated, improve skills in introducing CBT to patients and begin to use CBT strategies with patients. Using the Visual Analogue Scales (scaled 0-10) participants initially reported low levels of confidence in understanding, explaining and using CBT skills (mean 2.33; median 2). However, confidence in all areas increased after training (mean 7.18; median 7). All participants reported improvement in the selected goal. Of 8 goals rated, 7 reported an increase of +1, and 2 reported a change of +2. Further research is planned through subsequent workshops to: Follow up the participants into clinical practice To explore the possibility of "10 minute" CBT through GPs and practice staff Auditing the key support and resources required to deliver high quality CBT. Using the RAISE audit tool as part of a systematic approach to measuring and improving the quality and efficiency of CBT within and across services Martin Groom, Leeds PCMHT IAPT; Jaime Delgadillo, Leeds PCMHT IAPT IAPT services are commissioned to deliver CBT which closely resembles treatment used in the randomised controlled trials underpinning NICE guidance. However, competencies, specific procedures and skills cannot be divorced from the support systems and resources that ensure their delivery. Roth and Pilling, (2008) propose that resource and support such as training and supervision are a part of the fidelity of treatment. This poster outlines what the RAISE audit tool is and how it can be used as part of a systematic approach to ensuring the delivery of competent and effective practice. By defining, quantifying and measuring key elements of resource such as supervision, training and access to video and audio equipment, services can identify specific strengths, as well as particular gaps between best practice and the existing situation. This poster shows how the RAISE tool has been used as part of an audit cycle in the Leeds IAPT service. The poster reflects on what has been learnt, and considers how the RAISE tool could be used to measure and benchmark services nationally to enhance quality, efficiency and effectiveness. Good data on what the key support and resources required to deliver CBT effectively and efficiently informs cilnical governance via for example processes of audit, benchmarking and making this information available to stakeholders including members of the public. CBT therpists who have what they need to do their jobs (supervsion to specific standards, and frequencies, targetted CPD, good IT support, access to audio , video and web based media) will be more effective and efficient. Ths in turn should lead to better outcomes for our clients.

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Intellectual and Developmental Disabilities

Keynote Addresses

Learning to listen: what aspects of CBT work for people with intellectual disabilities? Andrew Jahoda, Institute of Health and Wellbeing, University of Glasgow Communicative and cognitive difficulties of people with learning disabilities are reasons why they have been excluded from talking therapies such as CBT. The effort to increase access to CBT for people with mild to moderate learning disabilities has stimulated important work about the abilities required to participate meaningfully in this therapy. However, there has been less emphasis on finding out how people with learning disabilities can best be supported to engage in therapy, or the importance of different elements of therapy to outcome. This talk will draw on two strands of research to begin to address these questions. Firstly, it will consider findings from process research, exploring how such individuals experience therapy. Secondly, it will draw on the results from a recently completed group anger management intervention to identify the elements of therapy linked to outcome.

Symposia Developing Cognitive-Behavioural Interventions for People with Autism

Convenor: Dougal Hare, University of Manchester

Parent accounts of anxiety in ASD: a focus group study Fiona Knott, University of Reading; Ann Ozsivadjian, Newcomen Centre, Guy's Hospital; Iliana Magiati, National University of Singapore Anxiety disorders are common among children and young people with Autism Spectrum Disorders (ASD). However, despite growing knowledge about the phenomenology and treatment of anxiety disorders, relatively little is understood about the triggers, behavioural indicators and cognitions associated with anxiety in day to day life. We report the findings of an exploratory study, involving a series of 5 focus groups with 17 mothers of children and adolescents with ASD and anxiety. Parents gave strikingly similar descriptions of the triggers and behavioural signs associated with anxiety. It was common for children to show their anxiety through behavioural changes, notably ‘meltdowns’. Mothers reported that their children had great difficulty expressing their worries verbally and described following a ‘detective’ process to help understand their children’s concerns. The implications of the focus group findings are discussed in relation to recent advances in cognitive behavioural therapy for anxiety in ASD. The PAsSA trial: protocols and initial experiences Peter Langdon, University of East Anglia; Glynis Murphy, University of Kent The People with Asperger Syndrome and Anxiety (PAsSA) treatment trial is a NIHR funded single blind cross-over trial of group cognitive behavioural therapy for adults with Asperger Syndrome and high functioning autism who have clinically significant difficulties with anxiety. Thirty-five adults with Asperger’s or high functioning autism have been recruited, and the trial is still running. During this talk the protocol and treatment manual will be presented. Some of the initial observations will be discussed, including issues associated with recruitment and assessment. Evidence for the Effectiveness of Cognitive Behavioural Strategies with Children Diagnosed with Asperger syndrome Kate Sofronoff, University of Queensland This paper will firstly review the strength of the evidence for cognitive behaviour therapy in working with children diagnosed with Asperger syndrome. There will be a brief overview of trials that have been conducted with this population and the results that have been reported. The paper will then focus more specifically on trials that have evaluated interventions for anxiety and social functioning and on the modifications that may need to be made to such interventions to accommodate the cognitive profile of a young person with Asperger syndrome. There is an emphasis in this review on issues concerning the use of positive strategies, of tailoring strategies and programs to suit an individual child, the importance of parent involvement, the use of visual supports and the need for creativity when working with these children. Anxiety and Asperger’s Syndrome: An Investigation Into The Delivery of a Novel Real-Time Stress Management Approach. Carolyn Gracey, University of Manchester; Dougal Hare, University of Manchester For many people with Asperger’s syndrome (AS), anxiety is a major problem. Cognitive Behavioural Therapy (CBT) is recommended as the psychological treatment of choice for anxiety in people without AS, but little is known about its suitability for people with AS. People with AS often show a different cognitive profile to individuals without AS and it is possible that that they have qualitatively different fears (Hare, Wood & Skirrow 2008). Despite the high occurrence of anxiety in this population, there has been a paucity of research into effective and ecologically-valid interventions, with most studies relying on reports of past experiences of anxiety. This study further explored the phenomenology of everyday anxiety in this population and the feasibility of using portable Personal Digital Assistants (PDA). A case series design was used based upon a modified experience sampling methodology to capture everyday experiences and deliver real-time stress management techniques to N=9 adults with AS. The study found that the AS group were highly anxious, with their anxiety being both idiosyncratic and associated with increased self-focus, worries about everyday events and rumination. The real-time stress management techniques were found to reduce subjective ratings of anxiety in individuals with AS during the time of the intervention. Individuals with AS differed in their experience of anxiety and the use of PDAs provided a feasible mechanism for treatment. Hand-held digital technology offers the possibility of developing more idiosyncratic didactic interventions for such anxiety building on the efficacy of such approaches demonstrated in the present study.

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Posters Measuring Anxiety in Autism Spectrum Disorders: Parent-child agreement Katy Hopkins, University of Reading; Fiona Knott, University of Reading; Lucy Willetts, University of Reading Children with Autism Spectrum Disorder are twice as likely to have an anxiety disorder as their typically developing counterparts; however, lack of standardised measures of anxiety for these children mean diagnosis is difficult. Children with ASD have problems with communication, understanding and expressing emotion and flexibility of thought. This has cast doubt upon their ability to reliably self-report on their anxiety. In typical development, child self-report is used alongside parent-report to diagnose anxiety. This study aimed to ascertain whether two existing measures of child anxiety are suitable for use in a group of children with high functioning ASD by examining levels of parent-child agreement. Anxiety was measured using a semi-structured interview (ADIS-C) and a questionnaire (SCAS). Both measures have parent- and child-report versions and have been standardised for use in children without ASD. Mothers and children were interviewed and filled out the questionnaires separately and concurrently and anxiety assessments were scored blindly. Possible explanations, diagnostic implications and directions for future research are discussed. Parent-child agreement on the ADIS was good for the most common disorders; however there was also a lot of disagreement, which was reflected in the primary diagnoses: mothers and children agreed about the presence and severity of an anxiety disorder but often disagreed on the type of disorder. The SCAS showed a similar pattern results, parent-child agreement was better for the ‘total anxiety score’ than for many of the subscale scores, however, in general parent-child agreement on the SCAS was better than on the ADIS. In order to treat anxiety in ASD it is important to be able to accurately diagnose it. Identifying which children are able to report on their own anxiety and assessing the usefulness of parent-report in this population is essential to the development of treatments.

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Older Adults

Keynote Address

Sex, lies and video tapes: The use of CBT and schemas across the lifespan Ian James, Newcastle Psychology and Challenging Behaviour Teams, Northumberland, Tyne & Wear NHS Foundation Trust This presentation examines my work over the last 23 years, highlighting the relevance of the recurrent themes of schemas, conceptualisations, competence and supervision. The talk spans my early work on human errors in the nuclear power industry, my pre-qualification experience as a sex therapist, employment and teaching on the Newcastle CT course, involvement in the development of the CTS-R. Over the last 15 years I have produced CBT models for older people, particularly those who challenge. In this role I have been involved in the refinement of doll therapy and the use of therapeutic lies. Dissemination has been an important feature of my career, with many peer-reviewed articles and 4 books. Over time I have also attempted to illustrate my work, via video tapes and more latterly DVDs.

Symposia

CBT for Anxiety in People with Mild Cognitive Impairment or Dementia Convenor: Georgina Charlesworth, University College London and North East London NHS Foundation Trust Discussant: Ian James, Newcastle Psychology and Challenging Behaviour Teams, Northumberland, Tyne & Wear NHS Foundation Trust

Anxiety in people with mild cognitive impairment or dementia: overview of the evidence base and introduction to the symposium Georgina Charlesworth, University College London and North East London NHS Foundation Trust Fear of developing memory problems is a common concern for people approaching later life, and anxiety symptoms are often observed in people with a diagnosis of mild cognitive impairment (MCI) and those with dementing illnesses such as Alzheimer's disease and Vascular dementia. Although dementias are not 'caused' by age, the prevalence of most dementias increases with age, and the world wide demographic changes indicate that health services should equip themselves to address the health needs of older populations. IAPT services are in need of developing their response to the aging population as people over the age of 65 were considerably under-represented in the first wave of IAPT. In response, one of the stated aims of the Department of Health's 4-year action plan on 'Talking Therapies" (a supporting document to 'No health without mental health' for people of all ages) is to improve access to older people with anxiety and depression, including those with dementia and their carers. In this clinical symposium we hope to raise awareness of the developing evidence base for CBT for anxiety in people with significant progressive memory loss. Early recognition of ‘brains at risk’ and treatment of emotional responses to the experience of Mild Cognitive Impairment Gwyn Higginson, Mental Health and Vascular Wellbeing CBT Service, North Staffordshire Combined Healthcare NHS Trust By combining the Interacting Subsystems Model and Compassion Focus Framework within a CBT shame sensitive assessment and formulation, therapists can enable individuals to reflect on the experience of developing information processing difficulties (memory deficits may not be the primary symptom). This can enable language to develop to facilitate the patient in communicating and explain triggers of their emotional response. Therapist knowledge of new research confirming the impact of neurologically silent infarcts on information processing is crucial in working with individuals with long term physical health conditions that place ‘brains at risk’ (e.g. diabetes, blood pressure, Hyperlipidaemia, heart disease/cardiac surgery, stroke, carotid and peripheral artery disease, atrial fibrillation). We have developed an ‘alerter checklist’ for therapists and other staff to use at assessment to identify ‘brains at risk’ and patterns of slowed processing, sequencing difficulties and executive dysfunction. The myth of ‘normal ageing’ is no excuse not to explore the impact of cognitive processing deficits on ability to achieve life’s goals within ones value and belief systems. For individuals with ‘brains at risk’ with experience of treatment resistant common mental health disorders, the awareness of processing problems can come as a great relief. Awareness of neurologically silent but emotionally threatening changes can guide therapists in formulation and delivery of CBT approaches to give hope and an explanation that ‘It is not your fault’. Compassion focused therapy with accommodations for processing difficulties allow patients to manage and tolerate fear and other foms of distress. Powerlessness, hopelessness and feeling trapped can be turned into ‘in control’, hopefulness and exploring management strategies. Overcoming practical, attitudinal and neuropsychological barriers to CBT for people with anxiety and dementia – Clinical reflections on a pilot trial Astrid Schepers, North East London NHS Foundation Trust; Georgina Charlesworth, University College London and North East London NHS Foundation Trust; Aimee Spector, University College London “CBT for People with Dementia and Anxiety” is a current single blind RCT pilot research study run collaboratively by the North East London Foundation Trust and University College London, funded by the National Institute of Health Research. The study aims to recruit 50 person-carer dyads, randomised to either CBT intervention or treatment as usual. The intervention is a 10-week manual-based course of CBT for the person with dementia supported by their family carer. The manual has been developed specifically for this project and will be revised on the basis of the results. Working as a clinical psychologist on the project has given the author an opportunity to gather experience in providing CBT for people with anxiety and dementia, exploring its challenges and limitations, as well as trying to adapt the approach where necessary and viable. For example, CBT is often described as a therapy approach that emphasises the independence

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and autonomy of the client and their cognitive abilities such as changing perspectives, transferring and generalising. When working with people with dementia these processes can be restricted, requiring flexibility from the therapist and support through the carer. This presentation aims to reflect on the practical, attitudinal and neuropsychological barriers encountered when providing CBT for people with dementia and anxiety and their carers within the research trial. Barriers will be presented as themes, linked into current literature. Ideas of how to overcome barriers will be developed and illustrated with examples from clinical practice. Developing IAPT for people with dementia and their family carers Don Brechin, Leeds Partnership NHS Foundation Trust Over the last 18 months a multi-disciplinary group of professionals have been meeting representatives from the DoH to examine how people with dementia and their carers can better access IAPT services. This paper reflects on these discussions and the models of service that have been proposed. This work has been supported by the British Psychological Society and its special interest group for older people (PSIGE).

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Severe and Enduring Problems

Keynote Addresses

Translating Cognitive Research Findings into Effective and Accessible CBT for Psychosis Philippa Garety, Professor of Clinical Psychology, Institute of Psychiatry, King’s College London and Joint Leader, Psychosis Clinical Academic Group, South London and Maudsley NHS FT Two key sets of cognitive processes are known to contribute to delusion persistence: emotional processes and reasoning biases. This keynote will address how we translate the recent findings of cognitive research into new treatment approaches for people with psychosis. A number of questions will be addressed. Which cognitive processes are identified as causal in delusion persistence? Do they differ by delusion sub type? Are certain processes tractable and so should be targeted in developing new treatments for people with distressing psychosis? Is there any evidence which can tell us about the more effective and easily disseminated elements of CBT for Psychosis (CBTp)? In this keynote, I will present recent data on the contribution of negative and positive cognition, reasoning and belief flexibility to persecutory and grandiose delusions. Converging findings, from detailed investigations of acute psychosis using Experience Sampling Methodology over two weeks, to cross-sectional and longitudinal studies which examine the interplay of negative and positive cognition and affect, reasoning and delusions over one year, provide strong and consistent evidence that affect and reasoning are key causal factors in psychosis. Some differ markedly and surprisingly by sub-type of delusion. So, what new treatment approaches shall we employ for effective CBTp? Recent studies of a range of innovative treatment approaches, which target emotional processes (worry, anxious avoidance, depression) and reasoning processes (data gathering, hypothesis generation, flexible thinking), demonstrate improved outcomes which are valued by people with psychosis. Other empirically identified candidate processes are now being translated into trial therapies. Some of these treatment targets may be readily addressed in brief ‘low intensity’ formats or using computerised packages, which will be described. These offer exciting prospects for widening access to effective CBTp.

Think Effectively About Mood Swings (TEAMS): Can we integrate the past, present and future 'waves' within CBT for bipolar disorders? Warren Mansell, University of Manchester The theory, evidence and practice of Think Effectively About Mood Swings (TEAMS) will be described. TEAMS is based on an integrative cognitive model of mood swings and bipolar disorders that identifies extreme positive (e.g. “When I am full of energy, all my problems disappear”) and extreme negative (e.g. “When I am agitated I always end up making a fool of myself”) appraisals of internal states - these are the client’s perceived changes in mood, arousal, affect and behaviour. The conflicting positive and negative appraisals are seen to maintain and escalate symptoms and disrupt functioning (Mansell et al., 2007). The model is maybe unique in that it can be utilised across different therapeutic approaches. Cognitive therapists can help clients to identify and challenge their appraisals; behaviour therapists can help clients engage in exposure to previously avoided internal states; cognitive behaviour therapists can formulate cycles of internal states, appraisals and behaviours to devise experiments to test longstanding beliefs; ‘third wave’ therapists can help clients to mindfully face their internal states, and associated self-states, in ways that are accepting and in tune with their deeply held values. How can one model lend itself to multiple approaches? The answer is through utilising a more fundamental integrative framework - Perceptual Control Theory (PCT; Powers et al., 1960; Powers, 1973). The empirical groundings of PCT have been in development since the 1950s, yet it could be considered to be informing a ‘future wave’ of CBT. PCT explains how varied and ‘complex’ behaviour that we witness in other people can be rooted in a more tightly focused attempt to achieve homeostasis of key variables, including internal states. PCT also emphasises the role of control in well-being, and conflict in psychological distress. Several recent studies illustrate that it is the conflict between appraisals, and therefore the opposing attempts to try to stabilise internal states that is characteristic of bipolar vulnerability. Implications for research, including computer modelling, interviews with patients, and an ongoing NIHR-supported randomised controlled trial of TEAMS will be discussed.

Symposia Too Much of a Good Thing? Theory and Research investigating the Emotionally Over-Controlled Personality Proto-Type Convenor: Thomas Lynch, University of Southampton

From Self-Control to Self-Regulation: A Novel Neuroregulatory-Personality Theory Thomas Lynch, University of Southampton Mental health is often equated with self-control—the ability to inhibit various urges, impulses, behaviors, or desires. Indeed, the capacity for self-control is highly valued by most societies and failures in self-control characterize many of the personal and social problems afflicting modern civilization—including substance abuse, criminal activities, domestic violence, financial difficulties, teen pregnancy, smoking, and obesity (Baumeister, Heatherton, & Tice, 1994; Moffitt et al., 2011). However, too much self-control can be equally problematic. Excessive self-control is associated with social isolation, poor interpersonal functioning, perfectionism, rigidity, lack of emotional expression, and severe and difficult-to-treat mental health problems, such as anorexia nervosa, chronic depression, and obsessive-compulsive personality disorder. This presentation introduces an innovative trans-diagnostic neuroregulatory model of personality and socio-emotional functioning that challenges linear assumptions regarding the nature of self-control—and how this theory has influenced the development of new treatment approaches targeting emotional over-control (EOC). The presentation will outline how EOC behavior may lead to chronic or difficult-to-treat disorders—positing a novel mechanism linking the communicative functions of emotional expression to the formation of close social bonds. EOC is considered a personality prototype resulting from transactions

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between temperamental predispositions for heightened threat and diminished reward sensitivity and family/environmental experiences emphasizing mistakes as intolerable and self-control as imperative. The importance of social-safety, self-inquiry, and flexible responding will be discussed as a means of clinical change The Social Consequences of Controlling Facial Expressions Megan Barnsley, University of Exeter; Guy Mizon, University of Exeter; Roelie Hempel, University of Southampton; Thomas Lynch, University of Southampton Facial expressions are a key component of interpersonal interactions. Previous research has shown that when individuals suppress facial expressions of emotion, partners are less willing to spend time with them in the future and report feeling less rapport (Butler et al., 2003). Inhibiting facial expressions has also been shown to increase sympathetic nervous system activation (Gross & Levenson, 1997). We designed two experiments to further evaluate the effects of controlling facial expressions on both regulators and observers. In experiment one, 82 participants carried out Bonanno et al.’s (2004) Expressive Regulation paradigm, which involved participants enhancing, maintaining or suppressing their facial expressions whilst viewing emotive pictures. During the task continuous measurements of heart rate (HR) and skin conductance level (SCL) were recorded. Our data show that although regulating facial expressions did not affect self-reported ratings of felt emotion, enhancing and suppressing facial expressions increased SCL compared to the maintain condition (F2,160 = 42.44, p < .001), but differed in their effect on HR; enhanced emotion was associated with increased HR, whilst suppressed emotion showed the opposite effect (F2,160 = 31.51, p < .001). Experiment two looked at the consequences of expressive regulation on others’ willingness to affiliate. A subset of videos from experiment one were shown to 42 naive observers. The observers rated each individual shown for attractiveness, familiarity, distinctiveness, and the amount of time they would be willing to spend with them. Again continuous measurements of HR and SCL were recorded. We found that the observers were most willing to spend time with individuals in the enhance condition, followed by the maintain condition, with individuals in the suppress condition being rated least favourably (F2,1476 = 95.60, p < .001). This effect remained significant even when attractiveness, familiarity and distinctiveness were controlled for (p < .001). In addition to this, the observers’ physiological responses were also influenced by instruction; HR was lowest when viewing enhanced expressions and highest when viewing suppressed expressions (F2,78 = 11.70, p < .001). In conclusion, our data show that expressive regulation affects the physiology of both regulators and observers. We propose that over-control of facial expression impairs the communication of safety signals that facilitate social interactions, resulting in negative outcomes. Anorexia Nervosa: The Problem of Over-Control Katie Gray, University of Southampton; Roelie Hempel, University of Southampton; Marian Titley, Haldon Eating Disorders Unit, Devon Partnership Trust; Sarah Burford, Haldon Eating Disorders Unit, Devon Partnership Trust; Thomas Lynch, University of Southampton Self-control—inhibiting acting on urges, impulses, and desires—is highly valued in most societies, and failures in self-control characterize many of the personal and social problems afflicting modern civilization. However, too much self-control can be equally problematic. Emotional over-control (EOC) is beginning to be recognized as an important factor associated with social isolation, poor interpersonal functioning, and difficult-to-treat mental health problems, such as Anorexia Nervosa (AN). EOC is considered a personality prototype resulting from transactions between temperamental predispositions for heightened threat and diminished reward sensitivity and family/environmental experiences emphasizing mistakes as intolerable and self-control as imperative. AN has been linked to prototypical over-controlled deficits—including masking inner feelings, social cognitive deficits, rigidity, perfectionism, and aloof/distant interpersonal relationships. We present results from two studies: preliminary results from an open-trial examining a novel adaptation of Dialectical Behavior Therapy (DBT) for EOC applied to Anorexia Nervosa; and an experimental session with AN patients and healthy controls. Forty-one AN inpatients (mean BMI = 14.4) were recruited for the DBT open trial. Self-report measures assessing quality of life and eating disorder behaviours were completed at the start and end of treatment (mean length of treatment = 20 weeks). In the second study, 22 AN patients and 21 healthy controls matched on age and gender, completed questionnaires and experimental tasks associated with the construct of EOC and social functioning. Open-trial results (pre to post paired-samples t-tests; all p-values <.05) indicated that self-reported levels of key eating disorder behaviours (including restraint and concerns with weight, shape and eating) all significantly reduced, whilst quality of life increased, after the adapted DBT for EOC treatment. Results from the experimental session showed that individuals with AN were significantly more ambivalent over emotional expression, more conscientious, more neurotic and less extraverted than controls (AN vs. Controls independent samples t-tests; all p-values <.05). In addition, AN patients scored significantly higher for both mother and father invalidation than controls and had significantly higher perfectionistic childhood environments. Overall, AN appears to fit well within the construct of EOC, with results indicating both the expected pattern of coping (e.g. ‘mask inner feelings’) and parental/environmental factors (e.g. perfectionistic environments) in AN individuals compared to healthy controls. Although results from the open-trial must be interpreted with caution, due to the small sample and lack of a comparison control group, preliminary findings are promising—suggesting the potential utility of applying DBT for EOC for the treatment of AN. The Mediational Effect of Ego-Resiliency on the Relationship between Temperament, Childhood Invalidation, and Interpersonal Functioning Claire Duffy, University of Exeter; Roelie Hempel, University of Southampton; Thomas Lynch, University of Southampton Based on existing theories of personality and socio-emotional functioning (e.g. Clark, 2005; Lynch, Hempel & Clark, 2012) a model is tested proposing that problems with interpersonal functioning are predicted by temperament (threat and reward sensitivity) and level of childhood invalidation, while these relationships are mediated by individual differences in self-control. Contrary to the general assumption that self-control has a positive linear relationship with interpersonal functioning, this study hypothesised that the relationship is a quadratic one: either too much or too little self-control is maladaptive, while flexible self-control is considered to be most adaptive. A UK community sample (n =512; 414 female, mean age 23.5 years, SD =9.4) completed an online survey. Several measures were used as indicators for our constructs of reward sensitivity, threat sensitivity, invalidating childhood, self-control, and interpersonal functioning. Using Structural Equation Modelling, the best fit for our data was sought. Models with and without the following mediators were tested: Self-Control (comprising Ego-Resiliency, Over- and Under-Control), Ego-Resiliency (ER), Over-Control (OC), Under-Control (UC), and any combination thereof.

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Linear modelling of Self-Control as a mediator did not lead to significant model fit, possibly due to the quadratic nature of its relation with interpersonal problems. Instead, the best model fit was found with ER as mediator (CFI = 0.95, RMSEA= 0.081). ER partially mediated the relationships between interpersonal functioning and reward sensitivity, threat sensitivity, and invalidating childhood. OC as mediator also provided an adequate, albeit looser, fit of the observed data (CFI=0.932, RMSEA= 0.096). Correlational analyses showed a negative relationship between interpersonal problems and ER (r=-0.44, p < 0.001), but a positive relationship between interpersonal problems and both OC and UC indicators (all p< 0.05). In conclusion, either too much or too little control is associated with more interpersonal problems, while increased ER decreases the likelihood of interpersonal problems. In addition, ER partially mediated the relationship between temperament and childhood invalidation. Thus, temperament and childhood experiences are important for interpersonal functioning, but their influence can be lessened or accentuated by our individual capacity to self-regulate. This model provides promising support for therapeutical interventions aiming to improve flexible self-control.

New Trajectories in Bipolar Disorder Research Convenor: Kim Wright, University of Exeter

Discussant: Jeremy Thomas

Understanding the relationship between sleep, routine and mood in bipolar disorder and non-clinical populations Faye Banks, Lancaster University; Steven Jones, Lancaster University; Fiona Lobban, Lancaster University Objective: Sleep disturbance and lifestyle regularity have been implicated in the course of bipolar disorder for some time, however it is still unclear how these factors interact with mood change. Recent research suggests that appraisal styles may act as a mediator in the relationship between circadian stability (i.e. stability of sleep and routine) and mood in individuals deemed at risk for developing bipolar disorder (Ankers & Jones, 2009). Method: In an attempt to investigate relationships between circadian stability, appraisal style, and mood in individuals with and without bipolar disorder, an online survey was administered. Respondents of the survey include: 1) individuals with a diagnosis of bipolar disorder 2) individuals without a diagnosed mental health problem or chronic pain disorder divided into: a) A high-risk group of individuals deemed at risk for bipolar disorder b) A control group of individuals deemed not to be at risk for bipolar disorder 3) Individuals with a diagnosis of fibromyalgia. All respondents completed online measures of sleep quality, lifestyle regularity, appraisal style and mood. Results: Findings relating to the relationship between circadian stability, appraisal style and mood in all 4 populations will be presented. Conclusions: It is intended that the results of the survey will highlight potential treatment mechanisms for individuals with bipolar disorder and those at risk of developing the disorder. Emotional priming effects – Evidence for a manic defense in bipolar disorder? Thomas Meyer, Newcastle University and Academic Psychiatry, Regional Affective Disorders Service, NTW, Newcastle upon Tyne; Anthony Redhead, Redcar & Cleveland Affective Disorders Service, TEWV, Redcar; Nicol Ferrier, Newcastle University / Academic Psychiatry, Regional Affective Disorders Service, NTW, Newcastle upon Tyne; Gabriele Jordan, Newcastle University Introduction: Biased information processing styles are central to many cognitive models of unipolar depression (UD). The manic defense hypothesis (MDH) posits that mania and depression are subject to the same underlying psychological processes. Goal of the present study was to test whether there is an incipient negative bias in emotional processing in BD as predicted by the MDH. Previous studies measuring automatic processing of emotional information (e.g. faces) to test the MDH were inconsistent. Method: N = 17 euthymic bipolar patients were recruited and matched with 17 control participants (HCs) for age and gender. An affective priming paradigm was used with supraliminal (> perceptual threshold) and subliminal (< perceptual threshold) primes using IAPS pictures as primes and words as targets. Results & Conclusion: Similar to UD, we found evidence for a negative bias in BD bit not HCs when presented subliminally. However, a similar interference for subliminal positive stimuli was found as well suggesting a rather generalised impairment in the early stages of emotional processing in BD. Clinically this implies that emotional regulation might be affected very early in the process and impacts on regular information processing. High and Happy? Exploring the experience of positive states of mind in people who have been given a diagnosis of bipolar disorder Leo Russell, University of Plymouth; Duncan Moss, University of Plymouth Objectives: To approach the experience of "happiness" and "mania" for people who have been given a diagnosis of "bipolar disorder" and to explore how they might differentiate or associate between these experiences. Design: A qualitative design was used in which four participants who had been given a diagnosis of "bipolar disorder" were interviewed individually regarding their experiences and ideas about "mania" and "happiness". Methods: Transcriptions from the interviews were analysed using the iterative process of interpretative phenomenological analysis (IPA). Results: Four super-ordinate themes were identified. Two highlighted the conceptual fluidity and similarities between their ideas about and experiences of "happiness" and "mania". Two emphasised the differences between these notions for the participants, which reflected the destruction, disruption and chaos of "mania" in contrast to the importance of self -acceptance, peacefulness and social connection for "happiness". Conclusion: There may be benefit in maintaining an active dialogue or "poly-vocality" about the meanings of "happiness" in clinical work with people who experience "positive states" of mind, which are personally problematic. This can be supported by drawing on ideas and narratives about "happiness" from the field of positive psychology.

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Appraisals of and responses to hypomanic states in bipolar affective disorder Mariana Giurgiu, University of East Anglia/Suffolk PCT; Malcolm Adams, University of East Anglia Background: There has been an increased interest in the last decade in studying the cognitive processes that could explain the development and maintenance of bipolar affective disorder. Further research is needed to understand the interpretations people with bipolar affective disorder make about their energetic, positive moods and the mechanisms used to regulate their mood states. The present study extends previous research into the integrative cognitive model of Mansell, Morrison, Reid, Lowens & Tai, (2007) with focus on exploring the ways in which hypomanic states are thought about and responded to by people with experience of bipolar affective disorder when in remission. This study is the first to look concomitantly at appraisals of hypomanic experiences and strategies of response to positive mood in a clinical population of participants with bipolar affective disorder. Method: A remitted bipolar group (N=29) was compared with healthy controls (N=27) on measures of interpretations of hypomanic states (Hypomanic Attitudes and Positive Predictions Inventory, Mansell & Sadhani, 2007) and ruminative responses in regards to positive mood (Response to Positive Affect Questionnaire; Feldman, Joorman & Johnson, 2008). Levels of current mood were controlled for. Results: Results indicated that people with a diagnosis of bipolar affective disorder, in a remitted phase, showed elevated levels of positive, extreme beliefs about their hypomanic states as well as higher levels of catastrophic, self-and-other critical and loss of control beliefs than people with no history of mental health difficulties. It was found that remitted bipolar affective participants are ambivalent about positive mood states. They engaged in mental processes that intensified as well as diminished positive mood states to a higher degree than healthy controls. Within the bipolar group tendency to dampen positive affect was positively correlated with catastrophic and self-and-other critical beliefs about activated states. A positive association was also identified between self-activating beliefs and positive rumination strategies. None of these patterns of associations were found in the non-clinical group. Conclusions: The findings bring further evidence for the theory driven cognitive model developed by Mansell et al., (2007), highlighting the importance of focusing in clinical practice on working with the meaning attached to hypomanic, energetic states, and the need to incorporate emotion regulation techniques in the treatment of this client group. Future research is needed to identify the factors that “attenuate” the intensity and the frequency of these extreme, opposing interpretations and the impact of addressing them on treatment effectiveness and illness course. Response to different types of positive mood state in people diagnosed with Bipolar Disorder Claire Delduca, University of Exeter; Kim Wright, University of Exeter The BAS dysregulation theory of Bipolar Disorder (Depue et al., 1987; 1989) proposes that episodes of hypomania represent excessive and prolonged periods of elevated approach motivation (AM). There is evidence for excessively high goal setting and excessive goal-striving behaviour amongst people with Bipolar Disorder, as well as increased tendency to engage in stimulating activities even outside of a hypomanic episode. These types of behaviour would be expected to trigger further increases in AM, raising the possibility that in individuals with Bipolar Disorder elevated AM and behaviours interact, contributing to an “upward spiral”. The current study tests the hypothesis that individuals with Bipolar Disorder tend to respond to high activation positive affect with behaviours that would be likely to trigger further increases in this state, namely activities that are directed towards goal pursuit or are highly physically stimulating. Two groups of individuals were tested, one group of individuals with a diagnosis of Bipolar Disorder and a control group comprising individuals with no history of affective disorder. Participants completed an initial set of measures of current levels of hypomanic and depressive symptoms. They then completed two versions of each of two measures of response to positive mood. One version asked participants to report their response to low activation positive affect, and the other to high activation PA. One month later, participants recompleted measures of symptom levels. The results will be discussed with reference to the clinical utility of understanding how individuals use and respond to positive mood.

New Developments and Interventions for Bipolar Disorder Convenor: Alyson Dodd, Lancaster University

Interpersonal Psychotherapy Therapy (IPT) group treatment for young people with bipolar affective disorder: A pragmatic randomised control trial Matthias Schwannauer, University of Edinburgh In this paper we are going to present the development and efficacy of IPT for adolescents with bipolar disorders. Community studies have shown a point prevalence of 1 to 2% for bipolar disorders and recent studies are showing suicide to be one of the chief cause of death in young people. Clinical and epidemiological data have documented that bipolar disorder and recurrent mood difficulties in adolescents are a largely underrecognised underserved population. The undertreatment of adolescents with bipolar disorders, including limited access to appropriate psychological therapies, can be explained by a combination of their limited access to and underutilisation of mental health care. The implementation and evaluation of IPT as treatment that is regarded by adolescents as "more immediately relevant" must be an objective for anyone aiming to better meet the needs of this vulnerable group. In this presentation we will highlight the development of a bespoke practice model of IPT-A for young people with bipolar disorder, considering attachment theory and key features of adolescent development. The paper will present results of a pragmatic RCT of IPT for group for adolescents with bipolar disorders. The session will focus on the group application of the IPT model to bipolar disorder and present the outcome of a randomised trial in the Child and Adolescent Mental Health Services in Edinburgh, Scotland, examining the effects of treatment on core symptoms, coping styles and interpersonal problems. The results showed clear improvement in core symptomatology and quality of life for following intervention. Think Effectively About Mood Swings (TEAMS): A Pilot Randomised Controlled Trial of CBT for Bipolar Disorders Sara Tai, University of Manchester Think Effectively About Mood Swings (TEAMS) is a new cognitive behavioural approach to working with people with bipolar disorders and mood swings. It is based on an integrative cognitive model (Mansell, Morrison, Reid, Lowens, & Tai, 2007), which proposes that people with bipolar disorders have multiple and conflicting beliefs related to their internal states and how to control them (e.g. high moods; energy levels; rates of thinking). Behavioural attempts to exert control over moods

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perceived as being important for achieving any one specific goal can often lead to other important personal goals being compromised. These behavioural control strategies are thus counterproductive as they maintain mood swings and subsequent distress. This presentation will provide a brief overview of the empirical evidence for our integrative cognitive model, as a platform on which to outline the components of TEAMS therapy. Our recent case series, demonstrated that beliefs implicated in the maintenance of symptoms were reduced over the course of TEAMS CBT based on the model (Searson, Mansell, Lowens & Tai, 2012). This was particularly effective for people with persistent depression, for whom medication has limited impact. Within this presentation, the main principles of the TEAMS approach will be outlined. Essentially TEAMS involves developing clients’ awareness of their internal states and their conflicting beliefs about them (“I must not let people see me depressed appear energetic” vs “When I am full of energy other people criticise and control me”) and also increasing flexibility of thinking in order to broaden the bandwidth of tolerance to a variety of internal states relevant to achieving important personal goals. An update on the evaluation of TEAMS therapy will also be provided, including an overview of the design and methodology of the NIHR- funded pilot randomised controlled trial of TEAMS for people with bipolar disorder (Tai, Mansell, Morriss, Tinning, Dunn, Davies & Morrison, in preparation). An online randomised clinical controlled trial of ‘Living with Bipolar’: Results at 3 and 6 months follow-up Nicholas Todd, Lancaster University Objectives: Bipolar Disorder (BD) is a common and severe form of mental illness and estimated to cost the UK £7 billion per annum. Although service users respond well to psychological interventions there are severe inequalities in access. This study pilots a free to access recovery informed web-based intervention for BD to increase access to NICE-guidance recommended psychological interventions. Design: A small online randomised controlled trial evaluates the feasibility, acceptability and potential effectiveness of the intervention compared to treatment as usual. Feasibility and acceptability will be assessed by recruitment and retention rates, website usage statistics, user satisfaction scales and a series of qualitative interviews. Effectiveness will be assessed on a range of outcome measures including quality of life, mood symptoms, coping, recovery and illness beliefs. Methods: Analysis of Covariance will be used to compare the impact of the web based intervention with treatment as usual. Thematic analysis (Braun & Clarke, 2006) will be used to analyse the qualitative interviews. Results: Results will be available by July 2012. Conclusions: Scientifically this intervention will build on the growing evidence base for psychological interventions for BD and the results of this trial will inform a definitive trial which will include an implementation phase to investigate the potential use of the intervention within the National Health Service. REACT – Relatives Education And Coping Toolkit: Feasibility and outcome Fiona Lobban, Lancaster University Evidence supports the effectiveness of Family Interventions (FIs) in improving outcome for people with psychosis and relatives. As an adjunct to pharmacotherapy, FIs reduce relapse & hospitalisation rates. Research is limited in its focus on people with more chronic mental health difficulties, and lack of attention to outcomes for relatives. However, interventions that are well integrated into early intervention services (EIS) show reductions in relatives’ distress. Significant barriers exist to the dissemination of effective interventions through NHS EIS. These include clinicians with high caseloads and lack of confidence & training in working with relatives. As a result, relatives report negative impacts on many areas of life. Relatives at first episode are at even higher risk of distress than those at later stages. There is a clear need for an intervention that can be widely available to relatives, is easy to use, phase specific, recovery focussed, does not require extensive clinical resources, targets key appraisals and coping strategies and empowers relatives. The REACT study tests the hypothesis is that it will be possible to develop and implement a supported self-management intervention for relatives of people experiencing recent psychosis (including bipolar disorder) that will significantly reduce relatives’ distress (General Health Questionnaire (GHQ)) compared to current support. This presentation will cover the main findings of this study. Developing New Approaches to Bipolar Disorder: An update from the PARADES programme Steven Jones, Lancaster University Bipolar disorder affects over a million people in the UK and costs over £5.2 billion per year. Despite a high level of need and contrary to NICE recommendations people do not have access structured psychological therapy for this conditions. The PARADES programme was funded by NIHR in 2008 to evaluate new psychological therapies for bipolar disorder and to learn more about suicidality in bipolar disorder. This talk will explain the context and rationale behind the PARADES programme and provide a brief update on progress with four of its workstreams namely; i) Group psychoeducation for bipolar disorder; ii) CBT for comorbid anxiety in bipolar disorder; iii) CBI for alcohol problems in bipolar disorder; iv) Factors associated with Suicidality in bipolar disorder. Clinical and research implications of work to date will be discussed.

Recent Developments in CBT for Psychosis: What Can We Learn From the Social Anxiety Literature? Convenor: Katherine Newman Taylor, University of Southampton & Southern Health NHSF Trust Chair: Lusia Stopa, University of Southampton

Social anxiety following psychosis: A comparison with social anxiety without psychosis Sarah Cooke, University of East Anglia, and Norfolk and Waveney Mental Health NHS Foundation Trust Social anxiety (SA) is common in people with psychosis, but it is often left untreated (Lysaker & Hammersley, 2006). Birchwood (2003) proposed three pathways to SA in psychosis: SA may be triggered by childhood experiences such as trauma, by psychotic symptoms, or may develop following a psychotic episode if the diagnosis is appraised as shameful. Voges and Addington (2005) found a link between negative self-statements and SA in psychosis, supporting the relevance of SA models (e.g. Clark & Wells, 1995) and schema research in psychosis (Fowler et al., 2006). Lockett (2010; 2011) explored the images experienced by people with SA and psychosis, and found that people experienced a mixture of typical SA images (e.g. being ridiculed) and images containing actual or physical threat (e.g. being kidnapped). She proposed a two-path schema-based model of SA in psychosis incorporating the roles of traumatic past interpersonal experiences, shame and paranoia. However, more data are required to validate cognitive aspects of the model, and research is needed to test the hypothesised roles of trauma and shame.

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The current study recruited participants with SA as a primary diagnosis and participants in an Early Intervention Service who also have SA, in order to examine SA in the two groups. Participants were compared on self-report measures of shame, socially anxious cognitions and schemas. Additionally, exploratory analyses assessed images and memories experienced in social situations, and trauma symptoms. The findings further our understanding of SA in psychosis and indicate the likely value of linked interventions. Imagery in persecutory delusions: An investigation of mental imagery in clinical and non-clinical populations Natalie St Just, University of Southampton; Lusia Stopa, University of Southampton; Katherine Newman Taylor, University of Southampton and Hampshire Partnership NHS Foundation Trust Imagery is recognised as a key component in the maintenance and alleviation of distress in social anxiety, PTSD and other forms of anxiety, but we know very little about imagery in psychosis. Preliminary studies (e.g. Morrison et al., 2002; Morrison, 2004) indicate that people with psychosis experience mental images that are intrusive and associated with early aversive memories, affect and cognition. The current study investigated mental imagery in persecutory delusions, in line with the cognitive model proposed by Freeman and colleagues (2002). Imagery and memories associated with interpersonal mistrust and harm to the self were examined in people with persecutory delusions and a non-clinical control group. The clinical group reported higher belief conviction and more depressive affect linked to their images and memories. This group also adopted an observer perspective in relation to their images and memories to a greater extent than the controls. Qualitative analysis was used to explore the experience and meaning of interpersonal mistrust imagery and memories in the two groups. Preliminary findings indicate the quality and role of imagery in people with persecutory delusions, with implications for clinical practice. What impact does the treatment of social anxiety have on residual paranoia in people recovering from psychosis? Richard White, University of East Anglia, and Norfolk and Waveney Mental Health NHS Foundation Trust; Ruth Turner, University of East Anglia, and Norfolk and Waveney Mental Health NHS Foundation Trust Social anxiety frequently co-occurs with psychosis, but is considered to be separate from the core syndrome of psychosis, as opposed to being an epiphenomenon of psychotic symptoms, including paranoia. However, the separation of psychotic symptoms and accompanying psychological problems may not be so clear-cut. Indeed, theories regarding the psychological mechanisms maintaining psychotic symptoms posit that the processes underlying anxiety may also underlie psychotic symptoms. In this sense, it may not be unreasonable to hypothesise that an intervention which targets these core anxiety processes would have a positive impact on both psychotic symptoms and co-occurring anxiety problems. In this presentation we will discuss preliminary results from an ongoing randomised control trial investigating the impact of a CBT-based intervention targeting social anxiety in a first episode of psychosis cohort. We will focus on the impact of the intervention on paranoia measures, as assessed by the PANSS and self-report measures. There will also be a consideration of the phenomenology of the social anxiety reported by participants in the trial, as well as how more paranoid cognitions were dealt with in the therapy, for example through incorporation to social anxiety models and formulations. Formulating paranoia following a cognitive model of social anxiety; A single case study Katherine Newman Taylor, University of Southampton and Southern Health NHS Foundation Trust; Lusia Stopa, University of Southampton While we recognise clinical differences, it is likely that many of the same psychological processes contribute to the maintenance of both social anxiety and paranoia. The cognitive models suggest that both groups are characterised by expectations of social threat, and beliefs about the self as bad or flawed (Clark & Wells, 1995; Freeman et al., 2002; Hofmann, 2007; Rapee & Heimberg, 1997). In addition to similarities in the content of cognition, current models indicate that paranoia is maintained, at least in part, by processes common to the anxiety disorders. Freeman and colleagues (2002) explicitly base their model of paranoia on Clark’s (1999) seminal paper articulating key processes involved in the maintenance of anxiety, specifically: the use of safety-seeking behaviours, attentional deployment, spontaneous imagery, emotional reasoning, memory processes and the nature of the threat representation. As cognitive behavioural therapists, we base our interventions on psychological conceptualisation of the development and maintenance of distress and disability. Accurate formulation of these processes is therefore key to effective therapy. We suggest that a model of paranoia based on the Clark and Wells (1995) model of social anxiety is likely to have considerable clinical utility. In this paper, we present a single case study of a person who engaged in CBT to address distressing persecutory delusions. The assessment and formulation is based on the Clark and Wells (1995) model of social anxiety. The process of case conceptualisation and intervention will be described, as well as the impact of therapy on levels of distress and functioning. Cognitive Behavioural Therapy for Auditory Verbal Hallucinations ('Hearing Voices'): From Causes to Effects in Clinical Practice Convenor: Simon McCarthy-Jones, Macquarie University, Australia

Chair: Robert Dudley, Northumberland, Tyne and Wear Foundation Trust & Newcastle University

Considering the evidence for utilising CBT with distressing voices: problems and possibilities Simon McCarthy-Jones, Macquarie University This paper will begin by reviewing the evidence base for the effectiveness of CBT for clients with distressing auditory verbal hallucinations (AVHs). It will be concluded that at present the evidence from randomised controlled trials of CBT for AVHs is surprisingly weak. The various possible reasons for this will be explored. The first is that CBT is effective, but methodological limitations of existing studies have led to failures to detect this. Evidence for this will be examined and improvements to study designs will be suggested. A second potential reason for this finding is that current CBT practice is not fully consistent with what we know of the phenomenology and causes of AVHs. A review of the phenomenology and biopsychosocial-spiritual causes of AVHs will suggest that the CBT toolkit may indeed be expanded in order to provide more effective help for clients suffering from distressing voices.

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Auditory verbal hallucinations: Insights from the phenomenology of inner speech Charles Fernyhough, University of Durham Inner speech is a puzzling and little understood phenomenon. It plays an important role in cognitive models of auditory verbal hallucinations (AVHs), but there has been relatively little research into its phenomenology, development and cognitive functions. My work in this area stems from a developmental perspective which views inner speech as the end product of a gradual process of internalisation of linguistic exchanges with others. I will describe this account and its implications for the phenomenology and heterogeneity of inner speech. I will then briefly review inner speech models of AVHs with particular reference to relevant phenomenological features of dialogicality, condensation, etc. If CBT is to be effective with AVHs, it needs to be sensitive to the phenomenological variability in inner speech experiences, especially given that AVHs are explicitly or implicitly defined in opposition to ‘normal’ inner experience. I conclude by considering how existing CBT approaches can be enhanced by careful attention to these phenomenological variables. Tailoring CBT to specific subtypes of auditory verbal hallucinations Guy Dodgson, Northumberland, Tyne & Wear NHS Foundation Trust; Jenna Robson, Northumberland, Tyne & Wear NHS Foundation Trust Investigations into the aetiology and phenomenology of auditory verbal hallucinations (AVHs) suggest that there may well be several different subtypes of this experience. Dodgson and Gordon (2009) suggested a subtype which they labelled hypervigilance hallucinations (HH) which they attributed to cognitive biases in a highly aroused state. This model describes the process behind an illusion, but recent research suggests that HH may develop into Inner Speech (IS) voices. Garwood et al (in submission) used cluster analysis to investigate if the phenomenology of voice hearing fell into clusters. HH and IS subcategories emerged, however all the people who described a HH experience also had a voice that appeared consistent with IS. The development of this sub category allowed identification of appropriate sub categories including greater accuracy of identifying IS voices. Other work also identified that most treatments for AVHs are not rooted in the theoretical accounts of the phenomena which may explain why CBT treatments for AVHs have a disappointing effect size. This presentation will highlight the rationale for a recent treatment manual which is firmly rooted in theoretical models behind IS and HH voices. It identified the treatment strategies used for each of the sub types and offer some practical techniques for trying to reduce distress and conviction in the voice-hearing experience. The psychoeducation and treatment strategies target the proposed mechanisms from cognitive models of AVHs. A multiple baseline single case design was conducted with seven individuals to a pilot the effectiveness of this treatment manual. Initial results are promising and this will be presented. CBRT: Putting the 'Relating' into CBT for distressing voices Mark Hayward, University of Sussex Cognitive models of auditory hallucinations are being elaborated in an attempt to more fully understand the variables that determine the distress often experienced by hearers. There is a growing body of literature that aims to explore the relevance of the concept of ‘relating’ to the experience of auditory hallucinations. Three different theoretical perspectives have been utilized in this respect: Benjamin’s Structural Analysis of Social Behaviour; Gilbert’s Social Rank Theory; and Birtchnell’s Relating Theory. Collectively, the use of these theories suggest that the experience of auditory hallucinations can be understood within interpersonal frameworks, and the relationships that hearers develop with their hallucinations share many properties with interpersonal relationships within the social world. This paper will focus upon one of the interpersonal theories – Birtchnell’s Relating Theory – and offer lessons learnt from qualitative and quantitative studies that have informed our understanding of voices within a relational framework. Issues of personification, proximity and engagement are prominent, as is the influence of relationships within the social environment of the client. This paper will place a significant focus upon the development of the therapeutic approaches that have evolved from these understandings. Relating Therapy and Cognitive Behavioural Relating Therapy encourage clients to turn towards and learn about the reciprocal processes that maintain the distress that is often associated with hearing voices. Clients are encouraged to take responsibility for their own relating and to develop more assertive ways of responding to the voices they hear. Two small case series have suggested that these forms of therapy are acceptable to clients and can be effective in modifying relating variables and emotional responses, and these benefits have been corroborated through stakeholder interviews. The implications of these therapeutic developments will be explored with reference to both clinical practice and the future research agenda.

Dissociation in the Real World Convenor: Julia Coakes, The Retreat

Discussant: Julia Coakes, The Retreat

The Phenomenology of Dissociation Chris Holman, The Retreat Dissociation is a psychological mechanism associated with a trauma theory of distress. It has in recent years become the focus of considerable attention by many people working in mental healthcare, and there is an apparent assumption we all know what we are referring to when we use the term. In this paper I will discuss the types and presentations of dissociation, and the borderline between dissociative experiences and psychosis. I will examine the ways dissociation has been described and categorised by leading authorities. I will try to link the presentations of dissociation with hypothesised brain mechanisms, and to the principles of treatment. Dissociation; is it past it’s ‘use by’ date? Mark McFetridge, the Retreat York As clinicians find themselves increasingly working with people with complex presentations, the author presents the assessment data of individuals referred on to a specialist tertiary service over the period of a decade. Many have significant problems with dissociation and have diagnosable dissociative disorders, in addition to problems with affect regulation, attachment and reported histories of trauma.

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The follow-up outcome data for those individuals with significantly high DES scores on assessment are compared to those with lower self-reported dissociation, and the results and implications for recovery are discussed. One individual’s severe dissociation and therapy are considered in detail. She reflects on this twelve years later, considering what helped in particular, and putting therapy into the broader context of her life and recovery. Dissociative disorders in therapy - techniques and pitfalls Julia Coakes, The Retreat A case of a woman with a severe dissociative disorder is discussed exploring how the treatment has developed and the impact of the therapeutic relationship. The use of compassionate mind work, imagery, mindfulness and EMDR is discussed and feedback from the client on these models is reviewed. The case is considered in the light of new models of dissociation and the work on integrating the apparently normal personality and emotional personality is explored. The impact of the current NHS funding restrictions on this type of work is also considered.

Dissociation Past, Present and Future: Cognitive Insights Convenor: Fiona Kennedy, Private Practitioner

The Brain and Dissociation Helen Kennerley, Oxford Cognitive Therapy Centre; The paper will explore the neuro-biological and psychological explanations for the different presentations of dissociation, including:Detachment,Compartmentalisation,Absorption. In particular, the paper will outline the neurobiology of traumatic memories which can present in the form of flashbacks and other unwanted intrusions, whether this is in relation to PTSD or other psychological disorders. Finally, and perhaps most importantly, the paper explores how an increased understanding of the brain processes underlying dissociative experiences can inform our clinical formulations, clinical practice and the management of dissociation-related problems. Imagery and dissociation Lusia Stopa, Southampton University This paper examines the contribution of mental imagery to normal and abnormal dissociative states. Mental imagery describes the experience of internally generated percepts that can occur in any sensory modality. Imagery underpins many dissociative states. For example, day dreaming is characterised by turning attention to an internal mental landscape that is frequently populated by visual images of desired future events. When individuals experience an acute episode of dissociation; e.g. at the time of trauma, they often describe looking down on the event from above. This perception of events from an altered and in many cases ‘out of body’ perspective necessarily depends on mental imagery which is constructed on-line. In spite of the importance of mental imagery in dissociation, to date this has not been systematically examined. Instead, there has been a tendency to focus on more trait-like characteristics such as “fantasy-proneness” (e.g. Wilson and Barber, 1981) and hypnotisability (Lynn & Ruhe, 1986). This paper will review the existing literature in order to provide a coherent account of what is currently known about the relationship between imagery and dissociation. It will suggest ways that we can understand this relationship consider its implications for clinical practice and outline a programme of research to refine our understanding of how imagery underpins dissociation and interacts with other psychological processes that contribute to dissociative states. The Role of Dissociation in Psychosis Katherine Newman-Taylor, Southampton University Cognitive theory and therapy for psychosis has developed dramatically over the last two decades. We now have psychological models to guide our understanding and interventions with people living with voices, paranoia and other psychotic experiences. Furthermore, the National Institute for Clinical Excellence (2009) recommends cognitive behavioural therapy and family interventions in the treatment of people with a diagnosis of schizophrenia. It is perhaps surprising, then, that dissociation in relation to psychosis has received little attention to date. Clinically, we know that people with psychosis often describe fragmented experiences, may ‘tune out’ when talking about difficult experiences or struggle to describe particular memories with coherence and clarity. Yet, with notable exceptions (see Dell & O’Neill, 2009; Moskowitz et al., 2008), there has been little examination of either conceptual or clinical links between dissociation and psychosis. Ross (2008) argues that this gap in the literature is due to historical and erroneous distinctions between environmental versus genetic aetiology, neurotic versus psychotic symptomatology, and psychotherapeutic verses medical interventions as treatments of choice. There is growing evidence that dissociation mediates the relationship between traumatic events and psychopathology. Given the clear empirical links between trauma and psychosis, it is now necessary to scrutinise the role of dissociation in this group. This paper will summarise our current knowledge of the relationship between dissociation and psychosis within a cognitive behavioural framework. It will be shown that there is good theoretical reason to expect dissociation to be a key process in the maintenance of distress in psychosis, but that much of the current research is flawed by the absence of any consideration or assessment of dissociation. The reason it is important to understand these relationships is in order to assess, formulate and work effectively in clinical practice. Broadly speaking, cognitive behavioural interventions for people with psychosis aim to support people to live well with voices and other intrusive experiences, and to re-evaluate key cognitions (such as paranoid beliefs and self appraisals) associated with distress and disability. By contrast, trauma based interventions, including those for dissociation, aim to facilitate the integration of fragmented experience and thereby reduce distressing intrusions. It is essential, therefore, that we are able to formulate accurately the psychological processes involved in psychosis, including dissociation, if we are to offer the most effective therapeutic interventions.

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Where Can the Roots of Dissociation be found in Childhood? David Pearson, Retired Consultant Clinical Psychologist Almost invariably, adult clients who have problems with dissociation also report childhoods that were abusive, neglectful or bizarre. Many experiences in childhood may be considered as dissociative but are seen as ‘normal’ or even encouraged by family or carers. Consider the following example: Kathy asked her imaginary friend George whether he enjoyed the party and he said it was really good but he did not like Jean who he felt was showing off. George went on to say that if Jean could not behave better then Kathy should not be friends with Jean. Kathy thanked George for the conversation, it was good advice and she decided not to be friends with Jean any more, and to stop talking to her. Kathy also thought that it is a good job that George is here with her to give good advice as she can’t always make these decisions and anyway she can sometimes forget what decisions she has made. If Kathy is seven years old then this report may be seen as ‘cute’ and may be even viewed as Kathy being creative, encouraged by parents who can often use George to their advantage particularly at meal times. If on the other hand Kathy is 37, depending on the context, this could be viewed as a psychotic episode of voice hearing or even intrusive thoughts and memory impairment which she is unable to control. Kathy may be seen as a woman who is unable to recognise that her thoughts are not voices and depending on our orientation, we as clinicians may be interested in why she cannot integrate her thoughts and reality, perhaps being interested whether her voices are perceived as being inside or outside of her head. The only thing that changed in these two interpretations of Kathy’s report was her age. This raises the question in diagnostic terms as to when does ‘cute’ become ‘psychotic or dissociative’; is it perhaps on your tenth, fifteenth or eighteenth birthday? This example is of course clearly fabricated, but it does serve to demonstrate that these processes are available during childhood. Research has clearly provided data to show that abuse and neglect damages development. This damage can be physical, psychological and neurological. Abuse and neglect can produce long term damage that can be recognised and diagnosed. Failure to thrive indicates that children are physically damaged in these circumstances and attachment disorder has a cluster of symptoms that have been suggested to mimic borderline personality disorder. There is also evidence that neurobiological damage can also be long term. This paper will look at what happens when expected parts of child development combine with damage and whether the resulting mixture can form the foundations for later dissociative problems. Can expected, non-clinical parts of child development ‘carry’ pathology as the child moves towards adulthood? Control Theory and Dissociation Warren Mansell, University of Manchester; Timothy Carey, Flinders University; , This paper uses Perceptual Control Theory (Powers, Clark, & McFarland, 1960; Powers, 1973, 2005, 2008) to explain dissociation. In particular, it focuses on the phenomena that are described under the umbrella of ‘dissociation’ and concentrates on defining when, how, and why, these phenomena would be significant problems for a person. It is widely accepted that dissociative experiences lie on a continuum with normal experiences (Ray, 1996). This paper provides a framework for these normal processes and illuminates when they present as significant problems and therefore how to treat them. In essence, we conclude that dissociation represents functional splits within a person’s mind. These splits become a clinical problem only when they disrupt the capacity of the individual to realise important personal goals (e.g. to maintain a social identity, to form close relationships, to keep safe, and so on). Therapy involves helping the person experiencing dissociation to become more aware of the dissociation process and to let go of rigid ways of controlling it (e.g. social withdrawal, self-criticism). Through this increased awareness they can learn more flexible control over their dissociative experiences so that the experiences and their attempts to manage them no longer inhibit their pursuit of their most important life goals.

Learning From and Alongside Service Users: The Recovery Programme Convenor: Mary Welford, Greater Manchester West Mental Health NHS Foundation Trust

An overview of the Recovery programme: lessons for research and practice Tony Morrison, University of Manchester The NIHR funded RECOVERY programme builds on our track record of collaborative research on psychological approaches to understanding and treating psychosis, by extending this work to encompass understanding and promoting recovery from psychosis, in a manner that is acceptable to and empowering of service users. Our user-led study of recovery identified a number of common themes including understanding of self, empowerment, rebuilding life and the inspiration of hope. There is demand for recovery orientated services, but little is known about psychosocial factors that influence recovery or specific treatments that promote recovery from psychosis. Our programme incorporates a series of linked studies to: (a) develop a meaningful and patient-centred measure of recovery; (b) study psychological processes that impeded or assist the process of recovery in different domains;(c) investigate the causes of patient suicide and identify methods of preventing suicide; (d) evaluate individual, group and self-help psychological interventions to maximise recovery from psychosis; and (e) assess the extent to which our research and treatment findings from patients with psychosis can be applied to patients with bipolar disorder. An overview of the history and principles of the research programme will be provided, focusing on lessons learnt for both research and clinical practice in relation to the measurement and facilitation of recovery from psychosis, collaborative working with service users and the use of mixed research methodologies. Service User Involvement in the Recovery Programme Liz Pitt, Greater Manchester West Mental Health NHS Foundation Trust The Recovery Programme is a collaborative research project with a meaningful level of service user involvement. It has received a gold award for good pratice in service user involvement from the Mental Health Research Network. The presentation will outline the different levels of service user involvement in the Recovery Programme describing what is involved at each level. It will highlight what service users have valued about their involvement and what they feel the wider impact has been. There will be reflections on what could be improved and the lessons learnt about service user involvement in research for the future.

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Recovery focused, cognitive behaviourally oriented supported self help for people with psychosis: outcomes from a service user preference trial Gillian Haddock, University of Manchester; and the Self help therapy and recovery trial (STAR-T) team*, University of Manchester and Greater Manchester West NHS Trust Despite psychological interventions, such as cognitive behaviour therapy (CBT) for psychosis being recognised as important options for people experiencing psychosis, , implementation within services is poor. Although the reasons for this are complex, and are, in part, related to the way the workforce are trained and supported to deliver interventions, it has also been suggested that this may be due to problems in relation to the treatment and the way it is delivered. For example, psychological treatments have predominantly been developed by clinicians and researchers with little direct input from service users experiencing psychosis which may have resulted in a treatment which is not entirely relevant for their needs. Also, the main outcomes targeted in intervention trials to evaluate psychological treatments for psychosis have predominantly focused on psychotic symptoms and these may not reflect the most important outcomes for service users in relation to their own recovery from psychosis. Finally, the way that psychological treatments have usually been delivered has been in the form of face to face therapy; a format that may not suit all service users with psychosis. This paper will report outcomes from a trial which has tried to address these three issues in relation to implementation of psychological therapies for psychosis, the Self Help Therapy and Recovery trial (STAR-T). The trial gave participants choice about how they wanted their treatment delivered, offered treatment which focused on personal recovery goals and which delivered the intervention in different formats. The trial provided three options: 1) to be randomly allocated to any treatment option, 2) treatment as usual only, 3) the use of a CBT oriented self help manual (developed by service users and clinicians) plus telephone support (up to 30 sessions) from a CBT therapist, and 4) all options described in option 3 plus 12, recovery focused, fortnightly groups delivered jointly by a service user and a cognitive behaviour therapist. Therapy was conducted over a 9 month therapy envelope and outcomes were assessed at 9 and 15 months. Preliminary results suggested that the options were acceptable to service users involved and that the majority of participants had a preference about how their treatment was delivered. The main outcomes were related to recovery and well being and these will be reported in this paper. *The Self help therapy and recovery trial (STAR-T) team include: Christine Barrowclough, Liz Pitt, Jason Price, James Kelly, John Mulligan, Sandra Neil, Zoe Rivers, Mary Welford, Chris Taylor, Samantha Hartley, Rachel Watts, Kimberley Drummond, Sarah Woodward, the NIHR funded Recovery programme team and the programme Service User Reference Group Formulating Resilience from Suicide: A necessarily collaborative approach James Kelly, Greater Manchester West Mental Health NHS Foundation Trust; The Recovery Programme- Prevention of Suicide Team Many people with experiences of psychosis feel suicidal at some point, with 4 -10% going on to kill themselves. CBT has been found to be effective in reducing ‘psychotic symptoms’ but has been less effective at reducing hopelessness and suicidal ideation. The Cognitive Behavioural Suicide Prevention for psychosis (CBSPp) trial therefore aimed to address this. The therapy protocol (Tarrier & Gooding, unpublished; Tarrier et al., in press) provided a theoretical, ‘top-down’ understanding of suicide. However, during the course of the trial, the therapy benefitted greatly from the ‘bottom up’, lived experience of service user input. This came from individuals participating in the trial, from a Service User Consultant and from the Service User Reference Group. The therapy melded to the needs of the participants, and to the lived experience of suicidal feelings. Key aspects of the therapy included dealing with the shame of talking about suicide, both for therapist and client and formulating and enhancing natural resilience factors. This is a necessarily collaborative approach in which each client contributed greatly to the development of their own therapy, but also, to broader theoretical developments in the prevention of suicide. Key findings are discussed along with a consideration of how to empower research participants in the development of theory and practice and new directions to enhance individualised therapies. The Recovery Programme- Prevention of Suicide Team included the following: Yvonne Awenat, Nick Tarrier, Patricia Gooding, Mary Welford, Sandra Neil, Janet Maxwell, Dan Pratt, Natasha Snelson, Sehar Maqsood, Peter Taylor, Judith Johnson, the NIHR funded Recovery Programme Team, The Programme Service User Reference Group and the Manchester Suicide Research Group. Recovering with the Recovery Research Programme Yvonne Awenat, University of Manchester This presentation outlines my involvement in the NIHR Recovery Research Programme from the perspective of a person with 'lived experience' of mental health problems describing the resulting transformation in my quality of life and health along the continuum of the journey of Recovery.

Psychosis: Basic Processes Chair: Catherine Crane, Oxford Mindfulness Centre, University of Oxford

Cognitive factors maintaining persecutory delusions in psychosis: the contribution of depression. Natasha Vorontsova, Institute of Psychiatry, King’s College London; Daniel Freeman, University of Oxford; Philippa Garety, Institute of Psychiatry, King’s College London Persecutory delusions are one of the most common and distressing symptoms of psychosis (e.g. Appelbaum et al., 1999; Sartorius et al., 1986). Development of better treatments requires an improved understanding of the mechanisms which maintain paranoid beliefs. Many studies indicate an association of persecutory delusions with depression (e.g. Smith et al., 2006). A direct role for depression-related cognitive factors in the maintenance of persecutory delusions has not been systematically examined, despite such processes being implicated in a cognitive model (Freeman et al., 2002). In this talk, the findings from a prospective study of maintenance factors will be presented. This project examined, over time, the contribution of depression and associated cognitive processes to the persistence of persecutory delusions over six months in a sample of 60 patients with schizophrenia spectrum disorders. We hypothesised that depression, along with negative schematic beliefs, memory bias, rumination and problem solving difficulties, would lead to the persistence of paranoid fears. A longitudinal design enabled hypothesis-driven tests of maintenance factors. We conclude that depression and associated cognitive features can predict the persistence of persecutory beliefs over time. Among participants with persecutory delusions, high levels of concurrent depression predicted the persistence of paranoia over 6 months. Significant cognitive predictors included negative schematic beliefs about the self and problem solving difficulties. It is possible that treating

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depression and enhancing problem solving skills in people with psychosis could help to speed improvements in positive symptoms such as delusions of persecution.

When feeling anxious makes people with psychosis feel lonely – An experimental investigation into pathways of social support and first episode psychosis Oliver Suendermann, Institute of Psychiatry; Juliana Onwumere, Institute of Psychiatry; Fergus Kane, Institute of Psychiatry; Elizabeth Kuipers, Institute of Psychiatry People with psychosis commonly have poorer social support than the general population. However, we know very little about mechanisms by which poor relationships and support make symptoms and functioning in psychosis worse. Cognitive models of psychosis propose that adverse social environments are one factor contributing to the maintenance of psychotic appraisals. This study aims to investigate social support in first episode psychosis patients, and experimentally study one potential pathway (anxiety) between poor social relationships and psychosis. The study aims to asses 42 first episode patients (currently N=24). Design is cross-sectional. The session uses questionnaire and interview measures to assess symptoms, functioning and social support. A mood-induction task involves watching neutral and emotional pictures on a computer screen. Visual analogue scales assess changes in state symptoms, anxiety and loneliness. A significant number of first onset psychosis patients perceive their social support to be low. These patients appear to be more susceptible to feeling lonely when anxious. Anxiety may be one pathway by which poor perceived support makes psychosis symptoms worse. Preliminary results show that low perceived social support is associated with more symptoms and poorer functioning. Furthermore, patients with low perceived social support appear to be more easily triggered into feeling lonely when anxious than those with high perceived support. A better understanding of how poor perceived support makes symptoms worse may help to design more effective interventions. For example, directly targeting dysfunctional appraisals of relationships may further improve psychosis intervention.

Positive and Negative Core Schema in Psychosis Christopher Taylor, Lancashire Care NHS Foundation Trust & University of Manchester; Gillian Haddock, University of Manchester The role of cognitive schema in psychosis is increasingly a focus of interest for researchers and psychological practitioners and cognitive models of psychosis have suggested an important role for schema. The aim of this study was to explore the relationship between four types of schema (positive-self, negative-self, positive-other, negative-other) and to investigate their specific relationship with psychotic experiences, while controlling for confounding factors such as depression and positive feelings. The study utilised a correlational cross-sectional design. Schema were measured using the Brief Core Schema Scales (Fowler et al. 2006) and psychotic experiences were assessed using interview based measures (Positive and Negative Syndrome Scales and Psychotic Symptom Rating Scales). The Service User Experiences of Psychosis Scale (Haddock et al. 2011), a service user self-report measure assessing impact of psychotic symptoms was also administered. Depression and positive feelings were measured (WHO-QOL Positive Feelings Facet; Calgary Depression Scale). This study provides additional evidence for the role of schema in relation to psychosis, particularly in relation to threatening psychotic experiences and negative-other schema. In total, 85 participants with experience of psychosis (aged 18-65) were recruited. Negative-other schema were associated with threatening psychotic experiences but not with delusions involving control over-ride experiences of psychosis. Negative-self schema were associated with hallucinations and delusions, mainly in the presence of depression. Negative-other schema were associated with threat experiences and suspiciousness/persecution. Positive-other schema were associated with pleasant experiences of psychosis, but not when controlling for positive affect. It provides further support for working with schema within cognitive behavioural interventions, both to reduce negative schema and enhance positive schema to decrease the impact of distressing psychotic experiences.

Childhood trauma increases risk for psychosis: Results of a meta-analysis of the empirical literature Filippo Varese, University of Manchester (UK); Feikje Smeets, Maastricht University (NL); Marjan Drukker, Maastricht University (NL); Ritsaert Lieverse, Maastricht University (NL); John Read, University of Auckland (NZ); Jim van Os, Maastricht University (NL); Richard Bentall, University of Liverpool (UK) The association between childhood trauma and psychosis has been a topic of enduring controversy. A meta-analysis was carried out to examine the available empirical findings on this topic. A database search (from January 1980 through November 2011) was conducted to retrieve papers which investigated the association between childhood adversity (sexual abuse, physical abuse, emotional/psychological abuse, neglect, parental death and bullying) and psychotic symptoms or illness. We included prospective cohort studies, large-scale cross-sectional studies and case-control studies comparing the prevalence of adverse events between psychotic patients and healthy controls. The final analysis included 18 case-control studies (n = 2048 psychotic patients and 1856 non-psychiatric controls), 10 prospective and quasi-prospective studies (n= 41 803) and 8 population-based cross- sectional studies (n= 35 546). These findings suggest that exposure to childhood adversity represents an important risk-factor for psychosis, and stress the importance of early disruptive experiences on subsequent adult functioning. Implications for future research, clinical interventions and primary preventive practice will be discussed. Significant associations between adversity and psychosis were observed across all research designs, with an overall effect of OR = 2.78 (95% CI = 2.34-3.31). The estimated population attributable risk was 33% (16%-47%). Exposure to any type of adversity was associated with increased risk for psychosis. Dose-response associations were observed in 9 out of 10 studies which tested for these associations. The trauma-psychosis link was robust and significant in studies which controlled for demographic and clinical confounders, including genetic vulnerability. Psychosocial interventions addressing sequelae of childhood trauma should be made more available, and should be considered amongst the treatment option for clients with psychosis. Clinicians should routinely inquire about trauma to develop comprehensive formulations and tratment plans.

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Treatment of Psychosis Chair: Steve Moorhead, Northumberland Tyne and Wear NHS Foundation Trust

A mixed-methods evaluation of a pilot psychosocial intervention group for older people with schizophrenia Katherine Berry, University of Manchester; Nitin Purandare, University of Exeter; Richard Drake, University of Manchester; Richard Elmsley, University of Manchester; Lisa Jones, University of Lancaster; Christine Barrowclough, University of Manchester There is a strong evidence base for psychological treatments in younger adults with schizophrenia, but limited work has been done on adapting these interventions for older people. We describe a study of a pilot psychosocial intervention group specifically designed to meet the needs of older people with schizophrenia in NHS settings. We used a mixed-methods approach to evaluate the group. We assessed feasibility and acceptability by monitoring uptake and retention in the study. We used a within groups design comparing participants on a range of potentially relevant outcomes at baseline and post-treatment. Treatment acceptability was also assessed by semi-structured interviews conducted at the end of treatment. The intervention holds promise as a treatment for older people with schizophrenia and further evaluation is warranted We recruited eleven participants to the study and seven of these completed the majority of the group sessions. At a group level participants made improvements in self-esteem and negative symptoms which were statistically significant even in this small sample. Feedback interviews suggested that participants valued the social contact provided by the group and made actual changes in their day-to-day lives as a result of attending. Psychological treatments for schizophrenia and can be adapted for older people with the diagnosis.

Report of a Feasibility study of a Mindfulness Group for Clients, Carers and Staff of an Early Intervention in Psychosis Service Steve Moorhead, Northumberland Tyne and Wear NHS Foundation Trust; Liddell Alice, Northumberland Tyne and Wear NHS Foundation Trust Mindfulness meditation is developing momentum as a mental health promoting activity in clinical and non-clinical settings. Our Early Intervention in Psychosis (EIP) service wished to determine its acceptability and utility among a mixed group of participants. All clinical team members, their patients and their carers were offered an 8-week mindfulness group. Participants rated acceptability before and after. They prospectively identified, then monitored, distress associated with areas of their lives they hoped might improve. Findings support further implementation. The goal of inclusion was achieved with some reservation about staff preparation. Nineteen participants provided a mean attendance of 11.25 per group. The group was overwhelmingly positively perceived and distress associated with participants' items significantly improved. This report supports continued development of Mindfulness-based group interventions, particularly for service users and their carers, but with provisos that careful evaluation continues and recommendation of one-to-one preparation with staff participants if included. The latter would substantially increase the resource implications.

Clinicians' opinion of what client characteristics predict positive outcome in Cognitive Behavioural Therapy for Psychosis Siobhan Currell, Newcastle University & Northumberland, Tyne and Wear NHS Foundation Trust Cognitive Behavioural Therapy for psychosis (CBTp) is recommended by NICE for the treatment of schizophrenia; however, there is less of an established evidence base than in CBT for anxiety or depression. To find out why, we need to know what factors influence outcome. A limited amount of research has considered client factors that affect the likelihood of a positive outcome in CBT, but most of these studies have excluded psychosis (Safran and Segal, 96; Myhr, 07). Clinicians’ views have not been sought about client factors and there is utility in seeking such views at this early stage of the research cycle. This exploratory study seeks to systematically investigate expert opinion about what client characteristics predict positive outcome in CBTp. The current study employs Q-methodology (Stephenson, 1935) which has proven effective in translating subjective views into observable statistical data. In phase 1, a Q-set of client characteristics that might affect outcome was developed through a systematic literature search, pilot work, discussion with the research team, and interviews with five local mental health professionals. This resulted in a Q-set of 384 items, which was reduced to 61 items (40-80 items is deemed satisfactory - Watts and Stenner, 2005). In phase 2, 21 participants were asked to rate the items based on how important they are in effecting a positive outcome, on a forced normal distribution ranging from -5 ‘least important’ to +5 ‘most important’. Participants were clinicians familiar with psychosis and CBT through education, profession, practice or knowledge. In the discussion, we reflect on the interpretation of these results, and develop the implications for the practice of CBTp. 21 completed Q-sorts were analysed using PQ Method 2.11 (Schmolck, 2002), a specialist software which conducts a by-person factor analysis. Principal Components Analysis yielded four unrotated factors with eigenvalues exceeding 1, accounting for 67% of the total variance. Four factors were rotated using Varimax procedure and selected for further analysis. 18 significant, non-confounding loadings were used to define each factor. Interpretation of the emerging factors was achieved using qualitative analysis and the four factors were named: acceptance of and ability to undertake key processes central to CBT; being present in the here and now; secure base; active collaboration. Items related to therapeutic alliance were consensus items highly endorsed by participants throughout all factors. Some consensus items were consistently rated towards the least significant end of the distribution: ‘little or no family history of mental health problems’; ‘being female’; ‘older age of onset’; ‘being of above average intelligence’. Clinically, we can consider how to provide therapy at the right stage of change for the client, to ensure timely, effective treatments. The results provide a language with which to talk about client factors and outcome. Furthermore, we can talk openly and inform clients about potential reservations regarding therapy, and how to help them develop factors they might lack. By predicting obstacles, we can discover whether preparatory work could increase clients’ readiness for therapy or maximize the chance of clients benefitting from CBTp.

Behavioural Experiments with Psychosis: Theory and Practice Thomas Christodoulides, NTW NHS Foundation Trust and Chris Harrop, West London Mental Health NHS Trust Psychosis is characterized by beliefs that are unusual, unfounded and resistant to change. Such beliefs can vary enourmously. Commonly reported examples include persecutory ideas, grandiose beliefs, thought insertion, ESP, and the omnipotence of voices. For the cognitive therapist, working with such beliefs can present something of a challenge. Behavioural experiments (BEs) can be used to help clients question their delusions, create and test alternative perspectives and challenge the strength of their voices. Although the utility of BEs with psychosis is well reported, their technical application poses

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challenges that need addressing to ensure a successful outcome for the cognitive therapist and client. Clinicians working within severe and enduring mental health were invited to a one day workshop to share success stories of conducting BEs with this population. Clinical expertise was gained from within the field (Professor Tony Morrison highlighted disorder specific issues) and beyond (Professor Paul Salkovskis shared lessons learnt from working with the anxiety disorders). We discuss issues and guidance on the selection of belief to explore, matching the belief to the BE, and on the effective formatting of BEs with psychosis. Best practice guidance on some of the technical aspects of conducting BEs with psychosis was compiled. Cognitive therapists will gain some inspiration, practical tips and systematic questions to apply to their clinical practice when constructing and conducting BEs with psychosis.

The efficacy of CBT and clinical supervision in promoting the recovery of individuals with Schizophrenia who present with complex needs Martina Gibbons, Private Practice Trinity College Dublin; Anne Cleary, Hse West Galway Mental Health Services This paper will look at two case studies which aim to describe how offering CBT to people who experienced on going positive and negative symptoms of schizophrenia over many years aided their recovery and improved quality of life. Furthermore it will illustrate how clinical supervision assists the therapist in modifying the therapy process to successfully meet the need of the client. Complex cases can frustrate clinicians and absorb disproportionate amounts of service resources. High quality supervision is generally acknowledged as being a key component in working with this complex group of clients, such as those suffering from Schizophrenia, along with offering supervision on clinical practice it can also act as a support for a clinician. Clinical implications will be discussed with a focus on treatment delivery and issues pertaining to the supervision.

Skills Classes

Running Acceptance and Commitment Therapy (ACT) Groups for Psychosis Louise Johns, Joseph Oliver & Eric Morris, South London and Maudsley NHS Foundation Trust Acceptance and Commitment Therapy (ACT) is a cognitive-behavioural intervention that combines mindfulness with clarifying the client’s personal values in order to make commitments to behavioural change (Hayes, Strosahl, Bunting, Twohig & Wilson, 2004). ACT focuses on changing the person’s relationship with his/her symptoms, emphasising acceptance of difficult internal experiences rather than attempting to change them directly. It looks at the impact and behavioural consequences of symptoms, and focuses on helping a person to move forward in their life rather than examining the cause or veracity of symptoms. Evidence from RCTs demonstrates the utility of ACT for psychosis in terms of reductions in relapse/rehospitalisation rates and psychotic symptoms, and indicates that ACT can be effective in fewer sessions than traditional CBT (Bach & Hayes, 2002; Gaudiano & Herbert, 2006). Protocols for ACT have been developed for brief group therapy, which may have value in terms of cost and reductions in waiting times for therapy. Our clinical-research team is currently evaluating group ACT for psychosis in routine mental health services, in terms of feasibility, acceptability, and clinical outcomes. We are testing the hypotheses that service users who attend an ACT group will show improvements in daily functioning, mood, and relationship with symptoms. Values clarification is a core component of our 4-session ACT For Life Group Intervention. By the end of the class, participants will have learned about and practiced the ACT skill of identifying values with clients and helping clients to work towards goals consistent with these values. Participants should be able to apply the knowledge and skills acquired to their clinical work with clients with psychosis. Objectives : By the end of the class, participants will be able to: 1. Describe the rationale and core clinical processes in ACT for Psychosis (ACTp) 2. Lead exercises in values clarification, willingness and committed action 3. Outline briefly the session content of the ACT For Life Group Intervention Implications: Participants will have good opportunity to practice the clinical exercises. They will be able to apply the knowledge and skills acquired to their everyday practice with clients with psychosis. Participants will also learn about our group ACT protocol and will be given information about how to access further resources and supervision. Dr Johns is a consultant clinical psychologist in CBT for psychosis at PICuP, South London and Maudsley NHS Foundation Trust (SLaM). She is also an honorary lecturer at the Institute of Psychiatry, King’s College London. She has published 40 articles in psychosis and is co-editing a book on ACT and Mindfulness for Psychosis with Joseph Oliver and Eric Morris. Dr Oliver is a clinical psychologist in early intervention for psychosis at SLaM. He is also a clinical tutor at the Institute of Psychiatry. He has been developing and researching ACT for psychosis, and regularly delivers ACT training nationally and internationally. References Bach, P., & Hayes, S.C. (2002) The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129-1139 Gaudiano, B.A., & Herbert, J.D. (2006) Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: Pilot results. Behaviour Research and Therapy, 44, 415-437 Hayes, S.C., Strosahl, H., Bunting, K., Twohig, M., & Wilson, K.G. (2004) What is Acceptance and Commitment Therapy? In S.C. Hayes & K.D. Strosahl (Eds). A Practical Guide to Acceptance and Commitment Therapy. New York, Springer

Posters The role of nursing staff in transforming problems with borderline personality disorder inpatient admissions into opportunities: Incorporating dialectical behaviour therapy skills into acute psychiatric inpatient units Christopher Rae, The Logos Centre; Jayne Fitches, The Logos Centre Borderline personality disorder (BPD) is a complex and enduring psychological condition. To manage associated risks, especially self-harming and suicidal behaviours, inpatient admissions frequently occur but this poses problems in maintaining continuity of community based psychological treatment. Patients with BPD are admitted to inpatient units more frequently than patients with other disorders and represent up to 20% of psychiatric admissions Dialectical behaviour therapy (DBT) is one of the third wave developments of CBT. Training inpatient nursing staff in skills from DBT, an evidence based treatment

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for BPD, can help to maximise the continuity of therapeutic input and promote patient’s functional and effective behaviours during admissions. The most immediately relevant skills for inpatient staff to be focussing on teaching and reinforcing to patients are the distress tolerance and emotional regulation skills. These are likely to have most impact on the behaviours which have prompted or prolonged the admission. Patients who are part of a community DBT treatment programme will have been taught mindfulness as it is the first set of skills to be covered; they may not have yet been taught other skills prior to admission therefore training for inpatient staff on mindfulness is not such a priority - but they must have an understanding to prompt and remind patients to use mindfulness Whilst BPD remains a complex and challenging condition to treat there is mounting evidence that DBT is an effective intervention. Given the propensity for BPD patients to be admitted to inpatient units, training all levels of nursing staff in appropriate DBT skills is an advantageous step to maintaining the continuity and therapeutic input for patients during a time when utilising functional and effective skills and behaviours is most required. Though there are barriers to achieving this milieu, maximising effective coping strategies and skilful behaviours are key aspects of helping patients reduce inpatient admissions and develop a life worth living. One of the key potential benefits of staff utilising DBT skills is the opportunity to address problems caused by the interruption of therapy which can contribute to protracted admissions and set backs in therapeutic progress. These periods of reduced DBT therapy, particularly in the early stages of therapy, caused by admissions often contribute to the de-skilling of patients which means when they return to community services and therapy work often has to focus on reviewing and rehearsing previously learned skills which have been under practiced or forgotten. If inpatient staff were to continue the teaching and practicing of skills with the patient whilst admitted then the momentum of effective skills utilisation would more likely be maintained. • Maintain therapeutic continuity of treatment plan from community to inpatient settings • Developing and empowering inpatient nursing staff to utilise cognitive and behavioural interventions • Provide patients with skills to use in crisis situations • To move towards a more successful and faster discharge How acceptable is Acceptance and Commitment Therapy to keyworker staff working with individuals with substance misuse difficulties? An exploratory pilot study John Boorman, Alpha Hosptial; Chris Cullen, Keel University & North Staffordshire Combined Healthcare NHS Trust; Adrian Neal, Coventry University, Faculty of Health and Life Sciences; Melanie Day, Coventry and Warwickshire NHS Partnership Trust Substance misuse is a significant clinical problem which affects large numbers of people in the UK. It has previously been suggested that treatment acceptability (Kazdin, 1980) is crucial for influencing the success of a specific treatment, as interventions viewed as more acceptable are more likely to be utilised and implemented (Gresham & Lopez, 1996). Keyworkers are often the main point of contact for clients with long term substance abuse problems who deliver individual counselling, and low intensity (CBT) psychosocial interventions. Acceptance and Commitment Therapy (ACT; Hayes et al., 1999), is one of the third wave of cognitive-behaviour therapies which has received preliminary support highlighting its potential. Research questions 1) Do keyworker staff find ACT an acceptable substance misuse treatment? 2) What are the experiences and perceptions of keyworker staff with regard to how ACT compares to other substance misuse treatments available? 3) What are keyworkers’ subjective opinions regarding the concept of treatment. Design. It was concluded that the most appropriate means for analysing the data was to adopt a Grounded Theory technique based on Charmaz (2006). The rationale for adopting this method is linked directly to the aims of the project, which seek to explore the experiences and perceptions of keyworker staff with regard to the treatment acceptability of ACT as a treatment for substance misuse. Grounded Theory methodology has also been used in previous treatment acceptability research (e.g. Norman et al., 2008; Truscott et al., 2000). Furthermore, there has been recognition of some of the limitations of previous research which have used quantitative methodologies (Calvert & Johnson, 1990; Finn & Sladezek, 2001; Spirrison, Noland, & Savoie, 1992). A purposive theoretical sampling technique (Silverman, 2000) was employed when selecting the participants for the current study. Keyworker staff were approached for this study as they often represent the practitioner in most regular contact with clients with substance abuse issues (NTA, 2006), and are the named practitioners who are responsible for ensuring the client’s care plan is delivered and reviewed. It has been documented that there are a number of ex-users working in the area of substance abuse (Drug Misuse, Psychosocial Interventions, NICE, 2007). A total of seven keyworkers were recruited to participate from a local substance misuse service (community drug teams). Each individual underwent a semi-structured interview. Prior to interview each participant was presented with a clinical vignette designed specifically for this study, outlining how ACT would be used to treat this clinical population. ACT may be an acceptable form of psychosocial treatment for clients with substance misuse difficulties. The intervention appeared to compare favourably to other established substance misuse treatments (e.g. motivational interviewing, CBT), and in some instances was seen to be more appealing than CBT. ACT’s emphasis on experiential delivery, which may be useful in dealing with complex clients who have been in treatment for a long time, and may perhaps respond to something new and different. Participants also found ACT’s underlying treatment philosophy acceptable, as it encourages clients to approach (accept) painful thoughts and emotions rather than avoid them through drug use. Whilst ‘Acceptance’ was identified as an agreeable concept for keyworkers, there was the assumption that clients could reject this, as clients would be reluctant to take ownership and responsibility of their problems, and a desire not to experience internal distress. It would be seem important to attempt to replicate the current study with clients engaged in substance misuse services, to find out whether they would also find ACT acceptable, and see whether similar theoretical concepts emerged. Each of the participant’s interviews were transcribed verbatim by the lead researcher. A systematic analysis of the data was carried out where each interview transcript underwent a series of analytic processes as outlined by Charmaz (1995; 2006). The current theoretical model was devised following analysis of participant’s responses on the treatment acceptability of ACT. The six core categories’ include; Acceptance, Client Characteristics, Implementation, Skills Development, Other Treatments, and Influence of Philosophy of Values. A number of key concepts arose from the data that highlighted the multi-faceted and interconnected nature of treatment acceptability. Whilst ACT’s treatment philosophy, including its

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emphasis on acceptance and skill development, was generally deemed an acceptable component, other factors (were observed to directly influence whether ACT would be viewed as acceptable. These include; (a) the characteristics of the client, specifically the role of drug taking, the current stage of treatment, and clients’ capacity and readiness to change; and (b) how the treatment is implemented, which appears to be directly influenced by the roles of the practitioner and the service when delivering ACT. Both of these aspects were thought to either increase or decrease the acceptability of ACT. As it is often widely acknowledged that individuals who abuse substances are one of the more challenging clinical populations to engage in treatment (Joe, Simpson & Broome, 1998; Miller & Rollnick, 2002), any treatment which might be deemed acceptable should warrant further consideration. Furthermore, as dropout rates can often be substantial with individuals being treated in substance misuse rehabilitation programmes, any intervention which may positively influence this important factor needs to be examined further. CBT has always looked to add techniques which would enhance the treatment delivery for specific clinical subgroups. One of the main outcomes of this research suggested that acceptance and mindfulness techniques appear to be an acceptable form of treatment from those who routinely work within this field. Therefore, incorporating acceptance and mindfulness techniques into standard CBT treatment for substance misuse may enhance an individual’s clinical practice, as what is deemed acceptable by clients could be argued to have a greater chance of being utilised. Decreasing Anxiety and Increasing Cognitive Flexibility in a Young Girl With Asperger Syndrome Ian Gilmour, Moss, Rowden, Freigang, and Associates Two cognitive behavioural interventions were done with an eight-year-old girl with autism spectrum conditions. The first targeted food refusal and the second, a year later, increased her cognitive flexibility within family interactions. Intervention 1: The girl complained of an upset stomach before her school lunch (no medical reason) resulting in refusal to eat (she eventually lost 15% of body weight). The hypothesis for treatment was that she experienced anxiousness associated with her ASC at the upcoming transition to recess but failed to recognize it as anxiety. The intervention restructured her reaction to an upset stomach just prior to lunch. She was taught to use symptoms as a cue to initiate pre-taught self- management strategies. When she felt symptoms, she recorded how her stomach felt before eating and then, her food consumption. These strategies were successful and she regained lost weight. Intervention 2: The hypothesis for intervention 2 focused on her lack of flexibility in any kind of deviation from preconceived ideas about how family interactions should occur. This perseveration formed what she called “rules.” These dictated, for example, which a) family member could sit with her on the couch; and b) she always needed to win at a game. The intervention consisted of her identifying 30 “rules.” She was asked which "rules" she would not discard and four “rules” that she could possibly change. Children with Asperger Syndrome although of average or superior intellectual abilities lack an awareness of their own theory of mind and have impaired theory of mind about the intentions, beliefs and feelings of others. The girl accepted that her view of the world was valid and could not identify weight loss as anxiousness or understand that her elaborate family based rituals imposed stress and hardship on her family. The results of the intervention allowed her to form an initial understanding of anxiety and what she could do to resist it. The second intervention resulted in literally the first instance of cognitive flexibility she had experienced. More work needs to be done to solidify that gain. In intervention 1: The girl regained lost weight and had maintained that gain at a one year follow-up. In intervention 2: The girl discarded the first 4 “rules” plus another 7. Her mother reported that “rule” changes had produced more cognitive flexibility which positively impacted family functioning. Children with autism spectrum conditions (ASC) are often excluded from accessing CBT. The practical implications is that children with ASC can benefit from this type of therapy but require adaptations such as visual materials to participate successfully. Description of North East Traumatic Stress Centre Alice Lidell, Newcastle Cognitive and Behavioural Therapy Centre; Sally Standart, North East Traumatic Stress Centre; Kevin Meares, North East Traumatic Stress Centre The North East Trauma Centre is a relatively new trauma service. We offer evidence based therapies for PTSD. We have a reemit to treat complex presentations of PTSD. We have reviewed our last two years worth of referrals to describe the population that is referred, assessed and treated by our service. We wanted to describe those elements of the client's presentation that might be helpful in understanding complexity and engagement. This work spans audit and service evaluation. As our service is commissioned to treat complex presentations, this work begins to explore the question of complexity. Our service follows Herman's Framework for the treatment of PTSD and we try to tease out what factors might contribute to complexity. We are stuck by the rates of attrition with about 50% of referrals ending up on our waiting list. This seems to have little to do with what factors we have measured in terms of complexity. We also note that the quality of referral received has a strong influence of the assessment process. The reason why people may not engage in therapy is not clear, however clinical impressions suggest that clients may be at different stages of their recovery or of the change process. We propose to present data on the breakdown of Type I and Type II traumas, complexity in Type I trauma, type of traumas, factors that might add to complexity, analysis of cluster data, attrition through service pathway and an exploration of some differences between clients who are screened out or accepted for therapy, those who engage and do not engage in therapy and those who complete and those who drop out of treatment based on the dimensions assessed in this audit. In general terms, for PTSD the evidence base is not at the complex end of the market. Defining complexity is problematic however and this work may add to our understanding of complexity in complex trauma. We note the success of using Herman's Three Phase Model to structure our assessment of suitability in terms of stability or readiness for trauma-focused therapy.

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Therapeutic Techniques

Skills Classes

Imagery-focused CBT for traumatic bereavement Jennifer Wild, University of Oxford Posttraumatic stress disorder (PTSD) following traumatic bereavement is common, and difficult to treat. Following spousal bereavement by illness, PTSD rates are as high as 10% (Zisook, Chentsova-Dutton, & Shuchter, 2004). Following traumatic loss, PTSD can be as high as 39%. The National Institute for Health and Clinical Excellence recommend an extension of the suggested 8 to 12 sessions of trauma-focused psychological therapy for PTSD when an individual presents with traumatic bereavement. Imagery techniques have been evaluated as effective in treating distress linked to traumatic memories (Wild, Hackmann, & Clark, 2007; 2008) and are a key component of cognitive behavioural therapy for PTSD. Objectives 1. Participants will learn key imagery exercises to address loss in patients with PTSD. 2. Participants will learn how to update common emotional hot spots linked to traumatic bereavement. 3. Participants will learn how to combine imagery and reliving techniques to facilitate recovery from traumatic grief. Dr Jennifer Wild is a senior research fellow in clinical psychology at the University of Oxford. She has been a key contributor to the development and evaluation of trauma-focused psychological therapy for PTSD and cognitive therapy for social phobia. She runs a large-scale project in collaboration with the London Ambulance Service to identify predictors of PTSD in this at-risk population. References Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and practice. Behaviour Research and Therapy, 37, 715-740. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319-345. Wild, J. & Clark, D.M. (2011) Imagery rescripting of early traumatic memories in social phobia. Cognitive and Behavioral Practice, 18, 433-443. Wild, J., Hackmann, A., & Clark, D.M. (2007). When the present visits the past: Updating traumatic memories in social phobia. Imagery Special Edition: Journal of Behavior Therapy and Experimental Psychiatry, 38, 386-401. Wild, J., Hackmann, A., & Clark, D.M. (2008). Rescripting early memories linked to negative images in social phobia: A pilot study. Behavior Therapy, 39, 47-56.

Seeing the Difference: The Application of Cognitive and Motivational Imagery to Athletes and Exercisers Jennifer Cumming, School of Sport and Exercise Sciences, University of Birmingham Imagery is an established mental technique that improves performance in both sport and exercise. Its main purpose is to aid self-regulation of thoughts, feelings and behaviours, whether this is during the preparation of an elite athlete for performing on the world stage or helping an individual feel more confident in overcoming barriers to exercise. Research over the last decade has considerably advanced our understanding of how to improve the effectiveness of imaging and how to best implement these benefits. Drawing from this literature, the skills class will introduce the latest models on the application of imagery for a range of cognitive, affective and behavioural outcomes, such as building self-confidence or regulating anxiety levels. By the end of this class, participants will feel equipped to lead imagery sessions with athletes and exercisers and will be able to generalise these principles to other types of clients. Learning objectives 1. Use objective and subjective methods for measuring athletes’ and exercisers’ imagery ability 2. Use different methods to train a person’s ability to image 3. Follow a checklist for maximising the effectiveness of the imagery experience 4. Write guided imagery instructions and scripts for athletes and exercisers Dr Jennifer Cumming is a Chartered Sport and Exercise Psychologist and a Senior Lecturer in Sport and Exercise Psychology at the University of Birmingham. She is an expert in the measurement and application of mental skills in sport, exercise and dance. As well as publishing over sixty papers in peer-reviewed journals, Dr Cumming has extensive applied experience delivering interventions to elite athletes, including golfer, long-distance runners, short track speed skaters and para dressage riders. Background readings: Cumming, J., & Ramsey R. (2009). Sport imagery interventions. In S. Mellalieu & S. Hanton (Eds.), Advances in applied sport psychology: A review (p. 5-36). London: Routledge. Murphy, S., Nordin, S. M., & Cumming, J. (2008). Imagery in sport, exercise and dance. In T. Horn (Ed.), Advances in sport and exercise psychology (3rd edition, pp. 297-324). Champagne, IL: Human Kinetics. Williams, S. E., Cumming, J., & Balanos, G. (2010). The use of imagery to manipulate challenge and threat appraisal states in athletes.

Journal of Sport & Exercise Psychology, 32, 339-358.

How to integrate Compassion Focused Therapy within Familiar CBT Approaches Mary Welford, Greater Manchester West Mental Health NHS Foundation Trust CBT has proved to be of great benefit for a range of individuals. If such work produces a sustained improvement in an individual’s wellbeing it can be viewed as the most compassionate approach to adopt and should be recommended. However, what happens when your client reports they can see the logic but they do not feel any different; they know they are not to blame but they still feel at fault; they know there may be no danger but they still feel as though something terrible will happen, despite all of your and their best efforts. In such cases should we do more of the same or try something different? Compassion Focused Therapy (CFT) was developed by Paul Gilbert as a way of addressing shame and self-criticism. The therapy aims to ‘tone up’ feelings of contentment, safeness and soothing in order to help regulate the drive and threat systems of the brain. This helps the individual bridge the gap between knowing something and feeling it. It is a standalone therapy but aspects of the approach can be ‘sprinkled in’ to other forms of therapy to ‘warm it up’ or allow cognitive work to ‘sink in’.

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This skills class will briefly review the theory and practice of CFT before looking at familiar CBT approaches and how CFT may be integrated. Objectives

Delegates will be briefly reminded of, or introduced to, Compassion Focused Therapy and Compassionate Mind Training

A rationale will be given for why CFT may be a useful framework to think about blocks in the practice of CBT

Literature, mircoskills and techniques will be presented that can be woven in to CBT practice in order to negotiate or overcome roadblocks

Finally the application of CFT into the lives of therapists will be discussed as a way to help us all feel less shame and less self-critical and find a better place to listen to, learn from and assist those whom we see in practice

Mary Welford is a Consultant Clinical Psychologist working in Greater Manchester. She has been involved with a range of CBT trials focusing on psychological difficulties such as Generalised Anxiety, PTSD and recovery from psychosis. Within her clinical practice Mary predominantly uses Compassion Focused Therapy (CFT) to address difficulties with anxiety and depression through to psychosis and personality difficulties. She is currently chair of the Compassionate Mind Foundation. Mary has been involved with the BABCP for many years and has held roles such as Branch Liaison Officer, Magazine Editor and European Scientific Committee Member.

Using CBT to Help People Cope With Unemployment Robert L. Leahy, American Institute for Cognitive Therapy and Weill-Cornell Medical College, USA The unemployed face increased risk for binge drinking, depression, anxiety, and suicide, with rates of mortality 2 ½ times never unemployed over a 23 year period. Many of the unemployed carry the “scar” throughout their lives, with significantly higher rates of future unemployment, and increased risk of cardiovascular disease and suicide. Unemployment is one of the leading “life crises” and is often accompanied by shame, isolation, passivity, self-criticism, rumination, worry, and family conflict. We will consider how the cognitive behavioural therapist can assist the unemployed in validating emotions without getting stuck in being a victim, learn to accept what is “given”-- but commit to change and action, decrease rumination, use behavioural activation to accomplish valued goals, modify destructive self-talk, reduce shame, overcome passivity and isolation, and develop a more balanced approach to this time “in between”. The unemployed in the USA spend 31 minutes per day looking for a job, with this time ranked the most depressing time of the day by respondents The CBT approach to unemployment is based on three key assumptions: 1) your job is to find a job; 2) your second job is to take care of yourself; and 3) you need to focus on what you can control. For some, the period of in-between is a time for re-examining the values of materialism, relationships, and social support. Objectives: You Will Learn: 1. How to evaluate the major risk areas for patients (e.g., rumination, passivity, stuck as a victim, shame, hopelessness, etc.). 2. Develop a strategic self-help plan customized to patients. 3. Implement in-session and between-session interventions. Robert L. Leahy (B.A., M.S., Ph.D. Yale University) is the Director of the American Institute for Cognitive Therapy. He has authored and edited 21 books on cognitive therapy and psychological processes and is the Past-President of the Association for Behavioral and Cognitive Therapy (ABCT), Past-President of the International Association for Cognitive Psychotherapy, Past-President of the Academy of Cognitive Therapy and Clinical Professor of Psychology in Psychiatry at Weill-Cornell Medical School. Dr. Leahy recently received the Aaron T. Beck Award for Outstanding Contributions in Cognitive-Behavioral Therapy. He has authored several popular audience books, The Worry Cure, Anxiety-Free: Unravel Your Fears before They Unravel You and Beat the Blues Before They Beat You: How to Overcome Depression. His recent clinical books include Emotion Regulation in Psychotherapy: A Practitioner's Guide (with Tirch and Napolitano), Treatment Plans and Interventions for Depression and Anxiety Disorders, Second Edition (with Holland and McGinn), and Treatment Plans and Interventions for Bulimia and Binge-Eating Disorder (with Zweig). He is currently completing a self-help book to assist people in coping with the emotional difficulties of unemployment. References Leahy, R. L. (2009). Unemployment anxiety. The Behavior Therapist, 32(3) 1- McKee-Ryan, F. M., Song, Z., Wanberg, C. R., & Kinicki, A. J. (2005). Psychological and physical well-being during unemployment: A meta-analytic study. Journal of Applied Psychology, 90(1), 53-76.

How to Enhance the Therapeutic Value of the Therapeutic Relationship Tim Carey, Flinders University, Australia and Sara Tai, University of Manchester Although the importance of the therapeutic relationship is undisputed, the distillation of the crucial ingredients that make the relationship therapeutic has been less straightforward. Recent work has suggested that it is the congruency between the therapist’s approach and the expectations of the patient that is crucial for establishment of an effective therapeutic relationship. Perceptual Control Theory (PCT) provides a simple yet robust framework for understanding this congruency in terms of the alignment of the therapist’s and the patient’s goals. By focusing on the goals that each person in the relationship are trying to achieve within therapy the therapist is able to enhance the impact of the therapeutic relationship and provide treatment that is more effective and efficient. Using this framework to conceptualise and consider the interactions between the therapist and the patient will allow therapists to promote engagement and understand resistance and ambivalence in a constructive way. This can be particularly useful in situations where engagement is problematic and therapeutic roadblocks frequently occur. In this skills class participants will learn about the ways in which people act in order to achieve their own goals as well as the way in which the goals for any individual are arranged hierarchically within their system of beliefs, values, and attitudes. Through practical demonstrations and exercises, participants will be able to identify and explore their own goals and hierarchies and understand the way in which the pursuit of different goals can either enhance or impede the therapeutic process. Using the principles of PCT, simple yet effective techniques will be taught that therapists will be able to learn quickly and apply easily in their daily practice to improve the therapeutic value of the relationships they establish with patients. Techniques such as questioning about process rather than content and promoting openness and transparency will be some of the areas covered. The workshop will be presented by practicing clinicians and will equip participants with skills they will be able to use immediately in order to achieve the following outcomes in their practice: • Enhanced therapeutic engagement for a wider range of patients; • Increased ability to develop opportunities for collaborative working;

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• Increased confidence for therapists in terms of the important aspects of the therapeutic relationship to focus on; • Improved outcomes with more patients achieving more of their goals efficiently; and, • Greater clarity for therapists regarding their role.

Objectives: By the end of the workshop the participants will have had opportunities to: 1. Identify important goals in therapy for the therapist; 2. Consider the way in which particular goals are affected by other goals within the hierarchy; 3. Understand the behaviour of patients in terms of the goals they are pursuing; 4. Analyse therapeutic interactions in terms of the alignment of goals; and, 5. Develop simple plans for promoting the understanding and facilitation of patient goal achievement within therapy. Dr Tim Carey is an Associate Professor in Mental Health in Alice Springs. He has been investigating the importance of goals in therapy through the framework of Perceptual Control Theory for over 10 years. He supervises others in the use of MOL and has conducted training workshops in the UK, Canada, and Australia. Dr Sara Tai is Senior Lecturer in Clinical Psychology at Manchester University. She is an experienced practitioner, researcher and trainer of CBT and MOL, providing supervision and workshops internationally. She is involved in research on psychoses and bipolar disorders in China, USA Europe and the UK. References 1. Carey, T. A., Kelly, R. E., Mansell, W., & Tai, S. J. (submitted). What’s therapeutic about the therapeutic relationship? The Cognitive Behaviour Therapist. 2. Mansell, W., Carey, T. A., & Tai. S. J. (in press, with publication prior to the 2012 BABCP conference planned). A transdiagnostic approach to CBT using Method of Levels therapy: Distinctive features. Routledge.

Using Imagery in CBT Treatment of Long-term Conditions Stephanie Fitzgerald, Charlie Waller Institute, University of Reading, and Ann Hackmann, University of Oxford Individuals dealing with long-term conditions (LTC) experience a wide variety of emotions and are vulnerable to developing depression and anxiety. CBT has been shown to be an effective treatment in helping those with LTC overcome these difficulties and move towards an acceptance of their condition and a healthier mental state. It is also important to consider the impact on therapists of working with those with LTC and some of the challenges this work poses for therapists. One crucial area that can be neglected in standard CBT treatment is the area of imagery. The images that individuals hold about their LTC and any associated pain or physical symptom, can provide a ‘block’ to therapeutic engagement, as the CBT treatment may not fit with the images individuals hold regarding their condition. Therefore by incorporating imagery into the CBT treatment, it is likely that the effectiveness of CBT will be increased and result in better patient outcomes. Objectives: By the end of the class, participants will: 1. Have knowledge of the psychological difficulties faced by those with Long-Term Conditions, and those experienced by their therapists 2. Be able to formulate these difficulties and incorporate imagery into formulation. 3. Understand the role of negative images and memories in maintaining psychological distress 4. Have knowledge of a number of direct and indirect techniques for working with distressing images 5. Have practiced an imagery rescripting technique. Implications: By learning to identify negative emotions and work with imagery as part of CBT treatment for LTC, we can increase the likelihood of patient engagement and the effectiveness of the treatment itself. The use of imagery in everyday practice provides a useful addition to standard CBT treatment and results in better patient outcomes. Dr. Ann Hackman is a Clinical Psychologist, who is an associate member of the Oxford Cognitive Therapy Centre, and the Oxford Mindfulness Centre, and teaches for both organisations, as well as providing MBCT classes for patients and for the general public. For many years she worked in research groups refining protocols for the treatment of anxiety disorders. Her special interest is in working with imagery in cognitive therapy, and with James Bennett-Levy and Emily Holmes she has recently published the Oxford Guide to Imagery in Cognitive Therapy (2011). Dr Stephanie Fitzgerald is a Clinical Psychologist working at the Charlie Waller Institute, based at University of Reading. She has worked with those diagnosed with various long-term conditions including Chronic Fatigue Syndrome (CFS) and cancer and specialises in the treatment of anxiety disorders. References Hackmann, A., Bennett-Levy, J. and Holmes, E.A. (2011). Oxford Guide to Imagery in Cognitive Therapy. Oxford: Oxford University Press. Muse, K., McManus, F., Hackmann, A., Williams, M. & Williams, J. M. G. (2010). Intrusive imagery in severe health anxiety: Prevalence, nature and links with memories and maintenance cycles. Behaviour Research and Therapy. Wheatley, J., Brewin, C.R., Patel, T., Hackmann, A., Wells, A., Fisher, P. et al. (2007) “I’ll believe it when I see it”: Imagery rescripting of intrusive sensory memories in depression. Journal of Behavior Therapy and Experimental Psychiatry, 38, 4, 371-385. White, C.A., (2012), CBT for Long-Term Medical Conditions: A Practical Guide, Wiley-Blackwell. http://iapt.nmhdu.org.uk/silo/files/longterm-conditions-positive-practice-guide.pdf

IAPT Long Term Conditions Positive Practice Guide.

Making CBT Memorable: How to Use Story and Analogy in Daily Practice Paul Blenkiron, Leeds and York Partnership NHS Foundation Trust To apply CBT effectively, clinicians need to engage and inspire their clients. Narrative is a powerful tool that blends the science with the art of therapy. By using a story, analogy or metaphor, we can heighten impact - through engagement with the 'heart' as well as the 'head'. Evidence shows that this approach enables clients to build bridges between their thoughts, feelings and behaviour, heighten a person's recall of learning and improve the outcome. This skills class will help therapists introduce short stories and analogies into the CBT session when it is appropriate to do so, and to develop the clients' own ideas into personalised metaphors for change. Objectives 1) Understand how a narrative approach may be used in CBT - when assessing suitability, explaining basic principles and planning specific interventions (e.g. behavioural experiments) 2) Begin to work with practical stories and analogies for specific disorders (e.g. anxiety and depression) and psychological processes (e.g. avoidance and rumination)

http://iapt.nmhdu.org.uk/silo/files/longterm-conditions-positive-practice-guide.pdf

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Implications: This workshop is intended to help CBT practitioners improve their communication of key ideas and techniques so that the impact for their clients is heightened. The session will also allow therapists to listen out for (and unpack) a clients own 'story', consolidate the therapeutic relationship and avoid ending up in metaphorical 'hot water'. Paul Blenkiron is a consultant psychiatrist with a special interest in CBT. He is an accredited member of the BABCP, with 15 years' experience of integrating CBT into front line NHS care. He is also an Honorary Senior Lecturer at Leeds University and a CBT course facilitator at York Univeristy. In 2011 Paul was awarded a Fellowship with the National Institute for Health and Clinical Excellence to promote evidence based practice in mental and psychological health. Paul has led several national training workshops on CBT and produced over 70 research and clinical publications. These include the innovative book Stories and Analogies in CBT (2010) and acting as co-contributor to the new Encyclopaedia of the Sciences of Learning (2011). References Blenkiron, P. (2010) Stories and Analogies in Cognitive Behaviour Therapy. Oxford: Wiley-Blackwell, ISBN 978-0-4700-5896-1 Stott, R, Mansell, M, Salkovskis, P, Lavendar, A & Cartwright Hatton, S (2010). Oxford Guide to Metaphors in CBT: Building Cognitive Bridges. Oxford University Press. Blenkiron, P. (2011) Analogy Therapy. In: Encyclopaedia of the Sciences of Learning. Ed: Seel, NM New York: Springer. ISBN 978-1-4419-1427-9

Developing Change Methods to Engage with the Disengaged in Military Trauma Pete Roberts, CBT Lead, Department of Community Mental Health There is an increasing recognition of a veteran population who fail to engage with treatment in the National Health Service MURRISON (2010), WOODHEAD (2011). Although the current evidence suggests that the rate of PTSD in the UK Armed Forces is not increasing WOODHEAD et al (2011) attempts to increase the treatment engagement of veterans may increase the numbers accessing such services in the future. War trauma is classified as complex TERR (1991) and determining the context of the events and eliciting resulting distortions can be problematic .Other challenges in clinical practice include co morbid alcohol abuse IVERSEN et al (2007), multiple trauma exposure, emotional numbing and avoidance of techniques which may elicit intense emotional responses. This makes engaging Service personnel in change methods such as standardised imaginal exposure more difficult. Articulating and recording thoughts also results in poor compliance with maintaining written records as homework. This may in part be attributed to literacy ability as concluded by the Defence Committee Report (2004-05) The value of trauma narratives generally is also questioned from the recent NICE review (2011). Accessing “hotspots” of trauma memories HOLMES et al (2005) may prove more problematic where the emotions of shame and guilt feature in the reminders of a military incident(s). Given such challenges, particularly with those misusing alcohol, innovative techniques are emerging from military CBT practice to elicit the cognitive distortions and effect new learning by mobilising the client’s own expertise to control the intensity of emotional exposure. The author has developed the birds eye view (BEV) technique which allows the patient to visualise aspects of the event by changing the perspective when recalling the experience on a flip chart by “sketch map” whilst the therapist notes timelines and SUDS. Learning Objectives: By the end of the class participants may be able to:

Identify some of the key factors which may inhibit recovery from military trauma.

Make a developmental formulation noting the context of how the trauma may be experienced.

To observe a skills practice demonstration using the BEV procedure for participants.

To explore potential areas for further development and application in other trauma treatment settings. Implications in the Science and Practice of CBT: This skills class offers the possibility for CBT therapists to view a newly emerging graded imaginal exposure procedure evolving in military CBT which could be developed and utilised in other settings. Pete Roberts OBE is the CBT Lead in Army Primary Healthcare for the North of England. He is a CBT advanced nurse who works with military and veteran populations within the Region. He is also an IAPT supervisor for high intensity therapists who treat veterans. He co-authored and developed the early intervention known as TRiM and provides PTSD training which is ESTSS approved for all MOD specialist clinicians. References: Cahill, S.P., Foa,E.B., Hembree, E.A., Marshall, R.D., Nacash, N. (2006) Dissemination of Exposure Therapy in the Treatment of Posttraumatic Stress Disorder. Journal of Traumatic Stress 19, (5) pp597 -610 Ehlers, A.& Clark, D.M. (2000) A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345 1Fear NT, Iversen A, Meltzer H, Workman L, Hull L, Greenberg N, Barker C, Browne T, Earnshaw M, Horn O, Jones M, Murphy D., Rona RJ, Hotopf M & Wessely S. (2007) Patterns of drinking in the UK Armed Forces, Addiction, Vol. 102, pp. 1749-1759 Grunnert B,. Smucker M, Weis J,. Rusch M (2003) When prolonged exposure fails: Adding an imagery-based cognitive restructuring component in the treatment of industrial accident victims suffering from PTSD Cognitive and Behavioural Practice Volume 10, Issue 4, 333-346 Holmes, E.A., Grey, N., & Young, K.A.D. (2005). Intrusive images and “hotspots” of trauma memories in posttraumatic stress disorder: an exploratory investigation of emotions and cognitive themes. Journal of Behaviour Therapy and Experimental Psychiatry, 36, 3-17 Iversen A., Waterdrinker A., Fear N.T., Greenberg N., Barker K., Hotopf M., Hull L. & Wessely S. (2007) Factors associated with heavy alcohol consumption in the U.K. armed forces: data from a health survey of Gulf, Bosnia, and era veterans. Military Medicine, Vol. 172, No. 9,

pp. 956-61

Posters A case study of a client with 'shy bladder syndrome’ Matthew Cole, York Stress & Trauma Centre Client presents with a 40 years history of shy bladder syndrome, which has affected his life. He cannot use public toilets, he is unable to use toilets in resturants, theatre's cinema's conferences etc. Also client has a diagnosis of parkinson's disease. Explored early history which revealed a series of incidents at boarding school which affected his confidence and self esteem in his ability to urinate in public (toilets) We conceptualised this using Herberts type 1 trauma formulation and worked on these earlier trauma memories Review of treatment techniques utilised and how effective a combination of CBT and EMDR can be. Client is now able to freely use public toilets, he can now eat in resturants and socialse freely which has reinvigorated the qaulity of his life. To encourage others professional to use integration of evidenced based therapies when working with clients and how this can speed up the process of psychotherapy and enhance its effectiveness.

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A study of the perceptions and practice of physicians on the use of cognitive behavioural therapy (CBT) Aloke Sen, Stockport NHS Foundation Trust; Donald Menzies, Stockport NHS Foundation Trust Cognitive behavioural therapy (CBT) uses relaxation, “cognitive restructuring” of thoughts, and exposure to triggering scenarios to help improve common mental health conditions (e.g. anxiety and depression)1. CBT is also reported to be of benefit in conditions that are less well defined in clinical terms (e.g. chronic fatigue, irritable bowel syndrome, and stress)2-3. The National Institute for Health and Clinical Excellence (NICE) guidance advocates its primary use for common mental health conditions, for encouraging return to work after prolonged sickness absence4, and the UK government aims to expand services and access to CBT. The UK government has also noted the financial burden caused by long-term sickness absence5. In the United States, the cost of work absence for mental health conditions is estimated at $200 billion a year6, whereas forty million workdays per year are lost in the UK due to mental health and emotional issues7. Consequently, work-related illness is high on the political agenda. Rehabilitation back to work is a current trend as evidenced by the introduction of general practitioner fit notes in April 2010. Mental health conditions are the main cause for “work-related sickness absence”8. However, musculoskeletal conditions also have a significant impact on ill health and work8-9. It is also a common scenario for a worker to have negative perceptions about their workplace, such as perceived conflicts with colleagues. Therefore, physicians form an important liaison role as opposed to a patient's general practitioner. Unfortunately, occupational health services are limited in the United Kingdom compared to some other European countries such as the Netherlands10. The benefits of CBT in the workplace were reported as long ago as 1980, when Field et al described how a “stress management programme” aimed at industrial managers could alter and “reduce physiological tension” through “cognitive restructuring techniques”1. In 1981, Forman et al reported on “stress management training” in school psychologists using a CBT training programme, with an associated reduction in anxiety and improved job satisfaction11. Other studies in the 1980s also reported reduced depression levels and an improved ability to deal with job-related stress and burnout using CBT techniques12-13; more specifically inexperienced nurses working in a burns unit were found to have less work related anxiety when subjected to cognitive behavioural techniques14 .In the 1990s, Grossi et al looked at the “psychosocial correlates of long term sick leave among patients with musculoskeletal pain”15. Their results demonstrated that “emotional distress, coping style and perceived disability are associated with sick leave”. They concluded that CBT should be used in the management of musculoskeletal pain in cases of long-term sickness absence. In the same decade, Okada et al reported that “nurses’ automatic thoughts” were significantly associated with “burnout”, and that cognitive therapy could be a useful means of treatment16. The benefits of CBT have also been reported in reducing stress in other groups of clinical staff, including general practitioners17. More recently, a study on “workplace interventions for people with common mental health problems” by Seymour and Grove in 2005 recommended CBT as the preferred intervention for helping people with common mental health problems remain at work18. However, although there is evidence to suggest that CBT may improve measures of wellbeing (including sickness absence) for a variety of health conditions, there does seem to be a paucity of evidence on the practice and beliefs of physicians about CBT. To compare perceptions and practices of physicians with the evidence base for cognitive behavioural therapy (CBT) in the context of work and sickness absence. The null hypothesis is that perceptions and practices of physicians associate with the evidence base for CBT. A cross-sectional questionnaire based study of physicians’ beliefs and practice relating to CBT. In this study, physicians’ practices and perceptions on CBT vary in relation to published evidence, depending on individual conditions. There are a few areas (e.g. depression, chronic pain) where practices and perceptions appear to match the published evidence, however, there are many areas where the evidence is not matched (e.g. musculoskeletal pain, fibromyalgia, CFS, PTSD, phobia). There is a paucity of high-quality research available that demonstrates true sickness absence reduction for the health issues investigated in this study, and more high-quality randomised controlled trials (ideally multicentre) need to be performed (e.g. to see if CBT is beneficial in reducing sickness absence).It is important that physicians working within an occupational medicine setting are aware about advising and/or making a referral for CBT in view of the evidence base, and more work needs to be done in this area. It is also important that limited CBT resources are used where evidence exists for its benefit, and where shown to be most effective. The feasibility and effectiveness of in-house occupational health CBT services needs more enquiry and research. There is a potential for in-house CBT to be delivered in an effective manner and possible future work may include qualitative research, such as focus group or individual interviews with physicians, nurses, patients, human resource advisers, and managers of organisations. Patient satisfaction surveys on the use of in-house CBT (especially with feedback on its delivery from a physician) are also required. Physicians are an expensive resource, so the cost effectiveness of having them deliver CBT needs investigation. However, physicians could learn some CBT techniques to use in their consultations, but such implementations would need ongoing monitoring, audit and ideally research relating to their effectiveness. 190 physicians (with NHS identifying information in their contact details) were included in the survey from which 64 responded (response rate 34%). From the 64 responders, 78.1% were based in England, 73% were male, and 52.4% were aged 46-55 years.From the 64 responders, the following proportions felt that CBT benefits reduction in sickness absence for: depression (93.8%); stress (82.8%); anxiety (98.4%); irritable bowel syndrome (48.4%); chronic fatigue syndrome (75%); fibromyalgia (57.9%); chronic pain (66.7%); musculoskeletal disease (46.9%); severe mental health diseases such as schizophrenia (10.9%). The older the age of the responders, the more they were less likely to think that CBT had a positive effect on work (p= 0.03) and the more they were less likely to consider CBT as being effective in reducing sickness absence compared to younger responders (p=0.009). Additionally, older responders were significantly less inclined to agree that CBT reduced sickness absence for depression as compared to younger responders (p = 0.04). It is important that physicians working within an occupational medicine setting are aware and educated about advising and/or making a referral for CBT in view of the evidence base, and additional research needs to be undertaken which investigates benefits to patients. Classification of Metaphors in Cognitive Behavioural Therapy Sawako Nagaoka, Research Centre for Child Mental Development, Graduate School of Medicine, Chiba University; Ryotaro Ishikawa, Research Centre for Child Mental Development, Graduate School of Medicine, Chiba University; Osamu Kobori, Centre for Forensic Mental Health, Chiba University; Eiji Shimizu, Research Centre for Child Mental Development, Graduate School of Medicine, Chiba University

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Metaphor is commonly used therapeutic tools in Cognitive behavioural therapy (CBT), which makes CBT further effective. The use of Metaphors in CBT provides a method to enhance information processing in sessions (Stott et al., 2010). Beck (1995) suggests that metaphors can allow patients to distance themselves from their beliefs by reflecting on a different situation. The purpose of this study is to collect and classify the examples of metaphors used in CBT. Metaphors were collected from the record of the literature (Stott et al , 2010) about the metaphor in CBT, and tapes of CBT sessions in our clinic. Data were analysed using qualitative methodology. The effective use of metaphors is often difficult, because Metaphors are dependent on patient's experiential basis, and this basis is complex and based on a history of interaction with the environment. However, the effective use of metaphors in CBT can provides useful guidance for patients. The result showed that metaphors were classified into three categories; a) Metaphors to share the experiences. These Metaphors enhance a collaboration because the therapist and the patient vividly understands the experiences. b) Metaphors for psychoeducation. By comparing unfamiliar psychological terms to other familiar terms, patients are able to gain a better understanding of their states. c) Metaphors to discover alternative explanation in a similar (imagined) situation which is less distressing to the patient. These are metaphors as a strategy for change. Patients are able to replace their problems to other situations, and they acquire more objective viewpoints. It has long been known how metaphors have great persuasive capacity. By knowing types of metaphors in CBT, therapists will be able to use a metaphor more effectively. Assessment of Integrated Therapeutic Approaches (AITS) (for caring systems) Clare Brizzolara, University of Sunderland The MSc in CBT and Recovery in Psychosis and Complex Mental Health (University of Sunderland) recruits students from a wide range of clinical backgrounds and mental health services. Therefore, the content of the module pertaining to family work has been updated to reflect an integrated therapeutic approach (ITA) so therapists can deliver interventions to families and caring systems of a diverse composition, in relation to the Social GRRAACCESS (Burnham et al 2008). It was identified however, that a marking tool specific to this model was unavailable to assess the students in session therapy skills; therefore development of the Assessment of Integrated Therapeutic Skills (AITS) (for caring systems) was initiated via a literature review of the family work models used with psychosis and the model specific assessment tools already in existence. Eleven assessment tools were identified which were considered the most suitable for assessing audio recorded clinical sessions. A comparison was made between the tools to determine the therapeutic model to which it pertained; whether or not it included formulation of the family problem; session execution and interpersonal skills; the type of marking criteria used and whether or not it was valid and reliable. Three model specific assessment tools were identified and compared to the observable skills contained within the assessment tool of ITA (Burbach and Stanbridge 2001 Unpublished). Several comparisons were made but not all skills within the ITA were replicated in the model specific tools; therefore these were included within a final draft. One considers that a more accurate assessment of competency should include the occurrence of specific skills within a therapeutic session. Whilst it has been designed to meet a specific need by the MSc in CBT and Recovery at the University of Sunderland further study of its application is required to test its construct validity and reliability. Of priority however, is analysis of the competencies produced by CORE (Centre of Outcomes Research and Effectiveness) for CBT and Systemic therapies, which would be invaluable to ensure contemporaneous module content and competent practitioners. Furthermore, robust development of the tool would also include a comparison of application with another tool. One would anticipate in the future it would play a significant role in the efficacy testing of an ITA. Therefore, the AITS is by no means final, and anticipated feedback from users and the wider academic community will ensure it remains reflexive to those it serves. The development of the AITS proceeded through five drafts, and the the complexities of quantifying the skills in to a pass mark of 40% to reflect clinical competency was resolved by clustering essential and non-essential skills into stages, each increasing in increments of nineteen marks. Subsequent feedback from student cohorts remains positive with regards to ease of use, validity and reliability. The critical evaluation of different therapeutic models of family work has identified numerous similarities but has also identified the specific characterists which distinguishes one therapeutic approach from another. With consideration to the Social GRRAACCESS, CBT could blended and dovetailed with other psychotherapeutic treatments and models to suit the specific needs and characteristics of a diverse client group. Ultimately, the structure and fundamentals of CBT might eventually be subsumed in to everyday clinical practice.

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Training and Professional Issues

Symposia

What Can the NHS Learn From the Third Sector in the Delivery of CBT? Convenor: Roz Shafran, Charlie Waller Institute, University of Reading

Rethink Mental Illness: Should CBT therapists rethink their relationship with the third sector? John Rose, Associate Director of Psychological Therapies, Rethink & Ruth Jordan, Clinical Lead, Health in Mind, NE Essex IAPT service Rethink Mental Illness is the largest national voluntary sector provider of mental health services, with about 250 services and over 150 support groups. We directly help almost 60,000 people every year across England to get through crises, to live independently and to realise they are not alone. Rethink provides expert accredited advise and information, including many free factsheets and webpages to everyone affected by mental health problems including people who use services, carers, family and friends, as well as giving help to health professionals, employers and staff. It also provides evidence to the media and government to improve mental health policy. This presentation will focus on the work that Rethink does which has direct relevance for CBT practitioners working in all sectors. Integrated working between the NHS and the charitable third sector for the treatment of trauma Suzanna Rose, Academic Lead Berkshire Healthcare NHS Foundation Trust & Imogen Sturgeon-Clegg, Combat Stress UK Over recent years there has been a strong move towards more integrated working between the NHS and the charitable third sector. This has resulted in good and productive working relationships with positive outcomes. This presentation will highlight the author’s experience of working from an NHS Trust base with organisations such as the Charlie Waller Memorial Trust, Royal British Legion, Combat Stress and the British Red Cross. It will highlight the benefits and give tips to avoid pitfalls in order that the CBT therapist can gain confidence and maximise benefit from learning from and working with the third sector. The Succeed Foundation: Implications for the practice and dissemination of CBT Karine Berthou, Founder and CEO of The Succeed Foundation The Succeed Foundation promotes and develops evidence based programmes to treat and prevent eating disorders. Succeed is all about developing new tools and investing in research to provide new material for evidence-based programmes. We support the dissemination of CBT because it has proven to be successful when used to treat anorexia, bulimia and atypical eating disorders. At the moment, the Succeed Body Image Programme (SBIP), which is based on cognitive dissonance, is among the first programmes that we are disseminating to young women aged 18 to 25. We are currently developing an adaptation of this programme for men and older women. But we also want to get more involved with CBT, we are working on a DVD for carers, based on CBT, but we need more adaptable programmes on CBT. This talk will address how Succeed, as a third sector agency, has engaged with the clinical and research worlds to facilitate such developments, and its future plans. The implications of this engagement for CBT therapists will be discussed. Talking Space: An example of successful partnership between the NHS and MIND Patrick Taylor, Director of Oxfordshire Mind & Joanne Ryder Consultant Counselling Psychologist, Lead Clinical Supervisor TalkingSpace, Oxford Health NHS Foundation Trust TalkingSpace is a unique partnership between Oxford Health NHS Foundation Trust and Oxfordshire Mind. This paper will discuss the practical experience of making this partnership work in order to provide an integrated service for patients, as well as value for commissioners. It will also outline the obstacles overcome, not least in bringing together two very different organisational cultures, one a large NHS Trust and the other a Charity organisation, to make IAPT successful in Oxfordshire.

CBT Skills Training: Supporting Clinical Competency Development Convenor: Wendy Turton, University of Southampton Chair: Lusia Stopa, CBT Programme Director, University of Southampton

Honing the Art of Cognitive Behavioural Therapy through Experiential Learning. Wendy Turton, University of Southampton “Learning is the process whereby knowledge is created through the transformation of experience” (Kolb, 1984, pp38) Learning to ‘do’ therapy is more than knowing the theory; scientific understanding and art of delivery need to be fostered concurrently for practitioner understanding, confidence, and competence to develop effectively. The idea of learning how to ‘do’ psychological therapy by receiving therapy is longstanding and in the majority of psychotherapy training courses some form of personal therapy is standard. Interestingly, this has not historically been the case in CBT training, although it has become more de rigueur over recent years. The main proponents of supplementing learning through doing in the 1990s were Judith Beck (1995), the daughter of the ‘father of CBT’ Aaron T Beck (1976), and Christine Padesky, Aaron T Beck’s one-time doctoral student, ‘to fully understand the process of the therapy, there is no substitute for using cognitive therapy methods on oneself ‘ (Padesky 1996, pp 288). In recent years Bennett-Levy and colleagues (e.g. 2001; 2006, 2007, 2009) have explored the issue of skill acquisition in CBT training. Bennett-Levy, Turner, Beaty et al., (2001) conceptualised learning CBT through self-application and reflection as Self-Practice, i.e. participating in CBT methods, and Self-Reflection. They argued that if these two activities were utilised systematically as part of clinical CBT training then the learning process was advantaged through enhancements in therapeutic understandings, including a deeper understanding of the therapist’s role, the cognitive model, and change processes.

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One pedagogic approach to developing the art of effective, empathetic, and collaborative therapeutic intervention, which utilises both self-practice and self-reflection, is experiential role play involving peer-practice and reflection. This presentation details an example of such a learning activity undertaken by students during the introductory module of their CBT for Anxiety Disorders and Depression (IAPT) Post Graduate Diploma training. It could be argued that the learning available from this ‘Fundamentals of CBT’ module is the key which unlocks the development of CBT skill acquisition and application, and that developing a critically reflective understanding of what it is to be engaged in a psychotherapeutic process is potentially a pivotal component of effective therapist development. Ten steps to CBT supervision. Ken Gordon, University of Southampton Clinical supervision is recognised as essential for CBT therapists, both during training and in subsequent practice, and there has been a rapidly growing demand for accredited therapists to deliver supervision. However, this can be a daunting prospect. Supervision is a highly complex activity with several overlapping purposes, summarised as normative, formative and restorative by Hawkins & Shoet (2006). The supervisor must enact multiple roles and use several modes of activity (Padesky, 1997). To date, this process has been rather poorly researched (Watkins, 1997), and a consensus on good practice and evidence-based procedures is only slowly emerging (Pretorius, 2006, Roth & Pilling, 2008, Milne 2009, Milne & Dunkerley, 2010). Against this backdrop, we have developed a simple 10-step sequence of actions to be taken within any CBT supervision session, which aims to give clear and accessible guidance to supervisors and ensure they manage the session in an efficient, helpful and well-focused style. The paper will introduce, discuss and illustrate this 10-step process. Particular emphasis will be given to the development of productive supervision questions, and we will also discuss ways to include a range of supervision methods that encompass observational and experiential, as well as reflective learning processes. Does supervisor training work? An assessment of the impact of IAPT supervision training on self-reported competencies. Katherine Newman Taylor, University of Southampton; Ken Gordon, University of Southampton; Simon Grist, University of Southampton In the current economic climate, the recent investment in primary care psychological therapies has been both remarkable and controversial. Rightly, there are clear expectations that we deliver adherent models of care and evaluate the services provided. Supervision is widely recognised to be a key component in the delivery and governance of effective psychological therapies. Arguably, however, the systematic examination and evaluation of supervisory practice has been largely neglected to date (Milne & Dunkerley, 2010). Mirroring the competency framework for the delivery of psychological therapies, Roth and Pilling (2007) have developed a framework for supervision of psychological therapies. This outlines the generic, specific, applied and meta-competencies required of effective supervisors. In this paper, we describe the impact of a five day supervisor training for High Intensity and Psychological Wellbeing Practitioners in Hampshire. The training was developed in line with National IAPT expectations, and followed an evidence based clinical supervision model (Milne, 2009). The training took place in three blocks (of one or two days), over four months. Self-reported assessments of competencies were assessed at three time points. The impact and limitations of the training are described, and the implications for delivery of high quality and effective therapeutic interventions in primary care are discussed. “Digging a hole when you need to build a bridge”: Obstacles to clinical learning and ways of overcoming these using role play. Lusia Stopa, University of Southampton In order to be effective as trainers, we need to understand how people learn, and in particular, we need to understand how they acquire therapeutic competencies. An important part of this process is the ability to be explicit about what blocks learning. In this presentation, I will discuss some of the common obstacles to learning that trainee cognitive therapists’ encounter. For example, trainee therapists are often unsure about what they need to know or uncertain about what to do next when they elicit information about cognitions and behaviours. A common response to this uncertainty is to ask for more and more information (“digging a deeper hole”), but this simply confuses them even more. What they need to do is use their theoretical knowledge to build a scaffold or a “bridge” that allows the client to take a step forward. I will discuss a range of common problems that trainee therapists’ encounter and then explore ways to use role play in order to overcome these. Role play is a form of active learning that is used to develop therapeutic skills and competencies. It is widely used in cognitive therapy training and yet there is a very limited evidence base on the most effective way to use it. Most of the existing evidence on the effectiveness of role-play examines its use in medical training rather than in a psychotherapeutic context. The Southampton CBT team has started to investigate different methods of delivering role-play in order to teach therapeutic competencies and to overcome obstacles to learning. For example, is it more useful to use a dyadic structure with one student playing the clinician and the other a patient, or is it better to use a triadic structure, which includes an ‘observer’ who evaluates a particular component of the role play. We are particularly interested in matching role plays to learning outcomes in order to ensure that the role play offers an effective teaching tool. Teaching CBT skills to unqualified homelessness workers: Ethics and outcomes Nick Maguire, University of Southampton Homelessness is a worsening social issue, rough sleepers particularly suffering high incidence of chronic mental and physical health problems. With little access to statutory health or social services, homeless people are in the main served by third sector organisations. These staff, although very experienced, often lack appropriate training to enabling change for individuals, or a clear idea about what change may be useful. The current economic climate and residual ideas about homelessness being primarily about lack of housing means that widespread psychological provision for this excluded population is unlikely in the short to medium term. Therefore it may be more pragmatic and sustainable to provide training and supervision to those already working with homeless people. This however poses a dilemma: Is it ethical to teach techniques generated as part of a formal psychological therapy to unqualified staff who may not have sustainable access to supervision? And if so what are the limits governing what is taught? This presentation covers these issues in terms of decisions about what is taught as ‘techniques’ and what is avoided, in terms of being part of a formal therapy. Outcome results from two studies measuring the impact of training and supervision will be presented, and the pedagogical issues around equipping people with skills are discussed.

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Cognitive Therapy in Context Convenor: Charles Young, Rhodes University

Guidelines for delivering Culturally Sensitive Cognitive Behaviour Therapy (CS-CBT) for South Asian Muslims: Findings from Developing Culturally Sensitive CBT Project, Southampton Farooq Naeem, Southampton University Cognitive Behaviour has a strong evidence base and is recommended by National Organizations in both the UK and USA. There is some evidence from research to suggest that CBT might need some adaptations when working with clients from non European background. Most research on this area originates from the US. Developing culturally sensitive CBT project at Southampton University involved adaptation of CBT for black and ethnic minority communities in UK and for local population in Pakistan. A series of mixed method studies were conducted in Pakistan and in UK. We adapted CBT for depression and psychosis in Pakistan, while in the UK CBT was adapted for psychosis. Based on this work guidelines were developed for adapting CBT. We will describe the guiding principles for working with South Asian Muslims (SAM), using CBT, which emerged from our work. We found that in order to effectively work with clients from SAM background, therapists need to consider and develop three fundamental areas of cultural competence;, (1) Awareness of relevant cultural issues and preparation for therapy; (2) Assessment and engagement and, (3) Adjustments in therapy techniques. Awareness of cultural issues in turn includes awareness of cultural and religious issues, capacity and circumstances of both the individual and the system and cognitions and beliefs. Overall, findings from, developing culturally sensitive CBT project suggest that minor adjustments in therapy are required in order to work with SAM clients. However, further work is required in this field. The aim of this presentation is to describe guidelines which emerged from our work on developing culturally sensitive CBT with SAM. 1.Naeem F, Kingdon, D (2012) (Editors) CBT in non Western Countries. Nova Science Publishers, Newyork, USA 2.Naeem F (2012) Adaptation of Cognitive Behaviour Therapy for Depression in Pakistan: A methodology for adapting Cognitive Behavior Therapy in Non Western Cultures. Lambert Academic Publishers. Germany. 3.Naeem F, Phiri P, Rathod S, Kingdon D (2010) Using CBT with diverse client: Working with South Asian Muslim. Book chapter in “How to Survive as a CBT Therapist”. Editors Mueller M & Westbrook D. Oxford University Press, Oxford, UK. Development and testing of a culturally adapted group psychological Intervention for Postnatal Depression in British Mother’s of South Asian Origin Samiyah Naeem, Lancashire Care NHS Foundation Trust; N Husain, The University of Manchester & Lancashire Care NHS Foundation Trust; N Chaudhry, Lancashire Care NHS Foundation Trust; S Khan, The University of Manchester; A Rahman, The University of Liverpool; A Bokhari, Cheethamhill Medical Centre Background: Postnatal Depression (PND) is a public health concern which can lead to long standing difficulties in new mothers. It is estimated that PND affects between 10-15 % of all mothers in Western society. In our recent study the prevalence of depression in British Pakistani women was 17% during pregnancy and 19% in the postnatal period. We have designed a culturally adapted psychological intervention the Positive Health Programme (PHP). This is based on the principles of CBT whilst focusing on culturally specific psychosocial factors. Method: A psychological intervention trial based on the principles of CBT was carried out in Pakistan. Using the findings of our work in Pakistan and qualitative interviews with British mothers of Pakistani origin to understand the difficulties faced by these women we developed the manualized intervention (PHP). Using PHP we carried out a feasibility trial of the group psychological intervention. The intervention has been further refined by carrying out focus groups with the community and health professionals. Results: The trial of the PHP found a significant improvement in depression in the intervention group. The British mothers of Pakistani origin showed a preference towards group interventions and a need for social support due to their persistent psychosocial difficulties. Discussion: Now using a randomised controlled design we aim to learn whether the PHP is associated with improved maternal engagement and reduction in depression scores as compared to TAU. We will evaluate the experience of participating mothers and providers to revise the PHP in preparation for a large multicentre definitive trial. A Randomised Controlled Trial of Culturally Adapted Cognitive Behaviour Therapy for Psychosis for Black and Minority Ethnic Communities (CaCBTp) Peter Phiri, University of Southampton & Southern Health NHS Foundation Trust; Shanaya Rathod, Southern Health NHS Foundation Trust; Charlotte Underwood, Southern Health NHS Foundation Trust; Mahesh Thagadu, Southern Health NHS Foundation Trust; Uma Padmanabi, Southern Health NHS Foundation Trust; Scott Harris, University of Southampton Background: Studies of cognitive behavioural therapy (CBT) for psychosis ‘a debilitating illness of the mind, often characterised by symptoms such as hallucinations, delusional beliefs, thought disorder and bizarre behaviours’ demonstrate that African Caribbean and Black African patients have higher drop-out rates and poor outcomes from treatment. A recent qualitative study on ethnic minority groups concluded that CBT would be acceptable if it was culturally adapted to meet the needs of this population. Aim: To test the feasibility of culturally adapted CBT for psychosis to the Black British, Africa Caribbean/Black African and South Asian Muslim groups. Method: A single-blind randomised controlled trial was conducted in three centres in the UK. A total of 35 participants with a diagnosis of schizophrenia, schizo-affective, delusional disorders, psychosis (mean age, 33.5 years; 61% male; 39% female) were recruited, assessed at baseline and randomly allocated to CaCBTp arm (n = 16) and TAU arm (n = 17). Further assessments were completed post-treatment and at 6 months follow-up using the Comprehensive Psychopathological Rating Scale (CPRS) and Insight in Psychosis Scale. Participants in the CBT group also completed the Patient Experience Questionnaire (PEQ) to measure satisfaction of the adapted intervention. CaCBTp participants were offered 16 sessions with trained therapists while TAU group continued with standard treatment. Analysis was based on the principles of intention to treat (ITT) and further supplemented with sensitivity analysis. Results: CaCBTp group showed significant reduction of symptomatology in the CPRS: mean total scores post-treatment for TAU were M = 18.60 (SD = 14.84) and CaCBTp group M = 16.23 (10.77) respectively. One way ANOVA showed p <.01. Eta is .57, a large

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effect. The magnitude of the effect change was on average 11 units higher in the CaCBTp group than in the TAU group. CPRS subscales mean scores of the MADRAS at 6 months follow-up were TAU (M = 4.46, SD = 5.23); CaCBTp (M = 3.54, SD = 2.94); p <.01 Partial eta squared = .48, a large effect. The mean Insight total score at follow up for the TAU group was M = 11.06 (SD = 1.83) and CaCBTp group M = 9.84 (SD = 3.26) respectively. One way ANOVA showed; p =.02. Eta is .18, adjusted for baseline. Delusions had significant effect; p =.03 post-treatment, but not sustained at follow up; p =. 25. BRAINS (negative symptoms) subscale adjusted for baseline; p< .01; the Brief Anxiety scale at follow-up; p <.01, Partial eta squared =.51, a large effect. The mean (SD) number of CaCBTp sessions for the (n =15) participants was 13.6 (4.9). Overall satisfaction with treatment experience was based on PEQ item 10: (n=14), M = 4.36 (S.D. = 1.082) S.E. = .28 (88.2% CI = 3.71, 4.71). Conclusion: CaCBTp group achieved a significant improvement post-treatment in the reduction of positive and negative symptoms in comparison to TAU despite being worse off at baseline. CaCBTp group highly rated therapy experience and satisfaction with the adapted intervention. Implications are discussed in terms of low attrition rates, further modifications and policy makers. Negative appraisals reported by HIV-positive South African participants: implications for the practice of cognitive therapy in South Africa Charles Young, Rhodes University; Melissa Boulind, Rhodes University, South Africa Despite efforts to establish a society based on democratic values, social justice and human rights, South Africa remains one of the most unequal countries in the world, and this inequality continues to be largely defined by race (Seekings & Nattrass, 2006). Although there is a growing black middle class and although the highest income groups are rapidly becoming deracialised, the overwhelming majority of those locked in poverty are black (Seekings & Nattrass, 2006). What is more is that the trend appears to be worsening: income inequalities between black and white households have increased since 1995 (Butler, 2004), as have income inequalities between wealthy and impoverished black South Africans (Seekings & Nattrass, 2006). These income inequalities are reproduced with the uneven burden of mental illness and inequitable access to quality healthcare. Like many developing countries, South Africa has endured high rates of political and criminal violence, gender-based violence, childhood physical abuse, road traffic accidents, industrial accidents and burns (Edwards, 2005; Kaminer & Eagle, 2010), and the burden of these traumas is carried most heavily by those who are socially and economically marginalised. Moreover, South Africa has the largest population of HIV-positive people in the world (Department of Health, 2009) alongside pervasive HIV-related stigma (Kalichman et al., 2005). The prevalence of HIV infections is similarly unevenly distributed across social strata and has significant mental health consequences (Freeman, Nkomo, Kafaar & Kelly, 2008). Thus, those who are most marginalised experience the harshest realities of the South African social context, and the likely result is problematic appraisals that emphasise defeat and alienation and that confer vulnerability to mental illness. Drawing on a qualitative thematic analysis of interviews with a small number of impoverished HIV-positive participants who also meet the diagnostic criteria for HIV-related posttraumatic stress disorder and who have sought medical treatment at a public healthcare facility in a rural area of the KwaZulu-Natal province of South Africa, this paper illustrates this relationship between prominent contextual factors such as stigma, racism and poverty, and problematic appraisals and associated compensatory strategies. In addition to cognitive therapy interventions to target the negative appraisals associated with HIV infection, this research also calls for structural interventions that address the factors that give rise to the mental health problems in the first place. CBT: The Nepal Experience Susmita Halder, Consultant Clinical Psychologist, India Cognitive Behaviour Therapy (CBT) is an established mode of treatment in different psychiatric conditions. It is a treatment of choice especially in depression and other anxiety spectrum disorders. In spite of having a Western origin, the treatment modality is been used extensively all around the world. Efficacy studies are being reported across different population and are abundant in literature. However cross cultural impact on modifications of CBT and adaptations are less documented. The chapter focuses on the prevailing use of CBT, along with local considerations and adaptations in Nepal. . Cognitive behaviour therapy can be indisputably considered one of the least documented therapeutic modalities in Nepal. There are hardly any randomised controlled studies on efficacy of CBT or uses of CBT in this Himalayan Kingdom. A recent study done at the department of psychiatry, B P Koirala Institute of Health Sciences; reveals that counselling/ Psychoeducation was used as treatment modality in 14 of the 129 psychiatric cases referred in a month. Structured CBT didn’t find a mention. While basic principles of applying CBT to Nepalese population remain the same, as in any other part of the world; the treatment modality requires some modifications and changes to suit the population. The lecture will discuss on the issues that have a major impact on how CBT is carried upon, the roadblocks, and local considerations for adaptation, that have been covered under the following headings:

• Health care system and mental health in Nepal • Services and resources • Man power and training

• Cultural and local considerations • Family dynamics • Age and gender issues

• Language and communication • Expression of distress and symptoms • Therapist – Client relationships

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Using Cognitive Formulations With Staff Teams: Examining the Clinical and Organisational Value of Differing Consultation Approaches Convenor: Stephen Kellett, University of Sheffield

Cognitive analytic consultancy in assertive outreach; a pragmatic randomised control trial Stephen Kellett, University of Sheffield; Mark Wilbram, Barnsley PCT NHS Trust; Claire Davis, University of Nottingham; Gillian Hardy, University of Sheffield; Cognitive Analytic Consultancy (CAC) has recently been developed to help teams manage 'difficult' patients or patients for whom individual therapy in not indicated. A randomised controlled trial was conducted in which patients in an Assertive Outreach Team were randomised either into cognitive analytic consultancy (CAC; n= 10) or treatment as usual (TAU; n = 10). Patients completed measures of psychological functioning (CORE-OM, Work and Social Adjustment Scale) at four time points (baseline team training, cognitive analytic case formulation, cognitive analytic team supervision and 3-month follow-up). Staff completed the Service Engagement Scale concerning patients in the relevant arms and the Team Climate Inventory at the same time points. Team members were also interviewed before and following the project and the transcripts subject to content analysis. No differences were found between CAC and TAU in terms of patient outcomes. The climate of the team in which the project was based significantly improved in terms of participative safety, support for innovation and task orientation over the course of the trial. Qualitative results mirrored and extended the quantitative findings noting that that CAC was associated with enhanced clinical and team practices. The results are discussed in terms of methodological limitations, the advantages and disadvantages of consultation to mental health teams and the potential for the further development of the CAC model. Changes to direct care staff thoughts, emotional responses and client outcomes following cognitive behavioural formulation development workshop Barry Ingram, Tyne & Wear NHS Foundation Trust & Newcastle University Collaborative case formulation development workshops have been developed within intellectual/developmental disabilities services. These aim to help develop and share formulations with direct care staff in relation to the clients they are supporting who display significant psychosocial difficulties (e.g. challenging behaviour). Cognitive behavioural principles are applied with the outcome an agreed, shared case formulation that guides treatment planning. It is hypothesized that these workshops shift care staff thoughts and emotional response in relation to clients, which then mediates helping behaviour and reduces client psychological distress. A quasi experimental design has been used to examine these potential shifts. The presentation will outline data (n>50) that indicates changes in staff attributions and emotional responses alongside changes in client outcomes (e.g. challenging behaviour; anxiety/depression) following formulation workshops. This will include exploration of the convergence of views held by staff team members in relation to the individual supported and the shifts in resilience of the staff team. The further exploration of the links between staff responses and client outcome will be considered alongside future developments for an open trial of the effectiveness of these workshops. Investigating the use of psychological formulations to modify psychiatric staff perceptions of service users with psychosis Kath Berry, School of Psychological Sciences University of Manchester Psychiatric staff play a key role in the lives of people with psychosis and the quality of staff and service user relationships is associated with relapse and recovery. One factor that determines the capacity of staff to form positive therapeutic relationships is their appraisals of service users’ mental health problems. This paper describes a feasibility and acceptability study of an intervention to improve staff and service user relationships in a sample of people with a diagnosis of psychosis living in 24-hour supported accommodation. The intervention involves developing psychological formulations with staff teams to help them comprehend and understand service users’ behaviour and interactions. The project aims to recruit 80 staff and 40 service users across the North West of England. Key outcomes measures include: uptake of the intervention, staff and service user relationships, staff stress, service user symptoms and staff and service user perceptions of acceptability. The paper will present baseline data for the study, uptake data for the intervention and key themes derived from feedback interviews. Compassionate recovery: Individualised support in early psychosis (CR:ISP) from implementing improvement strategies based on an integrated care pathway Andrew Gumley, Institute of Health and Wellbeing, University of Glasgow & NHS Greater Glasgow and Clyde, ESTEEM Early Intervention Service Integrated Care Pathways (ICPs) form a key part of the Scottish Government’s Strategy to implement effective service redesign. Furthermore, the Healthcare Quality Strategy for NHS Scotland prioritizes caring and compassion in staff and services, via effective collaboration between clinicians and patients. In our previous research, we have been able to identify a group of individuals with first episode psychosis, that experience significant difficulties engaging and collaborating with services. This group is at heightened risk of poor outcome reflected in higher negative symptoms and failure to achieve remission at 12-months. In line with the Healthcare Quality Strategy our aim is to implement and evaluate an Integrated Care Pathway for improving (a) the standard of person centred care and (b) increasing the availability of effective psychological interventions for individuals with first episode psychosis. This project focuses on the development of individualized compassion focused multi-disciplinary formulation to enhance recovery for individuals at risk of arrested recovery. The presentation will therefore outline the methods, progress and experience of implementing formulation-informed care for early psychosis.

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Utilising New Technologies in Training and Therapy Chair: Jennifer Wild, Experimental Psychology, University of Oxford

Randomised trial comparing Internet-based training in cognitive behavioural therapy to delayed-training control Sarah Rakovshik, Oxford University; Freda McManus, Oxford University & Oxford Cognitive Therapy Centre; David Westbrook, Oxford Cognitive Therapy Centre; Alla Kholomogorova, Moscow State University of Psychology and Education & Moscow Research Institute of Psychiatry; Natalya Garanyan, Moscow State University of Psychology and Education & Moscow Research Institute of Psychiatry; Dennis Ougrin, Kings College London, Institute of Psychiatry There is a need for effective, scalable methods of training clinicians in evidence-based interventions, particularly for populations with significant barriers to accessing traditional methods of training (e.g., developing economies, non-English speaking populations). Hence this study examined the effectiveness of internet-based training (IBT) in cognitive behavioural therapy (CBT) for participants in Russia with limited previous knowledge or training in CBT. Participants (N = 63) were randomized to either delayed training control or immediate Internet-based training (IBT: approximately three hours over the course of one month). Participants were assessed immediately prior to and following the training / delay on (a) standardised role-play of a CBT assessment and (b) ability to construct CBT formulation of the role-play ‘patient’. IBT may be an effective and scalable method of CBT dissemination with particular potential for training CBT skills in populations with significant barrier to accessing traditional methods of training. Participants allocated to IBT had significantly higher scores on measures of CBT assessment and formulation skills, with between group effects sizes of d = 0.77 – 1.10. Participants reported IBT to be a feasible and acceptable form of CBT dissemination. Results suggest that IBT may have the potential to be an effective, acceptable and scalable method of increasing CBT competence, thus making CBT training accessible to a wide range of therapists, and increasing availibility of evidenced-based psychological treatments for clinical populations.

Cognitive Behaviour Therapy Delivered Face-To-Face With Support Via The Internet And An iPad – A Standard Approach In The Future? Kristoffer Månsson, Department of Behavioural Sciences and Learning, Linköping University; Per Carlbring, Department of Psychology, Umeå University; Gerhard Andersson, Department of Behavioural Sciences and Learning, Linköping University Cognitive Behavior Therapy delivered face-to-face (CBT) or via the internet with therapist support (iCBT), has been evaluated in several randomized controlled trials. Some advantages by delivering treatment via the internet may be noted, such as availability in time and space and standardized interventions. These benefits would be interesting to use and inject into a traditional CBT. We created a new web-based platform, accessible via a computer or an Apple iPad. We included some standard CBT content such as agenda setting, treatment goals and a library containing information in purpose of giving psychoeducation. The platform also contains an encrypted message system, allowing for contact between sessions, or contact replacing a therapy session due to impediment or illness. A total of 15 participants fulfilling any criteria of anxiety or depression according to DSM-IV, was included in the study. 8 psychologists, during their last term of the education, volunteered as therapists. Therapy outcome measures that was used: Beck Anxiety Inventory (BAI), Montgomery Asberg Depression Rating Scale - Self Rated (MADRS-S), Patient Health Questionnaire (PHQ 9), Generalized Anxiety Disorder Screener (GAD 7), Quality Of Life Inventory (QOLI) and Working Alliance Inventory (WAI). A qualitative interview has been conducted to examine the experience of using the support of internet, both as a patient and psychologist. Both quantitative and qualitative results will be discussed. An demonstration of the web-based platform will be given. A repeated measure and effect sizes (Cohen´s d) are presented by each outcome measure, primary and secondary. Post-treatment assessments was completed by May 2012. Improving conditions of delivering evidence based psychological treatment.

Mind Above Mood: Using A Mobile Phone Application to Increase Treatment-Seeking Alex Gyani, University of Reading; Jack Rostron, University of Reading; Sam Allen, University of Reading; Katy Mawhood, University of Reading; Suzanna Rose, Berkshire Healthcare NHS Foundation Trust; Roz Shafran, University of Reading The ‘Improving Access to Psychological Therapies’ (IAPT) programme has increased the provision of evidence-based treatments for common mental health disorders. Its introduction of self-referral highlights the fact that the first step of the care pathway is not referral, but treatment seeking. However, self-referral has been found to be under-used and IAPT access rates are currently slightly below initial targets. A number of barriers to effective treatment seeking have been identified. These include: an uncertainty of where to find treatment, fear of stigma and the lack recognition that problems could have a mental health origin. Online experience sampling or ‘mood monitoring’ tools are available to help people with common mental health disorders identify low mood and anxiety. The aim of this study is to test the hypothesis that such tools will increase treatment seeking. The current study developed an iPhone application (‘Mind Above Mood’) to evaluate the effectiveness of mood monitoring in increasing treatment seeking, using validated depression and anxiety inventories. In this paper the theoretical background, aims and content of the Mind Above Mood application will be presented and the case will be made for the use of new technologies to help increase the utilization of psychological therapies. This study is in the process of being run and no results are currently available, however, the study's progress will be discussed. This paper aims to promote discussion about the use of new technologies in healthcare and the study's findings may have implications for those aiming to encourage people to use psychological therapy services.

A skeptics' guide to internet-based CBT for mixed anxiety and depression: Does it really work?? Results from a RCT and Effectiveness in Primary Care. Jill Newby, Clinical Research Unit for Anxiety and Depression (CRUfAD), St. Vincent's Hospital, Sydney, Australia; Anna MacKenzie, Clinical Research Unit for Anxiety and Depression (CRUfAD), St. Vincent's Hospital, Sydney, Australia; Gavin Andrews, Clinical Research Unit for Anxiety and Depression (CRUfAD), St. Vincent's Hospital, Sydney, Australia; Karen McIntyre, Clinical Research Unit for Anxiety and Depression (CRUfAD), St. Vincent's Hospital, Sydney, Australia; Sarah Watts, Clinical Research Unit for Anxiety and Depression (CRUfAD), St. Vincent's Hospital, Sydney, Australia Co-morbidity between depression and anxiety is the norm, rather than the exception. Effective, affordable and accessible transdiagnostic treatments for co-morbid anxiety and depression are needed. Although transdiagnostic internet CBT courses (iCBT) exist, effect sizes are moderate in RCT’s, and the effectiveness and adherence to such courses have never been studied in primary care settings. This raises the question: does iCBT for depression and anxiety really work in real-world settings? In study 1, a RCT was conducted in www.virtualclinic.org.au, comparing a new 6-lesson iCBT program for co-morbid GAD and MDD (n=46), compared to a Wait-List Control group (WLC) (n=53). In study 2, the same iCBT course was made available to primary care practitioners in www.crufadclinic.org for use with patients (n=294) to examine the adherence to,

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and effectiveness of the course when delivered in primary care. iCBT for mixed anxiety and depression is accessible and efficacious, but when translated into real-world settings, drop-out rates are high, posing a significant problem for iCBT. Future research is needed to investigate how to improve adherence to iCBT using practical measures in primary care. iCBT was more effective than WLC in reducing depression (PHQ-9), and anxiety (GAD-7) symptoms. Gains were maintained at 3-month follow-up. Effect sizes were similar across settings, yet treatment adherence was much lower in primary care (35%-55% versus 89%). Practitioners should consider using iCBT with patients with co-morbid anxiety and depression as either a stand-alone treatment or treatment adjunct. The results suggest practitioners pay close attention to encouraging patients to adhere to iCBT programs to get the most benefit.

Project SNIPE: A European trial of a personalised social norms feedback intervention for polysubstance use in university students Robert Dempsey, University of Bradford, UK; Robert Dempsey, University of Bradford, UK; John McAlaney, University of Bradford, UK Rates of alcohol and other substance use can be high amongst university student populations and may be associated with poorer academic performance and future health problems. The social norms approach, a popular e-health intervention developed in the USA, attempts to address misperceptions of substance use rates and the perceived normalcy of substance use amongst university student populations through personalised feedback interventions delivered over the internet. Project SNIPE is the first cross-European feasibility study of a social norms intervention for polysubstance use in university students (across the UK, Belgium, Denmark, Germany, Slovak Republic, Spain and Turkey). Students across 26 European universities complete a survey about their own substance use behaviours and attitudes, and their perceptions of the substance use behaviours and attitudes of their fellow students at their institution. Participants at the intervention sites gain access to a website providing personalised gender-specific normative feedback relating to the actual substance use rates and attitudes of their peer group based on the baseline survey. Control sites receive the personalised feedback at a later date, with a follow-up survey launched Spring/Summer 2012 assessing post-intervention changes in substance use behaviours and attitudes. This talk will also reflect upon the challenges associated with conducting a social norms intervention across seven European countries This talk will present the results of the baseline survey (collected Spring 2012) and qualitative work exploring the effect of social experiences and normative influences upon substance use as well as barriers to participation in e-health interventions. Project SNIPE is a computerised/web-based form of a positive intervention that attempts to promote healthy behaviour change. The social norms approach offers a different, less negative and less lecturing approach to promoting attitudinal and behaviour change in high-risk individuals, and has a strong social psychological component. The talk will also consider the use of mobile and new technologies for delivering personalised feedback for health behaviours, which may offer a more direct means of delivering behaviour change interventions which may provide a more engaging and involving means of retaining participants in interventions, particularly as many web-based interventions can be associated with high rates of attrition.

Skills Classes

Culturally Adapted Cognitive Behaviour Therapy for Mental Illness Shanaya Rathod, Interim Director of Research and Outcomes, Southern Health NHS Foundation Trust Cognitive Behaviour Therapy (CBT) is the most widely recommended psychological therapy for most mental health problems including depression, anxiety, obsessive compulsive disorder and psychosis in the United Kingdom (e.g. NICE 2009) and many other countries. However, explanations used in CBT are based on Western concepts and illness models. There has been little attention given to modifying the therapeutic framework and practice of therapy (Williams et al, 2006) to incorporate an understanding of diverse ethnic, cultural and religious contexts (Rathod et al, 2008). Metanalysis of culturally adapted evidence based treatments in comparison to traditional treatments have shown a modest to large effect size (Wykes 2008; Griner and Smith 2006). The speaker and research team have developed a culturally adapted CBT (Rathod et. al. 2010) and tested outcomes through a feasibility trial. Objectives At the conclusion of this session participants will be able to 1. Understand the reasons for culturally adapting Cognitive Behaviour Therapy to facilitate engagement and improve outcomes in patients from ethnic minority communities 2. Recognize themes and be able to adapt therapy to diverse cultures and appreciate the impact of culture on treatment when interacting with patients from these communities 3. Develop case formulations taking into account relevant cultural factors 4. Develop a dialogue and practice with confidence when addressing difficult cultural issues of patients Sahnaya Rathod is Clinical Service director and Director of Research and Outcomes with Southern Health NHS Foundation Trust. He is a Fellow with National Institute of Health and Clinical Excellence. He has recieved grants from the DH (DRE) to develop a Culturally Adapted CBT and test its feasibility in the UK and has published books, papers in peer reviewed journals and lectured at National and International events. References Rathod, S., Phiri, P., Kingdon, D., Gobbi, M. Developing Culturally sensitive Cognitive behaviour therapy for Psychosis for Ethnic minority patients by Exploration and Incorporation of Service Users’ and Health Professionals' Views and Opinions. Journal of behavioural and Cognitive Psychotherapies, 2010. 38; 511-33. Rathod, S., Kingdon, D., Cognitive behaviour therapy across cultures. Psychiatry. 2009; 8 (9): 370-371 Rathod, S., Kingdon, D., Smith, P., Turkington, D. Insight into schizophrenia: the effects of cognitive behavioural therapy on the components of insight and association with sociodemographics - data on a previously published randomised controlled trial. Schizophrenia Research, 2005, 74/2-3: 211-219.

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Clinical Roundtable

Delivering Acceptance and Commitment Therapy in Groups Convenor: John Boorman, Alpha Hospitals, Woking Speakers: Eric Morris, South London & Maudsley NHS Trust; Nic Wilkinson, Sheffield Health & Social Care NHS Foundation Trust; Louise Johns, Institue of Psychiatry; John Boorman, Alpha Hospitals, Woking; Jo Lloyd, Goldsmiths, University of London; Joe Oliver, South London & Maudsley NHS Trust As one of the themes for this 40th BABCP conference is focusing on present and future developments of CBT, this round table will examine the merits of using Acceptance and Commitment Therapy as group psychological intervention. Mindfulness and acceptance strategies are becoming increasingly mainstream within the field of psychology. The influence of these so called “third wave approaches” has been felt within the many areas of psychological therapies, and Acceptance and Commitment Therapy (ACT) has been shown to be useful in treating a wide range of problems. Delivering psychological groups programmes has long been viewed as a cost effective and clinically useful treatment modality. For this round table discussion 4 different ACT group treatment approaches will be presented and used as the focus point of the audience discussion. 1) ACT Groups for Psychosis: Eric Morris, Joe Oliver, Lambeth Early Onset (LEO) for Psychosis, South London & Maudsley NHS Trust, & Louise Johns, PICuP outpatient for Psychosis Clinic, Institute of Psychiatry & South London & Maudsley NHS Trust. 2) ACT Groups for Adolescents: John Boorman, Alpha Hospitals, Woking. 3) ACT Groups for the Workplace: Jo Lloyd, Goldsmiths, University of London. 4) ACT Groups for Pain: Nic Wilkinson, Diabetes Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Trust. Implications: 1) Learn how to incorporate acceptance and mindfulness processes into current clinical practice. 2) Learn how to facilitate running Acceptance and Commitment Therapy Groups. 3) Learn how to facilitate behaviour change from a contextual perspective.

Posters A qualitative analysis of experts’ experiences of how CBT competence is conceptualised and assessed Kate Muse, University of Oxford; Freda McManus, University of Oxford, Oxford Cognitive Therapy Centre The ability to reliably assess CBT competence is crucial to the success of the UK’s current drive to expand CBT training and service provision, and to the widespread dissemination of CBT into routine clinical practice settings. There is however a lack of consensus regarding the definition of CBT competence and the way it should be assessed. Hence, the purpose of the present study is to use qualitative methodology to explore expert assessors’ conceptualisations of CBT competence, and their experiences of making judgements regarding the competence of CBT therapists. Twenty expert CBT therapists with significant experience of assessing CBT competence in a range of training, research and clinical practice settings will take part in the study. Participants’ experiences and opinions of assessing CBT competence will be explored using semi-structured interviews and the interview transcripts will be analysed using Interpretative Phenomenological Analysis. It is hoped that by providing an insight into the way in which CBT competence is currently conceptualised and assessed, results of the study will highlight ways in which the assessment of CBT competence could be further improved upon in the future. A summary of the key themes which emerge from Interpretative Phenomenological Analysis of participants’ interviews will be presented. This should offer insight into what experts across a range of contexts understand CBT competence to be and highlight commonalities and differences in the ways in which CBT competence is currently judged and assessed. The findings from this study may contribute to the enhancement of current methods of assessing CBT competence as well as the future development of novel assessment methods. Adaptation and psychometric testing of the CTS-R for use in chronic low back pain Zara Hansen, Warwick Clinical Trials Unit; Jane Kidd, Warwick Clinical Trials Unit; Sarah E Lamb, Warwick Clinical Trials Unit Low back pain (LBP) is a common problem for which Cognitive Behavioural Therapy (CBT) has shown potential benefits. Due to limited access to CBT qualified professionals, simplified CB approaches are being tested, often delivered by physiotherapists. The key components of a CB approach for LBP have not yet been established along with the competency of physiotherapists to deliver these components. The aim of this study was to develop a competency tool for assessing physiotherapists delivering a CB approach for chronic LBP. Level IV evidence was obtained from experts through a Delphi consensus method. Experts met predefined criteria; they had to work closely with physiotherapists, have a CBT post graduate training qualification and also have applied CB approaches in LBP. A Delphi method consists of a series of questionnaire rounds. The 1st round of the Delphi asked the experts which competencies should be included from a validated CBT competency assessment tool, the Cognitive Therapy Scale - Revised (CTS-R; Blackburn et al 2001) and also asked experts to identify appropriate additional competencies. The 2nd and 3rd rounds gained consensus and asked experts to define the minimum competency level. The new tool then underwent intra and inter-rater reliability testing against a sample of session recordings from a large scale RCT of CB approaches for LBP (Lamb et al 2010). The original CTS-R has been adapted by a panel of experts to assess physiotherapist’s competency to deliver a CB approach. The tool is usable and reliable. The nine experts were 4 clinical psychologists and 5 physiotherapists. They voted to include all original 12 items of the CTS-R although 3 of them were significantly altered to bring them in line with the target therapist and patient population. A further 8 potential competencies were identified although 5 were rejected in Rounds 2 and 3. The 3 new competencies were entitled ‘Facilitating Behavioural Change’, ‘Supporting Change’, and ‘Professional Boundaries’. Minimum competency was set as 4 for 11 items and 3 for the remaining 4 items. The final measure had high internal consistency (Cronbachs ? = 0.99). Reliability was tested with an intra-class correlation coefficient and was very good; intra-rater 0.92 (.79 -.97), inter-rater reliability amongst 4 raters was 0.82 (.30 - .99). The tool can be used to structure training of physiotherapists delivering CB approaches in LBP and also can be used to improve competency

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through a process of evaluation. The tool may actually have a wider remit in the assessment of other health professionals using a CB approach in all chronic pain conditions. Do Psychotherapists use research to enhance their clinical practice? Alex Gyani, University of Reading; Roz Shafran, University of Reading; Suzanna Rose, Berkshire Healthcare NHS Foundation Trust The scientist-practitioner model requires clinicians to have a current understanding of evidence-based treatment. Numerous studies indicate that research is not used to enhance clinical decision making and that the methods therapists use to enhance their clinical decisions vary depending on their theoretical orientation. In this study, a survey was sent to 4,144 psychological therapists in England to investigate the methods they use to enhance their practice. These findings indicate that many therapists do not use research to enhance their clinical practice but this varies according to theoretical orientation. This survey was conducted online and the response rate was 18.3%. Most respondents identified themselves as CBT (Cognitive Behavioural Therapy) therapists, creative arts therapists, psychodynamic therapists, integrative therapists or humanistic/experiential therapists. Respondents felt that intuition and personal experience were more influential than research evidence in choosing their theoretical orientation, although this varied by theoretical orientation. When looking to enhance their clinical practice, therapists were significantly more likely to use personal experience with previous clients and supervision than research evidence from clinical trials. CBT therapists were more likely than others to consider research evidence from clinical trials and creative arts therapists used evidence from case studies more frequently than others. The implication of these results for the training and continued professional development of psychotherapists is discussed. The impact of supervision in the delivery of a CBT based intervention Sanchia Biswas, City University; Emma Hollywell, City University; Andre Geel In London, around 3000 people are seen on the streets each year, around half with an alcohol problem, 41% with a drug issue and 35% with some form of mental health problem (CLG, 2011). Relapse prevention is an important component of substance misuse as it aims to prevent high-risk situations, and improve individual coping skills. The relapse prevention model developed by Marlatt & Gordon (1985) suggests that relapse prevention is based upon cognitive-behavioural techniques. Evidence shows that cognitive behavioural therapy (CBT) can be effective in the treatment of substance misuse (Beck, Wright, Newman and Liese, 2001). The success of relapse prevention for a substance misuse client group is highly dependent upon the individual’s motivation for change and also the quality of service provision. It is essential for health professionals to receive frequent clinical supervision. For example, Butterwood and Woods (1998) state that clinical supervision is essential for managing, enhancing and monitoring the delivery of high quality services for patients. However, following recent cutbacks, supervision can be less frequent, expensive and time consuming. A lack of supervision may impact upon the confidence levels of healthcare professionals and their ability to deliver interventions successfully, and effectively. This study aims to focus upon the use of the relapse prevention protocol (CBT-based) devised for use by all staff working within Addictions Services in Central and North West London. The research questions for this study are: a) Does training in Relapse Prevention increase the use of the protocol? b) Does training in Relapse Prevention increase the confidence of delivering the protocol? c) Does supervision mediate the relationship between confidence and delivery if Relapse Prevention?

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40th Anniversary Founder Celebrations

Symposia

Celebrating 40 years of BABCP: A Symposium in Honour of Andrew Mathews - A Founder Member Emily Holmes, University of Oxford

Can neuroimaging tell us anything about how cognitive biases are learnt? An investigation by a second order Mathewsite Michael Browning, University of Oxford Cognitive bias modification (CBM) procedures, pioneered by Andrew Mathews, have received a great deal of interest recently, as early evidence suggests that they may usefully be deployed in clinical settings. However, CBM tasks are also an extremely useful experimental tool with which to explore the processes by which emotional disorders develop and the mechanisms by which treatments may work. In this talk I will describe two experimental neuroimaging studies which have investigated the neural machinary which allow processing biases to be modified in response to environmental information—an event expected to occur during the both the development and resoultion of episodes of anxiety and depression. This work suggests that an indivdual’s biases reflect their expectations about the environment and that these expectations may be shaped by CBM tasks. Specifically, activity in the lateral prefrontal cortex reflects the surprise produced when a CBM task is inconsistent with an individual’s expectations. The surprise is, in turn, used to update future expectations, coded in the activity of the orbitofrontal cortex, so that they more closely match the information contained in the CBM task. Finally, novel approaches for enhancing bias learning, suggested by this neural model will be discussed. Although these studies are based on the pioneering cognitive models developed by Andrew Mathews, the speaker has never worked directly with him. However the speaker’s doctoral supervisor is a first order Mathewsite, so it is hoped that at least some of the information presented will be correct. Habits of Research on Emotional Disorders Paula Hertel, Trinity University, USA From his roots in conditioning through his bouts with Stroop, dot-probe methodologies, and implicit memory to his current interests in cognitive bias modification, Andrew Mathews has focused on the importance of automatic cognitive processes in establishing, maintaining, and treating emotional disorders. Following a whirlwind tour through some of these findings, I present recent evidence concerning automatic versus controlled components of trained interpretive biases. Using process-dissociation procedures, these components are examined as an attempt to simulate implicit vs. explicit transfer of trained interpretations of emotionally ambiguous scenarios. The contribution of attentional bias to worry: Distinguishing the roles of selective engagement and disengagement Colette Hirsch, King's College London, Institute of Psychiatry; Colette Hirsch, King's College London, Institute of Psychiatry; Colin Macleod, University of Western Australia; Andrew Mathews, University of California, Davis; Sarra Hayes, King's College London, Institute of Psychiatry Over the past thirty years the advances in our understanding of how cognitive biases that maintain psychological problems have been pioneered by Andrew Mathews. In some of his early work he established that people with GAD have an attentional bias towards threatening information. More recent research into anxiety and attentional bias suggests that this is driven by enhanced engagement with threat, while other research suggests that this may be driven by delayed disengagement from threat. However, while these studies provide evidence for the existence of a given type of attentional bias, they do not examine the causal role these processes have on maintaining anxiety and worry. The current study investigated the causal contribution of biased attentional engagement with threatening information, and biased attentional disengagement from threatening information, to worry. Variants of a novel attention modification paradigm were developed, designed to induce a group difference either in participants’ tendency to selectively engage with, or disengage from, threatening meanings. An index of threat bias, reflecting relative speeding to process threat word compared to non-threat word content, confirmed that both procedures were effective in inducing differential attentional bias. Importantly, when the induced group difference in attentional bias followed the procedure designed to influence selective engagement with threat meanings, it also gave rise to a corresponding group difference in worry. This was not the case when it was induced by the procedure designed to influence selective disengagement from threat meanings. These findings suggest that facilitated attentional engagement with threat meanings may causally contribute to variability in worry.

Enhancing Positive Affect via Cognitive Bias Modification for Global Bias Laura Hoppitt, University of East Anglia; Sophie Waters, University of East Anglia; Judi Walsh, University of East Anglia In 2000, two seminal studies demonstrated that threat-related cognitive biases could be modified using computer based training tasks, and that this modification might influence anxiety (Grey & Mathews, 2000; Mathews & Mackintosh, 2000). Since then, modifying threat-related cognitive biases via computer based training tasks have been shown to be useful both in answering theoretical questions regarding psychopathology, and as a potential treatment tool. To date, the majority of Cognitive Bias Modification (CBM) experiments focus upon interpretation, imagery, attention to threat or memory, and aim to reduce symptoms such as anxiety and negative affect, as opposed to enhancing positive mood. The present study aimed to train a bias specifically associated with positive affect (a global bias i.e., “seeing the bigger picture”), in an attempt enhance positive experience during a positive mood induction task. Forty undergraduate volunteers participated in the study and were randomly allocated to either global bias training or local bias training. Training and test materials utilised the Navon Figures, which are large letters (global format e.g., an “H”) made up of smaller letters (local format, e.g., smaller “F’s”). On each trial participants were asked to respond to the figure presented by reporting whether one of two target letters were present in the display. In the global training condition the target letters always represented the global

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format of the figure, in the local training condition the target letters always represented the local format of the figure. Following training, participants completed a positive Velten statements task, designed to induce positive affect. We measured positive and negative affect (using the Positive and Negative Affect Schedule) and state anxiety (using the Spielberger State Trait Anxiety Inventory) pre-and post this task. Our results showed that change in global bias significantly predicted change in positive affect, with a greater induction of global bias being associated with greater improvements in positive affect. Interestingly, this effect was specific to positive affect, and change in global bias did not predict change in negative affect or anxiety during the mood induction task. These results are broadly consistent with theories that describe global processing bias as being causal in the enhancement of positive emotion (e.g., Broaden and Build theory, Fredrickson, 2001). In addition they suggest another type of cognitive bias that might be amenable to manipulation via CBM procedures. Andrew Mathews - a snapshot and some mental images: a clinical psychology scientist who inspires others Emily Holmes, University of Oxford; This symposium is a tribute to Andrew Mathews. Andrew has a nasty habit of positively modifying the biases of clinical scientists, so needs to be approached with caution. Image 1: my first meeting with Andrew in the café outside the British Library, animatedly discussing one of his recent papers and implications for mental imagery. Image 2: PhD theses - Andrew’s own PhD thesis had included mental imagery, and I was extremely fortunate to become his last PhD student and focus on this very topic. Image 4: At work, the Emotion group meeting at the CBU, debating, sometimes disagreeing and sometimes agreeing, always learning. Image 4: Away from work – running around and picking fruit in the garden at the CBU in Cambridge with Andrew, Valerie and Bundy. Image 5: Andrew and Valerie again, generously bringing wine to toast a paper that had been accepted for publication. Image 6: Being on the BABCP board and finding an early BABCP document with Andrew’s name on. Later, Andrew modestly explaining later yes, he’d been involved in the early days at BABCP. Image 7: Andrew’s retirement celebrations, introducing and linking people, the international dimension. Future images: Inspiring more bad habits - passing on large doses of Andrew and Valerie’s particular research spirit and generosity, and hopefully doing so in enough style to infect the next generation of clinical scientists.

Celebrating 40 Years of BABCP: A Symposium in Honour of William Yule – A Founder Member Convenor: Patrick Smith, Institute of Psychiatry, King's College London and South London and Maudsley NHS Foundation Trust

Fear and loathing at the Maudsley: CBT for anxiety past and present Paul Salkovskis, University of Bath The Maudsley and Institute of Psychiatry has had a central place in the development of the treatment of anxiety in first BT then CBT, and Bill Yule has in turn been central to those developments. In this presentation, the development and evolution of rapid and highly effective treatments for anxiety in general and specific phobias in particular are reviewed. Of particular importance is the fact that anxiety can be costly in both financial and human terms, and yule be amazed at the bill! Underexposed? The treatment of PTSD in pre-schoolers, children and adolescents Richard Meiser-Stedman, Medical Research Council Cognition & Brain Sciences Unit, Cambridge In 1974 Yule and colleagues demonstrated the successful treatment of noise phobia in an 11 year old boy using flooding. A little over a decade later, Saigh published the first case study detailing the behavioural treatment of PTSD in a child; in particular, the use of in vitro flooding for a six year old boy’s war-related trauma. In this presentation I will outline developments in the treatment of PTSD in youth since these landmark studies. While there have been a number of significant advances, principles established in these papers remain central to the successful treatment of PTSD in youth and underline Professor William Yule’s monumental contribution to the field. Individual Parent Training: Mechanisms of action and strategies when it doesn’t work Stephen Scott, Institute of Psychiatry King's College London; National Academy for Parenting Research There is much focus now on group parent training but it is grounded in operant psychology as applied to individual cases from the late 1960’s on. William Yule was a pioneer of this approach, one of a small band of radicals who introduced it to the UK. It was, and still is, profoundly different from the approach used by many therapists for children with disruptive behaviour. This talk, illustrated with video clips of practice, will show how the fundamental principles are still valid today and how they can be added to by four other theoretical approaches when cases fail to progress. These are systems theory, attachment theory, motivational interviewing and cognitive restructuring. Reference Scott, S & Dadds, M (2009) When parent training doesn’t work: Theory-driven clinical strategies. Journal of Child Psychology and Psychiatry 50, 1441-1450 Stressbusters: How Professor Yule Effected a C Change in CBT for Adolescent Depression Paul Abeles, Royal Manchester Children’s Hospital, CMFTManchester In the year 2000, Prof Bill Yule again led the development of innovative work with children and young people. “Stressbusters” is a Computerised CBT (CCBT) interactive computer software programme based on a clinically effective, face-to-face CBT protocol for young people with depression. It was designed for teenagers with mild to moderate depression, and comprises eight 45-minute sessions. Each Stressbusters session is an interactive multi-media presentation featuring audio narration synchronized with videos, animations, graphics and printouts. The program has a narrator to guide the user and each session building on the knowledge gained in previous sessions and on the tasks carried out at home. Sessions contain flexible “add-ons” such as written fact sheets (e.g. anxiety, bullying etc), which can be printed out and taken away together with other handouts (e.g. mood diary sheets) produced by the programme. The video inserts are of three teenagers who feature throughout the 8 sessions. Stressbusters participants hear about their lives and watch how the teenagers have used the program in a combination of short video sequences, talking heads and voiceovers. As the narrator talks, key words and simple graphics appear on the screen. The adolescent inputs information that is stored and used throughout the program, having the option to either

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drag/select text from lists or use free-text entry. The sessions contain the following content: (1) Introduction to the programme and goal setting (2) Getting activated (3) Emotional recognition (4) Noticing thoughts (5) Thought challenging (6) Problem solving (7) Improving social skills (8) Relapse prevention. This presentation will first provide a brief background to the development of Stressbusters, and will then showcase a “live” and interactive multi-media demonstration of the programme software. Following this, there will be a description of the clinical studies that have evaluated the Stressbusters intervention. Promising preliminary data for the clinical efficacy of Stressbusters will be reported from the results of a case series of 23 young people with symptoms of depression, recruited from CAMHS teams in Manchester and London. In addition, the details of two ongoing Randomised Control Trials, based in London and York will be outlined. Finally, some consideration will be given to how Stressbusters might be integrated into CAMHS practice, as well as discussing future plans for Stressbusters.

Celebrating 40 Years of BABCP: A Symposium in Honour of Isaac Marks - A Founder Member Convenor: Karina Lovell, University of Manchester

Isaac Marks - His visions for the future - revisited and re-assessed Kevin Gournay, Institute of Psychiatry, Kings College: London Isaac Marks has, over more than 40 years, demonstrated time and again that he has the gift of prescience. This paper will consider some of important messages he conveyed to the wider mental health community - and beyond. Of particular importance he recognised the need to plan for an appropriately skilled workforce to deliver evidence based therapies and in inimitable fashion set out, with meticulous care the epidemiological base, the average number of treatment sessions required and relative success rates; he warned against an over-enthusiastic approach to spreading the message of the efficacy of (then) behaviour therapy. He foresaw the importance of nurses as therapists; self help; computers etc etc. He made enemies along the way - he voiced uncomfortable truths - some of these will be mentioned in this paper. His life's work will not be forgotten - in particular countless people with mental health problems and generations of mental health professionals will forever be in his debt. ‘Innovations in delivering CBT’: The MUSICIAN study Karina Lovell, University of Manchester; John McBeth, Univeristy of Manchester; Gary Macfarlane, University of Aberdeen; Gordon Prescott, University of Aberdeen; Graham Scotland, Univeristy of Aberdeen; Phil Keeley, University of Manchester; Phil Hannaford, University of Aberdeen; Paul McNamee, University of Aberdeen; Deborah P. M. Symmons, Univeristy of Manchester; Chrysa Gkazinou, University of Aberdeen; Marcus Beasley, University of Aberdeen The delivery of psychological treatments, principally CBT based, is rapidly changing with innovations being adopted which have the potential to enhance the accessibility, availability, and cost-effectiveness of mental health care services. The telephone has the ability to overcome many of the social, physical and economic barriers which prevent access to mental health services, and is increasingly being used as a means to support treatment delivery. The telephone has been used in differing and flexible ways to deliver psychological interventions, with some studies using mixed models, using both face to face and telephone sessions, as an adjunct to other treatments, and treatment delivered completely by telephone. Drawing on work from our group on a number of completed and ongoing trials including 1) The MUSICIAN study which evaluated the efficacy of telephone delivered CBT for chronic widespread pain will be discussed. From anxiety disorders to somatoform disorders: Translation of a cognitive behavioural model Trudie Chalder, Kings College London Twenty five years ago anxiety disorders were understood and treated using a three systems model. The three systems model highlighted the importance of behavioural responses in relation to cognitive and physiological responses. This model has been successfully applied to both chronic fatigue syndrome and irritable bowel with good effects. Several randomised controlled trials have shown that CBT based on this model improves symptoms and disability. Mechanisms of change have also been investigated. Behaviour change and change in catastrophic thinking are deemed important in changing both symptoms and disability. Future research should be directed toward understanding how treatments work. BABCP: Aspirations Met and Remaining Isaac Marks, Professor Emeritus, Institute of Psychiatry, King's College London The founding of the-then BABP in 1972 and its renaming as the BABCP 20 years later was well documented by Lomas (1985 & 2008). The `C' indicated that behavioural and cognitive methods are often combined. In the 40 years since the BABP began with 196 members, BABCP membership has expanded fully 46 times to over 9000 members today. Of the 9000, 24% are clinical psychologists, 17% mental health nurses, 11% counsellors, 4% social workers, 3% occupational therapists, and 3% psychiatrists. BABCP members do treatment, teaching and research. A remaining aspiration is for cognitive, behavioural and other psychotherapy to be integrated into a fully-fledged science.

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Panel Discussions

Celebrating 40 Years of BABCP: A Panel Discussion in Honour of Ivy Blackburn – A Founder Member Convenor: Rob Dudley, University of Newcastle Speakers: Kate Davidson, University of Glasgow; Anne Garland, Nottinghamshire Healthcare NHS Trust; Ian James, University of Northumbria at Newcastle; Richard Moore, University of Cambridge; Peter Armstrong, University of Newcastle

Legend has it that the first words ever spoken by Ivy to her mum, when growing up on the sunny island of Mauritius, were: “And how does that make you feel”. We don’t know the response, but it would be consistent with her later achievements. Ivy won a scholarship to study in Edinburgh and remained there until 1993. She was then persuaded to move to the Newcastle Cognitive Therapy Centre as head of training and research. The following year she became director of the Newcastle post-qualification course, also becoming visiting professor at both Durham and Northumbria Universities. Amongst her many accomplishments, Ivy worked closely with Beck, conducted the first British controlled study into the efficacy of CBT in depression, and was chair of the BABCP (1993-1994). Amongst a generation of therapists, Ivy will be very well-known as an inspiring teacher, researcher and formidable supervisor.

This discussion will comprise presentations by some of Ivy’s closest friends and colleagues. Each will acknowledge her personal importance as well as the legacy that she has left in CBT. Her colleagues will describe her role in research in Edinburgh, as well as her valued role as a trainer and supervisor. As well as focusing on Ivy’s past contributions, the symposium will address how her work has contributed to current approaches to CBT and what we can learn from Ivy’s approach in order to develop better treatment and dissemination methods in future.

Celebrating 40 Years of BABCP: A Panel Discussion in Honour of Joan Kirk - A Founder Member Convenor: Roz Shafran, Charlie Waller Institute, University of Reading Speakers: Ann Hackmann, Oxford Cognitive Therapy Centre; Melanie Fennell, University of Oxford; Paul Salkovskis,

University of Bath; David Westbrook, University of Oxford; Ivy Blackburn, BABCP Founder Member

This discussion will comprise presentations by some of Joan Kirk’s closest friends and colleagues. Each will acknowledge her personal importance as well as the legacy that she has left in CBT. Ann Hackmann will describe the time before the Oxford Cognitive Therapy Centre was established, i.e. how Joan steadily built up the psychology department after her arrival in the early 1970s, and brought cognitive therapy to Oxford by encouraging input from Gary Emery in 1979. Her colleagues will take up the story and describe Joan’s role in the establishment and development of the Oxford Cognitive Thereapy Centre along with her support and enthusiasm for the ‘scientist practitioner’ model. Her contribution has led to a strong tradition of ‘real world research’ in Oxford – in other words the empirical evaluation of ordinary services outside typical academic, university-based research departments. Some examples of such research in Oxford will be discussed, as well as some thoughts about how clinicians can still do research even in these difficult times. Her contribution to the cognitive behavioural theory and treatment of obsessive compulsive disorder will be described along with her broader inspiration for work in areas such as imagery. As well as focusing on Joan’s past contributions, the symposium will address how her work has contributed to current approaches to CBT and dissemination and what we can learn from Joan’s approach in order to develop better treatment and dissemination methods in future.

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Mixed Categories

Symposia

Child and Adolescent Mental Health & IAPT and Primary Care New innovations. Putting the IA in C+A IAPT Convenor: Chris Williams, University of Glasgow

Disseminating CBT through existing clinical teams Craig Thompson, Northumbria University National clinical guidelines continue to advocate for the use of Cognitive Behavioural Therapy in the treatment of a wide range of emotional and psychological difficulties in children and young people. The development of Children and Young Peoples IAPT has begun to address the disparity between the demand and the availability of such interventions, but access remains a problem in many geographical areas. This section of the symposium presents a tiered training and supervision framework which was used successfully to develop Cognitive Behavioural Therapy capacity for children and young people in mainstream CAMHS within the city of Sunderland. The advantages and disadvantages of using a capacity building model such as this will be explored and the key learning points from this experience will be disseminated. A Qualitative Study Exploring Parent's Experiences of using an Online Self-help Package designed for Individuals supporting those with Anorexia Nervosa Louise Ewan, University of Dundee; Aoife McNulty, University of Glasgow Anorexia Nervosa (AN) is a disorder characterised by deliberate and sustained weight loss. The majority of sufferers are female and the disorder tends to develop during early adolescence. NICE recommends that the majority of those with AN be managed on an outpatient basis, therefore placing family members at the forefront of care. This can potentially place considerable strain on family functioning. Parents of children with an eating disorder report poorer relationship bonds with the sufferer and also with their spouse and other children. Parents of children with AN experience high levels of distress, burden and psychological morbidity with supporters often reporting symptoms of anxiety and depression. It is evident therefore that parents and the wider family unit have significant needs which need to be met in order to improve their own self-care as well as to enable effective caregiving. Addressing carers’ needs may potentially reduce carer distress and better allow the family to serve as an important resource in treatment, which in turn may help reduce relapse. Skills-based interventions, such as online educational packages, may constructively alter parental reactions to reduce unhelpful responses that maintain their loved one’s illness, such as high levels of expressed emotion or age-inappropriate levels of care. Such a package has recently been created; Overcoming Anorexia Online (OAO). This web-based intervention helps supporters change the ways in which they offer support to individuals with AN using a formulation-based “systemic” cognitive-behavioural approach based on the five areas CBT model. This study adopts a qualitative methodology using semi-structured interviews and comprised the second phase of a recent study which was looking at the feasibility and short-term impact of carers using OAO. Ten parents of young people aged 13-19 who had a diagnosis of AN and who had used the intervention as part of the larger study were interviewed to explore their responses to, and experiences of using the OAO intervention. Telephone interviews were conducted at the participant’s convenience and lasted approximately 40 minutes. A list of topics, derived from the intervention process and earlier studies provided a provisional structure for the interview. Topics included: Knowledge of AN prior to accessing OAO; How useful they found OAO; Any difficulties they had with the package; How OAO compares to previous support accessed; Impact of OAO on the carer. All interviews were recorded and transcribed verbatim. Inductive content analysis was used to analyse the interview content. The results are reported in two parts, ‘parent’s experiences prior to using OAO’ and ‘parent’s experiences of using OAO’. A number of themes emerged under both of these headings including for part 1; powerlessness; Limited knowledge and understanding of AN; Difficulty communicating; Lack of support available for carers; and Carers want help. For the second part the themes included; Superiority of OAO; Reaffirmation of caring ability; Carer mental health; and Relationship dynamics. What do young people want when using CBT self-help resources? Paul Farrand, Mood Disorders Centre, University of Exeter CBT self-help has emerged as an acceptable and evidence based intervention amongst adults. However, with respect to young people little is known regarding either attitudes held towards using CBT self-help or how best to implement CBT self-help interventions. This presentation reports the findings of two questionnaire based studies of over 1000 young people that explore the attitudes held towards using CBT self-help and to understand help-seeking behaviour amongst this group in order to inform how best to develop and implement interventions based upon CBT self-help. In summary results indicate that 73% of young people would intend to adopt CBT self-help were it available with a strong preference for use at home with the school Form Tutor identified for support across several emotional and personal difficulties presented. Results are discussed with reference to the implementation of CBT self-help interventions for young people, especially as part of the Improving Access to Psychological Therapies Children and Young Persons project. Developing and evaluating novel books, classes and online cCBT resources for young people with depression & anxiety Chris Williams, University of Glasgow; Helen Minnis, University of Glasgow; Christabel Boyle, NHS Greater Glasgow and Clyde; Nicky Dummett, St James's Hospital, Leeds; Alastair Lyon, NHS Greater Glasgow and Clyde Young people get bored. They also prefer to work on things they want to, when they want to. They vary as to how engaged they wish to be with support. They can lack trust in supporting practitioners. They also live in family situations which sometimes are supportive and helpful- and at other times are undermining and damaging. Family and systemic factors matter as does the level of cognitive development and ability to read and engage with the traditional language of CBT. All of

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these factors raise challenges as to how to deliver CBT in fresh and varied ways that can intrigue, engage and aid young people and their carers in turning the corner. The presentation will describe the development of a range of CBT self-help resources for young people that can be used in a way and at a level of engagement the young person wants. These include written booklets, the Living Life to the Full Classes (YP version) and a novel website which is being developed specifically for young people entitled We Eat Elephants. Key issues will be discussed including how to address systemic factors within self-help resources, managing risk in low intensity working together with the results of a pilot of the use of the books in a school-based setting. References: Boyle, C., Lynch, L., Lyon, A., Williams, C. (2011). The use and feasibility of a CBT intervention. Child and Adolescent Mental Health. 16 (3) 128-135. First published online: 30 Nov 2010 | DOI: 10.1111/j.1475-3588.2010.00586.x Overcoming teenage low mood and depression: a five areas approach. Dummett, N. and Williams C (2008). Hodder Arnold: London.

IAPT and Primary Care & Severe and Enduring Problems Increasing Access to Talking Therapies for People with Severe Mental Health Conditions: Can we Start a Revolution? Convenor: Adrian Whittington, Sussex Partnership NHS Foundation Trust

Discussant: Paul Johanson, NHS South East Coast

Talking Therapies for Severe Mental Health Conditions: The State of the Nation Kathy Greenwood, Sussex Partnership NHS Trust; Kate Cavanagh, University of Sussex; More than 1.5 million people in England have severe mental health conditions such as chronic or severe depression or anxiety, schizophrenia, bipolar disorder and personality disorder. There is evidence that talking therapies, including cognitive behavioural therapies, and other psychologically informed ways of working, can benefit people experiencing severe mental health conditions. Yet, a recent survey by Rethink found that only half of those with severe mental health conditions had been offered access to indicated talking therapies, which might improve both their psychological and physical health and quality of life. In 2011, the Improving Access to Psychological Therapies (IAPT) Programme broadened to consider psychosis, bipolar disorder and personality disorder. This programme extension is beginning to explore national priorities for service level developments to ensure that more people with severe mental health conditions are able to access cost-effective evidence-based psychological treatments and psychologically informed services. Initial priorities for the programme highlighted in the Talking Therapies Four Year Plan of Action include improved implementation of NICE recommended talking therapies for serious mental health conditions and a realisation of the benefits of talking therapies for common mental health problems alongside serious mental health conditions. Meeting these targets will require significant service development initiatives alongside enhanced training and supervision for mental health practitioners working with people with severe mental health conditions. This talk will present a summary of the current state of knowledge about what works in talking therapies for severe mental health conditions, and what other psychologically informed ways of working may be beneficial in these conditions. We’ll explore some effective models for developing and delivering services that increase access to cost effective evidence based psychological interventions - and we’ll highlight what we still have to learn. How to do Organisational and Cultural Change Adrian Whittington, Sussex Partnership NHS Trust Rational/technical models of organisational change suggest that a transition to a service that offers accessible psychological therapies for people with severe mental health conditions should simply be a matter of managing the contingencies effectively. Experience of those who have been trying to achieve this for many years suggests that there may be more to it. With Payment by Results on the horizon perhaps the contingencies are set in a direction that can allow a new step forward. The present constellation of circumstances is examined in the context of different models of organisational change to determine whether we may have an unusually favourable opportunity to bring about the desired change now. Models of cultural change offer valuable insights that add to the raitonal/technical models, suggesting that more radical approaches may be needed, which all members of the system can contribute to. Whatever our position: eductor, service manager, student, or service user, cultural change theory suggests that through our interactions we can help to generate movement. No more “train and pray” - a joined up educational approach Lydia Turner, University of Sussex Traditionally CBT training has been the remit of the Higher Education organisation with a philosophy that the student comes into classes to learn the required knowledge and skills, returning to their workplace to practice under self arranged supervision. This presents problems if there is insufficient communication between the organisation undertaking the training or education and the students’ manager or supervisor. Risks are greater if the student is not required to have a mental health background, they do not work within an environment which gives them access to suitable clients or if there is no requirement for the student to see only clients for which they have been trained. These scenarios may result in poor knowledge-skills fusing, poor quality CBT practices, poor support for the student and consequential skills decay. Although IAPT has addressed these issues to some extent with the requirement that students have a core profession or equivalent, that supervisors are BABCP accredited and that the role has specific criteria, students still fall between the gaps, with tensions between students meeting learning objectives and workplace demands and targets. This presentation will address these issues and offer organisational solutions in the form of more ‘joined up thinking’, more effective communication and suggest a psychologically minded strategic approach whereby ‘best outcome for the client’ is held as a principle at the centre of the training. The presentation will discuss a way of training CBT students which requires students, training personnel, and organisational staff to work together to ensure that the student receives the best, most relevant training within a supported educational and workplace environment. The learner as a change agent Peter Garwood, Sussex Partnership NHS Foundation Trust Improving Access to Psychological Therapies (IAPT) paved the way for systematic delivery of psychological therapy within primary care by prescribing pathways for the academic/service delivery interface. IAPT has published it’s intention to develop similar models to address the needs of people with serious mental health difficulties.

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One can argue that those people best placed to be providing CBT are those practitioners already working within secondary mental health services (steps 4 & 5) alongside service users experiencing serious mental illness. A unique postgraduate diploma/ MSc developed in partnership between Sussex University and Sussex Partnership NHS Foundation Trust has been designed to maximise the implementation of CBT for people with complex mental health difficulties by customising the learning experience to maximise opportunity for academic success and ongoing CBT implementation. This course also fully prepares successful candidates for BABCP accreditation. This presentation will illustrate the experience of a novel cohort of CBT trainees undertaking the aforementioned course with particular reference to their experience as ‘change agents’; practitioners actively engaged in developing and implementing CBT for complex difficulties within Steps 4 & 5. The presentation will identify characteristics of the cohort, illustrate the roadblocks to learning experienced and address the process and content of solutions identified by the trainees. Consideration will be given to the impact trainees are having on the implementation of CBT within their services and the conditions necessary for them to thrive on completion of their training.

Training and Professional Issues & IAPT and Primary Care London IAPT Training: Recent Developments in IAPT Evaluation and Expansion: Evidence Based Training for Evidence Based Choices, Improving Mental Health to Meet the Needs of All

Convenor: Sheena Liness, Institute of Psychiatry, King's College London

Update on Competence Frameworks Tony Roth, University College London The CBT competence framework was developed in the context of the IAPT programme. There are now several modality-specific frameworks (for example, frameworks for the additional modalities now included in IAPT) as well as frameworks for specific populations (such as children and adolescents). Further frameworks are being developed for people with schizophrenia, bipolar disorder and personality disorder. The presentation will describe the development of these frameworks and their relevance for CBT practice across a number of clinical areas, outline the ways in which the frameworks have been used and consider how they might be used in the future. IAPT Wave 1 (2008-2011): Assessment and Evaluation of High Intensity CBT Training Sheena Liness, Institute of Psychiatry, King's College London The Institute of Psychiatry, King’s College London is now in its fourth year of the delivery of High Intensity CBT training, ‘top up’ training and supervision training. Sheena Liness will present an evaluation of the IoP/KCL IAPT 1st Wave (2008 – 2011) High Intensity CBT Training with a focus on trainees’ therapy competence and academic attainment pre to post training. This presentation will track student progression across a number of variables such as the Cognitive Therapy Scale-Revised CTS-R (Blackburn I M et al 2001) clinical outcome, academic assessments and completion rates. Comparisons will be made across mental health professions, assessor versus self-therapy ratings, IAPT site differences and access to specialist CBT supervision placements. Areas of good practise and possible barriers to learning will be presented, along with the changes and improvements in the IoP/KCL IAPT CBT training that resulted from this evaluation. Training therapists to adapt CBT for anxiety and depression to meet the needs of people with long term medical conditions Jane Hutton, South London and Maudsley and King’s College Hospital NHS Foundation Trusts 15.4 million people in England have a long-term medical condition and this is expected to rise as the population ages. Anxiety and depression are very common in this group and impact strongly on general well-being, medical outcomes and use of health service resources. There is evidence that CBT can improve psychological, symptomatic and functional status, but addressing the interplay of anxiety and depression with long-term medical conditions requires specific knowledge and skills. In this session, I will describe a training programme designed to build such skills and knowledge. The first aim of the training was to develop a working knowledge of four common medical conditions (cardiac illness, diabetes, chronic obstructive pulmonary disease and chronic pain) including their psychological aspects, relevant services, and how to access further information. The second aim was to develop skills to assess and formulate the needs of people with chronic medical conditions, and to adapt cognitive-behavioural interventions for depression and anxiety appropriately. The structure of the teaching will be described and its content outlined. Data will be presented on the impact of the training on therapists’ confidence in working with clients with a chronic medical condition and depression or anxiety, and on their knowledge of key relevant facts about the medical conditions covered. An overview of the London CBT training to meet the needs of older adults in IAPT services Steve Boddington, South London & Maudsley NHS Foundation Trust This paper will outline the range of workshops currently provided as part of the London High Intensity and PWP training programmes. It will also present the ‘top up’ training designed to equip London IAPT High Intensity staff to work effectively with older people. This will include data on staff receiving the core training as well as those attending additional master classes; feedback on the relevance and applicability of this training and it’s impact on participants’ attitudes to working with this age group. Proposals for modifying the programme will be discussed in light of this feedback and the national IAPT/PSIGE development of a training curriculum for working with older people. Behavioural Couples Therapy Training Michael Worrell and Sarah Corrie, CNWL Foundation Trust Royal Holloway University of London Behavioural Couples Therapy (BCT) is an evidence-based psychological treatment that has acquired a significant amount of empirical support for the benefits it provides, both in terms of reducing couple distress and improving specific psychological disorders, such as depression. In this respect, it is recognised, in the current NICE guidelines for the treatment and management of depression in adults, as an effective treatment for individuals suffering from depression, namely “for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit”. Currently, there exists the need to increase access, within the IAPT service delivery programme, to evidence-based psychological treatments other than individual cognitive behaviour therapy. BCT is such an approach that is distinct from individual CBT, in that it works within a

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couple's relationship and uses a range of techniques that target the relationship to alleviate individual psychological distress along with increasing relationship well-being; yet, it complements individual CBT as a post-qualification modality. This presentation will describe the foundations of BCT and outline the development, delivery and evaluation of a 5 day intensive training in BCT followed by a 12 month period of sustained practice and supervision. The training was developed and delivered by Professor Don Baucom and Sarah Boeding from the University of North Carolina at Chapel Hill, in association with Central and North West London Foundation NHS Trust. Particular challenges and dilemmas of High Intensity Therapists undertaking this training will be discussed as well as service challenges for IAPT and plans for further research and development.

Clinical Roundtable IAPT and Primary Care & Severe and Enduring Problems IAPT for Psychosis: A large step in the right direction? Convenor: Alison Brabban, IAPT National Advisor for SMI Speakers: Elizabeth Kuipers, Professor of Clinical Psychology, Institute of Psychiatry, (Chair of NICE Schizophrenia Guideline Update); Philippa Garety, Professor of Clinical Psychology, Institute of Psychiatry; Peter Kinderman, Professor of Clinical Psychology, Liverpool University; Richard Bentall, Professor of Clinical Psychology, Liverpool University

The IAPT programme has now expanded and hopes to improve access to psychological therapies for those affected by psychosis. With the psychological therapy resource for this client group being so scarce at present, many challenges lie ahead. This round table plans to present the evidence base for psychological therapies for psychosis, to discuss whether the current diagnostic centred approach is a help or hindrance when planning services and to consider how or whether elements of the traditional IAPT model can be applied to psychosis. Panel members will also present their own personal perspective on where they believe this project should be heading. Each panel member will give a short presentation, with the majority of the session being allocated for questions and comments from the audience.

Panel Discussions Child and Adolescent Mental Health & IAPT and Primary Care Transforming Mental Health Services for Children and Adolescents Convenor: Pamela Myles, Charlie Waller Institute, University of Reading Chair: Roz Shafran, University of Reading Speakers: Kathyrn Pugh, National IAPT Advisor, CYP; Stephen Scott, Institute of Psychiatry, King's College London; Yvonne Taylor, Oxford Health NHS Foundation Trust; Deborah McNally, Salford Cognitive Therapy Training Centre; Peter Fuggle, University College London

The Children and Young People's (CYP) IAPT Project is a Service Transformation Project for Child and Adolescent Mental Health Services (CAMHS). The focus of CYP IAPT is on extending training to staff and service managers in CAMHS and embedding evidence based practice across services, making sure that the whole service use session by session outcome monitoring. The first phase of the programme includes training CAMHS practitioners to deliver CBT or Parenting interventions. Peter Fonagy is the Clinical Adviser for the project and will open the discussion with an overview of the project, its accomplishments and challenges. Stephen Scott will provide a description of the parenting component of the project. Peter Fuggle will describe how the project has been implemented in London and useful tools that he and his colleagues have developed. Deb McNally will describe the CBT component of the project and progress and pitfalls experienced with implementation in the North of England. Finally, Yvonne Taylor will describe the challenges of maximising the opportunity offered to the whole of the CAMHS service, in particular the integration of routine outcome monitoring.

Child and Adolescent Mental Health & IAPT and Primary Care CYP-IAPT Parent Training: Making It Happen! Convenor: Caroline White, Central Manchester University Hospitals NHS Foundation Trust Speakers: Caroline White, Central Manchester University Hospitals NHS Foundation Trust; Deb McNally, Greater Manchester West NHS Foundation Trust and University of Manchester; Angela Latham, Central Manchester University Hospitals NHS

Foundation Trust

Launched in October 2011, the Children & Young Peoples Improving Access to Psychological Therapies (CYP-IAPT) initiative brings together universities and teaching providers with local child and adolescent mental health services to form partnerships. The project sees an investment of £32m nationally over the next four years to transform services for children and young people’s mental health and will provide increased access to psychological therapies for children and young people. The project aims to provide training to the existing workforce to deliver evidence based talking therapies which comply with the NICE guidance in the form of cognitive behavioural therapy (CBT) for disorders of anxiety and depression and parenting training (PT) for conduct disorders. In addition, training is provided for service leads to support sustainable service transformation and for clinical supervisors to ensure the trainees receive the highest quality clinical supervision. The remit of CYP-IAPT is not about creating new stand alone services or a new workforce, but transforming existing services and systems. Service change is always a challenging process. The panel will outline CYP-IAPT and raise for discussion the issues and lessons learnt to date about its implementation and development. In particular the panel will focus on the development of the parent training strand, as this is a new development for IAPT as a whole; and presents new challenges and barriers for services in shaping a sustainable model for delivery of this evidence based intervention with treatment fidelity. Questions and issues raised by the audience will be encouraged with a view to facilitating a useful discussion to explore implementation issues and potential solutions.

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