KEYNOTE ADDRESSES

1.   Metacognition and Emotional Disorder: Advances in Cognitive Therapy. Adrian Wells

2.   Improving the Efficiency of Cognitive Behavioural Treatment. Derek Johnston

3.   Evidenced-based Treatments for Children: Promises and Pitfalls. Tom Ollendick

4.   Prochaska and Di Clemente Revisited. Art Freeman

5.   Choice, Accessibility and Equity in CBT. David Richards

6.   Adaptation of PST for the Treatment of Sexual Offenders. Christine Maguth Nezu

7.   An Integrative Model of Eating Disorders and their Treatment, Bryan Lask

8.   CBT for Psychosis: Family and Individual Approaches. Elizabeth Kuipers

9.   Preventing Severe Conduct Problems in Children. Robert McMahon         

10. Problem Solving and Behaviour Therapy. Art Nezu

11. The Role of Overvalued Threat Expectancies in the Anxiety Disorders. Ross G. Menzies       

KEYNOTE ADDRESS ABSTRACTS

1.            Metacognition and Emotional Disorder: Advances in Cognitive Therapy

Adrian Wells, University of Manchester, UK

A new level of psychological explanation is required if we are to advance general cognitive theory and therapy of emotional disorders. This level should enable us to conceptualise the factors that control, correct, appraise, and regulate thinking itself. This level belongs to the realm of metacognition, to which Wells and Matthews (1994) gave prominence in a generic information-processing model of emotional disorder. An implicit assumption in the practice of CBT is that the cognitive system of disordered individuals retains the capacity to be modified by conscious verbal and behavioural manipulations. However, there have been few attempts to delineate the internal cognitive mechanisms that support or prevent this process. In the Wells and Matthews (1994) Self-Regulatory Executive Function (S-REF) model a distinction is made between two general modes of processing, subsequently labeled the object mode and metacognitive mode (Wells, 2000) that have implications for modifying cognition. Furthermore, the model identifies a maladaptive processing configuration characterised by worry/rumination, self-focused attention, and threat-monitoring, involved in vulnerability and problem maintenance. This configuration is driven by dysfunctional metacognitive beliefs that are plan-like specifications for processing. The model suggests that CBT should focus on modifying dynamic aspects of cognition such as attention, thinking styles, and flexibility of modes of processing as well as focusing on thought content. The S-REF model offers an understanding of how multiple components of beliefs and thinking interact over time to create meaning and mental fixation or change.

References: Wells A & Matthews G (1994). Attention and Emotion: A Clinical Perspective. Hove, UK: Elbaum.

Wells, A (2000). Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Chichester, UK: Wiley.

2.         Improving the Efficiency of Cognitive Behaviour Therapy.

Derek W Johnston, University of St Andrews

Cognitive behaviour therapy is a scarce, carefully rationed, resource.  To improve the nation’s health effective therapies have to be delivered with maximum efficiency. Innovative use of new technologies such as hand held computers, the internet (perhaps on one’s domestic TV or even one’s cell phone), can, and increasingly will, aid conventional face to face methods of delivery and extend therapy into new situations and new client groups.   While exciting and important, new technology is not an alternative to increasing the effectiveness of our interventions through increased understanding of the psychological processes that underlie maladaptive behaviour and its modification. I shall discuss developments in the twin areas of the efficiency and effectiveness of cognitive behaviour therapy and their interaction. I shall draw my examples  from two quite different areas, the study of  anxiety and of cardiovascular disease.

3.            Evidence-Based Treatments for Children and Adolescents: Promises and Pitfalls

Thomas H. Ollendick Virginia Polytechnic Institute and State University

In this address, I will examine the current status of evidence-based treatments for children and adolescents and, in doing so, comment upon the promises of this approach and some of the pitfalls associated with it.  Quite obviously, the identification, development and promulgation of such treatments have not been without considerable controversy.  Three major criticisms have been raised: 1) cognitive-behavioral treatments have more empirical support than other treatments, but have the other treatments been adequately evaluated? 2) evidence-based treatments should be conducted with treatment manuals, but should use of manuals be a necessary condition? And 3) evidence has come largely from efficacy trials, but what is the role for effectiveness studies and how will evidence-based treatments work in real clinical practice?  These issues will be discussed and the limitations of the evidence-based approach will be highlighted. Finally, a rapprochement will be suggested that incorporates evidence-based strategies with individualized functional analytic procedures to produce optimal therapeutic outcomes.

4.         We Have the Technology to Fly but Is the Patient Willing and Able to Get on Board? Prochaska and Di Clemente Revisited.

Arthur Freeman, Philadelphia College of Osteopathic Medicine, ISA

Prochaska and Di Clemente have developed a simple and useful model for understanding the stages of change that patients' progress through in the therapeutic collaboration. This model, accepted as the basis for treatment programs in substance abuse, does, however, lack the specificity that is an essential part of the cognitive behavioral treatment model.   Their model includes and monitors the patient's progress through the stages of Precontemplation, Contemplation, Preparation, Action, and Maintenance.  The revised stages include Noncontemplation, Anticontemplation, Precontemplation, Contemplation, Action Planning, Action, Lapse Activation and Redirection, Relapse and Redirection, Termination, and Maintenance. This expansion and specification of the Prochaska-Di Clemente model from five stages to 10 stages allows for the treatment planning specificity that is the hallmark of CBT.

5.                  All Professions are Conspiracies against the Laity: .MAPLE – Choice, Accessibility and Equity in CBT.

Keynote Address to Mark the Forthcoming Retirement of Professor Isaac Marks

David Richards, University of Manchester

Mental health problems contribute 23% to the global burden of disease in developed countries. In the UK, recent legislation attempts to address this by modernising mental health services so that they provide evidence based, accessible and non-discriminatory services for both serious and common

mental health problems. Cognitive behaviour therapy (CBT) has a robust evidence base which fits very well with the thrust of policy. However, CBT's delivery systems are rooted in traditional service models, which pay little attention to the growing evidence base for brief and single-strand

treatments over complex or multi-strand interventions. Services characterised by 9-5 working, hourly appointments and face to face therapy disenfranchise the majority of people who would benefit from CBT. Drawing on 40 years of inspirational work by Professor Isaac Marks, this keynote

address will argue that the evidence exists for service protocols which promote equity, accessibility and choice and that CBT services should be organised around multiple levels of entry and service delivery rather than the more usual secondary care referral systems.

6.         Sex, Lies, and Behavior Therapy: Adapting: Problem-Solving Therapy to Sex Offenders

Christine Maguth Nezu, MCP Hahnemann University, USA

Assessment and treatment of sexual offenders have become the focus of an increased number of clinical programs, articles in the professional literature, public interest and policy,  and media attention.  Most cognitive-behavioral programs involve some form of social competency

training, such as social and interpersonal problem-solving, goal setting, or decision making. In this presentation, Dr. Maguth Nezu will offer theoretical and empirical support for including training in social problem-solving skills, as a potentially  important component of sex offender treatment.  Adaptation of social problem solving therapy to this challenging population  will be illustrated.

7.         An Integrative Model of Eating Disorders and Their Treatment

Bryan Lask, St George’s Eating Disorders Service, London

Eating disorders in childhood and adolescence include a number of different conditions, each with a complex pathogenesis and potential for severe complications and poor outcome.  The disorders to be discussed include anorexia nervosa, bulimia nervosa, food avoidance emotional disorder, functional dysphagia, selective eating and pervasive refusal syndrome.

Clearly there is a need for a rapidly initiated treatment programme.  In all but the mildest cases this will be both intensive and comprehensive.

The ingredients of an integrated and comprehensive treatment programme may include:

1. Creating a therapeutic alliance; 2. The provision of information and education of the parents and other family members; 3. Involving the parents and ensuring that the adults take responsibility; 4. Consideration and information of any need for hospitalisation; 5. Calculation of a healthy weight range; 6. Family and/or parental counselling; 7. Schooling considerations; 8. Restoration of healthy eating patterns; 9. Cognitive behavioural therapy; 10. Psychodynamic psychotherapy; 11. Group work; 12. Physiotherapy and exercise; 13. Medication.

This presentation will focus on the application of an integrative model in practice.

8.         CBT for Psychosis: Family and Individual Approaches.

Elizabeth Kuipers, Institute of Psychiatry, London

Psychosis used to be seen either as not amenable to psychological therapies or likely to be made worse by them.. The advances of a dimensional model of symptoms, the single symptom rather than the diagnostic approach, and the success of psychological interventions in other conditions (such as anxiety and depression) have begun to open up the possibility that psychosis was on a continuum with normality. Thus similar psychological interventions might be applicable.

These theoretical ideas have been bolstered by evidence, first from the success of family interventions in psychosis, and more recently the improvements seen from individual treatment approaches, both using adaptations of cognitive behavioural methods.

The research in both these areas will be summarised. Implications for future directions and for the applicability of those ideas to other areas previously thought of as “intractable” will be discussed.

9.            Preventing Severe Conduct Problems in Children: The Fast Track       Project"

Robert J. McMahon, University of Washington. Seattle, Washington, USA

Children who begin to engage in conduct problem behaviors during the preschool and early school-age periods are at significant risk for negative outcomes in adolescence and adulthood.  During adolescence, children who display this "early-starting" pattern of conduct problems are more likely to engage in high levels of serious conduct problems, to use alcohol and other drugs, to drop out of school, to engage in risky sexual activity, and to display other behavior disorders.  As adults, they are more likely to receive diagnoses of Antisocial Personality Disorder and Substance Use Disorder, to engage in criminal behavior, and have a  poorer outcome on a variety of quality of life indices.

To date, treatment-oriented approaches, which have tended to be relatively and narrowly focused, have had limited success in altering the negative life course trajectories of these children with early-starting conduct problems.  Increasingly, attention is being focused on prevention as a more developmentally appropriate means of intervention.

Fast Track is an ongoing, comprehensive, multi-site intervention trial that is designed to prevent serious and chronic conduct problems.  It is a collaborative project that is being carried out by the Conduct Problems Prevention Research Group at four sites in the United States. 

The Fast Track intervention is based on a developmental model of conduct problems that posits the interaction of multiple influences (child characteristics, the family, school, peer group, and neighborhood) on the development of antisocial behavior.  The intervention begins in 1st grade and continues through 10th grade.  The elementary-school phase of the intervention combines  targeted interventions (parent training, home visiting, child social skills training, child friendship enhancement, and academic tutoring) for the highest risk children with a universal intervention directed to the promotion of social and emotional competence in the intervention schools. The high-risk intervention sample consists of approximately 450 children who were selected at school entry on the basis of high levels of conduct problems at both home and school during the kindergarten year.  There is a comparable sample of high-risk children who do not participate in the intervention, and a community comparison sample as well.  The universal component of the intervention was administered in 200 classrooms to all children, with a comparable number of classrooms serving as controls.

This presentation will discuss the developmental model and the manner in which it has guided the intervention strategy, and the ways in which prevention trials such as Fast Track can serve not only to assess intervention outcomes but also test developmental theories of change.  I will present findings concerning the intervention effects over the first several years with the high-risk sample as well as the effects of the universal intervention during this same period.  Finally, I will describe changes in the developmental model that are related to the onset of early adolescence and the transition to middle school, and how these changes influence intervention strategies being implemented during the adolescence phase of the project.

10.        Problem Solving and Behavior Therapy

Arthur M. Nezu, MCP Hahnemann University, USA

For decades, problem-solving therapy approaches have played an important, albeit minor role, in the adoption and expansion of cognitive behavioral therapies.  Dr. Art Nezu, a pioneer in the development and evaluation of problem-solving interventions, will provide a state-of-the art overview of more recent applications of this approach.  In addition to discussing the importance of problem-solving principles as components of clinical interventions, he will also highlight their utility for use

by the cognitive-behavioral therapist him or herself.  This latter emphasis cuts across case formulation, clinical assessment, and clinical supervision as well.

11.       Confessions of a Compulsive Checker: The Role of Overvalued Threat Expectancies in the Anxiety Disorders.

Ross G. Menzies, University o f Sydney, Australia

In this keynote address, it is argued that overvalued ideas about threat play a pivotal role in the mediation of the anxiety disorders. A description of the speaker's personal battle with obsessive-compulsive checking will be used to illustrate the importance of threat beliefs in this disorder. Such overvalued threat beliefs have become the focus of a decade's laboratory and clinical work at the Anxiety Disorders Clinic, The University of Sydney. The results of studies involving spider phobics, height phobics, social phobics and obsessive-compulsive subjects suggest that danger expectancies are a potent proximal cause of anxiety. This work provides the scientific foundation for the Danger Ideation Reduction Therapy (DIRT) package for compulsive washing/cleaning. The results of studies of the efficacy of this treatment suggest that targeting threat expectancy may be sufficient for the elimination of anxiety and avoidance in many cases of OCD and related disorders.