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SYMPOSIA ABSTRACTS - FRIDAY 21 JUNE SYMPOSIUM 11
Cognition, Development and Depression Shirley Reynolds, University of East Anglia
Cognitive Development in Young Children and Their Ability to Engage in the Concepts of Cognitive Therapy Liz Doherr and Shirley Reynolds, University of East Anglia, Norwich There is a growing demand to develop safe and effective methods of treatment for young children with depression. Adaptations of cognitive therapy for children are promising (e.g. Kendall & Braswell, 1985) but there is limited high quality evidence. A specific problem in adapting cognitive therapy is young children’s capacity to understand and use cognitive concepts. Developmental research and theory suggests that these abilities are unlikely to be present in children under 12 years (e.g. Dush, Hirt & Schroeder, 1989). In a meta-analytic review of cognitive behaviour therapy for children Durlak, Fuhrman & Lampman (1991) revealed that therapy was significantly more effective for children over 11 compared with younger children. This paper examined children’s ability to use concepts of cognitive therapy. 72 children aged 5 to 8 years were selected from two schools. One school used a standard curriculum (School A), the other a novel, philosophy-based curriculum with weekly philosophy lessons for all children (School B). Schools were matched for the social composition of their catchment areas. Tasks, adapted from Greenberg and Padesky (1995), were developed to assess the children’s ability to generate post-event attributions and alternative explanations for hypothetical events, to name different emotions, and to link thoughts and feelings. The majority of children in both schools and at all ages could engage in the tasks of cognitive therapy. However, children from School B were significantly more able to perform the tasks than children in School A. This finding held irrespective of the age, gender or IQ of the children.
Negative Cognitions in Adolescents Imogen Hobbis, Brookside Family Consultation Centre, Cambridge Up to 8% of adolescents suffer from depression (Peterson, 1993). Early onset of depression indicates a more serious long-term prognosis and is associated with poor academic performance (Gotlib, et al. 1993). Thus, identifying and treating depression in this age-group is of high clinical priority. Can depressed adolescents be reliably distinguished from non depressed adolescents? Some authors have suggested that normal adolescents are ego-centric, self-conscious, and prone to cognitive errors e.g. dichotomous thinking and magical causality (e.g. Garbet et al., 1993). Importantly, these characteristics are similar to those identified in depressed adults yet current thinking suggests that negative cognitions are only manifest in those experiencing a depressive episode. It is therefore possible that normal adolescent characteristics may be wrongly attributed to depression rather than to normal developmental processes. This study investigated negative cognitions in normal adolescents. Adolescents aged 14 to 18 were recruited from schools (N = 401). They completed measures of depressive symptoms, negative cognitions and dysfunctional assumptions. The presence of negative cognitions was only associated with high levels of depression but dysfunctional assumptions were more common. It is proposed that dysfunctional assumptions may be partly activated in adolescents so that they influence attitudes and beliefs but not so that depressive episodes are triggered.
Cognitive Vulnerability To Postnatal Depressive Symptomatology Alison E. Hipwell & Shirley Reynolds, School of Health Policy & Practice, , University of East Anglia, Norwich, NR4 7 TJ Depressive disorders arising in the postnatal period can affect 10-15% of women and there is growing evidence for a range of adverse consequences for the mother, her child, and the nature of their relationship long after the symptoms may have remitted. Nevertheless, detection of women who may be at risk of depression following childbirth continues to be relatively unreliable. Drawing on a diathesis-stress model, the current study used a prospective design to investigate cognitive factors that might indicate a vulnerability to postnatal depressive symptomatology. A cohort of primiparous women were interviewed during the third trimester of pregnancy and followed through to 2 months post delivery. Ninety-four women without current mental health problems completed the study. Three sets of cognitive measures were included in the antenatal interview: specificity of autobiographical recall, actual:ideal self-discrepancy, and self-devaluation. It was hypothesised that these cognitive characteristics would predict mood score at 2 months postpartum (Time 3), but not at the earlier follow-up stage of 2 weeks when biological/hormonal factors were likely to play a role in aetiology (Time 2). The results showed that degree of self-devaluation, and low specificity of recall, predicted depressive symptoms at Time 3, and that self-devaluation also mediated the effects of early experience of mothering and neurotic personality style on postnatal mood. Self-discrepancy scores were not found to be useful in predicting mood in the current sample. The clinical implications of these findings will be discussed.
Cognitive therapy for depression in older adults Georgina Charlesworth, University of East Anglia It has been said that age increases diversity, and this is reflected in older adults who are referred for therapy. Treatment trials for depression in later life have demonstrated that age per se should not exclude an individual from therapy. Indeed, the dimensions that prompt the need for adaptations in therapy for older adults are equally applicable to people of any age. These dimensions include an individual's cognitive capacity, physical health status, degree of adversity in their current life circumstances, and beliefs about their own self-efficacy and the role of significant others. This paper focuses specifically on the theme of loss of support from a spouse who previously, perhaps for many decades, compensated for self-perceived limitations. The importance of perceived self-efficacy and the identification of coping mechanisms will be emphasised, especially where formerly useful strategies have become redundant or self-defeating. Adaptations to compensate for cognitive limitations, techniques for cognitive skills training and use of 'mini-formulations' will be reviewed and applied to case examples from a randomised controlled trial of cognitive therapy for depressed carers of people with dementia.
SYMPOSIUM 12
Cognitive Processes Across Disorders: Implications for Theory, Treatment and Classification Warren Mansell, University of Oxford
Managing Unwanted Thoughts: The Effects of Thought Suppression in Insomnia, Acute Stress Disorder and Chronic Pain Allison G. Harvey, Department Of Experimental Psychology, University Of Oxford The investigation of management strategies for unwanted thoughts has been fertile territory for clinical researchers in recent years. In particular, the paradoxical effects of thought suppression have been implicated as a mechanism by which intrusions, characteristic of several disorders, may be maintained. This presentation will describe the results of three studies, each aiming to index the effects of thought suppression. In Study 1 participants with and without acute stress disorder (ASD) monitored their trauma-related thoughts for three 5-minute periods. In Period 1, all participants were instructed to think about anything. For Period 2, participants were instructed to either suppress their trauma-related thoughts or to continue to think about anything. In Period 3, all participants were again instructed to think about anything. Participants given suppression instructions demonstrated an increase in trauma-related thoughts during Period 3. In Study 2 consecutive referrals for pain management were asked to monitor their pain-related thoughts for three 5-minute periods. The design was identical to that used in Study 1 except that for Period 2 participants received one of three sets of instructions; suppress pain-related thoughts, attend to pain-related thoughts, or continue to think about anything. Suppressors experienced reduced pain-related thoughts during Period 2. In Study 3 insomniacs and good sleepers were asked to either suppress their thinking during the pre-sleep period or not to suppress. Participants instructed to suppress their thoughts estimated their sleep onset latency to be longer and their sleep quality to be worse than participants given non-suppression instructions. The theoretical implications of these findings will be discussed.
Self-regulation and Anxiety: Instances of Maladaptive Metacognitive Monitoring and Control? Adrian Wells, Department of Clinical Psychology, University of Manchester In a self-regulatory (S-REF) model of emotional disorders, Wells and Matthews (1994) assert that maladaptive metacognitive control and self-monitoring are a central component of emotional vulnerability. This paper presents an overview of the nature of maladaptive self-monitoring, and the results of two studies of metacognitive control in anxiety disorders. Anxiety disorders are associated with the inappropriate use of internal sources of data to guide decisions concerning self-regulation. In addition, emotional disorder appears to be linked to the selection of particular thought control strategies. Two studies explored the choice of thought control strategies across disorders of anxiety and depression, and the thought control strategies predictive of acute PTSD symptoms following stress. The results are consistent with the S-REF model suggesting that particular patterns of metacognitive control are associated with emotional disorder.
Common Cognitive Processes In Psychosis And Anxiety Disorders: Implications Morrison A P, Department of Psychology, University of Manchester In this paper, a cognitive approach to the understanding of psychosis will be outlined which is influenced by current conceptualisations of anxiety disorders. This approach highlights several common cognitive processes and structures that appear to be involved in the development and maintenance of both psychosis and anxiety; these processes include misinterpretation, self-focussed attention, safety behaviours, strategies used to control unwanted thoughts and metacognitive beliefs. The results of several experimental studies examining the roles of such processes in psychosis will be summarised and reference will be made to corresponding studies of anxiety. The implications of this approach for research and practice will be discussed.
Fragments of Memory in Sensory Modalities Across the Disorders Ann Hackmann, Department of Psychiatry, University of Oxford One of the cardinal features of posttraumatic
stress disorder is that of re-experiencing. Patients report unwanted
images, flashbacks and nightmares, accompanied by physiological and
affective responses.
Is Maladaptive Self-Regulation at the Heart of Psychopathology? A Short Integrative Review Warren Mansell, Department of Psychiatry, University of Oxford Research indicates that certain specific cognitive processes appear to precipitate and maintain a range of psychological disorders. Several attempts have been made to integrate these processes using generic models that draw on the theoretical frameworks developed within cognitive science and social psychology. This presentation will focus on how behaviour self-regulation / control systems theory (e.g. Carver & Scheier, 1982, 1998; Powers, 1973) can lead to an approach that is consistent with current evidence and may be more capable of integration with other psychological and biological disciplines. The theory aims to provide explicit, working models of human behaviour which regard goal-directed activity as the process of controlling one's perception through control of one's environment. At the heart of the theory is the feedback loop. A negative (approach) loop alters behaviour in order to reduce the discrepancy between current perception and an internalised standard (reference value), whereas a positive (avoidance) loop aims to increase the discrepancy between current perception and a reference value. Control systems are organised in multi-level hierarchies of feedback loops that control perception from lower-order sensations up to higher-order goals. A key cause of psychopathology is the conflict caused when two control systems attempt to adjust behaviour with respect to different reference values. The possible implications of the approach for understanding the role of thought suppression, self-focused attention, automatic processes, loss of control, perceptual distortions, imagery and implicational meaning in psychological disorders will be discussed, along with its current limitations.
SYMPOSIUM 13
Cognitive Behavioural Treatment of Somatic Symptoms Trudie Chalder, Guy’s King’s and St Thomas’ School of Medicine, Physical symptoms without identifiable organic pathology have been referred to by a variety of labels such as medically unexplained symptoms, hypochondriasis, somatisation and psychosomatic. Everyone experiences physical symptoms, unrelated to specific aetiology from time to time. However, when the symptoms become the focus of an individuals attention the severity of the symptom often increases and varying degrees of disability results. The aim of this symposium is to present examples of how different somatic symptoms and illnesses are approached depending on the extent of the disability, the setting in which patients are seen and the context in which symptoms arise.
Cognitive Behavioural Treatment of Chronic Fatigue Syndrome: Evidence From Randomised Controlled Trials and 5 Year Follow Up. Alicia Deale, Kaneez Husain, Trudie Chalder & Simon Wessely, Department of Psychological Medicine, Guy’s, King’s & St Thomas’ School of Medicine & Institute of Psychiatry, King’s College, London. Cognitive Behaviour Therapy appears to be a promising treatment for Chronic Fatigue Syndrome, but only three randomised controlled evaluations have been published. Of these, one found brief CBT to be no more effective than good clinical care, and two found more intensive therapy produced significant benefits in the short term, which increased over a 6-8 month period after treatment ended. The question of whether improvements are maintained in the long term is central to evaluating of the efficacy of CBT for CFS. Untreated, CFS follows a fluctuating course of partial remission and relapse. Patients who improve following CBT may find that gains are transient or cyclical. This paper will present results of a recently completed long term follow-up study of 60 CFS patients. Five years after participating in a randomised controlled trial of CBT versus Relaxation, patients were interviewed by an assessor blind to the original treatment, and completed a battery of questionnaires. The outcome for patients at 5-year follow-up will be discussed, together with predictors of outcome and the implications of findings for future clinical practice.
Family Focused Cognitive Behavioural Psychotherapy For Adolescents with Chronic Fatigue Syndrome. Case Examples. Vincent Deary, Cognitive Behaviour Therapist, Department of Psychological Medicine, South London and Maudsley NHS Trust, Bessemer Road, London SE5. The work of the cognitive behavioural therapist can change dramatically when carried out in the arena of the family. In dealing with an ill child within a family it quickly becomes obvious that we are not just dealing within an individual, but with a system. This is perhaps most obvious in the issue of illness beliefs, an area we know to be central to the management of CFS. In the adult sufferer, the symptoms and the beliefs about the symptoms occur in the one individual. With an ill child, however, it is often the case that the child’s symptoms will be interpreted and managed by the adults involved. Thus it is crucial that we treat the family as a system, and work to engage all the involved individuals. The presentation will present a case example of an adolescent with CFS, and discuss how the treatment of this works in practice.
Who Believes They Have Gulf War Syndrome and Why? Suggestions for Therapeutic Interventions Trudie Chalder, Senior Lecturer, Department of Psychological Medicine, Guy’s King’s and St Thomas’ School of Medicine, 103, Denmark Hill, London, SE5 8AZ. The term Gulf War Syndrome (GWS) has been used to describe veterans who experienced a range of health problems on return from the Gulf War. A random sample of UK Gulf war veterans was asked whether they believed they had GWS. They were also asked to complete measures on symptoms, fatigue, psychological distress, post traumatic stress, physical functioning and health perception. Logistic regression was used to examine which factors were associated with holding the belief. 17.3% (95% CI: 15.9-18.7) of UK Gulf war veterans believed they had GWS. Holding this belief was associated with worse current health, lower rank, less education and no longer serving in the army. The strongest association was knowing another person who also thought they had GWS. Despite the level of symptomatology and distress reported by Gulf War veterans who believe they have the syndrome, they were not substantially disabled. Possible psychological interventions drawn from social psychology for use with this group will be suggested, taking into account the particular attributes of the group.
In Patient Treatment of Somatisation Disorder: Inter-Disciplinary Working and Flexibility of Approach. Michelle McAlpine, Clinical Nurse Specialist. Department of Neuropsychiatry, Room 32 Out patients Dept , Maudsley Hospital, Denmark Hill, SE5 8AZ. Patients who develop medically unexplained physical symptoms present the therapist with a number of challenges, not least of which includes engagement in a psychologically based treatment. In the more severe cases, patients can develop secondary physical problems brought about by increasing symptom led inactivity and reliance on aids and adaptations. This further compounds the problem. When the severity of the problem is such that in-patient treatment is deemed essential, the need for CBT led multi-disciplinary treatment programme is required. The speaker will focus on three treatment issues. Engaging such patients in a multi-disciplinary treatment programme, giving case examples of how difficulties were overcome. Co-ordination and role of other involved disciplines, including Physiotherapists, Occupational Therapists and Nurses. Finally, the need to deliver CBT in a pragmatic, flexible style will be discussed. Once again, case examples will be used to illustrate how treatment techniques can be adapted and implemented.
Causal Attributions for Somatic Sensations in Patients with Chronic Fatigue Syndrome and their Partners. Janet Butler1, Trudie Chalder2, Simon Wessely2 1. MRC Research Fellow, University Mental Health Group, Royal South Hants Hospital. Brintons Terrace, Southampton SO14 0YG. 2) Department of Psychological Medicine, Guy’s King’s and St Thomas’ School of Medicine, 103, Denmark Hill, London, SE5 8AZ. Patients with Chronic Fatigue Syndrome (CFS) often make somatic attributions for their illness. This relates to poor outcome and may indicate a general tendency to make somatic attributions for symptoms. Carers may also make somatic attributions for their partners symptoms. This cross-sectional study based on self-report questionnaire data aimed to investigate the type of attributions for symptoms made by patients with CFS and to compare this to attributions made by their partners. It was hypothesised that patients with CFS would make more somatic attributions for their own symptoms than control subjects partners of patients with CFS would make more somatic attributions for their ill relative’s symptoms but would be similar to controls regarding their own symptoms. Fifty patients with CFS were compared to 50 controls from a fracture clinic in the same hospital and 46 relatives living with the patients with CFS. CFS patients were more likely to make somatic attributions for their symptoms, particularly those they had rarely experienced before. Making somatic attributions was not related to illness duration but did relate to increased disability. The relatives of patients with CFS made significantly more somatic attributions for symptoms in their ill relative. However they resembled the fracture clinic controls in terms of making predominantly normalising attributions for their own symptoms.
SYMPOSIUM 14
Eating Disorders: New Developments in Theory and Research Myra Cooper and Roz Shafran, University of Oxford
A Direct Evaluation of the Cognitive-Behavioural Model of Bulimia Nervosa Susan Byrne, University of Oxford and Neil McLean, University of Western Australia This study represented the first formal attempt to directly evaluate the cognitive-behavioural model of bulimia nervosa (Fairburn & Cooper, 1989) - the model on which the most widely used treatment for this disorder is based. A large amount of research has attested to the clinical effectiveness of cognitive-behavioural therapy (CBT) as a treatment for bulimia nervosa, but these studies provide only indirect support for the model on which this treatment is based. The model itself has received much less empirical scrutiny than the treatment method it has inspired. Fairburn’s model proposes that extreme concern with weight and shape, in combination with low self-esteem, leads people to severely restrict their food intake. Binge eating is thought to be triggered by minor transgressions of this strict dietary restraint, and purging is seen as a means of coping with the loss of control over eating. The major predictions of the model were tested using structural equation modelling. Data was collected from the responses of 526 subjects (10% of whom had full or partial syndrome bulimia nervosa) to a number of self-report measures, including the Eating Disorders Inventory II, the Bulimia Test-Revised, the Three Factor Eating Questionnaire, and the Rosenberg Self-Esteem Scale. The results indicated that the factors of self-esteem, overconcern with weight and shape, and dietary restraint accounted for a large proportion of the variance in binge eating and purging. The key pathway in the model was the link between overconcern with weight and shape and the adoption of extreme measures of weight control, which then feed into a cycle of binge eating and purging. The reciprocal nature of the binge-purge cycle was clearly confirmed by the results. An unexpected finding was that, contrary to Fairburn’s hypothesis, high levels of dietary restraint did not predict increased binge eating. It was hypothesized that it is not dietary restraint per se, but rather a person’s reaction to a (perceived or actual) violation of dietary restraint, which precipitates binge eating. The results suggest that while the various individual components of the cognitive-behavioural model work together to maintain the bulimic cycle, they may operate in a slightly different way to that proposed by the model.
A Cognitive Model of Bulimia Nervosa Myra Cooper, Isis Education Centre, Warneford Hospital, Oxford, UK Adrian Wells, University of Manchester & Gillian Todd, University of Cambridge No detailed formulation of binge-eating episodes, encompassing cognition, emotion, behaviour and physiology, exists for bulimia nervosa. Neither is there a detailed cognitive explanation of the development of the disorder. Based on our research findings, we describe a new cognitive model of bulimia nervosa. It includes the nature of the typical cycles that maintain binge-eating, as well as the nature and role of beliefs and early experience in its’ development. In the vicious cycle portion of the model initial triggers for eating include situations unrelated to eating, weight and shape, as well as a focus on bodily sensations. This activates negative self-beliefs, negative automatic thoughts and negative feelings. Positive beliefs about eating (how eating will help with negative thoughts and emotions) then act together with negative beliefs about eating (the undesirable consequences of eating) to create cognitive dissonance. This is resolved by permissive thoughts, and reinforces thoughts of no control. Once eating occurs, negative beliefs about weight gain and unpleasant feelings of over-fullness lead to purging, thus maintaining negative self-beliefs. In the developmental portion of the model, negative early experiences give rise to dysfunctional beliefs, including negative self-beliefs and three types of underlying assumption; two related to weight and shape and one related to eating. These assumptions reflect schema compensation processes. The evidence on which the model is based is presented, including detailed semi-structured interviews with patients (and controls), and factor analysis of the Eating Disorder Belief Questionnaire. The consistency of the model with existing research and with developments in the understanding of normal eating is also summarised. Finally, implications for treatment are considered.
Cognitions and their Origins in Women with Anorexia Nervosa, Normal Dieters and Female Controls Hannah Turner, The Juniper Centre, Specialist Community Eating Disorder Service, Harefield Clinic, Exford Avenue, Harefield, SouthamptonMyra Cooper, Isis Education Centre, Warneford Hospital, Oxford Objectives. To investigate cognitions and their origins in female patients with anorexia nervosa, normal dieters and female non-dieting controls. To explore group differences in the meaning attached to dieting and the role of early experiences in the development of negative self-beliefs. Rationale. It has been suggested that negative automatic thoughts, underlying assumptions and negative self-beliefs play an important role in the development and maintenance of anorexia nervosa. However empirical investigation of whether subtle differences in cognitive characteristics exist between normal dieters and patients with anorexia nervosa remains limited. Design and Method. Following a pilot study all participants completed a semi-structured interview. Results. When discussing eating related concerns clinical participants reported negative automatic thoughts that were characteristically different from those reported by non-clinical participants. These differences were also evident, although to a slightly lesser extent, when discussing concerns about weight and shape. Clinical participants reported more assumptions related to eating, and weight and shape as a means to acceptance by self and others than non-clinical participants. A similar pattern of group difference was reported in degree of belief and associated distress. Clinical participants identified more negative self-beliefs than non-clinical participants. A similar pattern of group difference was reported in degree of rational and emotional belief, and associated distress. All clinical participants identified an association between negative early experiences and negative self-beliefs, and all reported a link between negative self-beliefs and dieting. Conclusion. There are clear differences in cognitive characteristics between women with anorexia nervosa, normal dieters and non-dieting female controls.
Loneliness and Abandonment Cognitions in Bulimics: A Problem for CBT Glenn Waller, St George’s Hospital Medical School, University of London A large proportion of bulimic episodes are triggered by intolerable negative affective states, which are driven by the activation of core beliefs. The bulimic behaviours serve the function of blocking awareness of the emotional state and the threatening cognitions. Emotions that have been identified as important include anger, anxiety and depression. Anecdotal accounts also suggest that loneliness and abandonment fears are strong triggers for overeating and bingeing, and this is consistent with the small empirical literature on social antecedents to bulimic behaviours. However, there is little empirical support for this cognitive/emotional trigger. It is argued that loneliness is an important emotion to understand in formulating bulimic and other escape behaviours, but that loneliness/abandonment fears seem to operate via a very different route to other affective states. They appear to be processed via a much faster functional and neurological mechanism, which results in preconscious processing of this emotional material. Studies will be presented to demonstrate this preconscious mechanism at work, and a model of the processing of abandonment cognitions will be outlined for future testing. Such a preconscious route presents clear problems for conventional CBT, with its stress on the utility of conscious decision-making process (inherent in Socratic dialogue). Potential methods for addressing this difficulty include restructuring of core beliefs (through schema-focused CBT or imagery rescripting) and the use of subliminal activation of counter-schematic information.
SYMPOSIUM 15
Eating Disorders in Children and Adolescents Myra Cooper and Roz Shafran, University of Oxford
Peer Influence on Children's Weight Concerns and Dieting Andrew J Hill and Jenny Murphy, Academic Unit of Psychiatry & Behavioural Sciences, University of Leeds Socio-cultural accounts of the development of eating disorders identify three primary channels via which important cultural themes such as the thin ideal, and the centrality of appearance for women are transmitted: media, families, peers. Of these, peer influence has the least research evidence although several mechanisms have been proposed. For example, talking about weight and dieting ('fat talk') can involve the simple exchange of information and advice. It can also serve to highlight the importance of thinness and permit sharing the negative perception of body areas, making these views normative and promoting group affiliation. There is some evidence for these processes in adolescent girls. An alternative peer influence is 'fat teasing'. Broadly assessed measures of peer teasing about weight predict weight concern in adolescent girls. However, past research does not distinguish teasing about overweight from teasing about underweight. Nor has it evaluated how common such experiences are or at what age they are apparent. In a study of 449, 11 and 12 year olds, 12% of the girls and 16% of boys reported overweight-related victimisation. Both girls and boys victimised for overweight were significantly heavier than their non-victimised peers, although being overweight was not a pre-requisite for such victimisation. Fat teasing was significantly associated with low body shape satisfaction and low self-esteem, and increased dieting behaviour. Girls victimised for overweight were the most likely to be dissatisfied with their physical appearance and to be dieting. In addition, girls were more likely to be teased by boys, than boys teased by girls. Further research into peer influence in this area is warranted, especially given the links with weight control and the increasing use of peer support schemes in school health promotion and social welfare.
Concerns about Weight and Shape and Dietary Restraint in Overweight 12 Year Old Girls Alison Burrows1 and Myra Cooper2 1Avon and Western Wiltshire Mental Health Care NHS Trust & 2Oxford Doctoral Course in Clinical Psychology Childhood obesity increases the risk of a later eating disorder. Concerns about weight, shape and eating and attempts at dietary restraint may also increase this risk, particularly if low self esteem and symptoms of depression are present. Objectives: This study investigated concerns about weight, shape and eating and attempts at dietary restraint in overweight and average weight 11-12 year old girls. Self esteem and symptoms of depression were also investigated in both groups. Design and Method: Eighteen overweight girls (BMI 23 or above) and 18 average weight girls (BMI 16-18) completed the child version of the Eating Disorders Examination (CH-EDE), the Harter Self-Perception Profile and the Short Moods and Feelings Questionnaire (SMFQ). Results: Overweight girls had more concerns about weight, shape and eating and attempted dietary restraint more than the average weight girls. They also had a more negative perception of their athletic competence, physical appearance and global self-worth and more symptoms of depression than average weight girls. Conclusion: Overweight girls aged 11-12, compared to average weight girls of the same age, show some of the psychological features associated with the development of eating disorders. The presence of these features may help explain why childhood obesity increases the risk of a later eating disorder
Working with Body Image Disturbance in Children and Adolescents with Eating Disorders Rachel Bryant-Waugh, Eating Disorders Team, Great Ormond Street Hospital This presentation will address the issue of body image in the treatment of children and adolescents with a range of types of eating difficulties. Specific cognitions regarding body weight and shape form part of the core psychopathology of anorexia nervosa and bulimia nervosa. Children with clinical eating disturbances tend to vary in terms of cognitive content and cognitive processes relating to body image. These variations will be illustrated using clinical case material. It is proposed that, as body image disturbance often functions as a major maintaining factor of the eating problem, it is important to explore effective means of addressing it. A model will be put forward that incorporates developmental and systemic issues in the conceptualisation of body image disturbance. Clinical application of the model as a precursor to cognitive behavioural work with children and young adolescents will be described. It is maintained that such an approach enhances personal relevance for the young person thereby enhancing possibilities for successful engagement and effective intervention.
CBT for Adolescents with Anorexia Nervosa Anne Stewart, Highfield Adolescent Unit, Warneford Hospital, Oxford This theoretical and clinical paper will address the use of cognitive therapy for adolescents with anorexia nervosa. Research on cognitive therapy in anorexia nervosa is at an early stage and very little work has been done with the younger age group. By contrast, there is considerable evidence for the efficacy of family therapy in the treatment of adolescents with anorexia nervosa. In practice, a combination of individual and family approaches is often used. This paper presents an approach which combines family therapy with individual cognitive therapy. A cognitive model for the development and maintenance of anorexia nervosa in adolescents will be briefly presented. This utilises ideas from models previously developed, however, incorporates a systemic and developmental focus relevant to adolescents. The model takes into account a range of beliefs, including beliefs about the illness and need for treatment, beliefs about weight and shape and underlying core beliefs relating to low self esteem and perfectionism. A treatment strategy based on this model and taking account of current research evidence will be described. The treatment has three phases, an initial family based phase where the focus is on weight restoration, a second phase using individual cognitive therapy and a final phase which incorporates family and individual approaches. The cognitive therapy phase is described in detail. During this treatment a range of beliefs is addressed. Techniques including identifying and challenging distorted or unhelpful beliefs, decreasing maladaptive and increasing adaptive behaviours, and developing a positive sense of self separate from the anorexia. Case examples will be used to illustrate the treatment approach.
SYMPOSIUM 16
Naturalistic Cognition: Methods for Studying Anxiety and Depression Andrew MacLeod, Royal Holloway, University of London
Future-Directed Thinking in Anxiety And Depression Andrew MacLeod, Royal Holloway, University of London Individuals’ spontaneous or minimally cued responses are appealing to researchers as they offer to provide information with high face validity. The challenge is how to establish reliability and generalisability of such responses. Findings from a number of studies using an adapted verbal fluency paradigm to examine future-directed thinking are presented. The task elicits thinking about the future by asking participants to think about what they are looking forward to or not looking forward to in different future time periods (e.g., the next week or the next year). All participants are given a fixed time limit to think of responses for each period and the main measure is the number of responses provided in each condition. Thus, the task combines both individual elements – responses are unique to each person – and generalisable elements – all participants receive the same time limits and responses are scored in the same way. Results comparing anxious and depressed participants have demonstrated a relationship between anxiety and increased negative thoughts about the future, and between depression and decreased positive thoughts about the future. The task also allows a content analysis of responses, and a preliminary content analysis of anxious and depressed patients’ thoughts about the future will be presented.
The Role of Mental Simulation in Thinking about Future Outcomes: Extension to Clinical Populations Jonathan Wheatley, University of East London, Stuart Linke, Camden & Islington Health Authority, Gary Brown, Canterbury Christ Church University College: Salomons In previous research, a paradigm was developed for studying dynamic aspects of ongoing thought processes drawing on the theories of Kahneman and Tversky (1982) on heuristics in thinking and judgment. Specifically, the potential role of the simulation heuristic in worry about future outcomes was examined in a sample of women pregnant for the first time. Natural-language protocols were elicited from participants regarding a future situation, in this case arriving at the hospital in time to give birth. They were coded for “goodness-of-simulation” (GOS) in terms of the simulation heuristic. The prediction that higher GOS would lead to higher subjective probability of a positive outcome and therefore less worry was supported. The method is potentially broadly applicable to various clinical phenomena. However, generalizing and extending the approach poses certain challenges. In particular, examining negative outcomes rather than positive outcomes, as would be the case in studying most clinical phenomena, presents a different set of considerations than use of the paradigm with positive outcomes. In addition, the approach was developed with a circumscribed, uniform problem (giving birth). Most clinical problems, even of the same disorder, are not as uniform across individuals. The present paper describes a pilot of study meant to extend the simulation paradigm for use with clinical populations in which negative future thinking is a prominent feature. A small sample of outpatients with long-standing obsessive-compulsive disorder was studied using a within-subjects design. The prediction was that goodness-of-simulation would be highest for a scenario based on an individual’s own obsessive fear, but would not be as high for yoked control scenarios based on the fears of other participants with a dissimilar OCD problem. In addition, both personal and yoked scenarios should be better simulated than a general worry scenario and a non-worry scenario. Preliminary results are presented and discussed.
Positive Experiences in Daily Life: Depressed Versus Healthy Individuals Daniela Q.C.M. Barge-Schaapveld, Clinical Operations Europe, Solvay Pharmaceuticals, Nancy A. Nicolson, Department of Psychiatry and Neuropsychology, Maastricht University “Loss of interest or pleasure in all or almost all activities, most of the day, nearly every day” is one of the two defining symptoms of major depression. And yet, with the available arsenal of evaluations, it has been difficult to measure (the lack of) positive experiences in daily life of depressed patients because retrospective measures are vulnerable to influences of current affective state, forgetting, and cognitive re-framing. We therefore used the Experience Sampling Method (ESM), a naturalistic time-sampling approach, to assess daily life experiences in 63 depressed outpatients and a group of 22 healthy controls, similar in sex, age, living circumstances and work status. Participants completed ESM self-report forms 10 times a day for 6 days, in response to signals from a pre-programmed wristwatch. Results presented here will focus on differences between depressed patients and healthy controls in level and variability of positive affect, frequency and enjoyment of activities, occurrence of positive events, and percentage of ‘good’ moments. In addition, examples drawn from a larger ESM database will illustrate how this method has been used to test a range of hypotheses concerning daily time use and subjective experience in other psychiatric and psychosomatic illnesses, including anxiety disorders.
Using Sentence Completion to Measure Depressive Thinking Stephen Barton, University of Leeds There are two broad categories of cognitive assessment: (1) idiographic (diaries, think-alouds, interviews, thought-listing) where the data is sensitive to the cognitions of particular individuals, (2) nomothetic (checklists, questionnaires, judgement tasks), where the data yields a quantitative measure on a validated construct of interest. In practice, idiographic methods are relied upon to support cognitive therapy with particular clients, while nomothetic measures are generally used to evaluate change following an intervention. This paper argues for the benefits of cognitive measures that can function at both levels. Sentence completion is one technique that has sufficient structure to support nomothetic measurement, combined with an open-ended format that sensitively elicits the cognitions of the particular client. A new 48-item Sentence Completion Test for Depression (SCD) will be described, illustrating its development, clinical usage and validation. Particular focus will be placed on its usage within naturalistic clinical settings, supporting the conceptualisation of complex mood disorders.
Cognitive Bias in Social Phobia Lusia Stopa, University of Southampton Cognitive theories of social phobia suggest that biases in interpretation and in thinking may play an important role in maintaining the disorder. This paper reports data from two studies which demonstrate specific cognitive biases in social phobia. The first study examined whether social phobics have a tendency to interpret ambiguous social events in a negative fashion and whether they are likely to interpret mildly negative social events in a catastrophic way. The second study looked at the kinds of thoughts which social phobics have when they are actually in a social situation. In the first study, patients with generalized social phobia, equally anxious patients with another anxiety disorder and non-patient controls were presented with ambiguous scenarios depicting social and non-social events, and with unambiguous scenarios depicting mildly negative events. Interpretations were assessed in two ways: by participants’ answers to open-ended questions and by their rankings and belief ratings for experimenter-provided alternative explanations. Social phobics interpreted ambiguous social events and catastrophised in response to mildly negative events compared to the two control groups. In the second study, social phobics, anxious controls and non-patient controls took part in a conversation with a stooge and then recorded their thoughts by speaking out loud and by an experimenter-designed questionnaire. Social phobics had more negative self-evaluative thoughts than the control groups. One of the challenges in research into cognitive processes in social phobia is to develop methods which allow naturalistic investigation while retaining the benefits of experimental control. This presentation will conclude with a critical review of the methods which were used in the experiments described above.
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Cognitive Behavioural Treatment of Somatic Symptoms (Continued) Trudie Chalder, Guy’s King’s and St Thomas’ School of Medicine,
Aspects of the Therapeutic Alliance Associated with a Good Outcome, An Analysis of the Process of Therapy Taken from a Randomised Controlled Trial of CBT Versus Counselling for Patients with Chronic Fatigue in Primary Care. Emma Godfrey, Department of General Practice and Primary Care, Guy’s King’s and St Thomas’ School of Medicine, 5 Lambeth Walk, London SE11 6SP. In this RCT, CBT and counselling were found to be equivalent in effect for this patient group. However there were significant differences between the six therapists (3 CBT and 3 counselling) involved in the trial, irrespective the type of treatment they were offering. This prompted a process analysis, using a rating scale developed for this purpose, of a sample of 70 sessions of therapy conducted during this trial. Factors which predicted a good outcome across treatment modalities were examined. Four independent assessors were trained to rate audio tapes selected from the trial, in terms of both the therapeutic alliance and specific elements of the two treatment modalities. The results showed several aspects of the therapeutic alliance, common to both treatments, were associated with a good outcome. The methodology used to assess the process and content of therapy, as well as the results obtained, will be presented at this conference. Discussion of some of the practical and clinical implications of this study will also be explored.
Risk Factors for the Development of Chronic Fatigue Syndrome: Implications for the Cognitive Behavioural Model. Linda Fisher, Cognitive Behaviour Therapist, Department of Psychological Medicine, South London and Maudsley NHS Trust, Bessemer Road, London SE5. A description of the problems that patients with CFS face is presented and UK diagnostic criteria are given. The cognitive behavioural formulation of CFS is given and the model is described in detail. Most research to date has focused on the onset and maintenance of CFS. This evidence is reviewed in brief in the context of the cognitive behavioural model. New evidence that examines the otherwise neglected area of vulnerability or predisposition to the development of CFS in adult life is presented. A case control design has been used to compare childhood experiences of illness and parenting in adults with CFS and a fracture clinic control group. Results from the study are given and both relevance to other research findings and clinical implications are discussed.
Cognitive Behavioural Treatment of Non Epileptic Seizures. Results of a Pilot Study. Sarah Mitchell O’Malley, Department of Neuropsychiatry, Maudsley Hospital and The Institute of Psychiatry. Denmark Hill, London SE5 8AZ. Despite a growing literature on non-epileptic seizures or pseudo seizures, little is known about the treatment of this disorder. This presentation is based on the first uncontrolled study of cognitive behaviour therapy for non-epileptic seizures. Some of the issues which arose during the active phase of treatment will also be addressed. The purpose of the pilot study was to determine the efficacy of cognitive behavioural therapy as a treatment for adults who experience non-epileptic seizures. Twenty subjects were treated with 12 sessions of cognitive behavioural therapy for 1 hour. Clinical measures were administered at weeks 1, 6 and 12 and then in follow-up at 1,3,6 and 12 month follow-up, to measure treatment outcome, seizure reduction and global improvement. The results indicate that patients who complete 12 sessions of cognitive behavioural therapy experience a significant reduction in seizure frequency, an increase in confidence and global improvement. We are now proceeding to a randomised controlled trial with this patient group, comparing cognitive behavioural therapy with a supportive counselling treatment.
Cognitive Behavioural Treatment of Irritable Bowel Syndrome in Primary Care: Training Nurses to Use Core Strategies. Simon Darnley, Research Co-ordinator, Department of General Practice and Primary Care, Guy’s King’s and St Thomas’ School of Medicine, 5 Lambeth Walk, London SE11 6SP. Irritable bowel syndrome is one of the most common gastrointestinal disorders yet many patients do not benefit from explanation, reassurance and symptomatic management and develop a chronic illness with high health care costs. Cognitive behavioural therapy (CBT) has been shown to be a promising intervention for these problems but specially trained CBT therapists are still overworked and thinly spread. To address these issues we have started training general nurses working in primary care settings to use CBT techniques with IBS patients. This training is being evaluated as part of a randomised control trial designed to establish whether early intervention with CBT is advantageous over current treatment in primary care settings. The structure, content and cognitive behavioural model used in the training will be presented along with a case example and a discussion on some of the practical and clinical issues involved.
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Latest Thoughts on Theory and Practice in Therapy for Delusions and Hallucinations Til Wykes, Institute of Psychiatry, London
Hallucinations and Their Treatment Gill Haddock, Withington Hospital. Manchester Recent randomised controlled trials have indicated that individual cognitive-behaviour therapy (CBT) in conjunction with medication for schizophrenia can significantly improve patient outcomes. These interventions have usually focused on reducing the severity of positive symptoms such as hallucinations and delusions. However, these trials indicate that greater benefits may be achieved for delusions rather than hallucinations. This may be because broad based CBT techniques may not address the underlying cognitive deficits thought to contribute to the occurrence of hallucinations. For example there is evidence that hallucinators show specific deficits in source monitoring of verbal and other material and have characteristic beliefs about their voices which contribute to the distress associated with them. When these factors are taken into account when delivering cognitive treatments, pilot studies have shown that significant clinical gains can be made with hallucinations. This paper will review these studies and describe how these treatments can be integrated to produce a voice oriented cognitive therapy (VOCT).
Auditory Hallucinations in Psychiatric and Non-Psychiatric Samples: Understanding the Hallucinatory Experience LC Johns, Department of Clinical Psychology, University of Manchester, D Hemsley and E Kuipers, Institute of Psychiatry, London, UK. Hallucinations span a number of diagnoses and are also reported by individuals with no significant medical or psychiatric history. Reports of hallucinations in various conditions and samples of people provide evidence for the view that hallucinations lie on a continuum of perceptual experiences. This paper reviews the literature on the occurrence and phenomenology of hallucinations in different conditions, and presents data from a symptom-based study comparing hallucinations in a psychiatric and non-psychiatric sample. Results from previous studies and the current study show both similarities and differences in hallucinatory experiences across subject groups. What become apparent from these studies are the many components of the auditory hallucination. The data also show the existence of continuity and discontinuity across subject groups for different aspects of the hallucinatory experience. A multi-level model of auditory hallucinations is presented, which includes underlying pathophysiology, cognitive mechanisms, primary experiential aspects, secondary factors of appraisal and attribution of the experience, emotional and behavioural responses, and the influence of context (personal and environmental). The model highlights various targets for intervention.
Group Cognitive Treatment for Persistent Auditory Hallucinations: A Controlled Trial T. Wykes, A-M. Parr and S. Landau, Department of Psychology, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK The trial evaluated group therapy for voices, which incorporated cognitive behavioural principles using a waiting list control design. Therapy was provided in one-hour sessions over six weeks with a follow up session one-month later. Assessments were carried out at baseline, pre-treatment, post-treatment and follow-up. Patients who fulfilled DSMIV criteria for schizophrenia and were experiencing distressing auditory hallucinations were recruited. There were significant gains in symptoms and insight, and a strong trend in the auditory hallucinations scores, all of which were maintained at follow-up. There was also an increase in the range and effectiveness of coping strategies. The gains were similar to those reported in trials of individual CBT. This type of treatment may prove to be a cost-effective adjunct to pharmacotherapy in the reduction of persistent psychotic symptoms and their associated distress.
A Cognitive Approach to Auditory Hallucinations: From Theory to Therapy Morrison A P, Department of Clinical Psychology, Mental Health Services of Salford In this paper, a cognitive approach to the understanding of auditory hallucinations will be outlined. This approach suggests that meta-cognitive beliefs inconsistent with intrusive thoughts may lead to their external attribution as auditory hallucinations and that hallucinatory phenomena are normal responses to certain events. It is also argued that the misinterpretation of such experiences causes the distress and disability commonly associated with hearing voices. Experimental evidence from several studies of cognitive processes in-patients experiencing auditory hallucinations that test specific predictions of this cognitive approach will be summarised. The clinical implications of this approach will be discussed, and the components of interventions based on this model will be outlined.
Why Psychosis is not Just a Neurodevelopmental Disorder Richard Bentall, University of Manchester In recent years it has been fashionable to attribute psychosis to neurodevelopmental abnormalities - some kind of neurological time bomb which is laid down in very early life but which does not 'explode' until maturity. At the same time, researchers have felt the need to play down the role of environmental and family determinants of psychotic symptoms. In this paper I will examine the logic of the neurological time bomb hypothesis, and argue for a rethink about the role of environmental determinants. The neurological time bomb hypothesis attempts to explain why adolescence and early adulthood are high risk periods for psychosis, and therefore fails to explain why perhaps the majority of patients become psychotic outside this period. Although convincing evidence of neuropsychological precursors of psychosis has been reported, these findings have been reported for a number of diagnostic groups, and are therefore nonspecific. The size of these effects appears to be modest. Moreover, neurocognitive abnormalities in-patients seem to be only modestly related, or not related at all, to positive symptoms. Although very limited research efforts have been directed towards detecting environmental determinants of psychosis, the available evidence is very consistent, and points to (i) family relationship problems, including abnormal attachments, in future psychotic patients; and (ii) a very high level of trauma in the life histories of psychotic patients. These findings seem to be associated with positive symptoms. A valid developmental approach to psychosis must examine the role of both biological and environmental factors. More research attention needs to be directed towards the latter. Obviously it will be important to carry out such research in a way that is sensitive, and that is not perceived as victimising by patients' families.
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Relationships between Child Behaviour Problems and the Family Environment Rachel Calam, University of Manchester
Maternal Depression and Attribution for Child Behaviours Christine Barrowclough and Rachel Calam, University of Manchester A number of models have been proposed to account for the raised prevalence of child difficulties in the context of maternal depression. A consistent finding is that depressed mothers appraise their child’s behaviour more negatively. A recent study is described in which one aspect of maternal appraisal – attributions for child problems – is examined in samples of depressed and non-depressed women. The finding that depressed women show a more blaming attributional bias towards their children, lends support to the importance of cognitive mediators in understanding the links between depressed mood and dysfunctional parenting, and hence the association between depressed mood and poor child outcomes. The paper will outline a model for understanding such links, discuss clinical implications, and introduce research issues, which will be followed through in other papers in this symposium.
Expressed Emotion, Attributions and Depression in Mothers of Children with Problem Behavior Catherine A Bolton*, Rachel M Calam*, Christine Barrowclough*, Janine Roberts, **, Sarah Peters***& Alison J Wearden* *University of Manchester, ** Child and Adolescent Psychology Services, South Manchester *** University of Liverpool The relationship between EE and spontaneous casual attributions was examined in 61 mothers of children referred for problem behavior. Consistent with previous research, high EE mothers, compared to low EE mothers, were more likely to make attributions that judge the cause of problem behavior to be personal to and controllable by the child and also made more 'child-blaming' attributions than low EE mothers. Mothers' depressed mood was found to be associated with 'child-blaming' attributions and higher levels of EE. These results indicate the relevance of the EE-attribution model in mothers of children with problem behavior and suggest that maternal depressed mood is an important additional factor in developing the EE-attribution model for this population.
Maternal Attributions for Problem Child Behaviour: A Longitudinal Study of Mothers and their Children Sarah Peters, University of Liverpool, Rachel Calam, Richard Harrington and Catherine Bolton, University of Manchester Expressed Emotion (EE) describes the temperature of conflict between two individuals. Although well established as an outcome predictor for numerous medical and psychiatric conditions including child behaviour disorders, mechanisms by which EE is maintained remain unclear. The link between attributional style and EE has been established in areas of adult mental health where high parental/spousal EE is associated with a belief that causes for symptoms are internal to, personal to and controllable by the patient. This pattern of causal attribution has been described as ‘blaming’ since the patient is considered responsible for the outcome of the illness event. Parental attributional style has been associated with child behaviour in clinical and community populations and with different parenting styles. More recently, we have shown that blaming attributions are more common amongst high EE mothers of children with problem behaviour than low EE mothers. This study aims to investigate the effect of change in attributional style on child and parenting behaviour. 75 mothers and children referred to clinical psychology/psychiatry services for problem behaviour were invited to join a parenting intervention partly designed to alter attributional style. Using the CFI methodology, mothers were rated for EE. Spontaneous attributions for negative child behaviour were coded along several dimensions. Children’s responses were assessed by mothers, independently by teachers and by children themselves using the Berkeley Puppet Interview. The consequences of change for the parent and child are examined with reference to the attributional-affect model of behaviour and implications for future research and clinical practice discussed.
Attributions and Maternal Depression in the Development of Children’s Emotional and Behavioural Problems. Chrissie Verduyn* & Rachel Calam**, *Royal Manchester Children’s Hospital, ** University of Manchester Maternal depression has shown a consistent association with the development of emotional and behavioural problems in childhood and adolescence. A large community sample of mothers of pre-school age children were screened and 4 groups identified of high and low scores on measures of depression and pre-school behaviour problems (total n=139). In order to explore relationships between maternal depression and child behaviour problems, groups were compared on measures of mothers’ causal attributions of their child’s behaviour, of quality of parents relationship and on a measure of mother-child interaction. Preliminary results will be discussed.
The Role of Maternal Behaviour and Cognitions in the Development of Young Children’s Behaviour Problems. Charlotte Wilson*, Frances Gardner**, Jenny Burton**, Sarah Ward*** *Academic Division of Clinical Psychology, University of Manchester, Withington Hospital, West Didsbury, Manchester, M20 2LR. ** Oxford University Department of Social Policy and Social Work, Barnett House, Wellington Square, Oxford, OX1 2ER. *** Department of Clinical Psychology, Isis Centre, Warneford Hospital, Old Road, Oxford, OX3 7JX. Children’s behaviour problems constitute a significant mental health problem. They are common, persistent, costly to society, and have poor prognosis for the children affected by them. Evidence suggests that parenting behaviours may play a causal role in the development of behaviour problems, and many of these are addressed in effective parenting programmes, including early intervention. However, there is less evidence about the role of parenting cognitions in the development of young children’s behaviour problems. Many studies of parenting cognitions have examined parental attributions. These have been found to be linked to children’s behaviour problems, and also to parent’s reports of their own behaviour. The present study extends previous findings by examining maternal attributions and children’s behaviour problems at two time points, while the children are young. The study also examines observed maternal and child behaviour in addition to mothers’ reports of these. Finally this study examines maternal negative fleeting thoughts, and links these to both observations of mother and child behaviour, and to maternal attributions. The results indicate that maternal attributions are linked to children’s behaviour problems in children as young as three, and furthermore, that the behaviour problem level at three adds to a prediction of maternal attributions one year later. Maternal attributions are somewhat associated with observed maternal and child behaviour. Additionally maternal negative fleeting thoughts are meaningfully related to child behaviour and maternal behaviour and attributions. Implications for further work and parenting programmes will be discussed.
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Diffusion of Psychological Innovation: Our Experience with Triple P (Positive Parenting Programme) Matthew R Sanders, University of Queeensland, Australia
Triple P (Positive Parenting Program): A Multi-level Parenting and Family Support Strategy. Sanders, M.R., Markie-Dadds, C., Turner, K.M.T., & Brechman-Toussaint, M., School Of Psychology, The University Of Queensland, Brisbane, Australia). This paper describes the theoretical and empirical basis of a multi-level parenting and family support strategy, known as Triple P (Positive Parenting Program). The progression of the intervention from single case demonstrations to clinical trial methodology and then to population-based intervention is described. Each of the five levels of intervention is outlined together with supporting evidence from several ongoing clinical trials. Several areas for future research and program development are identified.
The Role of Training and Accreditation in the Multi-disciplinary Dissemination of an Empirically Validated Behavioral Family Intervention Strategy Brechman-Toussaint, M Sanders, M.R., Markie-Dadds, C., & Turner, K.M.T., School Of Psychology, The University Of Queensland, Brisbane, Australia. Despite the availability of empirically validated family intervention strategies, many practitioners continue to use intervention procedures, which have little demonstrated efficacy in terms of clinical outcome when working with families. This paper presents a model for training professionals from a range of disciplines within the health, education and welfare sectors, who regularly consult with families about child behaviour, for the delivery of an empirically validated behavioural family intervention strategy. Results from a large-scale trial which involved the development and delivery of a competency based training and accreditation system designed to teach both the theoretical and professional skills needed to competently deliver a multi-level parenting strategy will be presented. The impact of the training process will be discussed in terms of the number of practitioners who have successfully completed training, practitioner satisfaction and increases in self-reported confidence and competence across a range of parent consultation skills post training. The importance of active skills rehearsal and the adoption of a self-regulation model of behaviour change during training will be highlighted and potential obstacles and barriers to effective training and dissemination will be identified and discussed.
Dissemination of Psychological Innovation in New Disciplines: A study of aids and obstacles to program implementation. Turner, K.M.T., Sanders, M.R. School Of Psychology, The University Of Queensland, Brisbane, Australia Primary care health and welfare professionals are well positioned to provide parenting support, yet primary care settings are under-utilised for the provision of effective mental health programs for children and families. Primary care services can undertake several important tasks to promote children’s mental health including: early detection of significant deviations from normal development; provision of advice to parents seeking information about developmental issues; provision of brief behavioural counselling for child behaviour problems; and referral of moderate to severe child behaviour problems to specialised services. This paper reports on the dissemination of a parenting and family support strategy in primary care settings. The effectiveness of a 2-day training program for professionals interested in developing their skills in the detection and management of children showing mild to moderately severe behavioural disturbances is evaluated. Results for over 800 participating primary care professionals are reported, including changes in their confidence in their parent consultation skills following training, and a 6 month follow up survey of program use and content knowledge. A model of obstacles and aids to program implementation following training is discussed.
An Integrative Ecological Approach to Dissemination with a Statewide Government Agency. Markie-Dadds, C., Brechman-Toussaint, M., Sanders, M.R. School of Psychology, The University of Queensland, Brisbane, Australia. This paper will report on a large-scale trial in Queensland where an empirically supported family intervention is being disseminated within existing health care services. The paper describes an integrative ecological approach to dissemination which combines two potentially complementary perspectives to professional behaviour change: (1) a systems-contextual approach views the attitudes, knowledge and consulting practices of professionals as being embedded within the broader organisational environment within which a practitioner works and (2) a self-regulatory perspective which involves the promotion of personal responsibility for self-directed change by professionals. The paper will provide an overview of the specific components of the dissemination strategy. This approach to dissemination is predicted to be associated with higher levels of program uptake and better treatment integrity than traditional methods of disseminating new intervention to professionals that typically involve workshops or continuing professional education programs. Data will be presented on participant satisfaction with the training process, consultative skills of participants, and extent of implementation of Triple P across more than 30 locations in Queensland.
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Cognitive Factors in the Etiology, Maintenance and Treatment of PTSD Freda McManus, Warneford Hospital, University of Oxford
Cognitive factors involved in posttraumatic stress disorder (PTSD): Findings from assault victims in Mozambique Emma Dunmore, University of Surrey and Alfredo Bonate, Eduardo Mondlane University, Mozambique Research in the United Kingdom has identified a number of cognitive variables associated with the onset and maintenance of PTSD following assault (Dunmore et al., 1998, submitted). These variables include cognitive processing style during the assault, appraisals of assault sequalae, maladaptive control strategies and negative beliefs about the self and the world. These findings are consistent with the cognitive model of PTSD recently put forward by Ehlers and Clark (2000). It is not known whether similar cognitive variables might be related to PTSD for victims in non-western populations. To begin to address this question the current study investigated the relationship between PTSD and several cognitive variables in assault victims in Mozambique. Eighty-six individuals who had experienced physical or sexual assault, or domestic violence at least 4 weeks previously were included in the study. A structured interview was used to assess assault characteristics and questionnaires assessed cognitive variables and PTSD severity. Fifty eight percent of participants met diagnostic criteria for PTSD using the self report version of the PTSD symptom scale (Foa et al., 1993). As in previous studies (e.g. Kilpatrick et al., 1989) PTSD severity was significantly associated with perceived life threat. Other cognitive variables associated with PTSD were: mental defeat during the assault, maladaptive control strategies (avoidance and safety seeking) and negative beliefs about the self and the world. The implications of these findings are discussed.
Enhanced Perceptual Priming for Stimuli That Occur in a Traumatic Context Tanja Michael and Anke Ehlers, University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford Patients with posttraumatic stress disorder (PTSD) involuntarily and recurrently re-experience fragments of the trauma. Ehlers and Clark’s (2000) cognitive model of PTSD suggests that such intrusions result from deficits in processing the meaning of the event, strong perceptual priming, and poor incorporation of the trauma into the autobiographical memory base. Experiment 1 tested the hypotheses that (a) there is enhanced perceptual priming for stimuli that occur in a traumatic context and (b) cognitive processing styles influence the degree of priming. Healthy volunteers watched unpleasant and neutral picture stories on a computer screen. Cognitive processing styles were assessed by questionnaires. Priming was measured with an object identification task. The results showed that neutral stimuli that occurred in a traumatic context were more strongly primed than equivalent stimuli in a neutral context. Low conceptual processing was correlated with priming. Experiment 2 examined whether incorporating traumatic material into the autobiographical memory base leads to (a) less priming and (b) fewer intrusions. Participants were again exposed to the picture stories. An experimental manipulation was added after exposure. Half of the participants had to answer questions that enhanced the elaboration of their experience while watching the stories, in particular linking it to other autobiographical memories. The other half worked on several cognitive tasks that served as a control condition. Priming was again measured with an object identification task. The results showed that the experimental group had less priming and fewer intrusions than the control group. The strength of the priming effect correlated with the number of intrusions in the control condition.
The Phenomenology of Intrusive Memories in PTSD Ann Hackmann, University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford, This paper reports on a systematic study of intrusive fragments of memory in-patients with PTSD. Intrusions were rated on a weekly basis thoughout a course of cognitive behaviour therapy. The results presented cover the sensory content of the intrusions, their meaning, frequency, triggers, vividness and the amount of distress evoked. Data will be presented to illustrate what happens to the intrusions over time, as therapy takes effect.
A Case Example of Longer-Term Cognitive-Behavioural Therapy for PTSD Following an Assault and Longstanding Low Self-Esteem. Nick Grey, Stress Clinic, Camden & Islington Community NHS Trust A case is presented of a 26-year-old woman who developed Post-traumatic Stress Disorder (PTSD) following a prolonged assault. The case is conceptualised using the recent cognitive model for PTSD as proposed by Ehlers & Clark (2000). Whilst originally conceptualised as a simple fear-based traumatic reaction, during exposure / reliving treatment it became clear that there were a number of peritraumatic emotional hotspots other than fear. In particular an image of the attacker towering over the patient triggered intense feelings of shame and was associated with the cognition ‘I am the lowest of the low’. The exposure / reliving intervention resulted in some limited improvement. Simple verbal cognitive restructuring was unsuccessfully used to address the remaining hotspots. It was formulated that this was due to their match to longstanding generalized negative beliefs about herself. Therefore schema-focused cognitive techniques more appropriate to that level of cognition were adopted. Towards the end of treatment cognitive restructuring was successfully used for the shame-based peritraumatic emotional hotspot within the exposure / reliving. It is argued that this case lends support to the cognitive model for PTSD. Furthermore it is argued that careful attention should be paid to the variety of peritraumatic emotional hotspots which may only be identified during exposure / reliving. Possible clinical approaches are suggested for dealing with these, which may particularly help people who do not improve with traditional prolonged exposure treatment. |