CONTENTS

 Roundtable Debate 

Over-Valued Ideas: The Last Frontier in Cognitive Behaviour Therapy?

 Open Papers

1.   Training and Other Issues

2    Cognition and Emotion: Findings across Disorders

3.   Issues in Training and Supervision

4.   Developmental Issues

5.   Affective, Obsessional and other Difficulties

6.   Depression and Related Issues

SYMPOSIA ABSTRACTS

DEBATE

Over-valued Ideas: The Last Frontier in Cognitive Behaviour Therapy

  Overvalued Ideas are Derived from Idealised Values That are Identified with the Self

David Veale, Royal Free and University College Medical School & The Priory Hospital North London.

Overvalued ideas are an important but neglected area of psychopathology with few experimental studies. They are pathognomic of anorexia nervosa, body dysmorphic disorder (BDD), gender dysphoria, apotemnophilia, the litigious paranoid state and pseudocyesis. They may also occur in some types of morbid jealousy, OCD (especially hoarding) or hypochondriasis. Whereas negative thoughts, obsessions and even delusions have been amenable to various pharmacological or psychological therapies, overvalued ideas are generally resistant to change. I will present a cognitive behavioural model of over-valued ideas, which draws upon the philosophical distinction between beliefs, values and evaluations. I will argue that overvalued ideas are derived from an idealised value, which has developed into such an over-riding importance, that it defines the “self “ or identity of the individual. An example in BDD is the importance of appearance (the value) so that patient sees him or her self as an aesthetic and social object. I will argue that values are more important than the beliefs (the over-valued idea or delusion) about their appearance (for example that “one’s nose is too crooked and red”).

A second characteristic of idealised values is the rigidity with which they are held. Such patients are unable to adapt to different circumstances and ignore the consequences of acting on their value. Thus if the low weight and starvation diet threatens the survival of a patient with anorexia nervosa, the person fails to adapt their value of the importance of self-control and continues in the same starvation diet.

I will suggest a number of strategies that can be used in cognitive behaviour therapy for helping patients with idealised values that involve (a) motivational interviewing (b) strengthening the development of alternative values by reverse role play. (c) using the Big “I”, little “i” technique for developing a healthier view of the self.

Chipping Away at the Anorexic Identity

Janet Treasure, Institute of Psychiatry, London.

One of the most difficult aspects of the management of anorexia nervosa is its ego syntonic nature. They come into our offices not wanting to change. As therapists we can become preoccupied by our emotional response to the overt negative consequences and may not be able to understand their perspective. The first step in management is to understand the positive aspects of anorexia nervosa.  Often this is to provide safety and security and emotional regulation. The aim of therapy is to provide more adaptive attachments and to develop a sense of identity without the values of anorexia nervosa.

Apotemnophilia and Gender Dysphoria

Keren Fisher, Consultant Clinical Psychologist, The Royal National Orthopaedic Hospital, London.

It is uncertain whether the model of overvalued ideas is appropriate for this group of disorders.  Apotemnophilia is a word that has been coined to describe a desire for amputation of a healthy limb but it usually refers to sexual deviance which does not necessarily apply.  Indeed, assessment must discriminate between those who mutilate themselves for relief of tension, require amputation to validate an invalid role, have fantasies about amputation in a sexual context or require amputation to correct a mismatch between the physical and the hypothesised cortical representation of the body.  This last group are more similar to those with gender dysphoria who clearly perceive themselves in the wrong physical body.  Body dysmorphic disorder does not properly explain this condition as the limb, which is targeted for amputation, is not considered ugly, only supernumerary to a perfect body.  There is some evidence in the gender dysphoria literature of actual brain differences between non affected males and male to female transsexuals.  Similarly, we know that representation of the limbs in the “phantom” does not always coincide with the actual body.  Reduplication and inattention exist in neurological conditions so research needs to focus on the sensory awareness of the supposedly superfluous limb. 

Patients who have fixed ideas of how their body should appear have not so far been helped by various forms of psychiatric or psychotherapeutic intervention, whereas, reassignment by surgery to the opposite sex or to an amputee population seems to have a good outcome in the majority of patients studied.

Paul Salkovskis, Oxford University

Abstract Unavailable

Phillipa Garety, Kings, Guy’s and St Thomas’ Medical School

Abstract Unavailable

OPEN PAPERS

1. Training and Other Issues

 Effectiveness of Cognitive-Behavioural Therapy Training: Proposals for Measurement and Evaluation

Mark Latham, Leeds Community and Mental Health Services Trust & Chris Atha, Wakefield and Pontefract Community Trust

Considering the central role of measurement and evaluation in cognitive-behavioural therapy (CBT), it is surprising that more emphasis has not been placed on establishing whether CBT training is effective. The authors will put forward several possible reasons as to why this might be so, but then go on to argue that the difficulties are not insurmountable.

Three main questions arise:

To what extent does CBT training

(i) increase the knowledge and skills levels of trainees?

(ii) affect the way trainees work with clients?

(iii) improve clinical outcome for clients?

The authors will present their own evaluation of training with two cohorts of trainees on an introductory course to CBT theory and practice (33 weeks of half a day). All trainees were asked to complete a 25 minute videotaped role play of an initial assessment interview and a 20 item written test covering theoretical and clinical knowledge of CBT, prior to starting the course to establish baseline levels of skills and knowledge respectively. Both measures were repeated in the last few weeks of the course. The videotapes were rated blindly by two independent assessors, using the Cognitive Therapy Scale (Young and Beck 1980) and a scale designed by the authors to assess therapeutic skills in initial assessment interviews. Results showed significant change on measures of knowledge and skills between pre and post measurement points. Methodological limitations of the study will be described. Suggestions will be made for increasing the overall effectiveness of measurement and evaluation of CBT training.

References: Young J and Beck AT (1980) Cognitive therapy scale: rating manual. Unpublished manuscript. Philadelphia, PA: Center for Cognitive Therapy.

Beyond Sheep: Training and Supervision in CBT the New Zealand Way

Henck van Bilsen & Lynne Norris, Auckland Institute for Cognitive and Behaviour Therapies

Auckland, New Zealand

The Auckland Institute for Cognitive and Behaviour Therapies was founded in 1996 when the authors arrived in New Zealand. The Institute has three clinics offering CBT in the greater Auckland area.

The Institute offers certificate (600 learning hours) and Diploma (1200 learning hours) training in CBT. Currently there are about 40 students enrolled in several stages in the certificate and diploma programmes, while there are already 18 graduates of the certificate programme. In September 1999 the Institute received recognition from New Zealand’s governing education body as a ‘Private Training Establishment’. The Ministry of Health has purchased so far 44 student placements on the certificate programme.

In this paper the content and structure of the certificate and diploma programme are described.

Which CBT topics are mandatory?

Which topics are choice topics?

How is the connection between training and supervision organised?

Which supervision style is most effective?

How do we link student’s clinical practice with their study?

What kinds of professionals enroll in the programme?

The discussion will focus on issues like: how to get students to practice what they have learned, how to motivate students to try out something new in an overwhelmingly busy schedule, how to asses for competence?

Implementing our Bicultural Responsibilities at the University Of Waikato

Anne Phipps and Averil Herbert, University of Waikato, New Zealand

In today’s world the need for clinical psychologists to be culturally responsive is starting to be recognised given that many societies are comprised of a range of ethnic groups. In Aotearoa/New Zealand while we too are experiencing an increase in cultural diversity the emphasis is focused on the two main cultures - Maori (the indigenous people) and Pakeha (the dominant group which is comprised of those with essentially European origins). Acceptance of and commitment to the Treaty of Waitangi makes the New Zealand situation potentially unique in that it requires adherence to the concept of partnership and not just sensitivity to ethnic differences and needs. For clinical psychologists in New Zealand cognitive behaviour therapy, once thought to be culture-free, is being reconsidered from the perspective of biculturalism. For us, taking this bicultural approach raises challenges for training and services, which are somewhat different from a cultural competence requirement.

At the University of Waikato, the Postgraduate Diploma in Clinical Psychology (PGDCP) programme trains clinical psychologists to become generalist practitioners. Six to eight students are selected each year for entry into the three-year training programme so at any given time there may be up to 25 students in various stages of training. Over the last four years our focus increasingly has been to encourage Maori to consider clinical psychology as a career and to provide an environment which respects Maori values and practices and supports both Maori and Pakeha students through their training. Three clinically experienced staff members, the Director, a Lecturer and a Senior Clinical Tutor are involved with the PGDCP training programme and work closely together on the challenges and opportunities that this situation presents.

This presentation will discuss aspects of these issues such as why we take this approach, how we implement it, and our success to date.

Seeing is Believing: An Innovative Method of Increasing Collaboration During Case Formulation

Mark Latham and Heather Lucas, Leeds Community and Mental Health Services Trust and Mark Wilson, Community Health Sheffield Trust

Cognitive-Behavioural Therapy (CBT) is collaborative in style, emphasising a self-help model with the client gradually becoming more his/ her own therapist as the therapy progresses  (Padesky 1995). Individual case formulation has increasingly been seen as important in CBT over the past few years (Butler 1998): Its principle functions are to increase understanding of the client's problem for both client and therapist and to guide subsequent treatment interventions (Padesky 1996).  An innovative method of formulating visually with clients will be presented. Whilst offering little that is new in terms of content in case formulation, it will be argued that the process of this method has several advantages over more traditional approaches, particularly in optimising collaboration and enhancing flexibility. Videotaped examples of its use will be shown in order to demonstrate its application in clinical practice. Support for the efficacy of the technique will be drawn from indirect evidence regarding the importance of the therapeutic relationship. Suggestions will be made for future evaluations of its impact on therapy outcome.

References: Butler G (1998) Clinical Formulation, in AS Bellack and M Hersen (Eds) Comprehensive Clinical Psychology, Vol 6, Pergamon Press, Oxford; Padesky CA (1996) Developing Cognitive Therapist Competency: Teaching and Supervision Models, p.274, in Paul M. Salkovskis (Ed.) Frontiers of Cognitive Therapy, The Guilford Press, New York; Padesky CA and Greenberger D (1995) Clinician's Guide to Mind Over Mood, pp.6-10, The Guilford Press, New York.

Cognitive Behaviour Therapy Approach to Disputing Dysfunctional Thoughts: From Theory to Practice

Danny C.K.Lam,

Disputing or helping clients to change the way they think about negative events can often be the most difficult part of the therapeutic process. In the eyes of some clients, the dysfunctional thoughts that cause emotional and behavioural disturbances are both logical and rational. They are often able to substantiate their 'rationality and logic' with evidence, due to the selective nature of their thinking process.

An effective strategy in shifting the client's dysfunctional thinking is to engage the client in an examination of his/her dysfunctional thinking and to develop objective and abstract thinking that the client could relate to his/her personal experience/problem. Another useful disputing strategy is to help the client to realise the consequences of holding on to his/her dysfunctional thinking and the potential benefits to changing. In this paper, the author uses a number of case examples to discuss the rationale that underpins different practical strategies for effective disputing. These strategies constitute a useful 'disputing framework' that inform the conceptual and practical issues underpinning a range of evidence-based disputing techniques that target the change at the levels of cognition, emotion and behaviour.

2.  Cognition and Emotion: Findings Across Disorders

A Longitudinal Study of Cognitive Abnormalities in Delusions at Different Levels of Information Processing

Emmanuele Peters, Institute of Psychiatry, S. Day, University College, London, and Philipa Garety, St Thomas' Hospital, London

Three tasks were included in this study: negative priming, a probabilistic task, and the pragmatic inference task (PIT). Negative priming is at the interface of preconscious/conscious processing. The probabilistic task measures controlled reasoning processes. The PIT is concerned with implicit attributions, accessing preconscious schema. Seventeen deluded, 18 depressed inpatients, and 20 normal controls, had data available at two time points (symptomatic and remitted for the patient groups). At Time 1 the deluded sample made up their mind on the basis of less evidence than both other groups on the probabilistic task, and were more influenced by evidence than both other groups on the probabilistic task, and were more influenced by disconfirmatory evidence than the normals. No differences were found on the PIT or negative priming at either time point, suggesting hat the abnormality in delusions lies at the conscious, reasoning level. When remitted, differences on the probabilistic task disappeared, although this was due to the depressed and normals making up their minds significantly quicker than at time 1, suggesting a practice effect. The deluded remained stable on the data-gathering part of the task, but there was a trend towards normalisation on the probability judgement condition. This supports recent suggestions that the reasoning bias is one of data-gathering rather than probabilistic judgment.

The Role of Magical Thinking in Obsessive-Compulsive Concerns.

Danielle A. Einstein¹ and Ross G. Menzies^{2 1}Department of Medical Psychology, Westmead Hospital, Sydney NSW Australia. ²School of Behavioural and Community Health Sciences, The University of Sydney, Lidcombe NSW 2141 Australia.

Thought Action Fusion (TAF) has been postulated by cognitive theorists to be an important presenting feature of many individuals with Obsessive Compulsive Disorder (OCD). However an extremely similar construct, Magical Thinking, may provide a more accurate depiction of difficulties encountered by individuals with OCD.  In this study the strength of the relationship between TAF and obsessive compulsive symptoms was compared to the strength of the relationships observed between magical thinking, superstitious thinking and obsessive compulsive symptoms. These relationships were explored within a normal sample. The Maudsley Obsessive Compulsive Inventory, the Padua Inventory, the Thought Action Fusion Scale, the Magical Ideation Scale and the Lucky beliefs and behaviour scales were administered to 85 participants. Correlations between the independent variables indicated small to moderate positive relationships between all scales except TAF moral. Significant correlations were obtained between TAF Likelihood for self, Lucky behaviours, Lucky beliefs and the Padua Inventory (.34 ³ r ³ .30). TAF Likelihood for self was also significantly correlated with the MOCI (r = .32). Magical Ideation demonstrated significant correlations with the MOCI (r = .42) and the Padua (r = .53). Importantly, partial correlations revealed that all relationships between the independent variables and obsessive compulsive symptoms were accounted for by Magical Ideation. That is, no correlation between TAF, Lucky beliefs/behaviours and the two global OCD scales remained significant when Magical Ideation scores were held constant. The data suggest that the constructs of TAF, Superstitious beliefs and Superstitious behaviours, are related to OC symptomatology only to the extent that they relate to the core construct of Magical thinking. The Magical Ideation scale demonstrated the strongest correlations with obsessive compulsive symptoms suggesting that it should be used as a primary measure of magical thinking in preference to the remaining scales. The findings suggest that targeting magical thinking may be beneficial in the management of obsessive compulsive symptomatology. Treatment procedures designed to reduce magical thinking will be described, and initial case outcome data presented.

Can Problem-Solving in Depression be Improved with Specific Autobiographical Memories?

Lorna Goddard, St. George’s Hospital Medical School, Barbara Dritschel & Andy Burton

University of East London

Previous research has found a connection between poor social problem-solving skills (SPS) in depression and the use of a non-specific knowledge base. Our aim in this study was to examine if priming specific autobiographical memory retrieval in a clinically depressed group would therefore improve SPS skills. Participants performed the Means-End Problem-Solving task (MEPS) task. Prior to problem solving, the primed group were required to retrieve a specific memory. The non-primed group were questioned about their memory retrieval after problem solving. We predicted that the primed group would retrieve more specific memories and subsequently exhibit superior problem solving relative to the non-primed group where retrieval was left to take a natural course. Participants were also asked to judge whether the memories that they retrieved were helpful or unhelpful for problem solving.  Results showed that specific memory retrieval was greatly increased in those who were primed. However, this did not have an apparent effect on problem solving. Nevertheless, those who were primed to retrieve specific memories reported a significantly higher proportion of memories, which they perceived as helpful to the problem-solving process. We argue that the priming technique may, therefore, have positively affected components of the problem-solving process which are not readily observable with the MEPS technique and that amnestic therapies may well be beneficial for problem-solving in depression.

Future Thinking in Eating Disorders

Joanne Godley,  King’s College Hospital Medical School, Denmark Hill, London, Kate Tchanturia, Institute of Psychiatry, De Crespigny Park, London, Andy MacLeod,  Royal Holloway, University of London, Egham

and Ulrike Schmidt., Eating Disorders Unit, South London & Maudsley NHS Trust, Denmark Hill, London

Aims: The importance of the kinds of thoughts that individuals have about their future has been highlighted in cognitive theories of depression and anxiety. The present study is the first to examine future-directed thinking in-patients with eating disorders compared with community controls. Subjects and Methods: 26 patients with anorexia nervosa, 19 patients with bulimia nervosa and 36 female controls were interviewed using the “Future Thinking Task” (FTT). This is an adaptation of a standard verbal fluency paradigm, and past research has proven it to be a robust measure when used with individuals who engage in self-harm, or have depression or anxiety disorders. The Future-thinking task asks people to generate future positive and negative anticipated events, over three time periods. In addition to the quantitative aspects of future thinking, the FTT also incorporates qualitative aspects of the anticipated events, the likelihood of the event actually occurring, and the emotional value of the event assuming it did occur. The Short Eating Disorder Evaluation and the Hospital Anxiety and Depression Scale were also administered. Results: Both anorexia nervosa patients and bulimia nervosa patients were significantly more negative than controls in their future-oriented cognitions. Bulimia nervosa patients also showed a significant reduction in their positive future-oriented cognitions, with anorexia nervosa patients showing only a trend in the same direction, compared to controls. Conclusions: Bulimia nervosa patients resemble individuals who are both anxious and depressed, whereas those with anorexia nervosa resemble individuals with anxiety disorders in their future-oriented cognitions.

 Peri-Traumatic Information Processing and the Development of Intrusions

Emily Holmes, Royal Holloway, University of London,  Chris Brewin. University College London and  Teresa Peck ,  Royal Holloway, University of London 

How does what people do during trauma effect the development of their intrusive memories? Peri-traumatic dissociation, namely dissociation at the time of trauma, is believed to lead to more intrusions of the trauma. Retrospective accounts by trauma survivors indicate that if they dissociated during trauma they were more likely to be affected by post-traumatic stress symptoms (Shalev, Peri, Canetti and Schreiber, 1996). However, there has been a lack of experimental or prospective evidence to support this. Further, little research has investigated behaviours during trauma that may protect against intrusion development. The current study aims to investigate peri-traumatic behaviour and the subsequent development of intrusions using an experimental paradigm.

Student participants were exposed to an analogue trauma - a stressful film of road traffic accidents. Alternative predictions were made about the effects of 3 concurrent task conditions while viewing the stressful film, regarding the amount and duration of subsequent intrusions. According to Dual Processing Theory (Brewin, Dagleish and Joseph, 1996) a peri-traumatic dissociation task may lead to the encoding of the trauma in a more sensory, situationally accessible memory (SAM). This type of memory would lead to the trauma being spontaneously re-experienced as intrusions. Conversely, a peri-traumatic task, which interrupted memory encoding in the SAM system, such as a visuo-spatial tapping task, would be predicted to lead to less intrusions. The experiment compared intrusion development between 3 peri-traumatic conditions: (1) a dissociation task, (2) a visuo-spatial tapping task and (3) a no-task control.

Sixty-nine student participants were screened for their ability to dissociate voluntarily using a dot staring task. State dissociation was assessed using a self-report questionnaire and change in heart rate to obtain subjective and objective measures. The fifty-one participants who dissociated and passed the screen, were then randomly assigned to 1 of the 3 experimental conditions. After viewing the stressful film, participants kept a diary for one week to record any intrusions. In this they rated how fragmented and distressing any intrusions were. After one week, participants returned for a follow-up. They completed a measure of explicit memory and a questionnaire to describe their most prominent intrusion.

Preliminary analysis of the results indicates that there is a significant difference in the number of intrusions and days with intrusions between experimental conditions in the direction predicted. Specific results concerning intrusion development will be discussed in more detail, including measures of explicit memory, attention, mood and intrusion phenomenology.

Implications of the study for our understanding of re-experiencing symptoms in post-traumatic stress disorder will be discussed.

3.   Issues in Training and Supervision

 Using Cognitive Therapy Techniques in The Training Process

Frank Wills, Principal Lecturer in Counselling, Department of Health and Social Care, University of Wales College Newport.

A number of studies have suggested that ‘personal philosophy’ is a key variable in determining choice of orientation for counsellors and psychotherapists ( Dryden & Vasco, 1994). A key element in determining preference for Cognitive Therapy seems to be the degree to which a trainee is open to scientific reasoning and a somewhat ‘tough-minded’ approach. (Erickson, 1993, Wills, 1999, 2000).

Another major factor seems to be the degree to which the trainee is comfortable with structure (Wills, 1999). Although these general charactertistics are somewhat predictive of both interest in and facility in learning Cognitive Therapy, individual trainees also show variations in the way they assimilate and adapt to Cognitive Therapy concepts in training. Methods such as thought records can be adapted for use during training so that the way trainees take on ideas can be tracked and modified in the case of difficulty. This matches moves in Higher Education research towards more thoroughgoing methods of understanding how student epistemological frameworks develop.(Laurillard, 1993).

Do We Preach What We Practice? The Potential Utility of Problem-Based Learning in the Training of Mental Health Professionals.

Dale Huey, Lecturer in Clinical Psychology, University of Newcastle and Newcastle Cognitive & Behavioural Therapies Centre.

Cognitive and behavioural psychotherapists, like most health professionals, are in essence clinical problem-solvers. When dealing with mental health problems there maybe an even greater reliance upon inductive clinical reasoning during the problem-solving process. For example, rather than being able to take a more deductive approach to developing a provisional problem formulation, practitioners may have to rely upon making sense of the co-occurrence of often complex and poorly delineated problems. There have been a number of claims made, predominantly in the literature on medical education, regarding the utility of problem-based learning (PBL)—a systematised form of discovery learning—for achieving aims central to the performance of this role. The claims made pertain to the perceived benefits of PBL over traditional lecture-based learning or other forms of expositional teaching. In this paper, after further elaborating the nature of mental health practice and describing PBL, we will review the putative cognitive benefits of PBL and explore how these may be particularly pertinent to scientific mental health practice. Comparisons will be made between facilitating learning within professional education and within therapy.

Can General Practitioners be Taught to Utilise Cognitive Behavioural Techniques for Panic Disorder?

Julie Forrest, Community Health Sheffield NHS Trust, Sheffield., Charles T. Heatley, Birley Health Centre, Sheffield and Tom Ricketts, Community Health Sheffield NHS Trust, Sheffield.

Objective: To determine the effectiveness of a training package for General Practitioners utilising a CBT guided self-help manual for clients suffering from Panic Disorder. Design: Randomised Controlled Trial. Subjects: 17 GPs, largely GP principals from the Sheffield area. Interventions: 2 x 3 1/2 hour training sessions followed by 6 fortnightly 1 1/2 hour group supervision sessions. Models included both exposure based and cognitive approaches. A guided self-help client manual was provided. Method: Random allocation to two training groups, with the second group acting as a control to the first. All participants were assessed at 4 month intervals, before the first training, after the first training, and after the second training. Main Outcome Measures: Assessment of knowledge about Panic Disorder by multiple choice questionnaire. Assessment of clinical skills by means of an innovative videotaped case study method. This involved participants making written responses to a four-part video. These responses were rated blind against validated criteria by two separate raters.

Results: Knowledge did not change significantly as measured by the multiple choice questionnaire. Participants started from a high baseline level of knowledge. There was a significant improvement in ability to assess and plan management of the cases against the criteria (p < .001). Conclusions; Training GPs in the utilisation of CBT techniques via guided self-help improves their ability to assess and manage Panic Disorder. It may be that baseline knowledge is such that diagnosis of Panic Disorder is not a necessary target for training. Further research with a larger sample is proposed.

'Flexible Formats of Clinical Supervision’: Description, Evaluation, and Implementation Derek Milne & Veronica Oliver, Centre for Applied Psychology, University of Newcastle 

Clinical supervision is central to initial professional training and to continuing professional development, taking up a significant proportion of mental health professionals time.  However, the methods used in supervision appear to be dominated by the 1:1 format.  This is problematic, given the growing demand for more supervision within the professions, and the drive for enhanced efficiency in the NHS.  To contribute to a solution, the present paper provides a summary of the major options for more flexible and efficient supervision formats.  Clinical psychology is presented as the illustrative profession.  These options were developed and evaluated through a national survey of clinical psychology training courses (N=13) and a regional action research project.  The project involved over 100 clinical psychology supervisees, supervisors, service managers, and course tutors in open meetings and individual interviews, and gathered data on the use of and attitudes towards flexible supervision formats.  The presentation will describe these major options in more detail, as well as reporting the results which suggested that 1:1 supervision was most frequently practiced, but that group, co- and mixed supervision formats were also used and were perceived favourably.  It is concluded that flexible formats of supervision are practiced amongst UK clinical psychologists to a significant extent, similar to that of other mental health professionals in the USA.  However, more widespread implementation of these formats would necessitate considerable investment in supervisor training and support, especially in group supervision formats. CBT  concepts will be used to formulate the implementation challenge to both the organisation and the individual. 

The Issue of Suitability for Supervision in Cognitive-Behavioural Therapy

Mark Latham, Cognitive-behavioural Nurse Therapist, Leeds Community and Mental Health Services Trust

The higher profile of cognitive-behavioural therapy (CBT) over recent years has led to a growing number of clinicians with widely varying degrees of training and experience practising CBT (or CBT-type interventions). Many of these clinicians seek clinical supervision from their more highly trained colleagues. Notions of "suitability" are often used when selecting those clients most likely to benefit from CBT and sometimes when choosing those health professionals most likely to benefit from CBT training. However, there has been little emphasis placed on who might be the best recipients of CBT clinical supervision. It is argued that this issue is likely to become more important as the demand for such supervision increases. The prioritisation of scarce resources suggests that only those clinicians that are likely to use CBT supervision to the substantial benefit of their clients should receive it. Otherwise, the supervisors are better employed by working directly with clients rather than with supervisees who are unlikely to translate CBT supervision into enhanced practice.

The findings of an initial study into this area will be presented. Several problems will be highlighted, including choosing appropriate criteria, assessing potential supervisees using these criteria, and the dangers of being either too rigid or too flexible in their application. Finally, some proposals will be made as to how to take forward the idea of selecting suitable supervisees for CBT clinical supervision.

4.  Developmental Issues

Cognitive Behaviour Therapy for Children: Can Children Distinguish Thoughts from Behaviours?

Sarah Quakley and Sian Coker,  School of Health Policy And Practice, University Of East Anglia, Norwich And Karen Palmer, Norfolk Mental Health Care Trust

Despite accounts of adapting cognitive-behavioural techniques for use with young children (e.g. Kendall, 1992, young and brown, 1996) there is little evidence that cognitive behaviour therapy is effective with children, particularly young children. Some authors have argued that young children lack the cognitive capacity to engage in the varied cognitive tasks central to cognitive behaviour therapy.

Seventy two children (31 aged 7-8 and 41 aged 10-11) completed a simple card sort task in which cards with either though statements of behaviour statements written on them were presented to the children in random order and the children were asked to sort the cards into either a 'thinking sentences' or a 'doing sentences' pile. The dependent variable was the number of correctly sorted cards. This was based on a similar task taken from Greenberger and Padesky (1995). Half of the children in each group were provided with concrete visual cue and half were not. IQ level was estimated using the Similarities sub-test from the WISC III.

The results indicated that 71% of 7-8 year olds and 95% of 10-11 year olds were able to correctly sort over 85% of the stimuli. The use of visual cues did not enhance performance in either age group. The effects of IQ were more significant amongst 7-8 years old children; children who failed to complete the task successfully had significantly lower scores on the Similarities sub-test.

The finding suggest that cognitive behaviour therapy may be both acceptable and appropriate for use with most young children. Further research into the specific tasks of cognitive therapy, the developmental level of young children, the adaptation of tasks for children at different level of development is required. This would provide a good basis for formal evaluation of cognitive therapy with children under 12.

Childline at the Red Cross House in Reykjavik, Iceland

Helgi Hjartson, Department of Counselling and Psychology in Day Care Centre in Reykjavik and & Eirikur Orn Arnarson, National University Hospital, Reykjavik, Iceland

Telephone calls received since the inauguration of the Childline at the Red Cross House in Reykjavik in 1987 were included in this study. The purpose of the investigation was to find out the reason for calling and to compare the telephone calls received from children and adolescents with those from adults. The 26837 telephone calls registered at the Childline during the period 1987 until the end of October 1995 formed the basis for data analysis. The Childline registration sheet was used for collecting data for subsequent analysis. The registration sheet filled in by the employee is divided into two parts: general information about the caller and the reason for calling. More girls than boys called the Childline, which is in accord with previous findings. About half the calls made by children and adolescents were from the country, the reason being limited social services available in the country. Another explanation is the closely-knit community in the country encouraging seeking outside support. Most of the calls were made by children and adolescent callers between 12.00 and 16.00 p.m. after school while parents were at work. There is a marked difference between adults and children and adolescent callers in relation the subjects of discussion. Children and adolescents talked about matters relating to those common in adolescence, e.g. love, relationships with adults, questions relating to body image, sex, questions pertaining to pregnancy and abortion. Most of the adults sought advice about their child. Many callers in both groups were in low spirits when they called. A gender difference was reflected in girls in relation to difficulties experienced in love, pregnancy and abortion. More women than men contacted the Childline seeking advice relating to her child whereas men sought advice for their personal problem. Th experience of the Childline underlines the importance of such a service being available for children and adolescents in an emergency, for seeking advice and being able to talk to someone when in need.

The Validity of Dynamic Assessment Methods and Treatment Approaches for Chinese Children with Learning Disabilities

Alice Cheng Lai, The Hong Kong Polytechnic University, Hong Kong, China

Dynamic assessment involves measuring both unassisted and assisted performances. The paper will report a case study approach of the validity of dynamic assessment and treatment strategies among children with learning difficulties. Previous research has indicated that dynamic assessment techniques have offered benefits with regards to improving the assessment and treatment of children, especially children with learning difficulties.  The children in this study had to compose an article with an assigned topic, which is one of the typical tasks in the local schools. When the children experienced difficulties they were given a series of hints.  The children’s performance at the static pretest, post-test and dynamic training phase were measured and analyzed among poor readers and children with specific reading difficulties.  The results of the study provide some evidence that dynamic measures have a degree of concurrent and predictive validity, especially among children with learning difficulties.  The discussion will be related to the potential implications for our views of assessment and teaching of children with learning difficulties and specific learning disabilities.

Childhood Contextual Correlates and Adult Psycho-Social Consequences of The Forgetting of Childhood Sexual Abuse

E. Hunter, Department of Psychiatry, Institute of Psychiatry, University of London & B. Andrews

Psychology Department, Royal Holloway, University of London.

Introduction:  A substantial number of empirical studies have investigated the reported forgetting of childhood sexual abuse (CSA). However, relatively few childhood factors, which might have an influence on memory, have been examined, and few studies have investigated the possible effects of such forgetting on adult psychological and social functioning.  Method: Semi-structured interviews were conducted with 82 women and men who reported CSA. These participants were asked in detail about their childhood experiences, current social functioning, and adult clinical history. Regression analyses were conducted to determine the contribution of individual factors in predicting subsequent reports of forgetting. Results. Four childhood factors significantly predicted abuse forgetting : frequency of the abuse, and of peri-traumatic dissociative reactions; normalising of the abuse by the perpetrator; and paternal antipathy. No significant differences were found between those with, and without, a period of abuse forgetting in terms of current or lifetime episodes of depression; alcohol/substance misuse or marital or work status. However, those reporting a period of abuse forgetting were significantly more likely to have obtained university degrees, and to score higher on the measure of current dissociative functioning. Discussion. Childhood cognitive and emotional factors may have an influence on whether sexual abuse is remembered or forgotten. The results largely failed to find support for predictions that abuse forgetting is either beneficial or detrimental to adult psycho-social functioning, although there may be some benefits in terms of academic achievement. Finally, dissociation appears to play an important role in the forgetting of such aversive experiences

CBT for Adolescents with Impaired Functioning after Psychiatric Illness: Efficacy of a Group Treatment Study

Bea Vickers, Imperial College of Science, Technology and Medicine, London

Deficits in social functioning are known to be core features of most psychiatric and psychological conditions suffered by adolescents, are frequently residual symptoms following recovery from illness, and constitute risk factors for future relapse.

The present study is a preliminary evaluation of the effectiveness of a new cognitive-behavioural group treatment protocol for residual deficits in functioning following psychiatric illness, in adolescents. Eight adolescents, who had all received treatment for a variety of psychological and psychiatric conditions, were treated in a 12-session group programme. Treatment emphasised the acquisition of skills by repeated practice and homework, and involved problem solving, cognitive restructuring, anger management, social anxiety management, and relapse prevention. The clinical changes in adolescents who attended the group programme are described as brief case vignettes, and quantitative outcomes in terms of parent, school and self-reports at the end of the programme are presented. Both types of measures indicate a marked clinical gain from the group intervention, particularly for teenagers whose primary deficits were in social skills. Overall, these findings support the continued evaluation of this protocol for adolescents with impaired functioning after psychiatric illness.

Alcohol Use Among British University Students : A Time for Intervention?

Hayley Pattinson, Val Curran and Maeve Ennis, Sub-department of Clinical Health Psychology, University College London

Is there a need for the development of early intervention programmes to address problems of alcohol use within the undergraduate population? In 1992 the government published the 'Health of the Nation', outlining health targets for the NHS to achieve by the year 2005. One of the targets that this paper identified was the reduction of alcohol-related problems. Research examining the impact of alcohol-related problems on the health service, reported that 25% of general medical hospital beds are filled with patients with such problems (Glass and Strang 1991). Although, it has been identified that the heaviest consumers of alcohol are young men aged 18-24 years (Office for national Statistics 1998), little research has been carried out on the student population, where alcohol is frequently viewed as being both affordable and accessible. With an increasing number of young adults now applying to universities and concerns regarding the level of alcohol misuse within the health professions (BMA 1998; Glatt 1982), the BMA highlighted the need for research to examine patterns of alcohol use in undergraduate students, to determine whether patterns of alcohol misuse begin at this early stage. This study therefore aimed to examine the health and well being of psychology and medical undergraduates attending a British university, in particularly focusing on patterns of alcohol use and possible links with anxiety and depression.

A total of 570 questionnaire responses were received, with a response rate of 98.2% for questionnaires administered during lectures. Students were asked to complete a pack containing AUDIT (Alcohol Use Disorders Identification Test), GHQ-12 and the HAD scale, in addition to a questionnaire specifically designed to elicit attitudes regarding alcohol use and the university culture.

Preliminary analyses of the results indicate that there is a significant difference in the level of alcohol use between psychology and medical students that is contrary to expectations. It would appear that the student population as a whole is consuming alcohol at a level that is linked with the onset of alcohol-related problems and dependence (Saunders et al. 1993), and that 80% believe that the university culture is responsible for actively encouraging high levels of drinking. This research clearly raises issues regarding the attitudes towards alcohol consumption within the university system and what the prolonged effects of drinking at this level may be. This paper will also explore possible links between alcohol use and levels of anxiety, to establish whether there is a causal link between drinking and levels of stress.

It is anticipated that the findings of this study will have implications for university guidelines and for undergraduate education programmes.

5.   Affective, Obsessional and Other Difficulties

Panic Disorder with Agoraphobia Associated with Dizziness:  Characteristic Symptoms and Psychosocial Sequelae

Lucy Yardley^a*, Natalie Owen^b, Irwin Nazareth^c, Linda Luxon^{d a}Department of Psychology, University of Southampton, Highfield, Southampton SO17 1BJ, UK ^bPsychobiology Group, Department of Epidemiology and Public Health, University College London, Gower St, London W1E 6BT

^cDepartment of Primary Care and Population Sciences, Royal Free and University College Medical School, University College London, Rowland Hill St, London NW3 2PF ^dDepartment of Neuro-otology, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG

Background Dizziness is a very common symptom of panic, especially in conjunction with agoraphobia.  Dizziness may simply be a somatic symptom of anxiety arousal, but hospital studies have shown considerable co-morbidity between panic disorder and balance disorders, which cause dizziness.  Consequently, in an unknown proportion of cases of dizziness, deficient balance system function may contribute to symptomatology

Aims: The first aim of this study was to assess the prevalence of symptoms of panic disorder and agoraphobia in a representative community sample of people reporting dizziness.  The second aim was to identify unique characteristics of people with specifically dizziness-related panic by comparing the physical and psychological profile of those whose panic was consistently linked to attacks of dizziness and those in whom dizziness was just one of many, variable somatic symptoms of panic. 

Methods: A representative sample of 128 people with current dizziness was obtained from an epidemiological survey in the community.  Participants completed a set of validated questionnaires assessing symptoms of balance disorder, somatic anxiety, panic attacks and agoraphobia, and levels of disability and handicap. 

Results: Nearly two-thirds of the sample reported having panic attacks, and one in four met the central criteria for panic disorder.  Predictably, those with panic and dizziness reported significantly more anxiety, depression, phobia and autonomic symptoms than those with only dizziness.

The frequency, number and duration of dizziness and balance-related symptoms did not differ in those with or without panic symptoms, and similar rates of giddiness and instability were reported in all sub-groups.  However, people whose panic symptoms were consistently associated with dizziness reported higher rates of vertigo than other panickers, and higher rates of fainting than both other panickers and people with dizziness but no panic.  People whose panic was consistently associated with dizziness also reported higher levels of agoraphobic behaviour and occupational disability than did other panickers. 

Conclusions: A high proportion of people with dizziness reported panic, and those whose panic was consistently linked with dizziness had more behavioural problems (occupational disability and agoraphobia) than other panickers.  Dizziness linked to deficient balance system function may therefore be a significant contributing factor to agoraphobia.  However, evidence of minor deficiencies of balance system function is quite common in ‘healthy’ people, who will admit on questioning to mild dizziness, especially in the perceptually disorienting situations feared by people with agoraphobia (e.g. busy public spaces, transport).  It is possible that concern about dizziness (especially if perceived as likely to lead to falling or fainting) may be the cause both of panic and agoraphobia, and of seeking and obtaining confirmation of balance system dysfunction, thus explaining the co-morbidity between panic and balance disorder.  Explanation of balance system function and perceptual-motor triggers for disorientation may help people with dizziness-related panic and agoraphobia to predict and control attacks of dizziness, thus reducing vulnerability to dizziness-provoked panic and agoraphobia.

Psychosocial Characteristics of Unipolar and Bipolar Patients, Pre and Post Cognitive Therapy: A Case Series.

Marie Pope University of Newcastle, Jan Scott University of Glasgow, Anne Garland Salford NHS Trust and Steve Moorhead University of Newcastle

From its original development for the treatment of unipolar depression, cognitive therapy has been successfully used to treat an increasingly diverse population. There is current activity in the employment of cognitive techniques for schizophrenia and personality disorders, and also recently for bipolar disorder.

It is the aim of this paper to compare case studies of 2 unipolar (chronic depression), and 2 bipolar patients, who have received modified Beckian cognitive therapy. The comparisons will include psychosocial assessments given pre-therapy, and at longer term follow-up. The assessments comprise measures of: mood state, dysfunctional beliefs, self-esteem, and social adjustment.

There will also be a summary of the protocol, describing models of treatment given, number of sessions, and time scales.

In order to gain some understanding of the salient factors occurring in the process of treating these 2 groups, clinical observations of therapists, will also be included for interest.

The sample has been selected from 2 independent studies, ‘Prevention of Relapse in Residual Depression by Cognitive Therapy’, (Paykel et al `99), and the other currently under review, ‘Cognitive Therapy for Bipolar Disorder, A Pilot Study’, (Scott et al).

It is hoped that this brief description of 4 patients will give some insight into the treatment of 2 different and difficult populations.

Response to Cognitive Therapy in Depression: The Role of Stable Hopelessness

Willem Kuyken, School of Psychology, University of Exeter and Aaron T. Beck, Department of Psychiatry, University of Pennsylvania

This study prospectively examined the effect of stable hopelessness on outcome in cognitive therapy. Hopelessness, a particular form of dysfunctional cognitions about the future, predicts suicide attempts and suicide completion (Beck, Brown, Berchick, Stewart, & Steer, 1990). Furthermore, there is indirect evidence that hopelessness predicts response to cognitive therapy, in terms of early termination of therapy (Dahlsgaard, Beck, & Brown, 1998). In a naturalistic study set in an outpatient cognitive therapy clinic, over 100 depressed patients were followed over the course of cognitive therapy. Initial hopelessness and stability in hopelessness were assessed using the Beck Hopelessness Scale (Beck & Steer, 1993). As was hypothesized, our preliminary analyses of pre- / post-therapy comparisons suggest that patients whose level of hope changes with early interventions make more rapid and pronounced improvements during “real world” cognitive therapy.

Obsessive Compulsive Disorder and Brain Injury: Case Illustration of a Cognitive Behaviour Therapy in Neuro-Rehabilitation

Huw Williams and Jonathan Evans, Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely

Many survivors of brain injury become depressed or anxious due to the range of losses, stresses, and diminution of coping skills they experience. We present a case illustration of a survivor of traumatic brain injury that presented with an obsessive-compulsive disorder. We describe how his pattern of symptoms emerged as a result of the interaction of premorbid personality, adjustment issues, and neuropsychological factors. We describe how his behaviors were managed through the integration of group and individual cognitive rehabilitation and cognitive behavioural approaches. Attention, relaxation and mindfulness training were provided to enable him to minimize checking rituals. We present outcome data showing how his symptoms decreased to non-clinical levels and he achieved his desired social roles. The implication of neuropsychological factors in OCD is discussed.

Long-Term Efficacy of a Cognitive Behavioural Intervention for Recently Diagnosed Rheumatoid Arthritis.

Sharpe, L., Sensky, T. Timberlake, N., Ryan, B. & Allard, S. 

Aims: This study examined the long-term efficacy of a cognitive and behavioural intervention (CBT) for patients with recent onset, seropositive rheumatoid arthritis. Earlier results from this cohort indicated that CBT reduced levels of depression and improved joint function. The aim was to test the longer-term efficacy of this approach.

Method: Fifty-three participants with a diagnosis of classical or definite rheumatoid arthritis, who were seropositive and had less than two years of disease history were recruited into the trial. All participants received routine medical management during the study, although half were randomly allocated to receive an adjunctive psychological intervention. All assessments were conducted blind to the allocation. Analyses were conducted of treatment completers only at pre-treatment, post-treatment and 18 months’ follow-up. 

Results: Significant differences were found between the groups at both post-treatment and six-month follow-up in depressive symptoms.  While the CBT group showed a reduction in depressive symptoms, the same symptoms increased in the Standard group. These results were maintained at eighteen month follow-up. At outcome but not follow-up, the CBT group also showed reduction in c-reactive protein levels. However, the CBT group did show significant improvements at the eighteen month follow up in both levels of anxiety and disability. These indicated that those receiving CBT were less depressed, less anxious and less disabled even eighteen months after intervention.

Conclusion: These results indicate that cognitive-behavioural intervention offered as an adjunct to standard clinical management early in the course of RA is not only efficacious in producing short term reductions in both psychological and physical morbidity, but also offers longer term benefits to patients. Since disability is one of the best prognostic factors of longer term function in RA, it is argued that CBT should be considered in the routine management of patients with RA.

6.   Depression and Related Issues

The Course of Depression in Recent Onset Rheumatoid Arthritis: The Predictive Role Of Disability, Illness Perceptions, Pain and Coping.

Louise Sharpe^{a, c}, Tom Sensky^b,c, Simon Allard^c.

^a Department of Psychology, Royal Holloway, University of London, Egham, Surrey, UK.

^b Imperial College, University of London, London UK.

^c West Middlesex University Hospital, Twickenham Rd, Isleworth, Middlesex, UK.

The aim of this study was to investigate the course of depression for patients with recently diagnosed Rheumatoid Arthritis and to determine whether levels of depression could be predicted. Fifty-six patients with less than a two year history of rheumatoid arthritis were assessed on a variety of clinical outcome and process measures. Twenty-two of the sample were followed up on six assessment occasions over a twenty-one month period. The results indicated that patients became significantly more depressed over time. A series of stepwise multiple regression equations were conducted to examine predictors at each assessment of depression on the subsequent occasion. A set of five predictors were found, which were related to outcome, which were initial level of depression, disability, pain, beliefs about the consequences of arthritis and coping strategies. Coping strategies appeared to be important predictors early in the illness and when assessment periods were more closely spaced together. In the two final assessments, the other four factors were consistently associated with subsequent depression with the regression equation accounting for 77% of the variance. This is the first study to document the importance of illness perceptions in recent onset rheumatoid arthritis. The implications for management of early RA are discussed.

Response to Cognitive Therapy in Depression:: The Role of Maladaptive Beliefs and Personality Disorders

Willem Kuyken, University Of Exeter, Nicole Kurzer Robert J. De Rubeis, Aaron T Beck and Gregory K Brown, University Of Pennsylvania

This study examined whether personality disorder status and beliefs that characterise Clusrer C personality disorders negatively affect response to cognitive therapy. In a naturalistic study set in an outpatient cognitive therapy clinic, 162 depressed patients with and without personality disorder were followed over the course of cognitive therapy. Pre-/post-therapy comparisons suggested that patients with or without personality disorder respond to a comparable degree to 'real world' cognitive therapy. As would be hypothesized by cognitive theory of personality disorder (beck, freeman and associates, 1990), it was not personality disorder per se that predicted outcome, but rather the maladaptive beliefs, specifically avoidant and paranoid beliefs, that predicted some of the variance in therapy outcome.

Predicting Outcome in Clients Attending a Cognitive-Behavioural Clinic for Depression

Jane Cahill, Michael Barkham, Gillian Hardy, Anne Rees, David Shapiro, and Norman Macaskill. University of Leeds

Although there is convincing evidence that cognitive therapy CT therapy is effective for the treatment of depression, the extent of improvement varies considerably between clients both in naturalistic settings and in clinical trials. In this study we explore the impact on CT outcomes of factors or parameters widely studied in non-CT therapies that may explain this variability and lead in time to improvements in CT effectiveness.  We considered differences (1) in outcome between clients who had been offered different lengths of treatment, (2) in the rates of change between subsets of depressive symptoms, (3) in outcome and rates of change between clients who completed therapy and clients who did not complete (withdrawal from therapy was not negotiated), and (4) in the ability of cognitive and interpersonal styles to predict outcome.

Clients (N=66), who received a DSM-IV diagnosis of major depressive episode, were offered either 12 or between 12 and 20 sessions of CT. They completed a Beck Depression Inventory (BDI) before every therapy session.  A sub-set of clients (N=24) was administered measures of cognitive and interpersonal styles prior to treatment.

The number of sessions offered to clients did not impact on treatment outcome. Different subsets of BDI items responded to therapy at different rates, lending support to Howard et al’s (1993) phase model of therapy. Clients’ interpersonal style (specifically, an underinvolved style) but not their cognitive style, was predictive of treatment outcome.  As predicted, the impact of the underinvolved interpersonal style on outcome was mediated through the therapeutic alliance.

Memories for Childhood Autobiographical Information : Comparing Adult Sexual Abuse Survivors with Controls

Elaine Hunter, Institute of Psychiatry, London  & Bernice. Andrews, Royal Holloway, University of London.

Although there exists a substantial body of research, which has examined the reported forgetting of childhood sexual abuse in adult survivors, relatively little is known about whether abuse survivors show  other memory impairments. In the current study we investigated differences in non-traumatic autobiographical memory for both personal semantic information and episodic memory between abuse survivors who report a period of forgetting their abuse (n=47), survivors with continuous recall (n=35) and controls (n=60), using the childhood section of the Autobiographical Memory Interview (AMI: Kopelman, Wilson & Baddeley, 1990).

The findings were that on the Personal Semantic section of the AMI, the abuse survivor group showed significant impairments compared to the control group. Furthermore, when comparisons were conducted within the abuse survivor group between those survivors with a period of reported forgetting, and those without, the former group were significantly more impaired. Similar analyses were conducted with the scores on the Autobiographical Incident section of the AMI, but no significant group differences were found.

These results suggest that a reported  history of childhood sexual abuse is associated with impairment in non-traumatic autobiographical memory, and this impairment is particularly marked in survivors who also report a period of forgetting their abuse. The findings lend empirical support to the notion that exposure to trauma disrupts the efficient functioning of memory, and that this may affect memory for autobiographical facts unconnected to the abuse during this period.                that exposure to trauma disrupts the efficient functioning of memory, and that this may lead to memory impairments which are not limited solely to memories of the trauma itself, but may affect memory for autobiographical facts unconnected to the abuse during this period.           

The Relationship Between Inflated Personal Responsibility and Exaggerated Danger Expectancies in Obsessive-Compulsive Concerns.

Ross G. Menzies¹, Lynne M. Harris¹, Steven R. Cumming¹, Danielle A. Einstein²

¹School of Behavioural and Community Health Sciences, The University of Sydney, Lidcombe NSW 2141 Australia.

²Department of Medical Psychology, Westmead Hospital, Sydney NSW Australia.

The association between responsibility for a negative outcome, perceived severity of the outcome, and perceived likelihood of the outcome was examined in a sample of 70 undergraduate students. Participants were asked to rate the likelihood and severity of ten negative outcomes, five related to contamination and five related to checking. Thirty-eight participants completed a version of the questionnaire that presented the subject as responsible for the action that may lead to a negative outcome (‘personally responsible’ group). The remaining 32 completed a version of the questionnaire that presented someone else performing the actions that may lead to a negative outcome (‘other responsible’ group). Significant differences emerged between the personally responsible and other responsible groups for severity of outcome ratings but not for likelihood of outcome ratings. Specifically, for both washing and checking concerns, participants in the personally responsible group rated the severity of the potential negative outcome as greater than did those in the other responsible group. The results support the claimed general tendency for individuals to regard an outcome as more aversive if they are personally responsible for that outcome, rather than someone else being responsible. The results suggest that, in general, increasing perceptions of personal responsibility will increase cost or severity estimates in subjective danger calculations, and that responsibility may influence OCD phenomena in this way. Finally, the results suggest that attempts to manipulate responsibility in the laboratory may be confounded by necessarily impacting on cost estimates, and therefore on danger expectancies. A comprehensive cognitive model of obsessive-compulsive phenomena based on these and related findings will be presented.