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Belief change is an important element of much CBT, yet very little consideration has been given to the theories of knowledge, the epistemology, which underlie this process. This article argues that understanding the epistemic basis of the techniques therapists use can help guide their choice of interventions. The empirical evidence for cognitive restructuring is considered, the importance of distancing and decentring noted, and three epistemic styles are identified: the rational-empiricist, pragmatist and ‘constructivist’ approaches. Different schools of CBT emphasise one or more of these. The article describes how these epistemes can be used to make decisions about which cognitive interventions to use, particularly when clients may be sceptical about reality testing because of entrenched beliefs or real-life adversity.

Cognitive behavioral therapy (CBT) has the strongest evidence base of all the psychological treatments for depression. It has been shown to be effective in reducing symptoms of depression and preventing relapse. All models of CBT share in common an assumption that emotional states are created and maintained through learned patterns of thoughts and behaviors and that new and more helpful patterns can be learned through psychological interventions. They also share a commitment to empirical testing of the theory and clinical practice. Beck’s Cognitive Therapy sees negative distorted thinking as central to depression and is the most established form of CBT for depression. Behavioral approaches, such as Behavioral Activation, which emphasize behavioral rather than cognitive change, also has a growing evidence base. Promising results are emerging from therapies such as Mindfulness Based Cognitive Therapy (MBCT) and rumination-focused therapy that focus on the process of managing thoughts rather than their content. Its efficacy-established CBT now faces the challenge of cost-effective dissemination to depressed people in the community.

In this chapter, the authors describe schema informed therapy, offered across time limited settings and with patients with complex presentations. The authors lay out a framework for deciding how and when to use protocol based Schema Therapy (ST) as opposed to schema informed therapy. The chapter begins by describing a course of therapy (20–30 sessions’ therapy) for patients with complexity whose treatment cannot be easily accommodated within a disorder specific model – the discussion outlines indications for this, such as dissociation, self-harm, or emotional instability. The authors describe how this brief approach emphasises the use of formulation, as well as overcoming compensatory strategies, rather than focusing on longer term schema and core belief change. The authors demonstrate that this approach allows the therapist to work relatively briefly with maintaining beliefs and behaviours that can help improve functioning and begin to develop a healthy adult state. The authors then progress to describe how ST techniques can be incorporated into brief work with complex cases, and also incorporated into standard Cognitive–Behavioural Therapy (CBT) work. In standard CBT, these ways of working can be used to overcome impasses and augment cognitive and behavioural methods with emotive and experiential work. The authors include examples of the use of chair work, imagery rescripting, ‘limited reparenting’, letters that aren’t sent and ways of working with the interpersonal relationship. Finally, service considerations, including supervision and support, are discussed.

BackgroundDepression is one of the most common mental disorders in people with advanced cancer. Although cognitive–behavioural therapy (CBT) has been shown to be effective for depression in people with cancer, it is unclear whether this is the case for people with advanced cancer and depression.AimsWe sought to determine whether CBT is more clinically effective than treatment as usual (TAU) for treating depression in people with advanced cancer (trial registration number ISRCTN07622709).MethodA multi-centre, parallel-group single-blind randomised controlled trial comparing TAU with CBT (plus TAU). Participants (n = 230) with advanced cancer and depression were randomly allocated to (a) up to 12 sessions of individual CBT or (b) TAU. The primary outcome measure was the Beck Depression Inventory-II (BDI-II). Secondary outcome measures included the Patient Health Questionnaire-9, the Eastern Cooperative Oncology Group Performance Status, and Satisfaction with Care.ResultsMultilevel modelling, including complier-average intention-to-treat analysis, found no benefit of CBT. CBT delivery was proficient, but there was no treatment effect (−0.84, 95% CI −2.76 to 1.08) or effects for secondary measures. Exploratory subgroup analysis suggested an effect of CBT on the BDI-II in those widowed, divorced or separated (−7.21, 95% CI −11.15 to −3.28).ConclusionsUK National Institute for Health and Care Excellence (NICE) guidelines recommend CBT for treating depression. Delivery of CBT through the Improving Access to Psychological Therapies (IAPT) programme has been advocated for long-term conditions such as cancer. Although it is feasible to deliver CBT through IAPT proficiently to people with advanced cancer, this is not clinically effective. CBT for people widowed, divorced or separated needs further exploration. Alternate models of CBT delivery may yield different results.

SummaryDr Gipps claims that the cognitive therapy for depression rests on a mistake. But his anachronistic analysis of Beck's early research from the perspective of current psychoanalytic theory misses the point. The value of the research was not that it disproved psychoanalytic theory, but that it generated a model of depression that has revolutionised psychotherapy research. Psychoanalysts are belatedly adopting research methods that Beck pioneered half a century ago. The cognitive model of depression has explanatory power for both maintenance and vulnerability and has substantial research underpinning it. Cognitive therapy for depression has a larger body of evidence for its efficacy and relapse prevention effect than any other psychotherapy. Transference-focused approaches to depression have yet to establish themselves in the same way.

Significant advances have been made in our understanding of psychological adjustment to cancer over the last 40 years. Most clinicians now recognise the importance of psychosocial factors and the need for skills in emotional support. In the first phase of psycho-oncology, pioneering work in the 1970s and 1980s mapped the extent of psychological morbidity in cancer. This has been followed by a second phase where clinical trials have demonstrated that psychological treatments are effective. But although clinicians may feel more confident in identifying distress and listening to the patient, they rarely feel confident that they possess the skills to help. This paper will review the progress through the first two phases and argue that we are now in the third phase where we can begin to examine methods for delivering cost-effective psychological care. One of these methods is to equip staff with basic skills to understand and manage psychological distress. This paper will also describe a programme over the last 10 years to evaluate the effectiveness and clinical impact of such training for palliative care professionals.

‘Fighting spirit’ in early-stage cancer comprises optimism about prognosis, a belief that the disease and/or its effects are controllable, and a determination to cope with the situation using various active coping methods. It is associated with better adjustment. In advanced cancer, the usefulness of this coping style is contentious. This systematic review identified eight studies that investigated these qualities in advanced cancer. They provided some evidence that positive attitude and self-efficacy may be associated with better emotional adjustment; active, problem-focused coping appears to be adaptive and avoidant coping maladaptive. However, major methodological flaws make any conclusions highly speculative. Further research in this area using larger samples and longitudinal design is required. Copyright © 2010 John Wiley & Sons, Ltd.

Deliberate non-fatal acts of self-harm, including self-poisoning and self-injury are a significant public health challenge: the incidence of self-harm in young people is in the region of 7–14%. This paper considers the application of cognitive behaviour therapy to people who harm themselves through attempted suicide or self-injury. Models and interventions for self-harm based on problem-solving, Beck's cognitive therapy and other cognitive behaviour therapies are considered, as well as interventions for this behaviour used within the context of treatments for borderline personality disorder. A model of coping with adversity, based on a combination of Lazarus & Folkman's theory of stress and coping and Beck's cognitive therapy is presented. The model is then used to consider how people who self-harm may be helped to better manage the consequences of affective arousal in stressful situations.

BackgroundCognitive behaviour therapy (CBT) has been shown to reduce psychological morbidity in people with cancer, but no randomized controlled trial (RCT) exists in palliative care. We aimed to determine whether home care nurses could be taught to deliver basic cognitive behavioural techniques and so reduce symptoms of anxiety and depression.MethodClinical nurse specialists (CNSs) at St Christopher's Hospice were randomly allocated to receive training in CBT or continue their usual practice. At the end of the trial, nurses were rated on the Cognitive Therapy First Aid Rating Scale (CTFARS) for CBT competence. Home care patients who scored as possible cases on the Hospital Anxiety and Depression Scale (HADS) entered the trial. Participants received home care nursing visits. Assessments were carried out at baseline, 6, 10 and 16 weeks.ResultsEight nurses received CBT training and seven continued practice as usual. The mean CTFARS scores were 35.9 for the CBT nurses and 19.0 for the controls (p=0.02). A total of 328 patients (54%) were possible cases and 80 entered the trial; most of those excluded were too ill to participate. There was an interaction between group and time: individuals receiving CBT had lower anxiety scores over time [coefficient −0.20, 95% confidence interval (CI) −0.35 to −0.05, p=0.01]. No effect of the training was found for depression.ConclusionsIt is possible to conduct a randomized trial of psychological interventions in palliative care but there is considerable attrition from physical morbidity and mortality. Nurses can learn to integrate basic CBT methods into their clinical practice. This training may be associated with better outcomes for symptoms of anxiety.

Negative thoughts about the self are a core component of Beck's cognitive triad of depression, and are seen by some as the central cognitive symptom of the disorder. The role of negative thoughts about the self in secondary depression associated with medical illness is less clear: thoughts relating to hopelessness and helplessness rather than guilt, self blame and failure may be more prominent. This study tested the hypothesis that the cognitive symptoms of depression in cancer patients would be less negatively self-referent than a psychiatric control group. Forty patients with cancer referred to a psychological medicine department were matched for age, sex and BDI score with 40 patients referred to a psychological therapies department for CBT. The cognitive-affective section of the BDI (items 1–14) was divided into a negative self-referent cognitions subscale (items 3, 5, 7, 8) and a mood-motivation subscale. These two subscales were then compared with the somatic-performance subscale (items 15–21). As a percentage of the total matched BDI score, the cancer patients had more somatic symptoms (42.7 v 34.8%), equivalent mood/motivation symptoms (44.5 v 45.6%) and less negative self-referent symptoms (12.8 v 19.5%). This difference may apply more to mild symptoms than moderate-severe symptoms. Some preliminary support for the hypothesis is therefore available.

BackgroundAbusive experiences in childhood and adulthood increase risks of psychiatric morbidity in women and independently increase risks of further abuse over the lifetime. It is unclear which experiences are most damaging.AimsTo measure lifetime prevalence of abusive experiences and psychiatric morbidity, and to analyse associations in women primary care attenders.MethodA cross-sectional, self-report survey of 1207 women attending 13 surgeries in the London borough of Hackney, UK. Independent associations between demographic measures, abusive experiences and psychiatric outcome were established using logistic regression.ResultsChildhood sexual abuse had few associations with adult mental health measures, in contrast to physical abuse. Sexual assault in adulthood was associated with substance misuse; rape with anxiety, depression and post-traumatic stress disorder but not substance misuse. Domestic violence showed strongest associations with most mental health measures, increased for experiences in the past year.ConclusionsAbuse in childhood and adulthood have differential effects on mental health; effects are increased by recency and severity. Women should be routinely questioned about ongoing and recent experiences as well as childhood.

The Cancer Coping Questionnaire is a brief, self-rating scale designed to measure coping strategies taught in Adjuvant Psychological Therapy. This paper describes the development of the 21 item Cancer Coping Questionnaire (CCQ) in a sample of 201 patients with mixed cancers. The construct validity and reliability of the instrument are reported from work on 3 samples (a mixed cancer group, n=42; women with breast cancer, n=50; and a group of patients referred for psychological help, n=48). The CCQ showed very good internal reliability and test-retest reliability. As hypothesised cancer patients with more psychological morbidity demonstrated lower CCQ scores, and the CCQ correlated with measures of adjustment to cancer. Compared with an established coping inventory (the Coping Responses Indices; CRI) the CCQs overall individual scale (items 1-14) assessed similar coping areas, particularly in relation to the CRIs foci of coping. The CCQ correlated with Active Behavioural Coping methods on the CRI. The study did not demonstrate sufficiently consistent results concerning the Interpersonal Scale of the CCQ to confirm its validity. Further psychometric work is needed, but the study demonstrated the reliability and validity of the CCQ, supporting the view that change in CCQ scores with cognitive therapy indicates improvement in coping.

This study tested the use of a problem solving measure (The Problem Solving Scale: Center for Cognitive Therapy, 1988) as a predictor of outcome in patients receiving cognitive behaviour therapy (CBT) in an NHS psychotherapy service. Lower scores at assessment on the Problem Solving Scale (PSS) were predicted to be associated with poorer outcome for all diagnoses (but particularly depression) and higher dropout. The PSS predicted outcome for depressed patients receiving CBT, but not anxious patients or patients with other disorders. Poorer problem solving was not associated with dropout from therapy. Components of the scale that were most closely correlated with global outcome seemed to reflect the behavioural activation and cognitive restructuring skills taught in CBT for depression. Since this is the second study to connect PSS scores with outcome in depression (Scott, Harrington, House, & Ferrier, 1996), the possibility that aspects of learned resourcefulness are relevant to patients' suitability for CBT remains alive, and further research in this area is indicated.

This study compared the effectiveness of two psychological treatments in a group of 57 patients with various types of cancer attending the Royal Marsden Hospital. Patients referred for psychiatric assessment who met criteria for an abnormal adjustment reaction were randomly allocated to either 8 weeks of Adjuvant Psychological Therapy (APT), a problem-focused, cognitive behavioural treatment programme, or 8 weeks of a comparison treatment of supportive counselling. At 8 weeks from the baseline assessment, APT had produced a significantly greater change than the counselling intervention on fighting spirit, helplessness, coping with cancer, anxiety, and self-defined problems. At 4 months from baseline, APT had produced a significantly greater change than counselling on fighting spirit, coping with cancer, anxiety and self defined problems. It is concluded that APT produces greater change in anxiety, adjustment to cancer and use of coping strategies than a non-directive, supportive intervention over an 8 week period of treatment. This difference persists at follow up 4 months after baseline assessment.

Patients, doctors, and even judges are perplexed by conditions of uncertain existence or etiology, which may affect both mind and body [1]. "Psychosomatic" conditions such as irritable bowel syndrome, premenstrual syndrome, chronic fatigue syndrome, "repetitive strain injury," and other chronic pain syndromes are common, but do not easily fit into a medical philosophy of a separate and divisible mind and body. In this schema, patients suffer from either physical disease or mental illness. The stigma attached to mental illnesses understandably leads many patients to seek a physical diagnosis. Physical diseases will be excluded perhaps by referral to a general physician. The patient may then be told that there is nothing physically wrong. This explanation may be angrily rejected, especially if the physician suggests that the symptoms are "all in the mind" and that the patient should see a psychiatrist. The patient feels accused of either madness or malingering. If he or she then overcomes the stigma and receives psychiatric intervention, they may be told that there is "no formal mental illness present." The patient and general practitioner are back to where they started, with no adequate explanation, diagnosis, or treatment. The frustration and "heart-sink" felt by both patient and doctor is understandable. A rational approach to understanding and treating these conditions can only come when preconceptions about etiology are set aside, and there is a readiness to examine both physiological and psychological components at the same time [2]. Attempts to find physical explanations for psychosomatic illnesses have often failed. For instance, gut motility studies do not always distinguish irritable bowel syndrome subjects from healthy controls [3]. The etiological evidence for viral or immune disorders in chronic fatigue syndrome is inconsistent [4]. Hormonal abnormalities do not provide a comprehensive explanation of premenstrual syndrome [5]. On the other hand, psychiatric disorders often fail to provide comprehensive answers. Although psychiatric disorders often present with physical symptoms [6, 7], and there are past and current associations between psychosomatic and psychiatric disorders [8, 9], a significant number of patients with psychosomatic disorders are

In many ways cognitive and behavioural therapies represent the acceptable face of psychotherapy for the general psychiatrist. They are brief, focused, problem-oriented treatments, which take symptoms seriously. They show an affinity for the medical model in their acceptance of diagnostic categories and their commitment to effective evaluation of treatments through randomised controlled trials. The wide applicability of these therapies is also attractive to the general psychiatrist. Cognitive and behavioural techniques are of major importance in the treatment of anxiety disorders, depression, eating disorders, and sexual dysfunctions, and beyond this core group the methods can be applied to enhance coping and change unwanted behaviours in conditions as diverse as cancer, chronic pain, substance abuse, anger control, schizophrenia, and challenging behaviours in people with learning disabilities.

Our objective was to establish a mechanism for monitoring indicators of the state of health of inner London's mental illness services. Data were collected for a census week around 15 June 1994. Local data collection was coordinated by consultant pyschiatrists working in inner London services. Twelve services participated with a combined catchment population of 2.6 m. They included ten London services which were among the 17 most socially deprived areas of England. Main indicators were admission bed occupancy levels (including an estimate of the total requirement), proportion of patients detained under the Mental Health Act, number of assaults committed by inpatients, number of emergency assessments and CPN caseloads. The mean true bed occupancy (which reflects the number of patients who were receiving, or required, in-patient care on census day) was 130%. To meet all need for acute psychiatric care, including for patients who should have been admitted and those discharged prematurely because beds were full, a further 426 beds would have been required. Fifty per cent of patients were legally detained. Physical assaults were virtually a daily occurrence on the admission units. Average community pyschiatric nurse caseloads were 37, suggesting that the majority were not working intensively with limited caseloads of patients with severe mental illness. These indicators, although imperfect, will allow for some measurement of the impact of local and central initiatives on the poor state of London's mental illness services.

Depressed individuals tend to assign internal, stable, and global causes to negative events. The present study investigated the specificity of this effect to depression and compared depressive attributional styles of individuals with major depression (MD), post-traumatic stress disorder (PTSD), and healthy controls. We indexed attributional style using the depressive attributions questionnaire in 164 participants. Additionally, we assessed appraisals characteristic of PTSD using the post-traumatic cognitions inventory (PTCI), depressive rumination, trauma history, and depression and PTSD symptom severity. Individuals with MD endorsed a depressive attributional style to a greater extent than both individuals with PTSD, who were not depressed, and healthy controls. Depressive attributional style was associated with the severity of depressive and PTSD symptoms, number and distress of traumatic experiences, frequency of rumination, and post-traumatic cognitions. Depressive attributions and PTCI appraisals independently predicted MD and PTSD symptom severity. They may thus be useful in predictingMDand PTSD, and should be targeted in psychological treatments of these conditions. © Springer Science+Business Media, LLC 2011.

Patients attending the Royal Marsden Hospital with newly diagnosed cancers or first recurrence were screened for psychological morbidity. A total of 174 patients who met the inclusion criteria were randomly allocated to either adjuvant psychological therapy, a brief, cognitive—behavioural treatment specially designed for cancer patients, or a routine care control. This paper reports the results of the study one year after the baseline assessment. A total of 134 patients completed questionnaires at one year. Patients who received therapy showed significantly less psychological distress measured on the Psychological Adjustment to Illness Scale. There was a tendency for patients in the therapy group to show more change on measures of helplessness and anxiety. Using the criteria for psychological morbidity employed at the time of entry into the study, at one year only 19% of therapy patients were still in the clinical range for anxiety compared with 44% of the control patients; 11% of therapy patients were in the clinical range for depression compared with 18% of the control patients. This study demonstrates that a brief psychological intervention can produce improvement in psychological functioning which persists up to 10 months after the end of the intervention; in particular, the number of patients who would still meet criteria for ‘caseness’ is reduced. These findings justify further investigation of the efficacy of adjuvant psychological therapy in cancer patients.