Mental imagery, or ‘seeing with the mind’s eye’ (Kosslyn et al. 2001), provokes strong emotional responses (Ji et al., 2016). To date, there is a lack of data on the content and clinical characteristics (e.g. vividness, likelihood, emotional effects) of spontaneous mental images (MI) in people with bipolar disorder (BD) according to their thymic states.

The current study sought to assess the characteristics associated with the contents of MI in people with BD.

Forty-two euthymic individuals diagnosed with BD (American Psychiatric Association, 2013) were asked to self-report their MI during depression, (hypo)mania and euthymia. Participants also rated levels of vividness, likelihood and emotional activation related to MI (i.e. valence, arousal, type of emotion).

The contents of the MI revealed phenomenological aspects of BD. Different themes were associated with each thymic phase. In (hypo)mania and in euthymia, the mental images were assessed as being as vivid as probable (p>.05). (Hypo)manic and euthymic-related MI activated more pleasure than displeasure (p<.001) and were mainly associated with joy. In depression, MI were assessed as more vivid than likely (p<.05). In depression, MI activated more displeasure than pleasure (p<.0001) and induced mainly sadness.

Overall, a congruence between the contents of images and the three thymic phases was found. The content of the MI was related to self-reported emotional effects that were congruent with the thymic phases concerned. The results add new clinical information for the use of imagery-based cognitive therapy in individuals with BD.

Anxiety disorders are the most frequently diagnosed psychiatric conditions in children and adolescents. Cognitive behavioural therapy (CBT) is a well-established and effective treatment for anxiety and related disorders across the lifespan. Expectations of psychotherapy have been demonstrated to affect outcomes, yet there is sparse existing literature on adolescent patient and parent perspectives of CBT prior to engagement with treatment.

This study aimed to qualitatively explore the expectations and perceptions of CBT for anxiety and related disorders among adolescent patients and parents.

Fourteen adolescent patients and 16 parents participated in semi-structured individual interviews or focus groups consisting of 2–3 participants. Interview transcripts were analysed using inductive analysis.

Three themes were identified: worries about CBT, expectations and knowledge of the CBT process, and the role of parents and families. Overall, we found that adolescents and parents had generally positive views of CBT. The outset of CBT saw adolescents and parents express concern about stigma as well as the ambiguity of CBT. Parents continued to express a lack of understanding of what CBT entailed during their child’s treatment course.

These results suggest that both adolescents and parents would benefit from early discussion and reinforcement of expectations for CBT treatment. Further research efforts are warranted and should be directed towards determining appropriate expectations for parental involvement in a child’s CBT course and effective communication of treatment expectations to both adolescents and parents.

Some patients return for further psychological treatment in routine services, although it is unclear how common this is, as scarce research is available on this topic.

To estimate the treatment return rate and describe the clinical characteristics of patients who return for anxiety and depression treatment.

A large dataset (N=21,029) of routinely collected clinical data (2010–2015) from an English psychological therapy service was analysed using descriptive statistics.

The return rate for at least one additional treatment episode within 1–5 years was 13.7%. Furthermore, 14.5% of the total sessions provided by the service were delivered to treatment-returning patients. Of those who returned, 58.0% continued to show clinically significant depression and/or anxiety symptoms at the end of their first treatment, while 32.0% had experienced a demonstrable relapse before their second treatment.

This study estimates that approximately one in seven patients return to the same service for additional psychological treatment within 1–5 years. Multiple factors may influence the need for additional treatment, and this may have a major impact on service activity. Future research needs to further explore and better determine the characteristics of treatment returners, prioritise enhancement of first treatment recovery, and evaluate relapse prevention interventions.

Alopecia areata (AA) is an immunological disorder characterised by hair loss. Individuals with AA report high levels of social anxiety. One intervention that holds potential for reducing social anxiety in individuals with AA is mindfulness-based cognitive therapy (MBCT).

Our key aim was to investigate whether MBCT reduces social anxiety in individuals with AA. The study also investigated whether MBCT reduces depression, general anxiety, and increases quality of life and increases trait mindfulness in individuals with AA.

Five participants with AA took part in an 8-session in-person MBCT intervention. A multiple-baseline single-group case series design was adopted. Idiographic measures of social anxiety were measured each day from baseline, through intervention, to follow-up. Standardised questionnaires of trait mindfulness, social anxiety, depression, anxiety, and quality of life were completed at baseline, post-intervention, and at 4-week follow-up.

All participants completed the MBCT course, but one participant was excluded from the idiographic analysis due to a high amount of missing data. The remaining four participants demonstrated reductions in idiographic measures of social anxiety from baseline to follow-up. These effects were larger between baseline and follow-up, than between baseline and post-intervention. Two participants demonstrated significant improvement in standardised measures of wellbeing from baseline to follow-up – they also practised mindfulness most regularly at home between sessions.

MBCT may be effective in reducing social anxiety and improving wellbeing in individuals with AA, although this might be dependent on the extent to which participants regularly practise mindfulness exercises.

Approximately 10% of young people ‘often’ feel lonely, with loneliness being predictive of multiple physical and mental health problems. Research has found CBT to be effective for reducing loneliness in adults, but interventions for young people who report loneliness as their primary difficulty are lacking.

CBT for Chronic Loneliness in Young People was developed as a modular intervention. This was evaluated in a single-case experimental design (SCED) with seven participants aged 11–18 years. The primary outcome was self-reported loneliness on the Three-Item Loneliness Scale. Secondary outcomes were self-reported loneliness on the UCLA-LS-3, and self- and parent-reported RCADS and SDQ impact scores. Feasibility and participant satisfaction were also assessed.

At post-intervention, there was a 66.41% reduction in loneliness, with all seven participants reporting a significant reduction on the primary outcome measure (p < .001). There was also a reduction on the UCLA-LS-3 of a large effect (d = 1.53). Reductions of a large effect size were also found for parent-reported total RCADS (d = 2.19) and SDQ impact scores (d = 2.15) and self-reported total RCADS scores (d = 1.81), with a small reduction in self-reported SDQ impact scores (d = 0.41). Participants reported high levels of satisfaction, with the protocol being feasible and acceptable.

We conclude that CBT for Chronic Loneliness in Young People may be an effective intervention for reducing loneliness and co-occurring mental health difficulties in young people. The intervention should now be evaluated further through a randomised controlled trial (RCT).

Staff retention, particularly in the Psychological Wellbeing Practitioner (PWP) workforce, has historically been challenging for Improving Access to Psychological Therapy (IAPT) services. This study sought to develop an explanatory model of the resilience-building process in PWPs working within the IAPT programme.

A qualitative design was conducted, using a grounded theory methodology. Participants were recruited from two IAPT services in the National Health Service (NHS), which were part of the same Mental Health Trust. Ten PWPs were interviewed via videoconferencing using semi-structured interviews.

An explanatory model of resilience in PWPs encompassed three phases: the experience of work-related challenges, the connection with their values and the related appraisal of adversity in resilient ways, and the implementation of effective coping strategies.

The model highlights that PWPs develop resilience through values-based sensemaking and by proactively engaging in effective coping mechanisms. This study contributes to the current understanding of the process of resilience in PWPs. More research is needed to explore the developmental processes underlying PWPs’ resilience. The implications of the findings in relation to existing conceptualisations of resilience, staff wellbeing and retention are explored. Recommendations for future research are also given.

Anxiety sensitivity (AS) and disgust sensitivity (DS) are transdiagnostic vulnerability factors for anxiety. Both correlate with blood-injection-injury (BII) phobia symptoms in several studies; however, there is ambiguity about their relative contributions, and studies investigating this have relied on unselected samples. Furthermore, although DS reliably predicts BII in studies that do not account for AS, this may be limited to domain-specific DS rather than DS more broadly.

The aims of this study were to examine AS and DS as separate and simultaneous predictors of BII fears in a sample with a wide range of BII symptoms, and with attention to the specificity of DS to BII-relevant domains.

Fifty-three participants who scored above a clinical threshold on a validated measure of dental anxiety, and who represented a wide range of BII severity, completed measures of AS, DS and BII symptoms.

AS and DS were moderately to strongly correlated with BII severity (r = .40 and .47, p = .004 and <.001), and both independently predicted BII severity when entered as simultaneous predictors (β = .32 and .35, p = .045 and .015). Furthermore, after omitting DS about injections and blood draws, domain-general DS was still moderately correlated with BII severity (r = .33, p = .017). However, domain-general DS did not significantly predict BII severity after accounting for AS (β = .20, p = .164).

AS and DS both predict BII symptoms, and prospective research is warranted to examine them as potential vulnerability factors.

The processing-mode theory of rumination proposes that an abstract mode of rumination results in more maladaptive consequences than a concrete ruminative mode. It is supported by evidence mostly from the area of depression and little is known of the relative consequences of abstract versus concrete rumination for anger.

We investigated the differential effects of abstract versus concrete rumination about anger on individuals’ current affect. We hypothesized that abstract rumination would increase current anger and negative affect, and decrease positive affect, to a greater extent than concrete rumination.

In a within-subject design, 120 participants were instructed to focus on a past social event that resulted in intense anger and then to ruminate about the event in both an abstract and a concrete mode, in a randomly assigned order. Current anger, negative and positive affect were assessed before and after each rumination phase.

Anger and negative affect increased and positive affect decreased from pre- to post-rumination. Contrary to expectations, these patterns were observed irrespective of the ruminative mode induced.

This initial study does not support the hypothesis that abstract and concrete rumination about anger have different consequences for current affect. Replications and more extensive designs are needed.

Intake assessments vary in their focus on strengths and solutions compared with problems. They provide therapists with first impressions of their clients. Research shows that first impressions may have strong and lasting effects.

To compare how solution- versus problem-focused case descriptions influence therapists’ emotions and initial expectations for successfully working with a client.

Vignettes describing clients were manipulated to focus either on solutions and strengths, or on problems. In a within-subject experimental design, 33 (Sample 1) and 29 (Sample 2) trainee therapists each read four case descriptions (two solution-focused and two problem-focused vignettes; order fully counterbalanced). After each vignette, participants rated their affect and expectations for successfully working with the client.

In both samples, solution-focused vignettes were associated with significantly higher levels of positive affect and positive expectations for treatment, and with significantly lower levels of negative affect, compared with problem-focused vignettes. Effect size differences between conditions were generally large (Cohen’s d between .63 and 1.22).

Focusing on clients’ goals, their strengths, and actively highlighting better moments and areas of problem-free functioning may increase therapists’ positive emotions and their hope for clients’ successful treatment. A next step is to examine the degree to which these positive short-term effects are, in turn, predictive of better clinical outcomes in therapy. Future research could additionally examine whether supporting therapists to frame clients’ initial assessments in solution-focused ways may be one way to contribute to workforce well-being.

It is almost 40 years since Borkovec et al. (1983) provided the definition of worry that has guided theory, research and treatment of Generalized Anxiety Disorder (GAD). This review first considers the relative paucity of research but the proliferation of models. It then considers nine models from 1994 to 2021 with the aim of understanding why so many models have been developed.

By extracting and coding the components of the models, it is possible to identify similarities and differences between them. While there are a number of unique features, the results indicate a high degree of similarity or overlap between models. The question of why we have so many models is considered in relation to the nature of GAD. Next, the treatment outcome literature is considered based on recent meta-analyses. This leads to the conclusion that while efficacy is established, the outcomes for the field as a whole leave room for improvement. While there may be scope to improve outcomes with existing treatments, it is argued that rather than continue in the same direction, an alternative is to simplify models and so simplify treatments.

Several approaches are considered that could lead to simplification of models resulting in simpler or single-strand treatments targeting specific processes. A requirement for these approaches is the development of brief assessments of key processes from different models. Finally, it is suggested that better outcomes at the group level may eventually be achieved by narrower treatments that target specific processes relevant to the individual.

Cluain Mhuire is a secondary adult mental health service based in Ireland. The COVID-19 pandemic resulted in many services moving online, including our coping with depression group. A shortened, online version of the face-to-face group was piloted; however, analysis showed that it was not as effective as the longer face-to-face group. Thus, a 12-session, 2.5-hour online group CBT (gCBT) was subsequently run to directly compare the online therapy with the original face-to-face group.

The primary objective of the study is to evaluate the effectiveness of a 12-week gCBT programme adapted to videoconferencing in reducing self-reported symptoms of depression and anxiety and enhancing quality of life (QoL). Results will be compared with the same group programme delivered face-to-face.

This is a between-groups, naturalistic treatment outcome study. Pre and post measures include the Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and the World Health Organisation Quality of Life Scale (WHOQoL-Bref). A mixed between-within subjects analysis of variance was performed to assess the impact of the three interventions (face-to-face, 8-session online and 12-session online) on participant scores; 112 participants (65 women, 47 men) were recruited (mean age=41.85, SD=13.08).

All three interventions significantly improved depression, anxiety and QoL scores. There was no significant difference between the treatment groups. Attendance was highest in the 12-session online group, followed by the 8-session online group and 12-session in-person group.

These results add to the growing evidence supporting the effectiveness of internet-delivered gCBT in reducing depressive symptoms.

Tourette syndrome (TS) is a neurological condition; its etiology is not yet fully understood. Cognitive behavioural therapy with habit reversal training is the recommended first-line treatment, but is not effective in all patients. This is the first report examining the usefulness of decoupling, a behavioural self-help treatment originally developed for patients with body-focused repetitive behaviours, in a patient with TS.

Patient P.Z. showed 10 motor and three vocal tics on the Adult Tic Questionnaire (ATQ) before treatment. He was taught decoupling by the first author.

The application of decoupling led to a reduction of P.Z.’s eye tics, which was one of his first and most enduring and severe tics. It was not effective for other areas. Quality of life and depression improved, which P.Z. attributed to the improvement of his tics.

Decoupling may be adopted as an alternative, when habit reversal training is not feasible. Future research, preferably using a controlled design with a large sample, may elucidate whether decoupling is only effective for tics relating to the eyes, the most common symptom in tic disorder/TS, or whether its effects extend to other symptoms.

The COVID-19 pandemic highlighted the under-utilisation of statutory mental health care services by minority ethnic groups in the United Kingdom (UK).

To improve ethnicity reporting to better understand the needs of patients accessing a primary care talking therapies service.

We conducted a clinical audit to observe outcomes from pre-COVID (2019), first wave of COVID-19 (2020) and 2021 for three broad ethnic categories: black African/Caribbean, Asian and white British. Intervention was conducted on staff to improve data recording of ethnicity. A patient survey was sent to those identified as dropped out from treatment from May 2020 to April 2021. A total of 229 patients responded to the survey. The survey asked for reasons that impacted on not continuing with sessions.

Quantitative analysis showed a statistically significant difference on discharge outcome between white British and black African/Caribbean (p=<0.0001), with black African/Caribbean patients most likely to drop out of treatment, and in 2020 the Asian population was below the recovery target of 50%. Qualitative analysis revealed therapist factors included lack of confidence in therapist and not being listened to, patient factors included neurodiversity, being unsure whether it would be helpful and confidentiality concerns, and service factors included being notified of discharge from the service, remote delivery of therapy, treatment options, and treatment materials.

Services must work towards improving service provision by capturing hidden disparities and socialising treatment to meet the needs of minority ethnic groups in the UK. The present study recommends culturally adapted treatment and co-producing therapy materials.

People with post-traumatic stress disorder (PTSD) exhibit negative cognitions, predictive of PTSD severity. The Post-Traumatic Cognitions Inventory (PTCI) is a widely used instrument measuring trauma-related cognitions and beliefs with three subscales: negative thoughts of self (SELF), negative cognitions about the world (WORLD), and self-blame (BLAME).

The current study attempted to validate the use of the PTCI in people with serious mental illness (SMI), who have greater exposure to trauma and elevated rates of PTSD, using confirmatory factor analysis (CFA) and examining convergent and divergent correlations with relevant constructs.

Participants were 432 individuals with SMI and co-occurring PTSD diagnosis based on the Clinician Administered PTSD Scale, who completed PTCI and other clinical ratings.

CFAs provided adequate support for Foa’s three-factor model (SELF, WORLD, BLAME), and adequate support for Sexton’s four-factor model that also included a COPE subscale. Both models achieved measurement invariance at configural, metric and scalar levels for three diagnostic groups: schizophrenia, bipolar and major depression, as well as for ethnicity (White vs Black), and gender (male vs female). Validity of both models was supported by significant correlations between PTCI subscales, and self-reported and clinician assessed PTSD symptoms and associated symptoms.

Findings provide support for the psychometric properties of the PTCI and the conceptualization of Sexton’s four-factor and Foa’s three-factor models of PTCI among individuals diagnosed with SMI (Foa et al., 1999).

There is wide variation in the problems prioritised by people with psychosis in cognitive behavioural therapy for psychosis (CBTp). While research trials and mental health services have often prioritised reduction in psychiatric symptoms, service users may prioritise issues not directly related to psychosis. This discrepancy suggests potential challenges in treatment outcome research.

The present study aimed to examine the types of problems that were recorded on problem lists generated in CBTp trials.

Problem and goals lists for 110 participants were extracted from CBTp therapy notes. Subsequently, problems were coded into 23 distinct categories by pooling together items that appeared thematically related.

More than half of participants (59.62%) listed a non-psychosis-related priority problem, and 22.12% did not list any psychosis related problems. Chi-square tests indicated there was no difference between participants from early intervention (EI) and other services in terms of priority problem (χ2 = 0.06, p = .804), but that those from EI were more likely to include any psychosis-related problems in their lists (χ2 = 6.66, p = .010).

The findings of this study suggest that psychiatric symptom reduction is not the primary goal of CBTp for most service users, particularly those who are not under the care of EI services. The implications for future research and clinical practice are discussed.

Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients do not complete therapy, do not respond to it, or subsequently relapse. Non-responders, and those at risk of relapse, are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk. This is a heterogeneous group of clients who are currently difficult to treat.

The aim was to develop a CBT model of depression that will be effective for difficult-to-treat clients who have not responded to standard CBT.

The method was to unify theory, evidence and clinical strategies within the field of CBT to develop an integrated CBT model. Single case methods were used to develop the treatment components.

A self-regulation model of depression has been developed. It proposes that depression is maintained by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life goals. Depression is more difficult to treat when these processes become interlocked. Treatment based on the model builds self-regulation skills and restructures self-identity, rather than target negative beliefs. A bespoke therapy plan is formed out of ten treatment components, based on an individual case formulation.

A self-regulation model of depression is proposed that integrates theory, evidence and practice within the field of CBT. It has been developed with difficult-to-treat cases as its primary purpose. A case example is described in a concurrent article (Barton et al., 2022) and further empirical tests are on-going.