Depression and anxiety are major contributors to growing healthcare costs in the UK, particularly with an increasingly ageing population. However, identification of mental health needs in older adults has been overshadowed by a tendency to focus on physical health issues, despite the established co-morbidity of depression, anxiety and physical health conditions. When older adults seek psychological support, treatment options may vary and may be time limited, either because of protocol guidance or due to the resource constraints of psychology services. Time-limited treatment, common in many adult services, may not best meet the needs of older adults, whose physical, cognitive and emotional needs alter with age. It is, therefore, important to identify treatments that best meet the needs of older adults who seek psychological support, but who may arrive with complex mental and physical health histories. This paper aims to explore how a case formulation-driven approach that draws on the theoretical underpinnings of cognitive behavioural therapy (CBT) and compassion-focused therapy (CFT) can be used to reduce anxiety and depression in an older adult with a complex multi-morbid mental and physical health history. This study employs a single-case (A–B) experimental design [assessment (A), CBT and CFT intervention (B)] over 28 sessions. Results suggest the greatest reductions in depression and anxiety (as measured using PHQ-9 and GAD-7) occurred during the CFT phase of the intervention, although scores failed to drop below subclinical levels in any phase of the intervention. This case highlights the value of incorporating CFT with CBT in case formulation-driven interventions.

As a principle-driven treatment, dialectical behaviour therapy (DBT) offers concepts and strategies that can be flexibly applied to address unique types of invalidation, such as stigma experienced by marginalized groups. A pilot DBT skills training group that included material on using skills to dialectically manage the effects of stigma was conducted with four sexual and gender minority (SGM) veterans. The group included standard DBT skills along with explicitly teaching about stigma commonly faced by SGM individuals and ways to apply DBT skills to the experiences of stigma. This pilot group was conducted to determine the acceptability of such a group as well as its effects on symptoms (depression, emotion regulation), use of DBT skills in daily living, and the psychological burden of stigma-related experiences. The group was well-received by participants; outcomes suggest promising trends in reducing psychological distress and increasing use of DBT skills to cope. Implications for clinical practice using a dialectical approach to stigma management and future directions are provided.

Previous research has shown that psychoeducation for bipolar disorder (BD) improves symptoms and reduces relapse risk, but there is little research on how this impacts stigma, perceived recovery and views about diagnosis. The aim of this study was to explore whether a cognitive behaviour therapy (CBT)-based 12-week BD psychoeducation group conducted in a community mental health team for adults impacted perceived stigma, diagnosis-related self-esteem, recovery and views about diagnosis. The case series pre- and post-group had 23 participants across three groups. The Brief Illness Perception Questionnaire, views on Manic Depression Questionnaire, Bipolar Recovery Questionnaire and author-constructed questions were completed pre and post. Twenty participants completed the group. An intent-to-treat repeated measures multiple analysis of variance showed significantly improved perceived recovery and improvements in sense of control and understanding around their diagnosis. Other specific questions such as understanding of triggers and impact of thinking patterns also improved. However, there was no change in the perceived stigma or self-esteem associated with living with BD. CBT-based psychoeducation groups may help improve perceived recovery and factors such as sense of control in BD. However, there appears to be no impact on stigma and self-esteem, and the role of non-specific factors needs to be examined further.

The use of transdiagnostic mental health treatments in low resource settings has been proposed as a possible aid in scaling up mental health services. Modular, multi-problem transdiagnostic treatments can be used to treat a range of mental health problems and are designed to handle comorbidity. Two randomized controlled trials have been completed on one treatment – the Common Elements Treatment Approach, or CETA – delivered by lay counsellors in Iraq and Thailand. This paper utilizes data from two clinical trials to explore the delivery of CETA by lay providers, examining fidelity and flexibility of element use. Data were collected at every therapy session. Clients completed a short symptom assessment and providers described the clinical elements delivered during sessions. Analyses included descriptive statistics of delivery including selection and sequencing of treatment elements, and the variance in element dose, clustering at the counsellor level, using multi-level models. Results indicate that lay providers in low resource settings (with supervision) demonstrated fidelity to the recommended CETA elements, order and dose, and occasionally added in elements and flexed dosage based on client presentation (i.e. flexibility). This modular approach did not result in significantly longer treatment duration. Our analysis suggests that lay providers were able to learn decision-making processes of CETA based on client presentation and adjust treatment as needed with supervision. As modular multi-problem transdiagnostic treatments continue to be explored in low resource settings, research should continue to focus on ‘unpacking’ lay counsellor delivery of these interventions, decision-making processes, and the level of supervision required.

Exposure therapy is consistently indicated as the first-line treatment for anxiety-related disorders. Unfortunately, therapists often deliver exposure therapy in an overly cautious, less effective manner, characterized by using their own ‘therapist safety behaviours’. Cognitive behavioural models postulate that beliefs about therapist safety behaviours are related to their use; however, little is known about the beliefs therapists hold regarding therapist safety behaviour use. The present study aimed to identify the beliefs exposure therapists have regarding the necessity of therapist safety behaviours and to examine the relationship between this construct and therapist safety behaviour use. Australian psychologists (n = 98) completed an online survey that included existing measures of therapist safety behaviour use, therapist negative beliefs about exposure therapy, likelihood to exclude anxious clients from exposure therapy, and use of intensifying exposure techniques. Participants also completed the Exposure Implementation Beliefs Scale (EIBS), a measure created for the present study which assesses beliefs regarding the necessity of therapist safety behaviours. Beliefs about the necessity of therapist safety behaviours – particularly in protecting the client – significantly predicted therapist safety behaviour use. Findings suggest that exposure therapy training media should aim to decrease therapist safety behaviour use by addressing beliefs about the necessity of therapist safety behaviours, especially in protecting the client.

Psychoeducation courses have gained some empirical support as effective early intervention strategies. Many of these courses reflect traditional cognitive behaviour therapy (CBT) thinking but psychoeducation courses based on other approaches are beginning to emerge. One such course, ‘ACTivate Your Life’, is based on acceptance and commitment therapy (ACT). The aim of this preliminary investigation is to evaluate a four-session (eight-hour) ACT psychoeducation intervention delivered within the Abertawe Bro Morgannwg University (ABMU) Health Board. Participants were invited to complete four outcome measures (assessing depression, anxiety, self-esteem and life satisfaction) and two process measures (assessing mindfulness self-efficacy and psychological flexibility) at pre- and post-intervention. Statistical analysis indicated that participants’ scores across each of the measured domains showed highly significant changes. These results suggest that a brief psychoeducation ACT course may be useful in helping people in need of early psychological intervention, and that further research is now needed to provide a definitive evaluation of its effectiveness.

The UK government implemented national social-distancing measures in response to the global COVID19 pandemic. As a result, many appointments in the National Health Service (NHS) took place virtually, including psychological interventions in out-patient settings. This study explored the experiences of adolescents participating in a dialectical behaviour therapy (DBT-A) programme via teletherapy (i.e. via video or telephone call) in a Children and Adolescent Mental Health Service (CAMHS). Thirteen adolescents with emotion dysregulation and related problems completed an online qualitative survey about their experience and acceptance of DBT-A delivered virtually. Thematic analysis was conducted on the survey data and generated three over-arching themes: (1) sense of loss; (2) feeling uncontained; and (3) benefits of virtual DBT. These over-arching themes were composed of eight subthemes (‘loss of connection with group and therapist’; ‘loss of skills-building opportunities’; ‘limited privacy’; ‘lack of safe therapy space’; ‘difficult endings’; ‘home comforts’; ‘convenience and accessibility’; and ‘easier to participate with others’). This study suggests that adolescents doing virtual DBT-A need approaches that acknowledge and address the additional relational, emotional and practical challenges of online therapy while maintaining fidelity to the evidence-based treatment model. Suggestions for further research and preliminary practice guidelines are discussed.

Currently recommended psychotherapies for depression are not always delivered in a consistent manner. There is an assumption that the use of clinical supervision will ensure reliable treatment and patient recovery. However, there is limited research supporting this assumption. This study explored the role of supervision in the treatment of depression. In particular, it examined how supervisors’ own characteristics and those of patients can influence the focus of supervision sessions. Clinical supervisors who worked with cognitive behavioural therapy (CBT) therapists treating depression cases were asked to indicate their supervision focus for three different patient vignettes. These vignettes varied in clinical complexity. Participants’ intolerance to uncertainty and their self-esteem were also assessed. Supervisors tended to focus their supervisees on the use of evidence-based therapeutic techniques for both straightforward and complex cases. However, their approach was less evidence-based for diffuse cases. Three supervisory types emerged: an ‘Alliance- and Technique-Focused’ group, a ‘Case Management-Focused’ group, and an ‘Unfocused’ group. Personal characteristics of the supervisors varied across the groups. The content of supervision sessions is influenced by factors from outside the therapy process. These factors might cause supervisors to avoid focusing on evidence-based aspects of therapy, thus feeding therapist drift. Suggestions are made for new supervision protocols that consider the supervisor's personal characteristics.

This paper looks at issues regarding case formulation in psychotherapy. Case formulation is well recognized as being helpful in the conceptualizing of psychological problems and as a useful tool in the practice of cognitive therapy. Control, as opposed to behaviour, is increasingly being seen as that human process most relevant to psychopathology. We look at the diagnosis and treatment of a small number of people, treated in a naturalistic setting, who were selected without any specific criteria other than being people whose problems were treated using the Method of Levels, a form of cognitive therapy based on the principles of Perceptual Control Theory, and who completed both pre- and post-treatment questionnaires. We then consider how the problems these people presented with, and their treatment, might be formulated as a result of taking this approach.

There is a very high prevalence of post-traumatic stress disorder (PTSD) within refugee populations and survivors of torture. Refugees, asylum seekers and survivors of torture who access IAPT (Improving Access to Psychological Therapies) can present with unique clinical challenges for cognitive behavioural therapy (CBT) therapists. The use of reflective practice can be beneficial particularly when there is added complexity in the client's clinical presentation. The aim of this paper is to provide an overview of how reflective practice can improve clinical work with this patient group and to identify some of the challenges that refugees, asylum seekers and survivors of torture may present with during therapy. The paper sets out how the use of the critical incident analysis model and clinical supervision can assist to develop reflective practice skills and improve the clinical practice of IAPT CBT therapists who work with diverse populations.

According to interpersonal theory of personality, interpersonal behaviours can be causal and maintaining factors in emotional disorders. However, interpersonal styles have not yet been investigated in the treatment of obsessive compulsive disorder (OCD). The aim of the study was to investigate interpersonal style in OCD. The Inventory of Interpersonal Problems – Circumplex was used to assess the interpersonal styles of 101 outpatients with OCD treated with cognitive behavioural therapy (CBT). Patients with OCD had more interpersonal problems than the healthy control group. However, the OCD group presented with slightly fewer interpersonal problems than a further comparison group of psychiatric outpatients. Interpersonal style did not predict improvement in OCD symptoms. Following CBT for OCD, there were small to moderate improvements in interpersonal problems. These changes remained stable at 12-month follow-up. Although the OCD group reported reduced interpersonal problems post-treatment, the group still experienced more submissiveness compared to healthy controls. Interpersonal problems in OCD appeared to be more attributable to comorbid conditions than to OCD-specific symptoms. Although patients with OCD were found to have interpersonal styles that might cause some problems, these were minimal at baseline and did not significantly affect OCD treatment outcomes. Interpersonal problems in this population might be more strongly related to depressive symptoms than to OCD-specific symptoms. CBT was associated with slight improvements in interpersonal problems.

Web-based interventions for depression have burgeoned over the past 10 years as researchers and health professionals aim to harness the reach and cost-effectiveness that the internet promises. Despite strong clinical evidence of their effectiveness and policy support, web-based interventions have not become widely used in practice. We explored this translation gap by conducting an implementation pilot of MindBalance, a web-based intervention for depression built on the SilverCloud platform, in three IAPT services. We posed three questions: (1) Who chooses to use MindBalance? (2) Is MindBalance effective for these clients? (3) How do clients use MindBalance? Our results for questions (1) and (2) are commensurate with the positive findings in the literature on patient acceptability and clinical effectiveness for such interventions. Client usage, captured in adherence data as well as usage case-studies, was diverse and differed markedly from face-to-face sessions. The most surprising result, however, concerned the small number of people who were offered the intervention. We reflect upon why this was and discuss implementation issues that primary mental health services should consider when adding a web-based intervention to their services.

Large psycho-education groups are being increasingly used in mental-health promotion and the treatment of common mental-health problems. In individual therapy there is a well-established link between therapist empathy, therapeutic relationship and patient outcome but the role of empathy within large psycho-educational groups is unknown. This service evaluation investigated the impact of a 6-week large psycho-education group on patient outcome and the role of perceived therapist empathy on outcome. Within a before–after experimental design, 66 participants completed baseline and endpoint measures; Clinical Outcome Routine Evaluation (CORE), Patient Enablement Instrument (PEI), and the modified Consultation and Relational Empathy (CARE) measure. The results showed that the intervention had a positive impact on patient outcome; the CORE score reduced significantly over the 6 weeks by 0.63 (95% CI 0.82–1.14) (t = 9.18, d.f. = 55, p = <0.001) and attendees felt highly enabled. Attendees perceived the course leader as highly empathetic. However, the relationship between perceived empathy and attendee outcome was less clear; no significant relationship was found with the main outcome measure (the change in CORE score). Factors that influenced the main outcome included age, symptom severity at baseline, having a long-term illness or disability, and whether attendees tried the techniques at home (homework). These findings suggest that large group psycho-education is an effective treatment for mild to moderate mental-health problems, at least in the short term. The role of therapist empathy remains ambiguous but may be important for some patient outcomes.

This study aimed to examine how people change in order to achieve and maintain a personally comfortable weight and what changes for them as they change. Six students who changed to achieve and maintain a personally comfortable weight for a minimum of 1 year were recruited. Semi-structured interviews explored participants’ experiences of what changed and how they changed. The interviews were analysed using interpretative phenomenological analysis. Two superordinate themes emerged. The first was ‘awareness’ which contained the subthemes: unaware self, revelation, and conscious monitoring and maintenance of awareness. The second was ‘goals and needs’ which contained the subthemes: social- vs. self-acceptance, removing negative emotions, weight control vs. other life goals, and ideal vs. perceived health and appearance. The findings are discussed in relation to the existing literature on the development of eating problems, involving social acceptance, self-esteem, coping with negative moods, and weight control. Perceptual Control Theory was used to provide an explanation for how these participants changed and maintained their change.

Surveys are a powerful technique in cognitive behavioural therapy (CBT). A form of behavioural experiment, surveys can be used to test beliefs, normalise symptoms and experiences, and generate compassionate perspectives. In this article, we discuss why and when to use surveys in CBT interventions for a range of psychological disorders. We also present a step-by-step guide to collaboratively designing surveys with patients, selecting the appropriate recipients, sending out surveys, discussing responses and using key learning as a part of therapy. In doing so, we hope to demonstrate that surveys are a flexible, impactful, time-efficient, individualised technique which can be readily and effectively integrated into CBT interventions.

The aim of this study was to investigate, from a lived experience perspective, specialist psychological therapists’ views on therapeutic adaptations to cognitive behaviour therapy (CBT) for autism that are most helpful for service users and enable best practice. Psychological therapist participants took part in semi-structured interviews led by a researcher with lived experience of autism. A thematic analysis was carried out. Participants (n=8) reported that challenges for service users were anxiety about the therapeutic relationship; communication difficulties with understanding and being understood; emotion recognition difficulties impeding trust and development of the therapeutic relationship; relationships with family interfering with the intervention; information processing impairments, necessitating a slower pace to the intervention; and avoidance of therapy due to anxiety. Goals were forming relationships and building social confidence and skills. Demographic differences were age, with older service users deemed less open to change and younger service users less mature and more often accompanied by family; and gender, with female service users deemed more socially able than males. Therapeutic adaptations were to increase collaboration; support emotional literacy, to help service users understand their own and others’ emotions; focus on special interests; use visual prompts, to improve communication and understanding; be consistent, to build trust and reduce anxiety; accommodate sensory needs, to reduce anxiety and build engagement; avoid metaphors, to reduce communication difficulties; and use role-play, to build and enhance social skills. Therefore, adapting CBT may support clinicians and reduce challenges for people with autism, while lived experience perspectives ensure adaptations meet service users’ needs.

There has been a large increase in the migration of Muslim populations towards the western world and the USA in the past decade. Many have migrated in the hope of finding a safe home away from war, persecution, or a better economic situation, with many coming from Afghanistan and Syria. Gender and sexual minorities (GSM), or individuals who are not heterosexual and do not identify with their sex assigned at birth, are disproportionately over-represented within migrating groups. While most of these individuals will not have received psychotherapy in their home countries, it is likely they would receive or be required to obtain psychological services as part of the asylum process or through psychoeducational services as a requirement to receive assistance. In exploring the specific needs of Muslim GSM individuals, we highlight the diverse impacts of minority stress, shame, and how these might be mitigated through the integration of acceptance and commitment therapy (ACT) and compassion-focused therapy (CFT). ACT and CFT may provide a helpful framework for a culturally adapted therapy that targets the needs of those experiencing intersectional Muslim and GSM identities, and can foster the cultivation of a meaningful life that can include all aspects of their identities.