The last two decades have seen considerable development in our understanding of delusions, with medical perspectives broadening into more holistic bio-psychosocial models. Of particular relevance to services is the increasing evidence base for cognitive behavioural models and treatments. A number of national initiatives have aimed to ensure these developments are reflected in services. Primarily these have targeted adult services, yet delusions are no less common in older adults. Across two older adult services this study searched over 10,000 clinical notes to assess the number of individuals experiencing delusions, explored the perspectives of 27 staff members regarding their clinical approaches to working with delusions, and delivered a brief training on cognitive behavioural models and treatments of delusions. Three service users contributed to the training content. Endorsement of theoretical perspectives regarding delusions were measured pre- and post-training. Results showed over 20% of patients in the service may be experiencing paranoia or delusions, but only a handful were referred for CBT. Of 27 staff participants, less than half had received training on working with delusions, most of which was from as many as 20 years ago. Nearly all reported that a lack of knowledge prevented them from considering psychological perspectives. A quarter of staff across the two teams attended the training. No immediate changes in outcome measures were seen immediately post-training, with a striking diversity in approach reported by different members of staff. All staff qualitatively reported finding the training valuable, although engagement was dampened by high levels of stress and burnout.

1. (1) To understand the developing cognitive behavioural evidence base for understanding and treating delusions in older adults.

2. (2) To understand the need for this growing evidence base to be reflected in services, including older adult services, not only in structured interventions offered by psychological therapists, but also in patient interactions and care planning by all professions working in multi-disciplinary teams.

3. (3) To understand some of the key challenges in assessing and improving current understanding of cognitive behavioural approaches to delusions within services.

Smartphone apps combined with psychological interventions may be beneficial for increasing adherence to treatment tasks and augmenting outcomes. Yet, there is limited research on the acceptability and feasibility of adjunctive smartphone apps with psychological therapies for adolescents engaging in self-harm and suicidal behaviours. This study aimed to evaluate the acceptability and feasibility of integrating the Dialectical Behaviour Therapy (DBT) Coach app as an adjunct to a comprehensive DBT programme. The study also aimed to explore statistical trends of the potential relationship between the DBT Coach app and symptom reduction, including self-harm, borderline personality disorder symptoms, emotion dysregulation, and DBT skill use, to inform future study design. A mixed-method design was used to evaluate the acceptability and feasibility of the app and clinician’s portal from the perspective of adolescent and clinician participants. Thematic analysis was used to analyse qualitative data. Results indicated varied experiences of acceptability and feasibility of the DBT Coach app and portal as an adjunct to DBT. Thematic analysis generated four over-arching themes and ten subthemes. The regression analysis provided statistical trends regarding potential relationships between app use and clinical outcomes, which would be helpful to explore in future research. Findings suggest that the app and portal were acceptable and feasible for the most part, with some barriers and challenges identified. Implications of this study are discussed.

1. (1) To learn about the acceptability and feasibility of using a smartphone application as an adjunct to a DBT skills group within a comprehensive DBT programme for adolescents.

2. (2) To explore whether there is a relationship between app use and clinical outcome at the end of the group intervention.

3. (3) To learn about the experiences of adolescents and clinicians using the smartphone app as an adjunct to the DBT skills group.

Maladaptive daydreaming (MD) is an increasingly recognised mental health difficulty, which refers to a compulsive cycle of dissociative absorption in vivid mental fantasy that results in clinical distress and functional impairment. Fantasies are usually complex in plot and characters, and are highly pleasurable and absorbing. MD provides temporary escape, soothing, or attempted processing of difficult internal and external experiences, but results in longer-term negative consequences that both create and exacerbate real-life suffering. The literature thus far has expanded beyond defining and understanding MD and has turned its attention towards assessment and pilot interventions. This paper presents the first formulation framework and associated diagrammatic model of MD, drawing upon the existing evidence base and cognitive behavioural theory to capture its development, maintenance, and processes. The model was reviewed by two leading experts in the field and trialled by three contributors with lived experience of MD. Feedback was positive, suggesting it accurately captured and organised the complexity and depth of the MD experience, facilitated the development of personal insight, and fostered a sense of hope with regard to creating change. The model is intended for use within clinical practice to aid mental health professionals and people with MD to guide assessment, collaborative discovery and formulation, and intervention. It is imperative that the model be tested further within research and clinical practice to further ensure its efficacy, validity, and applicability for people with MD.

1. (1) To consider the development and maintenance factors, and processes involved in MD from a cognitive behavioural perspective.

2. (2) To introduce a new formulation model for MD and understand how the model can be used in clinical practice.

3. (3) To highlight how psychological formulation has the power to better understand and organise the complex and often overwhelming MD phenomenon and provide hope for meaningful change.

Effective, evidence-based psychological therapies for prolonged grief reactions exist but are not routinely available in United Kingdom National Health Service (NHS) services. This audit evaluated the feasibility and clinical effectiveness of a high-intensity prolonged grief disorder therapy (PGDT) treatment pathway in an NHS Talking Therapies (NHS-TT) context for clients with a prolonged grief reaction alongside depression, anxiety and/or post-traumatic stress disorder. Seventeen experienced high-intensity therapists were trained to deliver PGDT. Ninety-one clients were treated between April 2022 and April 2024, 80 of whom met criteria and were included in this audit; 83% of clients completed at least four treatment sessions (a liberal estimate of minimum adequate dose), the mean number of sessions attended was 10.29 (SD=5.81) and rates of drop-out were low (16%). Data completeness rates were 100% depression, anxiety and functioning measures and 61% for the grief outcome (Brief Grief Questionnaire; BGQ). There was no evidence of treatment-related harms. There were statistically significant, large pre–post treatment effect size improvements across outcomes from intake to last treatment session (p<.001; Cohen’s d>1.05). According to NHS-TT outcome metrics for combined changes in anxiety and depression, 82% of clients exhibited reliable improvement, 72% showed recovery, and 68% of clients achieved reliable recovery. On the BGQ, rates of reliable improvement were 77% and rates of recovery were 63%. Effects held when focusing on the subgroup with more severe grief symptoms (intake BGQ≥8; n=40). These findings suggest it is feasible and probably effective to implement a PGDT pathway in an NHS-TT context.

1. (1) To become familiar with prolonged grief disorder (PGD) as a diagnostic construct.

2. (2) To gain insight into using prolonged grief disorder therapy (PGDT) to treat PGD.

3. (3) To understand ways to train and supervise National Health Service Talking Therapies (NHS-TT) high-intensity therapists to implement PGDT.

4. (4) To evaluate the potential feasibility and effectiveness of implementing PGDT in an NHS-TT context.

Economic variables such as socioeconomic status and debt are linked with an increased risk of a range of mental health problems and appear to increase the risk of developing of post-traumatic stress disorder (PTSD). Previous research has shown that people living in more deprived areas have more severe symptoms of depression and anxiety after treatment in England’s NHS Talking Therapies services. However, no research has examined if there is a relationship between neighbourhood deprivation and outcomes for PTSD specifically. This study was an audit of existing data from a single NHS Talking Therapies service. The postcodes of 138 service users who had received psychological therapy for PTSD were used to link data from the English Indices of Deprivation. This was analysed with the PCL-5 measure of PTSD symptoms pre- and post-treatment. There was no significant association between neighbourhood deprivation measures on risk of drop-out from therapy for PTSD, number of sessions received or PTSD symptom severity at the start of treatment. However, post-treatment PCL-5 scores were significantly more severe for those living in highly deprived neighbourhoods, with lower estimated income and greater health and disability. There was also a non-significant trend for the same pattern based on employment and crime rates. There was no impact of access to housing and services or living environment. Those living in more deprived neighbourhoods experienced less of a reduction in PTSD symptoms after treatment from NHS Talking Therapies services. Given the small sample size in a single city, this finding needs to be replicated with a larger sample.

1. (1) Previous literature has shown that socioeconomic deprivation increases the risk of a range of mental health problems.

2. (2) Existing research suggests that economic variables such as income and employment are associated with greater incidence of PTSD.

3. (3) In the current study, those living in more deprived areas experienced less of a reduction in PTSD symptoms following psychological therapy through NHS Talking Therapies.

4. (4) The relatively poorer treatment outcomes in the current study are not explained by differences in baseline PTSD severity or drop-out rates, which were not significantly different comparing patients from different socioeconomic strata.

The objectives of study 1 were to use expert opinion to identify the limitations of the Health Anxiety Inventory – Short Version (SHAI) for administration in medical populations and to develop an adapted version for medical populations. The objective of the second study was to evaluate the psychometric properties of the adapted measure. A three-round Delphi study method was used in study 1. Eight experts with experience of living with a physical health condition and four experts by profession working within physical health were invited to review the SHAI. Study 2 employed a cross-sectional mixed methods questionnaire design. Individuals with multiple sclerosis (n=115), myalgic encephalomyelitis/chronic fatigue syndrome (n=84) and chronic pain (n=116) were invited to complete a battery of questionnaires via an online survey. The adapted version of the SHAI for Medical Populations (HAI-M) consisted of 12 items scoring from 0 to 3, reaching high consensus (75% agreement) for administration in medical populations. All groups rated the HAI-M as more acceptable than the SHAI and no significant differences were found on HAI-M scores between clinical groups. The HAI-M demonstrated high internal consistency (.875), good test–retest reliability (.812) and convergent validity (.801). Divergent validity was also acceptable (.515). This study provides preliminary evidence for a psychometrically sound health anxiety screening tool for use in medical populations.

1. (1) To gain insights into the presentation of health anxiety in medical conditions.

2. (2) To consider the validity and reliability of using questionnaire measures developed using analogue sample norms, and how this may affect measurement when used in different context and settings.

3. (3) The process of systematically adapting, developing and testing standardised measures for use in special subgroups.

Traumatic brain injury (TBI) can alter day-to-day life. While changes in cognition and physical function are most often cited, emotional disturbances, notably depression, are also common. For individuals who experience depression symptoms, mindfulness-based cognitive therapy (MBCT) may afford the opportunity to address these symptoms by teaching skills to mitigate negative thought patterns and foster acceptance. Yet, as with any treatment for depression, MBCT may not be the best fit for everyone. According to the literature, characteristics such as age, gender, and baseline mindfulness or pain levels have the potential to affect treatment response. While these factors have yet to be explored within a TBI sample, we must additionally consider whether possible cognitive impairment due to TBI plays a role in treatment response. Drawing from an earlier multi-site randomized controlled trial to explore the efficacy of MBCT for depression in a TBI sample, the current study examined the associations between a number of baseline factors (demographic, emotional, physical, and cognitive) and decreased depression scores post-intervention. Partial correlations adjusted for gender. Findings indicated that only higher levels of pain at baseline were associated with lesser effectiveness of the intervention. MBCT offers a good treatment option for most individuals experiencing depression following TBI.

1. (1) To explore factors associated with treatment response to MBCT for depression after TBI.

2. (2) To understand how cognitive impairment resulting from TBI need not preclude treatment response.

3. (3) To reflect on the role of pain in treatment response.

Cognitive behavioural therapy (CBT) and eye-movement desensitisation and reprocessing (EMDR) are NICE-recommended evidence-based treatments for post-traumatic stress disorder (PTSD). However, there is less specification of which individuals might find CBT versus EMDR more effective, or whether other factors influence treatment outcomes. This study describes a service evaluation of trauma-focused CBT (CT-PTSD) and EMDR treatment outcomes for PTSD in a London out-patient NHS Talking Therapies (NHS TT) service over 11 years (N=1580). The evaluation was conducted in an adult sample (mean age 37 years), of which 65% were women. The mean number of treatment episodes for PTSD in the service in the sample was 2.39 (SD=1.86), and the mean number of therapy sessions attended was 6.15 (SD=6.43). When using NHS TT recovery criteria, there was no significant difference between PTSD recovery rates in the service for those who received CT-PTSD (40.8%) versus EMDR (43.6%). CT-PTSD was associated with greater reductions in anxious and depressive (but not PTSD-specific) symptoms than EMDR, but this was confounded by the fact that individuals receiving CT-PTSD in the service had higher anxiety and depression scores at start-of-treatment. Older age and non-female gender were associated with higher anxiety and depression scores. PTSD recovery rates were comparable to other NHS TT services. There is no clear indication that either CBT or EMDR is a more effective treatment for PTSD symptoms in the service, although preliminary findings could inform treatment planning regarding differential effects of the treatments on anxious and depressive symptoms. Other clinical implications are discussed.

1. (1) To gain a better understanding of the relative effectiveness of trauma-focused CBT and EMDR for PTSD, as provided in a working NHS TT service.

2. (2) To allow better-informed clinical and treatment pathway planning for individuals with trauma problems in a talking therapies service.

3. (3) To contribute to the wider research literature on effective interventions for trauma within cognitive therapy and NHS frameworks.

Despite high levels of depression and anxiety, there is relatively little attention to psychological treatment approaches to mental health issues for older adults living in nursing homes. Recent studies support the use of cognitive behaviour therapy (CBT) in this population and here we aim to highlight how CBT can be successfully adapted and implemented with beneficial results. The ELders AT Ease (ELATE) program is a unique service delivery model illustrating delivery of CBT with older adults living in nursing homes. The six modules forming the program, based on CBT, are described. A systems wide approach to delivery is emphasised and illustrated through two clinical case descriptions. Innovative mental health programs can have positive benefits for both residents and staff and support the use of CBT in this vulnerable and under-served client group.

1. (1) Knowledge of the content and application of CBT for older adults living in nursing homes.

2. (2) Understanding of CBT session structure as applied to older adults living in nursing homes.

3. (3) Recognising and utilising specific strategies to highlight a systemic approach as central to implementing CBT strategies, such as behavioural activation and reminiscence, with considered involvement by staff and family.

Family-based treatment (FBT) has proven efficacy among adolescents with eating disorders (ED). However, it is not effective or suitable for all young people and their families, which makes alternative treatments important. This is the first pilot study to compare the relative effectiveness of manualised enhanced cognitive behaviour therapy (CBT-E) among a transdiagnostic eating disorder sample of adolescents for whom CBT-E was their first ED treatment (n=42), and a group who had previously started FBT which had been discontinued without full recovery (n=27). Participants (n=69) aged 13–17 with an eating disorder completed manualised CBT-E. Outcome measures included body mass index (BMI) centile, ED psychopathology and clinical impairment. Across the cohort, results showed improvements across ED psychopathology, clinical impairment and BMI centile. The effect of the intervention on ED psychopathology and clinical impairment did not vary between groups, nor did attrition rates. There was a difference between the groups on BMI centile, with those who had previously been treated with FBT showing no change in BMI centile, whereas those with no previous FBT increased BMI at post-treatment. Implications from this research suggest that CBT-E is a viable promising alternative and could be offered among those for whom FBT has not achieved full recovery.

1. (1) Delivering CBT-E to adolescents with eating disorders who have previously engaged in FBT but have not achieved full recovery is a promising subsequent treatment option.

2. (2) CBT-E was similarly completed and displayed similar overall group reductions in eating disorder symptoms in those who had discontinued FBT without full recovery compared with those who had not previously engaged with FBT.

3. (3) Results suggest that CBT-E could be offered when FBT has not achieved full recovery, although more research is required to understand optimal timings of treatment transition in such instances.

Cognitive behavioural therapy (CBT) is one of the best-evidenced psychosocial interventions for psychosis and is recommended by the National Institute for Health and Care Excellence and the American Psychiatric Association. CBT was developed and derived from Western cultural values, which may not be appropriate for non-Western cultures. Trials of CBT in Western countries have indicated that participants from ethnic minority groups demonstrate low rates of engagement, retention, and recruitment. This indicates that the principles underlying CBT may conflict with individual beliefs and cultural values in non-Western countries. Therefore, we interviewed 15 people diagnosed with schizophrenia and 15 with their family members to explore the beliefs and attitudes of people diagnosed with schizophrenia and their family members concerning the proposed CBT intervention for psychosis in the Saudi context. The findings revealed that most participants accepted the proposed intervention. Important factors that influenced participants’ engagement and motivation in the CBT intervention were related to the therapist’s qualities (sex, empathy, and competence), family involvement, religion, and the number and format of CBT sessions for psychosis.

1. (1) To explore the beliefs and attitudes of people diagnosed with schizophrenia concerning the proposed CBT intervention for psychosis and how to improve it to make it more appropriate for their needs and cultures.

2. (2) To explore the beliefs and attitudes of family members of people diagnosed with schizophrenia concerning the proposed CBT intervention for psychosis and how to improve it to make it more appropriate to their needs and culture.

Implementation of video call-based cognitive behavioural therapy (CBT) has increased significantly since the COVID-19 pandemic, enabling more flexible delivery, but less is known about user experience and effectiveness. This systematic review and meta-analysis investigated feasibility, acceptability, and effectiveness of individual video call-based CBT for adults with mild to moderate mental health conditions (Prospero CRD42021291055). Medline, Embase, PsycINFO and Web of Science were searched until 4 September 2023. The Effective Public Health Practice Project Quality Assessment Tool (EPHPP) assessed methodological quality of studies. Meta-analysis was conducted in R. Thirty studies (n=3275), published 2000 to 2022, mainly in the USA (n=22/30, 73%), were included. There were 15 randomised control trials, one controlled clinical trial, and 14 uncontrolled studies. Findings indicated feasibility, acceptability and effectiveness (effect size range 0.02–8.30), especially in post-traumatic stress disorder (PTSD) for military populations. Other studies investigated depression, obsessive-compulsive disorder, panic with agoraphobia, insomnia, and anxiety. Studies indicated that initial challenges with video call-based CBT subsided as therapy progressed and technical difficulties were managed with limited impact on care. EPHPP ratings were strong (n=12/30, 40%), moderate (n=12/30, 40%), and weak (n=6/30, 20%). Meta-analysis on 12 studies indicated that the difference in effectiveness of video call-based CBT and in-person CBT in reducing symptoms was not significant (SMD=0.044; CI=–0.086; 0.174). Video calls could increase access to CBT without diminishing effectiveness. Limitations include high prevalence of PTSD studies, lack of standardised definitions, and limited studies, especially those since the COVID-19 pandemic escalated use of video calls.

1. This review assesses feasibility, acceptability, and effectiveness of individual video call-based CBT for adults with mild to moderate common mental health conditions, as defined by the ICD-11.

2. Secondary aims were to assess if the therapeutic relationship is affected and identify any potential training needs in delivering video call-based CBT.

3. The adjunct meta-analysis quantitatively explored whether video call-based CBT is as effective as in-person interventions in symptom reduction on primary outcome measures by pooling estimates for studies that compare these treatment conditions.

Hoarding disorder (HD) is primarily characterised by difficulties with discarding possessions. Evidence-based psychological interventions such as CBT have been found to be of benefit to people with HD. However, people with HD may receive a psychosocial intervention provided by other professions such as social workers or a multi-disciplinary team before receiving psychological therapy, if at all.

The aim of this systematic review is to evaluate psychosocial interventions for HD.

Searches were conducted on three databases (PsycInfo; MEDLINE; Embase) and grey literature, and the search strategy was designed to capture psychosocial interventions for adults with HD.

Studies (n=5) were included where the outcome was related to a psychosocial factors, such as fire safety, tenancy preservation and QoL. These psychosocial interventions show improvements in those with HD, with effect sizes ranging from d=0.86 to d=1.41.

Despite the limited research on psychosocial interventions for HD, this systematic review suggests it is a promising area for further research in this area.

1. (1) To identify what psychosocial interventions are available for people experiencing hoarding difficulties.

2. (2) To identify how available psychosocial interventions for hoarding difficulties are delivered and by whom.

3. (3) To examine the effectiveness of psychosocial interventions for people experiencing hoarding difficulties.

Motor neuron disease (MND) is a progressive, fatal, neurodegenerative condition that affects motor neurons in the brain and spinal cord, resulting in loss of the ability to move, speak, swallow and breathe. Acceptance and commitment therapy (ACT) is an acceptance-based behavioural therapy that may be particularly beneficial for people living with MND (plwMND). This qualitative study aimed to explore plwMND’s experiences of receiving adapted ACT, tailored to their specific needs, and therapists’ experiences of delivering it.

Semi-structured qualitative interviews were conducted with plwMND who had received up to eight 1:1 sessions of adapted ACT and therapists who had delivered it within an uncontrolled feasibility study. Interviews explored experiences of ACT and how it could be optimised for plwMND. Interviews were audio recorded, transcribed and analysed using framework analysis.

Participants were 14 plwMND and 11 therapists. Data were coded into four over-arching themes: (i) an appropriate tool to navigate the disease course; (ii) the value of therapy outweighing the challenges; (iii) relevance to the individual; and (iv) involving others. These themes highlighted that ACT was perceived to be acceptable by plwMND and therapists, and many participants reported or anticipated beneficial outcomes in the future, despite some therapeutic challenges. They also highlighted how individual factors can influence experiences of ACT, and the potential benefit of involving others in therapy.

Qualitative data supported the acceptability of ACT for plwMND. Future research and clinical practice should address expectations and personal relevance of ACT to optimise its delivery to plwMND.

1. (1) To understand the views of people living with motor neuron disease (plwMND) and therapists on acceptance and commitment therapy (ACT) for people living with this condition.

2. (2) To understand the facilitators of and barriers to ACT for plwMND.

3. (3) To learn whether ACT that has been tailored to meet the specific needs of plwMND needs to be further adapted to potentially increase its acceptability to this population.

National guidance recommends that relatives of people with dementia receive support to develop coping strategies. STrAtegies for RelaTives (START) is an evidence-based manualised intervention for delivery on a one-to-one basis by trained graduate psychologists to family carers of people with dementia. However, implementation of START in standard National Health Service (NHS) provision has proved difficult. We describe collaboration between a Talking Therapies service and a Memory Service to co-facilitate and run START as a group. We consider implementation outcomes according to RE-AIM domains showing: the collaboration reached higher number of carers than other implementation initiatives (reach); there was significant reduction in caregiver anxiety and a trend towards significant reduction in depression (effectiveness); feedback from service users and clinicians on the service model has been positive (adoption); delivery has been supported by the written and audio materials (implementation); and the initiative has sustained over five years, despite the COVID-19 pandemic and staff turnover (maintenance). Finally, we discuss implications and potential future development.

1. (1) To develop knowledge about the content of the STrAtegies for RelaTives (START) coping intervention for family carers of people with dementia.

2. (2) To understand the similarities between low-intensity cognitive behavioural therapy for anxiety and depression, as provided by Psychological Wellbeing Practitioners (PWPs), and START psychoeducational content and skills exercises.

3. (3) To reflect on the rationale for group delivery of START.

4. (4) To consider the benefits of collaboration between Talking Therapies and Memory Services for implementing START.

Young people are increasingly distressed by the climate and ecological crises (eco-distress). This has been associated with the failure of people in power to act appropriately, which may cause moral distress and moral injury. We examined this hypothesis by interviewing 13 young adults (19–25 years) in the UK about their climate concerns and perceptions of how State actors and authorities are responding to climate change. Using reflexive thematic analysis, four themes were developed: (1) Climate change is a wicked problem, (2) Moral distress is associated with witnessing acts of omission and commission, (3) Moral distress drives eco-distress, and (4) Opportunities for moral repair. Climate concerns extended to broader concerns about ecological degradation (eco-distress), linked to feelings of moral distress arising from repeatedly witnessing powerful people failing to act on climate change. Eco-distress was also exacerbated by (a) witnessing others in society failing to take appropriate responsibility, (b) realising the limitations of individual action, and (c) being embedded within a culture where personal contribution to climate change is inescapable. In contrast, eco-distress was lessened by seeing authorities engage with the issues morally, and further mitigated by collective, ethical, pro-environmental action. This adds empirical evidence to support the hypothesis that eco-distress involves moral distress and injury arising when State authorities and other powerful bodies engage in wrongful acts and omissions on climate change. We argue that this is affecting the wellbeing of young people and supports the argument that such wrongful (in)action infringes human rights. Clinical implications are discussed.

1. (1) To understand how and why moral distress and moral injury relate to the distress that young people feel about climate change (eco-distress).

2. (2) To consider the clinical implications of formulating eco-distress in a way that includes reference to the violation of core moral codes.

3. (3) To explore what opportunities exist that could reduce moral distress and support young people.

4. (4) To understand how research into moral distress and moral injury in relation to climate change can offer important insight into the relevance of eco-distress to human rights infringements and justice-oriented care.

5. (5) To discuss practical solutions that might support moral repair, both in psychotherapy settings and in broader social policy.

Climate change distress is a challenge to people seeking help, and to those providing help. Those providing help are working in a new area of clinical practice where little is known, but they may also be experiencing climate change distress. The aim of this article is to highlight the personal and professional implications of the unfolding climate crisis and how we might better understand and support those with understandable, yet intense, emotional reactions to the climate crisis. This article consists of a first-person narrative by the first author, and a commentary on the narrative based on the psychology of climate change literature by the second author. We have worked independently on the narrative and commentary; each is responsible for their own contribution. The narrative highlights the first author’s personal experience of moving from denial to facing the truth of the climate crisis and the impact on professional practice. The commentary by the second author found that literature is scarce, but more familiar areas of practice may help to understand and respond to climate change distress. Practitioners face a situation where they may experience similar emotions to their clients, analogous to the shared threat of the pandemic. Awareness of the crisis is daunting, but therapy, self-reflection and action can help hold our emotions and support our clients. The evidence is limited but experience of the pandemic suggests that CBT can respond, adapt, innovate, and even revolutionise mental healthcare. These two perspectives suggest, despite the challenges, there may be reasons for hope.

1. (1) To increase familiarity with climate change distress and its multi-faceted presentations.

2. (2) To understand the importance of self-care for climate activists and the different forms this may take.

3. (3) To consider the implications of being a practitioner helping people with climate change distress, while also experiencing climate change distress.

4. (4) To reflect on the tensions between, and the potential integration of, the personal and the professional in the context of climate change.