Despite substantial investment, Improving Access to Psychological Therapies (IAPT) services in some areas continue to find that demand exceeds provision, leading to waiting lists for therapy. Routine engagement in services is low, with almost half of clients disengaging with the service before or after the initial contact. An audit was carried out to evaluate the impact of introducing a face-to-face initial session within the high-intensity step of an IAPT service. The service structure and pathway of one regional IAPT service is described. A longitudinal observational design was used. All clients discharged from the service within two calendar months – before and after the introduction of an initial face-to-face session were identified. Electronic records were reviewed for each client. Introduction of an initial face-to-face session was associated with an increase in clients attending at least one therapy session and clients completing a course of therapy. Inclusion of an initial face-to-face engagement session may take up additional time, but is likely to be worthwhile in regards to associated benefits in terms of client engagement.

Transdiagnostic cognitive behavioural therapy (CBT) focuses on the processes shared across disorders and can be applied to a wide range of mental health problems or comorbid conditions. The transdiagnostic approach provides the potential opportunity to improve access to CBT, particularly in countries such as Saudi Arabia, where the number of well-trained therapists is limited. This study aims to examine the feasibility and potential benefit of transdiagnostic CBT for Saudi patients. Case reports describe the outcome of transdiagnostic CBT for four female patients who presented a wide range of symptoms and conditions without conducting any specific diagnostic assessments. The results support the positive effect of this treatment method on depression, anxiety symptoms, and general functioning. Patient feedback and observable improvements also supported these outcomes. However, the results are limited by the small sample size and simple study design. Transdiagnostic CBT is a feasible treatment approach for patients in Saudi Arabia. However, to confirm this preliminary finding, more studies are required.

The main objectives of this study were to compare the perceived utility of two definitions of schema (i.e. a standard Beckian vs. a revised definition). Fifty clinicians with varying degrees of training in cognitive behavioural therapy (CBT) received a presentation on the Beckian definition of schema before completing two questionnaires, one assessing the perceived utility of the definition, and another assessing the targets they would address in therapy and the techniques they would use to do so, using the Beckian definition. They then received a presentation on a revised definition before completing the questionnaires again; this time in relation to the revised definition. In a non-inferiority analysis the revised definition was rated as possessing not less clinical utility than the Beckian definition and was indeed rated higher. More targets and techniques were selected following the revised definition, relative to the Beckian definition. Further, there was a significant interaction between definition and targets and techniques selected, with a greater increase in the targets and techniques that are consistent with the revised definition. The results were independent of experience within mental health and practising CBT therapists. The revised definition was perceived to have clinical utility and the use of it in therapy would lead to a wider range of targets being addressed while using a wider range of clinical techniques. Importantly, those targets and techniques relate specifically to the revised definition. The implications of the results and future areas of research are discussed.

This paper reports a piece of practitioner research to explore the use of a Session Bridging Worksheet (SBW) with clients on their homework adherence, experience of their therapist, and clinical outcomes. Clients were divided into two groups randomly. One group received CBT as normal (TAU group) and the other group received CBT and used a session bridging worksheet (SBW group). The perception of the therapist's ability to address potential barriers was better when the SBW was used by the client and this seems to have had a small positive effect on homework adherence. Differences in symptom measures (BDI, BAI, BHS) between the two groups are inconclusive. The limitations of the design of the study are discussed with suggestions for future research.

There is growing evidence that Behavioural Activation is an effective treatment for older adults with depression. However, there is a lack of detail given in studies about any adaptations made to interventions or efforts made to remove treatment barriers. Factors such as co-morbid physical health problems, cognitive impairment and problems with social support suggest there may be specific treatment considerations when developing interventions for this group. This article aims to describe adaptations made to a general adult Behavioural Activation manual using literature on treatment factors for older adults as an organizational framework. This information may be of use to mental health workers delivering behavioural interventions to older adults with depression and documents the initial phase of developing a complex intervention.

Cognitive Behavioural Therapy (CBT) including Exposure and Response Prevention (ERP) is recommended by NICE as the psychological treatment of choice for obsessive compulsive disorder (OCD). Twenty-five percent of OCD patients refuse ERP, and many psychologists advocate formulation-driven cognitive therapy, including ERP, as opposed to ERP alone. However, a recent meta-analysis suggested there is insufficient evidence to suggest ERP is improved by cognitive methods. This paper proposes to contribute to this debate by providing a detailed description of the treatment of a patient with intrusive cognitions of a sexual nature, who was treated successfully using behavioural experiments designed to test cognitions, rather than ERP. This is, arguably, the way in which most cognitive behavioural therapists would work with someone with OCD. However, this approach is not reflected in the literature at present. The authors report the patient's feedback that therapeutic change was brought about through cognitive shift, as a result of the formulation-driven behavioural experiments.

Low self-esteem is widely acknowledged to be associated with the phenomenology of a number of mental health diagnoses, including those which are treated under the umbrella of Improving Access to Psychological Therapies (IAPT) services. To evaluate the effectiveness of group Cognitive Behaviour Therapy (CBT) based on the work of Fennell in treating low self-esteem 50 participants attended a 10-week group programme. Pre- and post-group measures of depression, anxiety and self-esteem were compared using Mann–Whitney U tests. The results indicated that there was a statistically significant and clinically meaningful change across all pre- and post-group measures. Mean post-group measures indicated levels of depression and anxiety which were below caseness and a healthy level of self-esteem. Results indicated that gains were well maintained at 3-month follow-up. The results from this study highlight the effectiveness of group CBT for low self-esteem and thus contribute to the limited evidence base in this area. Results are discussed with consideration of the existing evidence base, implications for clinical practice, and future research.

While clinicians have described the benefits of using formulations within therapy, little is understood about the client's experience of the formulation process. Cognitive behaviour therapy (CBT) is currently the treatment of choice for many adult mental health difficulties. However, research exploring clients’ experiences of CBT formulation is very limited. The present study set out to explore experiences of CBT formulation in clients with depression. Seven participants were interviewed and the data analysed using Thematic Analysis. The analysis identified key themes such as: ‘Feeling trapped or restricted by depression’, ‘The development of the formulation – from coming to my own conclusions to something the therapist developed’, ‘From negative to mixed feelings: emotional reactions to the formulation during the therapeutic process’ and ‘A new journey: towards making a new sense of oneself’. The results of the study highlight the personal and emotional challenge of the formulation process for clients.

There is increasing evidence that mindfulness techniques can be used safely and effectively in the treatment of psychosis, but the potential benefits of these techniques for individuals during the early stages requires further exploration. This study investigated whether mindfulness training in a group setting is associated with a reduction in distress and an improvement in mindfulness skills for people who have psychotic experiences. Data are reported from eight participants who completed measures before and after attending a mindfulness group. There was a reduction in CORE and DASS scores and an increase in mindfulness skills following participation in the group. These findings suggest that mindfulness training can be beneficial for reducing distress and negative emotional states associated with early psychotic experiences during the critical period.

Cognitive-behavioural therapy (CBT) can be effective for anorexia nervosa. However, there is evidence that the delivery of treatments for the eating disorders is inconsistent. This study examined evidence that clinician characteristics and practice can influence the effective implementation of CBT. The participants were 100 qualified clinicians who routinely offered outpatient CBT to adults with anorexia nervosa. They completed a survey of their demographic characteristics, level of anxiety, clinical practice in CBT for anorexia nervosa, and beliefs about the relationship between weight gain and therapeutic alliance in the early part of such treatment. Greater reported levels of weight gain were associated with the use of manuals, early focus on weight gain as a target, structured eating, and a belief that weight gain precedes a good working alliance. Clinician anxiety and early focus on the therapeutic alliance rather than structured eating were associated with poorer outcomes. These conclusions need to be tested within clinical and research settings. However, they suggest that clinicians should be encouraged to use manual-based approaches when treating anorexia nervosa using CBT, as focusing on techniques might result in the best possible outcome in this early part of treatment.

Anxiety disorders and insomnia significantly impair daily functioning. Similar underlying mechanisms may account for the high comorbidity of both disorders, and respective treatments share pharmacological and behavioural features. This review suggests the utility of an integrated CBT approach in the treatment of generalized anxiety, post-traumatic stress, and panic disorders, and comorbid insomnia. Other anxiety disorders were not explored because current data are limited or inconsistent. A comprehensive, non-systematic review of the literature was conducted to evaluate the treatment of comorbid anxiety and insomnia disorders, and data reveal shared pharmacological and behavioural features of insomnia and anxiety disorders treatment. However, research demonstrates that CBT maintains successful treatment results longer than drug therapies. Despite similar treatment approaches, there is a paucity of research that explores integrated CBT approaches for comorbid anxiety and insomnia disorders. This review suggests that future research should assess the impact of combined therapeutic approaches on the simultaneous reduction of anxiety disorders, insomnia, and relapse rates.

Borderline personality disorder (BPD) is associated with problems in attention, memory, planning and cognitive flexibility, which may underpin aspects of behavioural dysregulation. Cognitive remediation (CR) is an individual psychological therapy which aims to improve thinking skills and thus positively impact everyday functioning. We aimed to assess the feasibility and acceptability of CR for two BPD patients who had not previously engaged with psychological therapy. Participants were assessed using neuropsychological, symptom and social functioning measures and then received up to 40 sessions of individual CR. They were re-assessed post-therapy and 3 months later, and rated their experience of CR. The participants reported increased self-esteem and improved memory. Neuropsychological tests showed executive functioning improvements post-therapy, which were partially maintained at follow-up. CR was a feasible and acceptable therapeutic approach for these two participants and may hold promise as a complementary therapeutic approach for BPD characterized by marked cognitive problems or difficulty in engaging in more emotionally focused psychotherapies.

Problem-solving and coping skills deficits have been shown in adolescents who experience suicide-related behaviours, including suicidal ideation. Little evidence exists about effective interventions for this population. We undertook a pilot study of an Internet-based CBT programme that included problem-solving skills training to investigate its impact on skills deficits. The study employed a pre-test/post-test design. Outcomes of interest were negative problem orientation, emotion- and task-focused coping, and adolescents’ perception of helpfulness of the intervention. Participants, recruited via the school wellbeing team, were assessed at baseline, at weekly intervention sessions and immediately post-intervention. Twenty-one adolescents completed the intervention. Over the course of the intervention, negative problem-solving orientation improved and students relied less on emotion-focused coping strategies. Because there was no control group, we cannot be certain that the changes seen between baseline and post-intervention can be attributed to the intervention. Adolescents rated the problem-solving and cognitive restructuring modules as particularly helpful. Interventions that include enhancement of problem-solving skills, as well as cognitive restructuring to address adolescents’ appraisal of problems and their ability to solve them appear promising for adolescents with suicidal ideation. Further investigation is warranted.

Self-Practice/Self-Reflection (SP/SR) has been developed as a self-experiential training strategy to enhance CBT therapists’ skills. SP/SR gives therapists an experience of CBT through practising CBT techniques on themselves, and reflecting on the experience and its implications for clinical practice. Many practitioners report significant professional and personal gains from SP/SR; however, there is considerable individual variation. This study examined individual experiences of SP/SR in order to develop a better understanding of idiosyncratic variations in participants’ approaches to SP/SR, and to inform the design and implementation of future SP/SR programmes. A single-case design was employed to examine the experiences of four trainee cognitive-behaviour therapists who were undertaking SP/SR as part of their professional training in CBT. Quantitative data from self-ratings of skill, and qualitative data from participants’ reflections and attributions following completion of SP/SR were examined. Both the participants, and two additional reviewers were consulted in the interpretation of the results. The impact of SP/SR appeared specific to each participant, reflecting different ways that participants engaged with SP/SR materials. The study suggests that for optimal development, engagement of the personal self and therapist self may be required.

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.

Cognitive behavioural treatments (CBTs) are well-established for obsessive compulsive disorder (OCD). However, few patients receive CBT, due to factors like geographical limitations, perceived stigmatization, and lack of CBT services. Some evidence suggests that computer-delivered cognitive-behavioural treatments (CCBTs) could be an effective strategy to improve patients’ access to CBT. To date a meta-analysis on effectiveness of CCBTs for OCD has not been conducted. The present study used meta-analytical techniques to summarize evidence on CCBTs for OCD on OCD and depression symptom outcomes at post-treatment and follow-up. A meta-analysis was conducted according to PRISMA guidelines. Treatments were classified as CCBTs if including evidence-based cognitive-behavioural components for OCD (psychoeducation, exposure and response prevention, cognitive restructuring), delivered through devices like computers, palmtops, telephone-interactive voice-response systems, CD-ROMS, and cell phones. Studies were included if they used validated outcomes for OCD. Eight studies met inclusion criteria (n = 392). A large effect favouring CCBTs over control conditions was found for OCD symptoms at post-treatment (d = 0.82, p = 0.001), but not for depression symptom outcomes (d = 0.15, p = 0.20). Theoretical implications and directions for research are discussed. A larger number of randomized controlled trials is required.

This study evaluated a 3-day Schema Therapy (ST) training programme for trainee clinical psychologists. The training used an experiential model of learning, which was intended to encourage the transfer of knowledge and techniques from the learning environment into clinical practice. Using a mixed-methods approach, the training programme was evaluated in terms of: (1) self-reported changes in knowledge, confidence and willingness to use ST-informed techniques; (2) whether the training was integrated into clinical practice; and (3) the perceived barriers/facilitators to achieving practice integration. Participants – 17 of the 19 trainee clinical psychologists enrolled on the ST training programme – completed assessments immediately pre- and post-training. Participants were subsequently followed-up for reassessment 3 months after the training. Group- and individual-level analyses showed that most participants reported training-related gains in knowledge and confidence; these were largely sustained at follow-up, and were associated with post-training practice integration of ST concepts and techniques. Analysis of qualitative data identified factors moderating use of training in practice. Findings of the study have implications for future delivery and evaluation of training in cognitive-behavioural therapies.

A feasibility study evaluated five adapted Mindfulness-based Cognitive Therapy (MBCT) groups that were delivered to staff in a National Health Service (NHS) mental health Trust as part of a staff health and wellbeing initiative. Using an uncontrolled design typical of a feasibility study, recruitment, retention and acceptability of the groups were assessed. Effectiveness was also measured at pre- and post-therapy, and at 3-month follow-up, using quantitative methods. In addition, qualitative methods were used to explore staff experiences of the groups. Results demonstrated high levels of feasibility, and significant improvements in staff perceived stress and self-compassion at both post-therapy and follow-up. Qualitative data suggested many staff felt the groups had improved their physical and emotional health, their ability to manage stress at work and the quality of their work with patients and of their relationships with colleagues. Although Mindfulness-based Stress Reduction (MBSR) has typically been used to help manage staff stress, these results are promising for the use of an adapted MBCT with this population. Challenges and factors contributing to these outcomes are discussed.

Mindfulness-based Cognitive Therapy (MBCT) was not intended for current depression, and lengthy mindfulness practices (≥30 min) can be challenging. Person-based cognitive therapy (PBCT) includes brief mindfulness practices (<10 min). While group PBCT can improve depressive symptoms whether benefits can be attributed to the brief practices is unclear. Twenty-eight participants with chronic major depression were randomly assigned to PBCT (n = 14) or treatment as usual (n = 14). Measures of mindfulness and depression were taken. Six PBCT participants were interviewed. Improvements in mindfulness in mediating the relationship between group and improvements in depressive symptoms just failed to reach statistical significance (95% confidence interval −0.97 to 14.84). Thematic analysis identified four themes: ‘altered relationship to symptoms’, ‘impact on self’, ‘the challenge of letting go’ and ‘effect of the group’. Although bootstrapped indirect effects were in the hypothesized direction they failed to reach statistical significance; this could be due to low power, but further research is needed. Qualitative themes support the potential of brief mindfulness practices and are similar to themes identified of mindfulness-based interventions with lengthier mindfulness practices. Findings suggest that some people experiencing current depression report benefit from the brief mindfulness practices included in PBCT but further research in larger samples is now needed.

Māori are the indigenous people of New Zealand and in 2006 comprised approximately 15% of the country's population. Epidemiological data suggests Māori experience rates of depression that are higher than the general population and are less likely to engage in treatment for mental health issues. The main aim of this study was to evaluate the effectiveness of an adapted approach to psychotherapy with Māori. The broad goals of which were to provide empirically grounded guidance for therapists aspiring to provide best practice to their Māori clients. This paper documents the evaluation of a cognitive behavioural therapy (CBT) treatment protocol specifically designed and adapted for delivery to adult Māori clients with a diagnosis of depression. The treatment protocol was administered to 16 Māori clients with a primary diagnosis of depression. The adapted treatment incorporated Māori processes for engagement, spirituality, family involvement and metaphor. The intervention exhibited considerable promise with large significant reductions in depressive symptomatology in the participant group. Furthermore, significant reductions in negative cognition were observed. This is the first piece of applied clinical research that has examined the effectiveness of an individual psychological therapy exclusively with Māori and the first to examine individual psychotherapy outcomes with an indigenous population using an effectiveness study. The findings have a number of implications for the treatment of Māori clients with depression. This study provides useful guidelines for clinicians providing psychological treatment to Māori and provides strong support for the cultural adaptation of psychological treatment with ethnic minority groups.