Drawing on extensive experience in training and supervising clinicians in enhanced cognitive behaviour therapy (CBT-E), we have identified ten prevalent misconceptions and communication gaps. These misunderstandings can impact the implementation of CBT-E and may potentially reduce its effectiveness. They include misconceptions regarding CBT-E’s flexibility, suitability for certain patient groups, real-world applicability, and alignment with anti-weight stigma principles. Such misunderstandings may make clinicians hesitant to recommend or deliver CBT-E appropriately. In the present paper, we address these misconceptions and gaps in communication and provide evidence-based guidance on CBT-E practice. We aim to enhance clinicians’ confidence in using CBT-E flexibly and appropriately, with the hope that this will improve its effectiveness.

Key learning aims

1. (1) Recognise common misconceptions and communication gaps about enhanced cognitive behaviour therapy (CBT-E) for eating disorders.

2. (2) Develop an understanding of how CBT-E can be implemented across diverse clinical settings and patient populations.

3. (3) Strengthen therapists’ confidence in delivering CBT-E flexibly while maintaining fidelity to its evidence-based framework.

Type 1 diabetes is a condition requiring complex self-management and is often associated with co-morbid mental health difficulties. The presence of mental health difficulties can lead to challenges with diabetes self-management and an increased chance of secondary diabetes complications. A difficulty faced by NHS services is that people with type 1 diabetes and co-morbid mental health difficulties may present with different mental health symptomatology, ranging from purely mental health based (e.g. depression and anxiety) to distress specifically related to living with type 1 diabetes (e.g. fear of hypoglycaemia). Through completion of consultancy work in the local area we identified a need for a Diabetes Presentation Classification Tool to aid collaborative care planning and decision making. Data collected during initial assessment in an NHS Talking Therapies service were used to classify people accessing the service with type 1 diabetes into either ‘diabetes-led’ or ‘depression-anxiety-based’ presentations. The Fleiss’ kappa inter-rater reliability score for the coding of presentations was 75%. Of 120 people discharged, the majority (85.8%) were classified as depression-anxiety based, with only 8.3% classified as diabetes-led. People with diabetes-led presentations had poorest recovery rate (28.6%), aligned with guidance that the needs of these people would be best addressed by a specialist team. This tool is designed to aid professionals with triaging people with type 1 diabetes based on their appropriateness for a primary care intervention or an intervention delivered by a clinical health psychology specialist service as part of the diabetes multi-disciplinary team (MDT).

Key learning aims

1. (1) To understand the current challenges and need for clear guidelines for the triage of people with type 1 diabetes experiencing psychological difficulties.

2. (2) To introduce the Diabetes Presentation Classification Tool and methods used to test its reliability and validity.

3. (3) To evaluate the outcomes (recovery rates) for people with type 1 diabetes classified with different presentations who have accessed treatment in NHS Talking Therapies.

Grandiose delusions have received comparatively little attention in the literature and there is limited empirical evidence assessing the efficacy of cognitive behaviour therapy for psychosis (CBTp) for individuals with grandiose beliefs. This case study presents Noah, a 23-year-old referred to our Early Intervention Service with persistent grandiose beliefs alongside other psychotic experiences. Noah received 26 sessions of CBTp. Scores on measures of perseverative thinking, delusional distress and conviction, wellbeing, and daily functioning were completed at baseline, mid-therapy, end of therapy, and at follow-up 12 weeks after the end of therapy. Results demonstrated improvement across all measures, particularly preservative thinking about beliefs. Improvement in all but one outcome was not only sustained but continued to increase at follow-up. This is one of few known reports on using CBTp with an individual with current grandiose delusions.

Post-traumatic stress disorder (PTSD) and complex-PTSD (cPTSD) can be experienced following experiences of domestic abuse (DA). People who have experienced DA are likely to face re-victimisation, especially when the threat of DA is ongoing. Trauma-focused cognitive behavioural therapy (TF-CBT) is recommended for PTSD. However, there are often concerns about offering this intervention where there is ongoing threat due to fears of desensitisation to risk and lack of stability. Recent reviews have illustrated that, on the contrary, TF-CBT can be effective at reducing PTSD and does not necessarily increase risk. However, research is lacking in community settings. The present case study utilised a single-case experimental design to measure the assessment (Phase A) and treatment (Phase B) of PTSD in response to DA using a TF-CBT model in a community NHS setting where there was a threat of further DA due to ongoing contact with the perpetrator. PTSD, anxiety, and depression scores reduced, and improvements were seen in idiosyncratic measures. Results are discussed in line with ongoing debates regarding offering TF-CBT to those at risk of ongoing threat.

Cognitive behavioural therapy (CBT) is a frontline treatment for a range of mental health problems and is increasingly offered as the psychological therapy of choice across the globe. Access to or benefit from this psychological therapy relies on proficiency in the dominant language of the area. However, to meet our clients’ needs in an increasingly mobile, multicultural, and diverse society, it may require adaptation through the use of spoken language interpreters. The benefits of interpreter-mediated CBT for mental health problems remains uncertain. The objective of this review is to systematically identify, evaluate, and integrate the existing empirical literature on interpreter-mediated CBT for mental health problems. A comprehensive search was conducted in July 2024 across CINAHL, MEDLINE, PsycINFO and Scopus. Studies meeting the inclusion criteria resulted in a total of eleven articles being included in the review. The included research shows promise in terms of feasibility and efficacy, but not conclusively. The narrative review enabled the synthesis of recommendations, which have been conceptualised as being at individual, service, and organisational levels. There is limited research and a need for further studies into the influence of other factors such as therapist proficiency, interpreter proficiency, complexity/co-morbidity and service context. Further evaluation should consider controlled trials of interpreter-mediated CBT, while also establishing its efficacy more robustly in regular practice. It should also further explore the experiences and perspectives of the client, interpreter, and therapist regarding the suggested recommendations.

Key learning aims

1. (1) Gain an understanding of the existing evidence on the effectiveness of interpreter-mediated CBT for various mental health problems across diverse populations.

2. (2) Learn about key recommendations emerging from empirical research on the implementation of interpreter-mediated CBT.

3. (3) Acquire clear, practical guidance that can inform the work of interpreters, practitioners, services, and healthcare systems to improve the delivery of interpreter-mediated CBT.

The internet has been increasingly employed in the treatment of binge eating, including to facilitate guided self-help (GSH). However, few studies have investigated provision of GSH over email and there are questions regarding the viability of this approach, and how facilitators might best deliver this treatment. We describe a case study of a woman in her early 50s with a diagnosis of binge-eating disorder (BED) who received email-supported GSH over 12 weeks within a larger randomised controlled trial. At assessment, she presented with regular binge eating episodes (approximately twice a week) in addition to co-morbid medical and psychiatric issues, for which she was prescribed several medications. Treatment, provided within the UK National Health Service, involved provision of a self-help manual (Overcoming Binge Eating; Fairburn, 2013) in addition to email support over 12 weeks. A summary of the intervention is provided, along with email excerpts to demonstrate practice, illustrate how treatment might be delivered, and outline the type of interaction that may occur during email support. Consistent with larger studies, improvement on several self-report symptom measures was seen, including eating disorder symptoms, psychosocial impairment, psychological distress, self-esteem, and therapeutic alliance, all of which met criteria for reliable improvement at post-treatment. This case study, which provides data from one individual, demonstrates delivery of GSH with email support for regular binge eating, which could be considered as an alternative to face-to-face treatment. Future work might look to enhance outcomes following GSH, including reducing drop-out, and increase dissemination and uptake of GSH.

Key learning aims

1. (1) Consider the potential role of email-assisted self-help in the treatment of recurrent binge eating.

2. (2) Provide guidance to support the delivery of guided self-help, particularly in an online format.

3. (3) Review an example of using a CBT-based self-help intervention to overcome binge eating in the presence of medical and psychiatric co-morbidity.

4. (4) Understand how to implement guided self-help for binge eating and use this approach to facilitate a strong therapeutic alliance and symptom change.

Co-morbid mental health diagnoses present challenges for services structured to provide disorder-specific models of treatment, such as NHS Talking Therapies services. Intolerance of uncertainty (IU) has been identified as both disorder specific and transdiagnostic, although little research explores transdiagnostic approaches to treatment of IU alone. A transdiagnostic cognitive behavioural therapy treatment targeting IU, the ‘Making Friends with Uncertainty’ (MFWU) group, was developed and piloted in a Talking Therapies primary care service in an earlier evaluation (Mofrad et al., 2020). The aim of this study was to replicate and further evaluate the intervention. Twenty people presenting with a range of anxiety disorders started the intervention in two groups. The study used a single group, within-subjects quasi-experimental design, collecting data at eight points for routine outcome measures of anxiety, depression and functioning, and five points for measures of anxiety disorder-specific symptoms and IU. Intention-to-treat analyses showed improvement on a general measure of anxiety as well as improvement on the measure of IU. Significantly there was improvement on the disorder specific measures even though the intervention was aimed at the underlying process of IU, rather than the particular symptoms targeted by these measures. The MFWU group may be an efficient and effective way to deliver a highly specified transdiagnostic intervention for intolerance of uncertainty when people are treated in a mixed group format.

Key learning aims

1. (1) To consider the effectiveness of a transdiagnostic group targeting IU.

2. (2) To develop understanding of a group intervention for building tolerance to uncertainty.

3. (3) To consider the impact of targeting IU on specific anxiety disorders.

4. (4) To offer a methodological framework for effectively evaluating a group intervention in routine practice.

For young people with eating disorders (EDs), family-based therapy (FBT) is generally recommended as first-line treatment. Although there is an abundance of evidence demonstrating the efficacy of FBT, less than half of young people achieve full remission with this treatment. Enhanced cognitive behaviour therapy (CBT-E) is an established alternative to FBT, demonstrating effectiveness in individuals who have not achieved full remission with FBT. It is also recommended when family therapy is unacceptable, contraindicated, or ineffective. Despite some overlap – particularly in addressing maintaining factors and prioritising weight normalisation – the two treatments diverge significantly in conceptualisation of the eating disorder, proposed mechanisms of action, role of both young people and parents, and strategies and processes of therapy. These differences may contribute to one treatment being effective where the other has not, but can present challenges and difficulties for the young person, family and clinician when transitioning from FBT to CBT-E. In this paper, we provide guidance for clinicians delivering CBT-E with young people who have a history of FBT treatment. We highlight common issues encountered among this cohort, discuss how they can present a barrier to successful implementation of CBT-E, and describe solutions.

Key learning aims

1. (1) To learn the commonly encountered barriers to treatment when implementing CBT-E for young people who have previously engaged in FBT.

2. (2) To learn strategies to overcome these barriers focusing on the young person, parents and multi-disciplinary team.

Seasonal affective disorder (SAD) is a seasonal pattern modifier to recurrent major depressive disorder. Despite cognitive behavioural therapy (CBT) having a strong evidence base of efficacy for depression, little research exists assessing CBT for SAD, especially in the acute phase of depression during winter months. The aim of this study was to determine the efficacy of CBT for acute SAD in adults. Eligible randomised controlled trials (RCTs) testing the efficacy of CBT on depression symptoms in adults with SAD were included. Depression outcomes were assessed using the Revised Cochrane Risk-of-Bias Tool for Randomized Trials. A meta-analysis using a fixed effects model was conducted to assess the effects of CBT on depression symptoms compared with light therapy (LT) at post-intervention and 1–2 years follow-up. Narrative synthesis was used for recurrence and remission rates. Three RCTs and two follow-up papers met the inclusion criteria. All RCTs measured efficacy of group-CBT for acute SAD and compared to LT. There was substantial variation in risk of bias for all outcomes across the trials. Three RCTs (n=220 participants) were included in the meta-analysis that found CBT was effective in reducing depressive symptoms compared with LT at 1–2-year follow-up post-intervention [MD=–4.5, 95% confidence interval (CI) (–6.88, –2.12), p<0.05]. There was no difference between CBT and LT at immediate post-intervention. Group-CBT appears equivalent to LT in treating acute SAD in adults at post-intervention, but appears more effective at long-term follow-up. The findings should be taken with caution due to few included studies and variation in risk of bias across studies.

Key learning aims

1. (1) Previous research into CBT and seasonal affective disorder has focused primarily on delivery of CBT during the non-acute phase of SAD, typically in non-winter months.

2. (2) There are limited high quality randomised controlled trials testing the efficacy of CBT for seasonal affective disorder in the acute phase during winter months.

3. (3) It appears that group-CBT for SAD is superior to LT at 1–2 years follow-up.

This paper describes the evaluation of a simple service adaptation and associated brief training for NHS Talking Therapies for Anxiety and Depression (NHS TTad) staff on working with autistic people. A simple question regarding whether clients identified themselves as autistic and an associated data system flag was introduced to an NHS TTad service. A brief training regarding the use of the flag, a brief overview of autism and a consideration of general adaptations that might help autistic people was developed. Core outcomes of confidence and therapy self-efficacy were reported for pre-training, immediately post-training and at three months post-training. At three-month follow-up, six therapists were interviewed to explore changes in practice following the training. There were significant changes in confidence and therapeutic self-efficacy post-training that were maintained at three-month follow-up. Therapists report several changes to practice that they related to the training. This is the first paper to describe and evaluate training for therapists in NHS TTad on working with autistic people.

Key learning aims

1. (1) To describe some of the challenges to NHS TTad services in working with autistic people.

2. (2) To describe the system adaptation and therapist training introduced to this service and the approach to evaluation.

3. (3) To report outcomes from the evaluation of the training for NHS TTad therapists in working with autistic adults.

4. (4) To consider further research and practice in the processes to make NHS TTad services more accessible and effective for autistic adults.

Increasing numbers of children and young people (CYP) are presenting with common mental health difficulties. In 2017, the UK government outlined a service transformation plan which led to the development and implementation of Mental Health Support Teams (MHSTs), to deliver evidence-based interventions in schools for mild to moderate mental health difficulties. This service evaluation aimed to evaluate the effectiveness of individual interventions delivered by MHST practitioners trained to deliver low-intensity cognitive behavioural interventions to CYP with mild to moderate mental health difficulties, within one service based in the South East of England. Four hundred and fifty-nine CYP engaged in an individual intervention delivered by MHST practitioners between January 2021 and December 2022. Interventions were delivered either online via video call or face-to-face. All children and their parents/carers were invited to complete two routine outcome measures (Revised Children’s Anxiety and Depression Scale (RCADS), and Strengths and Difficulties Questionnaire (SDQ)) at baseline and post-intervention. Outcome data demonstrated significant improvements across all child- and parent-rated RCADS anxiety and depression scales. Significant improvements were also shown for both child- and parent-rated SDQ total difficulties and impact scores. These all showed effect sizes ranging from medium to large. Girls presented higher scores pre- and post-intervention compared with boys apart from the OCD subscale; gender was not a predictor of improvement in the majority of analyses. Individual, low-intensity cognitive behavioural interventions delivered in this MHST service were effective in reducing symptoms of emotional and behavioural difficulties in CYP with mild to moderate mental health difficulties.

Key learning aims

1. (1) Understand the context of Mental Health Support Teams (MHSTs) as an early intervention service within school settings.

2. (2) Learn about the impact of MHST-delivered interventions on symptoms of emotional and behavioural difficulties in children and young people.

3. (3) To gain an understanding of how boys and girls may respond differently to MHST-delivered interventions.

Social anxiety disorder (SAD) is one of the most prevalent co-occurring conditions amongst cognitively unimpaired autistic people. The evidence-based treatment for social anxiety known as cognitive therapy for SAD (CT-SAD) may to an extent be beneficial to autistic people, but adaptations for autistic people are recommended to increase its effectiveness. The present study aimed to co-produce and pilot an adapted SAD treatment protocol for autistic people based on the Clark and Wells (1995) model, including assessing its feasibility and acceptability. A bespoke 12-week CBT online group intervention was created to meet the needs of autistic people with a diagnosis of SAD. The treatment protocol was created collaboratively with autistic people. It was piloted with seven adult participants (three males, four females) with autism or self-identified autism who completed the group intervention targeting SAD symptoms. With regard to feasibility, we met our initial aims of recruiting our intended sample size of a minimum of six participants for the intervention with an attendance rate of at least 80% of sessions. The excellent completion and attendance rates, respectively 100% and 95%, indicate that the intervention was acceptable to our participants. These findings extend previous research and support the continued adaptation of CBT interventions for autistic people. Furthermore, the evidence of feasibility indicates that further study to evaluate the efficacy of this group intervention is warranted.

Key learning aims

1. (1) To reflect on social anxiety, autism and identify ways to improve the delivery of cognitive therapy for autistic people.

2. (2) To identify useful adaptations to cognitive therapy for autistic people.

3. (3) To learn how to deliver group cognitive therapy remotely for autistic people who present with social anxiety.

The original declarative procedural reflective (DPR) model is a well-established model of therapist knowledge and skill development. To date, although it has been used to guide reflection and discussion around personal and practitioner selves, it has not emphasised the various intersecting identities of practitioners and how these interact within wider concepts such as power, society, service contexts and the patient and supervisory relationships. The learning, development and implementation of CBT skills does not occur in a vacuum or separate to the practitioner identities however relatively little has been written on this. This paper aims to expand the original DPR model to illustrate potential ways that social context, identity and power could be considered within CBT training, delivery and supervision. It delineates and explores the additional components of the model (i.e. practitioner identity(s), context/society and power) and then provides examples of how this framework could inform key CBT activities (including low-intensity CBT).

Behavioural activation (BA) is recommended for the treatment of depression but most research focuses on working age adults and there is a dearth of literature concerning the delivery of BA with people with co-occurring depression and mild cognitive impairment (MCI). This case study outlines a BA intervention with a male in his late 60s with depression and MCI and describes appropriate adaptations that were useful. Treatment consisted of psychoeducation of depression and BA, formulation, activity monitoring and scheduling, tackling self-critical thoughts and rumination, and relapse planning. The 12-session BA treatment resulted in a decrease in both depressive symptoms and psychological distress as well as an increase in the individual’s engagement with meaningful activities. This case study adds to the literature and strengthens the argument for the use of BA in the treatment of depression in older adults with MCI. Adaptations, conclusions and limitations are discussed.

Key learning aims

1. (1) To gain an understanding of the use of behavioural activation (BA) in the treatment of depression in older adults with mild cognitive impairment (MCI).

2. (2) To illustrate treatment of depression using BA with an older adult utilising the current evidence base.

3. (3) To outline adaptations that can be made to BA to help deliver this treatment with an older adult who has MCI.

The current case study was completed as part of the routine psychological therapy delivered in a Critical Care Psychology Service in the United Kingdom. For families of critically ill patients, an admission to the intensive care unit (ICU) can be a distressing and potentially traumatic experience. Relatives of ICU patients may, therefore, face ongoing psychological difficulties after their loved one’s discharge from hospital, an experience recognised as Post-Intensive Care Syndrome - Family (PICS-F). Psychological morbidity associated with PICS-F includes post-traumatic stress disorder (PTSD). Despite high rates of PTSD within this population, there are currently no published guidelines available for the treatment of PTSD in relatives following an ICU admission. Clinicians working in this field are consequently required to adapt existing psychological models and protocols recommended for treating PTSD, for application to ICU-related traumatic stressors. This case study describes how cognitive therapy for PTSD (CT-PTSD) was tailored to treat a 60-year-old female experiencing PTSD following her husband’s admission to the ICU. It also illustrates how critical illness can be conceptualised as an intangible loss that triggers a grief experience for relatives of ICU patients, causing PTSD symptoms to persist. The client attended 14 weekly sessions of CT-PTSD. Treatment included cognitive strategies for panic, imaginal re-living and a site visit, as well as consideration of the role of non-death loss and disenfranchised grief in the client’s experiences. At the end of treatment, the client no longer presented with clinically significant symptoms of PTSD, as assessed on the Impact of Events Scale-Revised (IES-R).

Cognitive therapy for post-traumatic stress disorder (PTSD) is recommended in a range of national and international guidelines. This clinical guidance paper specifically focuses on cognitive therapy for PTSD (CT-PTSD) where racism has been part of the index trauma event(s). It aims to support CBT therapists to maintain fidelity to the CT-PTSD model but also ensure that racism is integrated into the formulation and interventions in ways that are sensitive and validating. It explores barriers to this occurring ranging from societal factors (e.g. ongoing racism, discouragement from discussing racism), to therapist factors (e.g. lack of understanding of racism, lack of own understanding of racialised identity, anxiety, lack of knowledge, skills and confidence) and patient factors (e.g. shame, fear of therapist response). The paper aims to provide guidance on how these can be addressed alongside case illustrations and practical considerations for therapists and supervisors.