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.

Psychological interventions may assist in the management of bipolar disorder, but few studies have assessed the use of group therapy programs using telehealth.

The present study aimed to assess the feasibility and acceptability of a well-being group program for people living with bipolar disorder designed to be delivered via telehealth (Zoom platform) using a randomised controlled pilot design.

Participants were randomly assigned to either the 8-week well-being plan treatment condition or the wait-list control condition. They were administered a structured diagnostic instrument to confirm bipolar disorder diagnosis followed by a set of self-report questionnaires relating to mood, quality of life, personal recovery, and stigma.

A total of 32 participants (16 treatment; 16 control) were randomised with 12 participants completing the intervention, and 13 the control condition. The program appeared acceptable and feasible (75% retention rate) with a mean attendance being reported of 7.25 sessions attended out of a possible 8 sessions. Participants reported high levels of satisfaction overall with the intervention, with a mean score of 9.18 out of 10.

Preliminary evidence suggests that delivery of the group program online is feasible and acceptable for participants living with bipolar disorder. As the program was designed to prevent relapse over time, further research is needed to determine if the program may be helpful in improving symptom outcomes over a longer follow-up period.

Parents report that around 20% of infants cry a lot without apparent reason during the first four postnatal months. This crying can trigger parental depression, breastfeeding cessation, overfeeding, impaired parent–child relationships and child development, and infant abuse. The Surviving Crying (SC) cognitive behaviour therapy (CBT)-based materials were developed in earlier research to improve the coping, wellbeing and mental health of parents who judge their infant to be crying excessively.

This study set out to:

• develop a health visitor (HV) training module based on the SC materials, tailored to fit health visiting;

• assess whether HVs could deliver a SC-based service successfully;

• confirm whether parents gained similar benefits to those in the earlier study;

• prepare for a controlled trial of the SC-based service.

A training module was developed to enable HVs to deliver the SC materials, much of it provided online. Ten HVs took the training module (‘SC HVs’). They and the Institute of Health Visiting provided feedback to refine it. SC HV delivery of the CBT sessions to parents with excessively crying babies was assessed using a standardised test. Parental wellbeing was measured using validated questionnaires. Parents and SC HVs evaluated the effectiveness of the SC service using questionnaires or interviews.

The study produced the intended training module. Most SC HVs completed the training, and 50% delivered the SC-based service successfully. Both training and delivery were disrupted by the Covid-19 pandemic, illness and work pressures. Replicating earlier findings: most parents’ anxiety and depression scores declined substantially after receiving the SC service; improvements in parents’ confidence, frustration and sleep were found; and all parents and the SC HVs interviewed found the SC service useful and agreed it should be included in the National Health Service. A controlled trial of the resulting SC service is underway.

The measurement of process variables derived from cognitive behavioural theory can aid treatment development and support the clinician in following treatment progress. Self-report process measures are ideally brief, which reduces the burden on patients and facilitates the implementation of repeated measurements.

To develop 13 brief versions (3–6 items) of existing cognitive behavioural process scales for three common mental disorders: major depression, panic disorder, and social anxiety disorder.

Using data from a real-world teaching clinic offering internet-delivered cognitive behavior therapy (n=370), we drafted brief process scales and then validated these scales in later cohorts (n=293).

In the validation data, change in the brief process scales significantly mediated change in the corresponding domain outcomes, with standardized coefficient point estimates in the range of –0.53 to –0.21. Correlations with the original process scales were substantial (r=.83–.96), internal consistency was mostly adequate (α=0.65–0.86), and change scores were moderate to large (|d|=0.51–1.18). For depression, the brief Behavioral Activation for Depression Scale-Activation subscale was especially promising. For panic disorder, the brief Agoraphobic Cognitions Questionnaire-Physical Consequences subscale was especially promising. For social anxiety disorder, the Social Cognitions Questionnaire, the Social Probability and Cost Questionnaire, and the Social Behavior Questionnaire-Avoidance and Impression Management subscales were all promising.

Several brief process scales showed promise as measures of treatment processes in cognitive behaviour therapy. There is a need for replication and further evaluation using experimental designs, in other clinical settings, and preferably in larger samples.

1. (1) Telehealth platforms provide a unique opportunity for connection for those living with bipolar disorder.

2. (2) Telehealth platforms may increase feelings of personal safety but may also increase feelings of difference between group members.

3. (3) Symptoms may impact on engagement with anxiety and mood symptoms playing a role; however, telehealth may also decrease barriers to engagement.

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

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

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

Growing research indicates that death anxiety is implicated in many mental health conditions. This increasing evidence highlights a need for scalable, accessible and cost-effective psychological interventions to reduce death anxiety.

The present study outlines the results of a phase I trial for one such treatment: Overcome Death Anxiety (ODA). ODA is the first CBT-based online intervention for fears of death, and is an individualised program requiring no therapist guidance.

A sample of 20 individuals with various mental health diagnoses commenced the ODA program. Death anxiety was assessed at baseline and at post-intervention. Depression, anxiety and stress were also measured.

In total, 50% (10/20) reached the end of the program and completed post-treatment questionnaires. Of these, 60% (6/10) showed a clinically reliable reduction in their overall death anxiety, and 90% (9/10) showed a reduction on at least one facet of death anxiety. There were no adverse events noted.

ODA appears to be a safe and potentially effective treatment for death anxiety. The findings have provided initial evidence to support a randomised controlled trial using a larger sample, to further examine the efficacy of ODA.

Mental health and functional difficulties are highly comorbid across neurological disorders, but supportive care options are limited. This randomised controlled trial assessed the efficacy of a novel transdiagnostic internet-delivered psychological intervention for adults with neurological disorders.

221 participants with a confirmed diagnosis of epilepsy, multiple sclerosis, Parkinson's disease, or an acquired brain injury were allocated to either an immediate treatment group (n = 115) or treatment-as-usual waitlist control (n = 106). The intervention, the Wellbeing Neuro Course, was delivered online via the eCentreClinic website. The Course includes six lessons, based on cognitive behavioural therapy, delivered over 10 weeks with support from a psychologist via email and telephone. Primary outcomes were symptoms of depression (PHQ-9), anxiety (GAD-7) and disability (WHODAS 2.0).

215 participants commenced the trial (treatment n = 111; control n = 104) and were included in intention-to-treat analysis. At post-treatment, we observed significant between-group differences in depression (PHQ-9; difference = 3.07 [95% CI 2.04–4.11], g = 0.62), anxiety (GAD-7; difference = 1.87 [0.92–2.81], g = 0.41) and disability (WHODAS 2.0 difference = 3.08 [1.09–5.06], g = 0.31), that favoured treatment (all ps < 0.001). Treatment-related effects were maintained at 3-month follow-up. Findings were achieved with minimal clinician time (average of 95.7 min [s.d. = 59.3] per participant), highlighting the public health potential of this approach to care. No adverse treatment events were reported.

Internet-delivered psychological interventions could be a suitable model of accessible supportive care for patients with neurological disorders.

1. (1) To be aware of the international consensus for the use of psychological interventions as a component of ARFID treatment alongside medical and dietetic input.

2. (2) To understand that ARFID is characterised as a disturbance of eating behaviour, and as such, psychological intervention should target the drivers of this disturbance to promote behavioural change.

3. (3) To gain an overview of the multi-disciplinary team assessment as an important tool to understand the contribution of each of the three drivers proposed to underpin an ARFID presentation.

4. (4) To recognise when a CBT approach might be indicated, the current best evidence base for CBT for ARFID and how to adapt CBT to accommodate developmental stage and/or common co-occurring presentations.

Severe fatigue is a prominent symptom among adolescents with a chronic medical condition, with major impact on their well-being and daily functioning. Internet-based cognitive behavioural therapy (I-CBT) is a promising treatment for severe fatigue among adolescents with a chronic medical condition, but its effectiveness has not been studied.

We developed an I-CBT intervention for disabling fatigue in a chronic medical condition and tested its feasibility and effectiveness in an adolescent with an immune dysregulation disorder (IDD), namely juvenile idiopathic arthritis (JIA).

The application of I-CBT is illustrated through a clinical case study of a 15-year-old girl with JIA and chronic severe fatigue. An A-B single case experimental design was used with randomization of the waiting period prior to start of the intervention. Outcomes were weekly measures of fatigue severity, physical functioning, school absence and pain severity.

Fatigue severity significantly decreased following I-CBT. Improvements were observed towards increased school attendance and improved physical functioning following the intervention, but these effects were too small to become significant.

The study provides preliminary support for the feasibility and effectiveness of the application of I-CBT for severe fatigue in adolescents with a long-term medical condition.

This economic evaluation supplements a pragmatic randomized controlled trial conducted in community care settings, which showed superior improvement in the symptoms of adults with anxiety disorders who received 12 sessions of transdiagnostic cognitive-behavioural group therapy in addition to treatment as usual (tCBT + TAU) compared to TAU alone.

This study evaluates the cost-utility and cost-effectiveness of tCBT + TAU over an 8-month time horizon. For the reference case, quality-adjusted life years (QALYs) obtained using the EQ-5D-5L, and the health system perspective were chosen. Alternatively, anxiety-free days (AFDs), derived from the Beck Anxiety Inventory, and the limited societal perspective were considered. Unadjusted incremental cost-effectiveness/utility ratios were calculated. Net-benefit regressions were done for a willingness-to-pay (WTP) thresholds range to build cost-effectiveness acceptability curves (CEAC). Sensitivity analyses were included.

Compared to TAU (n = 114), tCBT + TAU (n = 117) generated additional QALYs, AFDs, and higher mental health care costs from the health system perspective. From the health system and the limited societal perspectives, at a WTP of Can$ 50 000/QALY, the CEACs showed that the probability of tCBT + TAU v. TAU being cost-effective was 97 and 89%. Promising cost-effectiveness results using AFDs are also presented. The participation of therapists from the public health sector could increase cost-effectiveness.

From the limited societal and health system perspectives, this first economic evaluation of tCBT shows favourable cost-effectiveness results at a WTP threshold of Can$ 50 000/QALY. Future research is needed to replicate findings in longer follow-up studies and different health system contexts to better inform decision-makers for a full-scale implementation.

There is a paucity of research on therapist competence development following extensive training in cognitive behavioural therapy (CBT). In addition, metacognitive ability (the knowledge and regulation of one’s cognitive processes) has been associated with learning in various domains but its role in learning CBT is unknown.

To investigate to what extent psychology and psychotherapy students acquired competence in CBT following extensive training, and the role of metacognition.

CBT competence and metacognitive activity were assessed in 73 psychology and psychotherapy students before and after 1.5 years of CBT training, using role-plays with a standardised patient.

Using linear mixed modelling, we found large improvements of CBT competence from pre- to post-assessment. At post-assessment, 72% performed above the competence threshold (36 points on the Cognitive Therapy Scale-Revised). Higher competence was correlated with lower accuracy in self-assessment, a measure of metacognitive ability. The more competent therapists tended to under-estimate their performance, while less competent therapists made more accurate self-assessments. Metacognitive activity did not predict CBT competence development. Participant characteristics (e.g. age, clinical experience) did not moderate competence development.

Competence improved over time and most students performed over the threshold post-assessment. The more competent therapists tended to under-rate their competence. In contrast to what has been found in other learning domains, metacognitive ability was not associated with competence development in our study. Hence, metacognition and competence may be unrelated in CBT or perhaps other methods are required to measure metacognition.

1. (1) The paper outlines an important cognitive behavioural framework for supporting adults with visible differences.

2. (2) The paper demonstrates the importance of user testing and client involvement in developing intervention models.

3. (3) The studies highlight one approach to the process of user testing that can produce a robust online intervention.

There is a known association between the core psychopathological features of anorexia nervosa (AN) and sexual dysfunctions, to the point that the recovery of healthy sexuality could be considered a marker of recovery. However, no studies have evaluated the role of insecure attachment in moderating this recovery during treatment.

To evaluate the role of insecure attachment as a possible moderator of the recovery of healthy sexuality in patients with AN treated with Enhanced Cognitive Behaviour Therapy (CBT-E).

A total of 65 patients with anorexia nervosa were treated with CBT-E in a multidisciplinary environment, after filling out self-administered questionnaires for the evaluation of general (SCL-90-R) and ED-specific psychopathology (EDE-Q), female sexuality (FSFI) and adult attachment style (ECR). The assessment was repeated after one (T1) and two years (T2).

At baseline, all domains of sexual dysfunction were significantly predicted by avoidant attachment. A significant amelioration of both general and eating disorder-specific psychopathology and sexual dysfunctions was observed at all follow-up evaluations with respect to baseline levels. However, only 45% of remitted patients also showed a complete recovery of healthy sexuality: this subgroup reported significantly lower avoidance scores when compared to patients who only recovered from AN. Moderation analysis indicated that sexual desire did not increase in participants with higher levels of avoidant attachment.

This study highlighted the crucial role of avoidant attachment in the relationship between AN and sexual dysfunctions, underlining the importance of assessing adult attachment for a better characterization and treatment. Attachment-focused interventions may be beneficial for a full recovery.

No significant relationships.

Stigma against lesbian, gay, bisexual or queer (LGBQ) people may increase their risk of mental illness and reduce their access to and/or benefit from evidence-based psychological treatments. Little is known about the feasibility, acceptability and effectiveness of adapted psychological interventions for sexual minority individuals in the UK.

To describe and evaluate a novel LGBQ Wellbeing group therapy for sexual minority adults experiencing common mental health problems, provided in a UK Improving Access to Psychological Therapies (IAPT) service.

An eight-session LGBQ Wellbeing group intervention was developed drawing on CBT and LGBQ affirmative principles. We compare the socio-demographic and clinical characteristics of patients who completed and dropped out of the groups, and explore changes in self-reported symptoms of depression, anxiety and functional impairment.

Over eight courses provided, 78 service-users attended at least one session, of whom 78.2% completed the intervention (drop-out rate 21.8%). Older participants were more likely to drop out. There was a lower proportion of female and bisexual or ethnic/racial minority individuals than would be expected. There were significant reductions in severity of depression, anxiety and functional impairment following the group, and more than half of those who completed the intervention needed no further treatment.

There was preliminary evidence of the feasibility of, and potential clinical benefit in, a group therapy intervention for sexual minority adults experiencing common mental health problems. Future research should investigate access and outcomes for participants with additional social disadvantage, e.g. those who are female, older, bisexual or ethnic/racial minority.

Despite its potential scalability, little is known about the outcomes of internet-based cognitive behaviour therapy (iCBT) for post-traumatic stress disorder (PTSD) when it is provided with minimal guidance from a clinician.

To evaluate the outcomes of minimally guided iCBT for PTSD in a randomised control trial (RCT, Study 1) and in an open trial in routine community care (Study 2).

A RCT compared the iCBT course (n=21) to a waitlist control (WLC, n=19) among participants diagnosed with PTSD. The iCBT group was followed up 3 months post-treatment. In Study 2, treatment outcomes were evaluated among 117 adults in routine community care. PTSD symptom severity was the primary outcome in both studies, with psychological distress and co-morbid anxiety and depressive symptoms providing secondary outcomes.

iCBT participants in both studies experienced significant reductions in PTSD symptom severity from pre- to post-treatment treatment (within-group Hedges’ g=.72–1.02), with RCT findings showing maintenance of gains at 3-month follow-up. The WLC group in the RCT also significantly improved, but Study 1 was under-powered and the medium between-group effect favouring iCBT did not reach significance (g=0.64; 95% CI, –0.10–1.38).

This research provides preliminary support for the utility of iCBT for PTSD when provided with minimal clinician guidance. Future studies are needed to clarify the effect of differing levels of clinician support on PTSD iCBT outcomes, as well as exploring how best to integrate iCBT into large-scale, routine clinical care of PTSD.

Cognitive therapy for social anxiety disorder (CT-SAD) is recommended by NICE (2013) as a first-line intervention. Take up in routine services is limited by the need for up to 14 ninety-min face-to-face sessions, some of which are out of the office. An internet-based version of the treatment (iCT-SAD) with remote therapist support may achieve similar outcomes with less therapist time.

102 patients with social anxiety disorder were randomised to iCT-SAD, CT-SAD, or waitlist (WAIT) control, each for 14 weeks. WAIT patients were randomised to the treatments after wait. Assessments were at pre-treatment/wait, midtreatment/wait, posttreatment/wait, and follow-ups 3 & 12 months after treatment. The pre-registered (ISRCTN 95 458 747) primary outcome was the social anxiety disorder composite, which combines 6 independent assessor and patient self-report scales of social anxiety. Secondary outcomes included disability, general anxiety, depression and a behaviour test.

CT-SAD and iCT-SAD were both superior to WAIT on all measures. iCT-SAD did not differ from CT-SAD on the primary outcome at post-treatment or follow-up. Total therapist time in iCT-SAD was 6.45 h. CT-SAD required 15.8 h for the same reduction in social anxiety. Mediation analysis indicated that change in process variables specified in cognitive models accounted for 60% of the improvements associated with either treatment. Unlike the primary outcome, there was a significant but small difference in favour of CT-SAD on the behaviour test.

When compared to conventional face-to-face therapy, iCT-SAD can more than double the amount of symptom change associated with each therapist hour.

1. (1) To consider whether CBT can be effectively delivered in routine care via VCT.

2. (2) To explore whether CBT delivered in routine care via VCT is acceptable to children, young people and their families.

3. (3) To reflect on the benefits of VCT and the collection of a variety of ROMs via digital platforms.