1. (1) To understand the process followed to establish a university-run cognitive behavioural therapy service for students and enable other institutions to replicate this model.

2. (2) To identify whether universities can deliver safe, effective mental health services that are fully evaluated and result in commensurate clinical outcomes to other service contexts.

3. (3) To reflect on key learning, challenges and ethical considerations in establishing such services.

The prevalence of mental health conditions is high for autistic adults. Yet, the IAPT manual states that referral rates into NHS Talking Therapies Services (NHS-TTS) do not reflect this nationally. Non-adapted treatment has been identified as a key barrier to accessing these services. It is therefore imperative that clinicians adapt to the needs of autistic individuals to make treatment accessible and effective. However, there is limited research in the field, especially for low-intensity cognitive behavioural therapy (LICBT). This service evaluation explores adapted LICBT for autistic adults within Plymouth’s NHS-TTS and Autism Service. It investigated clinical outcomes of adapted group and one-to-one LICBT with 84 participants. It hypothesised that psychometric measures for anxiety and depression would be lowered on treatment completion, whilst exploring whether either intervention showed a greater reduction. Additionally, semi-structured interviews were conducted with six participants from the sample to gather perspectives on what aspects of treatment were favourable or require improvement. A factorial ANOVA revealed that psychometric measures reduced on completion across both interventions, with a greater decrease for one-to-one treatment and the anxiety measure. In addition, four themes and nine subthemes emerged following a thematic analysis, which focus on different aspects of treatment, such as content, structure, interaction, and barriers to engagement. Findings indicated that adapted LICBT was associated with lower anxiety and depression for autistic adults. This consequently has implications for improving the current LICBT provisions being offered to autistic adults within the NHS-TTS.

1. (1) To understand some of the barriers autistic people face accessing an NHS Talking Therapies Service (NHS-TTS) and cognitive behavioural therapy (CBT).

2. (2) To reflect on the importance of adapting practice and CBT for autistic people.

3. (3) To present potential adaptations to low-intensity CBT for autistic adults with anxiety and depression.

Obsessive-compulsive disorder (OCD) symptoms are hypothesized to be driven by two core motivations: harm avoidance and incompleteness. While cognitive-behavioural therapy (CBT) is an effective treatment for OCD, many posit that OCD presentations characterized by high incompleteness may be harder to treat. The relationship between the core motivations and treatment outcomes remains to be further explored.

To investigate if harm avoidance and incompleteness decrease across group CBT and to examine the relationship between treatment outcomes and both baseline and changes in harm avoidance and incompleteness throughout treatment.

A naturalistic sample of 65 adult out-patients with OCD completed self-report questionnaires measuring OCD symptom severity and the core motivations before, during, and after 12 weeks of group CBT for OCD.

Harm avoidance and incompleteness scores significantly decreased from pre- to post-treatment. Pre-treatment harm avoidance and incompleteness levels did not predict post-treatment symptom severity, but changes in the core motivations throughout treatment were significant predictors of treatment outcome. Specifically, reductions in harm avoidance across treatment and reductions in incompleteness early in treatment, were associated with better treatment outcomes.

Participants who completed group CBT for OCD experienced modest reductions in the core motivations thought to maintain OCD symptoms and these changes predicted better outcomes. However, pre-treatment levels of harm avoidance and incompleteness do not appear to moderate treatment outcome.

Chronic pain is common and debilitating, and recommended treatments are only moderately effective for pain relief. Focus has shifted to refining targets for change within psychological therapy to improve pain management. Evidence has shown the role of intrusive images in many psychological disorders. However, only a few studies have advanced our knowledge of the presence and impact of mental imagery in chronic pain. This exploratory study aimed to increase our understanding of how people with chronic pain perceive intrusive visual images to influence their daily life. The study employed a qualitative design, using semi-structured interviews to explore the content, emotional valence, cognitive and behavioural impact of pain-related visual images of ten participants with self-reported diagnosis of chronic pain. Data analysis was conducted by performing an inductive thematic analysis. Three key themes were identified: (1) ‘I start to create images in my head’: pain-related mental images, which revolves around descriptions of participants’ most significant visual image; (2) metaphors for pain, related to the imagery as a means to conceptualise and give meaning to the pain; and (3) “With the pain comes the image”: a companion to pain, which focuses on the role of intrusive images in the experience of pain. Results show that pain-related mental imagery appeared to be an intrusive, uncontrollable, and vivid cognitive accompaniment for many pain sufferers. The findings suggest that mental images may serve as an additional target in cognitive behavioural therapy to enhance individuals’ cognitive, behavioural and emotional change.

1. (1) To understand the role of mental imagery in the daily life of individuals with chronic pain.

2. (2) To examine the impact of intrusive images on the emotions, cognitions, and behaviours of people with chronic pain.

3. (3) To consider clinical implications for CBT interventions targeting pain-related mental images to manage chronic pain.

Dermatillomania is characterised by repetitive skin picking, resulting in tissue damage and significant distress and/or functional impairment. Cognitive behavioural therapy (CBT) is the recommended psychological intervention for dermatillomania in clinical guidelines, with the evidence base also supporting habit reversal training (HRT) as part of CBT. However, research evaluating CBT and HRT for dermatillomania remains scarce. This case study describes a young woman with dermatillomania, in the context of co-morbid anxiety and low mood, treated with 20 sessions of CBT including HRT in a community setting. Guided by her formulation, additional techniques such as those fostering self-compassion were also integrated, and sociocultural factors were adapted for. Improvements were reported in client-centred goals and outcomes of global psychological distress, functioning, anxiety and symptoms and psychosocial impacts of skin picking. The intervention was well received by the client. Limitations as well as clinical practice implications and research recommendations for dermatillomania are discussed.

1. (1) To understand using CBT, including HRT, to treat a case of dermatillomania in the context of anxiety and depression.

2. (2) To use a formulation-driven approach to guide the intervention.

3. (3) To consider adapting interventions for sociocultural factors.

Symptom accommodation is suggested to maintain anxiety pathology and interfere with treatment effectiveness for anxiety and related disorders. However, little is known about symptom accommodation in generalized anxiety disorder (GAD).

This study investigated the associations between romantic partner symptom accommodation, GAD symptoms, intolerance of uncertainty (IU), relationship satisfaction, and cognitive behavioural therapy (CBT) outcomes from the perspective of the person with GAD.

One hundred and twelve people with GAD participated in group CBT and completed measures at pre- and post-treatment.

All participants endorsed that their partner engaged in symptom accommodation to some extent, and the most commonly endorsed type was providing reassurance. Greater self-reported partner symptom accommodation was associated with greater GAD symptoms, chronic worry severity, IU, and relationship satisfaction at baseline. Partner symptom accommodation was found to significantly decrease over treatment; however, less improvement in symptom accommodation from pre- to post-treatment was associated with worse treatment outcomes.

This study is the first to show that partner symptom accommodation is prevalent in adults with GAD and to elucidate the presentation and frequency of behaviours. The findings provide preliminary evidence that targeting partner symptom accommodation in treatment may improve CBT outcomes.

Augmented Depression Therapy (ADepT) is a novel wellbeing and recovery-oriented psychological treatment for depression. A recent pilot trial run in a university clinic setting suggests ADepT has potential to be superior to cognitive behavioural therapy (CBT) at treating anhedonic depression in a NHS Talking Therapies for anxiety and depression (NHS–TTad) context. Before proceeding to definitive trial in pragmatic settings, it is important to establish if therapists in routine NHS-TTad settings can be trained to deliver ADepT effectively and to assess therapist views on the feasibility and acceptability of ADepT in this context. A bespoke training and supervision pathway was developed (2-day workshop, four 2–hour skills classes, and 6 months of weekly supervision) and piloted with 11 experienced therapists working in a single NHS–TT service in Devon. Nine out of 11 therapists completed the placement, treating 24 clients with a primary presenting problem of depression; 21/24 completed a minimum adequate dose of therapy (≥8 sessions), with 17/24 (71%) showing reliable improvement and 12/24 (50%) exhibiting reliable recovery. Eight out of nine therapists submitted a session for competency assessment, all of whom were rated as competent. Nine therapists submitted feedback on their experiences of training. Eight out of nine therapists felt the ADepT model would be effective in an NHS–TTad context; that training was interesting, useful, well presented and enhanced their own wellbeing; and that they felt sufficiently skilled in core ADepT competencies at the end of the placement. This suggests that NHS–TTad therapists can be trained to deliver ADepT competently and view the treatment as feasible and acceptable.

1. (1) To become familiar with the Augmented Depression Therapy (ADepT) approach for enhancing wellbeing in depression.

2. (2) To evaluate the potential utility and feasibility of ADepT model in NHS Talking Therapies Services (NHS–TTad).

3. (3) To understand the pilot ADepT training and supervision pathway for CBT therapists in NHS–TTad services.

4. (4) To consider the opportunities and challenges of training therapists to deliver ADepT in NHS–TTad services.

Depression is a common co-morbidity in women with breast cancer. Previous systematic reviews investigating cognitive behavioural therapy (CBT) for depression in this population based their conclusions on findings from studies with varying and often limited specificity, quality and/or quantity of CBT within their interventions.

To determine the effectiveness of a specific, well-evidenced CBT protocol for depression in women with breast cancer.

Online databases were systematically searched to identify randomised controlled trials (RCTs) testing CBT (aligned to Beck’s protocol) as a treatment for depression in women with breast cancer. Screening, data extraction and risk of bias assessment were independently undertaken by two study authors. Both narrative synthesis and meta-analysis were used to analyse the data. The meta-analysis used a random effects model to compare CBT with non-active/active controls of depression using validated, self-report measures.

Six RCTs were included in the narrative synthesis, and five in the meta-analysis (n = 531 participants). Overall, CBT demonstrated an improvement in depression scores in the CBT condition versus active and non-active controls at post-intervention (SMD = –0.93 [95% CI –1.47, –0.40]). Narratively, five out of six RCTs reported statistically significant improvements in depression symptoms for CBT over control conditions for women with breast cancer.

CBT aligned to Beck’s protocol for depression appears effective for treating depression in women with breast cancer. However, further research is needed for women with stage IV breast cancer. The clinical recommendation is that therapists utilise Beck’s CBT protocol for depression, whilst considering the complex presentation and adapt their practice accordingly.

An average of 1300 adults develop First Episode Psychosis (FEP) in Ireland each year. Early Intervention in Psychosis (EIP) is now widely accepted as best practice in the treatment of conditions such as schizophrenia. A local EIP programme was established in the Dublin South Central Mental Health Service in 2012.

This is a cross-sectional study of service users presenting to the Dublin South Central Mental Health Service with FEP from 2016 to 2022 following the introduction of the EIP programme. We compared this to a previously published retrospective study of treatment as usual from 2002 to 2012.

Most service users in this study were male, single, unemployed and living with their partner or spouse across both time periods. Cognitive Behavioural Therapy for psychosis was provided to 12% (n = 8) of service users pre-EIP as compared to 52% (n = 30) post-programme introduction (p < 0.001), and 3% (n = 2) of service users engaged with behavioural family therapy pre-EIP as opposed to 15% (n = 9) after (p < 0.01). Rates of composite baseline physical healthcare monitoring improved significantly (p < 0.001).

Exclusive allocation of multidisciplinary team staff to EIP leads to improved compliance with recommended guidelines, particularly CBT-p, formal family therapy and physical health monitoring.

Cognitive behavioural therapy (CBT) is an empirically supported treatment for generalized anxiety disorder (GAD). Little is known about the effectiveness of CBT for GAD in real-world treatment settings.

This study investigated the effectiveness of group CBT and predictors of treatment response in an out-patient hospital clinic.

Participants (n = 386) with GAD participated in 12 sessions of group CBT at an out-patient clinic. Of those who provided at least partial data (n = 326), 84.5% completed treatment. Most questionnaires were completed at pre- and post-treatment; worry severity was assessed weekly.

Group CBT led to improvements in chronic worry (d = –0.91, n = 118), depressive symptoms (d = –1.22, n = 172), GAD symptom severity (d = –0.65, n = 171), intolerance of uncertainty (IU; d = –0.46, n = 174) and level of functional impairment (d = –0.35, n = 169). Greater pre-treatment GAD symptom severity (d = –0.17, n = 293), chronic worry (d = –0.20, n = 185), functional impairment (d = –0.12, n = 292), and number of comorbid diagnoses (d = –0.13, n = 299) predicted greater improvement in past week worry over treatment. Biological sex, age, depression symptom severity, number of treatment sessions attended, and IU did not predict change in past week worry over time.

These findings provide support for the effectiveness of group CBT for GAD and suggest the outcomes are robust and are either not impacted or are slightly positively impacted by several demographic and clinical factors.

Adolescence is an important period for the development of the possible self. It is also a time when depression is prevalent. The cognitive theory of depression proposes that a negative view of the future is a key feature of depression. Targeting these negative thoughts about the future during cognitive behavioural therapy may be helpful in depression. However, little is known about how adolescents envisage their future (i.e. possible) self, or if the content is associated with affect. The aim of this quantitative study is to describe how adolescents describe their ‘possible self’ and examine the relationship between the valence of the possible self and depression in adolescents.

Adolescents (n = 584) aged 13–18 years were recruited via opportunity sampling via their schools and completed measures of depression symptoms (the Mood and Feelings Questionnaire) and the ‘possible self’ (a variant of the ‘I Will Be’ task). Possible selves were coded for content and valence.

Despite depression severity, the most common possible selves generated by adolescents were positive and described interpersonal roles. The valence of the possible self was associated with depression severity but only accounted for 3.4% of the variance in severity.

The results support the cognitive model of depression. However, adolescents with elevated symptoms of depression were able to generate positive, possible selves and therefore may remain somewhat ‘hopeful’ about their future despite clinically significant depression symptoms. Future-oriented treatment approaches such as cognitive behavioural therapy that focus on changing unhelpful negative future thinking may not be appropriate for this population.

Timely intervention is beneficial to the effectiveness of eating disorder (ED) treatment, but limited capacity within ED services means that these disorders are often not treated with sufficient speed. This service evaluation extends previous research into guided self-help (GSH) for adults with bulimic spectrum EDs by assessing the feasibility, acceptability, and preliminary effectiveness of virtually delivered GSH using videoconferencing.

Patients with bulimia nervosa (BN), binge eating disorder (BED) and other specified feeding and eating disorders (OSFED) waiting for treatment in a large specialist adult ED out-patient service were offered virtually delivered GSH. The programme used an evidence-based cognitive behavioural self-help book. Individuals were supported by non-expert coaches, who delivered the eight-session programme via videoconferencing.

One hundred and thirty patients were allocated to a GSH coach between 1 September 2020 and 30 September 2022; 106 (82%) started treatment and 78 (60%) completed treatment. Amongst completers, there were large reductions in ED behaviours and attitudinal symptoms, measured by the ED-15. The largest effect sizes for change between pre- and post-treatment were seen for binge eating episode frequency (d = –0.89) and concerns around eating (d = –1.72). Patients from minoritised ethnic groups were over-represented in the non-completer group.

Virtually delivered GSH is feasible, acceptable and effective in reducing ED symptoms amongst those with bulimic spectrum disorders. Implementing virtually delivered GSH reduced waiting times, offering a potential solution for long waiting times for ED treatment. Further research is needed to compare GSH to other brief therapies and investigate barriers for patients from culturally diverse groups.

1. (1) To understand the issues surrounding the delivery of brief CBT to young people with OCD.

2. (2) To understand ways of reviewing, developing and improving the CBT materials with a range of young people, their parents, and clinicians.

3. (3) To understand how to consult with clinicians in relation to the implementation of the treatment.

4. (4) To consider how the process of this type of work can assist in the next steps of implementing a manualised intervention in routine CAMHS.

Cognitive behavioural therapy (CBT) is considered a frontline treatment for major depressive disorder (MDD) and is recommended as a preferred option in many Western healthcare settings. CBT has proven effective for clients from the majority population in Western countries, but to meet the needs of diverse clients it may require adaptation. The benefits of culturally adapted group CBT (CA-GCBT) for clients from diverse backgrounds remains uncertain. The objective of this review is to systematically identify, evaluate, and integrate the existing empirical literature on CA-GCBT for depressed clients from diverse backgrounds. A comprehensive search was conducted in April 2021 across various databases, including, MEDLINE, PsycINFO, Cinahl, Academic Search, and APA PsycArticle. Quantitative studies meeting the inclusion criteria resulted in a total of ten articles being included in the review. Results from the analysis revealed a statistically significant reduction in depressive symptoms following CA–GCBT in nine out of the ten studies, with one study providing descriptive results. Additionally, improvements were observed in dysfunctional beliefs, functioning, and quality of life ratings. These findings suggest promising outcomes for racially minoritised clients in Western countries and racial majority clients in non-Western countries. Adaptations in CA-GCBT primarily focus on modifying the group delivery, therapy content, staffing, processes, and client-specific factors. Overall, CA-GCBT shows promise as a treatment for depressed clients from diverse backgrounds. However, further evaluation is necessary to establish its efficacy in clinical practice more robustly, to identify which adaptations are most effective for specific populations and to explore the experiences of implementing or attending such group interventions.

1. (1) To explore the benefits of CA-GCBT for depressed clients from diverse backgrounds. Although CBT is a frontline treatment for MDD and often delivered in group format, it remains unclear whether CA-GCBT is beneficial.

2. (2) To summarise findings about the benefits of CA-GCBT for racially minoritised clients in Western countries and racial majority clients in non-Western countries.

3. (3) To outline the modifications made to common CBT group approaches to enhance cultural responsiveness for clients from diverse backgrounds.

4. (4) To provide support to therapists, healthcare services, and broader healthcare structures seeking to implement evidence-based knowledge when adapting group CBT for diverse cultural groups. This enables them to modify existing group CBT protocols or consider specific CA-GCBT interventions.

Research has demonstrated that implementation of Nocebo Hypothesis Cognitive Behavioural Therapy (NH-CBT) achieved full symptom remission in 93% of people with Functional Neurological Symptoms Disorder (FNSD), most of them exhibiting motor symptoms. The basis for NH-CBT is consistent with a predictive coding aetiological model of FNSD. This idea is transparently shared with people with FNSD in the form of telling them that their symptoms are caused by a nocebo effect, usually followed by some physical activity that aims to change the person’s belief about their body.

To demonstrate that a version of NH-CBT can also be effective in eliminating or reducing non-epileptic seizures (assumed to be a sub-type of FNSD).

A consecutive case series design was employed. Participants were treated with NH-CBT over a 12-week period. The primary outcome measure was seizure frequency. Numerous secondary measures were employed, as well as a brief qualitative interview to explore participants’ subjective experience of treatment.

Seven out of the 10 participants became seizure free at least 2 weeks before their post-treatment assessment, and all stayed seizure-free for at least 5 months. Six of those seven remained seizure free at 6-month follow-up. There were large positive effect sizes for the majority of secondary measures assessed.

This case series provides evidence of feasibility and likely utility of NH-CBT in reducing the frequency of non-epileptic seizures.

Evidence suggests that cognitive behavioural therapy (CBT) can be a helpful approach for older adults experiencing anxiety and depression. Some research has suggested this is also the case for those caring for a family member with dementia. Little research has been conducted into the impact of CBT for older adults juggling the demands of caring for multiple family members with dementia.

This case study aimed to evaluate the application of CBT to ‘Mrs P’, a 68-year-old client experiencing anxiety and depression whilst caring for two family members with dementia.

A single case experimental design study was conducted to assess the effectiveness of CBT formulation and intervention, including cognitive restructuring of unhelpful thoughts about caregiving and increasing engagement in pleasurable activities.

Mrs P’s depression and anxiety scores improved significantly throughout treatment, and she met her goal of being able to manage when caregiving activities go wrong during daily life.

CBT may be a helpful approach to reducing anxiety and depression in dementia family caregivers.

1. (1) Treatment goals are fundamental to a better understanding of how best to assess and plan treatments that meet the needs of patients with long-term conditions.

2. (2) We highlight the need to enhance practitioner competencies in aligning treatment with patient’s goals to ensure goal-based decision-making is achieved in practice.

3. (3) Key areas of goal-oriented therapy for patients with long-term conditions include integrating aspects of wanting to improve functioning, emotional health, condition management, and self-appraisal. These aspects should represent primary outcomes of treatment.

Sudden gains occur in a range of disorders and treatments and are of clinical and theoretical significance if they can shed light on therapeutic change processes. This study investigated the relationship between sudden gains in panic symptoms and preceding cognitive change during cognitive behavioural therapy (CBT) for panic disorder.

Participants with panic disorder completed in session measures of panic symptoms and catastrophic cognitions. Independent samples t-tests were used to compare the post-treatment score of those who met criteria for one or more sudden gain during treatment with those who did not, and to compare within-session cognitive change between pre-sudden gain sessions and the previous (control) session.

Twenty-two (42%) of 53 participants experienced a sudden gain during treatment. Participants demonstrating a sudden gain showed more improvement in panic symptoms from pre- to post-treatment than those without a sudden gain. The within-session cognitive change score in the pre-gain session was significantly greater than in the control session.

Sudden gains occurred in individual CBT for panic disorder and within-session cognitive change was associated with sudden gains. This is consistent with the cognitive model of panic disorder and highlights how sudden gains can help to identify key change processes.