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.

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.

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.

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.

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.

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.

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.

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.

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.

CBT for psychosis is an established and evolving psychological therapy. Historical controversies about the nature of psychosis persist, and more recent debates about the outcome literature lack precision, muddying the waters further. Based on our experience as clinicians, teachers and supervisors, and following NHS and national lead roles, we describe ten common misconceptions about CBT for psychosis. These include misconceptions about the evidence, the focus of therapy, ‘thinking positively’, and the nature of collaboration and the therapeutic relationship. We refute these misconceptions based on current theory, research, and best practice guidelines. We highlight the need to get out of the clinic room, measure the impact of therapy on personal recovery and autonomy, and meet training and governance requirements. It is essential that clinicians, service leads, and our professional bodies uphold core standards of care if people with psychosis are to have access to high quality CBT of the standard we would be happy to see offered to our own family and friends.

Key learning aims

1. (1) To recognise common misconceptions about CBT for psychosis.

2. (2) To counter these misconceptions theoretically and empirically – to inform ourselves, colleagues and service leads committed to ensuring high quality CBT for psychosis.

3. (3) To highlight statutory and professional body responsibilities to ensure parity of esteem for people with psychosis, who deserve high quality, ‘full dose’ treatments delivered by appropriately trained clinicians, and supported by robust governance systems, just as we would expect for people with physical health conditions.

Autistic adolescents are at higher risk of self-harm, suicidal behaviours, and emotion dysregulation compared with their non-autistic peers. Dialectical behaviour therapy (DBT) is an evidence-based treatment for self-harm and suicidal behaviour with emerging literature of the application of DBT for autistic populations. Despite this, no qualitative research has investigated the experiences of autistic adolescents of standard DBT. Therefore, this study aimed to explore autistic adolescents’ experiences of non-adapted DBT. Ten adolescents who had or were seeking an autism diagnosis, and were in a DBT programme, completed semi-structured interviews. Qualitative data from the interviews were analysed using reflexive thematic analysis. Themes were generated for each objective. Objective 1 included themes about the lived experience of autistic adolescents accessing DBT, including: ‘The impact of invalidation’, ‘Fostering acceptance and understanding’, ‘What does autism mean to me?’, and ‘Autism and mental health difficulties’. The themes regarding Objective 2 were about the experiences of the various modes of DBT and were organised by each client-facing mode. Objective 3 included themes highlighting the experience of utilising DBT skills in daily life, which included: ‘Barriers to skills use’, ‘Supporting skills use’, and ‘Skills practice or masking?’. Finally, Objective 4 included themes regarding the recommendations participants had for optimising DBT for autistic people: ‘Improving written materials’ and ‘General accessibility advice’. These findings suggest for DBT therapists to embody cultural humility, curiosity, validation, and flexibility when building neuro-affirmative competencies for supporting autistic individuals. Results are discussed in relation to the application and acceptability of DBT for this group.

Key learning aims

1. (1) Recent publications (e.g. Keenan et al., 2023) have explored the experience of autistic adults accessing DBT and highlighted the need for clinicians to work collaboratively with clients and make reasonable adjustments to improve autistic adults’ understanding and adherence to DBT.

2. (2) To date, no qualitative studies have explored the experience of autistic adolescents accessing the Rathus and Miller (2015) Adolescent DBT model. The current study explores the views of autistic adolescents on how autism is discussed and considered by clinicians when supporting them to access different components of DBT when describing the strengths and barriers they experience.

3. (3) Adopting a bottom-up approach, we identify key themes from adolescents’ perspectives on how to support them to access and engage with different DBT components, ranging from making environmental adaptations to meet individual sensory needs to improve accessibility, to providing more opportunities for personalised learning using neuro-affirmative examples that can improve generalisability of skills in everyday life. We provide recommendations for clinicians to consider on ways of adapting the process and content of DBT to increase accessibility and engagement for autistic adolescents in treatment.

Self-reflection is central to the development of psychotherapeutic competence. Given the positive reports of video analysis use in psychotherapy training, we suggest that self-reflection based on video analysis may be particularly effective. The aim of this study was to test whether video-based structured self-reflection (VSR) is superior to memory-based structured self-reflection (MSR) in terms of its effect on students’ psychotherapeutic competence and the therapeutic alliance. As part of a university seminar within a Master’s program, N=34 psychology students (M=25 years; n=32 identifying as female) were randomly assigned to 4 weeks of practice with either VSR (n=16) or MSR (n=18). Independent raters assessed students’ psychotherapeutic competence and the alliance before and after the practice phase (pre- and post-assessment). Students additionally rated their own competence during the practice phase. The written self-reflections were analysed using qualitative content analysis and frequency analysis. A repeated measures MANOVA revealed no significant differences between the study groups in the development of externally rated psychotherapeutic competencies from pre- to post-assessment. An analysis of students’ self-reported competencies during the practice phase revealed a significant time effect (η2G=0.12). Analysis of the written self-reflections showed that students focused mainly on the positive aspects of their behavior. The assumption that VSR is particularly beneficial was not confirmed. It seems that self-reflection requires additional guidance, feedback, and a sufficient time frame to effectively improve trainee skills.

Key learning aims

1. (1) To find out whether video-based structured self-reflection is an effective means of developing students’ psychotherapeutic skills and the therapeutic alliance.

2. (2) To identify the main characteristics of students’ self-reflections and the benefits and challenges they perceive during the self-reflection process.

3. (3) To draw methodologically valid conclusions for the implementation of self-reflection in the university context.

Depersonalisation (DP) and derealisation (DR) experiences can cause clients and therapists a lot of confusion and anxiety. Therapist confusion has led to the under-recognition of DP and DR symptoms, under-confidence in working therapeutically with this client group and unequal client access to effective cognitive behavioural therapy (CBT) interventions. Client confusion has resulted in missed opportunities to engage in meaningful discussions with therapists about their DP and DR experiences and under-confidence that CBT can be of help. This article seeks to provide clarity for clinicians and clients around key misconceptions we have identified from the authors’ clinical experience of using CBT to treat DP/DR, both when presenting as symptoms in the context of other diagnoses and when presenting as a primary depersonalisation derealisation disorder (DDD). In addressing symptom misconceptions, we want to increase clinicians’ confidence when assessing DP and DR. We hope this will lead to productive discussions with clients and the inclusion of these symptoms in clinical formulations. We draw attention to client misconceptions in the hope that this facilitates better therapeutic dialogues about DP and DR and the potential benefit of CBT. Finally, we address therapist misconceptions about the use of CBT with this population in the hope that we can encourage more CBT therapists to work more proactively, confidently and effectively with DP and DR.

Prolonged grief disorder therapy (PGDT) is designed to help clients resolve a persistent and debilitating grief reaction. Clinical trial and routine evaluation evidence supports the efficacy of PGDT in resolving stuck grief, but as yet no qualitative evaluation has been undertaken. The current study qualitatively examined client experiences and views of PGDT delivered within the context of a National Health Service Talking Therapies (NHS-TT) quality improvement project in Devon, United Kingdom (UK). Semi-structured interviews were conducted with 11 clients after completing PGDT which were analysed using the Framework Method. Clients reported being stuck with grief before treatment. PGDT was experienced as being acceptable to clients, resulting in profound changes to wellbeing and functioning. PGDT supported clients to move from denial and avoidance to acceptance and approach of their loss. Perceived change processes included normalising and validating grief, reconnecting to life values and goals, re-establishing social connection, and building emotional self-management skills, consistent with the logic model underpinning the intervention. A flexible, tailored therapeutic approach was emphasised as important for enhancing treatment experience and outcomes. Suggesting minor areas for improvement, some clients experienced homework tasks as repetitive and laborious, imaginal conversations were challenging for some, and the ending of therapy was at times described as painful. Clients felt PGDT was a valuable offering for NHS-TT services, offering something distinct from existing treatment pathways.

Key learning aims

1. (1) To gain insight into clients lived experience of prolonged grief disorder (PGD).

2. (2) To become familiar with prolonged grief disorder therapy (PGDT) as a treatment for PGD in NHS Talking Therapies (NHS-TT) services.

3. (3) To understand client views of PGDT, including what brought them to treatment, impacts of treatment, how the therapy may work, helpful and unhelpful aspects of PGDT, and if PGDT is seen as acceptable.

4. (4) To understand client views of feasibility of implementation of PGDT in an NHS-TT setting.

The experience of human trafficking is associated with a high prevalence of mental health problems, particularly post-traumatic stress disorder (PTSD), anxiety, and depression, for which cognitive behavioural therapy (CBT) would be indicated as an evidence-based intervention. However, lack of knowledge about trafficking survivors’ psychosocial needs, and the complexity of their presentation and circumstances can deter clinicians and impact on survivors’ access to evidence-based care. This article aims to offer guidance for clinicians working therapeutically with adult survivors of human trafficking. It draws on existing CBT evidence-based interventions, and highlights survivors’ holistic needs. This article proposes the use of an existing three-phased approach to treatment and draws upon cognitive behavioural principles. The psychological impacts of exploitation, key assessment topics, and safeguarding concerns are discussed. Considerations for psychological formulation and intervention are described, with a focus on trauma reactions, including PTSD. The integration of a survivor’s social and cultural context into treatment is also explored. CBT interventions can be adapted and applied effectively to address the mental health needs of survivors of trafficking alongside other support to meet their holistic needs.

Chronic pelvic pain (CPP) has exceptionally high co-morbidities with common mental health conditions and is often associated with gendered healthcare inequalities. This study aimed to investigate the ways in which cognitive behavioural therapists’ (CBT therapists) perceptions, understandings, and assumptions regarding women’s health and healthcare influence their therapeutic practice with women experiencing CPP. In-depth semi-structured interviews were conducted with 21 CBT therapists working in a variety of healthcare settings. Transcribed interviews were analysed using a mixed inductive and deductive thematic analysis (TA). Three themes were developed: the gendered nature of CPP, the role of CBT, and building relationships. Therapists treated CPP as a distinctly gendered condition, which may lead to male therapists being viewed as less able to empathise with those suffering from CPP, and CPP in trans clients being left undiscussed. Therapists displayed varied understandings of the role of CBT with CPP clients and discussed how standard CBT training under-recognises the importance of women’s health in therapy. They identified trust as a key barrier to mental health care in women with CPP, highlighting relationship-building as a priority with this client group. This study demonstrates the impact that therapists’ own perceptions regarding women’s health has on their treatment approach with CPP, underscoring the importance of reflective practice in this area. It also highlighted significant gaps in the literature relating to approaching gendered topics such as CPP with trans clients, and a need to integrate women’s health issues into core CBT training and long-term conditions (LTC) training.