Restless Legs Syndrome (RLS) is a neurological condition associated with sleep disturbance, depression, anxiety, and mild cognitive impairment (MCI). Responses to anti-depressant medication can be poor, emphasising the importance of psychological approaches. There is some evidence of interventions such as cognitive behaviourial therapy (CBT) improving sleep disturbance and anxiety associated with RLS; rational emotional behaviour therapy (REBT) improving RLS symptoms and sleep quality; and group CBT improving quality of life, mental health, sleep, anxiety, and RLS symptoms. There are no published papers of psychological interventions for people with RLS and MCI despite this being a typical presentation. This paper presents the case of Sally (a pseudonym), a 66-year-old woman who was housebound and presented with RLS, MCI, double incontinence, sleep disturbance, anxiety, and depression. She received 12 sessions of CBT adapted for co-presenting MCI and physical health conditions. Approaches used included breathing techniques, relaxation, behavioural activation, and mindfulness. Considering MCI was important when recognising and challenging self-critical thoughts and self-hatred. Written information was simplified and an approach used in dialectic behaviour therapy (DBT), STOP (Stop, Take a Step Back, Observe, Proceed Mindfully), was utilised as this helped Sally recognise thinking patterns and consider alternatives. At the end of therapy Sally’s RLS symptom severity, depression, and anxiety improved. Sally reported a more optimistic view of the future and was able to leave her house. This paper presents an overview of the literature relating to RLS and psychological interventions before describing Sally’s case, formulation, intervention and adaptions for MCI and physical health difficulties.

Key learning aims

1. (1) Restless Legs Syndrome (RLS) is a disabling neurological condition often associated with poor sleep, anxiety, depression, and mild cognitive impairment, which can be negatively impacted by pharmacological interventions, emphasising the importance of developing psychological approaches.

2. (2) This case example presents initial evidence that short-term transdiagnostic Cognitive Behavioural Therapy can be an effective intervention for reducing symptoms, anxiety and depression for people with RLS who present with other associated conditions.

3. (3) Successful interventions need to take into account associated conditions such as mild cognitive impairment which may require adaptions and simplifications to approaches for them to be utilised and effective.

Despite empirical support for cognitive behavioural therapy in the treatment of eating disorders (CBT-ED), real world adherence to CBT-ED is poor. The current study assessed the extent to which clinicians’ intolerance of uncertainty and attitudes towards evidence-based practice (EBP) are associated with adherence to CBT-ED. Licensed mental health clinicians (n = 221) who self-identified as having treated >4 patients with EDs in the past year completed the Intolerance of Uncertainty Scale (IUS), EBP Attitude Scale (EBPAS), and reported the percentage of patients with whom they used 15 CBT-ED techniques. Most clinicians (>55%) reported using cognitive-related techniques with >90% of patients, whereas less than half (<42%) reported using behavioural-related techniques with >90% of patients; only 7% reported regularly weighing >90% of patients. IUS was negatively and EBPAS was positively associated with adherence to CBT-ED techniques. There was a significant interaction between IUS and EBPAS, such that clinicians with favourable attitudes towards EBP reported high adherence regardless of their intolerance of uncertainty, whereas IUS was associated with lower adherence among clinicians with unfavourable attitudes towards EBP. Clinical training that fosters positive attitudes towards EBPs, particularly among clinicians with high intolerance of uncertainty, may improve CBT-ED adherence.

Key learning aims

1. (1) Clinicians indicated less adherence to behavioural than to cognitive components of cognitive behavioural therapy for eating disorders (CBT-ED).

2. (2) Clinician intolerance of uncertainty was associated with less adherence to CBT-ED.

3. (3) Clinicians’ attitude towards evidence-based practice buffers the association of clinician uncertainty intolerance with adherence to CBT-ED,

Interest in understanding outcomes in Talking Therapies for culturally and ethnically diverse clients has been steadily growing. This service improvement project utilised a mixed-method design combining auditing recovery data and exploring staff views and needs to create recommendations for staff training on culturally responsive therapy in a Talking Therapies service. Audit findings showed that diverse clients had significantly lower recovery rates than White British clients, with ethnicity, treatment type, number of sessions, and baseline severity predicting outcomes. A staff survey on delivering culturally responsive therapy indicated high motivation but varied perceived knowledge, skill and opportunity. Identified needs included improving cultural knowledge, the ability to adapt therapy, and creating reflective spaces. Thus, recommendations included training on key concepts and ideas relating to working within diverse cultures, adapting protocols, and improving culture-focused supervision. A lay summary is presented in Appendix A of the Supplementary material.

Key learning aims

1. (1) To understand recovery rates in culturally and ethnically diverse clients in a Talking Therapies service, and the factors influencing these outcomes.

2. (2) To understand how staff perceive capability, opportunities, and motivation to deliver culturally responsive therapy.

3. (3) To identify practical recommendations for staff training to improve the delivery of culturally responsive therapy which may help improve the recovery rates for culturally and ethnically diverse clients.

Violence risk is elevated during the early phase of psychosis and can have significant consequences for engagement, recovery, and safety. BRAVE (Behavioral Response Against Violence Engagement) is a cognitive-behavioural intervention adapted from the PICASSO model for use in early intervention services (EIS) that targets dynamic, modifiable mechanisms associated with psychosis-related violence. This open pilot trial evaluated the feasibility, acceptability, fidelity, and preliminary target engagement of BRAVE when delivered by clinicians within routine EIS care. Seven clinician–client dyads were enrolled across OnTrackNY sites; five completed the intervention, with a mean of 11.4 sessions. Feasibility and acceptability were high: clinicians rated BRAVE as useful and deliverable within standard visit structures. Fidelity ratings were high across both clinician and client checklists. Although violent behaviour was infrequent at baseline, exploratory clinical outcomes suggested reductions in violent ideation over time. The primary hypothesized mechanistic target, impulsivity, remained stable but secondary mechanistic outcomes showed directionally positive movement across the affective, cognitive, behavioural, and physiological domains expected to shift with BRAVE, including reductions in hostility, negative self-appraisal, persecutory thinking, substance use, and sleep disturbance, alongside increased coping self-efficacy. Overall, findings indicate that BRAVE can be implemented with high fidelity and strong acceptability within participating clinician–client dyads in EIS settings, and offer preliminary descriptive patterns consistent with the hypothesized mechanistic model.

Key learning aims

1. (1) To describe how BRAVE was adapted for early intervention services (EIS) and delivered by clinicians within routine care, including considerations of feasibility, acceptability, and fidelity.

2. (2) To summarize descriptive, pre–post observations from an open pilot trial of BRAVE, including changes in impulsivity and related affective, cognitive, behavioral, and physiological processes.

3. (3) To identify implications for future implementation and evaluation, including lessons learned about fidelity measurement, patient-facing materials, and considerations for a larger pragmatic trial.

Emetophobia (a specific phobia of vomiting) is an under-researched and often poorly understood condition compared with other anxiety disorders. It is often regarded as part of obsessive-compulsive disorder. It is the most common type of specific phobia that presents for treatment. Practitioners may feel less confident in treating emetophobia than in treating other specific phobias with standard exposure therapy. This article updates an evidence-based CBT approach, including exposure and response prevention, for the treatment of emetophobia. There are new insights into how individuals with emetophobia struggle to tolerate not knowing whether they are going to vomit. It aims to be a practical ‘how to’ guide for therapists, drawing on theory and the authors’ experience in this area. This highlights the need to adapt the general principles of treating specific phobias through exposure therapy. This is particularly true when the presentation shares processes with obsessive-compulsive disorder or is complicated by avoidant and restrictive food intake disorder, or sensory sensitivity due to features of the autistic spectrum. We will also consider new developments in current evidence-based approaches to treating emetophobia, such as virtual reality technology and intensive treatment.

Key learning aims

• This article assumes basic knowledge of key concepts in CBT with exposure using inhibitory learning and developing an alternative understanding of a problem (for example, Theory A/Theory B). By the end of this article, readers will be able to:

  1. (1) Understanding the epidemiology, clinical characteristics, co-morbidity, and cognitive behavioural model of emetophobia.

  2. (2) Assess and formulate the main presenting difficulties for a person with emetophobia.

  3. (3) Select appropriate cognitive, behavioural, and imagery interventions to help individuals with emetophobia.

Post-traumatic stress disorder (PTSD) is one of the most common anxiety disorders treated by NHS Talking Therapies for anxiety and depression services but outcomes lag behind national targets and research trial results. Both cognitive therapy for PTSD (CT-PTSD) and eye movement desensitisation reprocessing (EMDR) are recommended by NICE, but there is little clinical guidance about when either approach is more appropriate. This retrospective study examined the experience of clients with a problem descriptor of PTSD completing treatment over a 12 month period in a South London NHS Talking Therapies for anxiety and depression service. Both EMDR and CT-PTSD had similarly good outcomes across a range of demographic factors and presenting traumas. The study supports client preference as a key factor in choice of trauma therapy. Recovery in EMDR was associated with a higher number of memory processing sessions. Dropout accounted for a high proportion of non-recovered clients and was associated with higher starting depression scores. The study suggests that the start of memory processing work is a period of heightened risk for client dropout, and that therapists should take steps to mitigate this negative outcome.

Key learning aims

1. (1) To compare the effectiveness of CT-PTSD and EMDR in routine practice within a single Talking Therapies service in order to provide clinicians in routine practice with guidance to support client choice.

2. (2) To gain insight into the presentation and treatment factors associated with good outcomes.

3. (3) To provide clinicians with guidance about maximising treatment effectiveness, with a particular focus on memory-focused interventions and dropout.

Social anxiety disorder (SAD) in adolescence associates with impairment across several developmentally salient life domains. Treating adolescents’ SAD with school-based interventions has multiple benefits. We examined the preliminary feasibility and effectiveness of the brief Developmentally Oriented Cognitive Therapy for SAD (DOCT-SAD), among adolescents with SAD and their parents delivered in the school setting by school psychologists. Participants (n=11, mean age 15.8 years, females 81.8%) were recruited from secondary schools in Tampere, Finland. K-SADS-PL was used to determine primary and co-morbid disorders, augmented with ADIS-5. All participants had primary SAD. Structured feasibility interviews were administered at post-treatment to young people, parents, and school psychologists. Primary outcome measures (SPIN, ADIS-5 based CSR) and secondary outcome measures (SAFE, PHQ-9, YP-CORE, CALIS-C, and CALIS-P) were collected at pre- and post-treatment. On a scale of 0–10, young people perceived the treatment as suitable for them (mean 8.7, SD=1.0). Parents’ general experience of the DOCT-SAD treatment was overall positive (mean 8.9, SD=0.7). Treatment providers rated their general experience of the treatment as good (mean 8.5, SD=0.6). All participants completed the treatment. Significant pre–post decrease in SAD symptoms measured with SPIN was found (mean reduction −8.4, p=.021, r=0.7). Of participants, six (54.5%) were in diagnostic remission at post-treatment according to ADIS-5. The brief, 10-session DOCT-SAD intervention was accepted by young people, their parents and school psychologists. DOCT-SAD seems feasible and beneficial in treating adolescents with SAD in the school environment.

Transgender and gender diverse (TGD) young people face elevated risk of emotion dysregulation, depression, anxiety, and self-harm and suicide, likely due to chronic invalidation leading to emotion dysregulation. Dialectical Behaviour Therapy (DBT) is an effective intervention for these difficulties, but has not been fully optimised for TGD-specific experiences. TGD-specific charities may be viewed as safer and more accessible than NHS services, though they may lack resources for evidence-based interventions. This study aimed to optimise DBT skills training for TGD young people (DBT-TGD+) and assess the feasibility and acceptability of delivering this intervention within a TGD charity. Early indicators of effectiveness were also examined. An open pilot trial, with a case series design and qualitative methods, was conducted. TGD young people (aged 16–25 years) with self-reported emotion regulation difficulties attended a 16-week DBT skills training group co-facilitated by a psychologist and two TGD charity youth workers. Quantitative and qualitative data assessed feasibility, acceptability, mental health (emotion dysregulation, depression, anxiety), and TGD-specific outcomes. Reliable change and clinically significant change were calculated where norms existed. Qualitative data underwent reflexive thematic analysis. Twelve participants were recruited, with 75% retention and 80% average attendance. Participants and facilitators rated the intervention as feasible and acceptable. Qualitative findings highlighted perceived benefits. Reliable and clinically significant change ranged from 25% to 75% across mental health outcomes, with additional positive trends in some TGD-specific measures. DBT-TGD+ was feasible and acceptable to deliver in a TGD charity setting. Findings inform future intervention refinement and research.

Transition-aged youth (TAY) are vulnerable to experiencing mental health disorders, yet research is scarce on treatment outcomes for TAY receiving cognitive behavioural therapy (CBT), particularly for anxiety and related disorders. The present study aims to investigate whether there are differences in treatment outcomes for TAY relative to adults following completion of mixed-age disorder-specific CBT groups for social anxiety disorder (SAD), generalized anxiety disorder (GAD), and obsessive-compulsive disorder (OCD). A sample of 844 participants, including 232 TAY (aged 17–25) and 612 adults were compared on symptom specific measures (i.e. SPIN, GAD-7, Y-BOCS), group cohesion, attendance, drop-out rates, and general symptoms of low mood, stress, and anxiety (i.e. DASS-21) pre- and post-disorder specific CBT group treatment using linear mixed effects models. Although there were significant reductions in disorder-specific clinical symptoms and general symptoms of depression, stress, and anxiety in both TAY and adults from pre- to post-treatment, there were no significant differences between age groups in terms of treatment response, suggesting TAY responded as effectively as adults in mixed age treatment groups. There were no significant differences in terms of drop-out or group cohesion across age groups. TAY individuals had marginally lower attendance compared with adults, although this finding was not significant. These findings suggest that treatment as usual is effective in yielding significant improvement in anxiety and related symptoms across age groups. While these findings are encouraging for TAY who seek treatment, further research evaluating whether age-specific group CBT could enhance treatment outcomes for TAY is critical.

Individuals with symptoms of mild personality disorder should be proactively provided with treatment to reduce the likelihood of long-term negative outcomes. Whilst there is encouraging evidence for dialectical behaviour therapy skills training (DBT-ST), the research focuses on individuals with complex presentations (e.g. borderline personality disorder) in specialist mental health services. It is unclear whether DBT-ST is effective for individuals with symptoms of mild personality disorder. The aim of this study was to evaluate whether a DBT-ST intervention is effective for people with symptoms of mild personality disorder. Participants were 82 adults with symptoms of mild personality disorder. Participants received a 24-week DBT-ST intervention through either face-to-face or online appointments. Several outcome measures were collected. There was a significant reduction on outcome measures post-intervention although drop-out rates were high (47%). DBT-ST led to similar recovery rates when it was delivered through online or face-to-face appointments, indicating that it may be effective for people with symptoms of mild personality disorder in either format. Providing DBT-ST in primary care may impact the individual’s longer-term use of specialist services, although further research is needed.

Sexual (SM) and gender (GM) minoritised (SGM) people experience elevated rates of mental health difficulties and self-injury. Dialectical behaviour therapy (DBT) is effective for these difficulties, yet sexual orientation and gender identity are infrequently reported in psychological intervention research, limiting understanding of inclusion and outcome equity. This systematic review examined the proportion of DBT studies reporting sexual orientation and gender identity; the proportion of SGM participants in DBT samples; and the effectiveness, acceptability, and feasibility of DBT for SGM groups. Databases were systematically searched, and findings were synthesised using narrative and meta-analytic methods. Across 170 studies including comprehensive DBT, 10–11% reported sexual orientation and 12–17% reported gender identity beyond binary categories. Only 1–2% of all studies explicitly classified participants’ gender as cisgender and transgender, and up to 5% used broad gender categories such as ‘other’. Where data were available, SM participants comprised approximately 36% and GM participants 3–17% of samples. Pooled analyses indicated significant pre–post improvements for SM participants, with effects mostly comparable to heterosexual groups; GM outcomes were similar in fewer studies. Meta-analytic estimates showed negligible differences in treatment completion, with disparities largely confined to the pre-treatment phase and between subgroups. The limited reporting of sexual orientation and gender identity in DBT research constrains understanding of representation and equity in outcomes. Routine, collaboratively designed, data collection is essential to evaluate equity in DBT effectiveness and to prevent inadvertent invalidation through omission.

Key learning aims

1. (1) To identify the proportion of psychological intervention studies – focusing on dialectical behaviour therapy (DBT) – that report participants’ sexual orientation and gender identity.

2. (2) To determine the representation of SGM participants within DBT research samples.

3. (3) To evaluate the effectiveness, acceptability, and feasibility of DBT for SGM participants.

4. (4) To provide recommendations for improving the recording and reporting of sexual orientation and gender identity in psychological intervention research and clinical practice.

This paper outlines a prospective cognitive framework for understanding the intersectionality of gender diversity and neurodivergence (specifically being autistic). The framework aims to provide understanding of the overlap between being autistic and being transgender and gender diverse, where these two constructs intersect and where they are disparate. Within these two intersections, there is evidence that individuals may mask or camouflage parts of these intersections of their identity, which may in turn impact on emotional wellbeing. This framework aims to be supportive of staff and adult service users alike in understanding this intersectionality and to provide suggestions on how to use this framework within psychological therapy to support autistic transgender and gender diverse adults. Limitations, clinical implications and key messages are briefly included within the discussion. Due to the limited research in this area at present, it is likely that further research into this field is warranted and further evidence, service user feedback and trialling of the cognitive framework would be imperative to conclude its utility and efficacy in clinical practice.

NHS Talking Therapies for Anxiety and Depression (TTad) offers evidence-based psychological interventions for individuals with depression and anxiety disorders across England. Despite substantial progress in improving access to therapy, disparities remain, particularly for clients from diverse backgrounds. Given the increasing linguistic diversity across England and the reported preference among clients to engage in therapy in their first language, it is not yet known whether requiring or requesting an interpreter affects access to timely and appropriate therapy, or whether such needs contribute to disparities in treatment outcomes. This study, therefore, examined waiting times and outcomes for interpreter-mediated CBT within TTad. The sample consisted of 177,340 clients who accessed TTad services for the year 2022 to 2023 and received Step 3 CBT. Clients using an interpreter were significantly more likely to wait longer for treatment compared with those not using an interpreter. Treatment outcomes differed significantly; only 58.5% of clients using an interpreter showed reliable improvement, compared with 69.2% of those not using an interpreter. Similarly, reliable recovery was lower in the interpreter group (32.5%) versus the non-interpreter group (44.5%). Among those requiring an interpreter, the lowest reliable recovery was seen in clients using professional interpreters (28.8%). These findings highlight the need for targeted strategies to reduce delays and improve outcomes for interpreter-mediated therapy, ensuring more equitable access and effectiveness of psychological interventions within TTad. Further research is needed to explore the underlying factors contributing to these disparities and to identify best practices for delivering effective, culturally and linguistically appropriate therapy.

Key learning aims

1. (1) To examine whether a request or requirement for an interpreter is associated with increased or altered waiting times for Step 3 CBT within NHS Talking Therapies for anxiety and depression.

2. (2) To investigate differences in clinical outcomes, specifically reliable improvement and reliable recovery, for clients using interpreters compared with those who do not use interpreters.

3. (3) To compare outcomes across different interpreter arrangements, including professional interpreters, family/friend interpreters, others, and instances where interpreters did not attend, exploring any differences in outcomes.

Despite religion being an important part of some patients’ identity and value systems, therapists report finding it challenging to discuss religion in therapy. Avoiding religion for these patients can have detrimental effects on the therapeutic alliance, treatment outcomes, and parity of access for minoritised groups. Therefore, this clinical guidance paper aims to support therapists to bring religion into the therapy room by addressing six key concerns: (1) difficulties raising the topic, (2) ‘getting it wrong’ when discussing religion, (3) therapist and patient differences, (4) managing negative or ambivalent beliefs about religion, (5) perceptions of insufficient knowledge, and (6) a lack of time for meaningful discussions. These barriers are explored by drawing on empirical evidence, clinical experience, and illustrative case examples. The paper aims to provide suggestions and next steps for how therapists can reflect on and address these concerns, aiming to enhance confidence and competence in integrating religion into CBT.

Key learning aims

1. (1) To support therapists to overcome commonly held concerns around discussing religion in therapy.

2. (2) To provide practical guidance, tips, and suggestions for how therapists can discuss religion with patients.

3. (3) To help therapists to take responsibility for bringing religion into the therapy room where it is relevant.

Chemsex is a pattern of using specific drugs with the intent of enhancing the sexual experiences of men who have sex with men. Chemsex participation is often motivated by a desire for community connection or enhanced sexual pleasure. Many individuals who participate in chemsex can mitigate much of the associated risk and report limited, if any, harm. However, for some, chemsex can be problematic, precipitating or exacerbating mental health issues. Despite increasing amounts of research into chemsex, there is no consensus about how to best support people who participate in chemsex when they present for psychological therapies. In the absence of specific clinical guidelines, this paper explores the intersection of chemsex and mental health problems. Principles of affirming and non-stigmatising, assessment, formulation, and intervention strategies are discussed, and recommendations are made throughout. Drawing on contemporary evidence, we present cognitive behavioural approaches to supporting service users who participate in chemsex with anxiety, depression, and post-traumatic stress disorder. By enhancing cultural safety and tailoring existing evidence-based treatments, therapists can improve engagement and outcomes for individuals who engage in chemsex. We recommend an inclusive approach that champions service user choice, paired with a sensitive, sex-positive, and trauma-informed perspective. Therapists within Talking Therapy services are well placed to support service users who participate in chemsex and have co-occurring mental health difficulties.

Key learning aims

1. (1) To understand what chemsex is, what motivates chemsex participation, and the distribution of potential risks.

2. (2) To understand the intersection of sexuality, chemsex, and co-occurring mental health difficulties, including the role of pleasure, identity, shame and community.

3. (3) To identify the key barriers experienced by people who participate in chemsex when accessing mental health services, such as negative staff attitudes or fear of stigma.

4. (4) To explore cognitive behavioural approaches to working with people who participate in chemsex, and associated common mental health difficulties (anxiety, depression, and post-traumatic stress disorder).

5. (5) To identify practical strategies to engage service users who participate in chemsex.

Insomnia disorder is highly prevalent and frequently co-exists with other mental health conditions. Evidence suggests that targeting insomnia may improve overall mental health. Although the effectiveness of cognitive behavioural therapy for insomnia (CBT-I) is well established, it is rarely offered to patients as a discrete treatment. This study aimed to evaluate the outcomes of CBT-I delivered at Step 2 for reducing symptoms of insomnia, as well as anxiety, depression, and impaired functioning, following its implementation within an NHS Talking Therapies service. We examined routinely collected pre- and post-treatment outcomes from 35 patients (median age 60 years, interquartile range 44–68, 63% female) who received CBT-I. Insomnia severity was assessed during the first and last session using the Insomnia Severity Index, while secondary outcomes, including depression, anxiety, and impaired functioning were completed at each session. Intention-to-treat analyses demonstrated significant improvements in insomnia symptoms from pre- to post-treatment, with a large effect size (d = 0.85). Significant improvements were also observed across all secondary outcomes, with large effect sizes for depression (d = 1.01) and anxiety (d = 0.89), and a medium effect size for functioning (d = 0.58). The complete case analysis yielded larger effect sizes across most outcomes. These findings provide preliminary support for the potential benefits of CBT-I as a primary treatment for symptoms of insomnia, with secondary benefits for anxiety, depression, and functioning in patients presenting with mental health difficulties within an NHS Talking Therapies service. Implications for the service and future service evaluations are discussed.

Key learning aims

1. (1) To develop understanding of the evidence base for CBT-I for sleep and mental health outcomes.

2. (2) To consider the outcomes of CBT-I when delivered by Psychological Wellbeing Practitioners in an NHS Talking Therapies service.

3. (3) To evaluate clinical recovery rates in line with NHS Talking Therapies criteria.

A long-term physical health condition (LTC) is one ‘that cannot currently be cured but can be controlled with medication and/or other therapies’. Around 30% of people with an LTC have mental health co-morbidities. Systematic reviews suggest adapted cognitive behavioural therapy (CBT) produces positive outcomes for LTC clients compared with control conditions. However, limited research includes long-term follow-ups or the client’s voice, preventing conclusions about mechanisms of change or sustainability. This qualitative study explored long-term health experiences of CBT for adults with LTCs in UK primary care, and what elements of CBT participants deemed responsible for change. The sample included 10 individuals with an LTC. Findings were constructed through inductive-deductive reflexive thematic analysis, integrating participant-led narratives with psychological theory. Four themes were identified: a validating and normalising therapeutic relationship, lack of therapist skill and knowledge of LTCs, adjusting to and accepting LTC, and de-catastrophising LTC-specific beliefs. Participants discussed the importance of both common and specific factors. A trusting therapeutic relationship was essential, while collaboratively applying techniques to promote adjustment and acceptance was necessary for long-term gains. The study highlights embedding health psychology theory and third-wave approaches within a process-based, transdiagnostic framework enhanced through LTC-specific training and supervision. By attending to identity disruption, illness representations, values conflict, and low self-efficacy, therapists can deliver interventions that consider the lived realities of LTCs.

Key learning aims

1. (1) To explore how participants understood and described the emotional, cognitive, and identity-related changes that occurred following CBT, with particular attention to long-term adjustment and meaning making.

2. (2) To identify which therapeutic processes participants perceived as most helpful or unhelpful, including both CBT-specific strategies and common relational factors, and how these were thought to influence change.

3. (3) To contextualise participants’ accounts within broader health psychology and process-based frameworks, considering how their narratives reflect mechanisms highlighted in models such as the Self-Regulatory Model, the Transdiagnostic Model of Adjustment to LTCs, and third-wave approaches.

Cognitive behavioural therapy (CBT) is a widely recommended, evidence-based modality. Cost-effective interventions such as CBT are particularly valuable in low- and middle-income countries, which typically have considerable resource constraints and service delivery challenges. Despite its benefits, CBT remains under-utilised by clinical psychology practitioners in South Africa, possibly due to poor perceived self-competence of practitioners. We employed a qualitative exploratory design to explore student clinical psychologists’ perceived self-competence in delivering CBT in their first year of masters studies at one university in South Africa, using once-off individual semi-structured interviews (n=5). Data were analysed using reflexive thematic analysis, following an inductive-deductive approach. We identified two over-arching themes: (1) Training experiences shape perceived self-competence in CBT, and (2) Making sense of competence and readiness for practice. The findings suggest that perceived self-competence in CBT is shaped by training experiences, with supportive supervision, practical application, and positive client outcomes enhancing confidence. Limited prior exposure to CBT, rigid teaching approaches, and inconsistent feedback created challenges in developing self-competence which seemed to influence decisions about using CBT in practice. The findings provide important insights regarding the gaps in CBT training in South Africa, which may influence the use and uptake of CBT by future clinical psychologists. These findings highlight the importance of training environments that promote flexibility, experiential learning, expert supervision and constructive feedback in developing competence in evidence-based interventions. Further research is needed to establish whether these issues are shared amongst trainee students at other universities.

Key learning aims

1. Readers of this paper will be able to:

   1. (1) Identify factors influencing self-perception of CBT competence.

   2. (2) Understand how CBT training occurs as part of a Master of Clinical Psychology programme in South Africa.

   3. (3) Understand how the perception that CBT is rigid hinders CBT implementation.

To reduce the burden of depression, it is important to ensure that adolescents have access to effective, early interventions. Limited research has explored psychological practitioners’ views during the development of such interventions, despite the potential for this to improve implementation. A brief, imagery-based intervention (IMAGINE) has been co-developed to address issues in treatment provision for symptoms of depression in adolescents. Here, we investigate psychological practitioners’ and supervisors’ views about factors that may act as barriers and enablers to implementing IMAGINE. We used a qualitative interview study with (1) qualified low-intensity practitioners with experience of working in schools, and (2) clinical supervisors to these practitioners, working in England. Reflexive thematic analysis was initially inductive followed by a deductive mapping to normalisation process theory, a theory of how interventions become implemented and embedded in practice. Twenty-four participants (14 low-intensity practitioners and 10 supervisors) were interviewed. Six themes were identified: (1) ‘We could be doing more for young people with low mood’, (2) ‘IMAGINE stands out while feeling familiar’, (3) ‘Which young people is IMAGINE for?’, (4) ‘Pushing the depth of low-intensity practice’, (5) ‘Getting everyone on board’, and (6) ‘A good fit for services, more or less’. The findings show enthusiasm for new interventions to address adolescent depression, with low-intensity practitioners eager to enhance their clinical skills. This was balanced with concerns about the demand for low mood interventions and whether some components of IMAGINE fit within low-intensity practice. These insights suggest barriers and enablers for developing psychological interventions.

Key learning aims

1. (1) To identify implementation and contextual factors that may act as barriers and enablers to implementing imagery-based depression interventions in schools.

2. (2) To explore how an imagery-based psychological intervention for depression in adolescence is perceived from the perspective of psychological practitioners working in schools and their supervisors.

3. (3) To inform future research in the development of imagery- and school-based interventions for adolescent depression.

NHS Talking Therapies for anxiety and depression (NHS TTad) were established in 2008 to increase and improve treatment for anxiety and depression, with the intention of reducing inequalities through being particularly responsive to individuals from marginalised groups. However, racially minoritised clients are under-represented within NHS TTad services, and are more likely to drop out of treatment. A service evaluation was carried out at a central London NHS TTad service to explore the experiences of clients from the ethnic group that was most likely to disengage. The aim was to find ways in which the service could be improved to enhance the experiences of this group and increase the rate of treatment completion. A service audit revealed that clients with a Black background, regardless of their specific ethnicity, had the highest drop-out rate and were significantly more likely to disengage than the White British group. The service evaluation involved interviewing six clients from this group who had recently dropped out of or declined treatment. Interviews were structured and analysed using narrative inquiry, and pattern coding was used to reduce large amounts of data into four main themes. Overall, participants found accessing support relatively easy but had limited knowledge on the service. A lack of choice and flexibility around appointments were highlighted as key factors in not completing therapy. Based on their experiences, participants recommended incorporating community and cultural learning into therapists’ training, and giving clients the option to request a therapist from a similar background. Recommendations are provided for service delivery.

Key learning aims

1. (1) To identify which clients, based on ethnicity, are most likely to decline or discontinue treatment within an NHS TTad service in Central London.

2. (2) To increase understanding of the treatment experiences of clients from the ethnic group with the highest drop-out rates.

3. (3) To provide recommendations offered by these clients for service providers, aimed at improving engagement and treatment completion.