1. (1) To understand how Ehlers and Clark’s (2000) cognitive model and related treatment of PTSD can be applied when racism is part of the traumatic event.

2. (2) To provide guidance, tips and examples on how to identify key personal meanings around the trauma index event involving racism.

3. (3) The article will encourage therapists to reflect on their own identity and experiences (or lack of) around racism, considering how this might hinder or facilitate the appropriate inclusion of racist experience within CT-PTSD.

4. (4) To provide suggestions on how to ensure that supervision of CT-PTSD supports the consideration and addressing of relevant experiences of racism and supports therapists where patient experiences may overlap with their own experience of racism.

1. (1) Following reading this paper, readers will better understand the diagnostic and practice-based complexities involved in assessing traumatic events as a Psychological Wellbeing Practitioner (PWP) in an NHS Talking Therapies service.

2. (2) Readers will also be aware of the emotional challenges PWPs in this service have reported experiencing as a result of assessing service users that report having experienced traumatic events.

3. (3) The reader will also learn about PWPs’ perspectives on what could improve this NHS Talking Therapies service’s processes involved in assessing traumatic events and reflect on whether this might be generalisable across other, similar services.

Research on the acquisition of psychotherapeutic competencies attributes an important role to procedural knowledge. We developed and evaluated a brief video-based measure of procedural knowledge in clinical psychology (the Pro CliPs Task).

The Pro CliPs Task consists of seven distinct case vignettes, each presented in four brief videos, and eight open-ended questions pertaining to each case vignette. The instrument was developed and validated in a multi-stage process, which included conceptual development, a feasibility study and an evaluation study. In the feasibility study (n=66 psychology students), the item characteristics and reliability of the coding method for the open-ended answers, authenticity of the case vignettes and general applicability of the measure were assessed. The following evaluation study (n=68 psychology students, n=65 postgraduate psychotherapy trainees) was conducted to investigate the validity of the instrument.

The item characteristics of the Pro CliPs Task were largely found to be within the expected range and inter-rater reliability was excellent. The case vignettes used were perceived as highly authentic, and the Pro CliPs Task was generally evaluated positively by participants. In the evaluation study, the Pro CliPs Task was strongly associated with declarative knowledge and therapeutic self-efficacy. Postgraduate psychotherapy trainees outperformed psychology students in the Pro CliPs Task.

The Pro CliPs Task holds promise as a valid and brief measure of procedural knowledge in clinical psychology with potential for use in research, training and teaching contexts.

1. (1) To gain insight into the role of procedural knowledge in clinical psychology and the limitations regarding its assessment.

2. (2) To learn about the theoretical basis and conceptual development of the Pro CliPs Task, a recently developed measure to assess procedural knowledge in clinical psychology.

3. (3) To evaluate the Pro CliPs Task regarding its item characteristics, inter-rater reliability, applicability, authenticity and validity.

Young adults with a psychotic disorder often experience difficulties in social functioning. We developed a modular virtual reality treatment to improve social activities and participation by targeting common causes of social functioning difficulties in patients with a psychotic disorder (VR-SOAP). This paper details the development of this intervention, encompassing a piloting phase.

Using an iterative Scrum method with software engineers, clinicians, researchers, and individuals with lived experience of psychosis, we developed a treatment protocol along with a software prototype. Subsequently five patients with a psychotic disorder, aged 18–40, and three therapists, piloted VR-SOAP. Feasibility was assessed by means of interviews and session forms. Acceptability was evaluated along the seven domains of the Theoretical Framework of Acceptability (i.e. affective attitude, burden, ethicality, intervention coherence, opportunity costs, self-efficacy, and perceived effectiveness).

The final protocol consisted of the following modules and targets: 1. Motivation and Pleasure (negative symptoms); 2. Understanding Others (social cognition); 3. Safety and Trust (paranoid ideations and social anxiety); 4. Self-Image (self-esteem and self-stigma); 5. Communication (communication and interaction skills). Modules were piloted by the participating patients and therapists. The modules proved feasible and showed a high degree of acceptability on all seven domains of the acceptability framework.

The modular VR-SOAP treatment protocol and prototype was acceptable and feasible for therapists and patients. The primary recommendation for enhancement underscores the need for flexibility regarding the number of sessions and the content.

1. (1) Understanding the development and structure of a novel modular CBT treatment in VR.

2. (2) Learning to use specific VR modules to target negative symptoms, social cognition, paranoid ideations, social anxiety, self-esteem, and communication skills.

3. (3) Gaining insights into the feasibility and acceptability assessments of a novel modular CBT treatment in VR.

Exposure and response prevention (ERP) is the first-line psychological treatment for obsessive compulsive disorder (OCD). Recent research shows that the Bergen 4-day Treatment (B4DT), which is a concentrated ERP program, can be very effective. However, this intensive format has not been widely implemented, and it is unclear whether positive outcomes are unique to B4DT, or whether a similar intensive ERP program (not based on B4DT) is equally effective. We examined short- and long-term outcomes of the Melbourne Intensive Treatment-OCD (MIT-O) program, an out-patient intensive ERP program for OCD involving an intensive phase of four full-day sessions conducted over two weeks, and a supportive 21-day phase involving self-directed tasks and twice-a-week check-in calls with the therapy team. Participants were 21 individuals with OCD. The severity of OCD, depression, anxiety, stress, obsessive beliefs, and emotion regulation difficulties were assessed at four time points (pre-treatment, post-treatment, 6-month, and 12-month follow-up). Results showed a large and significant decrease in OCD and obsessive beliefs at post-treatment. These improvements were maintained at 12-month follow-up. Using international consensus criteria for treatment response, almost all participants (90.5%) showed at least partial treatment response and one-third were in remission at the final assessment. These results showed that the MIT-O program was effective, but post-treatment and 12-month remission rates were somewhat less favourable than previously published results from the B4DT program. Nevertheless, the MIT-O post-treatment outcomes were comparable to other CBT programs for OCD and should be considered when other longer term treatment formats such as in-patient treatments are not feasible.

1. (1) To evaluate the effectiveness of an intensive exposure and response prevention program in reducing obsessive compulsive disorder (OCD) symptoms.

2. (2) To examine the long-term maintenance of treatment gains at 6-month and 12-month follow-up assessments.

3. (3) To report the treatment response rate and remission outcomes achieved through the intensive format.

4. (4) To consider the broader implementation of intensive exposure and response prevention programs as an alternative format for OCD treatment.

This study described the development and assessment of the psychometric properties of the Dissociation-Integration of Self-States Scale (D-ISS). This is a new scale to assess dissociation at the ‘between modes’ or self-state (personality) level. The D-ISS is rooted in cognitive behavioural theory and designed to measure between-mode dissociation (dissociation between self-states) in clinical practice and research.

Study 1: D-ISS scale items were generated and then answered by 344 young adults (16–25 years) who reported experiencing stressful times. An exploratory factor analysis (EFA) was conducted and the results were used to refine the scale to 25 items.

Study 2: The final 25-item D-ISS was completed by 383 adults (18–65 years) who reported experiencing mental health difficulties. A confirmatory factor analysis (CFA) was conducted using the second dataset. Internal consistency, test–retest reliability, convergent validity and divergent validity of the final D-ISS was assessed.

Study 1: The EFA showed a clear 5-factor solution, which was used to refine the D-ISS to a total of 25 items with five items in each factor.

Study 2: The 5-factor solution from Study 1 was confirmed as a good fit by the CFA using the data collected in Study 2. The D-ISS demonstrated good internal reliability and test–retest reliability. The D-ISS showed no correlations with divergent scales. For convergent validity, the D-ISS showed moderate correlations with the Dissociative Experiences Scale (DES-II).

The new D-ISS measure of between-mode dissociation is reliable and valid for the population represented by our sample. Further research into its use in clinical populations is required.

1. (1) To understand and be able to use a new measure of dissociation at the personality or self-states level.

2. (2) To understand the cognitive behavioural model of dissociation.

3. (3) To understand the theoretical underpinnings of the scale, in terms of the effects of childhood and adult adversity and other factors on psychological development.

4. (4) To consider the potential clinical and research applications of the scale.

5. (5) To appreciate the limitations of the research so far and the nature of future research required.

The notion of cognitive detachment (i.e. the capacity to treat thoughts as just thoughts, with no greater significance or importance) is introduced in this paper. Its link to similar established terminologies (e.g. distancing, decentering, defusion/deliteralisation, detached mindfulness), importance within cognitive behaviour therapies and place within an adapted cognitive-behavioural framework is highlighted. The use of metaphor to facilitate cognitive detachment is then the primary focus of the paper. An overview of how metaphor has typically been used within psychotherapy is presented and reflects mostly the use of therapist-generated metaphor for psychoeducational purposes. While the use of metaphor in serving a therapeutic cognitive detachment function is not new, developing idiosyncratic client-generated metaphors in this regard has been largely neglected, despite the widely held view that client-generated metaphors are more potent. Practical guidance on how clinicians can collaboratively assist clients to intentionally generate their own personalised cognitive detachment metaphor is provided, and specific ways to elaborate metaphors during therapy to enhance metaphor application and hence effectiveness in enabling cognitive detachment is considered. Finally, clinical examples are provided to illustrate the varied, creative and rich metaphors that can emerge from this process.

1. (1) To introduce the term cognitive detachment and understand this important therapy target within an adapted cognitive-behavioural framework.

2. (2) To appreciate the broader use of metaphors in therapy and frame metaphor as one method for facilitating cognitive detachment.

3. (3) To motivate therapists to pursue idiosyncratic client-generated metaphor.

4. (4) To provide an instructional script to support therapists to help clients develop a personalised cognitive detachment metaphor.

5. (5) To provide specific guidance to therapists regarding methods for metaphor elaboration.

Drug and alcohol users have been suggested to face disproportionate exclusion from mental health services, but data on any such exclusion are not readily available. This study examined the clinical records of those excluded from an NHS Talking Therapies service due to drug or alcohol use, focusing on (1) quantitative levels of alcohol consumption, and (2) the rationales documented by clinicians for excluding these individuals. Our results suggest that over half (57%) of those excluded due to alcohol use were consuming below the 15-unit daily threshold recommended for signposting to specialist alcohol assessment. Clinicians cited various rationales for exclusion, including the potential for poor treatment outcomes and health risks associated with concurrent use. Due to being based on a single service, these findings may be limited in their generalisability, but they offer an initial signal that there is potential over-exclusion of some alcohol users from NHS Talking Therapies, and that rationales for exclusion may not consistently align with best practice principles. We discuss implications for NHS Talking Therapies clinicians, and for the development of future clinical guidance.

1. (1) To understand how different levels of drug or alcohol use may affect the outcomes of psychological therapy.

2. (2) To learn why individuals with drug or alcohol use experience exclusion from mental health services.

3. (3) To examine how clinical practice within an NHS Talking Therapies service aligns with best practice principles.

4. (4) To explore skills and clinical principles that can lead to optimal treatment planning for these individuals.

5. (5) To explore how integrated working between NHS Talking Therapies and local drug and alcohol services can enhance service-user experiences.

The last two decades have seen considerable development in our understanding of delusions, with medical perspectives broadening into more holistic bio-psychosocial models. Of particular relevance to services is the increasing evidence base for cognitive behavioural models and treatments. A number of national initiatives have aimed to ensure these developments are reflected in services. Primarily these have targeted adult services, yet delusions are no less common in older adults. Across two older adult services this study searched over 10,000 clinical notes to assess the number of individuals experiencing delusions, explored the perspectives of 27 staff members regarding their clinical approaches to working with delusions, and delivered a brief training on cognitive behavioural models and treatments of delusions. Three service users contributed to the training content. Endorsement of theoretical perspectives regarding delusions were measured pre- and post-training. Results showed over 20% of patients in the service may be experiencing paranoia or delusions, but only a handful were referred for CBT. Of 27 staff participants, less than half had received training on working with delusions, most of which was from as many as 20 years ago. Nearly all reported that a lack of knowledge prevented them from considering psychological perspectives. A quarter of staff across the two teams attended the training. No immediate changes in outcome measures were seen immediately post-training, with a striking diversity in approach reported by different members of staff. All staff qualitatively reported finding the training valuable, although engagement was dampened by high levels of stress and burnout.

1. (1) To understand the developing cognitive behavioural evidence base for understanding and treating delusions in older adults.

2. (2) To understand the need for this growing evidence base to be reflected in services, including older adult services, not only in structured interventions offered by psychological therapists, but also in patient interactions and care planning by all professions working in multi-disciplinary teams.

3. (3) To understand some of the key challenges in assessing and improving current understanding of cognitive behavioural approaches to delusions within services.

Smartphone apps combined with psychological interventions may be beneficial for increasing adherence to treatment tasks and augmenting outcomes. Yet, there is limited research on the acceptability and feasibility of adjunctive smartphone apps with psychological therapies for adolescents engaging in self-harm and suicidal behaviours. This study aimed to evaluate the acceptability and feasibility of integrating the Dialectical Behaviour Therapy (DBT) Coach app as an adjunct to a comprehensive DBT programme. The study also aimed to explore statistical trends of the potential relationship between the DBT Coach app and symptom reduction, including self-harm, borderline personality disorder symptoms, emotion dysregulation, and DBT skill use, to inform future study design. A mixed-method design was used to evaluate the acceptability and feasibility of the app and clinician’s portal from the perspective of adolescent and clinician participants. Thematic analysis was used to analyse qualitative data. Results indicated varied experiences of acceptability and feasibility of the DBT Coach app and portal as an adjunct to DBT. Thematic analysis generated four over-arching themes and ten subthemes. The regression analysis provided statistical trends regarding potential relationships between app use and clinical outcomes, which would be helpful to explore in future research. Findings suggest that the app and portal were acceptable and feasible for the most part, with some barriers and challenges identified. Implications of this study are discussed.

1. (1) To learn about the acceptability and feasibility of using a smartphone application as an adjunct to a DBT skills group within a comprehensive DBT programme for adolescents.

2. (2) To explore whether there is a relationship between app use and clinical outcome at the end of the group intervention.

3. (3) To learn about the experiences of adolescents and clinicians using the smartphone app as an adjunct to the DBT skills group.

Maladaptive daydreaming (MD) is an increasingly recognised mental health difficulty, which refers to a compulsive cycle of dissociative absorption in vivid mental fantasy that results in clinical distress and functional impairment. Fantasies are usually complex in plot and characters, and are highly pleasurable and absorbing. MD provides temporary escape, soothing, or attempted processing of difficult internal and external experiences, but results in longer-term negative consequences that both create and exacerbate real-life suffering. The literature thus far has expanded beyond defining and understanding MD and has turned its attention towards assessment and pilot interventions. This paper presents the first formulation framework and associated diagrammatic model of MD, drawing upon the existing evidence base and cognitive behavioural theory to capture its development, maintenance, and processes. The model was reviewed by two leading experts in the field and trialled by three contributors with lived experience of MD. Feedback was positive, suggesting it accurately captured and organised the complexity and depth of the MD experience, facilitated the development of personal insight, and fostered a sense of hope with regard to creating change. The model is intended for use within clinical practice to aid mental health professionals and people with MD to guide assessment, collaborative discovery and formulation, and intervention. It is imperative that the model be tested further within research and clinical practice to further ensure its efficacy, validity, and applicability for people with MD.

1. (1) To consider the development and maintenance factors, and processes involved in MD from a cognitive behavioural perspective.

2. (2) To introduce a new formulation model for MD and understand how the model can be used in clinical practice.

3. (3) To highlight how psychological formulation has the power to better understand and organise the complex and often overwhelming MD phenomenon and provide hope for meaningful change.

Effective, evidence-based psychological therapies for prolonged grief reactions exist but are not routinely available in United Kingdom National Health Service (NHS) services. This audit evaluated the feasibility and clinical effectiveness of a high-intensity prolonged grief disorder therapy (PGDT) treatment pathway in an NHS Talking Therapies (NHS-TT) context for clients with a prolonged grief reaction alongside depression, anxiety and/or post-traumatic stress disorder. Seventeen experienced high-intensity therapists were trained to deliver PGDT. Ninety-one clients were treated between April 2022 and April 2024, 80 of whom met criteria and were included in this audit; 83% of clients completed at least four treatment sessions (a liberal estimate of minimum adequate dose), the mean number of sessions attended was 10.29 (SD=5.81) and rates of drop-out were low (16%). Data completeness rates were 100% depression, anxiety and functioning measures and 61% for the grief outcome (Brief Grief Questionnaire; BGQ). There was no evidence of treatment-related harms. There were statistically significant, large pre–post treatment effect size improvements across outcomes from intake to last treatment session (p<.001; Cohen’s d>1.05). According to NHS-TT outcome metrics for combined changes in anxiety and depression, 82% of clients exhibited reliable improvement, 72% showed recovery, and 68% of clients achieved reliable recovery. On the BGQ, rates of reliable improvement were 77% and rates of recovery were 63%. Effects held when focusing on the subgroup with more severe grief symptoms (intake BGQ≥8; n=40). These findings suggest it is feasible and probably effective to implement a PGDT pathway in an NHS-TT context.

1. (1) To become familiar with prolonged grief disorder (PGD) as a diagnostic construct.

2. (2) To gain insight into using prolonged grief disorder therapy (PGDT) to treat PGD.

3. (3) To understand ways to train and supervise National Health Service Talking Therapies (NHS-TT) high-intensity therapists to implement PGDT.

4. (4) To evaluate the potential feasibility and effectiveness of implementing PGDT in an NHS-TT context.

Economic variables such as socioeconomic status and debt are linked with an increased risk of a range of mental health problems and appear to increase the risk of developing of post-traumatic stress disorder (PTSD). Previous research has shown that people living in more deprived areas have more severe symptoms of depression and anxiety after treatment in England’s NHS Talking Therapies services. However, no research has examined if there is a relationship between neighbourhood deprivation and outcomes for PTSD specifically. This study was an audit of existing data from a single NHS Talking Therapies service. The postcodes of 138 service users who had received psychological therapy for PTSD were used to link data from the English Indices of Deprivation. This was analysed with the PCL-5 measure of PTSD symptoms pre- and post-treatment. There was no significant association between neighbourhood deprivation measures on risk of drop-out from therapy for PTSD, number of sessions received or PTSD symptom severity at the start of treatment. However, post-treatment PCL-5 scores were significantly more severe for those living in highly deprived neighbourhoods, with lower estimated income and greater health and disability. There was also a non-significant trend for the same pattern based on employment and crime rates. There was no impact of access to housing and services or living environment. Those living in more deprived neighbourhoods experienced less of a reduction in PTSD symptoms after treatment from NHS Talking Therapies services. Given the small sample size in a single city, this finding needs to be replicated with a larger sample.

1. (1) Previous literature has shown that socioeconomic deprivation increases the risk of a range of mental health problems.

2. (2) Existing research suggests that economic variables such as income and employment are associated with greater incidence of PTSD.

3. (3) In the current study, those living in more deprived areas experienced less of a reduction in PTSD symptoms following psychological therapy through NHS Talking Therapies.

4. (4) The relatively poorer treatment outcomes in the current study are not explained by differences in baseline PTSD severity or drop-out rates, which were not significantly different comparing patients from different socioeconomic strata.

The objectives of study 1 were to use expert opinion to identify the limitations of the Health Anxiety Inventory – Short Version (SHAI) for administration in medical populations and to develop an adapted version for medical populations. The objective of the second study was to evaluate the psychometric properties of the adapted measure. A three-round Delphi study method was used in study 1. Eight experts with experience of living with a physical health condition and four experts by profession working within physical health were invited to review the SHAI. Study 2 employed a cross-sectional mixed methods questionnaire design. Individuals with multiple sclerosis (n=115), myalgic encephalomyelitis/chronic fatigue syndrome (n=84) and chronic pain (n=116) were invited to complete a battery of questionnaires via an online survey. The adapted version of the SHAI for Medical Populations (HAI-M) consisted of 12 items scoring from 0 to 3, reaching high consensus (75% agreement) for administration in medical populations. All groups rated the HAI-M as more acceptable than the SHAI and no significant differences were found on HAI-M scores between clinical groups. The HAI-M demonstrated high internal consistency (.875), good test–retest reliability (.812) and convergent validity (.801). Divergent validity was also acceptable (.515). This study provides preliminary evidence for a psychometrically sound health anxiety screening tool for use in medical populations.

1. (1) To gain insights into the presentation of health anxiety in medical conditions.

2. (2) To consider the validity and reliability of using questionnaire measures developed using analogue sample norms, and how this may affect measurement when used in different context and settings.

3. (3) The process of systematically adapting, developing and testing standardised measures for use in special subgroups.