Introduction
LTCs in NHS Talking Therapies (NHSTT) services
A long-term physical health condition (LTC) is defined as a condition ‘that cannot currently be cured but can be controlled with the use of medication and/or other therapies’ (Department of Health, 2010). LTCs affect over 15 million people in the UK, with many experiencing co-morbid depression or anxiety (NHS England, 2019), resulting in poorer health outcomes and increased healthcare costs, prompting the need for integrated physical and mental healthcare (Naylor, Reference Naylor2012).
Although NHS Talking Therapies (NHSTT) services aim to provide accessible psychological support to reduce the amount of expenditure within the benefits system and get more people into work (Layard et al., Reference Layard, Clark, Bell, Knapp, Meacher and Priebe2006), mental and physical health services are often siloed. The complexities of delivering CBT to individuals with LTCs, whose distress is often entangled with diagnostic ambiguity, identity disruption, and chronic uncertainty, raise questions about the long-term effectiveness of standard approaches (Clur and Barnard, Reference Clur and Barnard2025; Tao et al., Reference Tao, Lim, Yeung, Liu, Shris, Ma, Lee and Hou2023).
CBT and NICE guidelines for LTCs
CBT is recommended as the first-line treatment for individuals with depression and anxiety and co-morbid physical health conditions (National Institute for Health and Care Excellence, 2009). When adapted, CBT helps clients reframe unhelpful illness-specific beliefs and coping behaviours that reinforce distress (Pollock et al., Reference Pollock, van Agteren, Esterman and Carson-Chahhoud2019). Reviews demonstrate appropriately adapted CBT interventions can produce positive outcomes (Pollock et al., Reference Pollock, van Agteren, Esterman and Carson-Chahhoud2019; Sanders et al., Reference Sanders, Coppin, Moulson, Meola and Meryick2020). However, success is closely linked to how well therapy is tailored to the individual’s needs (Hassan et al., Reference Hassan, Bennett and Serfaty2018).
Third-wave approaches
Traditional CBT’s aim to reduce symptoms is arguably incompatible with people with LTCs, due to the long-term and chronic nature of their condition, and that pursuing this aim could result in disappointment and demoralisation for both therapist and client (Delgadillo et al., Reference Delgadillo, Dawson, Gilbody and Böhnke2017). CBT therapists are therefore increasingly encouraged to integrate third-wave approaches such as acceptance and commitment therapy (ACT) and compassion-focused therapy (CFT), particularly when working with LTC clients.
ACT promotes values-based living and psychological flexibility, an approach which lends itself well to clients with chronic conditions that cannot be ‘cured’ (Gloster et al., Reference Gloster, Walder, Levin, Twohig and Karekla2020; Hayes et al., Reference Hayes, Strosahl and Wilson2012), whilst CFT’s primary goal of reducing self-criticism may be appropriate for LTC clients who blame themselves or internalise negative healthcare experiences (Austin et al., Reference Austin, Drossaert, Schroevers, Sanderman, Kirby and Bohlmeijer2020; Gilbert, Reference Gilbert2010). Research suggests CFT can reduce pain-related distress and increase pain self-efficacy (Malpus et al., Reference Malpus, Nazar, Smith and Armitage2023).
Integration of health psychology theory
Given the high number of clients with LTCs in NHSTT services, more explicitly integrating health psychology theory into core CBT training may be beneficial, as although some CBT training programmes now include LTC-related teaching, this remains limited compared with the dedicated competencies outlined in the NHS LTC curriculum (Health Education England, 2023). Presenting key theories offers a framework for understanding participants’ accounts of CBT for LTCs, particularly emotional adjustment, identity change and meaning making.
The Chronic Illness Coping Model (CICM; Macdonald and Stalmeisters, Reference Macdonald and Stalmeisters2016), the Transdiagnostic Model of Adjustment to Long-Term Conditions (TMA-LTC; Carroll et al., Reference Carroll, Moon, Hudson, Hulme and Moss-Morris2022) and Leventhal’s Self-Regulatory Model (SRM; Leventhal et al., Reference Leventhal, Meyer, Nerenz and Rachman1980) are widely applied within health psychology and LTC-focused CBT training, with the TMA-LTC integrating core elements of the SRM into a practical, transdiagnostic framework (Carroll et al., Reference Carroll, Moon, Hudson, Hulme and Moss-Morris2022).
The CICM helps therapists formulate complex biopsychosocial presentations, the SRM offers a structured understanding of illness beliefs and coping, and the TMA-LTC highlights shared mechanisms, categorising coping into problem-focused, emotion-focused and avoidant styles. Together, these models align with CBT’s emphasis on reframing unhelpful beliefs and encouraging adaptive behaviour (Broekhuijse et al., Reference Broekhuijse, Munoz-Martinez, Garcia and Skinta2025), and provide a context for exploring how clients make sense of CBT.
Therapists have reported low confidence when working with LTCs, highlighting the need for better training and support (Carroll et al., Reference Carroll, Moss-Morris, Hulme and Hudson2021; McCrae et al., Reference McCrae, Correa, Chan, Jones and Lusignan2015). A NICE-commissioned review (David et al., Reference David, Bury, Campling, Carter, Garfield, Newbould and Rennie2006) suggests that integrating models such as the SRM into CBT can enhance work with illness representations, emotional responses and coping styles, supporting adaptive self-management. However, any one model will not fully capture the emotional, existential, and relational complexity of living with LTCs. Third-wave approaches such as ACT and CFT offer complementary processes, psychological flexibility, values-based action, and self-compassion, that better address identity disruption and loss (Klieman et al., Reference Klieman, Marks, Block-Lerner, Tirch, Brady, Foote and Silberstein-Tirch2025). Karekla, Karademas and Gloster (Reference Karekla, Karademas and Gloster2018) propose integrating ACT with the SRM to support holistic adjustment (Karekla et al., Reference Karekla, Karademas and Gloster2018), and the Health Education England Curriculum (2023) similarly advocates for LTC-specific competencies, emotionally attuned practice, and flexible, process-based CBT within NHSTT services (Health Education England, 2023).
Long-term outcomes and gaps in evidence
Evidence for long-term outcomes of CBT for LTC clients remains mixed. Some studies suggest benefits are maintained over time (Bernardy et al., Reference Bernardy, Klose, Busch, Choy and Hauser2013; Usami et al., Reference Usami, Carson, Helpson, Esterman, Soyza and Smith2017), whilst others report no significant long-term difference (Thabrew et al., Reference Thabrew, Stasiak, Hetrick, Donkin, Huss, Highlander, Wong and Merry2018). Follow-ups beyond 12 months are rare, and inconsistency in measurement tools makes comparisons difficult (Dysvik et al., Reference Dysvik, Kvaløy, Stokeeland and Natvig2010).
Moreover, many studies are conducted outside the UK or in research conditions that differ from NHSTT services. Group and digital formats are often used due to feasibility, yet face-to-face one-to-one therapy may be more acceptable for many LTC clients (Hind et al., Reference Hind, O’Cathain, Cooper, Parry, Isaac, Rose, Martin and Sharrack2010). Studies also often include non-specialist practitioners, such as nurses, which may affect applicability of results to NHSTT services (Kleinstäuber et al., Reference Kleinstäuber, Witthöft and Hiller2011). Vybíral et al. (Reference Vybíral, Ogles, Řiháček, Urbancová and Gocieková2025) argue the client’s perspective is clear evidence for the effects of therapy and must be central to clinical decision-making (Vybíral et al., Reference Vybíral, Ogles, Řiháček, Urbancová and Gocieková2025). Further research is therefore needed within NHSTT settings to explore long-term outcomes, particularly from the client’s perspective.
Process and outcome research
There is a growing shift in psychotherapy research from outcome-focused approaches (i.e. whether CBT works, measured by quantitative metrics) towards process research, which explores how and why therapy facilitates change (Thompson et al., Reference Thompson, Parker and Cave2021). This aligns with the shift in therapeutic focus, with the evolution of process-based therapy (PBT). PBT offers a flexible, evidence-informed framework for understanding how therapeutic change occurs across diverse contexts, including LTCs (Ciarrochi et al., Reference Ciarrochi, Hernández, Hill, Ong, Gloster, Levin, Yap, Fraser, Sahdra, Hofmann and Hayes2024). Rather than aiming solely for symptom reduction, PBT focuses on core biopsychosocial maintenance processes that are shared across disorders, such as avoidance, identity disruption, and psychological flexibility (Ciarrochi et al., Reference Ciarrochi, Hernández, Hill, Ong, Gloster, Levin, Yap, Fraser, Sahdra, Hofmann and Hayes2024).
In the context of LTCs, where the complexities of chronic illness often extend beyond protocol-led symptom management, PBT and process research are particularly valuable. Yet, research exploring clients’ subjective experiences, including their views on what helped or hindered progress, remains limited. Discrepancies between therapist and client perspectives are common (O’Brien et al., Reference O’Brien, Staud, Hassinger, McCulloch, Craggs, Atchison, Price and Robinson2010), and therapeutic change may arise from both specific factors (e.g. CBT techniques) and common factors such as empathy and alliance (Wampold, Reference Wampold1997). Some authors contend these are not discrete but interactive: specific techniques may only be effective when embedded within a strong relational foundation (Wampold and Budge, Reference Wampold and Budge2012).
Clients living with LTCs have been reported to value therapists who listen, validate, and personalise care, sometimes over any particular CBT strategy (Hodgetts and Wright, Reference Hodgetts and Wright2007). This suggests that client-centred, relationally attuned approaches that focus on meaningful processes of change, such as PBT, third wave and integrative therapies, may be especially beneficial for LTC clients.
This is the first known qualitative study to explore both the active ingredients of CBT for LTCs and the processes of therapeutic change 12 months or more after treatment within a UK NHSTT context. Findings may have wider relevance for services internationally that model their care systems on NHSTT, including in Norway, Australia, and Sweden (Clark, Reference Clark2019).
Aims of the current study
The study aimed to explore how adults with LTCs make sense of their experiences of CBT 12 months or more after completing treatment in NHSTT services. Using a reflexive thematic analysis approach that integrated both inductive insights from participants’ narratives and deductive engagement with psychological theory, the study sought to understand the processes that contributed to long-term adjustment.
More specifically, the study aimed to:
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• 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.
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• 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.
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• Contextualise participants’ accounts within broader health psychology and process-based frameworks, considering how their narratives reflect mechanisms highlighted in models such as the SRM, the TMA-LTC, and third-wave approaches.
These aims were designed to clarify the active ingredients of CBT for LTCs from the client perspective and to inform future adaptations of CBT within NHSTT.
Method
Design
An inductive-deductive approach to reflexive thematic analysis (RTA) (Braun and Clarke, Reference Braun and Clarke2021a) was chosen to analyse the data as it provided a flexible yet rigorous framework to explore whether participants found CBT helpful in managing long-term health challenges, whether alternative approaches (e.g. third-wave therapies) might have been more effective, and whether their accounts challenged dominant assumptions about CBT’s efficacy for LTCs. The primary researcher (J.H.) began with an inductive approach, allowing themes to develop directly from participants’ narratives to keep lived experience central. These themes were later organised using common and specific factors, enabling a deductive interpretation grounded in established CBT and health psychology theory. This dual analytic stance, consistent with Braun and Clarke’s (Reference Braun and Clarke2024) guidance, ensured findings remained both participant-led and theoretically situated, allowing for a rich, grounded understanding of the underlying mechanisms influencing participant experiences.
Participants
The study included 10 participants with one or more LTCs. Participants were recruited via social media and charity networks (e.g. Diabetes UK, Macmillan, Pain Concern). The advert included a link to the participant information sheet and data privacy notice via Qualtrics.
Eligibility required participants to be 18+ with at least one LTC lasting 3+ months, have completed at least six one-to-one CBT sessions (in line with NICE (2009) guidance) in an NHSTT service at least 12 months ago, and be willing to discuss their experience in a 60-minute interview.
Purposive and volunteer sampling ensured the selection of participants who could offer ‘information-rich’ data (Patton, Reference Patton2002). Following Braun and Clarke’s (Reference Braun and Clarke2021b) guidance, the study did not aim for ‘data saturation’ in the traditional sense, but instead followed the principle of ‘information power’, where a smaller sample is sufficient when data are rich, the analysis is theory-informed, and participants have lived experience relevant to the research question (Braun and Clarke, Reference Braun and Clarke2021b; British Psychological Society, 2021). This approach aligns with the RTA framework used, which emphasises depth of meaning over breadth (Braun and Clarke, Reference Braun and Clarke2024).
Procedure
Ethical approval was granted by the University of the West of England (UWE), and the study followed BPS (2009) and Data Protection Act (2018) guidelines and bided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. Participants completed a consent form and demographic questionnaire (gender, ethnicity, LTCs, CBT history, etc.) via Qualtrics.
All interviews took place via Microsoft Teams and were recorded, transcribed, checked for accuracy, and securely stored. Interviews lasted between 55 and 110 minutes (M=69.8 min). Participants were anonymised with pseudonyms. Audio recordings were deleted following the write-up.
Open-ended questions allowed participants to control the depth of disclosure. Risks were minimised by allowing participants to pause/stop interviews and by providing relevant support resources. Participants had the right to withdraw within 28 days post-interview without explanation.
Interview schedule
The interview schedule was adapted from the Change Interview Schedule (Elliott and Rodgers, Reference Elliott and Rodgers2008) which encourages exploration of both positive and negative experiences in therapy. Questions explored perceived changes during and after therapy, attributions for change, CBT strategies used and maintained, helpful and unhelpful aspects of therapy, barriers to engagement and progress, broader contextual influences, and suggestions for future service improvements. Additional questions included external influences on outcomes to help contextualise therapy experiences more broadly.
Data analysis
RTA, which involves identifying patterns of meaning across a data set (Braun and Clarke, Reference Braun and Clarke2021a), was used. The six phases of RTA were followed: (1) familiarisation with the data; (2) coding the full data set; (3) generating initial themes; (4) reviewing and refining themes; (5) naming themes and subthemes; (6) writing the analysis.
Semi-structured interviews were selected for their ability to generate rich, personal data (Braun and Clarke, Reference Braun and Clarke2021a). Interviews were initially analysed inductively, allowing patterns to develop from the data without being constrained by pre-existing frameworks. However, as the analysis progressed, the researchers noted recurring references to therapeutic factors, both specific CBT techniques (e.g. thought challenging, pacing) and common factors (e.g. feeling heard, validated), which reflected longstanding psychotherapy literature (Wampold, Reference Wampold2015). This led to an inductive-deductive approach to analysis using the common/specific factors distinction to organise the final write-up, although this did not guide initial coding. Organising the findings in this way builds on prior work (Thompson et al., Reference Thompson, Parker and Cave2021), and mirrors hybrid inductive-deductive approaches used in studies such as the ACTIB trial (Everitt et al., Reference Everitt, Landau, O’Reilly, Sibelli, Hughes, Windgassen, Holland, Little, McCrone, Bishop, Goldsmith, Coleman, Logan, Chalder and Moss-Morris2019) and aligns with broader methodological guidance (Gale et al., Reference Gale, Heath, Cameron, Rashid and Redwood2013).
Inductive coding involved repeated transcript readings. Codes were grouped into themes, some of which were then split into subthemes for clarity and depth. Themes were revised against the full data set and cross-checked for consistency, ensuring quotes were representative and meaningful. This approach allowed the data to stay grounded in participant narratives while also linking findings to established theoretical discussions in CBT and psychotherapy.
Theoretical position
RTA aligns with the primary researcher’s (J.H.) critical realist epistemology and subjectivist ontology, which accepts the existence of an objective reality while also acknowledging individuals interpret and experience reality differently based on social, emotional, and historical factors (Barnett-Page and Thomas, Reference Barnett-Page and Thomas2009). Braun and Clarke’s approach supports this by enabling systematic analysis of meaning, influenced by broader cultural and service-based discourses, such as those found in NHSTT services.
As a CBT therapist and lecturer, J.H. values evidence-based practice but also appreciates subjective, lived experiences. This dual focus informed the choice of RTA, which supports both inductive analysis and critical interpretation. RTA is suited to critical realism (King, Reference King2012), as it acknowledges multiple levels of meaning and recognises themes are constructed through interaction between researcher and data.
Results
A Cochrane review has recommended less RCTs and more targeted designs to explore which therapy components work for whom and why (Williams et al., Reference Williams, Fisher, Hearn and Eccleston2020). In line with this, this qualitative study offers initial insights into helpful and unhelpful aspects of CBT in the long-term from the LTC client’s perspective.
Four over-arching themes were identified: (1) a validating and normalising therapeutic relationship, (2) lack of therapist skill and knowledge of LTCs, (3) adjusting to and accepting LTC, and (4) decatastrophising and adjusting LTC-specific beliefs. The first over-arching theme included two subthemes: ‘space to offload’ and ‘therapist rigidity and lack of collaboration’. The second over-arching theme included two subthemes: ‘managing expectations of therapy’ and ‘therapist implementation of assessment and formulation’. The third over-arching theme included one subtheme: ‘developing compassion for and confidence in the new self’, as did the final over-arching theme, which included the subtheme: ‘values and committed action’. See thematic map in Fig. 1.
Thematic map.
Figure 1. Long description
The thematic map presents four overarching themes: (1) a validating and normalising therapeutic relationship, (2) lack of therapist skill and knowledge of long-term conditions (LTCs), (3) adjusting to and accepting LTC, and (4) decatastrophising and adjusting LTC-specific beliefs. Each overarching theme is linked to specific subthemes that illustrate key aspects of participants’ experiences. The theme ‘a validating and normalising therapeutic relationship’ comprises two subthemes: ‘space to offload’ and ‘therapist rigidity and lack of collaboration’. The theme ‘lack of therapist skill and knowledge of LTCs’ includes the subthemes ‘managing expectations of therapy’ and ‘therapist implementation of assessment and formulation’. The theme ‘adjusting to and accepting LTC’ contains one subtheme: ‘developing compassion for and confidence in the new self’. Finally, the theme ‘decatastrophising and adjusting LTC-specific beliefs’rdenca is associated with the subtheme ‘values and committed action’. The map visually depicts the relationships between these themes and subthemes, highlighting how both therapeutic processes and therapist-related factors interact to shape the delivery and experience of cognitive behavioural therapy for individuals with long-term conditions.
Six of ten participants (Elizabeth, Kate, Gemma, Stevie, Arthur, Millie) described positive therapy experiences with sustained benefits. Two participants (Amy, Sam) reported initial improvements but limited long-term impact. The remaining two (Constance, Ashleigh) had overall negative experiences. Factors linked to less benefit will be discussed further, but included premature ending of therapy, lack of relapse planning, and disengagement from home practice.
Amongst participants, common LTCs included chronic pain and chronic fatigue (both 60%), followed by arthritis (40%), inflammatory bowel disease (30%) and diabetes (10%). Most participants were aged between 18 and 35 years (70%), with the remainder (30%) aged between 36 and 60, or preferring not to say. Nine participants identified as female, one as male. Eight were White British, one Black British Caribbean, and one British Indian. Half reported having no religion. Five were healthcare professionals (HCPs), three were psychology students, one was retired, and one was part-time employed. All participants received one-to-one CBT: six had 6–12 sessions, two had 12–16, and two had 16–20. Eight completed CBT 1–2 years before the interview; two completed 2–5 years prior. All participants received one-to-one high-intensity CBT with a CBT therapist. See a summary of participant demographic characteristics in Fig. 2 below.
Demographic characteristics.
Figure 2. Long description
The table presents demographic characteristics of participants with long-term physical health conditions. It includes data on gender, age, marital status, highest educational level, employment, ethnicity, religion, physical health conditions, number of cognitive behavioral therapy sessions received, and years since completing the CBT course. The table has 17 rows and 4 columns, with column headers being Baseline characteristic, N, and percentage. Notable trends include a majority of participants being female, aged 26-35 years, single, with a bachelor’s degree, full-time employed, and of White/Caucasian ethnicity. Chronic pain and chronic fatigue are the most common physical health conditions. Most participants received 6-12 CBT sessions and completed the course 1-2 years ago.
Common factors themes
Over-arching theme: A validating and normalising therapeutic relationship
This was the most prominent theme. Many LTC clients may approach therapy sceptical of psychological explanations, fearing their problems will be seen as ‘all in their head’. A relational shift allowed participants to explore alternative self-narratives and reconnect with meaningful pursuits. Participants emphasised the importance of feeling understood and legitimised and provided with an opportunity to pause and reflect, without focusing on the need to ‘fix’:
‘… no one in my life also had a chronic condition … I just felt completely alone … And someone saying no, that’s quite normal. You’ve had your whole life flipped around …’ – Gemma
Validation and empathy helped participants see their distress as an understandable, as opposed to irrational, reaction to their LTC. Participants who did not feel validated described seeking support elsewhere:
‘… Doing [the course] is so much more beneficial to me than the CBT …’ – Amy
Several noted traditional thought challenging approaches were ineffective when inflexibly applied to cognitions that were realistic. These narratives reflect complex LTC-specific cognitions, including beliefs about symptom legitimacy, controllability, and emotional consequences, shaping how participants viewed the relevance of psychological interventions. The perceived mismatch between their LTC and the therapeutic focus can lead to disengagement or resistance:
‘… I didn’t think any of that worked. I think ’cause I was balanced in my thinking …’ – Sam
Some participants stated therapists should make it clear to the client they believe them from the offset, which normalised experiences and enhanced the therapeutic relationship:
‘… not under-estimate the importance of saying I believe you …’ – Kate
Kate highlights therapists should not assume clients feel believed. Mirroring language and exploring the client’s history, illness beliefs, and relationships are crucial.
Subtheme: Space to offload
This theme developed from participants’ descriptions of therapy as a space to release emotional burden without fear of judgement. Many participants found it healing to talk openly and reflect, setting the foundation upon which every other helpful aspect was built:
‘I think first and foremost was just literally having somebody to offload to.’ – Amy
Active listening and empathic responses helped participants look at their situation more objectively, validating their concerns whilst helping them recognise any unrealistic expectations. Even Constance found generally talking about her LTC beneficial:
‘… even though it [the CBT] wasn’t particularly helpful, it’s just made me more comfortable talking about it …’ – Constance
Talking appeared to support acceptance and assertive communication, improving relationships and expectations. However, Constance viewed this element of therapy as a natural ‘side effect’, rather than something specific to CBT. The findings suggest that for clients with LTCs, the perceived value of therapy may be related as much to the opportunity to be emotionally held and it does to specific interventions.
Subtheme: Therapist rigidity and lack of collaboration
Participants described therapy as less helpful, disempowering, invalidating, or even re-traumatising when therapists were rigid, inflexible, avoided LTC-related topics or emotional exploration:
‘… he was quite rigid … maybe the guidelines he was following … didn’t give him scope …’ – Elizabeth
This rigidity and failure to be collaborative is particularly problematic for LTC clients who can feel as though they are reduced to a diagnosis and often seek a space to process grief, interpersonal problems, or identity disruption. Ashleigh and Constance discussed how the lack of collaboration reinforced their belief of being out of control:
‘… It felt like something else happening to me that I didn’t want or couldn’t control. So yeah, I think that’s important … especially in this setting to not feel like you’re being done to.’ – Ashleigh
Participants speculated therapist rigidity may stem from service pressures or therapists’ lack of confidence. Collaboration, including client involvement in decisions, was vital but sometimes missing:
‘… she did make it very clear … if I didn’t feel like it was working, I could switch to someone else.’ – Stevie
For some, limited therapist collaboration left sessions feeling superficial or emotionally unsafe when key issues were overlooked and feedback was not elicited:
‘… at no point was I asked for feedback …’ – Ashleigh
Participants’ accounts suggest that therapist responsiveness and shared formulation foster relational safety, agency, and emotional engagement, key ingredients for effective CBT in chronic illness contexts. Lack of feedback limits opportunity to adapt therapy accordingly and risks a power imbalance and disengagement.
Over-arching theme: Lack of therapist skill and knowledge of LTCs
Limited therapist LTC knowledge, including an understanding of their fluctuating nature, emotional impact, and practical realities, impacted realistic goal setting and therefore client engagement and therapy relevance:
‘… if … I didn’t feel like they understood the long-term health conditions, I don’t think it would have got anywhere …’ – Ashleigh
Participants suggested service structure and the need to manage diverse caseloads under time pressure limited capacity to offer extended sessions or follow-ups, creating a barrier to long-term gains:
‘… the limited number of sessions … it felt very rushed in terms of teaching the techniques and I also found that for me there was no follow-up.’ – Kate
Training and flexibility are essential to counteract these limitations and prevent clients from feeling unseen or misinterpreted, reinforcing a fixed or pathologised self-concept:
‘… they could even ask, like, what’s an average day look like for you?’ – Arthur
Therapists should adopt a curious, open approach, actively challenging unhelpful therapist beliefs about working with this population to reduce avoidance and increase openness to exploring clients’ LTC experiences.
Subtheme: Managing expectations of therapy
This subtheme explores how participants managed gaps between their expectations of CBT and the reality of what was and can be offered. Expectations were shaped by prior clinical knowledge and experience, and cultural narratives about recovery. Clarifying goals early in therapy and appropriate use of language appeared important:
‘… setting realistic expectations is really important … my counsellor was framing it around acceptance and kindness to myself that did seem achievable.’ – Stevie
When CBT aligned with participants’ hopes for emotional exploration, identity work, or values clarification, it was experienced as validating and transformative. Reframing CBT as a space for acceptance and self-compassion resonated for clients. Open-mindedness and realistic expectations of therapy supported benefit:
‘I was being open minded to it, but … I had that feeling … “you can’t change the way I think – like I’m too smart for that”. Obviously, I was proved wrong … Just that whole thing, like I said, about expectations as well …’ – Arthur
Struggling for pain control was associated with poorer outcomes amongst participants. HCPs should therefore be careful about the language used, as terms such as ‘pain management’ can be misinterpreted.
Subtheme: Therapist implementation of assessment and formulation
Participants valued structured tools and shared formulations illustrating maintenance processes. Assessment and formulation helped therapist and client develop a shared understanding of the client’s experience, enabling interventions and obstacles to be appropriately targeted:
‘Visualising the maps … origin of a thought and thought cycles and where is it coming from …’ – Stevie
Detailed assessment and formulation appeared vital for building therapeutic alliance and identifying LTC-specific beliefs and behaviours. Early collaborative formulation helped participants understand CBT and set realistic expectations, which is especially important for LTC clients who may be uncertain about the purpose of psychological treatment. One participant with a negative experience highlighted the lack of formulation and overly therapist-led sessions:
‘… very little in the way of formulation … no structured techniques …’ – Ashleigh
Overall, participants valued therapists who validated and normalised their experience, allowing space for tailored formulation and reflection before introducing interventions. In contrast, participants who reported negative experiences described their therapists as rigid and non-collaborative, which inhibited trust and deeper therapeutic progress.
Specific factors themes
Over-arching theme: Adjusting to and accepting LTC
The second most prominent theme was CBT’s role in helping participants move from resistance and grief towards acceptance. This theme captured participants’ evolving relationship with their condition, including moments of acceptance, frustration, and re-identification. Acceptance appeared closely tied to the therapeutic relationship, in that a validating space where participants could reflect on their condition facilitated this process:
‘It gave me this, another word, acceptance as well, because before that, lots of denial and everything else.’ – Sam
Helping clients to accept their LTC was identified as more helpful than therapists who jumped straight into problem-solving. Some participants therefore felt there was not enough time within therapy to explore acceptance fully:
‘… that level of acceptance … we didn’t have the time to cover.’ – Elizabeth
CBT’s structured nature can cause therapists to overlook how the client’s experiences have shaped the way they relate to their condition. Elizabeth described burnout after trying to control her condition, reflecting on how ‘sometimes you just can’t make sense of what’s happening, and you have to just accept that’. Difficulty sitting with and accepting uncertainty was shared across participants:
‘… uncertainty and like the unpredictable nature of chronic conditions was really anxiety provoking’ – Gemma
Elizabeth and Gemma appeared to benefit most, learning to accept uncertainty is natural. Amy and Sam continued to struggle with uncertainty and found it difficult to change long-standing habits:
‘I know I still am … researching stuff … things like staying off Facebook and that I haven’t done because I like Facebook.’ – Amy
Mechanisms such as cognitive restructuring, behavioural experiments, assertiveness skills, and pacing supported acceptance and uncertainty tolerance, whilst lack of home practice adherence or premature endings hindered progress:
‘… adapting to new, new things wasn’t really covered … It helped in the short term … but then, there’s so many aspects to it, to dealing with a chronic health condition.’ – Amy
In some cases, homework was omitted due to therapist uncertainty or lack of collaboration. For others, client beliefs or characteristics (such as fatigue) may have interfered with homework adherence or engaging in therapeutic endings.
Subtheme: Developing compassion for and confidence in the ‘new self’
This subtheme developed from participants’ narratives describing a deep sense of loss following the onset or progression of their LTC. Participants described strong self-criticism tied to identity loss, which is a central, often overlooked dimension of living with an LTC that interfered with the process of acceptance for some:
‘This huge identity crisis … I used to be … very physically active … I needed all this help and I just wasn’t really coping very well with that.’ – Jane
Participants compared their ‘current self’ to their ‘old self’ unfavourably. This experience of loss was central to participants’ narratives, often accompanied by a reduced sense of psychological agency, and was intensified by low self-efficacy, meaning losses were more likely to be internalised as permanent, uncontrollable, and overwhelming. These attentional biases can lead the person’s identity to become centred on their LTC. Two participants described the absence of space in CBT to ‘grieve for their old self and process and adjust to their new self’:
‘working through that grief … I didn’t get that space … my whole life changed.’ – Elizabeth
The lack of opportunity for clients to process their diagnostic journey contributed to avoidance and identity rejection. In contrast, participants who described therapy as helping them make room for their condition and adjust their routines found it helpful:
‘It helped me to make space for my condition … that is linked to the acceptance, so it helped me realise that I do my days and my routines around my body.’ – Stevie
This space allowed participants to develop self-compassion and ‘defuse’ from their LTC, recognising grief as a normal response to loss which reduced shame and improved engagement.
Stevie found CBT ‘practical’, and valued tools such as maps for processing diagnosis before moving to intervention. Participants mentioned helpful CBT techniques including cognitive restructuring, pacing, and assertiveness:
‘CBT made me realise it’s OK to do my own thing and listen to my body … harder boundaries with myself and with other people … my symptoms did reduce.’ – Stevie
Practising self-compassion by giving oneself ‘permission to rest’ and engage in meaningful activity through pacing was key to managing burnout. Symptom reduction may therefore be unrealistic for LTC clients. Instead, focusing on values-based living and self-compassion can enhance outcomes.
Over-arching theme: Decatastrophising and adjusting LTC-specific beliefs
Participants shared how CBT helped them identify and challenge LTC-specific catastrophic thoughts:
‘Learning about the unhelpful thinking styles … seeing the categories … catch myself … that’s catastrophising.’ – Gemma
Some participants described moments where cognitive restructuring felt mismatched with the reality of their LTC. Therapists should therefore validate distress and focus on the helpfulness of thoughts and coping capacity:
“Theory A – Theory B … thought A is this thing’s going to get really bad and it’s going to be really horrible and thought B is actually it’ll be OK if something does happen …’ – Kate
Using structured techniques helped clients shift perspective. Conversely, inflexible, and unskilled implementation of cognitive restructuring created ruptures, resulting in clients feeling misunderstood or invalidated:
‘He would challenge something that actually was a concern, or genuinely, I did really need to think about because I could die.’ – Elizabeth
Poor therapist understanding of LTCs may explain inappropriate use of cognitive restructuring. Participants also discussed other CBT-specific strategies helped them become more aware of and learn to address unhelpful safety seeking behaviours, such as reassurance seeking:
‘… the therapist was able to identify … behaviours that I have around things like uncertainty.’ – Amy
Elizabeth reported progress using behavioural experiments, a CBT technique used as an information gathering exercise to test the accuracy of an individual’s beliefs:
‘We did some experiments … I worked up to me doing that [train travel] on my own … I was able to cope …’ – Elizabeth
Behavioural experiments, which the client should be encouraged to set themselves, helped test beliefs and reduce avoidance. Elizabeth found she could manage challenges even during symptom flare-ups, enhancing self-confidence and tolerance of uncertainty.
Subtheme: Values and committed action
Participants described how CBT supported them to reconnect with personal values and make decisions that aligned with what mattered to them. This was experienced as increasing enjoyment, purpose, and motivation.
One participant described how focusing on values helped shift attention away from worry:
‘It definitely helped with those values … I wanted to have the energy to kind of experience the world … Then I can focus on that rather than worrying.’ – Kate
Participants spoke about the importance of learning to prioritise what is important and acting with intention. Kate’s reflection highlights a shift from externally imposed expectations to intrinsic motivation. This shift made space for authentic living and created a sense of agency. Similarly, Arthur talks about finding a way to engage with art without triggering as much pain, meaning he was able to focus on engaging in a meaningful hobby in his daily life as opposed to ‘putting pressure’ on achieving the end goal of making it a career. However, Arthur found friction when goals ignored values:
“… he said to me like it sounds like you’re punishing yourself … I had a bit of friction with it … how do you achieve anything when you don’t have higher expectations? … it’s probably a thing about spending time ’cause I maybe only had five or six sessions.’ – Arthur
Participants described making compassionate, value-based decisions such as adjusting work, modifying hobbies, or setting boundaries. These changes were linked to improvements in wellbeing and a greater sense of agency.
Discussion
Key findings
This study explored how adults with LTCs made sense of their experiences of CBT 12 months or more after completing treatment in NHTT services. Using an inductive-deductive analytic approach, the findings showed how relational, cognitive, emotional, and behavioural processes shaped long-term adjustment. This section builds on these results by interpreting the themes in relation to existing psychological theory and clinical practice. It considers how participants’ accounts highlight mechanisms of change, the interaction between common and specific therapeutic factors, and the implications for delivering CBT to people living with LTCs.
The centrality of the therapeutic relationship
Across participants, the therapeutic relationship appeared to be a central mechanism of change, aligning with previous research (Wolf et al., Reference Wolf, Oppen and Hoogendoom2022). In CBT, the therapeutic relationship is seen as ‘a foundation upon which interventions are scaffolded, and the client’s response to various interventions itself shapes the therapeutic relationship’ (Dobson, Reference Dobson2022). Feeling believed, validated, and emotionally understood was described as essential for engagement, particularly given many participants’ prior experiences of dismissal or scepticism in healthcare settings. This aligns with longstanding evidence that common relational factors underpin therapeutic outcomes (Wampold, Reference Wampold1997; Wampold and Budge, Reference Wampold and Budge2012) and with research emphasising the importance of empathy and attunement in CBT (Dobson, Reference Dobson2022; Wolf et al., Reference Wolf, Oppen and Hoogendoom2022).
Participants who felt invalidated or unheard described disengagement, ruptures, or a sense that therapy was not relevant to their lived experience. These accounts reinforce the need for therapists to adopt a stance of curiosity and openness, particularly when working with clients whose distress is intertwined with complex physical symptoms and diagnostic uncertainty. The importance of validation is also reflected in literature on medically unexplained symptoms, where invalidation can exacerbate hopelessness and distress (Creed et al., Reference Creed, Henningsen and Fink2011; Stone et al., Reference Stone, Wojcik, Durrance, Carson, Lewis, MacKenzie and Warlow2002). This suggests that, for LTC clients, the therapeutic relationship is not merely a backdrop to CBT techniques but an active mechanism of change in its own right, supporting the notion that the therapeutic relationship and ‘talking’ is ‘a necessary but not sufficient agent of change’ (Beck et al., Reference Beck, Rush, Shaw and Emery1979).
Therapist knowledge and confidence in LTCs
Participants described considerable variation in therapists’ understanding of LTCs. When therapists showed confidence in discussing symptoms, fluctuations, and the emotional impact of chronic illness, therapy felt more relevant and effective. Limited LTC knowledge, however, led to unrealistic goals, inappropriate cognitive restructuring, or avoidance of illness-related topics. This reflects wider evidence that therapists often feel under-prepared to work with LTCs (Carroll et al., Reference Carroll, Moss-Morris, Hulme and Hudson2021; McCrae et al., Reference McCrae, Correa, Chan, Jones and Lusignan2015).
Collaborative assessment and formulation were central to positive experiences. Previous research suggests expectations predict engagement and outcomes (Pontén et al., Reference Pontén, Jonsjö, Vadenmark, Moberg, Grannas, Andersson and Jensen2024; Tsai et al., Reference Tsai, Ogrodniczuk, Sochting and Mirmiran2014). Shared formulations help clients understand maintenance processes and set realistic expectations (Corrie et al., Reference Corrie, Townend and Cockx2015; Halford and Brown, Reference Halford and Brown2009). However, participants noted that therapy sometimes became overly symptom-focused when formulation was absent or superficial. These accounts suggest that therapists may default to narrow, symptom-based models that overlook the relational, existential, and identity-based dimensions of chronic illness, leaving clients feeling unseen.
Variation in formulation quality appeared linked to therapist skill, confidence, and time constraints. This highlights the need for ongoing professional development supported by LTC-specific supervision, including training in LTCs, cultural competence and emotional intelligence, which can enhance therapists’ ability to adapt their approach (Chaddock et al., Reference Chaddock, Thwaites, Bennett-Levy and Freeston2014). Models such as the CICM may support therapists to integrate physical, psychological, and relational processes, identify modifiable areas, and create space for grief-related work. Such approaches align with the need for loss-focused CBT that validates ambiguous loss, identity disruption, and meaning reconstruction in the context of LTCs, emphasising the importance of tailoring interventions to clients’ illness beliefs and contextual realities (Uddin et al., Reference Uddin, McSharry, Bryne, Lorencatto and Toomey2024).
Acceptance, identity, and emotional adjustment
A prominent theme concerned participants’ movement from resistance and grief towards acceptance of their condition. Acceptance was described as a gradual, emotionally demanding process involving acknowledgement of limitations, adjustment of expectations, and development of a more compassionate relationship with the ‘new self’. These narratives resonate with research showing that acceptance is associated with improved wellbeing and reduced distress in LTCs (Casier et al., Reference Casier, Goubert, Theunis, Huse, De Baets, Matthys and Crombez2011; Coleman et al., Reference Coleman, Ellis-Caird, McGowan and Benhamin2016; Kristjansdottir et al., Reference Kristjansdottir, Stenberg and Mirkovic2018), whilst struggling for pain control has been found to be the single best predictor of worse pain, poorer activity, greater disability, worse depression and greater avoidance (Vowles et al., Reference Vowles, McCracken, Sowden and Ashworth2014).
Participants’ descriptions of identity disruption, grief, and self-criticism reflect well-established findings that chronic illness can destabilise core aspects of self-concept. Negative illness identity has been linked to poorer outcomes (Van Bulck et al., Reference Van Bulck, Goossens, Luyckx, Oris, Apers and Moons2018), while shame and perfectionism can further hinder adaptation (Dolezal and Lyons, Reference Dolezal and Lyons2017). Health psychology models such as the SRM (Hagger and Orbell, Reference Hagger and Orbell2003) and the TMA-LTC (Carroll et al., Reference Carroll, Moon, Hudson, Hulme and Moss-Morris2022) similarly highlight identity, illness beliefs, and coping styles as central to adjustment. Participants who had space to explore these issues described deeper and more sustained change, whereas those who lacked this space reported ongoing distress or unresolved emotional processes.
These findings also align with third-wave approaches such as ACT and CFT, which emphasise psychological flexibility, values-based action, and self-compassion (Gilbert, Reference Gilbert2010; Hayes et al., Reference Hayes, Strosahl and Wilson2012). Participants’ accounts of ‘making space’ for their condition and developing a more compassionate stance towards themselves reflect these processes. While not explicitly discussed by participants, ACT’s self-as-context concept could be valuable for clients over-identifying with their illness and experiencing a sense of loss (Hayes et al., Reference Hayes, Strosahl and Wilson2012). However, as noted in previous research, abstract ACT concepts may be challenging for clients experiencing fatigue or cognitive difficulties (McCracken and Vowles, Reference McCracken and Vowles2014), highlighting the need for careful assessment and pacing.
Cognitive and behavioural processes supporting change
Participants described CBT techniques, such as cognitive restructuring, behavioural experiments, pacing, and assertiveness, as helpful when personalised, collaborative, and grounded in an understanding of the LTC. These strategies supported reductions in catastrophic thinking, increased confidence, and greater tolerance of uncertainty. This aligns with evidence that decatastrophising can reduce pain and improve functioning in LTCs (Alda et al., Reference Alda, Luciano, Andrés, Serrano-Blanco, Rodero, López del Hoyo, Roca, Moreno, Magallón and García-Campayo2011; Smeets et al., Reference Smeets, Vlaeyen, Kester and Knottnerus2006; Vitoula et al., Reference Vitoula, Venneri, Varrassi, Paladini, Sykioti, Adewusi and Zis2018), and that an intolerance of uncertainty intensifies emotional distress (Dugas et al., Reference Dugas, Buhr and Ladouceur2004).
When cognitive restructuring was applied rigidly or without adequate exploration of the illness context, participants felt misunderstood or invalidated. This highlights the importance of flexible, formulation-driven CBT that distinguishes between realistic illness-related concerns and unhelpful catastrophic thinking. Behavioural experiments were described as particularly helpful for testing beliefs and reducing avoidance, consistent with their established role in CBT (Everitt et al., Reference Everitt, Landau, O’Reilly, Sibelli, Hughes, Windgassen, Holland, Little, McCrone, Bishop, Goldsmith, Coleman, Logan, Chalder and Moss-Morris2019).
Homework adherence and relapse planning also appeared to be important factors. Participants who struggled with home practice or whose therapy ended prematurely described limited long-term benefit. This aligns with evidence that homework adherence predicts outcomes (Lebeau et al., Reference Lebeau, Davies, Cuvler and Craske2013) and with NICE guidance emphasising the importance of relapse planning (National Institute for Health and Care Excellence, 2009).
Values, motivation, and meaning making
Values-based processes appeared to support participants in adapting to life with an LTC. Although not always framed as ACT, participants described CBT as helping them clarify what mattered, shift from external expectations to intrinsic motivations, and make intentional choices about how to live alongside their condition. This reflects evidence that values clarification enhances engagement and resilience in contemporary CBT (Bennion et al., Reference Bennion, Blakemore, Lovell and Bee2025; Vyskocilova et al., Reference Vyskocilova, Prasko, Ociskova, Sedlackova, Marackova, Holubova, Hruby and Slepecky2016) and aligns with ACT principles of committed action and psychological flexibility (Hayes et al., Reference Hayes, Strosahl and Wilson2012), as well as process-based therapy frameworks (Ciarrochi et al., Reference Ciarrochi, Hernández, Hill, Ong, Gloster, Levin, Yap, Fraser, Sahdra, Hofmann and Hayes2024).
Reconnecting with values also appeared to support identity reconstruction, offering a sense of agency even when symptoms persisted, consistent with research linking values-aligned behaviour to improved wellbeing (Peters and Brown, Reference Peters and Brown2022). However, some participants noted that time-limited sessions restricted deeper exploration of meaning and identity, highlighting challenges within NHTT services.
Overall, integrating values work flexibly within CBT, alongside pacing, cognitive restructuring, and behavioural experiments, may enhance psychological flexibility and support sustainable, compassionate engagement in daily life for people with LTCs.
Interplay of common and specific factors
The findings demonstrate change for people with LTCs resulted from the combination of common relational factors and specific CBT techniques. Participants described validation, empathy, and collaboration as essential foundations for engaging with therapeutic tasks, reflecting evidence that common factors play a major role in outcomes (Wampold, Reference Wampold1997; Wampold and Budge, Reference Wampold and Budge2012). At the same time, specific CBT strategies, such as cognitive restructuring, behavioural experiments, pacing, and values clarification, were viewed as crucial for testing beliefs, reducing avoidance, and rebuilding confidence.
Importantly, these elements were most effective when used together. Techniques worked best when delivered flexibly and sensitively within a strong therapeutic relationship and were experienced as unhelpful when applied rigidly or without understanding the illness context. NICE guidelines (2024) endorse client choice over therapy format and clinician characteristics (National Institute for Health and Care Excellence, 2024), although participants indicated this was inconsistently offered. This supports a process-based view of therapy (Ciarrochi et al., Reference Ciarrochi, Hernández, Hill, Ong, Gloster, Levin, Yap, Fraser, Sahdra, Hofmann and Hayes2024), where relational and technical components interact to support meaningful, sustained change.
Researcher reflections
RTA encourages reflexivity throughout analysis (Braun and Clarke, Reference Braun and Clarke2022). As a CBT therapist, J.H.’s ‘insider’ perspective enriched the analysis through familiarity with therapeutic processes and NHSTT contexts but also required careful reflexivity to avoid imposing professional assumptions on participants’ narratives. Strategies to mitigate this included adhering closely to the interview schedule, avoiding clinical jargon, reflecting on participant statements, and seeking feedback from supervisors with diverse professional backgrounds.
At the same time, J.H.’s ‘outsider’ stance, having no lived experience of personally suffering with the LTCs discussed by participants in this study, allowed for openness and reduced over-identification. Professional skills in empathy and active listening facilitated a safe, validating interview environment, as confirmed by participant and supervisor feedback.
The analysis was particularly shaped by J.H.’s observation that participants valued being emotionally understood over structured intervention or technique. This challenged assumptions about the primacy of technique within time limited NHSTT settings and highlighted the importance of balancing relational depth with therapeutic curiosity, flexibility, and exploration of identity, loss, and adjustment. Throughout, supervision and peer feedback were used to challenge moments of over-identification and ensure that participant voices remained central.
Clinical implications
These findings suggest that therapists would benefit from using models such as the CICM and SRM to collaboratively explore LTC narratives, illness beliefs, and relational influences in formulation, clarify goals early, and adjust pace and structure to accommodate fatigue and fluctuation. Expectations must be managed to avoid confusion or demoralisation. Reframing CBT as a space for acceptance and self-compassion rather than symptom reduction may support engagement.
Integrating third-wave approaches such as PBT, ACT and CFT can enhance psychological flexibility and values-driven living. Services should prioritise LTC-specific training, encourage reflection on therapist beliefs and avoidance, and offer supervision that normalises uncertainty. Embedding client choice and relapse planning, aligned with NICE guidance, as well as developing tools that capture subjective wellbeing, acceptance, and identity, can more accurately reflect the client’s voice in evaluation and outcome measurement and further strengthen outcomes.
Although this study focuses on CBT adaptations, several identified processes (e.g. emotional validation, relational safety, values-based reflection) may also be relevant to other structured modalities offered within NHSTT, including interpersonal therapy (IPT), dialectical behavioural therapy (DIT), and counselling for depression. This suggests that some mechanisms of change may operate across modalities and that clients with LTCs may benefit from flexible, integrative approaches tailored to their needs.
Beyond individual therapy, these findings have implications for public health messaging, training, and service design. Applying health psychology principles, such as message framing and stigma reduction, can improve engagement, especially among minoritised groups. At a systems level, the study raises concerns about time-limited, manualised interventions and calls for more flexible, needs-led models aligned with NICE guidance. Overall, the research supports integrated, process-sensitive psychological care for LTCs, emphasising collaborative formulation, narrative work, and therapist flexibility as key components of effective practice.
Recommendations for future research
This is the first qualitative study to report clients’ own accounts ≥12 months after one-to-one CBT delivered within NHS Talking Therapies for diverse LTCs, identifying which therapy components they attributed to lasting change and mapping these onto common versus CBT-specific processes. While recent studies show that CBT is broadly effective for improving mood and quality of life in people with LTCs, they focus heavily on symptom reduction and standardised outcomes at the expense of exploring emotional complexity, identity disruption, and relational depth, areas often overlooked in manualised CBT. NHS guidance supports LTC-specific pathways, but implementation remains inconsistent, and therapist knowledge gaps remain.
More studies into the long-term impact of CBT for LTC clients which foreground meaning making and lived experience and the need for emotionally attuned, values-based care, is needed to identify core psychological processes and sustained therapeutic mechanisms, barriers to engagement, and service design improvements. Incorporating measures such as the Illness Distress Scale (Jones et al., Reference Jones, Seaton, Brown, Jenkinson, Carroll, Dietz, Moss-Morris, Hudson and Wroe2025) (a promising novel alternative, with growing evidence supporting its reliability and validity), as well as more qualitative measures of progress, into routine practice could enhance the accuracy of assessment, better reflect client priorities, and support more tailored therapeutic interventions.
Finally, future studies should evaluate the role of therapist beliefs and attitudes towards LTCs, as well as the use of process-based CBT focusing on core psychological processes shared across LTCs (e.g. psychological inflexibility, behavioural and emotional avoidance, etc.), in shaping clinical engagement and treatment outcomes. Developing training that targets these beliefs and concepts may increase therapist confidence and reduce avoidance or rigidity.
Strengths and limitations
One strength is the depth and clarity of participant narratives, many of which were informed by health-related professional backgrounds. This perspective enriched the RTA, although it may have introduced bias towards certain cognitive frames or therapeutic expectations.
A broad representation of LTCs strengthened the study’s applicability, highlighting shared psychological processes. These findings support a PBT lens, suggesting common targets regardless of diagnosis (Hofmann and Hayes, Reference Hofmann and Hayes2019). Meta-analyses indicate transdiagnostic CBT improves distress and quality of life (Carroll et al., Reference Carroll, Moon, Hudson, Hulme and Moss-Morris2022; Schaeuffele et al., Reference Schaeuffele, Knaevelsrud, Schulz, Renneberg and Boettcher2021) and may enhance efficiency and accessibility, especially for co-morbidities, compared with rigid diagnostic protocols (Dalgleish et al., Reference Dalgleish, Black, Johnston and Bevan2020; Schaeuffele et al., Reference Schaeuffele, Knaevelsrud, Schulz, Renneberg and Boettcher2021).
However, J.H.’s background may have shaped attentional focus towards individual-level mechanisms, with less emphasis on sociocultural or systemic influences such as healthcare access or structural inequality. Reflexivity was essential in recognising how professional identity and training stage shaped interpretive choices, and how alternative settings might have foregrounded different dimensions of distress and adaptation.
Further limitations include sample homogeneity, with predominantly white, female, healthcare-affiliated participants. Broader demographic inclusion would improve applicability. The absence of older adults, a group commonly affected by LTCs, as well as a lack of participants from minoritised ethnic groups and those with limited digital access, suggests systemic barriers to engagement and further limits representativeness.
Participant recall bias may have affected accuracy due to retrospective design. While interviews were structured to aid memory, lack of access to clinical records introduced a reliance on self-report that may have omitted key details.
Categorising themes as common or specific factors posed interpretive challenges. Some therapeutic mechanisms, such as illness acceptance, straddle relational and technical domains. This overlap reflects the nuanced reality of psychotherapy and supports prior literature emphasising the interplay of multiple change processes.
Conclusion
This study explored four interwoven themes shaping long-term CBT outcomes for clients with LTCs: a validating and normalising therapeutic relationship, lack of therapist skill and knowledge of LTCs, adjusting to and accepting LTC, and de-catastrophising and adjusting LTC-specific beliefs. While a strong therapeutic bond consisting of empathy and curiosity is necessary, it is not sufficient; clients also require tailored tools, flexible pacing, and an approach honouring their unique health journey. Therapist LTC knowledge and confidence, along with collaborative formulation, is required to allow clients to reflect, process loss, practise self-compassion, and align behaviour with personal meaning.
This study highlights the critical value of embedding health psychology theory and third-wave interventions within a process-based, transdiagnostic approach to CBT for LTCs. By attending to identity disruption, illness representations, values conflict, low self-efficacy, and emotional invalidation, rather than solely focusing on symptom reduction, therapists can deliver interventions that consider the lived realities of LTCs. Embedding these insights into training, supervision, and service delivery may strengthen therapist confidence and enhance the relevance, accessibility, and long-term impact of CBT for people living with LTCs.
Key practice points
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(1) A validating, collaborative therapeutic relationship is essential for engagement and long-term benefit in CBT for LTCs.
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(2) CBT should be adapted to address identity disruption, values conflict, and emotional regulation, not just symptom reduction.
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(3) Therapist confidence and effectiveness improve when health psychology theory and third-wave principles are embedded into training and supervision.
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(4) Services should support therapists through LTC-specific training, supervision, and relapse planning to promote sustained benefits beyond treatment.
Data availability statement
The datasets generated during and/or analysed during the current study are not publicly available, as participants did not consent for their data to be shared in this manner.
Acknowledgements
None.
Author contributions
Jodie Hawkins: Conceptualization (lead), Data curation (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Project administration (lead), Resources (lead), Writing - original draft (lead), Writing - review & editing (lead); Julian Bath: Supervision (supporting), Writing - original draft (supporting), Writing - review & editing (supporting); Pippa Tollow: Supervision (lead), Writing - original draft (supporting), Writing - review & editing (supporting).
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethical standards
Ethical approval was granted by UWE Bristol on 05/04/24 (UWE REC ref. no: CHSS.24.02.106), and the study followed BPS (2009) and Data Protection Act (2018) guidelines and bided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. Participants have provided written informed consent to participate in this study and for the research to be published.
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