1. (1) To learn about the utility of adapting existing treatments as opposed to developing new treatments.

2. (2) To learn about the potential of propensity score matching in the analysis of routinely collected datasets.

3. (3) To learn about delivery of behavioural activation in groups.

4. (4) To better understand how to enhance and evaluate treatment protocols using theoretically informed and low-cost treatment augmentations.

Well-designed evaluations of psychological interventions on psychiatric intensive care units (PICUs) are a rarity.

To evaluate the effectiveness of cognitive behaviour therapy for intrusive taboo thoughts with a patient diagnosed with bipolar affective disorder admitted to a PICU due to significant ongoing risk of harm to self.

This was a four-phase ABC plus community follow-up (D) mixed methods n=1 single case experimental design. Four idiographic measures were collected daily across four phases; the baseline (A) was during PICU admission, the first treatment phase (B) was behavioural on the PICU, the second treatment phase (C) was cognitive on an acute ward and the follow-up phase (D) was conducted in the community. Four nomothetic measures were taken on admission, on discharge from the PICU, discharge from the acute ward and then at 4-week follow-up. The participant was also interviewed at follow-up using the Change Interview.

Compared with baseline, the behavioural and the cognitive interventions appeared effective in terms of improving calmness, optimism and rumination, but the effects on sociability were poor. There was evidence across idiographic and nomothetic outcomes of a relapse during the follow-up phase in the community. Eleven idiographic changes were reported in the interview and these tended to be unexpected, related to the therapy and personally important.

Single case methods can be responsive to tracking the progress of patients moving through in-patient pathways and differing modules of evidence-based interventions. There is a real need to implement robust outcome methodologies on PICUs to better evaluate the psychological aspects of care in this context.

Despite the importance of assessing the quality with which low-intensity (LI) group psychoeducational interventions are delivered, no measure of treatment integrity (TI) has been developed.

To develop a psychometrically robust TI measure for LI psychoeducational group interventions.

This study had two phases. Firstly, the group psychoeducation treatment integrity measure-expert rater (GPTIM-ER) and a detailed scoring manual were developed. This was piloted by n=5 expert raters rating the same LI group session; n=6 expert raters then assessed content validity. Secondly, 10 group psychoeducational sessions drawn from routine practice were then rated by n=8 expert raters using the GPTIM-ER; n=9 patients also rated the quality of the group sessions using a sister version (i.e. GPTIM-P) and clinical and service outcome data were drawn from the LI groups assessed.

The GPTIM-ER had excellent internal reliability, good test–retest reliability, but poor inter-rater reliability. The GPTIM-ER had excellent content validity, construct validity, formed a single factor scale and had reasonable predictive validity.

The GPTIM-ER has promising, but not complete, psychometric properties. The low inter-rater reliability scores between expert raters are the main ongoing concern and so further development and testing is required in future well-constructed studies.

There is some initial evidence that attachment security priming may be useful for promoting engagement in therapy and improving clinical outcomes.

This study sought to assess whether outcomes for behavioural activation delivered in routine care could be enhanced via the addition of attachment security priming.

This was a pragmatic two-arm feasibility and pilot additive randomised control trial. Participants were recruited with depression deemed suitable for a behavioural activation intervention at Step 2 of a Talking Therapies for Anxiety and Depression service. Ten psychological wellbeing practitioners were trained in implementing attachment security priming. Study participants were randomised to either behavioural activation (BA) or BA plus an attachment prime. The diagrammatic prime was integrated into the depression workbook. Feasibility outcomes were training satisfaction, recruitment, willingness to participate and study attrition rates. Pilot outcomes were comparisons of clinical outcomes, attendance, drop-out and stepping-up rates.

All practitioners recruited to the study, and training satisfaction was high. Of the 39 patients that were assessed for eligibility, 24 were randomised (61.53%) and there were no study drop-outs. No significant differences were found between the arms with regards to drop-out, attendance, stepping-up or clinical outcomes.

Further controlled research regarding the utility of attachment security priming is warranted in larger studies that utilise manipulation checks and monitor intervention adherence.

Some patients return for further psychological treatment in routine services, although it is unclear how common this is, as scarce research is available on this topic.

To estimate the treatment return rate and describe the clinical characteristics of patients who return for anxiety and depression treatment.

A large dataset (N=21,029) of routinely collected clinical data (2010–2015) from an English psychological therapy service was analysed using descriptive statistics.

The return rate for at least one additional treatment episode within 1–5 years was 13.7%. Furthermore, 14.5% of the total sessions provided by the service were delivered to treatment-returning patients. Of those who returned, 58.0% continued to show clinically significant depression and/or anxiety symptoms at the end of their first treatment, while 32.0% had experienced a demonstrable relapse before their second treatment.

This study estimates that approximately one in seven patients return to the same service for additional psychological treatment within 1–5 years. Multiple factors may influence the need for additional treatment, and this may have a major impact on service activity. Future research needs to further explore and better determine the characteristics of treatment returners, prioritise enhancement of first treatment recovery, and evaluate relapse prevention interventions.

Despite the use of case formulation being encouraged for in-patient psychiatric care, there have been no previous examples and evaluations of this type of work on a psychiatric intensive care unit (PICU).

To evaluate whether a schema-informed formulation with a patient diagnosed with emotionally unstable personality disorder (EUPD), autism spectrum disorder (ASD) and mild learning difficulties was effective in reducing the use of restrictive interventions.

A biphasic n = 1 quasi-experimental design with an 8-week baseline versus an 8-week intervention phase. The restrictive outcomes measured were use of physical restraint, seclusion, and intramuscular rapid tranquilisation. The formulation was developed through eight one-to-one sessions during the baseline period, and was implemented via six one-to-one sessions during the intervention phase and discussion at the ward reflective practice group. The intervention encouraged better communication of schema modes from the patient and for staff to then respond with bespoke mode support.

Incidents involving need for seclusion, restraint and rapid tranquilisation extinguished.

The need for making access to psychological input a routine aspect of the care in PICUs and the necessity for developing a methodologically more robust evidence base for psychological interventions on these wards.

Guided self-help (GSH) for anxiety is widely implemented in primary care services because of service efficiency gains, but there is also evidence of poor acceptability, low effectiveness and relapse.

The aim was to compare preferences for, acceptability and efficacy of cognitive–behavioural guided self-help (CBT-GSH) versus cognitive–analytic guided self-help (CAT-GSH).

This was a pragmatic, randomised, patient preference trial (Clinical trials identifier: NCT03730532). The Beck Anxiety Inventory (BAI) was the primary outcome at 8- and 24-week follow-up. Interventions were delivered competently on the telephone via structured workbooks over 6–8 (30–35 min) sessions by trained practitioners.

A total of 271 eligible participants were included, of whom 19 (7%) accepted being randomised and 252 (93%) chose their treatment. In the preference cohort, 181 (72%) chose CAT-GSH and 71 (28%) preferred CBT-GSH. BAI outcomes in the preference and randomised cohorts did not differ at 8 weeks (−0.80, 95% confidence interval (CI) −4.52 to 2.92) or 24 weeks (0.85, 95% CI −2.87 to 4.57). After controlling for allocation method and baseline covariates, there were no differences between CAT-GSH and CBT-GSH at 8 weeks (F(1, 263) = 0.22, P = 0.639) or at 24 weeks (F(1, 263) = 0.22, P = 0.639). Mean BAI change from baseline was a reduction of 9.28 for CAT-GSH and 9.78 for CBT-GSH at 8 weeks and 12.90 for CAT-GSH and 12.43 for CBT-GSH at 24 weeks.

Patients accessing routine primary care talking treatments prefer to choose the intervention they receive. CAT-GSH expands the treatment offer in primary care for patients with anxiety seeking a brief but analytically informed GSH solution.

The manner in which heuristics and biases influence clinical decision-making has not been fully investigated and the methods previously used have been rudimentary.

Two studies were conducted to design and test a trial-based methodology to assess the influence of heuristics and biases; specifically, with a focus on how practitioners make decisions about suitability for therapy, treatment fidelity and treatment continuation in psychological services.

Study 1 (N=12) used a qualitative design to develop two clinical vignette-based tasks that had the aim of triggering heuristics and biases during clinical decision making. Study 2 (N=133) then used a randomized crossover experimental design and involved psychological wellbeing practitioners (PWPs) working in the Improving Access to Psychological Therapies (IAPT) programme in England. Vignettes evoked heuristics (anchoring and halo effects) and biased responses away from normative decisions. Participants completed validated measures of decision-making style. The two decision-making tasks from the vignettes yielded a clinical decision score (CDS; higher scores being more consistent with normative/unbiased decisions).

Experimental manipulations used to evoke heuristics did not significantly bias CDS. Decision-making style was not consistently associated with CDS. Clinical decisions were generally normative, although with some variability.

Clinical decision-making can be ‘noisy’ (i.e. variable across practitioners and occasions), but there was little evidence that this variability was systematically influenced by anchoring and halo effects in a stepped-care context.

An Improving Access to Psychological Therapies (IAPT) service in England has implemented cognitive analytic therapy guided self-help (CAT-GSH) alongside cognitive behavioural guided self-help (CBT-GSH) in order to support enhanced patient choice. This study sought to explore the acceptability to psychological wellbeing practitioners (PWPs) of delivering CAT-GSH.

This study used a qualitative design with semi-structured interviews and associated thematic analysis (TA). A sample of n=12 PWPs experienced in delivering CAT-GSH were interviewed.

Five over-arching themes (containing 12 subthemes) were identified and conceptually mapped: (a) the past-present focus (made up of working with clients’ pasts and the different type of change work), (b) expanding the treatment offer (from the perspective of PWPs and clients), (c) the time and resources required to effectively deliver CAT-GSH (to enable safe and effective delivery for clients and personal/professional development for PWPs), (d) understanding CAT-GSH (made up of confidence, learning new therapeutic language/concepts and appreciating the difference with CBT-GSH) and (e) joint exploration (made up of therapeutic/supervisory relationships and enhanced collaboration).

CAT-GSH appears an acceptable (but challenging) approach for PWPs to deliver in IAPT services. Services should prioritise training and supervision for PWPs to ensure good governance of delivery.

The unified protocol (UP) is indicated when patients present with co-morbidity, but no studies have previously investigated the effectiveness of the UP with co-morbid health anxiety and depression.

An A/B single case design evaluated outcomes for a 27-year-old male presenting with health anxiety and co-morbid depression. Following a 21-day assessment-baseline period containing three sessions, the manualised UP was delivered across a 42-day period containing seven intervention sessions. Four idiographic measures (occurrence and duration of health checking, sleep duration and food intake satisfaction) were collected daily throughout, and two nomothetic measures were collected at four time points.

All sessions were attended. Number of health checking episodes reduced from four per day to two per day. A 59 minute per day reduction in time spent health checking occurred, and sleep increased by 100 minutes per night. There was little apparent change in terms of food intake satisfaction. There was a reliable and clinically significant reduction in depression.

Further testing of the effectiveness of the UP with co-morbid health anxiety and depression in true single case experimental designs is now indicated.

Whilst the delivery of low-intensity group psychoeducation is a key feature of the early steps of the Improving Access to Psychological Therapies (IAPT) programme, there is little consensus regarding the skills and competencies demanded.

To identify the competencies involved in facilitating CBT-based group psychoeducation in order to inform future measure development.

A Delphi study in which participants (n = 36) were relevant IAPT stakeholders and then an expert panel (n = 8) review of the competencies identified within the Delphi study to create a shortened, more practical list of competencies.

After three consultation rounds, consensus was reached on 36 competencies. These competencies were assigned to four main categories: group set-up, content, process and closure. A further expert review produced a shortened 16-item set of psychoeducation group facilitation competencies.

The current study has produced a promising framework for assessing facilitator competency in delivering CBT-based group psychoeducational interventions. Weaknesses in the Delphi approach are noted and directions for future measure development research are identified.

Outcome studies of the treatment of compulsive buying disorder (CBD) have rarely compared the effectiveness of differing active treatments.

This study sought to compare the effectiveness of cognitive behavioural therapy (CBT) and person-centred experiential therapy (PCE) in a cross-over design.

This was an ABC single case experimental design with extended follow-up with a female patient meeting diagnostic criteria for CBD. Ideographic CBD outcomes were intensively measured over a continuous 350-day time series. Following a 1-month baseline assessment phase (A; 28 days; three sessions), CBT was delivered via 13 out-patient sessions (B: 160 days) and then PCE was delivered via six out-patient sessions (C: 63 days). There was a 99-day follow-up period.

Frequency and duration of compulsive buying episodes decreased during active treatment. CBT and PCE were both highly effective compared with baseline for reducing shopping obsessions, excitement about shopping, compulsion to shop and improving self-esteem. When the PCE and CBT treatment phases were compared against each other, few differences were apparent in terms of outcome. There was no evidence of any relapse over the follow-up period. A reliable and clinically significant change on the primary nomothetic measure (i.e. Compulsive Buying Scale) was retained over time.

The study suggests that both CBT and PCE can be effective for CBD. Methodological limitations and suggestions for future CBD outcome research are discussed.

To outline the methods of a pragmatic patient preference trial in the Improving Access to Psychological Therapies (IAPT) programme comparing cognitive behavioural therapy guided self-help (CBT-GSH) with cognitive analytic therapy guided self-help (CAT-GSH).

A partially randomised patient preference trial (PRPPT) methodology. Participants will be assessed with the MINI to ascertain a diagnosis of an anxiety disorder. Treatment will be six to eight 35-minute sessions in each arm. The primary outcome measure is the Beck Anxiety Inventory (BAI), with secondary outcome measures of the IAPT minimum dataset and indices of service utilisation. Participants will be followed up at 8 and 24 weeks.

Choice, treatment completion, drop-out and step-up rates will be summarised via a CONSORT diagram. If there are no differences between randomised and preference participants within each form of GSH, then these groups will be collapsed to form a two-arm trial. The primary analysis will compare between-arm standardised effect sizes on the BAI measure, using Cohen’s d+ at 8- and 24-week follow-up. The proportions in each arm achieving reliable and clinical change on the BAI will be established, with interviews exploring the change process with participants achieving a reliable pre–post change on the GAD-7.

The utility of patient preference trials in mental health services are discussed and the necessary further development of robust evidence concerning low-intensity interventions is highlighted.

The cognitions and emotions of people prone to hoarding are key components of the dominant cognitive behavioural model of hoarding disorder.

This study sought to use Q-methodology to explore the thoughts and feelings of people that are prone to hoarding, to identify whether distinct clusters of participants could be found.

A 49-statement Q-set was generated following thematic analysis of initial interviews (n = 2) and a review of relevant measures and literature. Forty-one participants with problematic hoarding met various study inclusion criteria and completed the Q-sort (either online or offline). A by-person factor analysis was conducted and subsequent participant clusters compared on psychometric measures of mood, anxiety, hoarding and time taken on the online task as proxy for impulsivity.

Four distinct participant clusters were found constituting 34/41 (82.92%) of the participants, as the Q-sorts of n = 7 participants failed to cluster. The four clusters found were ‘overwhelmed’ (n = 11 participants); ‘aware of consequences’ (n = 13 participants); ‘object complexity’ (n = 6 participants) and ‘object–affect fusion’ (n = 4 participants). The clusters did not markedly differ with regard to hoarding severity, anxiety, depression or impulsivity.

Whilst the participant clusters reflect extant research evidence, they also reveal significant heterogeneity and so prompt the need for further research investigating emotional and cognitive differences between people prone to hoarding.

Group psychotherapy for older adults with generalised anxiety disorder is an under-researched area.

This report describes a mixed method evaluation of the acceptability and feasibility of an Overcoming Worry Group.

The Overcoming Worry Group was a novel adaptation of a cognitive behavioural therapy protocol targeting intolerance-of-uncertainty for generalised anxiety disorder, tailored for delivery to older adults in a group setting (n = 13).

The adapted protocol was found to be acceptable and feasible, and treatment outcomes observed were encouraging.

This proof-of-concept study provides evidence for an Overcoming Worry Group as an acceptable and feasible group treatment for older adults with generalised anxiety disorder.