1. (1) To consider how imaginal reliving can be incorporated into CBT for recurrent depression, when relational trauma is present.

2. (2) To consider the cognitive processing mode of depressed traumatised clients when appraising beliefs about self and others.

3. (3) To consider vulnerability to depression based on intrusive memories and conflicting self-representations, not only core beliefs.

Acculturative stress is a key social driver of health impacting the mental health of immigrants and refugees from Latin America, which contributes to inequities experienced by them. While there is a robust scientific literature describing and evaluating evidence-based treatments targeting a range of psychiatric disorders, these treatments often do not primarily target acculturative stress. Thus, the present study examined how psychotherapists ought to treat acculturative stress directly in their clinical practice. Ten therapists were interviewed using a qualitative descriptive approach. Rapid contemporary content analysis was used to describe Latino/Hispanic immigrants’ most common presenting problems, the context in which they provide care for these problems, and the psychotherapeutic approaches currently utilized or considered effective in mitigating acculturative stress. Findings revealed that common mental health conditions that therapists addressed among this population, including depression, anxiety and trauma-related somatization, including the unique context in which therapy was delivered. Additionally, specific strategies for addressing acculturative stress such as the importance of acknowledging this stressor, drawing out immigration journey narratives, and behavioural activation approaches were shared. The results from this study can be used to improve the effectiveness of mental health interventions addressing acculturative stress among immigrant and refugee populations.

1. (1) To explore how acculturative stress represents a key driver of mental health for immigrants and refugees from Latin America.

2. (2) To consider ways that cognitive behavioural therapy (CBT) elements can be applied to treating acculturative stress and mental health problems among immigrants and refugees from Latin America.

3. (3) To expand upon strategies that can be helpful in rapport-building and establishing trust with patients who are struggling with acculturative stress.

This study aimed to explore the views of family carers of people living with dementia from ethnic minority groups and their therapists on internet-delivered, self-help acceptance and commitment therapy for family carers (iACT4CARERS), enhanced with additional therapist guidance. To achieve this, a qualitative approach with semi-structured interviews was employed with ethnic minority carers who completed Enhanced iACT4CARERS (n=9) and therapists who supported them throughout the programme (n=5). The interviews were audio-recorded, transcribed and analysed using framework analysis. Four over-arching themes were identified: (1) Value of the programme to ethnic minority carers, (2) Barriers for ethnic minority carers, (3) Sense of connectedness through written feedback, and (4) Sense of connectedness through one-to-one sessions. Theme 1 reflected that ethnic minority carers valued ACT techniques, highlighting their usefulness and simplicity, leading to perceived benefits. Theme 2 revealed the irrelevance of examples provided of carer experiences throughout the programme due to differences in family carers’ experiences of providing care within ethnic minority communities. Theme 3 highlighted that carers’ engagement with the programme was facilitated by feelings of validation and encouragement received from their therapist via weekly written feedback. Finally, Theme 4 highlighted that additional one-to-one support sessions allowed both carers and therapists to develop strong therapeutic relationships. This enhanced subsequent text-based online interactions, allowing carers to be more open and engaged. Also, therapists reported that a strong sense of connectedness helped them to tailor their feedback. Enhanced iACT4CARERS that uses carers’ experiences more relevant to ethnic minority communities may be more acceptable.

1. (1) To understand the views of family carers of people living with dementia from ethnic minority groups and their therapists on internet-delivered, self-help acceptance and commitment therapy (ACT), which has been found to be feasible and acceptable with White British carers.

2. (2) To understand whether additional one-to-one support can help develop effective therapeutic relationships and thus improve the experiences of carers in completing the programme.

3. (3) To learn whether any cultural adaptations are needed to improve the acceptability of internet-delivered self-help ACT among this population.

1. (1) To better understand the barriers to accessing mental health services, including Talking Therapies, for racially-minoritised communities.

2. (2) Low and high intensity CBT practitioners to better understand the factors that impact the wellbeing of racially-minoritised communities and how to better support different communities.

3. (3) Consider how to address these barriers to accessing support such as Talking Therapies services, with implications for practice and policy development.

Augmented Depression Therapy (ADepT) is a novel wellbeing and recovery-oriented psychological treatment for depression. A recent pilot trial run in a university clinic setting suggests ADepT has potential to be superior to cognitive behavioural therapy (CBT) at treating anhedonic depression in a NHS Talking Therapies for anxiety and depression (NHS–TTad) context. Before proceeding to definitive trial in pragmatic settings, it is important to establish if therapists in routine NHS-TTad settings can be trained to deliver ADepT effectively and to assess therapist views on the feasibility and acceptability of ADepT in this context. A bespoke training and supervision pathway was developed (2-day workshop, four 2–hour skills classes, and 6 months of weekly supervision) and piloted with 11 experienced therapists working in a single NHS–TT service in Devon. Nine out of 11 therapists completed the placement, treating 24 clients with a primary presenting problem of depression; 21/24 completed a minimum adequate dose of therapy (≥8 sessions), with 17/24 (71%) showing reliable improvement and 12/24 (50%) exhibiting reliable recovery. Eight out of nine therapists submitted a session for competency assessment, all of whom were rated as competent. Nine therapists submitted feedback on their experiences of training. Eight out of nine therapists felt the ADepT model would be effective in an NHS–TTad context; that training was interesting, useful, well presented and enhanced their own wellbeing; and that they felt sufficiently skilled in core ADepT competencies at the end of the placement. This suggests that NHS–TTad therapists can be trained to deliver ADepT competently and view the treatment as feasible and acceptable.

1. (1) To become familiar with the Augmented Depression Therapy (ADepT) approach for enhancing wellbeing in depression.

2. (2) To evaluate the potential utility and feasibility of ADepT model in NHS Talking Therapies Services (NHS–TTad).

3. (3) To understand the pilot ADepT training and supervision pathway for CBT therapists in NHS–TTad services.

4. (4) To consider the opportunities and challenges of training therapists to deliver ADepT in NHS–TTad services.

Although anti-racist adaptations to dialectical behaviour therapy (DBT) are emerging, little qualitative research exists exploring adolescents’ perspectives on therapists’ approach, cultural competency and humility regarding ethnicity, race and culture (ERC) within DBT. This study explored diverse adolescents’ experiences of talking about ERC during all aspects of DBT treatment. Ten adolescents from diverse ERC backgrounds who attended DBT at a National and Specialist Child and Adolescent Mental Health Service (UK) completed semi-structured individual interviews that were transcribed verbatim and analysed using reflexive thematic analysis, adopting a critical realist approach. Five over-arching themes were developed from the data. Theme 1 captures the power for explicit ERC-related conversations to facilitate change, as they are frequently overlooked in therapy. Theme 2 discusses factors that facilitate or inhibit ERC-related discussions. Theme 3 captures the difficult ‘double bind’ that adolescents find themselves in: not wanting to be a spokesperson for ERC issues whilst hoping for their therapist to facilitate/model ERC-related discussions. Theme 4 explores how adolescents navigated their identity in relation to ERC, their wider systemic context, and experiences of ERC-related trauma. Theme 5 explored therapeutic alliance, and how therapists might encourage DBT skills use with greater ERC sensitivity, emphasising validation. Using a bottom-up approach, we show a clear mandate from diverse adolescents for (White) clinicians to proactively create the space and safety required for ERC-related discussions. We emphasise the importance of anti-racist praxis including cultural humility, multi-cultural competencies, and validation of ERC-related difficult experiences within a wider systemic context.

1. (1) A recent publication by Pierson et al. (2022) has raised the importance for White DBT therapists to adopt an anti-racist position and actively reflect on how a lack of anti-racist stance can form therapist treatment-interfering behaviours.

2. (2) The current study explores the views of adolescents from diverse ethnic, racial and cultural (ERC) backgrounds on how ERC issues are being brought into DBT.

3. (3) Adopting a bottom-up approach, we identify key themes from adolescents’ perspectives on the barriers and facilitators to talking about ERC in the therapy room, why such discussions are important in supporting adolescents to navigate their own identity in therapy, and recommendations for clinicians to consider on ways of increasing and enhancing such conversations in the clinical setting.

Meta-competencies govern the application of more basic therapeutic competencies and allow CBT therapists to know when and why particular skills are needed. Meta-competencies are particularly important when responding to the needs of complex or atypical clinical cases. We explore CBT meta-competencies through therapist reflections on complex clinical scenarios and judgements about CBT skills. Three groups of therapists were compared in their responses to four complex clinical scenarios: trainees, recently qualified and experienced therapists. Participants reflected on how they would respond in each scenario and made ratings of the importance of different skills. There was a highly significant difference between trainees and experienced therapists in the number of reflective statements made, but no differences in the number of anticipated actions. There were no group differences in judgements about CBT skills. Reflective capacity is a meta-competency and higher-order skill that CBT therapists continue to develop several years post-qualification. Further studies are needed to replicate this finding and understand its impact on clinical practice.

1. (1) To learn about CBT meta-competencies when considering clinical complexity.

2. (2) To learn how to test meta-competencies in groups of therapists with differing levels of experience.

3. (3) To identify which meta-competencies are prioritised in clinically complex scenarios.

4. (4) To support the development of the scale which measures meta-competencies in therapists.

Cognitive behavioural therapy training courses recruit individuals from a wide range of professional backgrounds; however, little is known about the motivations of individuals to train in CBT, compared with other therapeutic modalities. Previous research has found that role transition generates multiple intrapersonal conflicts for trainees, therefore it is of interest to better understand the impact of motivational factors on the experience of learning and practising CBT. Forty-three qualified CBT practitioners completed an online questionnaire with the data analysed using a grounded theory approach. A core category of ‘Alignment with CBT’ was drawn from the data, characterised by two distinct groups of therapists – ‘CBT endorsers’ and ‘career enhancers’. A model was developed consisting of universal and group specific factors related to motivation. The findings add to the literature on the impact of therapist characteristics on CBT practice. Practical applications of the model for trainers and supervisors are discussed.

As a result of reading this paper, readers should:

1. (1) Understand how various motivations to train in CBT affect engagement with theories and interventions;

2. (2) Be able to identify some of their own intrapersonal challenges in the application of CBT formulations and interventions;

3. (3) Recognise training and supervision strategies that might assist with identifying and managing challenges related to epistemic style and theoretical orientation.

1. (1) To understand the issues surrounding the delivery of brief CBT to young people with OCD.

2. (2) To understand ways of reviewing, developing and improving the CBT materials with a range of young people, their parents, and clinicians.

3. (3) To understand how to consult with clinicians in relation to the implementation of the treatment.

4. (4) To consider how the process of this type of work can assist in the next steps of implementing a manualised intervention in routine CAMHS.

1. (1) To expand upon the concept of the workbook as a therapeutic adjunct within the CBT literature.

2. (2) To explore how a popular CBT workbook is useful to practitioners, how it is typically used, and the breadth of usage.

3. (3) To consider whether and how workbooks are used flexibly by practitioners.

4. (4) To encourage practitioners across the range of experience to reflect on how workbooks support planning and delivery of therapeutic interventions.

1. (1) Integrating psychological services into physical health services has the potential to improve access to psychological support for minority groups facing multi-morbidity, such as Irish Travellers. This approach offers a less stigmatised route for individuals to receive help and involves fewer administrative processes, which may pose challenges for those with varying levels of literacy ability.

2. (2) This case example presents initial evidence that short-term transdiagnostic cognitive behavioural therapy can be an effective intervention for reducing depression and anxiety symptoms in older people from an Irish Traveller background.

3. (3) Successful outcomes in this case example hinged on:

   1. (a) A comprehensive formulation that considered the client’s full identity (e.g. cultural identity, intergenerational connections, cohort beliefs, physical health needs) in addition to their presenting problem.

   2. (b) Adapting the intervention to accommodate for culturally relevant aspects of the individual’s presentation. This involved modifying homework to reduce the literacy requirements, involving a trusted family member as a co-therapist, and integrating culturally relevant language into the therapy.

4. (4) This case report underscores the scarcity of rigorous research involving Irish Traveller populations and emphasises the need for further exploration of their experiences of mental health difficulties and engagement with mental health services. Further research should actively involve Irish Travellers to identify unmet needs and explore potential adaptations for therapeutic interventions. This would help to ensure accurate representation and prevent the homogenisation of this diverse group of individuals.

1. (1) To better understand the needs of the population and factors which impact wellbeing.

2. (2) To consider the muti-faceted barriers to access mental health support, such as CBT, and how to address these.

3. (3) To unpack what stigma means (internally and externally) for men in the population.

4. (4) How to support low- and high-intensity CBT practitioners to better work therapeutically to support Bangladeshi men.

Gender- and sexuality-minoritised (GSM) adolescents are at increased risk of self-harm and suicidal behaviours compared with their cisgender and heterosexual peers. This increased risk is thought to be explained in part by exposure to stigma and societal oppression. Dialectical behaviour therapy (DBT) is an evidence-based intervention for self-harm and suicidal behaviour that may have advantages for supporting GSM young people in distress. No study has yet sought to understand what GSM-associated difficulties may be important to consider in DBT for adolescents, or the experiences of GSM young people in a standard DBT programme. Therefore, this study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Qualitative interviews were conducted with 14 GSM young people in a comprehensive DBT programme and were analysed using reflexive thematic analysis. The analysis was supported by two further GSM young people who had finished DBT. The findings were split into three over-arching themes (Identity, Impact of Others, and Space for Sexual and Gender Identity in DBT), each with themes within. The identity-based theme included ‘identity confusion and acceptance’; the relationship-based themes included ‘cis-Heterosexism’ and ‘community connectedness’; and the space within DBT themes included ‘negotiating focus and targeting in DBT’ and ‘creating safety in DBT’. Findings are discussed in relation to implications and recommendations for therapists working with GSM young people within and outside of DBT.

1. (1) To learn about what gender- and sexuality-minoritised (GSM) young people consider to be important GSM-associated contributors to distress and thus potential treatment targets in DBT.

2. (2) To learn about what GSM young people felt were barriers to negotiating GSM-associated difficulties as a focus in DBT and how safety was created in the therapeutic relationship.

3. (3) To consider potential implications and recommendations for improvements to practice when supporting GSM young people in therapy.

1. (1) To gain insight into the differential development of generic and CBT specific competence during CBT training.

2. (2) To reflect on the significance of therapist characteristics in the training process.

3. (3) To reflect on the possible importance of reaching a high level of CBT competence during CBT training.

1. (1) To gain an understanding of some of the challenges in delivering CBT for trauma related to pregnancy loss.

2. (2) To reflect on treatment of co-morbid PTSD and depression through flexible use of evidence-based treatment, and consider alternative approaches to sequential treatment.

3. (3) To consider the impact of grief in formulation and treatment.

It is widely documented that Black, Asian and Minority Ethnic (BAME) communities experience poorer mental health, and have a poorer experience of mental health services. Therapists delivering cognitive behavioural therapy (CBT) in services such as NHS Talking Therapies Services for Anxiety and Depression, are working with increasingly diverse client groups, but treatment access and recovery rates remain below what they should be compared with the White British population. Previous research indicates that CBT therapists may not receive appropriate training that allows them to develop the skills required to work effectively transculturally. The present study therefore aimed to evaluate a CBT training programme within this context, from the perspective of previous course graduates. Thirty participants took part in an online survey with questions requiring both Likert-scaled answers and free-text responses. Descriptive statistics, inferential statistics and template analysis were used to analyse the data. The results of the survey were favourable overall for both White British and BAME respondents. Positive areas of practice highlighted included peer learning within a diverse cohort, building awareness of own biases, and reflective learning spaces. Areas of development included increased integration of teaching focused on adapting CBT models for minority groups, diversification of teaching staff, and reducing fear and avoidance of exploring issues related to equality, diversity and inclusion. Tentative implications for improving CBT training course delivery in this context have been offered.

1. (1) To acknowledge the challenges faced by service users from BAME communities in accessing equitable mental health treatment, including cognitive behavioural psychotherapy.

2. (2) To consider explanations for why CBT therapists working in NHS services might find it difficult to work effectively transculturally.

3. (3) To establish ways in which CBT training programmes might help therapists to embark more successfully on the journey of developing cultural competence, during training and beyond.

1. (1) Current evidence on the efficacy of psychological interventions for stroke survivors is limited.

2. (2) This case study describes the assessment, treatment and outcomes of post-stroke adjustment difficulties in a working-aged man using an ACT approach.

3. (3) Following six sessions of ACT delivered via telerehabilitation, the client no longer met clinical cut-off for psychological distress and depression. Moreover, his levels of psychological flexibility were comparable to non-clinical norms.

4. (4) Further exploration of psychological processes that facilitate post-stroke adjustment difficulties is recommended.

Self-harming behaviours are reported to be increasing amongst young people and are associated with increased risk of suicide. The recently published UK clinical guidelines highlight that cross-sector awareness and early psychosocial assessment of self-harming is necessary, alongside careful triaging as to the level of support required. Dialectical behaviour therapy for adolescents (DBT-A) is a recommended intervention for young people with more severe difficulties. The current study aims to contribute to the data available to inform ongoing clinical decisions about the feasibility and implementation of DBT-A by reporting the intervention method, participant characteristics, and clinical outcomes of a national (UK) DBT service for young people with high levels of need and risk. Young people who commenced treatment between 2015 and 2021 were included. Completion rates, reasons for non-completion, and discharge pathways are reported. Measurement and changes in outcomes, including self-harm, in-patient bed days, accident and emergency department attendances and education/work status, are reported, as well as for routine outcome measures assessing emotion dysregulation and symptoms of emerging borderline personality disorder, depression and anxiety. The clinical significance of these outcomes are considered. Ideas for service evaluation, which are feasible and replicable in busy clinical settings are proposed, as well as a discussion of potential adaptations to standardised protocols needed in this context to fit with National Health Service (NHS) resources and the needs of the target population.

1. (1) To learn about the implementation of dialectical behaviour therapy (DBT) and concurrent outcome monitoring in a UK National Health Service CAMHS out-patient setting.

2. (2) To understand the clinical profile and response to treatment of young people with high levels of suicidal and non-suicidal self-harming behaviours.

3. (3) To present a potential method for outcome monitoring and collection for CAMHS DBT services.

Although manual-based treatments are widely available in mental health care, they are often not delivered according to protocol. Treatment-, therapist- and organizational-related determinants are known to affect therapist adherence to treatment protocols, and subsequently treatment success. This study examined which determinants are associated with therapist adherence to the Community Reinforcement Approach (CRA) manual, an evidence-based behavioural treatment programme commonly used in addiction care. Using a cross-sectional design, adherence to the CRA manual and potential contributing determinants were assessed through a self-report survey among therapists (N = 69) working in out-patient addiction care. Correlation analysis and backward stepwise regression analysis were used to examine which treatment-, therapist- and organizational-related determinants were associated with CRA adherence. Significant associations with self-reported CRA adherence were found for nine out of 16 determinants examined. Three independent determinants explained 43% of the variance in CRA manual adherence, namely compatibility with the working method therapists were used to, perceived outcome expectations, and perceived adoption of CRA procedures by colleagues. These determinants should be considered when implementing CRA in addiction care, for example by investing in training and taking into account therapists’ previous treatment experience. This also accounts for creating positive outcome expectations and the use of descriptive norms by making experiences explicit of therapists and teams that excel. Future research should investigate which other determinants contribute to therapists’ adherence and focus on clarifying causality between determinants and adherence.

1. (1) To understand the importance of treatment, therapist and organizational determinants influencing therapist adherence to the CRA manual.

2. (2) To explain the three determinants that make the largest contribution to self-reported therapists’ adherence to the CRA manual, namely: compatibility with the working method, perceived outcome expectations, and perceived adoption of CRA procedures by colleagues.

3. (3) To reflect on the clinical implications regarding therapist training, implementation of manual-based treatments and future research.