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BackgroundPatients can struggle to make good use of psychotherapy owing to deficits in awareness, and digital technologies that support awareness are at a premium. Currently, when patients participate in cognitive analytic therapy (CAT), the technology supporting relational awareness work involves completion of paper-based worksheets as between-session tasks. ObjectiveWe aimed to design, with therapists and patients, a prototype digital mobile app. This was to help patients better engage in the “recognition” phase of the CAT treatment model by providing an unobtrusive means for practicing relational awareness with dynamic feedback on progress. MethodsA national online survey was conducted with CAT therapists (n=50) to determine readiness for adoption of a mobile app in clinical practice and to identify core content, functionality, and potential barriers to adoption. A prototype mobile app based on data and existing paper-based worksheets was built. Initial face-to-face user testing of the prototype system was completed with three therapists and three CAT expatients. ResultsAmong the therapists surveyed, 72% (36/50) reported not currently using any digital tools during CAT. However, the potential value of a mobile app to support patient awareness was widely endorsed. Areas of therapist concern were data security, data governance, and equality of access. These concerns were mirrored during subsequent user testing by CAT therapists. Expatients generated additional user specifications on the design, functionality, and usability of the app. Results from both streams were integrated to produce five key changes for the reiteration of the app. ConclusionsThe user-centered design process has enabled a prototype CAT-App to be developed to enhance the relational awareness work of CAT. This means that patients can now practice relational awareness in a much more unobtrusive manner and with ongoing dynamic feedback of progress. Testing the acceptability and feasibility of this technological innovation in clinical practice is the next stage in the research process, which has since been conducted and has been submitted. The important challenges of data protection and governance must be navigated in order to ensure implementation and adoption if the CAT-App is found to be acceptable and clinically effective.

BackgroundThere has been a lack of technological innovation regarding improving the delivery of integrative psychotherapies. This project sought to evaluate an app designed to replace previous paper-based methods supporting relational awareness and change during cognitive analytic therapy (CAT). ObjectiveWe aimed to assess patients’ and therapists’ experience of using the technology (ie, the “CAT-App”) and to evaluate the relationship between app usage and clinical outcome. MethodsThe design was a mixed methods case series. Patients completed the Clinical Outcomes in Routine Evaluation-Outcome Measure pre- and post-CAT. Mood data plus the frequency and effectiveness of relational awareness and change were collected via the app. Therapists and patients were interviewed about their experiences using the app. ResultsTen patients (treated by 3 therapists) were enrolled; seven completed treatment and 4 had a reliable improvement in their mental health. App usage and mood change did not differ according to clinical outcome, but there was a statistically significant difference in app usage between completers and dropouts. The qualitative themes described by the therapists were (1) the challenge of incorporating the technology into their clinical practice and (2) the barriers and benefits of the technology. Clients’ themes were (1) data protection, (2) motivation and engagement, and (3) restrictions versus flexibility. ConclusionsThe CAT-App is capable of supporting relational awareness and change and is an upgrade on older, paper-based formats. Further clinical evaluation is required.

Objectives: Clinical associate psychologists (CAPs) train under the auspices of the apprenticeship programme and are a new addition to the psychological workforce. This project sought to evaluate whether a "personal reformulation" (PR) was helpful in terms of personal and professional development during the apprenticeship. Methods: A mixed methods evaluation containing a longitudinal quantitative element and a "Big Q" qualitative element with a single cohort of N = 18 CAPs. A PR consists of a 2‐hr one‐to‐one session and a follow‐up session with a cognitive analytic psychotherapist. During a PR, a sequential diagrammatic reformulation is produced to aid recognition and revision of potentially problematic relationship patterns at work. Two outcome measures concerning reflective capacity and professional quality of life were completed at the start of the apprenticeship, pre‐PR and at 3‐month PR follow‐up. The semi‐structured interviews (n = 11) conducted at the follow‐up were analysed using reflexive thematic analysis. Results: Quantitative changes were limited to significant increases to general confidence and 8/12 apprentices had a reliable increase in confidence in communication. Qualitatively, five overarching themes were found: (1) gaining insight, (2) wellbeing, (3) nature of the space, (4) being an apprentice, and (5) moving forward. Conclusions: PRs were generally found to be emotionally challenging, but relatively large amounts of insight are possible from a very brief intervention that can contribute to personal and professional development during clinical training. More controlled research needs to be conducted and wider applications and evaluations of PRs in different professions would be welcome. [ABSTRACT FROM AUTHOR]

Key Points: Question: Is practitioner-supported mindfulness-based cognitive therapy self-help (MBCT-SH) clinically effective and cost-effective compared with practitioner-supported cognitive behavioral therapy self-help (CBT-SH) for adults experiencing mild to moderate depression? Findings: In this randomized clinical trial of 410 participants with mild to moderate depression, practitioner-supported MBCT-SH led to significantly greater reductions in depressive symptom severity at 16 weeks postrandomization compared with practitioner-supported CBT-SH. The probability of MBCT-SH being cost-effective compared with CBT-SH exceeded 95%. Meaning: Practitioner-supported MBCT-SH for mild to moderate depression was clinically effective and cost-effective compared with currently recommended practitioner-supported CBT-SH and should be made routinely available to adults experiencing mild to moderate depression. This randomized clinical trial evaluates whether practitioner-supported mindfulness-based cognitive therapy self-help is superior to practitioner-supported cognitive behavioral therapy self-help at reducing depressive symptom severity at 16 weeks postrandomization among patients with mild to moderate depression. Importance: Depression is prevalent. Treatment guidelines recommend practitioner-supported cognitive behavioral therapy self-help (CBT-SH) for mild to moderate depression in adults; however, dropout rates are high. Alternative approaches are required. Objective: To determine if practitioner-supported mindfulness-based cognitive therapy self-help (MBCT-SH) is superior to practitioner-supported CBT-SH at reducing depressive symptom severity at 16 weeks postrandomization among patients with mild to moderate depression and secondarily to examine if practitioner-supported MBCT-SH is cost-effective compared with practitioner-supported CBT-SH. Design, Setting, and Participants: This was an assessor- and participant-blinded superiority randomized clinical trial with 1:1 automated online allocation stratified by center and depression severity comparing practitioner-supported MBCT-SH with practitioner-supported CBT-SH for adults experiencing mild to moderate depression. Recruitment took place between November 24, 2017, and January 31, 2020. The study took place in 10 publicly funded psychological therapy services in England (Improving Access to Psychological Therapies [IAPT]). A total of 600 clients attending IAPT services were assessed for eligibility, and 410 were enrolled. Participants met diagnostic criteria for mild to moderate depression. Data were analyzed from January to October 2021. Interventions: Participants received a copy of either an MBCT-SH or CBT-SH workbook and were offered 6 support sessions with a trained practitioner. Main Outcomes and Measures: The preregistered primary outcome was Patient Health Questionnaire (PHQ-9) score at 16 weeks postrandomization. The primary analysis was intention-to-treat with treatment arms masked. Results: Of 410 randomized participants, 255 (62.2%) were female, and the median (IQR) age was 32 (25-45) years. At 16 weeks postrandomization, practitioner-supported MBCT-SH (n = 204; mean [SD] PHQ-9 score, 7.2 [4.8]) led to significantly greater reductions in depression symptom severity compared with practitioner-supported CBT-SH (n = 206; mean [SD] PHQ-9 score, 8.6 [5.5]), with a between-group difference of −1.5 PHQ-9 points (95% CI, −2.6 to −0.4; P =.009; d = −0.36). The probability of MBCT-SH being cost-effective compared with CBT-SH exceeded 95%. However, although between-group effects on secondary outcomes were in the hypothesized direction, they were mostly nonsignificant. Three serious adverse events were reported, all deemed not study related. Conclusions and Relevance: In this randomized clinical trial, practitioner-supported MBCT-SH was superior to standard recommended treatment (ie, practitioner-supported CBT-SH) for mild to moderate depression in terms of both clinical effectiveness and cost-effectiveness. Findings suggest that MBCT-SH for mild to moderate depression should be routinely offered to adults in primary care services. Trial Registration: isrctn.org Identifier: ISRCTN13495752 [ABSTRACT FROM AUTHOR]

The controversial move toward the development of a consensus on evidence-based or empirically supported therapies may be seen as an international crisis facing psychotherapists. Researchers long have complained that practicing therapists all too often continue to guide what they do therapeutically on the basis of their clinical experience and not the available research findings. Practicing therapists long have complained that therapy research bears only a remote resemblance to what goes on in actual clinical practice and that research reports are written for other researchers, not for clinicians. In the hope of turning our current crisis into an opportunity, this panel involved a dialogue that was designed to bridge this clinical-research gap.

Purpose: Persistent physical symptoms (PPS) are often associated with profound physical disability and psychological distress. Interventions for PPS that promote behavioural change aim to reduce levels of symptoms and improve overall functioning in patients. The evidence for these interventions is mixed, with effective relationships between patients and health practitioners (HPs) reported as the key to the success of primary care interventions. The objectives of this systematic review were to synthesize the qualitative evidence and to evaluate the acceptability of behavioural interventions for PPS in primary care, from the perspective of both patients and HPs. Methods: A comprehensive literature search was conducted in seven major electronic bibliographic databases, to February 2019. The aim was to identify a broad range of literature including, qualitative research, mixed methods research, and qualitative data embedded in trial reports or process evaluations. Fifty‐eight full papers were screened against the inclusion criteria. Nine studies were included and quality‐assessed. A qualitative evidence synthesis was conducted using thematic synthesis. Results: Some patients and HPs reported positive gains from taking part in or delivering interventions, with appropriate support and explanation of their symptoms important for patients. Barriers appeared to be underpinned by the relationship between the patients and HPs, and by beliefs and attitudes held by both parties. Conclusions: Patients should be provided with adequate information to make an informed decision about whether an intervention is appropriate for them, and interventions should not end suddenly or without adequate follow‐up. HPs should receive training and supervision to address their lack of confidence, and improve their knowledge of PPS. [ABSTRACT FROM AUTHOR]

Abstract Background People with multiple sclerosis (MS) are at high risk of depression. We undertook a pilot trial of computerised cognitive behavioural therapy (CCBT) for the treatment of depression in people with MS to test the feasibility of undertaking a full trial. Methods Participants with a diagnosis of MS and clinical levels of depression were recruited through out-patient clinics and postal screening questionnaires at two UK centres and randomised to CCBT or usual care. Clinical outcomes included the Beck Depression Inventory (BDI-II) and Multiple Sclerosis Impact Scale (MSIS-29) at baseline, 8 and 21 weeks. Feasibility outcomes included: recruitment rate; reasons for refusal, withdrawal and dropout; feasibility and acceptability of the proposed outcome measures; sample size estimation and variation in and preferences for service delivery. Results Twenty-four participants were recruited. The recruitment rate, calculated as the proportion of those invited to fill in a screening questionnaire who were consented into the trial, was 4.1%. Recruitment through out-patient clinics was somewhat slower than through screening questionnaire mail-out but the overall recruitment yield was similar. Of the 12 patients in the CCBT arm, 9 (75%) completed at least four, and 6 completed all 8 CCBT sessions. For completers, the median time (IQR) to complete all eight CCBT sessions was 15 (13 to 20) weeks. Participants expressed concern about the face validity of the Beck Depression Inventory II for the measurement of self-reported depression in people with MS. The MSIS-29 was the patient-reported outcome measure which participants felt best reflected their concerns. The estimated sample size for a full trial is between 180 and 390 participants. NHS partners were not delivering CCBT in community facilities and participants preferred to access CCBT at home, with no one expressing a preference for use of CCBT in an alternative location. Conclusions A definitive trial, with a recruitment window of one year, would require the participation of around 13 MS centres. This number of centres could be reduced by expanding the eligibility criteria to include either other neurological conditions or people with more severe depression. The MSIS-29 should be used as a patient-important outcome measurement. Trial registration ISRCTN: ISRCTN81846800

Abstract Background The evaluation of demonstration sites set up to provide improved access to psychological therapies (IAPT) comprised the study of all people identified as having common mental health problems (CMHP), those referred to the IAPT service, and a sample of attenders studied in-depth. Information technology makes it feasible to link practice, hospital and IAPT clinic data to evaluate the representativeness of these samples. However, researchers do not have permission to browse and link these data without the patients' consent. Objective To demonstrate the use of a mixed deterministic-probabilistic method of secure and private record linkage (SAPREL) - to describe selection bias in subjects chosen for in-depth evaluation. Method We extracted, pseudonymised and used fuzzy logic to link multiple health records without the researcher knowing the patient's identity. The method can be characterised as a three party protocol mainly using deterministic algorithms with dynamic linking strategies; though incorporating some elements of probabilistic linkage. Within the data providers' safe haven we extracted: Demographic data, hospital utilisation and IAPT clinic data; converted post code to index of multiple deprivation (IMD); and identified people with CMHP. We contrasted the age, gender, ethnicity and IMD for the in-depth evaluation sample with people referred to IAPT, use hospital services, and the population as a whole. Results The in IAPT-in-depth group had a mean age of 43.1 years; CI: 41.0 - 45.2 (n = 166); the IAPT-referred 40.2 years; CI: 39.4 - 40.9 (n = 1118); and those with CMHP 43.6 years SEM 0.15. (n = 12210). Whilst around 67% of those with a CMHP were women, compared to 70% of those referred to IAPT, and 75% of those subject to in-depth evaluation (Chi square p< 0.001). The mean IMD score for the in-depth evaluation group was 36.6; CI: 34.2 - 38.9; (n = 166); of those referred to IAPT 38.7; CI: 37.9 - 39.6; (n = 1117); and of people with CMHP 37.6; CI 37.3-37.9; (n = 12143). Conclusions The sample studied in-depth were older, more likely female, and less deprived than people with CMHP, and fewer had recorded ethnic minority status. Anonymous linkage using SAPREL provides insight into the representativeness of a study population and possible adjustment for selection bias.

Objective: This paper describes the development and summarizes the content of a competence framework for delivery of cognitive analytic therapy (CAT). Design: The framework was developed using the evidence‐based method developed by Roth and Pilling (2008, Behavioural and Cognitive Psychotherapy, 36, 129). Methods: A review of the CAT outcome literature identified where CAT interventions had evidence of efficacy. Standard texts on CAT were primary sources for details of theory and practice. This process was supported by an expert reference group (ERG). The role of the ERG was to provide professional advice on areas where the evidence base was lacking, but where CAT interventions were commonly used by therapists trained in the model. Results: A framework was produced and structured in terms of core knowledge, core skills, and meta‐competences (which require therapeutic judgement rather than simple adherence to a treatment protocol). Conclusions: The framework enables trainees, service users, service managers, and commissioners to better understand a) the core features of CAT and b) what competences need to be in place for CAT to be skilfully delivered in practice. Practitioner points: It is possible to define the core competences of CAT.Whilst generic competences are important, there are five CAT‐specific domains of competence.The CAT‐specific competences reflect the three‐phase structure of the therapy: reformulation, recognition, and revision. [ABSTRACT FROM AUTHOR]

Abstract Background Patients may find it difficult to distinguish between the symptoms of anxiety and those of asthma. Findings are equivocal on whether there is a specific link between anxiety and asthma. The aims of this study were to i) to identify the prevalence of anxiety, depression and panic fear in adults with asthma compared with that of the general population ii) to investigate whether there is a specific relationship between asthma and anxiety. Methods An epidemiological survey of 872 adults with a diagnosis of asthma identified from six General Practices in Sheffield, England. Community postal survey using self-completion questionnaire. Results The response rate was 59%. People with asthma had higher mean Hospital Anxiety and Depression Scale (HADS) anxiety scores than UK norms with a higher proportion above the clinical cut-off. Mean HADS depression scores were significantly higher than UK norms and norms for a general population sample of people registered with the same practice. These effects were age-related with the relationship between asthma and psychological distress most marked over the age of 45. The prevalence of asthma-specific panic fear was 15.7%. Conclusion A significant minority of people have high levels of panic fear (as measured by the Asthma Symptom Checklist) associated with asthma. However, in adults with asthma there is also high prevalence of both generalised anxiety and depression (as measured by the HADS), suggesting that the link of anxiety to asthma may be part of a broader relationship between psychological distress and chronic disease rather than a specific one.

This paper sought to assess whether cognitive analytic therapy (CAT) was effective with a male patient meeting diagnostic criteria for hoarding disorder (HD) who had been nonresponsive to two previous courses of cognitive behaviour therapy. An adjudicated hermeneutic single‐case efficacy design (HSCED) evaluation was undertaken. A rich case record (i.e., a summary document containing the case details, formulations, and detailed qualitative and quantitative outcomes) was created. The rich case record was then debated by affirmative (N = 3) and sceptic (N = 3) research teams. Expert judges (N = 3) reviewed the debate and then delivered a final verdict as to whether treatment had worked. Judges unanimously returned a verdict in favour of the sceptic position, concluding that CAT had not enabled change. Lack of change on the primary nomothetic hoarding outcome measure was particularly influential in the final judgement. In this case of HD, CAT was therefore not effective as an intervention. More research is needed before any definitive conclusions can be drawn however as to the wider utility of CAT with HD. Methodological limitations are outlined, alongside considerations for future research. [ABSTRACT FROM AUTHOR]

Background: It is estimated that between 3% and 15% of patients have a negative experience of psychotherapy, but little is understood about this. Aims: The aim of this study was to investigate the factors associated with patients' negative therapy experiences. Method: The data comprised 185 patient and 304 therapist questionnaires, 20 patient and 20 therapist interviews. Patients reported on an unhelpful or harmful experience of therapy, and therapists on a therapy where they thought the patient they were working with had a poor or harmful experience. These were transcribed and analysed using thematic analysis. Results: There was a Lack of fit between Patient needs, Therapist skills, and Service structures. This could result in Fault Lines, a tension between Safety and containment and Power and control. This tension led to Strain and Poor Engagement, which led to Consequences following the negative therapy experience. Conclusions: Patients require clear information, choice, involvement in decision-making, explicit contracting and clarity about sessions and progress. Opportunities for patient feedback should be the norm, where the therapist and service are vigilant for signs of deterioration and solutions considered. Clinical and methodological significance of this article: Estimates of "unwanted effects," including long-lasting effects, of psychotherapy have ranged from 3% to 15%. Few empirical studies have been conducted in this area. This study aimed to address this gap and provide clinicians with a model of risk factors for negative therapy effects. The findings of this study indicate the importance of providing patients with a supportive service structure that offers clear information, choice and involvement in decision-making. Explicit contracting at the beginning of therapy and clarity about sessions and progress are also important in managing patient expectations throughout. Opportunities for patient feedback should be provided. [ABSTRACT FROM AUTHOR]

Background: Despite repeated discussion of treatment safety, there remains little quantitative research directly addressing the potential of therapy to harm. In contrast, there are numerous sources of qualitative evidence on clients' negative experience of psychotherapy, which they report as harmful. Objective: To derive a model of process factors potentially leading to negative or harmful effects of therapy, from the clients' perspective, based on a systematic narrative synthesis of evidence on negative experiences and effects of psychotherapy from (a) qualitative research findings and (b) participants' testimony. Method: We adapted Greenberg (2007) task analysis as a discovery-oriented method for the systematic synthesis of qualitative research and service user testimony. A rational model of adverse processes in psychotherapy was empirically refined in two separate analyses, which were then compared and incorporated into a rational-empirical model. This was then validated against an independent qualitative study of negative effects. Results: Over 90% of the themes in the rational-empirical model were supported in the validation study. Contextual issues, such as lack of cultural validity and therapy options together with unmet client expectations fed into negative therapeutic processes (e.g., unresolved alliance ruptures). These involved a range of unhelpful therapist behaviors (e.g., rigidity, over-control, lack of knowledge) associated with clients feeling disempowered, silenced, or devalued. These were coupled with issues of power and blame. Conclusions: Task analysis can be adapted to extract meaning from large quantities of qualitative data, in different formats. The service user perspective reveals there are potentially harmful factors at each stage of the therapy journey which require remedial action. Implications of these findings for practice improvement are discussed. [ABSTRACT FROM AUTHOR]