David Clark, University of Oxford

Improving Access to Psychological Therapies: An Update on Science, Policy and Economics

Abstract soon



Trudie Chalder, King’s College London

Chronic fatigue syndrome: the trials and tribulations of outcome studies


Fatigue is best viewed on a continuum with fatigue as a symptom at one end of the spectrum and chronic fatigue syndrome (CFS) associated with profound disability at the other.  Up to 75% of people with CFS also have a mood disorder.  Over about 25 years worth of research trial findings show that both cognitive behaviour therapy (CBT) and graded exercise therapy (GET) are moderately effective treatments for CFS that are not associated with harm.  In primary care briefer interventions for fatigue have been shown to be efficacious.  Self -help books are available. The aim of this lecture is to describe the overlap between fatigue and emotion, the evidence for CBT and GET, the nature of the interventions and how they work according to recent meditational analyses and long term follow ups. 

Dave Richards, The University of Exeter

Clinical and Cost Effectiveness of Behavioural Activation versus Cognitive Behaviour Therapy for Depression: Outcomes from the UK COBRA non-inferiority Randomised Controlled Trial


Clinical and Cost Effectiveness of Behavioural Activation versus Cognitive Behaviour Therapy for Depression: Outcomes from the UK COBRA Non-inferiority Randomised Controlled Trial
Background: Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, CBT is a complex therapy that requires highly-trained and qualified practitioners, and its scalability is therefore limited by the costs of training and employing sufficient therapists to meet demand. Behavioural Activation (BA) is a psychological treatment for depression that may be an effective alternative to CBT and, because it is simpler, might also be delivered by less highly trained and specialised mental health workers.
Methods: COBRA is a two-arm non-inferiority patient level randomised controlled trial, including clinical, economic, and process evaluations comparing CBT delivered by highly trained professional therapists with BA delivered by junior professional or para-professional mental health workers to establish whether the clinical effectiveness of BA is non-inferior to CBT and if BA is cost effective compared to CBT.
COBRA is the largest specific trial of BA vs. CBT internationally and is one of the largest trials of CBT for depression ever conducted. We have recruited 440 people with major depressive disorder randomised to either CBT or BA. Our primary outcome was severity of depression symptoms (Patient Health Questionnaire-9) at twelve months follow up with secondary outcomes of severity of depression at 18 months, and anxiety (General Anxiety Disorder-7 questionnaire) and health related quality of life (Short-Form Health Survey-36) at twelve and 18 months.
Our economic evaluation has explored cost-effectiveness in terms of quality adjusted life years using the EuroQol–5D measure of health-related quality of life and our process analysis has examined qualitative perceptions of therapies and both moderators and mediators of effect.
This keynote will report our results and explore the significance of them for the psychological therapy of depression including the merits or not of including BA as a first line treatment of depression.

Lars Goran Ost, Stockholm University, Sweden

Intensive, brief, and effective treatments for anxiety disorders: A systematic review


CBT for anxiety disorders are usually carried out in weekly 50-60 min. sessions for 10-15 weeks, both in research studies and in clinical practice. In the early 1980’s I developed the one-session treatment for specific phobias and today more than 30 RCTs, on both children and adults, have been published by researchers in various countries. This format has later been successfully applied in RCTs for Social phobia specific subtype (Hinto, 2011) and PTSD (Basoglu, 2007). In the other anxiety disorders there are examples of effective treatments which are brief compared to the original format: Panic disorder with agoraphobia in two sessions (Salkovskis, 2006), Panic disorder without agoraphobia in five sessions (Clark, 1999), Generalized anxiety disorder in five sessions (Durham, 2004), and Obsessive-compulsive disorder in 4-5 days (Whiteside, 2010; Havnen, 2014). Some of the advantages of brief treatment are that patients don’t have to travel to a therapist weekly for a number of weeks, the treatment can be more cost-effectively than standard treatment, the attrition risk is reduced, and it can simplify dissemination of evidence-based treatments. Some disadvantages are the intensive treatment may not be suitable for anxiety disorders requiring a lot of exposure in natural situations in order to test catastrophic beliefs, and that some insurance companies and administrative booking programs in health care do not approve of this format. The keynote will systematically review intensive and brief treatments for anxiety disorders and compare its efficacy with standard treatments.

Andrew Gumley, University of Glasgow

Attachment and Caregiving in Psychosis: Current status and future directions


Recovery from psychosis can best be conceptualised as a journey involving a number of core processes including developing a sense of connectedness; hope and optimism for the future; a sense of identity; having meaning in life; and empowerment. I will propose that interpersonal relationships are the window through which these recovery processes unfold and that developing understandings of recovery that are rooted in an appreciation of attachment and resilience can offer new perspectives on theory, research, clinical practice and service organisation. Attachment theory provides a framework to understand the interpersonal roots of emotional regulation, resilience and adaptation to stressful life events and experiences. Attachment theory also emphasises the importance of the interpersonal (and the caregiving context) as an environment for individuals’ development and growth. Optimal caregiving environments are characterised by two key dimensions: safe haven (for responding to threat and resolving distress) and secure base (for facilitating the curiosity, exploration, autonomy and empowerment).  The presentation will provide a state of the art summary of the growing empirical literature on attachment and psychosis. This literature now comprises well over 30 studies and 2,500 participants. Based on our conceptualisation of this literature I will show how attachment theory can be used to (a) enhance strengths based approaches to Cognitive Behavioural Therapy for psychosis (CBTp), (b) to aid formulation and collaboration in CBTp and (c) cultivate service models that can attune to attachment needs of service users. I will illustrate these applications through a number of selected empirical studies and show how these studies can inform the development of new interventions and service models to promote empowerment and recovery. 

Kerry Young, Central and Northwest London Foundation Trust

Developing mental health services for traumatized refugees and asylum seekers - what should we be offering?


Most countries in Europe have seen a dramatic increase in the number of asylum seekers arriving over the last few years. If the UK were to follow suit and offer to take their share, what sort of mental health services would we need to offer?

In this presentation, I will discuss what we know about the mental health needs of refugees and asylum seekers. While estimates vary, we know that rates of depression and PTSD are elevated. Next, I will review the literature about how best to meet these needs and about what moderates good outcomes. Then, I will make concrete suggestions about what mental health services should look like for traumatized refugees and asylum seekers. Finally, I will try and share some of my enthusiasm for this amazing field of work in the hope that it will motivate others to join us.

Christine Padesky, The Center for Cognitive Therapy, USA

Mind Over Mood 2: The Challenges of Aligning Self-Help with Evidence-based Practice


There has been a rapid expansion in CBT protocols and practices since the first edition of Mind Over Mood was published in 1995. Our goals for the 2nd Edition of Mind Over Mood (MOM2) (Greenberger & Padesky, 2016) were to reflect the highest standards of evidence-based practice and, at the same time, offer an appealing and easy to use self-help workbook. Reaching these goals required rethinking the structure and content of MOM2 in ways we did not anticipate at the beginning of our four year effort. What we learned in the process offers helpful insights into current CBT practice as well as guidelines for integrating self-help into therapy.
This keynote highlights the practical and accessible solutions we derived to meet challenges such as: (1) MOM2 teaches readers to understand and manage a variety of moods, yet there are different treatment paths for each mood. How can a single book align with a myriad of evidence-based treatments and remain simple for readers to follow? (2) There are now many CBT therapies. We wanted to integrate classic CBT methods with evidence-based practices that emphasize acceptance, mindfulness, and positive psychology. How is it possible to meaningfully integrate multiple treatment perspectives and at the same time maintain a focus on step-by-step development of mood management skills? (3) Although self-help can be less rigorous than therapy, we wanted to encourage readers of MOM2 to follow evidence-based practices such as: regular completion of mood measures, rehearsal of skills until mastery is achieved, goal setting enhanced by motivational interviewing, and proactive relapse management. How can readers be enticed to follow such good treatment principles?
In learning how to solve these challenges we discovered that a self-help workbook can be aligned with evidence-based practice but only when the demands of each are fully understood.

Paul Ramchandani, Imperial College London

Prevention of mental health problems in early life: promises and pitfalls


There is huge potential to intervene early in life to prevent mental health problems from developing or becoming entrenched. It is in many ways so obvious a thing to do. However, the evidence for effective prevention in mental health is limited, some avenues of research are overlooked, and the potential for any harm is often ignored. I will describe some of these challenges, and outline some of the key early interventions used, including an ongoing trial of a video-feedback parenting intervention to prevent enduring behavioural problems in one and two year old children (Healthy Start, Happy Start: ISRCTN no: 58327365).

Carolyn Becker, Trinity University, USA

Translating empirically supported treatment into evidence based practice for eating disorders


Clinicians increasingly experience pressure to engage in evidence-based practice, which is often equated to delivery of empirically supported treatment (EST). Yet evidence-based practice actually consists of three components – only one of which includes ESTs. More specifically, in evidence-based practice, which is commonly conceptualized as a three legged stool, clinicians must incorporate each of the following into treatment: the best research available, including ESTs; clinical judgment; and patient values and preferences. This can be particularly challenging when patients present with high degrees of comorbidity. The aim of this talk is to consider each component of evidence based practice in the context of eating disorders. More specifically, this talk will review what randomized controlled trials do and do not tell us about the treatment of eating disorders. A primary aim will be to identify where research provides a good template for treatment versus areas where clinical judgment will have to play a larger role in the absence of clear data. Person’s case formulation approach then will be used to explore how clinical judgement can be integrated with ESTs to address gaps in research knowledge while simultaneously attempting to minimize the cognitive errors that often occur in human decision making. Lastly, this talk will consider what is known about the impact of patient preferences and values on treatment outcome and consider how this can be used to facilitate treatment given that patient values may change over the course of treatment.

Robert Leahy, The American Institute for Cognitive Therapy, USA

Theory of Emotion: Emotional Schemas and Psychopathology


The role of emotion has gained increasing importance in CBT. Research in cognitive social psychology indicates that affect forecasting (predictions about future emotional experience) is characterized by problematic heuristics that lead to over-prediction of durability and intensity and underestimates of mitigating factors and coping ability. This leads to time discounting about emotion—that is, over-emphasis on current experience while discounting future experience. in addition, even though emotions are “ephemeral”, more intense emotions are experienced as durable and these emotional experiences are used to predict future emotion. The Emotional Schema Model proposes that once the individual experiences an emotion, specific interpretations, evaluations and strategies are elicited.  These include beliefs about the duration, controllability, uniqueness, shame, comprehensibility, and complexity of emotion and, in addition, problematic strategies such as avoidance, suppression, blaming, and validation demands. These beliefs and strategies may either escalate emotion or result in confirming beliefs that emotions need to be avoided. We will review research on how emotional schemas are related to depression, anxiety, dispositional mindfulness, psychological flexibility, metacognitive dimensions of worry, and personality disorders. In addition, we will review how beliefs about the emotions of others may lead to unhelpful responses to the emotions of intimate partners. Strategies for modifying these emotional schemas will be reviewed.

Richard Hastings, Centre for Educational Development Appraisal and Research (CEDAR), University of Warwick

What is Positive Behavioural Support (PBS)? Developmental disabilities and beyond


10-15% of people with intellectual disabilities may engage in behaviours described as “challenging”, and similar behaviour problems are also seen in other settings such as mental health and dementia services. Practice has developed in developmental disabilities services to address challenging behaviour using a framework known as Positive Behavioural Support (PBS). In England, various documents emerging from the government Transforming Care programme (in response to the Winterbourne View scandal) recommend PBS should be included as a part of services’ response to “challenging behaviour”. However, there is confusion around what PBS is and an increasing emphasis on access to mainstream mental health services for people with intellectual disabilities. Therefore, everyone needs to understand PBS and how it might fit within services more widely. In this presentation, I will focus on the theoretical model underlying PBS, its defining features, and consider the application of PBS beyond developmental disability services.

Merel Kindt, Amsterdam University, the Netherlands

In search for therapeutic forgetting


For years it was believed that after fear memory has been established, the memory trace is engraved into the physical structure of the brain. At the turn of this century, a major breakthrough in neuroscience was achieved with the discovery that once (fear) memories are retrieved, they may enter a labile, protein synthesis dependent state, rendering it amenable to change. This process of memory reconsolidation may provide a window of opportunity to weaken or even erase emotional memory in patients with anxiety disorders and other related disorders. A technology that erases the emotional impact of unduly intense fear memories would signify a true paradigm shift in the practice of psychotherapy.
Pharmacologically induced amnesia has only been convincingly demonstrated for fears induced in the laboratory, basically in animals and healthy participants. In line with the fear-conditioning studies, we showed that disrupting the process of memory reconsolidation effectively transformed avoidance behaviour into approach behaviour in spider fearful individuals, without actually targeting the cognitive level of fear. As such, our findings also challenge one of the fundamental tenets of Cognitive Behavioural Therapy, where changes in dysfunctional beliefs are supposed to precede the behavioural modifications. Disrupting reconsolidation instead seems to act in a reverse order: it targets the emotional aspects and subsequently the cognitions may change. Along the same line, I will present several case descriptions in patients with other anxiety disorders and PTSD, who received only one or two Reconsolidation Intervention  sessions. To illustrate that the translation from basic science to clinical practice is not self-evident, I will also present non-effective case descriptions.
Even though the process of memory reconsolidation has the potential to actually erase excessive fear memory, we cannot observe the molecular and cellular processes in the human brain underlying either the presence or absence of memory expression. We can only infer the underlying neurobiological processes from the behavioural, physiological or neural read-outs of fear memory. Because there is no one-to-one relationship between these memory expressions and the underlying neurobiological processes, erasure of memory traces cannot be proven. However, by critically testing hypotheses that follow from the reconsolidation conjecture, we may gradually unveil some of the mysteries that underlie the plasticity of fear memory in humans.

Jennifer Wild, University of Oxford

Risk and Resilience: How Can We Prevent PTSD?


Posttraumatic stress disorder (PTSD) is the only disorder in DSM-V for which there is an external cause.  It is the only disorder for which a behavioural ‘medicine’ could be administered after exposure to the central trigger to protect against developing the disorder.  An enormous body of research has established risk factors for developing PTSD and emerging research has begun to evaluate resilience interventions aimed to protect individuals from developing the disorder.  Unfortunately, the currently available resilience interventions are not very successful, possibly because they fail to target predictors of risk.  I shall present results of our large-scale RCT of a widely available resilience intervention.  I will also present programmatic research, in which we first applied an established cognitive model of PTSD persistence to the prediction of trauma-related disorders. Our aim was to identify pre-trauma risk factors for post-trauma PTSD and depression in a large sample of individuals regularly exposed to trauma.  The talk will present the results of this prospective research as well as a number of novel experimental studies that demonstrate how we may successfully modify malleable predictors of risk with CBT to protect individuals from developing trauma-related disorders.  The talk culminates with a presentation of how we may protect emergency workers, individuals who risk their lives to promote our own physical health and safety, with an evidence-based preventative intervention.

Michael Duffy, Queen's University, Belfast

Understanding and treating conflict related trauma - reflections on research and clinical practice from Northern Ireland


The aftermath of the recent prolonged conflict in Northern Ireland has left a legacy of trauma-related illness. NICE guidelines recommend trauma-focused CBT (TFCBT) for the treatment of PTSD but how can these therapies be effective with PTSD linked to conflict and terrorism? This keynote will draw upon over 20 years clinical practice working with trauma linked to terrorism and conflict. The first question is whether psychological factors add to our understanding of predictors of PTSD among individuals exposed to potentially traumatic events. Previous meta-analyses by Brewin et al. (2000) and by Ozler et al. (2003) have identified a range of predictors of PTSD but the amount of variability in PTSD that they explain is modest. Ehring, Ehlers and Glucksman (2006, 2008) assessed a range of psychological factors specified in Ehlers and Clark’s [2000] cognitive model of PTSD and found that the cognitive factors were substantially more powerful in predicting PTSD. I will present 3 school and community studies that investigate whether the same psychological factors may be similarly powerful in predicting chronic PTSD following a terrorist bombing. The second question is whether TFCBT is effective for those who experience PTSD linked to trauma and conflict. I will present findings from 2 clinical studies of individuals with conflict related PTSD who were offered TFCBT based on the Ehlers & Clark (2000) model. In the first  study following a terrorist bombing incident substantial and significant improvements in PTSD were observed, with pre to post treatment effect sizes in line with those reported for TFCBT in trials with non-terrorism related PTSD. In the second study patients were randomized to either immediate TFCBT or Wait list. Patients typically had chronic PTSD (range 3 months to 32 years) mostly resulting from multiple traumas. Half had failed previous psychological treatments for PTSD. In contrast to no improvement on the wait list, immediate CT was associated with significant improvement in PTSD, depression and social/work related disability, which was maintained at follow-up. This keynote will report how large surveys can be designed to inform clinical practice and how clinicians can adapt TFCBT for a chronic, multiply traumatized population in the context of ongoing threat.

Freda McManus, University of Stirling

Developing new approaches to assessing competence in CBT


Effective assessment of Cognitive Behaviour Therapy (CBT) competence is crucial to the success of the current drive to expand CBT training and service provision, and to the widespread dissemination of CBT into routine practice. However, a lack of consensus about how CBT competence should be assessed has resulted in the use of numerous different methods, many of which have been widely criticised. This keynote will present the advantages and disadvantages of the various methods for assessing CBT competence within Miller's (1990) framework for assessing clinical skill, in the context of ‘evidence-based training’ (Ravoshik & McManus, 2010).

Observational ratings of therapists’ in session performance using  standardised rating scales is the ‘gold standard’ for assessing therapists’ ability to effectively apply their knowledge and skills within clinical practice settings (Barber et al., 2007; Muse & McManus, 2013). Given the need to further refine the rating scales that are currently available (Fairburn & Cooper, 2011; Muse & McManus, 2013; Muse & McManus, 2015), a BABCP funded initiative was to develop a novel CBT competence rating scale: the Assessment of Core CBT Skills (ACCS – Muse, McManus, Rakovshik & Thwaites, submitted). The ACCS aims to build upon existing tools (particularly the Cognitive Therapy Scale [] and the Cognitive Therapy Scale-Revised [CTS-R: Blackburn et al., 2001]) by providing a behaviourally-specific rating scale with discrete items applicable across a range of CBT interventions and adult mental health problems, and serving as a developmental tool for providing formative feedback and engaging in self-reflection. Results from preliminary studies investigating the psychometric properties of the ACCS rating scale in ‘real world’ CBT training and routine practice contexts suggest that both the self-rated and assessor-rated versions of the ACCS demonstrate good internal consistency, inter-rater reliability, and discriminant validity. Thus the ACCS is suitable for use in clinical practice, training settings and research studies, and can be used as a self-rating tool as well as an assessor-rated tool. In addition, the ACCS was found to be correlated with, but distinct from the Revised Cognitive Therapy Scale (CTS-R), was comparable to the CTS-R in terms of internal consistency and discriminant validity, and may have advantages over the CTS-R in terms of inter-rater reliability . Thus the ACCS may provide an acceptable alternative to the CTS-R, with updated criteria and broader applicability. 

Shirley Reynolds, The University of Reading

The puzzle of adolescent depression



Rory O'Connor, University of Glasgow

Understanding suicidal behaviour: From suicidal thoughts to suicide attempts


Suicide and attempted suicide are major public health concerns with complex aetiologies which encompass a multifaceted array of risk and protective factors.  There is growing recognition that we need to move beyond psychiatric categories to further our understanding of the pathways to both. As an individual makes a decision to take their own life, an appreciation of the psychology of the suicidal mind is central to suicide prevention.  Another key challenge is that our understanding of the factors that determine behavioural enaction (i.e., which individuals with suicidal thoughts will act on these thoughts) is limited.  Although a comprehensive understanding of these determinants of suicidality requires an appreciation of biological, psychological and social perspectives, the focus in this presentation is primarily on the psychological determinants of self-harm and suicide. The Integrated Motivational–Volitional (IMV) Model of Suicidal Behaviour (O’Connor, 2011) provides a framework in which to understand suicide and self-harm.  This tripartite model maps the relationship between background factors and trigger events, and the development of suicidal ideation/intent through to suicidal behaviour.  I will present a selection of empirical studies derived from the IMV model to illustrate how psychological factors increase suicide risk and what can be done to ameliorate such risk.  The implications for the prevention of self-harm and suicide will also be discussed.