Cognitive Behavioral Therapy Framework Research Articles

Experience of CBT in adults with ADHD: a mixed methods study.

The National Institute for Health and Care Excellence (NICE) recommends Cognitive-Behavioural therapy (CBT) as the psychotherapeutic treatment of choice for adults with Attention Deficit Hyperactivity Disorder (ADHD) in the UK. However, the literature often refers to adapted CBT programs tailored for ADHD and provides limited insight into how adults with ADHD experience and perceive this form of treatment in routine clinical practice. This mixed-methods study aims to explore ADHD individuals' experience and perception of CBT delivered in routine clinical practice, to gain a better understanding of this treatment's helpfulness and perceived effectiveness. A survey (n=46) and semi-structured in-depth interviews (n=10) were conducted to explore the experience of CBT and its perceived effectiveness in managing ADHD. The interviews were analysed using thematic analysis and the survey was synthesised using descriptive narratives. The thematic analysis highlighted three key themes: difficulties with the CBT framework, difficulties with CBT therapists, and consequences of CBT. The survey highlighted similar findings. Participants described the CBT framework as, generic, rigid, and too short, and described the CBT therapist as unspecialised, unempathetic, and not sufficiently adapting CBT to ADHD-related difficulties. Overall, participants found non-adapted, generic CBT in the UK to be unhelpful, overwhelming, and at times harmful to their mental well-being. Therefore, it is necessary for clinical bodies in the UK, while following the indicated NICE guidelines, to be mindful of adapting CBT delivery of CBT, to be most effective for people with ADHD and to mitigate potential harm.

How educational psychologists use cognitive behavioural therapy interventions: a systematic literature review

ABSTRACT This systematic literature review explored how educational psychologists (EPs) use cognitive behavioural therapy (CBT) interventions within school settings, with whom and to what effect. The information available on the intervention design and delivery was benchmarked against Fuggle et al.‘s framework that identified CBT competencies required for working with children and young people (CYP). Research into school-based CBT interventions involving EPs between 2013 and 2021 was systematically identified and assessed for quality using quantitative and qualitative frameworks. The aggregative analysis highlighted the heterogeneity of CBT interventions being used to support a range of outcomes. The heterogeneity of interventions made it difficult to draw decisive conclusions about the impact of CBT. Although intervention impact varied, overall a positive impact was observed particularly for CYP with anxiety. Benchmarking interventions against a CBT framework enabled competency profiling within EP practice, suggesting EPs could potentially work more collaboratively with school staff and parents. Implications for future research and practice are discussed.

Examining Feasibility, Acceptability, and Preliminary Outcomes of a Culturally Adapted Evidence-Based Postpartum Depression Preventive Intervention for Women in Doha, Qatar: Protocol for a Randomized Controlled Trial.

Postpartum depression and anxiety are the 2 most common perinatal mental health disorders, with prevalence rates higher among women living in the Middle East than in most Western countries. The negative outcomes associated with postpartum depression and anxiety are profound and include less responsive parenting and compromised infant and young child development. Although interventions exist to prevent postpartum depression and anxiety, to date, there have been no studies that have attempted to prevent postpartum depression or anxiety among Arabic-speaking women in the Middle East, including Qatar. The purpose of this study is to conduct a randomized controlled trial (RCT) of an evidence-based postpartum depression preventive intervention-Mothers and Babies (MB)-culturally adapted for use with Arabic-speaking women in Doha, Qatar. MB is guided by a cognitive behavioral therapy framework that focuses on increasing pleasant activities, promoting healthy thought patterns, and increasing the type and frequency of personal contacts. MB is tailored to specific needs and issues related to pregnancy and the postpartum period. A multidisciplinary and multiethnic investigator team adapted MB to promote cultural and contextual fit for Arabic-speaking women. Intervention concepts were reviewed to ensure core content would be understood by Arabic-speaking women in Qatar. Subsequently, images, activities, and examples in the intervention manuals were adapted, as needed, to make the content more relevant to Arab culture. To deliver the adapted intervention, 30 Arabic-speaking individuals with mental health backgrounds were trained. The adapted intervention was subsequently pilot-tested with 10 pregnant women receiving prenatal care at Sidra Hospital in Doha. We are now conducting an RCT to examine the effectiveness of the adapted intervention. We plan to enroll 210 pregnant individuals who are Arabic-speaking, with 1:1 randomization to the MB intervention or usual prenatal care. Among the enrolled participants, a stratified subsample of 40 pregnant women with diabetes is being recruited. Data collection will take place at baseline and a 6-month follow-up. The primary outcomes are depressive and anxiety symptoms and perceived stress. Diabetes self-care is the exploratory outcome for the subsample of individuals with diabetes. Intervention implementation will be assessed via client and provider surveys during and after intervention delivery. Power and sample size were calculated using a 2-sided 5% effort rate and assumed analyses on the individual level, accounting for attrition of 20%. The cultural adaptation and pilot study of the adapted MB intervention are completed. A total of 157 women have been enrolled in the RCT as of March 31, 2023. This study is highly innovative, as it is the first study to our knowledge to examine the effectiveness of an evidence-based postpartum depression preventive intervention in the Middle East. Limitations include a single follow-up time point and a small subsample of individuals with diabetes. ClinicalTrials.gov NCT04442529; https://www.clinicaltrials.gov/study/NCT04442529. DERR1-10.2196/11623.

Evaluating the efficacy of Web-Based Cognitive Behavioural Therapy for the treatment of patients with Bipolar II Disorder and residual depressive symptoms: Protocol for a randomized controlled trial.

Bipolar disorder (BD) is a highly prevalent psychiatric condition that can significantly impact every aspect of a person's life if left untreated. A subtype of BD, Bipolar disorder II (BD-II) is characterized by long depressive episodes and residual depression symptoms, with short-lived hypomanic episodes. Medication and psychotherapy, such as cognitive behavioral therapy (CBT), are the main treatment options for BD-II. CBT specific for BD-II involves the recognition of warning signs, potentially triggering stimuli, and the development of coping skills to increase euthymic periods and improve global functioning. However, access to in-person CBT may be limited by several barriers including low availability, high costs and geographical limitations. Thus, online adaptations of CBT (e-CBT) have become a promising solution to address these treatment barriers Nevertheless, e-CBT for the treatment of BD-II remains understudied. The proposed study aims to establish the first e-CBT program specific for the treatment of BD-II with residual depressive symptoms. The primary objective of this study will be to determine the effect of e-CBT in managing BD symptomatology. The secondary objective will be to assess the effects of this e-CBT program on quality of life, and resilience. The tertiary objective will involve gathering user feedback using a post-treatment survey to support the continuous improvement and optimization of the proposed program. Adult participants (n = 170) with a confirmed diagnosis of BD-II experiencing residual depressive symptoms will be randomly assigned to either the e-CBT plus TAU (n = 85) group or the TAU (n = 85) control group. Participants in the control group will be able to participate in the online program after the first 13 weeks. The e-CBT program will consist of 13 weekly online modules designed following a validated CBT framework. Participants will complete module-related homework and receive asynchronous personalized feedback from a therapist. TAU will consist of standard treatment services conducted outside of the current research study. Depression and manic symptoms quality of life and resiliency will be assessed using clinically validated symptomatology questionnaires at baseline, week 6, and week 13. The study received ethics approval in March 2020 and participant recruitment is expected to begin in February 2023 through targeted advertisements and physician referrals. Data collection and analysis are expected to conclude by December 2024. Linear and binomial regression (continuous and categorical outcomes respectively) will be conducted along with qualitative interpretive methods. The findings will be the first on the effectiveness of delivering e-CBT for patients with BD-II with residual depressive symptoms. This approach can provide an innovative method to address barriers to in-person psychotherapy by increasing accessibility and decreasing costs. clinicaltrials.gov (NCT04664257); clinicaltrials.gov/ct2/show/NCT04664257.

Computer-Assisted CBT May Help Alleviate Depression

Computer-Assisted CBT May Help Alleviate Depression

Cognitive-behavioral correlates of pupil control ideology.

Teacher's pupil control ideology is a central feature for the quality of the teacher-student relationship, which, in turn, impacts the teacher's level of well-being. The pupil control ideology refers to a teacher's belief system along a continuum from humanistic to custodial views. Teachers with humanistic orientation view students as responsible and, therefore, they exert a lower degree of control to manage students' classroom behaviors. Teachers with a custodial orientation view students as untrustworthy and, therefore, they exert a higher degree of control to manage students' classroom behaviors. The relationship between pupil control ideology and dysfunctional beliefs originated from the cognitive-behavioral therapy framework has not been investigated, despite existing evidence suggesting that the pupil control ideology is linked to stress and burnout. One hundred fifty-five teachers completed a set of self-report questionnaires measuring: (i) teacher's pupil-control ideology; (ii) perfectionistic and hostile automatic thoughts; (iii) irrational beliefs; (iv) unconditional self-acceptance; (v) early maladaptive schemas; and (vi) dimensions of perfectionism. The result suggests that teachers who adopt a custodial view on pupil control ideology endorse more dysfunctional beliefs than teachers who adopt a humanistic view. They tend to present a higher level of perfectionism, unrelenting standards, and problematic relational beliefs, including schemas of mistrust and entitlement. They also present more often other-directed demands and derogation of other thoughts. Such results picture a dysfunctional view on pupils who misbehave, as adversaries who threaten their rigid and/or perfectionistic expectations.

COVID-19 Pandemic: Demographic Predictors of Self-Isolation or Self-Quarantine and Impact of Isolation and Quarantine on Perceived Stress, Anxiety, and Depression.

Introduction: With the sudden onset and global dispersal of the SARS-CoV-2 virus, many nations including Canada attempted to reduce spread of the resultant COVID-19 syndrome with self-isolation and quarantine, while seeking a cure or vaccine for this disease. Understanding impacts of self-isolation and self-quarantine on stress, anxiety, and depression will help us to mitigate these issues through appropriate development of mental health services.Methods: The sample was drawn from individuals who self-subscribed to Text4Hope, a service that delivers text messages based on a cognitive behavioral therapy framework. Text4Hope was developed to support Albertans during the COVID-19 pandemic. Subscribers were asked for demographic information and if they had to self-isolate or self-quarantine during the pandemic via a survey link. Mental health was assessed using the validated instruments: Perceived Stress Scale (PSS), Generalized Anxiety Disorder-7 item scale (GAD-7), and the Patient Health Questionnaire-9 (PHQ-9). Descriptive statistics and Chi-Square test results were derived using Statistical Package for Social Sciences (SPSS) version-26.Results: 6,041 of 32,805 Text4Hope subscribers (18.4%) completed the survey. Of these respondents, 19.2% had self-isolated or self-quarantined in Alberta as of March 31, 2020 during the COVID-19 pandemic. Post-hoc analysis using adjusted residuals suggested that individuals aged 60 years of age or older, and retirees had a higher likelihood of self-isolation or self-quarantine, compared to respondents with other age or employment characteristics. One-week prevalence rates for self-reported measures of moderate to high stress, likely Generalized Anxiety Disorder (GAD), and likely Major Depressive Disorder (MDD) were 84.9, 46.7, and 41.4%, respectively. Respondents who had to self-isolate or self-quarantine during the COVID-19 pandemic were significantly more likely to present with moderate to high stress, significant anxiety symptomatology, and significant depressive symptomatology.Conclusions: Older age and employment status were significantly associated with the likelihood of self-isolation or self-quarantine. We found elevated self-reported levels of anxiety and depression associated with self-reported COVID-19 pandemic-related self-isolation and self-quarantine activity. These findings have mental health implications both during and after the pandemic and demonstrate the need for greater focus on psychological complications of self-isolation and self-quarantine, and development of optimal ways to manage these pandemic consequences.

Cognitive Behavioral Therapy for Late-Life Depression: Evidence, Issues, and Recommendations

This paper discusses relevant research on structured therapy techniques used in the course of cognitive behavioral therapy (CBT) that are helpful in treating older adults with depressive disorders. These findings are compared and contrasted with clinical observations pertinent to the identification of moderator/mediator and other contextual factors critical to the efficacy of CBT for the treatment of this population. While some of these techniques may be viewed as a specific type of intervention in their own right (e.g., Behavioral Activation and Lifeskills Approach), their underlying theory and specific operations are consistent with the underpinnings of other cognitive and behavioral strategies and may be frequently juxtaposed within a CBT framework, depending on the nature of the problem and the specific available resources. Several common issues identified as being problematic for clinicians new to clinical work with older adults are highlighted, and useful information on how to adapt/modify traditional CBT approaches to augment treatment outcome with older adults is provided. Clinicians who use CBT will be familiar with most components discussed, but one novel augmentation towards the development of an age-appropriate format of CBT, termed Lifeskills Approach, is included. In this approach, clinicians are encouraged to identify and incorporate evidence of prior successful coping strategies to challenges that occur across the lifespan. This approach values and respects how clients have overcome aversive life experiences to facilitate attentional deployment away from a narrative of failure to one of resilience and self-acceptance, thereby down-regulating emotional distress. An important consideration discussed is how to use behavioral activation effectively, particularly with persons who have mild cognitive impairment (MCI) or are in the early stages of dementia.

Aboriginal and Torres Strait Islander Health and Well‐Being: Implications for a Cognitive Behavioural Therapy Framework

ObjectiveIt has been acknowledged that the mental health of Aboriginal and Torres Strait Islander people has been “bedeviled” by the inappropriate application of non‐Indigenous models of mental health. To enhance Indigenous health and well‐being it is necessary for non‐Indigenous practitioners to find a culturally safe way to enter the negotiated space of cross‐cultural mental health. This will be facilitated through understanding both the points of similarity and divergence in perspectives of mental health across cultures. The current study aimed to explore urban Aboriginal and Torres Strait Islander's understandings of mental health using a social emotional well‐being and cognitive behavioural framework.MethodA qualitative research project was conducted with a sample of 19 Australian Aboriginal and Torres Strait Islander people. Data were collected via individual semi‐structured interviews and focus groups. Thematic analysis was conducted to identify themes within the data.ResultsQualitative: Four themes emerged as reflecting health and well‐being—coping skills, knowledge, social support, and connectedness. The theme of connectedness to country, family and kinship, cultural knowledge, and social networks emerged as reflecting a unique contribution to Indigenous health and well‐being. However, the themes of coping skills, knowledge, and social support shared cross‐cultural meaning. In particular, coping skills identified in the behavioural, emotional, and cognitive domains shared many cross‐culturally applicable avenues for intervention.ConclusionsTherapeutic interventions in these domains are already well established within cognitive behaviour therapies. Cross‐cultural understandings within these themes offer clinicians a culturally safe avenue for supporting Aboriginal and Torres Strait Islander health and well‐being.

USING A COGNITIVE BEHAVIORAL FRAMEWORK TO TRAIN STAFF SERVING INDIVIDUALS WHO EXPERIENCE CHRONIC HOMELESSNESS

Training in evidence‐based practices may better prepare providers to address the effect of behavioral health concerns on chronic homelessness. Through the Beck Initiative, a community–academic partnership, case managers (n = 19) were selected to incorporate a cognitive‐behavioral therapy (CBT) framework into services for chronic homelessness at seven sites in Philadelphia, PA. Details of the training components and development are presented. This training program demonstrated feasibility within these low‐demand shelter settings (79% completed training, 10% left employment during training, 10% did not complete). Feedback measures indicated positive feedback regarding acceptability, usefulness, and quality of training. Planned discharges from the shelters were significantly more frequent in the 6 months posttraining compared with the 6 months before training. The CBT framework shows early promise for improving services for people experiencing chronic homelessness. This program also demonstrates the benefit of involving community stakeholders and academic partners to address one aspect of chronic homelessness.

Religiously integrated cognitive behavioral therapy: a new method of treatment for major depression in patients with chronic medical illness.

Intervention studies have found that psychotherapeutic interventions that explicitly integrate clients' spiritual and religious beliefs in therapy are as effective, if not more so, in reducing depression than those that do not for religious clients. However, few empirical studies have examined the effectiveness of religiously (vs. spiritually) integrated psychotherapy, and no manualized mental health intervention had been developed for the medically ill with religious beliefs. To address this gap, we developed and implemented a novel religiously integrated adaptation of cognitive-behavioral therapy (CBT) for the treatment of depression in individuals with chronic medical illness. This article describes the development and implementation of the intervention. First, we provide a brief overview of CBT. Next, we describe how religious beliefs and behaviors can be integrated into a CBT framework. Finally, we describe Religiously Integrated Cognitive Behavioral Therapy (RCBT), a manualized therapeutic approach designed to assist depressed individuals to develop depression-reducing thoughts and behaviors informed by their own religious beliefs, practices, and resources. This treatment approach has been developed for 5 major world religions (Christianity, Judaism, Islam, Buddhism, and Hinduism), increasing its potential to aid the depressed medically ill from a variety of religious backgrounds.

A service evaluation of acceptability and patient experience of pharmacy consultations conducted within a CBT framework

Medicines adherence is a significant problem with up to 50% of medicines not being taken as intended by the prescriber. Of these nearly half are not taken intentionally, and this...

Cognitive behavioral approach to understanding irritable bowel syndrome.

Irritable bowel syndrome (IBS) is considered a biopsychosocial disorder, whose onset and precipitation are a consequence of interaction among multiple factors which include motility disturbances, abnormalities of gastrointestinal sensation, gut inflammation and infection, altered processing of afferent sensory information, psychological distress, and affective disturbances. Several models have been proposed in order to describe and explain IBS, each of them focusing on specific aspects or mechanisms of the disorder. This review attempts to present and discuss different determinants of IBS and its symptoms, from a cognitive behavioral therapy framework, distinguishing between the developmental predispositions and precipitants of the disorder, and its perpetuating cognitive, behavioral, affective and physiological factors. The main focus in understanding IBS will be placed on the numerous psychosocial factors, such as personality traits, early experiences, affective disturbances, altered attention and cognitions, avoidance behavior, stress, coping and social support. In conclusion, a symptom perpetuation model is proposed.

Effectiveness of Correctional Programs With Ethnically Diverse Offenders

Numerous studies have examined the effects of cognitive-behavioural therapy (CBT) on criminal recidivism, and several meta-analyses have confirmed the overall effectiveness of this approach. Few studies, however, have examined the efficacy of these programs specifically with adult offenders from diverse ethnic backgrounds. The present research uses meta-analytic techniques to examine the outcomes for Canadian federal offenders participating in correctional programs according to self-identified ethnic group (Caucasian, Aboriginal, Black, and Other). Correctional programs within the Correctional Service of Canada adhere to the Risk, Need, Responsivity principles outlined in the effective correctional literature. Within-group analyses compared offenders from the same ethnic background who participated in correctional programs with a nontreatment comparison group. Odds ratios ranged from 1.36 to 1.76, indicating significant reductions in recidivism for offenders participating in correctional programs, regardless of ethnic status. Furthermore, the difference in effect size magnitude between ethnic groups was nonsignificant suggesting offenders from a wide variety of ethnic backgrounds can benefit from correctional programs rigorously developed and implemented using a CBT framework.

Culturally Adapted Cognitive Behavioral Therapy for Body Dysmorphic Disorder: Case Examples.

Individuals with Body Dysmorphic Disorder (BDD) have distressing or impairing preoccupations with imagined or slight defects in their appearance (e.g., nose too big). BDD is a severe psychiatric disorder often associated with high rates of suicidality as well as social and occupational impairment (Phillips, Coles et al., 2005). Researchers have only recently begun to investigate psychological treatments for BDD, with available data suggesting that cognitive behavioral therapy (CBT) appears efficacious for BDD (Williams, Hadjistavropoulos, & Sharpe, 2006). To our knowledge, however, there are no reports of whether CBT for BDD can be effectively generalized to ethnic minority and other special populations. The current report suggests specific modifications within the CBT for BDD framework that might improve the effectiveness and retention rates of CBT among ethnic minority patients with BDD. Specifically, the present study describes the cases of Ben, a 40-year-old, Jewish, married male, and John, a 30-year-old, African American, single male, both with a primary diagnosis of BDD. Various treatment techniques were used to make the course of CBT more culturally responsive. This case report illustrates the challenges and benefits of integrating cultural variables into a CBT framework for BDD, and it highlights the need for more work in this area.

Presence of Mental Imagery Associated with Chronic Pelvic Pain: A Pilot Study

ObjectiveTo ascertain whether a small sample of patients with chronic pelvic pain experienced any pain-related cognitions in the form of mental images.PatientsTen women with chronic pelvic pain consecutively referred from a tertiary referral center by the physicians in charge of their treatment.Outcome measuresAn interview was used to determine the presence, emotional valence, content, and impact of cognitions about pain in the form of mental images and verbal thoughts. The Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), Spontaneous Use of Imagery Scale (SUIS), and Hospital Anxiety and Depression Scale (HADS) were completed.ResultsIn a population of patients with a prolonged duration of pain and high distress, all patients reported experiencing cognitions about pain in the form of mental images. For each patient, the most significant image was both negative in valence and intrusive. The associated emotional-behavioral pattern could be described within a cognitive behavioral therapy framework. Eight patients also reported coping imagery.ConclusionNegative pain-related cognitions in the form of intrusive mental imagery were reported by women with chronic pelvic pain. Targeting such imagery has led to interesting treatment innovation in the emotional disorders. Thus, imagery, hitherto neglected in pain phenomenology, could provide a novel target for cognitive behavioral therapy in chronic pain. These exciting yet preliminary results require replication and extension in a broader population of patients with chronic pain.

Efficacy of an Emotion-Focused Treatment for Prolonged Fatigue

Previous research findings have suggested a relationship between less adaptive emotional functioning and fatigue. The present study used a research design involving multiple baselines across participants to evaluate the efficacy of a new emotion-focused treatment for prolonged fatigue delivered in a cognitive behavioral therapy framework. The 13 adults participating in the study met the criteria for prolonged fatigue and provided fatigue baselines of 2, 5, or 8 weeks. The results indicated that the treatment was effective, with fatigue severity levels after the initiation of treatment significantly lower than that predicted by baseline patterns, as determined by the split median method of trend estimation. At 3-4 months after treatment, 8 of 11 clients who completed the treatment no longer met the criteria for prolonged fatigue.

Music therapy and emotional exploration: Exposing substance abuse clients to the experiences of non-drug-induced emotions

Recent cognitive behavioral therapy (CBT) approaches to treatment of substance use disorder (SUD) have emphasized the need for clients to explore emotional regulation and experiential avoidance. This study aimed to determine whether music therapy programs situated within a CBT framework facilitated the exploration of emotions in 24 adults with SUD attending a hospital open group CBT program. In a 7-week trial, the impact of a single music therapy session on participants’ emotional experience was assessed using a self-report questionnaire at the end of each participant's first session. Results indicated that music therapy sessions facilitate the experiencing of predominantly positive emotions, and that these were experienced to a moderate or high degree. Participants reported that music therapy was beneficial in allowing them to experience emotions without the need for substance use. It is recommended that clinicians include interventions that encourage the exploration of negative emotions so that clients can experience these in a safe environment.

Cognitive Behavioural Therapy and Homelessness: A Case Series Pilot Study

This paper describes a project set up to treat four homeless men using cognitive behavioural therapy (CBT). The referral criteria were that individuals had alcohol and/or substance misuse problems, were roofless (i.e. sleeping rough) immediately before the intervention began and found it difficult or impossible to access hostel places in Southampton. Excessive alcohol use, violence (against self, others and property) and prison sentences were all features of their presentation. The project involved three levels of CBT intervention provided by the clinical psychologist: 1) training for the staff to enable them to work within this model; 2) continued supervision within model to ensure consistency and sustainability; 3) individual formulation (description of the problem within the CBT framework) and psychotherapy. The house itself was also run on a collaborative basis. A number of measures including mental health and social functioning constructs were used to evaluate the project, in addition to some qualitative data. All residents reduced incidents of theft, violence and alcohol consumption. Risk to self and others was also reduced for all residents. Perceived self-efficacy increased slightly for all residents, and staff perceived that they could be more effective, less hopeless, and therefore possibly less stressed as a result of training. More data will be gathered over time.

Training case managers to deliver focused psychological strategies.

Anxiety and mood disorders are prevalent in the Australian community and can be functionally disabling. Access to treatment for these disorders can be difficult, particularly in rural areas where there is limited availability of specialist mental health practitioners such as psychiatrists and clinical psychologists. One way to address this problem is to improve the skills of local mental health practitioners in recognizing and providing treatment for these disorders. This paper describes a program that aimed to enhance access to psychological treatment for depression and anxiety by improving the skills of rural mental health case managers through training and education and support by psychiatrists and clinical psychologists. Thirty-two case managers participated in the program which delivered 10 training modules using a cognitive behavioural therapy framework. Case managers consisted primarily of psychiatric nurses, with others having social work or psychology backgrounds. Participants were assessed pre- and post-training using quantitative and qualitative measures. The effect of the training was noted in several areas including attitudinal changes, improved knowledge of psychological therapies, and changes to stated practice. However, there was concern expressed by participants about their competence and confidence to translate skills learned into practice. While the results of such a program are promising, they highlight some of the complexities of delivering such programs in rural settings.