Dave Dagnan

Autistic people experience depression at a higher rate than those who are not autistic. In England, therapy for depression is primarily delivered through NHS Talking Therapies for anxiety and depression (NHS TTad) services. These services are highly structured and deliver evidence‐based therapies; one of the evidence‐based therapies delivered in these services is Person‐Centred Experiential Counselling for Depression (PCE‐CfD). There are no studies describing how PCE‐CfD is offered to autistic people in NHS TTad. This paper presents the experience of six person‐centred counsellors in working with autistic people in NHS TTad. Counsellors were interviewed and the interviews were analysed using Interpretive Phenomenological Analysis (IPA). Counsellors experience tensions between their identity as person‐centred counsellors and a perceived and/or expected need to adapt to the needs of autistic people. This tension, and the ways in which counsellors respond and manage their responses, is evident across all emerging themes. The results are discussed in the context of the literature on counselling with autistic people. Implications for future research and counsellor training are discussed.

There is no research that considers service user perspectives on the quality of Community Teams for People with Learning Disabilities (CTPLDs) from within standard quality assessment frameworks. Two hundred and sixty-seven people with intellectual disabilities and 226 significant others completed an online survey detailing their experiences of six specialist CTPLDs in the North of England. Data were analysed using framework analysis. The data from service users and significant others were coded into the attributes of the Peripheral-Core-Pivotal (P-C-P) framework. Responses emphasised the Core attribute which describes service processes (78.0% of responses from people with intellectual disabilities and 73.8% of responses from significant others) and include aspects of empathy, assurance, reliability, and responsiveness, over Peripheral (service structure) and Pivotal (service outcome) attributes. We discuss the advantages of using a quality framework such as the P-C-P and the important aspects of service quality identified by people with intellectual disabilities and their significant others.

Background: There is an increasing interest in therapeutic alliance within talking therapy for people with intellectual disability. The applicability of frameworks such as Bordin's (1979) model of therapy alliance has not been considered. Method: A review of qualitative literature on people with intellectual disability's experience of talking therapy identified 23 papers. A ‘best fit’ framework synthesis was used to explore the applicability of Bordin's model to the experiences of people with intellectual disability in therapy. Results: The analysis supported Bordin's core themes of bond, task and goals. An additional theme was identified concerning the extension of the therapist's role to include active advocacy and support in the lives of people with intellectual disability outside of therapy. Conclusion: This study identified the experience of people with intellectual disability in therapy as consistent with Bordin's model and suggests that further research specific to the model would be productive.

This paper describes the evaluation of a simple service adaptation and associated brief training for NHS Talking Therapies for Anxiety and Depression (NHS TTad) staff on working with autistic people. A simple question regarding whether clients identified themselves as autistic and an associated data system flag was introduced to an NHS TTad service. A brief training regarding the use of the flag, a brief overview of autism and a consideration of general adaptations that might help autistic people was developed. Core outcomes of confidence and therapy self-efficacy were reported for pre-training, immediately post-training and at three months post-training. At three-month follow-up, six therapists were interviewed to explore changes in practice following the training. There were significant changes in confidence and therapeutic self-efficacy post-training that were maintained at three-month follow-up. Therapists report several changes to practice that they related to the training. This is the first paper to describe and evaluate training for therapists in NHS TTad on working with autistic people. Key learning aims: (1) To describe some of the challenges to NHS TTad services in working with autistic people. (2) To describe the system adaptation and therapist training introduced to this service and the approach to evaluation. (3) To report outcomes from the evaluation of the training for NHS TTad therapists in working with autistic adults. (4) To consider further research and practice in the processes to make NHS TTad services more accessible and effective for autistic adults.

Autistic adults experience higher rates of common mental health conditions than non-autistic adults and report greater difficulties accessing mental health services. In England, psychological therapy for anxiety and depression is primarily delivered through NHS Talking Therapies for Anxiety and Depression (TTad), but little is yet known about autistic adults’ experiences of these services. Using Interpretative Phenomenological Analysis, we conducted in-depth online interviews with five formally diagnosed autistic adults, all in their twenties at time of interview, who had received TTad therapy for depression and/or anxiety conditions. Four superordinate themes emerged: Pre-Therapeutic Context , highlighting how participants’ autism diagnoses had been transformative, and how diagnosis had shaped their therapy experiences; Therapeutic Relationship , emphasising the importance of a therapist's flexibility and understanding of autism, and the damage that could be done by them minimising the relevance of participants’ autism itself; Rigidity and Quantification , addressing challenges with standardised approaches and outcome measures; and Training and Adaptation , identifying how therapists often developed more effective approaches over time, to demonstrably positive therapeutic ends. Findings suggest that TTad services (and analogous international programmes) may require greater flexibility in delivery, enhanced autism awareness among practitioners, and potentially extended treatment timeframes for autistic clients. Lay The experiences of autistic adults who received talking therapy for depression and anxiety disorders We are a group of academic researchers, psychological therapists, and autistic individuals, with some of us being more than one of these things. We investigated how autistic adults experience talking therapy services in England, specifically focusing on their experiences with depression and anxiety treatment. We interviewed five autistic adults in their twenties who had received therapy through the NHS Talking Therapies for Anxiety and Depression (TTad) service. Our findings revealed that participants’ journeys to autism diagnosis significantly shaped how they engaged with therapy, and that therapists should not underestimate the difficulties of this journey. Participants reported that their therapists sometimes seemed unprepared to understand how autism impacts mental health. They also found the rigid structure of therapy and progress measurement methods challenging. However, therapy became more helpful when therapists demonstrated flexibility and willingness to adapt their approach. The participants emphasised the importance of autistic people continuing to access these services, as few alternatives were available to them when experiencing depression or anxiety. We recommend training for psychological therapists to better understand the specific needs of autistic people and how to adapt therapy approaches to make them more effective.

Background: The nine‐item Physical Health Questionnaire (PHQ‐9), the seven‐item Generalised Anxiety Disorder scale (GAD‐7) and the Work and Social Adjustment Scale (WSAS) are, respectively, self‐report measures of depression, generalised anxiety, and the impact of mental health on the person's personal functioning that are widely used in mainstream mental health services in England. The psychometric properties of these scales when used with people with intellectual disabilities have not been established.Method: Item level data for the PHQ‐9 (n = 128), GAD‐7 (n = 124) and WSAS (n = 133) for people with intellectual disabilities in an English NHS Talking Therapies for anxiety and depression (NHSTT) service in the north of England were analysed using internal reliability statistics and confirmatory factor analysis.Results: In this study, the full PHQ‐9, GAD‐7 and WSAS have Cronbach's α of 0.81, 0.84 and 0.81, respectively, and have acceptable ranges of corrected item‐total correlations. The two‐factor structures for the PHQ‐9 and the GAD‐7 were a better fit than single‐factor structures, although the single‐factor fit and the correlation between the two factors within each scale suggest that their use as a single scale is justified. The single‐factor structure for the WSAS was a good fit.Conclusions: In this study, the widely used PHQ‐9, GAD‐7 and WSAS demonstrate internal consistency values and factor analysis structure similar to those for individuals without intellectual disabilities. The data support the use of these measures for people with intellectual disabilities attending routine primary care mental health services.

Introduction Depression is three to four times more prevalent in autistic people and is related to reduced quality of life. There is a need for empirically supported psychological interventions for depression specifically adapted to meet the needs of autistic adults. ADEPT-2 aims to establish the clinical and cost-effectiveness of an adapted low-intensity psychological intervention (guided self-help) for depression in autistic adults. Methods and analysis A two parallel-group multicentre pragmatic randomised controlled trial investigating the effectiveness of GSH for depression in autistic adults. Participants (n=248) aged ≥18 years with a clinical diagnosis of autism currently experiencing depression will be randomised to GSH or treatment as usual (TAU). GSH is a low-intensity psychological intervention based on the principles of behavioural activation adapted for autism. GSH comprises informational materials for nine individual sessions facilitated online by a GSH coach who has received training and supervision in delivering the intervention. The primary outcome will be Beck Depression Inventory-II depression scores at 16 weeks post randomisation with follow-up measures at 32 and 52 weeks. Additional measures of anxiety, patient-rated global improvement, quality of life, work and social adjustment, positive and negative affect will be measured 16 and 52 weeks post randomisation. The primary health economic analysis will assess the cost-effectiveness of GSH compared with TAU over 52 weeks, from a societal perspective including the National Health Service, personal social services, personal expenses, voluntary services and productivity. An embedded qualitative study will explore the acceptability, experiences and adherence of participants and therapists to treatment principles. Ethics and dissemination This trial has been approved by the East of England - Essex Research Ethics Committee on 10 June 2022 (REC Reference number: 22/EE/0091). The findings of the research will be submitted for publication in peer-reviewed journals and disseminated in an appropriate format to trial participants and the wider public. Trial registration number ISRCTN17547011.

Objectives: We report the effect of quality of therapy delivery on outcomes in a randomized, controlled trial of behavioural activation (BA) and guided self‐help (GSH) for depression in adults with intellectual disabilities. Methods: A study specific measure of quality was used in a linear mixed effect model to determine the effects therapy and therapy quality on therapy outcome. Results: There was a significant interaction between quality and treatment type, with lower quality therapy associated with better outcome for GSH but poorer outcome for BA, with little difference in outcomes at higher levels of therapy quality. Conclusions: Factors suggesting high quality in individualized BA may indicate problematic engagement for GSH. More research into processes in therapy for people with intellectual disabilities is required.

This paper is an introduction to adaptations to make cognitive behaviour therapy (CBT) more accessible to people with intellectual disabilities. It is intended to inform therapists who may work with people with intellectual disabilities in mainstream services. The paper describes adaptations that consider neuropsychological processes, such as memory, and executive functions, such as planning, problem solving and self-regulation, and identifies that these factors are not unique to people with intellectual disabilities. We describe adaptations based on a review of literature describing CBT for people with intellectual disabilities (Surley and Dagnan, 2019) and draw on clinical experience to give examples of adaptations where possible. The paper particularly emphasises the generalisability of adaptations used with people with intellectual disabilities to therapy with wider populations and suggests that CBT therapists working in mainstream services will have the skills to be able to adapt therapy for people with intellectual disabilities. Key learning aims: (1) To overview the evidence base supporting the use of CBT with people with intellectual disabilities. (2) To describe the epidemiology of intellectual disability and discuss its implications for the generalisability of adaptations discussed in this paper. (3) To describe a range of adaptations to make CBT more accessible people with intellectual disabilities. (4) To consider whether such adaptations are part of the skill set of CBT therapists mainly working with people without intellectual disabilities.