Blake Farran Dear

Large language models are increasingly used within and alongside therapy. As large language models perform more therapy functions, questions arise about what the future might hold for therapists and what they will do. We argue that the enduring therapist role in the age of AI-assisted care is currently best understood through relational, adaptive, and accountability functions. These functions include therapeutic challenge, use of the therapeutic relationship as a mechanism of change, rupture detection and repair, bearing witness to suffering, calibration of pace and treatment burden, and clinical judgment under uncertainty across the broader care pathway. Drawing on psychotherapy theory, digital mental health research, the declarative-procedural-reflective model by Bennett-Levy, and our clinical experience, we propose a clinically informed, hypothesis-generating, relational-adaptive-accountability framework. This framework is intended to support further empirical testing and may have implications for workforce development, supervision, training, and service design.

Objective: Persistent pain affects around 20% of Australians after total knee replacement (TKR), yet no dedicated Australian model of care exists to address this unmet need. The Early Pain Intervention after Knee replacement (EPIK) model is being developed, informed by the effective and cost‐effective UK Support and Treatment After Replacement care pathway and extensive multistakeholder engagement. Before evaluating the EPIK model of care in a randomized controlled trial, it must be adapted for the Australian context. This qualitative study aimed to explore stakeholders’ perspectives to inform this adaptation. Methods: This qualitative descriptive study, guided by a subtle realist ontologic stance and a pragmatic epistemology, used semistructured interviews with key stakeholders across Australia. A preinterview screening questionnaire captured demographic, clinical, and professional characteristics which informed purposive sampling to ensure diverse views. Interviews were audio‐recorded, transcribed verbatim, and analyzed using inductive analysis. Results: Sixty‐one participants were interviewed (9 patients, 20 physiotherapists, 15 orthopedic surgeons, 14 general practitioners, 1 nurse, and 2 health fund managers) across all six states and the Australian Capital Territory, with 75% residing in metropolitan areas. We identified four key themes: (1) living with pain after TKR, (2) acceptability and value of EPIK, (3) defining the scope of the EPIK care coordinator, and (4) infrastructure and system‐level challenges. Conclusion: The EPIK model was well accepted by stakeholders as the first approach designed to improve care coordination for Australians with persistent pain after TKR, with potential to support a more efficient and patient‐centered health care system. These insights will inform the EPIK model, which will be tested in a registry‐nested randomized controlled trial.

Objectives: To evaluate the efficacy of the online cognitive-behavioral therapy (CBT)-based Pain Course on levels of pain, disability, and psychological well-being in adults with chronic pain living in Ireland, with a 2-year follow-up. Methods: One hundred thirty-three people were randomly assigned (ISRCTN 11292570) to either the Pain Course (n=66), comprising 5 lessons delivered over 8 weeks with clinician support, or to delayed access with usual care in the interim (n=67). The primary outcome was pain-related disability while secondary outcomes were depression, anxiety and average pain, and tertiary outcomes were pain self-efficacy, fear of movement, and pain acceptance. Outcomes were collected at post-treatment, and for the treatment group at 3-month follow-up (n=55 [83% retention]) and 2-year follow-up (n=29 [44% retention]). Results: Course completion rate was 80%. Improvements were significantly greater for Treatment Group participants compared with Control Group on measures of disability, anxiety, depression, and average pain at post-treatment (Cohen d =.48-1.00). Improvements in outcomes were in the range 12% to 44% and benefits were maintained or improved at 3-month follow-up. All tertiary outcomes also improved in the treatment group. There was substantial attrition at 2-year follow-up, but for those who responded, treatment effects were largely maintained. High treatment satisfaction ratings were expressed by over 80% of participants. Average clinician contact, per participant, was 81.06 minutes. Discussion: The findings of the current study in an Irish sample corroborate those of previous Pain Course efficacy trials and highlight the potential benefits of internet-based interventions for adults with chronic pain, with treatment effects maintained for up to 2 years in those who responded.

Background: Geography and socioeconomic disadvantage impede access to appropriate services for rural and remote-dwelling children with complex developmental and mental health needs. Telehealth offers opportunities to increase access to essential health and well-being services for people with complex needs who live in rural and remote areas, whose experiences of mental ill-health are frequently compounded by social marginalization and economic disadvantage. Objective: This study aimed to describe caregivers’ and service providers’ perspectives on the challenges and value of telehealth services for rural and remote children by drawing on experiences within a specialist service (Royal Far West; RFW) that provides mental and developmental health services to rural and remote-dwelling children and families in Australia. Methods: Participants included a convenience sample of caregivers of children who use RFW services (n=11) and service providers from RFW (n=21). Deidentified interview transcript data were analyzed thematically using framework analysis. Results: Caregivers were generally enthusiastic about telehealth but acknowledged potential technological limitations and challenges to effectively engaging some children. While acknowledging its value and importance, RFW service providers identified additional challenges with providing telehealth, such as limited capacity for some detailed clinical assessments and potential child and family risk and safety issues. Conclusions: Telehealth remains a vital option within multidisciplinary services to improve access and outcomes for children in rural and remote communities who present with complex mental and developmental health needs. Despite challenges, rural and remote caregivers and RFW service providers identified telehealth as a beneficial, accessible, and effective component of multidisciplinary care for children with complex mental and developmental health needs. These caregiver and service provider perspectives will inform ongoing service development, research, and advocacy.

A meaningful proportion of adults with anxiety and depression symptoms do not seek out psychological therapy. Studies show that higher treatment credibility (how logical therapy seems) and outcome expectations (perceptions of therapy effectiveness) are associated with greater treatment uptake. Most research has included individuals in therapy, who may perceive therapy as more logical and effective than those not seeking treatment. No studies have investigated these constructs in detail in the general community. This study examined perceptions of psychological therapy for anxiety and depression symptoms, and its relationship to treatment willingness in a community sample of Australian adults. Participant factors associated with credibility and expectations were explored. Participants (n = 911) completed an online survey covering demographic information, anxiety and depression symptoms, credibility and expectations, coping self-efficacy, and therapy willingness. Results indicated that participants held positive beliefs about therapy. Credibility and expectations uniquely predicted willingness to engage in therapy. Participant characteristics explained little variance in credibility and expectations. The findings have important implications for improving treatment uptake: credibility and expectations should be considered and could be targeted via public health interventions and in primary care settings. Research exploring optimal approaches for increasing credibility and expectations would be a valuable future direction.

BackgroundIn routine-care Internet-delivered cognitive behaviour therapy (ICBT), engagement may be better understood as a staged process (e.g., early discontinuation vs full completion), yet many studies use a single dropout definition and seldom test whether prediction models remain useful as services evolve over time.ObjectiveTo identify baseline predictors of completion and early dropout in routine-care ICBT and evaluate temporal transportability from earlier to later service years.MethodsWe analyzed de-identified routine-care data from a transdiagnostic ICBT program delivered from 2013 to 2024. Outcomes were completion (all five lessons vs fewer) and early dropout (0–1 lesson vs two or more). Multivariable logistic regression models used baseline demographic, clinical, and contextual intake variables. Models were developed in TRAIN (2013–2021) and applied without refitting to TEST (2022–2024). TEST performance was summarized using Brier score, area under the curve (AUC), and calibration.ResultsDemographic factors, including age, education, ethnicity, and relationship status, were more consistently associated with engagement than baseline symptom severity. Completion predictions showed modest discrimination and modest overprediction in TEST, whereas early-dropout predictions showed weaker discrimination, slight underprediction, and limited separation of higher- and lower-risk clients.ConclusionsScreening variables were more useful for predicting completion than early dropout. Engagement prediction in routine-care ICBT should be temporally evaluated and monitored for calibration drift. Understanding and preventing early dropout may require early in-treatment indicators, such as initial logins, lesson access, and early therapist contact, in addition to baseline screening variables.

Depression and anxiety are common but most adults experiencing these symptoms do not receive psychological treatment. Ultra-brief psychological treatments are a time-limited and potentially lower cost option for those who would otherwise not receive treatment. This prospectively registered review examined the acceptability and efficacy of ultra-brief psychological treatments for adults with depression or anxiety symptoms. A systematic search was undertaken up to April 2025. All clinical trials examining an ultra-brief psychological treatment for adults with depression or anxiety symptoms were included. This review returned 16,670 results and included 34 studies (N = 3,679). High rates of uptake (91% [95% CI 86, 94]) and completion (96% [95% CI 90, 98]) were reported. Compared to control, treatment resulted in small to moderate reductions in depression g = 0.35 (k = 20, 95% CI 0.13, 0.56) and moderate reductions in anxiety g = 0.51 (k = 14, 95% CI 0.40, 0.61) at post-treatment. Within-group effects appear to be maintained at follow-up. Overall heterogeneity was high; several moderators of between-group and within-group effects were identified. Control groups and follow-up periods varied greatly. Ultra-brief treatments appear to be acceptable and associated with significant symptom improvements. Larger clinical trials with longer follow-up periods are needed.

BACKGROUND Depressive and anxiety disorders contribute substantially to the global burden of disease. Many patients wait a long time for outpatient psychotherapy, during which symptoms may persist or worsen. Digital interventions may help bridge this gap, and ultra-brief treatments (UBTs) are especially promising because they are scalable, low-threshold, and require few resources. However, it remains unclear how such interventions should be constructed to maximize reductions in symptoms of depression and anxiety and meet the needs of patients waiting for face-to-face (f2f) psychotherapy. OBJECTIVE This study aims to optimize a digital UBT for patients waiting for outpatient psychotherapy by testing three intervention components: therapeutic content (resource-focused vs. problem-focused), guidance (with vs without human support), and expectation-optimization elements (with vs without). The primary goal is to identify the most promising UBT configuration for reducing anxiety and depressive symptoms. The study will also examine patient experiences with the UBT to gain knowledge on how a UBT should be constructed to best suit their needs. METHODS This randomized, balanced 2 × 2 × 2 factorial trial includes eight conditions. A total of 312 participants waiting for outpatient f2f-psychotherapy who meet diagnostic criteria for a depressive disorder, anxiety disorder, or both will be randomized. The primary endpoint is anxiety and depressive symptom severity 2 weeks after randomization, measured with the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS). Secondary outcomes include depression symptoms, quality of life, anxiety symptoms, treatment satisfaction, negative effects, treatment expectations, perceived resource activation and problem mastery, and working alliance. Assessments will be conducted at baseline and 2, 5, 9, and 24 weeks after randomization. Qualitative interviews on patient experiences with the UBT will be conducted with a subsample (N = 40) following the 9-week assessment. RESULTS Recruitment started in September 2025. As of the date of manuscript submission in May 2026, 108 participants have been randomized and recruitment is ongoing. First results are expected in late 2027. CONCLUSIONS This trial examines how a digital UBT should be constructed to reduce depression and anxiety symptoms in patients waiting for face-to-face therapy. The factorial design will help identify which components contribute to symptom improvement. Findings are expected to guide the development of an optimized, scalable digital intervention for future testing and potential integration into routine care. CLINICALTRIAL ClinicalTrials.gov, NCT07167849.