Abstract. In recent years that has been an increasing interest in supervision within the UK's cognitive behaviour therapy (CBT) community. This is because the role of supervision has begun to be recognized in relation to the delivery of effective clinical services (Department of Health, 1998), and because of a clear recognition of the need to ensure that CBT practitioners are competent. Perhaps less well recognized in CBT are a number of interesting educational approaches to supervision, ones that may make supervision more successful. This paper summarizes some of these theories from a CBT perspective. Whilst the evidence base does not yet justify being too prescriptive, it is argued that some of these theories, such as Vygotsky's notion of the "Zone of Proximal Development", provide helpful prompts for reflecting on CBT supervision. An integrative model is constructed from these theories, with illustrative examples and suggestions for future research.

Abstract.Cognitive behavioural therapy (CBT) for major depression is an effective treatment, but outcomes for complex cases, with co-occurring biological, psychological and social factors, are variable. Complexity factors can cause treatment to become diffuse, disorganized and over-complicated. At Step 3, disorder-specific protocols should be provided with therapy kept as simple as possible and delivered responsively, e.g. barriers to treatment should be tackled, ensure the client is well-prepared and seek to form a strong therapeutic alliance. At Step 4, if disorder-specific protocols have been ineffective, the priority is to formulate how complexity factors are interacting with the client's depression. An individualized formulation is used to carefully target these interactions. The treatment is still evidence-based and simple at the point of delivery, but there is greater emphasis on case-level interactions that are unique to each individual. Case examples are used to illustrate both approaches.

Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients are difficult to treat: they are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk, and are prone to drop out, non-response or relapse. CBT based on a self-regulation model (SR-CBT) has been developed for this client group which incorporates aspects of first, second and third wave therapies. The model and treatment components are described in a concurrent article (Barton et al., 2022). The aims of this study were: (1) to illustrate the application of high dose SR-CBT in a difficult-to-treat case, including treatment decisions, therapy process and outcomes, and (2) to highlight the similarities and differences between SR-CBT and standard CBT models. A single case quasi-experimental design was used with a depressed client who was an active participant in treatment decisions, data collection and interpretation. The client had highly recurrent depression with atypical features and had received several psychological therapies prior to receiving SR-CBT, including standard CBT. The client responded well to SR-CBT over a 10-month acute phase: compared with baseline, her moods were less severe and less reactive to setbacks and challenges. Over a 15-month maintenance phase, with approximately monthly booster sessions, the client maintained these gains and further stabilized her mood. High dose SR-CBT was effective in treating depression in a client who had not received lasting benefit from standard CBT and other therapies. An extended maintenance phase had a stabilizing effect and the client did not relapse. Further empirical studies are underway to replicate these results. Key learning aims (1) To find out similarities and differences between self-regulation CBT and other CBT models; (2) To discover how self-regulation CBT treatment components are delivered in a bespoke way, based on the needs of the individual case; (3) To consider the advantages of using single case methods in routine clinical practice, particularly with difficult-to-treat cases.

Background: Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients do not complete therapy, do not respond to it, or subsequently relapse. Non-responders, and those at risk of relapse, are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk. This is a heterogeneous group of clients who are currently difficult to treat. Aim: The aim was to develop a CBT model of depression that will be effective for difficult-to-treat clients who have not responded to standard CBT. Method: The method was to unify theory, evidence and clinical strategies within the field of CBT to develop an integrated CBT model. Single case methods were used to develop the treatment components. Results: A self-regulation model of depression has been developed. It proposes that depression is maintained by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life goals. Depression is more difficult to treat when these processes become interlocked. Treatment based on the model builds self-regulation skills and restructures self-identity, rather than target negative beliefs. A bespoke therapy plan is formed out of ten treatment components, based on an individual case formulation. Conclusions: A self-regulation model of depression is proposed that integrates theory, evidence and practice within the field of CBT. It has been developed with difficult-to-treat cases as its primary purpose. A case example is described in a concurrent article (Barton et al., 2022) and further empirical tests are on-going.