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When the going gets tough: overcoming common challenges to progress in CBT when treating persistent treatment resistant depression

Anne Garland

12 Mar 2024


Following the publication of the findings of the first World Health organisation (WHO) Global Burden of Disease (GBD) study in 2000, depression was declared ‘a major public health problem that affects patients and society’.  It is estimated depression affects over 120 million people worldwide with a lifetime prevalence ranging from 10% - 15% (Lepine and Briley, 2011).   It is well established in the research literature that depression is a relapsing and recurring illness. Taking the lifetime risk of depressive relapse and recurrence into consideration the human and economic cost of depression is immense.  The second WHO GBD study published in 2010 cites that within the mental and substance use disorders group, at 40.5%, depressive disorders account for the highest proportion of burden across all mental disorders both in terms of the most Disability-Adjusted-Life-Years (DALYs) and, at 42.5%, the most Years-Lived with Disability (YLDs). Further, in terms of the ten leading causes of total burden in 2010, mental disorders and substance use disorders accounted for 7.4% DALYs and 22.9% YLDs. A more recent WHO Global Burden of Disease (GBD) study (GBD, 2017), identified depression as possessing the greatest global burden of disease and declared it to be the leading cause of DALYs lost due to ill-health.


The workshop will focus on four common areas that can present as obstacles to implementing CBT treatment for persistent, treatment resistant depression which arise in the context of Adverse Childhood Events (ACEs) and their resonance in adult life:

• Interpersonal processes and the therapeutic relationship
• The role of avoidance and dependency as coping strategies
• Working with self-conscious emotions: shame, guilt, embarrassment, pride and hubris.

The workshop will concentrate on defining the parameters of these factors and the challenges they present, illustrated with clinical case examples. How to adapt CBT interventions when working with these factors will be presented. Consideration will be given to therapist factors in patient engagement and the role of the therapeutic relationship and CBT formulation as the bedrock for in engaging the client in approaching these obstacles. Workshop participants will have opportunity to bring their own clinical cases for discussion.

Learning Objectives

• To have the opportunity to consider the relationship between Adverse Childhood Events and persistent, treatment resistant depression.
• To have the opportunity through to examine interpersonal processes in CBT for persistent treatment resistant depression
• To have the opportunity to explore the challenges subjugation brings when using CBT to treat persistent treatment resistant depression.
• To develop theoretical knowledge in understanding the role of self-conscious emotions in persistent treatment resistant depression.
• For participants to have the opportunity to learn how to use CBT to tackle self-conscious emotions.

Training Modalities

The workshop will be delivered in discrete sections and will use a range of training modalities including didactic teaching followed by question and answers and some self- experiential components.

Key References

Morriss, R., Garland, A., Nixon, N., Boliang Guo., James, M., Kaylor-Hughes., C., Moore, R., Ramana, A., Sampson, C., Sweeney, T. and Dalgleish, T. (2016) The Efficacy and cost effectiveness of a specialist depression service versus specialist mental healthcare to manage persistent depression: a randomised controlled trial. The Lancet Psychiatry, 3 (9): pp. 821-831.

Newman, C.F. (2020). Principle-informed CBT in a complex case. Cognitive and Behavioral Practice. 

Thomson, L., Barker, M., Kaylor-Hughes, C., Garland, A., Ramana, R., Morriss, R., Hammond, E., Hopkins, G. and Simpson, S. (2018) How is a specialist depression service effective for persistent moderate to severe depressive disorder? A qualitative study of service user experience BMC Psychiatry, 18 (1) 194

Crandall, A.A’; Miller, J.R., Cheung, A., Novilla, K., Glade, R., Novilla, M.L., Magnusson, M., Leavitt, B.L., Barnes, M.D., and Hanson, L. (2019) ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health Child Abuse and Neglect, vol. 96.

About the presenter

Dr Anne Garland, Consultant Psychotherapist is the lead for depression at the Oxford Cognitive Therapy Centre, part of Oxford Health NHS Foundation Trust. Anne is a mental health nurse by profession, trained in both behavioural and cognitive psychotherapy. Anne has 32 years’ experience of working clinically using CBT and has specialised in treating persistent, treatment resistant depression for the last twenty five years. Anne has a national and international reputation as a CBT trainer with a focus on fundamental CBT skills, CBT for depression and complexity, formulation and clinical supervision. Anne has been involved both as a collaborator and grant holder in funded RCTs testing the clinical and cost effectiveness of CBT in the treatment of depression and in 2009 established the Nottingham Specialist Depression Service. This is a unique service within England offering NICE recommended pharmacological and psychological treatments for persistent, treatment resistant depression within a collaborative care model. Anne has published widely in the field of depression and CBT. Anne is also trained in MBCT and Compassion Focused Therapy. Anne has both a clinical and academic interest in the role of shame and self-criticism in depression

Who should attend

This workshop is suitable for any clinician working with persistent treatment resistant depression. The workshop will assume participants have an intermediate level of CBT knowledge and skill and are currently working with persistent treatment resistant depression.

Low Intensity clinical contact hours survey - BABCP Low Intensity Special Interest Group

Please click below if you are interested in contributing to the survey.


The BACP Low Intensity SIG are interested in the impact of clinical contact hours on Low Intensity/Wellbeing Practitioner wellbeing. This questionnaire contains six multi-choice questions and a free text box for you to share your experiences. The answers to these questions will help the BABCP SIG plan how to meet CPD topics and other developments within the SIG.  The SIG hope to produce a write up of the answers to this questionnaire to be shared with SIG members and to be used in training.

View Survey

This FREE conference is for Psychological Wellbeing Practitioners working in Talking Therapies for Anxiety and Depression services and is brought to you by Bespoke Mental Health in collaboration with the NHS England Talking Therapies National PWP Leads Network

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