Accurately evaluating how competently one is performing can be a precursor to seeking training and supervision, therefore contributing to safe, effective practice. Little is known about what predicts accurate self-evaluation. Prior research findings are inconsistent, with overestimation of self-rated competence in some studies and underestimation in others. We aimed to explore the relationship between therapists' reflective ability and the level of agreement between self-rated competence and competence rated by an experienced CBT assessor. Thirteen trainees undertaking a postgraduate CBT diploma submitted a series of recordings accompanied by self-ratings using the Cognitive Therapy Scale – Revised (CTS-R) and related written reflective analyses. Independent assessors marked the written analyses using a standardized marking scheme and rated the therapy sessions using the CTS-R. Trainees tended to overestimate or underestimate their competence in comparison to the independent assessors. The level of agreement between the assessors' ratings and self-evaluation of competence tended to improve during training, while reflective ability did not. Reflective ability was significantly related to level of agreement between self-rated and assessor-rated competence. Trainees do not consistently demonstrate the bias for overestimating their competence previously found in qualified therapists. During training, the tendency of an individual to over- or underestimate their competence may not remain stable, but tends to become more consistent with ratings undertaken by an experienced CBT assessor. Trainees who were rated as more reflective, tended to agree more closely with independent assessors on evaluation of competence. Therefore, enhancing reflective ability may help therapists to more accurately self-evaluate their competence.

Government policy, like evaluations of clinical practice, indicates the growing importance of supervision in fostering practitioner development and in improving the fidelity of therapies. However, instruments with which to measure competent supervision are often problematic, thereby hampering these key activities (e.g. they are rare, rely on self-ratings by participants, and psychometric data can be limited). To contribute to progress, this paper reviews the current options for measuring competent clinical supervision by means of direct observation, a favoured approach within cognitive behaviour therapy (CBT). We systematically reviewed 10 existing instruments that were designed to observe and quantify competent supervision, focusing on three broad criteria for sound measurement (i.e. an instrument's Design, Implementation, and Yield: DIY). Suggestions for future research on instruments that can fulfil the functions that are provided distinctively through direct observation are outlined.

There is growing evidence that Behavioural Activation is an effective treatment for older adults with depression. However, there is a lack of detail given in studies about any adaptations made to interventions or efforts made to remove treatment barriers. Factors such as co-morbid physical health problems, cognitive impairment and problems with social support suggest there may be specific treatment considerations when developing interventions for this group. This article aims to describe adaptations made to a general adult Behavioural Activation manual using literature on treatment factors for older adults as an organizational framework. This information may be of use to mental health workers delivering behavioural interventions to older adults with depression and documents the initial phase of developing a complex intervention.

Therapist cognitions about trauma-focused psychological therapies can affect our implementation of evidence-based therapies for post-traumatic stress disorder (PTSD), potentially reducing their effectiveness. Based on observations gleaned from teaching and supervising one of these treatments, cognitive therapy for PTSD (CT-PTSD), ten common ‘misconceptions’ were identified. These included misconceptions about the suitability of the treatment for some types of trauma and/or emotions, the need for stabilisation prior to memory work, the danger of ‘retraumatising’ patients with memory-focused work, the risks of using memory-focused techniques with patients who dissociate, the remote use of trauma-focused techniques, and the perception of trauma-focused CBT as inflexible. In this article, these misconceptions are analysed in light of existing evidence and guidance is provided on using trauma-focused CT-PTSD with a broad range of presentations.

The development and conceptual relationship of the constructs of threat appraisal (TA) and intolerance of uncertainty (IU) are explored in the context of anxiety disorders. A narrative review tracking the development of these constructs and their relationship is undertaken. There is some evidence to suggest that the interaction between the components of threat appraisal (probability × cost) may partially account for or provide a theoretical framework which explains presenting levels of anxiety. Furthermore, research suggested that IU is a construct which contributes to a broad range of anxiety disorders. It was concluded that distinctive cognitive biases linked with IU – such as interpreting ambiguous and uncertain (both positive and negative) information as highly concerning – suggests that IU is interpreted negatively independent of threat appraisal. These findings mean a number of issues remain unclear, including whether IU in anxiety-provoking situations is sufficient in itself – independent of threat appraisal – in eliciting high levels of anxiety. Additionally, it is unclear whether threat appraisal and IU act as independent constructs, or more in an interactive manner in anxiety. To achieve further clarity on these issues, methodological recommendations for future research are made.

NICE Clinical Guideline no. 78 recently identified Dialectical Behaviour Therapy (DBT) as an appropriate treatment approach for the effective treatment of suicidal behaviours in the context of borderline personality disorder. Uniquely among the cognitive behavioural therapies DBT is a team-based treatment. This paper focuses on the task of selecting and training a team before considering issues in the training and supervision of therapists learning this approach.

Vaginismus in one of the most frequent causes of non-consummation of marriage, and of infertility, in Arab-Muslim societies. Cognitive behavioural therapy (CBT) proved to be effective, but it is important to consider the cultural context of the patient attending CBT for vaginismus. The aim of our study was therefore to draw attention to the belief systems and behaviours linked to female sexuality and couple relationship in the Arab-Muslim culture. We present a series of four patients representative of the local culture and show how treatment strategies were adapted to fit these behaviours and belief systems, as well as environmental factors. We found that excessive closeness of family members, allowing the family to be intrusive and exercising pressure on the couple, a strict education which highly values virginity, transmits fear of ‘the male’ and fear of sex, and which links sex with pain, were the common denominator of all patients of our case series. We adapted the classical CBT strategies for vaginismus to our cultural context. The educational component was enlarged. Cognitive techniques were used to modify specific traditional beliefs. The integration of the family, and not only of the partner, into the treatment process proved uniquely beneficial for the patients.

At the very beginning of our lives we have similar needs, but as we get older the ways of maintaining our wellbeing will vary greatly. Quite simply, we get more different and complex as we age! Hence, attempts to both meet older people's needs and treat their psychological difficulties often require comprehensive assessments and biopsychosocial formulations. It is relevant to note that many of the latter formulations are informed by CBT theory, even when dealing with people presenting with dementia and challenging behaviour. Despite the conceptual complexities, there is increasing evidence to suggest that the most effective interventions for this ‘challenging’ population are basic communication strategies. This paper outlines the key principles of effective communication under the heading of Communication and Interaction Therapy (CAIT). The concepts underpinning CAIT are illustrated via a number of case studies of people living in 24-hour care. It will be argued that an implication of this approach is the judicious use of therapeutic lies, but only as a last resort.

Despite the acknowledged importance of clinical supervision, controlled research is minimal and has rarely addressed the measurement or manipulation of clinical supervision, hampering our understanding and application of the different supervision methods. We therefore compared two related approaches to supervision, cognitive-behavioural (CBT) and evidence-based clinical supervision (EBCS), evaluating their relative effectiveness in facilitating the experiential learning of one supervisee. Drawing on a multiple-baseline N = 1 design, we gathered mostly qualitative data by means of an episode analysis, a content analysis, a satisfaction questionnaire, and interviews with the supervisor and supervisee. We found that the EBCS approach was associated with higher supervision fidelity and increased engagement in experiential learning by the supervisee. This case study in the evaluation of supervision illustrates the successful application of some rarely applied qualitative methods and some potential supervision enhancements, which could contribute to the development of CBT supervision.

Inequalities in mental health treatment access and outcomes for minority ethnic and religious groups in the UK have been recognized for more than a decade; however, work to address these at an operational level is still emerging. In recognition of the need for culturally adapted therapies, researchers at the University of Leeds developed and piloted an adapted therapy for Muslim clients, based on behavioural activation (BA), an existing evidence-based psychosocial treatment for depression. Therapists and supervisors at Touchstone, Leeds have been trained to deliver the culturally adapted approach, which supports Muslim clients who choose to use ‘positive religious coping’ as a resource for health. This paper describes the key elements of the intervention and how it is being delivered in practice to increase service uptake and recovery in Muslim communities.

Increasingly, evidence suggests that computerized Cognitive Behavioural Therapy (cCBT) is effective at reducing adolescent anxiety and depression for young people in the general population or those ‘at risk’. However, less is known about the acceptability, feasibility and effectiveness of cCBT for adolescents with clinically significant levels of impairment. This study aimed to investigate the feasibility of using a novel cCBT intervention, ‘Pesky gNATs’, with adolescents aged between 13–18 years with anxiety and/or depression who met the criteria for specialist mental health services. Eleven participants were recruited from a Tier 3 child and adolescent mental health service (CAMHS). Recruitment, attendance and retention rates were recorded and qualitative feedback about the benefits and disadvantages of completing cCBT were obtained during the final session. In addition, a number of outcome measures were completed pre- and post- intervention to assess reliable and clinically significant change. The intervention was very brief comprising of just seven sessions. Participants showed high recruitment and retention rates. All participants who started the intervention completed it. All described the programme as useful and the majority identified several benefits. Four of 11 participants demonstrated reliable reductions in symptoms of depression and anxiety and six of 11 showed decreases in parent-reported symptoms of anxiety and depression following the seven-session intervention. This study demonstrates the acceptability and feasibility of using cCBT in a Tier 3 CAMHS setting. Further research is required to investigate the effect of Pesky gNATs on anxiety and depression in other Tier 3 settings.

This paper focuses on the Black minority ethnic population (Black British, Black African, Black Caribbean) and uses the term BME in reference to this group. Only 6.2% of BME people access psychological intervention for common mental disorders. In provision of cognitive behavioural therapy (CBT) the diversity in global majority populations1 requires culturally specific informed and responsive approaches. The Improving Access to Psychological Therapies (IAPT) programme needs to be accountable, culturally congruent and strategic, to ensure accessibility and improve outcomes for BME people. According to the Mental Health Foundation (2019), a higher percentage of Black, Asian and other minority ethnic populations (BAME) are diagnosed with common, severe and complex mental health disorders. Despite the weight of literature on this, little has changed. The NHS Implementation Plan outlines trajectories for increased access and reduced attrition within mental health services, addressing inequalities for BAME populations.

Evidence-based guidance and audits for provision of culturally sensitive and adapted therapies are presented in the pioneering (IAPT) BAME Positive Practice Guide (PPG). However, there are no funding arrangements or formal integrated frameworks to support implementation. The COVID-19 global pandemic and the high-profile death of George Floyd tragically exposed and highlighted the consequences of systemic racism. Understanding of the importance of service and clinical anti-racist practice is imperative for CBT therapists. Implementation of the BAME PPG audit tool ensures review of race equity in access, engagement, adaptation and workforce within IAPT and other mental health services. This could transform lives.

A feasibility study evaluated five adapted Mindfulness-based Cognitive Therapy (MBCT) groups that were delivered to staff in a National Health Service (NHS) mental health Trust as part of a staff health and wellbeing initiative. Using an uncontrolled design typical of a feasibility study, recruitment, retention and acceptability of the groups were assessed. Effectiveness was also measured at pre- and post-therapy, and at 3-month follow-up, using quantitative methods. In addition, qualitative methods were used to explore staff experiences of the groups. Results demonstrated high levels of feasibility, and significant improvements in staff perceived stress and self-compassion at both post-therapy and follow-up. Qualitative data suggested many staff felt the groups had improved their physical and emotional health, their ability to manage stress at work and the quality of their work with patients and of their relationships with colleagues. Although Mindfulness-based Stress Reduction (MBSR) has typically been used to help manage staff stress, these results are promising for the use of an adapted MBCT with this population. Challenges and factors contributing to these outcomes are discussed.

Written guidance is part of a coherent support system for CBT supervisors, consistent with general developments in evidence-based practice. In theory, training manuals can help by specifying educational procedures and providing support materials so as to foster fidelity, expertise and effectiveness among supervisors. Supervision guidelines can help by offering supervisors the fruits of research and expert consensus. Together with related resources, such written guidance promises to empower professionals and to benefit patients. But progress with written guidance is very limited within clinical supervision, particularly in controlled research. In marked contrast, locally developed guidance appears to have been implemented successfully within pragmatic studies, a marked achievement when also contrasted with the general healthcare literature. Using eight criteria, the available supervision research is reviewed and conclusions drawn on developing written guidance so as to better fulfil its promise.

While clinicians have described the benefits of using formulations within therapy, little is understood about the client's experience of the formulation process. Cognitive behaviour therapy (CBT) is currently the treatment of choice for many adult mental health difficulties. However, research exploring clients’ experiences of CBT formulation is very limited. The present study set out to explore experiences of CBT formulation in clients with depression. Seven participants were interviewed and the data analysed using Thematic Analysis. The analysis identified key themes such as: ‘Feeling trapped or restricted by depression’, ‘The development of the formulation – from coming to my own conclusions to something the therapist developed’, ‘From negative to mixed feelings: emotional reactions to the formulation during the therapeutic process’ and ‘A new journey: towards making a new sense of oneself’. The results of the study highlight the personal and emotional challenge of the formulation process for clients.

Despite an emerging evidence base for the efficacy of supported computerized cognitive behavioural therapy (eCBT), uptake in services has been slow. Therapists’ beliefs about eCBT may constitute a barrier to offering eCBT to clients, but little research has investigated this topic. The aim of this study was to investigate therapist attitudes towards eCBT in one inner-city Improving Access to Psychological Therapies (IAPT) service using a survey design. Data were analysed using descriptive statistics. Thirty-three therapists took part in the study. Although 97% of participants reported that they knew ‘what eCBT involves’, and 62% reported that they were ‘confident to offer eCBT to clients’, only 10% endorsed that ‘there is a strong evidence-base to support the use of eCBT’. Two-thirds of the sample believed that eCBT ‘could be effective for mild and moderate mental health difficulties’, but most participants believed that eCBT would perform ‘worse’ or ‘much worse’ than face-to-face interventions for a range of disorders. Barriers to offering eCBT related predominantly to assumptions about client expectations of therapy, and perceived lack of a therapeutic relationship. Participants identified the provision of training on eCBT for those recommending treatment options to clients as a potential solution. Results from this study highlight therapists’ attitudes to eCBT that might contribute to low uptake rates of eCBT. Particularly, misperceptions about the evidence base for eCBT may be prevalent. Appropriate training and ongoing supervision for therapists are considered as interventions that may increase acceptance of eCBT as a valid treatment option.

Experiences of racism can be a cumulative risk factor for developing mental health problems. Cognitive Behaviour Therapists working with Black and Minority Ethnic (BME) service users should be confident in their ability to establish the necessary rapport to ask about these experiences and be able to incorporate this information into longitudinal formulations and as part of maintenance cycles. This paper sets out guidelines as to how to do this as part of a wider engagement process.

There is increasing evidence that mindfulness techniques can be used safely and effectively in the treatment of psychosis, but the potential benefits of these techniques for individuals during the early stages requires further exploration. This study investigated whether mindfulness training in a group setting is associated with a reduction in distress and an improvement in mindfulness skills for people who have psychotic experiences. Data are reported from eight participants who completed measures before and after attending a mindfulness group. There was a reduction in CORE and DASS scores and an increase in mindfulness skills following participation in the group. These findings suggest that mindfulness training can be beneficial for reducing distress and negative emotional states associated with early psychotic experiences during the critical period.

Co-morbid mental health diagnoses present challenges for services structured to provide disorder-specific models of treatment, such as those structured around Improving Access to Psychological Therapies (IAPT). Intolerance of uncertainty (IU) has been identified as both disorder specific and transdiagnostic, although little research explores transdiagnostic approaches to treatment of IU alone. A cognitive behavioural therapy treatment targeting IU previously established for individual therapy was adapted for a group within an IAPT primary care service: the ‘Making Friends with Uncertainty’ (MFWU) group. Twenty patients presenting with symptoms of a range of disorders including generalised anxiety disorder, obsessive compulsive disorder and depression completed the intervention in three groups. Measures of IU, anxiety and depression administered in the first and final sessions of the group have been analysed as well as examining common themes in participant feedback and facilitators’ own reflections. The results showed that nine participants (45%) showed reliable change in IU following the group and 16 (80%) showed reliable change on a measure of depression or anxiety. A thematic analysis identified universality, tolerance and acceptance and the manifestation of IU in the group process as key. The results suggest that the MFWU group provides an effective and feasible option for individuals presenting to IAPT services, including those reporting co-morbid difficulties. Implications for future practice are discussed as iteration and evaluation of the framework and content will continue.

There is now expert consensus that directly observing the work of trainee therapists vs. relying upon self-report of sessions, is critical to providing the accurate feedback required to attain a range of competencies. In spite of this expert consensus however, and the broadly positive attitudes towards video review among supervisees, video feedback methods remain under-utilized in clinical supervision. This paper outlines some of the weaknesses that affect feedback based solely on self-report methods, before introducing some of the specific benefits that video feedback methods can offer the training and supervision context. It is argued that video feedback methods fit seamlessly into CBT supervision providing direct, accessible, effective, efficient and accurate observation of the learning situation, and optimizing the chances for accurate self-reflections and planning further improvements in performance. To demonstrate the utility of video feedback techniques to CBT supervision, two specific video feedback techniques are introduced and described: the Give-me-5 technique and the I-spy technique. Case examples of CBT supervision using the two techniques are provided and explored, and guidance as to the supervision contexts in which each of the two techniques are suitable, individually, and in tandem, are outlined. Finally, best practice guidelines for the use of video feedback techniques in supervision are outlined.