Cognitive behaviour therapy-enhanced (CBT-E) is an effective treatment for non-underweight patients with eating disorders. Its efficacy and effectiveness is investigated mostly among transdiagnostic samples and remains unknown for binge eating disorder. The aim of the present study was to assess several treatment outcome predictors and to compare effectiveness of CBT-E among adult out-patients with bulimia nervosa (n=370), binge eating disorder (n=113), and those with a restrictive food pattern diagnosed with other specified feeding and eating disorders (n=139). Effectiveness of CBT-E was assessed in routine clinical practice in a specialised eating disorders centre. Eating disorder pathology was measured with the EDEQ pre- and post-treatment, and at 20 weeks follow-up. Linear mixed model analyses with fixed effect were performed to compare treatment outcome among the eating disorder groups. Several predictors of treatment completion and outcome were examined with a regression analysis. No predictors for drop-out were found, except the diagnosis of bulimia nervosa. Eating disorder pathology decreased among all groups with effect sizes between 1.43 and 1.70 on the EDE-Q total score. There were no differences in remission rates between the three groups at end of treatment or at follow-up. Eating disorder severity at baseline affected treatment response. The results can be generalised to other specialised treatment centres. No subgroup of patients differentially benefited from CBT-E supporting the transdiagnostic perspective for the treatment of eating disorders. Longer-term follow-up data are necessary to measure persistence of treatment benefits.

Personal development is a vital requirement of counsellor development, and educators need to consider how best to promote and support students’ personal development throughout training. ‘Self-case study’ can provide both learning and personal development opportunities for counselling students. This qualitative narrative study explores seven students’ perspectives about their experiences of completing a self-case study as a learning requirement for a compulsory introductory course in cognitive therapy at undergraduate level. Unstructured individual interviews were used for data collection. Data analysis involved identifying themes and analysing the narrative structure of stories. The findings emphasized the view that self-case study provides useful learning opportunities in the areas of theory, practice and personal development. Most participants described transformational life changes resulting from completing a self-case study. This paper presents selected findings. The ethical issues and limitations of this study are discussed. Self-case study is recommended as a potentially effective education strategy.

Mindfulness meditation is developing momentum as a mental health promoting activity in clinical and non-clinical settings. Our Early Intervention in Psychosis (EIP) service wished to determine its acceptability and utility among a mixed group of participants. All clinical team members, their patients and their carers were offered an 8-week Mindfulness group. Participants rated acceptability before and after. They prospectively identified, then monitored, distress associated with areas of their lives they hoped might improve. Nineteen participants provided a mean attendance of 11.25 per group. The group was overwhelmingly positively perceived and distress associated with participants’ items significantly improved. Findings support further implementation. The goal of inclusion was achieved with some reservation about staff preparation.

Metaphor is a central tool of the therapist of many therapeutic modalities, and they are a particular feature of CBT. Metaphors can be essential tools in the therapeutic process; providing the therapist with a means of communicating potentially complex psychological concepts and theory to clients, and also being part of the process of change. This paper presents a series of metaphors that some of the most experienced and innovative practitioners in the world of CBT have found to be helpful. Each practitioner describes how to utilize the metaphor skilfully and effectively: providing some tips for facilitating both the presentation of metaphors to, and eliciting of metaphors from the client; and demonstrating how the use of metaphor can facilitate therapeutic change. Overall, the small selection of metaphors presented here demonstrate the great versatility of metaphor to address all kinds of issues in therapy, with a range of client groups and presenting difficulties; and how the shared exploration and collaboration of both client- and therapist-generated metaphors can be an important addition to the therapist's toolbox.

Persistent complex bereavement disorder (PCBD) has been included in the appendix of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders as a condition for further study, and a new diagnostic category of prolonged grief disorder (PGD) is likely to be added to the International Statistical Classification of Diseases and Related Health Problems (ICD-11) (Maercker et al., 2013). Whilst there is increasing evidence that prolonged grief has distinct characteristics (Bryant, 2012), there are clinical features that overlap with post-traumatic stress disorder (PTSD), such as intrusive memories, emotional numbing, and avoidance of trauma or loss reminders. Here we describe how the cognitive model for persistent PTSD (Ehlers and Clark, 2000) and trauma-focused cognitive therapy for PTSD (Ehlers et al., 2005) have been helpful in treating persistent complex grief.

Reappraisal strategies such as ‘thought challenging’ and ‘cost-benefits analysis’ are a hallmark of cognitive therapy, but sometimes fail to bring about lasting changes in the cognitive-affective structures underlying psychopathology. Modern theories of information processing suggest that experiential, action-based interventions such as chairwork may be a more efficacious route to cognitive modification. Based upon this hypothesis, a ‘dialogical’ approach to cognitive therapy is presented, which aims to bring about change through evocative, here-and-now interactions with parts of the self (self-to-self dialogues) and other individuals (self-to-other dialogues). Implementation principles and facilitation skills which guide this approach are outlined. To illustrate how dialogical interventions are utilized in clinical practice, chair-based strategies for socializing clients to the cognitive behavioural model, restructuring cognitions, facilitating emotional processing, resolving ambivalence, addressing distressing memories, building character strengths, and overcoming therapeutic impasses are described.

The present study aimed to explore patients’ experience with an Improving Access to Psychological Therapies (IAPT) service, and to investigate the reasons for discontinuing their treatment. A qualitative approach was adopted using thematic analysis of semi-structured interviews carried out with 818 patients attending for treatment in Talking Change from November 2015 to January 2019, retrospectively. The five main themes that emerged from the study were: ‘Felt better’, ‘Issues with group settings’, ‘Therapeutic alliance breakdown’, ‘Miscommunication’ and ‘Impracticalities’. The qualitative study uncovered a wide range of reasons for people who had dropped out from their treatment. The findings mainly emphasised general dissatisfaction and inconvenient appointments. However, improvement in symptoms of depression and anxiety was also identified as a key factor among patients who discontinued their treatment. This recovery is known as ‘progress withdrawal’ in which patients withdraw from treatment early due to good therapeutic progress. We present clinical and procedural implications arising from these themes.

Self-Practice/Self-Reflection (SP/SR) has been proposed both as an adjunct to therapy training programmes, and also as a means for therapist development among experienced therapists. Research suggests it develops aspects of knowledge and skill that may not be addressed through other training methods. With increasing interest in SP/SR, a growing evidence base regarding both participant benefits and potential risks from SP/SR, and the development of SP/SR programmes across a range of therapeutic modalities, we argue it is timely to identify a set of principles that can guide the design, adaptation and implementation of SP/SR programmes. At this stage, there is little empirical evidence to guide trainers wishing to implement SP/SR in different contexts. Accordingly, these principles have been derived from reflection on developing, testing and implementing SP/SR programmes as well as on other training and supervisory experience. The first set of principles detailed in Section 1 draw on various theories of learning and development and frame the processes involved, the next principles speak to the content of SP/SR programmes, and the final principles address structure. Within Section 2, the principles are then considered for their practical implications. In Section 3, the sharing of what are initially private self-reflections is then considered together with some implications for SP/SR programmes, especially when there is assessment involved. We argue that SP/SR will continue to progress with well-designed standard programmes, careful implementation, thoughtful adaptation, ongoing innovation, and especially more evaluation.

In this Introduction to the Special Issue of the Cognitive Behaviour Therapist on clinical supervision we start by highlighting the unmet and overdue need for coherent organizational systems to support, guide and develop clinical supervisors. We identify a seven-step, cyclical model that describes how such a system might work, with particular reference to CBT supervision. These steps start with conceptualization (e.g. definition of CBT supervision) and complete the problem-solving cycle with evaluation (e.g. corrective feedback). We provide an overview of typical research and development activity for each part of this model to illustrate how a sound supervision infrastructure might best be developed. The SOS model provides a systematic approach to indicate the organizational conditions under which CBT supervision might flourish.

Cultural competency is a core clinical skill. Yet, psychological therapists may be inadequately trained to deal with the needs of service users from Black, Asian and Minority Ethnic (BAME) backgrounds. This can lead to dissatisfaction with mental health services, disengagement from therapy, and poorer treatment outcomes when compared to the White British population. The aim of this study was to explore whether practitioners working for Improving Access to Psychological Therapies (IAPT) services are culturally competent to deal with the needs of diverse communities. Semi-structured interviews were carried out with a range of practitioners, from early career psychological wellbeing practitioners (PWPs) to senior cognitive behavioural therapists (n=16). Reflexive thematic analysis (RTA) was used to analyse the data, guided by a six-phase process to produce a robust pattern-based analysis. Overall, three themes were generated: (1) encountering cultural dissonance within therapy; (2) challenges in making cultural adaptations to therapy; and (3) identifying cultural competency needs. Out of sixteen participants, only nine therapists received one-day formal training throughout their therapeutic career, whilst seven reported receiving no cultural competence training at all. Overall, it appears that there is an urgent need and desire for therapists to be offered cultural competency training so that they can better serve BAME communities. Clinical implications and future recommendations are made.

Formulation is widely considered a critical component of psychological therapies, and is thought to have a number of benefits both for the therapeutic process and the client directly. However, the evidence base supporting formulation and its possible interventive capacity is limited, and there is little empirical evidence exploring how clients perceive formulation as part of therapy. Work with the client described in this single case report provided an opportunity to explore the use of formulation as intervention and evaluate ways in which it may or may not prove helpful by interviewing the client directly about her experience of the process. Implications for further research on the use and outcomes of formulation are discussed.

This article describes a clinical protocol for supporting those presenting with post-traumatic stress disorder (PTSD) and dissociative symptoms, particularly dissociative flashbacks, based on a cross-culturally applicable model. The protocol is discussed from the perspective of working with a refugee and asylum seeker population, although many of the principles will be applicable to clients from any background presenting with these dissociative symptoms. The protocol addresses the assessment and formulation of a client’s dissociative symptoms. It includes guidance on sharing psycho-education with clients regarding the evolutionary function of dissociation and developing practical strategies to monitor and manage dissociative symptoms. The strengths and limitations of this protocol are also discussed.

It is widely recognised that a diagnosis of a long-term physical health condition (LTC) is likely to have a significant impact on a person’s mental health. This is highlighted in the Five Year Forward View for Mental Health (NHS England, 2016) where significant numbers of patients projected to be seen through the expansion of Improving Access to Psychological Therapies (IAPT) services are to come from within the LTC community. IAPT services offer evidence-based therapeutic interventions for common mental health issues – anxiety disorders and depression. The South East Staffordshire IAPT services have developed an integrated pathway as a Wave 2 site for the delivery of cognitive behavioural therapy (CBT) adaptations for LTC. The main themes outlined in this paper focus on the innovations and service developments of IAPT-LTC including: the importance of engagement between mental health and medical healthcare professionals, identifying the key professionals in medical healthcare to enhance engagement, extended training for clinicians with in-house continued professional development, as an extension to the National IAPT-approved top-up training for LTC, and developments in clinical supervision structures and practice, along with future developments in the field of IAPT-LTC. These themes have direct relevance to CBT practitioners working within the LTC community in IAPT services. The four contrasting case studies demonstrate how the application of CBT can successfully be adapted to condition related beliefs and behaviours, despite the complexity of the medical condition. Findings show how integrated services and engaging with medical healthcare professionals had profound benefits for the patients, IAPT therapists and medical healthcare professionals.

There has been limited application of cognitive behavioural therapy (CBT) to the treatment of distressing visual hallucinations (VH) in people with psychosis. Preliminary research applying interventions to a novel presenting issue are enhanced by utilizing designs that allow strong inferences to be made about the effect of the intervention. Hence, this study aimed to measure change in appraisal, affect, and behaviour as a consequence of CBT VH, to improve understanding of the process of change. A multiple-baseline experimental single-case design methodology was used with five participants who received a CBT VH treatment package. Participants used daily diary measures to record appraisals, affect, and behaviours related to the distressing VH. Standardized measures were completed at each phase change. Four individuals completed therapy. Formal visual analysis of the data supported by statistical analysis indicated significant changes for appraisal and affect, with replication across three participants. Changes in frequency of VH were reported in two cases. Change was not evident on the standardized measures. This study replicates and extends the findings in showing potential value of CBT VH. Further research should consider alternative methods of capturing behavioural change. Attempts should also be made to replicate across therapists and centres.

The purpose of the present study was to explore the experience of being asked for reassurance from the perspective of carers of obsessive compulsive disorder (OCD) sufferers, and to examine its relationship to sufferers’ reassurance seeking by a direct comparison with data obtained from the person they normally offer reassurance to. Forty-two individuals with OCD and their carers completed alternate versions of the Reassurance Seeking Questionnaire. Result suggest that carers report most commonly providing reassurance when asked to do so, and the frequency of their reassurance provision is associated with how carefully sufferers seek reassurance, rather than their OCD symptom severity. The carer's perspectives on the impact of reassurance provision was accurate; both sufferers and carers perceive that reassurance works only temporarily, but even if the anxiety-relieving effect of reassurance decreases in the medium term, it is likely to be perceived as beneficial because carers accurately perceived that sufferers would feel much worse if they refused to provide reassurance. The present study is the first to quantitatively investigate carer's experiences of reassurance provision, and elucidate why carers feel the need to provide it.

This article provides guidance on the management of challenging behaviours (CBs) in dementia care, and introduces concepts from positive behavioural support not usually applied to dementia. While the use of formulations has received a lot of attention in recent years, the mechanisms of how to apply the formulation-led interventions requires more consideration. In order to assist caregivers to deliver effective interventions we need to have a better understanding of the CBs we are attempting to manage, and also produce management strategies with clearer goals. Ideally we would also want caregivers to be able to describe the skills they employ in a coherent manner in order to facilitate self-reflection and to be able to pass on their skills to junior colleagues. This paper attempts to fulfil these needs by integrating two new models with philosophies already used in dementia care. In terms of new concepts, the first is the Arousal Cycle, which gives caregivers an awareness of the five phases of a typical CB (wellbeing, trigger, escalation, CB, and recovery phase). In relation to the second, the Traffic Light analogy examines CBs in terms of four management stages: primary prevention, secondary prevention, reactive strategies, and calming strategies. It is proposed that we distinguish between these stages when composing our formulations and care plans, and thereby produce better targeted interventions. By the end of the paper the reader will have been presented with material integrating concepts from the fields of dementia and intellectual impairment, and been introduced to new ways of managing CBs.

Sexual minorities, including those identifying as lesbian, gay, bisexual or queer (LGBQ) are at heightened risk of experiencing mental health problems. Nationally, treatment outcomes within England’s Improving Access to Psychological Therapies (IAPT) services are worse for sexual minority patients than for heterosexuals. An IAPT service in London developed a cognitive behavioural therapy (CBT) group specifically for sexual minority patients to provide a safe, affirmative intervention to learn skills for overcoming depression, anxiety and stress. A qualitative online survey was emailed to all 59 service users who had completed the eight-session intervention, to explore their experiences inductively. Survey data were analysed using qualitative content analysis. Themes were identified in participants’ responses in order to establish which aspects of the group intervention were deemed to be helpful and unhelpful, and to explore suggestions for group improvement. Eighteen people completed the survey (response rate 30.5%). Respondents reported that they found the CBT frame of the group useful, with the LGBQ focus experienced as particularly beneficial, often enhancing engagement with CBT concepts and tools. In addition to generic elements of group therapy that some found difficult, others reported that intragroup diversity, such as generational differences, could lead to a reduced sense of connection. Several suggestions for group improvement were made, including incorporating more diverse perspectives and examples in session content and focusing more on issues relating to intersectionality. These results provide preliminary evidence that a culturally adapted CBT group intervention developed specifically for sexual minorities is acceptable and perceived as offering something unique and helpful.

The Improving Access to Psychological Therapies (IAPT) initiative was created to provide mental health services for those experiencing mild to moderate depression and anxiety. IAPT is commissioned on the basis that it achieves adequate performance on a number of ‘key performance indicators’, one of which is the proportion of clients who ‘move towards recovery’ following treatment. The impetus for the current evaluation was a significant reduction in the proportion of clients recovering within an IAPT service. Data for this clinical audit was obtained from IAPT electronic records (IAPTus). Three factors (waiting times, clinical contact and starting scores on the PHQ-9 and GAD-7) were examined and explored separately for each level of care (i.e. steps 2 and 3). These factors were analysed in relation to recovery and compared between periods of low and high recovery within the service. Results reveal that there was little change in the severity of clients’ starting scores between the periods of low and high recovery. Increased waiting time in the period of low recovery was not associated with recovery status. The amount of clinical contact was related to recovery at both time periods. Limitations and implications of the findings are discussed.

While the benefits of routine outcome measurement have been extolled and to some degree researched, it is surprising that service user opinions on this common therapy practice have largely not been investigated. This study aimed to assess service users’ experiences of completing measures during psychological therapy, with a view to exploring how therapists can maximize how helpful measures are in therapy. Fifteen participants completed surveys about the use of measures in their current episode of care. Ten clinicians also completed a survey about their use of, and views about, measures. Results showed that despite mixed experiences in how measures were explained and used, service users showed generally favourable attitudes towards their use in therapy, with them being perceived as most helpful when well integrated into sessions by their therapists. Clinicians reported using a wide range of measures, and generally endorsed positive beliefs about measures more strongly than negative ones. Implications for clinical practice, service development, and further research are discussed.

The relationship between trauma and psychosis is well established with a large amount of overlap between the ICD/DSM (International Classification of Diseases/Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria for post-traumatic stress disorder (PTSD) and psychosis and/or schizophrenia. In spite of co-morbidity and evidence of the links and underlying mechanisms, trauma is rarely a focus of intervention in psychosis. Psychosis has often been on the list of exclusion criteria for PTSD research studies. There is a lack of literature on the impact of trauma work with people experiencing psychosis. The National Institute for Health and Care Excellence (NICE) (2014) suggests that Early Intervention in Psychosis (EIP) service users should be assessed for PTSD, and PTSD guidelines (NICE, 2005) followed for those who show signs of post-traumatic stress. There is a need to evaluate the effectiveness of therapeutic approaches for people with PTSD and co-morbid psychosis. These case studies aim to provide initial evidence of how two EIP clients experienced and responded to NICE-recommended psychological therapy for trauma. This study aims to test the feasibility of trauma work delivered via a phasic approach in a novel population. Two EIP clients received psychological therapy [including trauma-focused cognitive behavioural therapy (CBT) and eye movement desensitization and reprocessing (EMDR)] for identified traumatic experiences. Assessment outcome measures were utilized to establish the effectiveness of the interventions. Both clients reported significant improvements following therapy, including reduced trauma-related distress, reduced distress from symptoms of psychosis and improved quality of life. Clients with co-morbid PTSD and symptoms of psychosis are likely to benefit from recommended psychological treatments for PTSD. Further research is required to address generalizability to a larger population.