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.

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.

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.

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.

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.

Whilst research into the association between social media and mental health is growing, clinical interest in the field has been dominated by a lack of theoretical integration and a focus on pathological patterns of use. Here we present a trans-diagnostic cognitive behavioural conceptualisation of the positive and negative roles of social media use in adolescence, with a focus on how it interacts with common mental health difficulties. Drawing on clinical experience and an integration of relevant theory/literature, the model proposes that particular patterns of social media use be judged as helpful/unhelpful to the extent that they help/hinder the adolescent from satisfying core needs, particularly those relating to acceptance and belonging. Furthermore, it introduces several key interacting processes, including purposeful/habitual modes of engagement, approach/avoidance behaviours, as well as the potential for social media to exacerbate/ameliorate cognitive biases. The purpose of the model is to act as an aide for therapists to collaboratively formulate the role of social media in young people’s lives, with a view to informing treatment, and ultimately, supporting the development of interventions to help young people use social media in the service of their needs and values.

Obsessive-compulsive symptoms (OCS) are a common phenomenon in patients with schizophrenia and are associated with additional clinical and functional impairments. So far treatment approaches have been limited to mainly pharmacological interventions with restricted effectiveness. Because cognitive behavioural therapy (CBT) is considered treatment of first choice for patients with primary obsessive-compulsive disorder (OCD), it seems compelling to consider it as a treatment option for comorbid OCS in schizophrenia. This research was conducted in order to investigate the theoretical and empirical basis for CBT in the treatment of comorbid OCS/OCD in schizophrenia. A comprehensive review and analysis of published literature was performed. Outcome measures from case-reports and a case-series showed favourable results with a significant reduction of symptom severity in 24/30 patients treated with CBT and exposure and response prevention (ERP) or ERP alone. CBT appears to offer a valuable opportunity to reduce symptom severity in this highly impaired group of patients. Based on these results and with a strong focus on tolerability concerns, suggestions for possible CBT approaches for the comorbid group are proposed. Further research within this field and systematic clinical evaluations are highly desirable.

The aim of this review was to ascertain whether an examination of the theory of structural dissociation of the personality (TSDP) and its treatment may lead to recommendations in the treatment of dissociative identity disorder (DID) and other trauma-related disorders utilizing CBT. An analysis of the neurobiology of trauma will aid this process. The literature review considers a variety of literature on TSDP. Several themes were identified which suggested that dissociation refers to a structural dividedness of the personality and that there is a psychobiological pathway for all trauma-related disorders. Additionally the role of bottom-up vs. top-down processing was explored. Recommendations for the treatment of trauma-related disorders using CBT have been made.

Exposure therapy is a widely used and well-evidenced treatment for a variety of avoidance behaviours. This paper offers a modest proposal for an improvement in how it is carried out (‘dynamic hierarchies’). The theoretical and practical context is set out, including some thoughts on the role of appraisals and cognitive dissonance, and some advantages of the method are suggested.

A 35-year-old Middle Eastern woman, experiencing moderate depression compounded by animal phobia was referred to an Improving Access to Psychological Therapies (IAPT) service. Shared understandings were gradually developed using written functional analyses translated in session. Activity scheduling was integrated with graded exposure to increase access to positive reinforcement. Questionnaires and subjective data indicated a reduction in phobic avoidance and functioning increased. Despite the complexity of working as a triad, a positive therapeutic relationship was achieved with increased mutual cultural understanding. Indirect communication led to difficulties maintaining guided discovery and focus. There is limited evidence to support CBT when delivered through an interpreter. IAPT recommendations suggest staff reflect the community; the North East has one of the lowest foreign-born populations in the UK indicating that IAPT services may be ill prepared to work with ethnic minorities. Learning points for the therapist were: maintain simplicity, take time to formulate incorporation of cultural difference, and use transcultural interventions. The interpreter brought advantages; providing means of communication and understanding of cultural differences. Disadvantages were the potential for bias or lost information, increased time and complexity of delivering therapy. This case indicates a deficit in high intensity training and lack of literature to support therapists.

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.

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.

This study explores the mental health difficulties associated with severe trauma as experienced by refugees and asylum seekers, and issues related to psychological treatments. An evaluation was conducted of a culturally adapted cognitive therapy group programme for Tamil refugees and asylum seekers in the Wandsworth IAPT (Improving Access to Psychological Therapies) service. Data were examined from 16 Tamil participants who accessed the service between 2014 and 2015 and subsequently engaged in the group programme between 2015 and 2016. The IAPT minimum data set (PHQ9, GAD-7, Phobia scale and WSAS) and IES-R (Impact of Events Scale Revised) were used as quantitative measures. Qualitative feedback about the programme was also obtained. A positive change in the wellbeing of participants was indicated by a reduction in the severity of negative symptoms for all metrics and qualitative feedback provided additional evidence that participants had benefited from the programme. The implications of these findings are discussed.

Cognitive-behavioural therapy (CBT) can be effective for anorexia nervosa. However, there is evidence that the delivery of treatments for the eating disorders is inconsistent. This study examined evidence that clinician characteristics and practice can influence the effective implementation of CBT. The participants were 100 qualified clinicians who routinely offered outpatient CBT to adults with anorexia nervosa. They completed a survey of their demographic characteristics, level of anxiety, clinical practice in CBT for anorexia nervosa, and beliefs about the relationship between weight gain and therapeutic alliance in the early part of such treatment. Greater reported levels of weight gain were associated with the use of manuals, early focus on weight gain as a target, structured eating, and a belief that weight gain precedes a good working alliance. Clinician anxiety and early focus on the therapeutic alliance rather than structured eating were associated with poorer outcomes. These conclusions need to be tested within clinical and research settings. However, they suggest that clinicians should be encouraged to use manual-based approaches when treating anorexia nervosa using CBT, as focusing on techniques might result in the best possible outcome in this early part of treatment.

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.

In a cisheteronormative culture, gender and sexual minorities (GSMs) may experience additional challenges that get in the way of a meaningful life. It is crucial that clinicians are mindful of these challenges and cognizant about the specificities of clinical work with GSMs. This article points out how societal structure interferes with mental health, and clarifies what clinicians must take into account when using affirmative cognitive behavioural therapy (CBT) interventions. Knowledge of up-to-date terminology and use of affirmative language are the first steps that contribute to clients’ experience of respect, which is paramount for the development of a good therapeutic relationship. Considering a conceptual framework of minority stress to understand vulnerability in GSM, specificities in formulation and key psychological processes are discussed. Moreover, guidelines and practical tools for intervention are presented within a CBT approach. Some reflections on therapists’ own personal biases are encouraged, in order to increase the efficacy of interventions.

The aim of this study was to conduct a systematic literature review to ascertain whether cognitive behavioural therapy (CBT) for social anxiety disorder (SAD) can be successfully used in non-Western contexts and demonstrate sufficient effectiveness. This area is largely under-researched with conflicting evidence presented in quantitative studies, with virtually no qualitative studies published. This review utilized realist review methodology and focused on qualitative case studies presented by clinicians. A systematic search of EBSCO HOST, The Cochrane Library Database, Google, Google Scholar and reference mining, using various combinations of terms relating to: (1) CBT, (2) social anxiety and (3) cultural diversity were employed. Seven case studies of cultural adaptations of CBT treatment for culturally diverse SAD sufferers were included. The treatment outcomes were generally promising in all cases (reporting significant decrease of SAD symptoms, maintained over time) and the success of therapy was often attributed to culturally specific modifications introduced. CBT can be an acceptable and effective treatment for culturally diverse SAD sufferers with ‘modest’ modifications, without major diversions from the original CBT models and protocols, but this finding must be treated with caution and more methodologically rigorous research (qualitative and quantitative) is needed to more fully understand what works, for whom and in what circumstances.

The COVID-19 pandemic increased population levels of depression and anxiety, and infection control measures obliged services to provide psychological therapies remotely. Evidence for the routine provision of psychological therapy via telephone and video-conferencing is limited. This study compared therapy outcomes for 5360 clients in two London Improving Access to Psychological Therapy (IAPT) services before and after homeworking produced a compete shift to remotely delivered therapy. Despite the psychological impacts of pandemic restrictions, and the use of a novel therapy modality in video-conferencing, recovery rates and net score change improved in both services, significantly in one. There was no significant worsening of outcomes for any demographic group or presenting disorder. The findings suggest that for those able to access it, therapy provided by telephone and video is a clinically effective option for IAPT services.

Cognitive behaviour therapy (CBT) is widely regarded as an effective treatment for social anxiety disorder (SAD) in Europe and North America. The theoretical orientations underlying CBT models and treatment interventions developed in Western cultures were typically constrained by Western conceptualizations of SAD. This case study reports on the use of CBT for Japanese SAD, demonstrating the successful implementation of cognitive techniques grounded in the Clark & Wells model. The patient was a Japanese female with excessively high standards for workplace social performance. Therapy mainly comprised case formulation, behavioural experiments, and opinion surveying based on the Clark & Wells model. These techniques allowed the patient to reduce the strength of maladaptive cognitions and lower her excessively high standards for social performance. CBT treatment using the Clark & Wells model was effective and suitable for Japanese SAD, at least in the present case. We also discuss the cross-cultural differences of SAD and adaptation of CBT.