Patients with social anxiety disorder (SAD) have a range of negative thoughts and beliefs about how they think they come across to others. These include specific fears about doing or saying something that will be judged negatively (e.g. ‘I’ll babble’, ‘I’ll have nothing to say’, ‘I’ll blush’, ‘I’ll sweat’, ‘I’ll shake’, etc.) and more persistent negative self-evaluative beliefs such as ‘I am unlikeable’, ‘I am foolish’, ‘I am inadequate’, ‘I am inferior’, ‘I am weird/different’ and ‘I am boring’. Some therapists may take the presence of such persistent negative self-evaluations as being a separate problem of ‘low self-esteem’, rather than seeing them as a core feature of SAD. This may lead to a delay in addressing the persistent negative self-evaluations until the last stages of treatment, as might be typically done in cognitive therapy for depression. It might also prompt therapist drift from the core interventions of NICE recommended cognitive therapy for social anxiety disorder (CT-SAD). Therapists may be tempted to devote considerable time to interventions for ‘low self-esteem’. Our experience from almost 30 years of treating SAD within the framework of the Clark and Wells (1995) model is that when these digressions are at the cost of core CT-SAD techniques, they have limited value. This article clarifies the role of persistent negative self-evaluations in SAD and shows how these beliefs can be more helpfully addressed from the start, and throughout the course of CT-SAD, using a range of experiential techniques.

The NICE guidance states that cognitive behavioural therapy (CBT) should now be offered to everyone with psychosis in the UK. This has rightly resulted in an increased demand for adherent therapy from qualified clinicians. Individualised formulation is a key component of CBT for psychosis, yet many trainees struggle to make sense of and apply the theoretical models on which these are based. This study explored trainee and recently qualified therapists’ experience of formulating CBT for psychosis, to help us understand how best to guide training and clinical practice. We ran focus groups with trainees who were completing, or had recently completed, postgraduate training in CBT for psychosis. We then analysed verbatim transcripts of the semi-structured interviews. and completed a thematic analysis of the data using inductive open coding. Three over-arching themes were generated: (1) purpose of formulation, (2) formulation in practice, and (3) (reflection on) learning to formulate. Training programmes and clinical supervisors should focus on fostering trainees’ and newly qualified therapists’ ability to develop simple, targeted formulations. These will draw on maintenance and developmental models of psychosis, depending on the person’s needs and goals. Opportunities for procedural learning are likely to improve skilful formulation, and use as the basis for therapeutic change.

People with psychosis often have prolonged in-patient1 admissions at high personal and economic costs. This is due in part to cognitive, affective and behavioural processes that delay recovery and discharge. For many, these processes are affected by enduring insecure attachment styles. People with insecure attachment struggle to manage strong feelings when unwell, and ward staff may struggle to know how best to offer support. Here, we outline the model of interpersonal process in cognitive therapy, and how this may be adapted to capture beliefs and behaviours associated with insecure attachment. Psychological interventions in acute care often fail due to implementation issues. For this reason, and in line with current guidance on developing complex interventions, we report on a series of Patient and Public Involvement (PPI) consultations with people with lived experience of psychosis, family members and ward staff on the potential utility of these attachment-based CBT models. The PPI meetings highlighted three themes: (1) the need to improve staff–patient interactions on wards; (2) continuity in staff–patient relationships is key to recovery; and (3) advantages and barriers to an attachment-based CBT approach. We conclude by describing how the models can be implemented in routine clinical practice, and generalised across services where interpersonal cognitive and behavioural processes may contribute to delays in people’s recovery.

In 1984 Jacobson and colleagues introduced the concept of reliable change, viz the amount of change on a measure that an individual needed to show to determine that it exceeded the extent of change likely due to measurement error alone. Establishing reliable change was a pre-requisite for determining clinical significance. This paper summarizes the rationale for determining reliable change as providing an individual-focused, idiographic alternative to the dominant nomothetic approach to clinical outcome research based on group mean data and statistical significance. The conventional computational steps for calculating an individual’s standardized difference (reliable change) score and the minimum raw change score on the measure (a reliable change index) required to classify individuals as reliably positively changed, indeterminate, or reliably deteriorated are described. Two methods for graphically representing reliable change are presented, and a range of possible uses in both research and practice settings are summarized. A number of issues and debates concerning the calculation of reliable change are reviewed. It is concluded that the concept of reliable change remains useful for both cognitive behavioural researchers and practitioners, but that there are options regarding methods of computation. In any use of reliable change, the rationale for selecting among method options and the exact computations used need clear and careful description so that we can continuously judge the utility and appropriateness of the use of reliable change and enhance its value to the field.

Providers of cognitive behavioural therapy (CBT) in adult mental health services in the UK are expected to deliver therapy suitable for adults of all ages. However, older people commonly present with co-morbidities that challenge delivery of single-diagnosis CBT protocols. Added to this, the difference in age between therapy-provider and service-user can compromise collaboration. In this paper, I consider two key areas of relevance for training and supervising CBT therapists for work with older people, namely multi-morbidities and intergenerational relations. The evolving evidence base for CBT with older people is summarised and a commentary provided on previous ‘old age’ case studies from the Cognitive Behaviour Therapist (tCBT). Strategies for collaborative relationships are discussed, as are strategies for ‘embedding the silver thread’. I conclude with recommendations for future directions for CBT training and supervision.

The UK government implemented national social-distancing measures in response to the global COVID19 pandemic. As a result, many appointments in the National Health Service (NHS) took place virtually, including psychological interventions in out-patient settings. This study explored the experiences of adolescents participating in a dialectical behaviour therapy (DBT-A) programme via teletherapy (i.e. via video or telephone call) in a Children and Adolescent Mental Health Service (CAMHS). Thirteen adolescents with emotion dysregulation and related problems completed an online qualitative survey about their experience and acceptance of DBT-A delivered virtually. Thematic analysis was conducted on the survey data and generated three over-arching themes: (1) sense of loss; (2) feeling uncontained; and (3) benefits of virtual DBT. These over-arching themes were composed of eight subthemes (‘loss of connection with group and therapist’; ‘loss of skills-building opportunities’; ‘limited privacy’; ‘lack of safe therapy space’; ‘difficult endings’; ‘home comforts’; ‘convenience and accessibility’; and ‘easier to participate with others’). This study suggests that adolescents doing virtual DBT-A need approaches that acknowledge and address the additional relational, emotional and practical challenges of online therapy while maintaining fidelity to the evidence-based treatment model. Suggestions for further research and preliminary practice guidelines are discussed.

Survivors of childhood trauma are at increased risk of complex post-traumatic stress disorder (CPTSD). The Recovering from Child Abuse Programme (RCAP) is a cognitive behavioural therapy (CBT) group promoting adaptive coping strategies which may help overcome CPTSD symptoms in adult survivors of childhood trauma. We sought to explore patient experiences of factors influencing treatment acceptability and potential mechanisms of therapeutic change in a sample of participants in the RCAP programme. As the group was delivered during the COVID-19 pandemic, necessitating a transition to remote therapy, we further aimed to capture experiences of the transition to telehealth delivery of the programme. A naturalistic sample of 10 women with CPTSD attending a specialist out-patient psychological trauma service participated in the study. Therapy sessions were recorded, transcribed verbatim and group members completed written feedback forms following each session. Reflexive thematic analysis was used to analyse the written feedback and transcripts. The RCAP was acceptable to group members and several themes were identified related to the experience of change in the group. Key themes centred on group solidarity; safety in the psychotherapeutic process; schema changes related to the self, others and future catalysed by the shifting of self-blame; increased emotional regulation to feel safer in the present; and increased future optimism. Therapeutic progress continued following the transition to telehealth, although face-to-face delivery was generally preferred. The programme was acceptable and led to cognitive change, enabling increased emotional regulation in the present and improved self-concept, thereby addressing key symptoms of CPTSD.

Digital CBT refers to the use of digital tools, platforms or devices to deliver or enhance cognitive behavioural therapy assessment, formulation, treatment, training and supervision. The ‘Advances in Digital CBT’ special issue aimed to document examples of innovative digital CBT practice in this rapidly developing field. In this paper, we have briefly summarised and synthesised the advances demonstrated in this group of articles. These include developments in our understanding of mental health apps, the use of digital tools as an adjunct to therapy, the effectiveness of remotely delivered CBT in routine clinical practice, our understanding of user experiences and involvement, and in digital CBT research methods. We consider the extent of current knowledge in these areas and identify where gaps in evidence lie and how the field could be taken forward to address these. Lastly, we reflect on the broader digital CBT picture and offer our suggestions of six key directions for future research: using robust study designs to evaluate and optimise digital tools; translating and culturally adapting digital tools and practices; understanding and addressing digital exclusion; exploring, reporting and addressing possible negative effects; improving user involvement in design and evaluation; and addressing the implementation gap for digital tools. We suggest that further advances in these areas would be of particular benefit to the digital CBT field.

Surveys are a powerful technique in cognitive behavioural therapy (CBT). A form of behavioural experiment, surveys can be used to test beliefs, normalise symptoms and experiences, and generate compassionate perspectives. In this article, we discuss why and when to use surveys in CBT interventions for a range of psychological disorders. We also present a step-by-step guide to collaboratively designing surveys with patients, selecting the appropriate recipients, sending out surveys, discussing responses and using key learning as a part of therapy. In doing so, we hope to demonstrate that surveys are a flexible, impactful, time-efficient, individualised technique which can be readily and effectively integrated into CBT interventions.

To increase access to support, an online psychosocial support tool for adults with visible differences was adapted for use without referral or supervision. This intervention combines a cognitive behavioural and social skills model of support. This study aimed to assess the usability and acceptability of Face IT@home as a self-help intervention. Eighty-one participants were recruited (32 with visible differences). Stage 1 included 14 participants (11 female, all with visible differences) who viewed two sessions of Face IT@home and undertook a semi-structured telephone interview. Stage 2 consisted of 14 think-aloud sessions (13 female, none with visible differences) with participants, supervised by researchers. Stage 3 employed 53 participants (47 female; 19 with visible differences), to view one session of Face IT@home and complete an online survey to evaluate usability and acceptability. User interviews, think-aloud studies and questionnaires identified usability and acceptability factors of Face IT@home that make it fit for purpose as a self-help tool. Participants suggested some changes to the Face IT@home program to improve usability. Participants reported that Face IT@home was a useful tool for people with visible differences and could be effective. The CBT-based model was considered a useful approach to addressing psychosocial concerns. The online self-help format will increase access to psychological support for adults with visible differences.

Mental health (MH) apps can be used as adjunctive tools in traditional face-to-face therapy to help implement components of evidence-based treatments. However, practitioners interested in using MH apps face a variety of challenges, including knowing which apps would be appropriate to use. Although some resources are available to help practitioners identify apps, granular analyses of how faithfully specific clinical skills are represented in apps are lacking. This study aimed to conduct a review and analysis of MH apps containing a core component of cognitive behaviour therapy (CBT) – cognitive restructuring (CR). A keyword search for apps providing CR functionality on the Apple App and Android Google Play stores yielded 246 apps after removal of duplicates, which was further reduced to 15 apps following verification of a CR component and application of other inclusionary/exclusionary criteria. Apps were coded based on their inclusion of core elements of CR, and general app features including app content, interoperability/data sharing, professional involvement, ethics, and data safeguards. They were also rated on user experience as assessed by the Mobile App Rating Scale (MARS). Whereas a majority of the CR apps include most core CR elements, they vary considerably with respect to more granular sub-elements of CR (e.g. rating the intensity of emotions), other general app features, and user experience (average MARS = 3.53, range from 2.30 to 4.58). Specific apps that fared best with respect to CR fidelity and user experience dimensions are highlighted, and implications of findings for clinicians, researchers and app developers are discussed.

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.

Cognitive behavioural therapists based in primary care are not usually expected to provide therapy to acutely suicidal individuals or work directly on suicidal thoughts. However, all practitioners should be vigilant about suicide risk and potentially help to reduce vulnerabilities to future suicide risk as part of their routine work. Many of the risk factors and processes hypothesised to play a role in the development of suicidal thinking and behaviours are likely to be evident within the usual content of standard evidence-based protocols for depression or anxiety disorders. In this paper we are suggesting that even within the current primary care remit, (i) an increased awareness of suicide risk vulnerability factors and (ii) using knowledge of a psychological model of suicidal behaviour to inform clinical care are likely to be extremely helpful in structuring clinical formulation and informing interventions.

Kleptomania is an addiction to stealing without an economic motive; therefore, an examination of effective interventions as a preventive measure is needed. The effectiveness of cognitive behavioural therapy (CBT) combined with mindfulness for the treatment of addiction has been previously indicated, and it is presumed to be effective for kleptomania; however, this relationship remains unstudied. Therefore, this study aimed to examine the effectiveness of cognitive behavioural group therapy (CBGT) combined with mindfulness for treating kleptomania. The results of a 12-session programme of CBGT combined with mindfulness for 22 patients with kleptomania showed that kleptomania symptoms and quality of life (QOL) improved. Furthermore, the recovery process revealed that the improvement of distress tolerance affected the improvement of kleptomania symptoms and that the improvement of reward perception and distress tolerance affected the improvement of stress response and QOL. These results suggest that CBGT combined with mindfulness may be effective in improving symptoms and QOL in kleptomania.

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.

Training as a cognitive behavioural therapist involves a considerable role transition for mental health professionals where they are expected to demonstrate competence in a range of new skills that emphasise collaboration and Socratic dialogue. This can be in stark contrast to the more didactic style that trainees are familiar with prior to embarking on their training. Guided discovery (GD) is an integral part of formulation and treatment, yet little is known at present about the experiences of cognitive behavioural therapy (CBT) trainees when learning this new skill; specifically, how they assimilate this with existing ways of working and the challenges this might involve. This research is a preliminary attempt to understand factors that help and hinder GD skill acquisition. Eighteen trainee CBT practitioners completed an online questionnaire with the subsequent data analysed using a grounded theory methodology. Three themes were identified: ‘Competing Selves’, ‘Style’ and ‘Active Engagement and Learning’. These themes were used to develop a preliminary model of factors that enable or inhibit skills in GD. The impact of previous professional roles appears to influence the acquisition of confidence and skill in GD. This paper discusses the implications of the findings for CBT trainers, supervisors and trainees.

Guided CBT self-help represents a low-intensity intervention to deliver evidence-based psychological therapy within the Improving Access to Psychological Therapies (IAPT) programme. Best practice guidance highlighting characteristics associated with CBT self-help is available to help services reach decisions regarding which interventions to adopt. However, at present a single process to evaluate written CBT self-help interventions informed by guidance is lacking. This study reports on the development of a standardised criteria-driven process that can be used to determine the extent written CBT self-help interventions are consistent with guidance regarding the fundamental characteristics of low-intensity CBT and high-quality written patient information. Following development, the process was piloted on 51 IAPT services, with 23 interventions identified as representing free-to-use written CBT self-help interventions. Overall, inter-rater reliability was acceptable. Following application of the criteria framework, 14 (61%) were considered suitable to be recommended for use within the IAPT programme. This pilot supports the development and potential utility of an independent criteria-driven process to appraise the suitability of written workbook-based CBT self-help interventions for use within the IAPT programme.

Despite its impressive evidence base, there is a widening access gap to receiving cognitive behavioural therapy (CBT). Video conferencing therapy (VCT) offers an effective solution for logistical barriers to treatment, which has been salient throughout the Coronavirus pandemic. However, research concerning the delivery of CBT via VCT for children and young people (CYP) is in its infancy, and clinical outcome data are limited. The aim of this service evaluation was to explore the effectiveness of a VCT CBT intervention for CYP referred from Child and Adolescent Mental Health Services (CAMHS) in the UK. A total of 989 records of CYP who had completed CBT via VCT in 2020 with Healios, a digital mental health company commissioned by the National Health Service (NHS), were examined to determine changes in anxiety, depression and progress towards personalised goals. Routine outcome measures (ROMs) were completed at baseline and endpoint, as well as session by session. Feedback was collected from CYP and their families at the end of treatment. There was a significant reduction in symptoms of anxiety and depression and significant progress towards goals, with pre- to post-effect sizes (Cohen’s d) demonstrating medium to large effects (d=.45 to d=−1.39). Reliable improvement ranged from 31 to 80%, clinical improvement ranged from 33 to 50%, and 25% clinically and reliably improved on at least one measure; 92% reported that they would recommend Healios. This service evaluation demonstrates that Healios’ CBT delivered via VCT is effective for CYP receiving it as part of routine mental health care.

Cognitive behaviour therapy (CBT) is considered to be the most empirically supported treatment in the Western world. However, many authors emphasize the need for cultural adaptations of CBT for patients in a non-Western context. Before considering such adaptations, it is important to investigate the reasons and the degree to which this type of treatment should be adapted. One important factor is the acceptability of CBT by local health care consumers in non-Western countries, for which there is only very limited empirical evidence. This explorative study aimed to investigate the acceptability of CBT’s principles and specific interventions in Indonesia. Lectures and video clips were developed, demonstrating various mainstream CBT principles and procedures. These were presented to 32 out-patients and mental health volunteers from various Indonesian community health centres (Puskesmas), who were asked to rate to what extent they considered the presented materials to be acceptable in accordance with their personal, family, cultural and religious values. Acceptance in all four value domains was rated as very high for the general features of CBT, as well as for the content of the video clips. There were no significant differences in acceptability between the value domains. The presented study suggests that mainstream CBT applications, which are slightly culturally adapted in terms of language, therapist–patient interaction and presentation, might resonate well with consumers in community health centres in Indonesia.