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.

This article outlines a cognitive behavioural therapy (CBT) approach to treating feelings of guilt and aims to be a practical ‘how to’ guide for therapists. The therapeutic techniques were developed in the context of working with clients with a diagnosis of post-traumatic stress disorder (PTSD); however, the ideas can also be used when working with clients who do not meet a diagnosis of PTSD but have experienced trauma or adversity and feel guilty. The techniques in this article are therefore widely applicable: to veterans, refugees, survivors of abuse, the bereaved, and healthcare professionals affected by COVID-19, amongst others. We consider how to assess and formulate feelings of guilt and suggest multiple cognitive and imagery strategies which can be used to reduce feelings of guilt. When working with clients with a diagnosis of PTSD, it is important to establish whether the guilt was first experienced during the traumatic event (peri-traumatically) or after the traumatic event (post-traumatically). If the guilt is peri-traumatic, following cognitive work, this new information may then need to be integrated into the traumatic memory during reliving.

Brief cognitive behavioural therapy (CBT) is effective in working with non-underweight eating disorder patients across transdiagnostic groups. However, it is not clear whether it will be as effective in the treatment of binge-eating disorder, where emotional eating is likely to play a larger role than starvation-driven eating. This case series tested whether brief, 10-session CBT (CBT-T) would be effective in a case series of 53 patients with binge-eating disorder. Attrition rates were comparable to previous research. Eating attitudes, binge frequency, anxiety and depression were measured. Remission was measured comparing different categorical methods: ‘cut-off’; reliable change index (RCI); and clinically significant change (CSC). CBT-T was effective for binge-eating disorder patients, at comparable levels to other non-underweight patients. All measures of pathology were significantly reduced, with large to moderate effect sizes. When categorical changes were used to indicate remission, RCI and CSC levels were more appropriate than existing cut-off methods, potentially because of the lower levels of initial restrained eating in this clinical group. CBT-T’s effectiveness in transdiagnostic groups is replicated in binge-eating disorder patients, despite their greater level of emotionally driven eating. More stringent definitions of remission (CSC and RCI) should be used more widely, to ensure realistic estimates.

The use of transdiagnostic mental health treatments in low resource settings has been proposed as a possible aid in scaling up mental health services. Modular, multi-problem transdiagnostic treatments can be used to treat a range of mental health problems and are designed to handle comorbidity. Two randomized controlled trials have been completed on one treatment – the Common Elements Treatment Approach, or CETA – delivered by lay counsellors in Iraq and Thailand. This paper utilizes data from two clinical trials to explore the delivery of CETA by lay providers, examining fidelity and flexibility of element use. Data were collected at every therapy session. Clients completed a short symptom assessment and providers described the clinical elements delivered during sessions. Analyses included descriptive statistics of delivery including selection and sequencing of treatment elements, and the variance in element dose, clustering at the counsellor level, using multi-level models. Results indicate that lay providers in low resource settings (with supervision) demonstrated fidelity to the recommended CETA elements, order and dose, and occasionally added in elements and flexed dosage based on client presentation (i.e. flexibility). This modular approach did not result in significantly longer treatment duration. Our analysis suggests that lay providers were able to learn decision-making processes of CETA based on client presentation and adjust treatment as needed with supervision. As modular multi-problem transdiagnostic treatments continue to be explored in low resource settings, research should continue to focus on ‘unpacking’ lay counsellor delivery of these interventions, decision-making processes, and the level of supervision required.

Culture plays a significant role in psychotherapy practice, with cultural adaptations being implemented more commonly as globalisation and cultural awareness increase. An abundance of systematic reviews, meta-analyses and randomised controlled trials exploring culturally adapted interventions have been published across the globe. In this paper, we present the historical background to cultural adaptation by summarising and evaluating previous frameworks, as well as reviewing current evidence for such adaptations and highlighting routes for further research. Around twenty cultural adaptation frameworks have been published, covering various population demographics and intervention types, providing general guidelines for the implementation of cultural adaptations to psychosocial interventions. Nearly all the frameworks used previous literature and research to develop models on culturally adapted interventions. Some even implemented stakeholder discussions, randomised control trials, and even pilot studies. A variety of cultural adaptation factors have been outlined and discussed; however, there is no agreement on which elements work and which do not. Existing evidence indicates that culturally adapted interventions are effective, regardless of intervention type or population. While cognitive behavioural therapy (CBT) was the most common intervention in trials, there are, at present, no high-quality comprehensive meta-analyses or systematic reviews on culturally adapted CBT which include all literature on this topic. This is needed in order to provide a holistic and detailed comprehension of where current understanding lies. We conclude our paper with recommendations for researchers, trainers and commissioners.

The Improving Access to Psychological Therapies (IAPT) programme started in 2008, but it contained little provision for specifically meeting the needs of Black, Asian and minority ethnic (BAME) groups. The purpose of this evaluation was to describe the experience of transition from BAME community mental health worker (CMHW) to IAPT low-intensity psychological wellbeing practitioner (PWP) in order to identify possible gains and losses for the former communities served, and the factors that might contribute to successful training of people with BAME expertise. Four former CMHWs who had transitioned into working as PWPs were interviewed. Semi-structured interviews were used. The data were analysed using thematic analysis. Six major themes were identified with the benefits of training emerging as an important factor for the participants in enhancing their role. Three of the themes interconnected and focused on the impact for BAME communities in terms of access to service and barriers. Evident in the interviews were descriptions of adaptations that were made as a result of CMHW having access to both new and old skills. Finally, two themes focused on the participant recommendations as to how IAPT services might become more culturally responsive. The findings suggest that there can be significant benefits for services to provide IAPT training to people already providing culturally specific services. The participants reported that low-intensity cognitive behavioural therapy (LICBT) was effective, but only when cultural sensitive adaptations were made. The evaluation has some clear recommendations as to how IAPT services might seek to offer culturally responsive CBT. Suggestions for carrying out further practice-based evaluations are made.

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.

Psychoeducation courses have gained some empirical support as effective early intervention strategies. Many of these courses reflect traditional cognitive behaviour therapy (CBT) thinking but psychoeducation courses based on other approaches are beginning to emerge. One such course, ‘ACTivate Your Life’, is based on acceptance and commitment therapy (ACT). The aim of this preliminary investigation is to evaluate a four-session (eight-hour) ACT psychoeducation intervention delivered within the Abertawe Bro Morgannwg University (ABMU) Health Board. Participants were invited to complete four outcome measures (assessing depression, anxiety, self-esteem and life satisfaction) and two process measures (assessing mindfulness self-efficacy and psychological flexibility) at pre- and post-intervention. Statistical analysis indicated that participants’ scores across each of the measured domains showed highly significant changes. These results suggest that a brief psychoeducation ACT course may be useful in helping people in need of early psychological intervention, and that further research is now needed to provide a definitive evaluation of its effectiveness.

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.

Currently recommended psychotherapies for depression are not always delivered in a consistent manner. There is an assumption that the use of clinical supervision will ensure reliable treatment and patient recovery. However, there is limited research supporting this assumption. This study explored the role of supervision in the treatment of depression. In particular, it examined how supervisors’ own characteristics and those of patients can influence the focus of supervision sessions. Clinical supervisors who worked with cognitive behavioural therapy (CBT) therapists treating depression cases were asked to indicate their supervision focus for three different patient vignettes. These vignettes varied in clinical complexity. Participants’ intolerance to uncertainty and their self-esteem were also assessed. Supervisors tended to focus their supervisees on the use of evidence-based therapeutic techniques for both straightforward and complex cases. However, their approach was less evidence-based for diffuse cases. Three supervisory types emerged: an ‘Alliance- and Technique-Focused’ group, a ‘Case Management-Focused’ group, and an ‘Unfocused’ group. Personal characteristics of the supervisors varied across the groups. The content of supervision sessions is influenced by factors from outside the therapy process. These factors might cause supervisors to avoid focusing on evidence-based aspects of therapy, thus feeding therapist drift. Suggestions are made for new supervision protocols that consider the supervisor's personal characteristics.

This paper looks at issues regarding case formulation in psychotherapy. Case formulation is well recognized as being helpful in the conceptualizing of psychological problems and as a useful tool in the practice of cognitive therapy. Control, as opposed to behaviour, is increasingly being seen as that human process most relevant to psychopathology. We look at the diagnosis and treatment of a small number of people, treated in a naturalistic setting, who were selected without any specific criteria other than being people whose problems were treated using the Method of Levels, a form of cognitive therapy based on the principles of Perceptual Control Theory, and who completed both pre- and post-treatment questionnaires. We then consider how the problems these people presented with, and their treatment, might be formulated as a result of taking this approach.

There is a very high prevalence of post-traumatic stress disorder (PTSD) within refugee populations and survivors of torture. Refugees, asylum seekers and survivors of torture who access IAPT (Improving Access to Psychological Therapies) can present with unique clinical challenges for cognitive behavioural therapy (CBT) therapists. The use of reflective practice can be beneficial particularly when there is added complexity in the client's clinical presentation. The aim of this paper is to provide an overview of how reflective practice can improve clinical work with this patient group and to identify some of the challenges that refugees, asylum seekers and survivors of torture may present with during therapy. The paper sets out how the use of the critical incident analysis model and clinical supervision can assist to develop reflective practice skills and improve the clinical practice of IAPT CBT therapists who work with diverse populations.

Large-scale cognitive behavioural therapy (CBT) training and implementation programmes, such as the pioneering Improving Access to Psychological Therapies (IAPT) initiative in the UK, aim to develop a workforce of competent therapists who can deliver evidence-based interventions skilfully. Self-awareness of competence enables CBT therapists to accurately evaluate their clinical practice and determine professional development needs. The accuracy of self-assessed competence, however, remains unclear when compared with assessments conducted by markers with expertise in CBT practice and evaluation. This study investigated the relationship between self- and expert-rated competence – assessed via therapy recordings rated on the Cognitive Therapy Scale Revised (CTS-R) scale – for a large sample of IAPT CBT trainees during training and, for the first time, at post-training follow-up. CBT trainees (n = 150) submitted therapy recordings at baseline, mid-training and end-of-training. At 12+ month follow-up, a subset of former trainees (n = 30) submitted recordings from clinical practice. There were positive relationships (r = .27 to .56) between self and expert CTS-R scores at all time points. The proportion of tapes demonstrating significant agreement between self and expert ratings (CTS-R difference <5 points) increased significantly across training and remained stable at follow-up. Findings indicate that accurate self-awareness of competence can be developed during structured CBT training and retained in the workplace. These outcomes are encouraging given the importance of self-awareness to CBT practice and accreditation. Future investigation into the development and maintenance of accurate self-awareness of competence is warranted.

Web-based interventions for depression have burgeoned over the past 10 years as researchers and health professionals aim to harness the reach and cost-effectiveness that the internet promises. Despite strong clinical evidence of their effectiveness and policy support, web-based interventions have not become widely used in practice. We explored this translation gap by conducting an implementation pilot of MindBalance, a web-based intervention for depression built on the SilverCloud platform, in three IAPT services. We posed three questions: (1) Who chooses to use MindBalance? (2) Is MindBalance effective for these clients? (3) How do clients use MindBalance? Our results for questions (1) and (2) are commensurate with the positive findings in the literature on patient acceptability and clinical effectiveness for such interventions. Client usage, captured in adherence data as well as usage case-studies, was diverse and differed markedly from face-to-face sessions. The most surprising result, however, concerned the small number of people who were offered the intervention. We reflect upon why this was and discuss implementation issues that primary mental health services should consider when adding a web-based intervention to their services.

There is a national drive to increase access to psychological therapies across England, with a specific focus on under-represented groups such as Black, Asian Minority and Ethnic (BAME) groups. Although prevalence rates for common mental health conditions such as depression and anxiety in Orthodox British Jews are less than those of the generic population in the United Kingdom, accessing services to help treat these conditions within this group are considerably less than other groups. This paper seeks to consider reasons for this, as well as what adaptations, both from a therapist and service perspective, can be made to increase access within the Orthodox Jewish community with lessons to be made to other BAME groups.

This study aimed to examine how people change in order to achieve and maintain a personally comfortable weight and what changes for them as they change. Six students who changed to achieve and maintain a personally comfortable weight for a minimum of 1 year were recruited. Semi-structured interviews explored participants’ experiences of what changed and how they changed. The interviews were analysed using interpretative phenomenological analysis. Two superordinate themes emerged. The first was ‘awareness’ which contained the subthemes: unaware self, revelation, and conscious monitoring and maintenance of awareness. The second was ‘goals and needs’ which contained the subthemes: social- vs. self-acceptance, removing negative emotions, weight control vs. other life goals, and ideal vs. perceived health and appearance. The findings are discussed in relation to the existing literature on the development of eating problems, involving social acceptance, self-esteem, coping with negative moods, and weight control. Perceptual Control Theory was used to provide an explanation for how these participants changed and maintained their change.

Although general cognitive behavioural therapy (CBT) can help alleviate distress associated with obsessive-compulsive disorder (OCD), strategies tailored to targeting specific cognitions, feelings, and behaviours associated with OCD such as exposure and ritual prevention (Ex/RP) and cognitive therapy (CT) have been shown to be a significantly more effective form of treatment. Treatment of individuals with unacceptable/taboo obsessions requires its own specific guidelines due to the stigmatizing and often misunderstood nature of accompanying thoughts and behaviours. In this article, OCD expert practitioners describe best practices surrounding two of the longest standing evidence-based treatment paradigms for OCD, CT and Ex/RP, tailored specifically to unacceptable and taboo obsessions, so that clients may experience the best possible outcomes that are sustained once treatment ends. In addition, CT specifically targets obsessions while Ex/RP addresses compulsions, allowing the two to be highly effective when combined together. A wide range of clinical recommendations on clinical competencies is offered, including essential knowledge, psychoeducation, designing fear hierarchies and exposures, instructing the client through behavioural experiments, and relapse prevention skills.

Large psycho-education groups are being increasingly used in mental-health promotion and the treatment of common mental-health problems. In individual therapy there is a well-established link between therapist empathy, therapeutic relationship and patient outcome but the role of empathy within large psycho-educational groups is unknown. This service evaluation investigated the impact of a 6-week large psycho-education group on patient outcome and the role of perceived therapist empathy on outcome. Within a before–after experimental design, 66 participants completed baseline and endpoint measures; Clinical Outcome Routine Evaluation (CORE), Patient Enablement Instrument (PEI), and the modified Consultation and Relational Empathy (CARE) measure. The results showed that the intervention had a positive impact on patient outcome; the CORE score reduced significantly over the 6 weeks by 0.63 (95% CI 0.82–1.14) (t = 9.18, d.f. = 55, p = <0.001) and attendees felt highly enabled. Attendees perceived the course leader as highly empathetic. However, the relationship between perceived empathy and attendee outcome was less clear; no significant relationship was found with the main outcome measure (the change in CORE score). Factors that influenced the main outcome included age, symptom severity at baseline, having a long-term illness or disability, and whether attendees tried the techniques at home (homework). These findings suggest that large group psycho-education is an effective treatment for mild to moderate mental-health problems, at least in the short term. The role of therapist empathy remains ambiguous but may be important for some patient outcomes.