When post-traumatic stress disorder (PTSD) co-occurs with obsessive compulsive disorder (OCD), symptoms of the former can interfere with evidence-based treatment of the latter. As a result, exposure-based treatments are recommended for both OCD and PTSD, potentially facilitating a concurrent treatment approach. This case study describes the application of concurrent cognitive behaviour therapy (CBT including exposure and response prevention; ERP) for OCD and narrative exposure therapy to treat a patient whose PTSD symptoms of intrusive images of memories and hyperarousal were interfering with standard CBT (including ERP) treatment for OCD. Following this concurrent approach, the patient’s symptoms of OCD reduced to non-clinical levels and showed reliable improvement in PTSD symptoms. Whilst further methodologically robust research is required, this case study highlights that this approach may be beneficial to the treatment of OCD where PTSD symptoms are impacting on treatment.

This paper is an introduction to adaptations to make cognitive behaviour therapy (CBT) more accessible to people with intellectual disabilities. It is intended to inform therapists who may work with people with intellectual disabilities in mainstream services.

The paper describes adaptations that consider neuropsychological processes, such as memory, and executive functions, such as planning, problem solving and self-regulation, and identifies that these factors are not unique to people with intellectual disabilities. We describe adaptations based on a review of literature describing CBT for people with intellectual disabilities (Surley and Dagnan, 2019) and draw on clinical experience to give examples of adaptations where possible. The paper particularly emphasises the generalisability of adaptations used with people with intellectual disabilities to therapy with wider populations and suggests that CBT therapists working in mainstream services will have the skills to be able to adapt therapy for people with intellectual disabilities.

Individuals from Black, Asian and Minority Ethnic (BAME) groups experience profound disparities in accessing mental healthcare, show poorer treatment outcomes, and high attrition rates when compared to their White British counterparts. Despite the national rollout of Improving Access to Psychological Therapies (IAPT) services, research exploring service users’ recovery narrative has been scarce. The aim of this study was to explore whether evidence-based psychological interventions are suitable to the needs of BAME communities. Semi-structured interviews were conducted with nine BAME service users who received evidence-based psychological treatment(s) from IAPT services. Reflexive thematic analysis (RTA) was used to analyse the data which included a six-phase process to produce a robust pattern-based analysis. Overall, three themes were generated. The first theme highlighted the importance of recognising cultural dissonance within therapy, which considered patient therapeutic expectations, therapeutic guilt, and conflicting cultural identities. The second theme identified the need for therapists to develop cultural competency. This included the importance of building therapeutic trust and exploration of patient culture within therapy. The final theme considered the road to recovery and highlighted challenges with therapeutic engagement and evaluations of therapeutic effectiveness. Overall, BAME service users felt that therapy was not a cure, but found it helpful. Clinical implications and future recommendations are discussed.

Avoidant Restrictive Food Intake Disorder (ARFID) is a condition characterised by a disturbance in eating behaviour that leads to a significant negative impact on physical, social and nutritional health. The diagnosis of ARFID relies on a comprehensive, multi-disciplinary assessment to understand the individual’s history, physical, social and mental health risk, and any co-occurring mental health difficulties. Consensus guidance suggests that psychological treatment, alongside medical and dietetic input is delivered with consideration of any appropriate adaptions to accommodate developmental stage and/or common co-occurring presentations. This paper has been authored by clinicians working in an out-patient setting for children and adolescents with ARFID, and focuses on the presentation and assessment of ARFID and cognitive behavioural therapy (CBT) approaches that can help children, young people and their families. After an introductory section, the paper is split into four sections: assessment of ARFID; drivers of avoidant restrictive eating behaviour; multi-disciplinary formulation and intervention planning; and treatment. The treatment section provides an overview of the available research on CBT for ARFID, and a brief summary of the broader evidence base for CBT in children and young people with anxiety. Following a review of the evidence base, three case descriptions are provided to illustrate the clinical application of CBT where fear-based avoidance is the main driver. The paper concludes with practice points for clinicians to take forward when working with children and young people with ARFID.

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.

Effective methods for training and education in the dissemination of evidence-based treatments is a priority. This commentary provides doctoral clinical psychology graduate student authors perspectives on common myths about cognitive behavioural therapy (CBT). Three myths were identified and considered: (1) CBT does not value the therapeutic relationship; (2) CBT is overly rigid; and (3) exposure techniques are cruel. Graduate students were engaged in a competency-based course in Cognitive Behavioural Approaches to Psychotherapy at an American Psychological Association (APA)-accredited doctoral clinical psychology program. The origins of common myths identified by graduate students included a lack of in-depth coverage of CBT and brief video segments provided during introductory courses, lived experience with CBT, and pre-determined views of manualized treatment and exposure techniques. Myth-addressing factors discussed by graduate students included holding space at the start of training for a discussion of attitudes about CBT, specific learning activities, and course content described in this commentary. Finally, self-reported changes in graduate students’ attitudes and behaviour following the course included a more favourable view of CBT as valuing the therapeutic relationship, as well as implementation of resources provided, and techniques learned and practised at practicum settings. Limitations and lessons learned are discussed through the lens of a model of adult learning that may be applied to future graduate training in evidence-based therapies like CBT.

This paper reports on the experience of the first cohort of cognitive behaviour therapists completing the first delivery of a UK government-funded mindfulness-based cognitive therapy (MBCT) teacher-training. Trainees completed a new curriculum approved by NHS England and commissioned by Health Education England (HEE) that enabled them to teach MBCT in Improving Access to Psychological Therapies (IAPT) services in England and to meet the criteria for registration for the British Association of Mindfulness-Based Approaches (BAMBA). The components of the training are described. Mixed quantitative and qualitative methods were used to assess the experiences of those trainees who completed that training. High levels of satisfaction were reported and the ‘embodiment’ of the trainers and supervisors was flagged as particularly significant. The retreat was experienced as a core component of the training that helped deepen mindfulness practice. Various challenges were identified, including from the retreat, technical difficulties and challenges with completion for a minority of trainees. Learning from the difficulties and responses to them are reported.

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.

Personal practice (PP) is widely practised and a requirement across major psychology and psychotherapy organizations and modalities. However, one of the challenges for training institutions is how to assess the quality of such PP. The Reflective Essay Marking Scale (REMS) was developed to improve standardization of marking reflective essays in cognitive behavioural psychotherapy (CBT) training. A small sample of 16 expert CBT participants recruited by email used the REMS to rate two mock reflective essays in a within-subjects design. The internal consistency of REMS was acceptable (Cronbach’s α=.73) with excellent inter-rater reliability. Across the raters, it sufficiently differentiated quality (t 12=4.91; p<.0001). Although these are the results of a preliminary and very small study with a small sample using mock essays, the REMS may be a useful scale, allowing CBT courses to account for students’ reflective work in a standardized way. A larger validation study is required in the future.

Traumatic loss is associated with high rates of post-traumatic stress disorder (PTSD) and appears to inhibit the natural process of grieving, meaning that patients who develop PTSD after loss trauma are also at risk of experiencing enduring grief. Here we present how to treat PTSD arising from traumatic bereavement with cognitive therapy (CT-PTSD; Ehlers et al., 2005). The paper describes the core components of CT-PTSD for bereavement trauma with illustrative examples, and clarifies how the therapy differs from treating PTSD associated with trauma where there is no loss of a significant other. A core aim of the treatment is to help the patient to shift their focus from loss to what has not been lost, from a focus on their loved one being gone to considering how they may take their loved one forward in an abstract, meaningful way to achieve a sense of continuity in the present with what has been lost in the past. This is often achieved with imagery transformation, a significant component of the memory updating procedure in CT-PTSD for bereavement trauma. We also consider how to approach complexities, such as suicide trauma, loss of a loved one in a conflicted relationship, pregnancy loss and loss of life caused by the patient.

The aim of this study was to investigate, from a lived experience perspective, specialist psychological therapists’ views on therapeutic adaptations to cognitive behaviour therapy (CBT) for autism that are most helpful for service users and enable best practice. Psychological therapist participants took part in semi-structured interviews led by a researcher with lived experience of autism. A thematic analysis was carried out. Participants (n=8) reported that challenges for service users were anxiety about the therapeutic relationship; communication difficulties with understanding and being understood; emotion recognition difficulties impeding trust and development of the therapeutic relationship; relationships with family interfering with the intervention; information processing impairments, necessitating a slower pace to the intervention; and avoidance of therapy due to anxiety. Goals were forming relationships and building social confidence and skills. Demographic differences were age, with older service users deemed less open to change and younger service users less mature and more often accompanied by family; and gender, with female service users deemed more socially able than males. Therapeutic adaptations were to increase collaboration; support emotional literacy, to help service users understand their own and others’ emotions; focus on special interests; use visual prompts, to improve communication and understanding; be consistent, to build trust and reduce anxiety; accommodate sensory needs, to reduce anxiety and build engagement; avoid metaphors, to reduce communication difficulties; and use role-play, to build and enhance social skills. Therefore, adapting CBT may support clinicians and reduce challenges for people with autism, while lived experience perspectives ensure adaptations meet service users’ needs.

The impact of racism to the individual is arguably immeasurable; however, the impact on psychotherapists who themselves have personally had either one or multiple experiences of racism and work with clients in therapy who have also experienced racism is an area with very little research. Semi-structured interviews were conducted with black cognitive behavioural therapists who have personally experienced racism and have also worked with clients who have experienced racism; data were analysed using interpretive phenomenological analysis. As this was a pilot study, only two participants were recruited to the study. Superordinate and subordinate themes were identified from the data and explored. The study highlighted that the impact of racism, racist experiences and microaggressions can lead to mental health problems, and there is need for further support for therapists, especially within the contexts of clinical supervision and from their organisation leadership. In addition, the need for further research was also identified, as well as improved training in working with disclosures of racism, and racial trauma within a therapeutic context was considered as important to the therapists of this pilot study.

The psychological literature highlights experiential avoidance as a transdiagnostic maintenance factor for a number of psychopathologies. Some attention has been given to therapist experiential avoidance, with the suggestion that this interferes with the acquisition and execution of CBT skills; there is, however, a paucity of research directly examining this relationship. This study aimed to measure experiential avoidance in trainee cognitive behavioural therapists, and establish any relationships with observed clinical competence. Twenty-nine trainee therapists took part in the study; levels of experiential avoidance were measured using the Multidimensional Experiential Avoidance Questionnaire and were analysed in relation to observed CBT skills assessed using the Cognitive Therapy Scale (Revised). No overall relationship between therapist experiential avoidance and clinical competency was observed. However, a number of significant associations were observed between individual dimensions of therapist experiential avoidance and CBT skills in collaboration, guided discovery, conceptual integration and homework setting. Aspects of therapist experiential avoidance during training may therefore be associated with the acquisition of key CBT skills. Tentative interpretations and recommendations for CBT training and supervision have been made, although further investigation is required.

Far from being a monolithic approach to psychotherapy, cognitive behavioural therapy (CBT) is in fact an umbrella term to describe a family of psychological therapies that share many common features but also have nuanced differences. Of the CBTs, two are often conflated under the ‘CBT’ moniker, namely cognitive therapy (CT) and rational emotive behaviour therapy (REBT). In this article, we explore some of the key differences and similarities between CT and REBT, touching on philosophy, practical implementation, and literature. We provide a brief hypothetical case study to demonstrate the different ways a therapist using CT and REBT might tackle the same client problem. We do not declare either approach superior, but suggest each might have their advantages in certain contexts and acknowledge that skilful practitioners could, and often do, integrate both approaches. As CBT continues to evolve and move into new areas, it is important that psychology practitioners and researchers are clear about which specific approach to CBT they are delivering, measuring and/or reporting on.

Cultural relevance is a core element of effective psychological interventions like cognitive behaviour therapy (CBT) or family intervention (FI), which can be considered Eurocentric. There have been few studies that have examined explanatory models of mental illness and its management in Pakistan to date. This study elicited patient- and carer-related health beliefs on psychosis including attributions to illness, and help-seeking behaviours to inform development of culturally sensitive treatment and improve outcomes in a unit in Lahore (Pakistan). The study group completed 45 semi-structured qualitative interviews at a mental health rehabilitation centre in Lahore. Data were analysed thematically using emerging themes and content analysis. Participants’ explanatory models for psychosis included religion or faith-driven beliefs, like previous wrong-doing and supernatural ideas such as black magic. Social factors that impacted families included high expectations, social stigma, and discriminations. Families first sought help from faith leaders and then medical or psychological sources of care. Participants had generally positive attitudes about their experience of psychological interventions.

There is preliminary evidence that CBT may be helpful for improving symptoms of misophonia, but the key mechanisms of change are not yet known for this disorder of decreased tolerance to everyday sounds. This detailed case study aimed to describe the delivery of intensive, formulation-driven CBT for an individual with misophonia and report on session-by-session outcomes using a multi-dimensional measurement tool (SFive). The patient was offered 12 hours of treatment over five sessions, using transdiagnostic and misophonia-specific interventions. Reliable and clinically significant change was found from baseline to one-month follow-up. Visual inspection of outcome graphs indicated that change occurred on the ‘outbursts’ and ‘internalising appraisals’ SFive subscales following assessment, and on the ‘emotional threat’ subscale after the first treatment session. The other two subscales started and remained below a clinically significant level. The biggest symptom change appeared to have occurred after the second session, which included interventions engaging with trigger sounds. The results demonstrated the individualised nature of misophonia, supporting the use of individually tailored treatment for misophonia and highlighting the importance of using a multi-dimensional measurement tool.

Previous research has shown that virtual reality (VR)-based exposure therapy is effective in the treatment of anxiety disorders. However, more information regarding the specific features of this intervention for the treatment of fear of flying (FoF) is needed. The primary aim of this systematic review was to update and analyse the existing data on the efficacy of VR exposure treatment (VRET) in FoF, providing information on the optimal methodological conditions for its administration. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was employed to select the articles. PsycInfo, Medline and Web of Science were chosen as databases with a wide range of publications related to health and psychology. Thirty-three eligible articles were included in this review. Results showed that participants’ anxiety decreased after being systematically exposed to flight-related VR environments. VRET is at least as effective as other evidence-based treatments, such as cognitive behavioural therapy (CBT) or in vivo exposure therapy (IVET), and therefore is a highly recommended alternative when IVET is difficult to administer, and an excellent complement to enhance CBT efficacy. Regarding sensory cues, the addition of motion feedback synchronised with visual and auditory cues during the exposure to VR environments might improve the efficacy of VRET for FoF, but more research supporting this statement is still needed.

The added value of using photographs to explore experiences has been embraced in research methods such as photo-elicitation and Photovoice. Despite evidence that photographs aid communication and understanding, there is little research investigating photograph use within cognitive behavioural therapy. This project explores participant experiences of taking and sharing photographs within a dialectical behaviour therapy (DBT)-informed emotional coping skills group intervention. Five service users were recruited from groups that had implemented the taking and sharing of photographs as a feature of homework tasks and feedback. Semi-structured interviews were conducted, using the photographs taken for the group as prompts, and interpretive phenomenological analysis was used to develop themes. Group evaluation data were used to support the analysis. Participants were positive about the impact of the photographs, despite initially experiencing anxieties regarding sharing them. The task supported them to express themselves in ways that added value to verbal feedback, which had benefits for group relationships and for the therapeutic tasks such as mindful observing. Further research is indicated, given the small sample and participants all being white, working-age females. However, the findings suggest that using photographs as homework tasks could support communication and the exploration of experiences that may be difficult to express using words.

This case study recounts an application of Ehlers and Clark’s (2000) cognitive model of post-traumatic stress disorder (PTSD) to post-intensive care unit (post-ICU) PTSD. An AB single case design was implemented. The referred patient, Rosalind (pseudonym), completed several psychometric measures prior to the commencement of therapy (establishing a baseline), as well as during and at the end of therapy. Idiosyncratic measures were also implemented to capture changes during specific phases of treatment. The importance of the therapeutic alliance, particularly in engendering a sense of safety, was highlighted. Findings support the use of cognitive therapy for PTSD (CT-PTSD) with an older adult, in the context of a coronavirus infectious disease (COVID-19)-related ICU admission. This case is also illustrative of the effectiveness of implementing CT-PTSD in the context of co–morbid difficulties and diagnoses of delirium, depression, and complicated grief.