Over the past decade, provision of cognitive behaviour therapy has expanded massively in the UK, both within the private sector and through the Improving Access to Psychological Therapies (IAPT) programme. Our aim in this study was to explore and compare the brand names adopted by IAPT and private CBT services. We obtained the names of all the IAPT and private services in England and created a word cloud for each sector. There was no significant difference in the proportion of services that adopted a brand name (72% of IAPT services vs 67% of the private services). In those with a brand name, IAPT services were significantly more likely than private services to contain positive words, and to have a theme of togetherness and collaboration. However, private services were more likely to include a psychological therapy in their name and have a theme of efficacy compared with IAPT. The most common keywords in IAPT services were ‘talking’ and ‘thinking’. IAPT services use a variety of euphemisms such as ‘talking’ for a psychological therapy. There is no theme for ‘doing’ in the IAPT or private services, despite behavioural interventions being one of the most common therapeutic components. The brand names in IAPT are overwhelmingly positive and convey the hope of a good outcome. They do not include the experience of difficult emotions, such as sadness and fear during therapy. We found just one private service that evoked the history of CBT named after Vic Meyer. Perhaps we will have some Clark and Layard centres in the years to come!

People with obsessive compulsive disorder (OCD) are likely to be more susceptible to the mental health impact of COVID-19. This paper shares the perspectives of expert clinicians working with OCD considering how to identify OCD in the context of COVID-19, changes in the presentation, and importantly what to consider when undertaking cognitive behaviour therapy (CBT) for OCD in the current climate. The expert consensus is that although the presentation of OCD and treatment may have become more difficult, CBT should still continue remotely unless there are specific reasons for it not to, e.g. increase in risk, no access to computer, or exposure tasks or behavioural experiments cannot be undertaken. The authors highlight some of the considerations to take in CBT in light of our current understanding of COVID-19, including therapists and clients taking calculated risks when developing behavioural experiments and exposure tasks, considering viral loading and vulnerability factors. Special considerations for young people and perinatal women are discussed, as well as foreseeing what life may be like for those with OCD after the pandemic is over.

Mental health staff may have limited exposure to emergencies associated with obsessive–compulsive disorder (OCD) during postgraduate training. The first time they encounter a person in the midst of severe obsessions, or one who has compulsively self-harmed in response to such obsessions, might be when working on call covering the emergency department. This educational article presents the lived experience of one of the authors as a clinical scenario. The scenario is then used to illustrate the severity of disability and the rates of self-harm and suicide-related mortality caused by OCD. The recognition and assessment of OCD is described, along with what helps in emergency situations. Written informed consent was obtained for the publication of clinical details.

This paper argues that intermittent nursing observations of in-patients at night do not reduce the risk of suicide or severe self-harm. Suicides between 23.00 h and 07.00 h are rare, and these overwhelmingly occur under intermittent observations. Such observation is purely a defensive intervention to document that a patient is safe at a particular time, as there is no engagement. For the large majority of in-patients, it has the unintended consequence of causing sleep deprivation. The intervention may cause harm to in-patients by making their disorder worse and increase their risk during the day. If patients are judged to be at immediate risk, then they should be placed on constant observation. If they are not, then optimising sleep is important for treating a psychiatric disorder and they should be placed on general observations.

In 2012, the coalition government introduced the legal right for National Health Service (NHS) patients in England to choose their mental healthcare provider for out-patient treatment. This was a significant step towards parity of care between mental and physical ill health, and NHS Improvement and NHS England have provided sensible guidance on its implementation. However, several factors prevent the system from working as it was intended: lack of awareness of the principle of patient choice for out-patient treatment; complacency from some trusts and commissioners; mental health trusts operating outside the e-referrals system; misuse of care pathways; lack of direct access by many general practitioners for out-of-area referrals; and delays in authorisation for funding. I describe how I have come to this conclusion and suggest some solutions.

Obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD) can take many different forms of presentations. The term ‘complex’ is common and inconsistently used in both OCD and BDD. Practitioners often refer to complex OCD or BDD when patients present with severe co-morbid problems, often in the context of personality difficulties, dissociation, difficult early relationships and trauma; or when the illness is chronic and debilitating with previous multiple treatment failures. Current best-evidence treatment protocols for both disorders focus heavily on exposure and response prevention (E/RP) but with moderate success, particularly in patients who are deemed ‘complex’, and often those with relevant shame and/or disgust-based past experiences. The aim of the present paper is to (a) describe factors that contribute to complexity in OCD and BDD, and (b) link these with theory and practice. We emphasize the importance of understanding both the function of OCD and BDD-related behaviours (rather than the content of obsessions or compulsion), and the context in which they occur such as the family. We illustrate complexity in OCD and BDD using real case material, using a functional and contextual approach to formulate the client's difficulties, and demonstrate how E/RP can be enhanced successfully with imagery rescripting, family work, and compassion-focused therapy.

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived flaw in one's appearance, and is often emotionally linked with early adverse experiences. Cognitive behavioural therapy (CBT) is effective but may not resolve shame and anger that can be at the emotional root of BDD. This paper presents a single-case study of a 25-year-old man with a history of treatment-resistant BDD characterized by a preoccupation with facial skin linked to a developmental history of sexual abuse and bullying. He was treated at a national residential specialist unit for 16 weeks during which time he received three individual 1-hour weekly CBT sessions (42 sessions overall), and participated in the residential group programme and therapeutic community. CBT was enhanced using imagery rescripting, compassion-focused therapy and family work to specifically target shame and anger-based past experiences. Severity of BDD was assessed with the BDD-Yale–Brown Obsessive Compulsive Scale (BDD-YBOCS) at pre-, mid-, post-, 3-month and 18-month follow-ups; a weekly self-report measure (Appearance Anxiety Inventory), and a client-drawn self-portrait of his perceived skin flaws at pre- and post-treatment. Treatment outcome was positive. The BDD-YBOCS dropped 94% from the extremely severe range pre-treatment to the sub-clinical range post-treatment. BDD symptoms improved progressively throughout treatment, and when the emotions of anger and shame were resolved (as reported by the client) fell to the non-clinical range. Gains were maintained at 18-month follow-up. We conclude that enhancing CBT for BDD using emotion-focused techniques is to be recommended, particularly when emotional memories continue to affect body shame.

Background: There is little data to inform the treatment of severe obsessive compulsive disorder (OCD) in an inpatient or residential setting. Aims: This paper aimed to: a) describe treatment outcomes at a residential unit over 11 years; b) investigate whether treatment was successful for a subset of severe treatment refractory residents; c) compare an intensive treatment programme to a “standard” treatment programme; and d) find predictors of self or early discharge from the unit. Method: We compared treatment outcomes for (i) a minimum 12-week treatment (hereafter “standard”) programme versus a 2-week intensive programme and (ii) for severe treatment refractory cases on the standard programme. We identified 472 residents with OCD admitted to the Anxiety Disorders Residential Unit at the Bethlem Royal Hospital between 2001 and 2012. Outcomes were measured with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Obsessive Compulsive Inventory (OCI), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) obtained throughout treatment and up to one year after discharge. Results: Although residents had very severe OCD on admission, sequential assessment with the Y-BOCS, OCI, BAI and BDI demonstrated that scores on all outcome measures significantly decreased from pre to posttreatment and were generally maintained at follow-up. There was no significant difference between those on the standard or the 2-week intensive programme. Sixty-nine per cent of residents with OCD made significant improvements, with at least a 25% reduction on the Y-BOCS. There were predictors of self or early discharge but none for outcome on the Y-BOCS. Conclusions: The data support the principle of stepped care for severe OCD.

Background: Allocation of trainee therapist cases is often performed based on intuition and clinical circumstances, with lack of empirical evidence on the role of severity of presenting problem. This has the potential to be anxiety-provoking for supervisors, trainees and service users themselves. Aims: To determine how therapist experience interacts with symptom severity in predicting client outcomes. Method: An intention-to-treat analysis of annual outcome data for primary and secondary care clients seen by a specialist anxiety disorders service. 196 clients were stratified into mild, moderate and baseline severe symptoms of anxiety (GAD-7) and depression (PHQ-9). We measured percentage change on these measures, as well as number of sessions and therapy dropout. We also examined rates of reliable and clinically significant change on disorder-specific measures. We hypothesized that qualified therapists would achieve better outcomes than trainees, particularly for severe presentations. Results: Overall, outcomes were comparable between trainee and qualified therapists on all measures, and trainees additionally utilized fewer therapy sessions. There was however an interaction between anxiety severity (GAD-7) and therapist group, such that severely anxious clients achieved greater symptom improvement with qualified as compared to trainee therapists. Further, for trainee but not qualified therapists, baseline anxiety was negatively associated with rate of reliable and clinically significant change on disorder-specific measures. Conclusions: These findings indicate generally favourable outcomes for trainee therapists delivering manualized treatments for anxiety disorders. They additionally suggest that trainee therapists may benefit from additional support when working with clients that present with severe anxiety.

Exposure and response prevention (ERP), a form of behavior therapy, is widely recognized as the most effective psychological treatment for obsessive-compulsive disorder (OCD). Cognitive therapy (meaning rational emotive behavior therapy [REBT], or the Salkovskis model for this article) has received increased attention as an effective method for OCD treatment. These methods have renewed hope for patients suffering with what had long been thought to be a treatment refractory condition. Yet many important issues require further discussion and investigation. At the Second International Conference on OCD, which was held in Guadeloupe, February 14–16, 1996, the following issues were highlighted:

1. Which psychotherapies are effective in the treatment of OCD?

2. What psychological strategies may be used to increase patient motivation during treatment?

3. Are relapse prevention strategies necessary after improvement?

4. How do economic factors affect the use of behavior therapy? How is OCD treatment uniform or varying from specialty providers to mental health generalists to primary care physicians? How do self-administered and therapist-administered ERP compare?

5. How does the efficacy of ERP or cognitive therapy and pharmacotherapy (either alone or in combination) compare?

6. Is ERP effective for complex forms of OCD?

7. In OCD treatment, is medication compliance improved if ERP or cognitive therapy is also used, and vice versa? How does this affect relapse rates? In addition, can doses of medications be lowered with the addition of ERP or cognitive therapy?

8. What is known about the brain function and biological changes associated with ERP and cognitive therapy?

It is hypothesized that body dysmorphic disorder (BDD) patients are firstly more “aesthetical,” an attribute much like being musical, which varies between different individuals. This results in a greater emotional response to more attractive individuals and placing greater value on the importance of appearance in their identity compared with healthy individuals. Some BDD patients may have greater aesthetic perceptual skills. This is manifested in their education or training in art and design. Secondly, BDD patients may have higher aesthetic standards than the rest of the population. Their failure to achieve an unrealistic aesthetic standard is at the core of BDD, leading to severe distress and handicap.