This article describes the clinical supervision of Multisystemic Therapy (MST), which takes place in the context of a quality assurance and quality improvement system that is used to support the transport and implementation of MST nationally and internationally. Information is provided about the assumptions, objectives, structure, process, and content of MST supervision; training and support provided to supervisors; methods used to measure adherence to the supervision model; and, findings supporting linkages between supervision, therapist adherence, and youth outcomes. MST supervision is considered in the context of recent efforts to identify empirically supported approaches to supervision and of recent developments in implementation research.

This paper reports from a study of an intervention aimed at strengthening mental health nursing staff supervision. We developed and tested a short-term group-based meta-supervision intervention as a supplement to usual supervision. The intervention drew on action learning principles to activate and inspire supervisees to develop strategies for influencing their own supervision practices. The core ‘meta-supervisory’ process was organized round participants’ reflections on the possible benefits of supervision, their perceived barriers to realizing the benefits, and the articulation of concrete actions to overcome the barriers. In this paper, we introduce previously reported findings from the study and present two novel supplementary analyses of data from the meta-supervision process. First, we analyse a transcript of an audio recording made during the intervention, which illustrates how supervisees generate empowering psychosocial resources through the group processes. Second, we analyse supervisees’ paraphrased accounts of barriers to effective supervision and their accounts of personal projects to overcome the barriers. Barriers ‘outside’ the supervision setting primarily inspired projects aimed at creating structural change, whereas barriers ‘inside’ the supervision setting inspired projects aimed at creating individual change. The meta-supervision intervention was effective in increasing participation in supervision, but it shared the same problems of resistance and reluctance as often observed in supervision in general. In the discussion, we compare our ‘bottom-up’ approach to activating supervisees and implementing supervision practices with ‘top-down’ approaches. The meta-supervision intervention illustrated the importance of engaging supervisees in their own supervision and suggested how it can have both individual and organizational benefits.

Although clinical supervision is deemed central to the delivery and dissemination of high quality CBT, knowledge of what constitutes ‘optimal’ CBT supervision remains limited. In consequence, understanding of how best to support the development of supervisors is also restricted. This article considers the professional development needs of CBT supervisors, identifying the current context in which CBT supervision is mandated and delivered and seeking to clarify the domains of knowledge, competence and skill that must be mastered. We propose ways in which CBT supervisors might construct their professional development activities and raise questions relating to the need for a more organizationally embedded approach to the development of CBT supervisors in the current professional climate.

There is now expert consensus that directly observing the work of trainee therapists vs. relying upon self-report of sessions, is critical to providing the accurate feedback required to attain a range of competencies. In spite of this expert consensus however, and the broadly positive attitudes towards video review among supervisees, video feedback methods remain under-utilized in clinical supervision. This paper outlines some of the weaknesses that affect feedback based solely on self-report methods, before introducing some of the specific benefits that video feedback methods can offer the training and supervision context. It is argued that video feedback methods fit seamlessly into CBT supervision providing direct, accessible, effective, efficient and accurate observation of the learning situation, and optimizing the chances for accurate self-reflections and planning further improvements in performance. To demonstrate the utility of video feedback techniques to CBT supervision, two specific video feedback techniques are introduced and described: the Give-me-5 technique and the I-spy technique. Case examples of CBT supervision using the two techniques are provided and explored, and guidance as to the supervision contexts in which each of the two techniques are suitable, individually, and in tandem, are outlined. Finally, best practice guidelines for the use of video feedback techniques in supervision are outlined.

Significant progress has been made internationally in the training of clinical supervisors, yet much remains to be done, such as refining training through the improved use of video material. A review of currently available video recordings used in supervisor training indicates that they are generally used informally, are manifestly lacking in procedural detail, are narrowly applied, and lack an educational rationale or research support. After reviewing current options, a more precise, comprehensive and educationally informed framework is proposed, broadening the video options to 10 complementary applications. Systematic links are made between these applications, the core supervision competencies, and the related workshop content (especially training objectives and learning outcomes), culminating in an educational rationale for the use of video within a supervisor training curriculum. It is concluded that application of this framework can enhance the effectiveness and efficiency of supervisor training, helping to maintain progress.

NHS Education for Scotland (NES) has developed a suite of training to address the learning and development needs of supervisors of psychological therapies in the National Health Service (NHS) in Scotland and to support quality of evidence-based practice in psychological therapies, in light of the recent expansion in this area of healthcare. In parallel with the structure of the recently developed supervisory competency frameworks, an initial training package addressing generic (cross-modality) supervision competences was supplemented by the development of a training package to meet the specific needs of supervisors of CBT: NES Specialist Supervision Training in CBT (NESSST CBT). A blended learning package was developed, in light of the emerging evidence around the effectiveness of e-learning, to produce a flexible and learner-centred training package. This paper describes the development, delivery and planned evaluation methods of NESSST CBT. Lessons learned during implementation are outlined, along with key challenges regarding the future of supervision training in Scotland and the UK.

Evaluating and enhancing supervisee competence is a key function of supervision and can be aided by the use of direct assessments of clinical competence, e.g. the Cognitive Therapy Scale – Revised (CTS-R). We aimed to review the literature regarding inter-rater reliability and training on the CTS and CTS-R to present exploratory data on training raters to use this measure. We employed a systematic review. An exploratory study evaluated the outcomes of a CTS-R supervisor training workshop (n = 34), including self-reported familiarity with and confidence in using the tool, and inter-rater consistency on three CTS-R subscales, pre- and post-training. CTS and CTS-R inter-rater reliability was variable, with evidence of rater training enhancing reliability, although the form, duration and frequency of such training is unclear. The exploratory study found that supervisors rated themselves as more familiar with and confident in using the CTS-R at the end of training compared to at the beginning. However, inter-rater reliability was poor at the beginning and end of the training. Rating competence requires supervisors to make qualitative judgements, which is inherently variable. Training raters has been shown to improve rater reliability, although this was not demonstrated in the exploratory study. Practice implications and future research priorities are identified.

There has recently been an increasing call for new research and development in cognitive behavioural supervision, particularly in the area of evidence-based clinical supervision. New developments in supervision technology offer the potential to answer this call by providing greater objective measurement and corrective feedback in supervision. In this article, two new technologies that hold particular promise in this area are described: software for routine outcome measurement and videoconference for internet-based live one-way-mirror supervision. Notable challenges involved in supervision technology are discussed, and an example of technology being integrated into a graduate clinical training programme is described.

Contributors to this Special Issue of the Cognitive Behaviour Therapist have considered the kind of infrastructure that should be in place to best support and guide CBT supervisors, providing practical advice and extensive procedural guidance. Here we briefly summarize and discuss in turn the 10 papers within this Special Issue, including suggestions for further enhancements. The first paper, by Milne and Reiser, conceptualized this infrastructure in terms of an ‘SOS’ (supporting our supervisors) framework, from identifying supervision competencies, to training, evaluation and feedback strategies. The next nine papers illustrate this framework with specific technical innovations, educational enhancements and procedural issues, or through comprehensive quality improvement systems, all designed to support supervisors. These papers suggest an assortment of workable infrastructure developments: two large-scale and comprehensive initiatives, some promising proposals and technologies, and a series of local, exploratory work. Collectively, they provide us with models for further developing evidence-based cognitive-behavioural supervision, and offer practical suggestions for giving supervisors the tools and support to maximize their supervisees’ learning, and to improve the associated client outcomes. Much research and development work remains to be done, and successful implementation will require institutional and political support, as well as cross-cultural adaptations. We conclude with an optimistic assessment of progress toward addressing some of the infrastructure improvements required to adequately support supervisors.

Traditionally studies have neglected emotion in psychosis, possibly as a consequence of psychiatry's emphasis on psychotic symptoms rather than individuals’ lived experience of emotions before, during and after psychotic episodes. This study sought to investigate how individuals experienced their emotions and delusions in the context of psychosis. A qualitative Interpretative Phenomenological Analysis (IPA) research methodology was used. Semi-structured interviews were conducted with a purposively sampled group of eight participants recruited from a local Early Intervention in Psychosis service. Four themes were generated by the analysis. The first highlighted emotional experiences prior to the onset of psychosis: ‘struggling with life distress’. The second highlighted the intense emotional experience within psychotic experiences: ‘transformed world and intense emotion’. The third theme highlighted self-critical tendencies in the post-onset phase of psychosis: ‘blame and guilt after the breakdown’. The final theme highlighted a mixture of emotions in the post-onset phase: ‘confusion, despair and hope’. There were many clinical implications highlighted in the study including the value of normalizing participants’ emotional experiences in order to promote engagement in services and of assessing for self-criticism, despair and hope following the psychotic experience, alongside therapeutically addressing the varying levels of emotional experiences before, during and after a psychotic breakdown.

Cognitive behaviour therapy (CBT) is now the psychological treatment of choice for psychosis but meta-analyses indicate a low effect size on delusions, so further innovations are clearly needed, and group CBT for psychosis (GCBTp) is an under-researched area. This study aimed to service-evaluate the feasibility, satisfaction, safety, and effectiveness of a CBT group specifically targeting medication-resistant single delusions in early psychosis patients (EI-GCBTp). Three separate EI-GCBTp groups were run resulting in a total of 11 medication-resistant early psychosis patients. A within-subjects design tested for group change across two time points: pre-baseline (4 weeks before treatment) to baseline (session 1 of treatment) and sessions 1–8 (the treatment period). Thirteen delusion dimensions were measured from three psychosis-specific questionnaires: The Psychotic Symptom Rating Scale (PSYRATS), Characteristics of Delusion Rating Scale, and the Belief Rating Scale. At least three patients attended each group, satisfaction scores were high, and no harm to patients was identified. With reference to effectiveness, the pre-baseline period showed virtually no change. In contrast, across the EI-GCBTp treatment period, the PSYRATS total demonstrated a statistically significant decrease in delusional severity (p < 0.01), a 31% symptom reduction, and a large effect size (Cohen's d = 1.2, 95% confidence interval = −2.53 to 0.05), statistically significant across four delusion dimensions. EI-GCBTp appears feasible, acceptable, safe, and preliminary uncontrolled effectiveness results suggest merit for larger-scale more rigorous testing of this treatment format for possible dimensional improvements of persistent delusions.

While there is considerable evidence that the factors involved in hoarding typically begin to manifest early in life (mostly in adolescence), the majority of those sampled in research studies are in their later years. As so much of our understanding of the psychological factors involved in hoarding is derived from those who are older and more chronically affected, the core hoarding psychopathology may have been masked, overlaid or even disregarded in previous research and in our approaches to clinical intervention. That is, factors relating primarily to chronicity of the problem and feelings of demoralization, hopelessness, loss and the extent of the damage caused to the person's life may swamp the processes which led to and maintain the problem. The present review examines the extent to which this is so and considers theoretical and clinical implications. The literature relevant to hoarding in later life was reviewed evaluatively in relation to a number of questions placing hoarding in a lifespan developmental context. Many studies relied on purely descriptive methodologies, meaning that typical case presentations and case histories are well documented, with less attention paid to underlying causal and maintaining mechanisms. Efforts to identify and control for factors relating to age or problem chronicity were minimal. A key future direction is the identification of younger samples of people who hoard in order to identify more clearly the processes which drive acquisition and retention of excessive amounts of material.

During the last decades, research on cognition has undergone a reformation, which is necessary to take into account when evaluating the cognitive and behavioural aspects of therapy. This reformation is due to the research programme called Embodied Cognition (EC). Although EC may have become the theoretical authority in current cognitive science, there are only sporadic examples of EC-based therapy, and no established framework. We aim to build such a framework on the aims, methods and techniques of the current third-wave of CBT. There appears to be a possibility for cross-fertilization between EC and CBT that could contribute to the development of theory and practice for both of them. We present a case-study of an EC-based model of intervention for working with self-control in cerebral palsy. We centre the results of the study and its discussion on how we should understand and work with self-control in a more general sense from both an EC and a CBT perspective. We end by elaborating the five learning objectives and present suggestions for follow-up reading.

Individuals working for the emergency services often bear witness to distressing events. This outcome study examines therapeutic interventions for Fire Service personnel (FSP) experiencing symptoms of trauma, depression, anxiety and low levels of self-compassion. This study aims to investigate the effectiveness of using Compassion-Focused Therapy (CFT) as an adjunct to Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) in reducing symptoms of trauma, anxiety and depression and increasing self-compassion. A convenience sample (n = 17) of participants, referred for therapy following a traumatic incident, were allocated to receive 12 sessions of either TF-CBT or TF-CBT coupled with CFT. The study employed a repeated-measures design. Data were gathered pre- and post-therapy, using three questionnaires: (1) Hospital Anxiety and Depression Scale; (2) Impact of Events Scale-R; (3) Self-Compassion Scale – Short Form. TF-CBT combined with CFT was more effective than TF-CBT alone on measures of self-compassion. Significant reductions in symptoms of depression, anxiety, hyperarousal, intrusion and avoidance and a significant increase in self-compassion occurred in both groups post-therapy. The study provides some preliminary evidence to suggest that FSP may benefit from therapeutic interventions aimed at cultivating self-compassion. Further research is warranted using a larger sample size and adequately powered randomized controlled trial, to detect statistically significant differences and to negate the risk of confound due to low numbers resulting in significant differences between groups at baseline. Using CFT as an adjunct to TF-CBT may help FSP, who bear witness to the distress of others, cultivate compassion for their own suffering.

Increasingly, evidence suggests that computerized Cognitive Behavioural Therapy (cCBT) is effective at reducing adolescent anxiety and depression for young people in the general population or those ‘at risk’. However, less is known about the acceptability, feasibility and effectiveness of cCBT for adolescents with clinically significant levels of impairment. This study aimed to investigate the feasibility of using a novel cCBT intervention, ‘Pesky gNATs’, with adolescents aged between 13–18 years with anxiety and/or depression who met the criteria for specialist mental health services. Eleven participants were recruited from a Tier 3 child and adolescent mental health service (CAMHS). Recruitment, attendance and retention rates were recorded and qualitative feedback about the benefits and disadvantages of completing cCBT were obtained during the final session. In addition, a number of outcome measures were completed pre- and post- intervention to assess reliable and clinically significant change. The intervention was very brief comprising of just seven sessions. Participants showed high recruitment and retention rates. All participants who started the intervention completed it. All described the programme as useful and the majority identified several benefits. Four of 11 participants demonstrated reliable reductions in symptoms of depression and anxiety and six of 11 showed decreases in parent-reported symptoms of anxiety and depression following the seven-session intervention. This study demonstrates the acceptability and feasibility of using cCBT in a Tier 3 CAMHS setting. Further research is required to investigate the effect of Pesky gNATs on anxiety and depression in other Tier 3 settings.

Intolerance of Uncertainty (IU) has been shown to underlie a range of disorders. Technological advances have produced a decline in our development of an ability to wait in the face of uncertainty. The paper provides an update on empirical, theoretical and neural research in IU. Einstein's extended trandiagnostic model of IU is described. This model is based on control theory. The research update and IU model propose specific tools which can be implemented within transdiagnostic treatment approaches.

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.

The need for development of effective models of training and superivision for trainee clinical psychologists to build CBT competencies and to implement high-quality CBT is frequently highlighted. Effectiveness of trainee therapist outcomes working within different models of training, supervision and services is also important to establish. This paper reports on the development and outcome effectiveness of a model of training and supervision aimed at increasing CBT clinical skills and competence of trainee clinical psychologists offering CBT for anxiety disorders in an anxiety disorders clinic (ADC) in inner-city London. Details of the training and supervision model are provided, which was conducted over a period of 3 months, with ongoing weekly supervision throughout the intervention period. Pre- and post-intervention data were analysed from service users who attended the ADC over a 2-year period. Over the 2-year period, 10 trainees treated 57 clients. Data from completer and intention-to-treat samples indicated that scores on four outcome measures improved significantly: at post-therapy, 75% of service users who completed the intervention showed reliable and clinically significant recovery or improvement. When supported by appropriate training and supervision, as outlined in this training model, initially inexperienced trainee psychologists can achieve outcomes comparable to those obtained in other secondary-care settings with qualified therapists.