Cognitive behaviour therapy (CBT) has become the first line of treatment for a wide range of mental health problems across many countries. The flexibility of CBT, and a strong evidence base and good track record of training and dissemination, has lent itself to scaling up of this therapy, and projects such as the Improving Access to Psychological Therapies (IAPT) programme in England have shown that large-scale projects to roll out CBT at a national level are possible (Clark, 2011).

This study describes a successful community-based partnership project between statutory and third-sector services in East London; The City and Hackney Black and Minority Ethnic (BME) Access Service [East London NHS Foundation Trust (ELFT)] collaborated with Derman, a local community organization supporting the well-being of Turkish-speaking communities, to explore the cultural adaptability of an empirically supported, third-wave cognitive behavioural intervention, Acceptance and Commitment Therapy (ACT). The aim was to develop a culturally acceptable group that was responsive to the therapeutic needs of participants from Turkish-speaking communities. The study implemented a mixed-method analysis with a one group pre/post-test design to examine the effectiveness of a 7-session culturally adapted ACT group intervention and a descriptive approach was implemented to assess usefulness, relevance and acceptability. Results demonstrated an overall positive effect of the culturally adapted ACT intervention in terms of both symptoms and patient-reported outcomes. Participants showed significant improvements on measures of depression (p = 0.014), anxiety (p = 0.041) and psychological distress (p = 0.003). The magnitude of these changes was categorized as large, with effect sizes from 0.90 to 2.03. Qualitative responses indicated that the group was experienced as enjoyable and useful and was considered to be an accessible and acceptable therapeutic format. Although a pilot within clinical practice, the findings provide preliminary support for the clinical utility of ACT as an effective, culturally acceptable therapeutic approach for Turkish-speaking communities living in an urban UK setting. The study highlights the importance of culturally appropriate service development and a need for further research within this area.

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.

Transdiagnostic cognitive behavioural therapy (CBT) focuses on the processes shared across disorders and can be applied to a wide range of mental health problems or comorbid conditions. The transdiagnostic approach provides the potential opportunity to improve access to CBT, particularly in countries such as Saudi Arabia, where the number of well-trained therapists is limited. This study aims to examine the feasibility and potential benefit of transdiagnostic CBT for Saudi patients. Case reports describe the outcome of transdiagnostic CBT for four female patients who presented a wide range of symptoms and conditions without conducting any specific diagnostic assessments. The results support the positive effect of this treatment method on depression, anxiety symptoms, and general functioning. Patient feedback and observable improvements also supported these outcomes. However, the results are limited by the small sample size and simple study design. Transdiagnostic CBT is a feasible treatment approach for patients in Saudi Arabia. However, to confirm this preliminary finding, more studies are required.

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.

CBT treatment programmes for children and adolescents with anxiety disorders are promising as indicated by efficacy research. Replicating this research in ordinary clinical care is crucial in order to establish the validity of these results and disseminate empirically based treatments to practitioners. This paper presents the first experiences of using a structured programme, the Friends for Life manual, in ordinary clinical care in Norway targeting anxiety problems in children aged between 7 and 12 years. The effects of the treatment are presented as multiple single-case studies. Clinical meaningful change is considered from two perspectives; diagnostic change and changes in self-report measures. At a statistical significance level the treatment effect can be characterized as modest. Independent of the symptom reduction, the children, families and therapist are in the main satisfied with the structured approach indicating the acceptability of the programme.

Cognitive behavioural therapy (CBT) videoconferencing has been demonstrated to be an effective treatment for anxiety disorders and an equal alternative to face-to-face CBT. However, qualitative patient and therapist experiences of CBT videoconferencing have been less researched. Due to COVID-19, mental health services have shifted to remote therapy methods; thus, understanding patient and therapist experiences are crucial to better inform service policies and best practices. The current study focused on patient and therapist experiences of CBT videoconferencing at the Centre for Anxiety Disorders and Trauma (CADAT). Researchers used qualitative content analysis to explore patients’ (n = 54) and therapists’ (n = 15) responses to an online survey. Results yielded four themes: behavioural experiments work well if the problem lends itself to videoconferencing, overall practicalities but some home environment implications, privacy and technical issues, high telepresence and the negative impact on the therapeutic alliance, and COVID-19 influences attitude positively. The findings have clinical implications for CBT videoconferencing, including a need for specific training in assessment and intervention for therapists using videoconferencing.

People with epilepsy are significantly more likely to have a mental health disorder than those without a chronic illness. The reasons for this are multiple but may include the mental health difficulties being perceived as complex due to the presence of a chronic illness. In part due to the apparent complexity of the co-occurring physical and mental illness, many are not offered evidence-based treatment (EBT) for the mental health disorder. There is little guidance to inform clinicians about the interventions to use to treat mental health disorders in people with epilepsy. The present paper reports a case of treatment for depression using a standard EBT in a young person with epilepsy. The patient also had clinically significant symptoms of anxiety and an eating disorder and would be considered ‘complex’ according to standard criteria. The intervention, however, was relatively simple and was delivered as guided self-help via 10 weekly telephone calls of approximately 30 minutes duration, and two follow-up calls at one month and three months post-intervention. Self-report and parent-report questionnaire measures were completed before and after the intervention, and at both follow-up time points. A blind-rated online diagnostic interview measure was also completed before and after the intervention. The young person and her family also completed a qualitative interview of their experiences of the intervention. This simple intervention was effective in working towards the client's goals, although pre–post measurement on standard measures was variable. This interesting case raises questions about whether patients with mental and physical comorbidities are complex, or just perceived as complex.

Eating disorders are commonly regarded as complex psychiatric conditions, although this perception might be a product of the high levels of physical and psychological co-morbidity that are present in many such cases, rather than being about complexity in the eating disorder per se. This paper will consider the reasons that eating disorders are seen as complex, and whether or not that perceived complexity should be seen as a genuine reason to deviate from existing evidence-based cognitive behavioural therapy (CBT) protocols. Case examples will be used to illustrate how complex presentations can require clinicians to work skilfully with relatively simple formulations to achieve the best outcome, rather than using unnecessarily complex formulations and treatments. The importance of clear supervision is also stressed, as it can play a role in clinicians’ perception of the need for a complex or simple formulation, it can support the clinician in developing a collaborative, focused and efficient formulation, and it can keep the clinician on track with an evidence-based CBT approach.

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.

This editorial introduces the special issue of The Cognitive Behaviour Therapist on Control Theory and CBT. The various routes through which Perceptual Control Theory (PCT) can inform CBT are explained and a range of theory, research and practice articles are introduced. Each focuses on encouraging and validating a Control Theory perspective to the clinical practice of cognitive behavioural therapies.

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.

There has been a large increase in the migration of Muslim populations towards the western world and the USA in the past decade. Many have migrated in the hope of finding a safe home away from war, persecution, or a better economic situation, with many coming from Afghanistan and Syria. Gender and sexual minorities (GSM), or individuals who are not heterosexual and do not identify with their sex assigned at birth, are disproportionately over-represented within migrating groups. While most of these individuals will not have received psychotherapy in their home countries, it is likely they would receive or be required to obtain psychological services as part of the asylum process or through psychoeducational services as a requirement to receive assistance. In exploring the specific needs of Muslim GSM individuals, we highlight the diverse impacts of minority stress, shame, and how these might be mitigated through the integration of acceptance and commitment therapy (ACT) and compassion-focused therapy (CFT). ACT and CFT may provide a helpful framework for a culturally adapted therapy that targets the needs of those experiencing intersectional Muslim and GSM identities, and can foster the cultivation of a meaningful life that can include all aspects of their identities.

This study examines potential barriers to the implementation of CBT as perceived by therapists participating in the training programmes of the Norwegian Association for Cognitive and Behavioural Therapy (NACBT). Based on a questionnaire to members of the NACBT, a factor analysis identified five underlying dimensions of implementation barriers. A one-way analysis of variance was conducted to examine differences in how barriers were perceived by therapists working in medicine, mental health and social services. A multiple regression analysis was performed to examine the relationship between the barriers and the therapists’ global satisfaction with CBT. The five factor-based barriers identified were related to Therapeutic skills, Aspects of the workplace, Supervision, Training, and Clients. Problems related to Supervision and Therapeutic skills were reported to be the most important obstacles. Nurses and others working at psychiatric wards reported the largest number, and psychologists and others working with outpatients, reported the lowest number of barriers. The study highlights the importance of implementation quality in the process of linking training and practice of CBT in Norway. Even if aspects of the training programmes were perceived to be among the smallest threats to implementation, training was not sufficient in order for candidates to implement CBT in clinical practice.

Cognitive behavioural interventions specifically for older people have been described and researched for the last 30 years. However, despite a robust evidence base to support the use of CBT in the treatment of mental disorders in younger adults, trials with older people have generally been of poor methodological quality. Therefore, the potential of CBT to improve the outcome of late-life mental illness has not yet been adequately tested and demonstrated. The priorities, if this is to happen, are to develop standardized, reproducible CBT interventions and to evaluate these in large trials alongside medication or as part of case-management interventions.

Many psychological therapies help clients to direct and sustain their awareness onto specific aspects of their problems to promote change. Yet, no theory-driven measure exists that can code moment-by-moment changes in awareness during a therapy session. It is known that awareness plays a crucial role in the process of change, but little is known about the underlying core processes. Perceptual Control Theory (PCT) offers a scientific explanation of psychological distress as loss of control and describes the role of awareness in processes responsible for restoring control by resolving any internal conflict. The Depth and Duration of Awareness Coding Scheme (D-DACS) was previously developed to capture the person’s current focus of awareness and its duration on the areas that from a PCT point of view are desirable in order to facilitate effective psychological change. The current research applies D-DACS to code three publicly available Method of Levels (MOL) therapy sessions delivered by an expert therapist and presents a visual representation of the client’s presumed attention in these sessions. The results showed that an average of 61.65% of the client’s attention was focused on the D-DACS areas, which is higher than the previous studies involving novel therapists. The produced visual representation of the clients’ presumed attention helps to examine the utility of this new coding scheme and further examine the validity of the underlying theory. Such work might help in examining effectiveness of therapy in meeting the underlying theoretical foundations of change. However, limitations and areas for improvement are also evident.

Recent policy, service and financial drivers that are aimed at improving access to psychological services with a particular focus on cognitive behavioural approaches have resulted in a number local and national service planning initiatives. The extent to which these developments ought to be informed by theory and research regarding the transfer of classroom-based learning to the work setting is made clear. The existing evidence base has implications for how education providers develop collaborative curricula with NHS employers in order to prepare students for the practice setting, and for how service providers support the students' knowledge, skills development, skills transfer and consolidation of these within the practice setting. The dangers of assuming that the dissemination of the clinical evidence base is straightforward within complex organizations and the structure of the NHS are also critically discussed.

We sought to investigate situation-specific inflated sense of responsibility and explanatory style in social anxiety disorder (SAD) according to the cognitive model. Participants aged 17–68 years (mean = 31.9, SD = 11.1) included waiting list patients referred to a primary care mental health service for cognitive behavioural therapy for SAD (n = 18) and non-anxious control participants (n = 65). A battery of psychometric measures, including a bespoke measure of responsibility beliefs, was used. Compared with controls, participants with SAD were more likely to demonstrate an inflated sense of responsibility (p ≤ 0.001), and to adopt a negative explanatory style specific to social interaction (p ≤ 0.01). Inflated sense of responsibility was found to correlate with SAD symptomatology (r = 0.47, p ≤ 0.05), and with increased usage of safety behaviours (r = 0.47, p ≤ 0.05). Caseness (β = 1.45, p ≤ 0.01) and stability of causal attribution (β = 0.25, p ≤ 0.001) were found to predict inflated responsibility in our sample. To our knowledge this study represents the first attempt to investigate inflated responsibility within the context of SAD. Our results support the notion of inflated responsibility as a feature of SAD.

NHS Education for Scotland (NES) plays a lead role in training the NHS Psychological Therapies workforce across Scotland. Ferguson et al. (2016) outlined the challenges, opportunities and proposed evaluation of the NES Specialist Supervision Training in Cognitive Behavioural Therapy (NESSST-CBT). The aims of the training were to provide an evidence-based, flexible and learner-focused training in CBT specific supervision competencies. This paper will provide an update on the evaluation of the training using Kirkpatrick’s Impact Evaluation Model (1967, 1987). Results indicate that: (1) delegates rated the training experience positively in various ways; (2) delegates described increases in their confidence and competence in using structured measures of CBT and supervision; (3) a majority of delegates completing a 3-month follow-up questionnaire described continued use of a structured CBT measure in supervision and for self-reflection; and (4) 392 psychological therapists in Scotland have now been formally trained in CBT specific supervision skills. NESSST-CBT continues to adapt and improve as a resource for staff as NES moves forward in its Digital Strategy for Scotland’s NHS and partnership staff. Further implications of this are discussed, as well as limitations of the study.

In this study, a convergent parallel mixed-methods design was used to explore stress, resilience and coping in psychological wellbeing practitioner (PWP) trainees (n = 90) at the beginning of their training. Psychometric tests were used to measure levels of self-reported stress, resilience and dispositional coping styles. Open-text survey data regarding the perceived sources of stress at the beginning of training were also qualitatively analysed using thematic analysis (TA). Results indicated that in the early weeks of their training, trainees reported lower levels of resilience and higher levels of stress than those found in the general population. Statistically significant negative correlations were found between stress and resilience, and between stress and the coping styles ‘Planning’, and ‘Active Coping’. Statistically significant positive correlations were found between stress and the coping styles of ‘Denial’ and ‘Focus on and Venting of Emotions’. The qualitative findings provided a context within which to understand these quantitative results. The three themes ‘I can find the unknown quite unsettling’, ‘I question my competences’ and ‘Learning, consolidating and putting it all into practice’ were generated through the qualitative analysis. These themes were connected by an over-arching theme which suggests that the perceived responsibility of the role is an important source of stress for PWP trainees. Implications for future research and the training of PWPs are discussed.