Borderline personality disorder (BPD) is associated with problems in attention, memory, planning and cognitive flexibility, which may underpin aspects of behavioural dysregulation. Cognitive remediation (CR) is an individual psychological therapy which aims to improve thinking skills and thus positively impact everyday functioning. We aimed to assess the feasibility and acceptability of CR for two BPD patients who had not previously engaged with psychological therapy. Participants were assessed using neuropsychological, symptom and social functioning measures and then received up to 40 sessions of individual CR. They were re-assessed post-therapy and 3 months later, and rated their experience of CR. The participants reported increased self-esteem and improved memory. Neuropsychological tests showed executive functioning improvements post-therapy, which were partially maintained at follow-up. CR was a feasible and acceptable therapeutic approach for these two participants and may hold promise as a complementary therapeutic approach for BPD characterized by marked cognitive problems or difficulty in engaging in more emotionally focused psychotherapies.

Socializing a client to the cognitive behavioural model is advised in almost every cognitive behavioural therapy (CBT) textbook, but there is limited evidence for whether socialization is measurable or important. The aim of the study was to pilot a written and interview-based measure of socialization to investigate whether socialization to the model can be measured in a sample of young people who have completed CBT. Sixteen participants (mean age 14.9 years, 75% female) completed a semi-structured socialization interview and a novel written measure of socialization. Treating clinicians were asked to provide subjective ratings of participant socialization. The structure and content of these measures was examined. A moderate but non-significant correlation was found between the novel written measure of socialization and clinician rating of socialization (r = .37). The concept of ‘socialization’ is not well understood and the socialization interview presented mixed, unclear results. This may be due to issues with the design, but may also be that socialization, as currently understood, is more complex than can be captured in this way. The important aspect of this study is introducing the concept of measuring socialization and factors that may be important in future research. Socialization to the model is an important construct within CBT but at present is a challenging concept to measure. Future research will need to focus on operationalizing the concept further and refining measures so that it can be accurately captured. Understanding which therapist and client behaviours contribute to the process of socialization could conceivably improve outcomes, but this cannot be done until this area is understood more fully.

Cognitive behaviour therapy (CBT) as a treatment for schizophrenia and psychotic-related disorders has been shown to have significantly greater drop-out rates in clients of black and minority ethnic (BME) groups. This has resulted in poor outcomes in treatments. Our recent qualitative study thus aimed to develop culturally sensitive CBT for BME clients. The study consisted of individual in-depth 1:1 interviews with patients with a diagnosis of schizophrenia, schizo-affective, delusional disorders or psychosis (n = 15) and focus groups with lay members (n = 52), CBT therapists (n = 22) and mental health practitioners (n = 25) on a data set of 114 participants. Several themes emerged relating to therapist awareness on culturally derived behaviours, beliefs and attitudes that can influence client response and participation in therapy. The current paper aims to explore one of these themes in greater detail, i.e. client-initiated therapist self-disclosure (TSD). Using thematic analysis, the paper highlights key elements of TSD and how this could impact on therapist’s reactions towards TSD, the therapeutic alliance and ultimately, the outcomes of therapy. The findings appear to show that TSD has significant relevance in psychological practice today. Some BME client groups appear to test therapists through initiating TSD. It is not the content of TSD they are testing per se, but how the therapist responds. Consequently, this requires therapists’ cognisance and sensitive responses in a manner that will nurture trust and promote rapport. Further investigation in this area is suggested with a recommendation for guidelines to be created for clinicians and training.

The distress inherent in obsessive compulsive disorder (OCD) can often lead to partners, family members and friends becoming entangled with the OCD in terms of being drawn into performing certain behaviours to try and reduce the distress of their loved one. In the past this has often been referred to somewhat pejoratively as collusion, or more neutrally as accommodation. In this paper we emphasise that this is usually a natural human response to seeing a loved one in distress and wanting to help. This paper provides detailed clinical guidance on how to understand this involvement and how to include others in the treatment of OCD along with practical tips and hints around potential blocks that may require troubleshooting. It also details the relatively recently introduced concept of approach-supporting behaviours, and provides guidance on how to distinguish these from safety-seeking behaviours. The ‘special case’ of reassurance seeking is also discussed.

Research on the relationship between military service and eating pathology has yielded mixed findings. Among those of military backgrounds, anorexia nervosa typically presents with co-occurring disorders that complicate diagnosis and treatment. The purpose of this paper is to present a case report of a retired Navy midshipman. The patient sought treatment for obsessive compulsive disorder (OCD), but his assessment revealed the primary pathology to be anorexia nervosa. This case illustrates ways in which military life may contribute to eating pathology and the complex overlap and differential diagnosis of anorexia nervosa and OCD.

This paper describes a service development which arose from an adult mental health inpatient ward team who wanted to be able to work more effectively to help patients who had major difficulties with emotion regulation. It was proposed that enhancing mindfulness through a Mindfulness-based Cognitive Therapy (MBCT) programme within the core staff team would enhance therapeutic milieu and therefore general outcomes associated with engagement and recovery. The training delivered was an adapted 8-week MBCT programme. A double baseline design was used with measures taken at 1 month before training and immediately before the programme started. Standardized and non-standardized measures were administered at pre-, mid-, post-, and 1-month follow-up points. Workshops and interviews supported the investigation of staff experience and impact of MBCT training. Participants in the training were nursing and occupational therapy staff. The trainer was the first author (C.M.), who is a cognitive behavioural therapist and mindfulness teacher at Newcastle Cognitive and Behavioural Therapies Centre, specializing in emotion regulation and stabilization. Results showed that staff reported a significant increase in mindfulness which had a positive impact upon their wellbeing and perceived ability to respond skilfully to challenging situations at work and at home. Gains were mostly in the first half of training but were maintained to the end and to follow-up. This adapted mindfulness training course appeared to be effective in meeting the need for a group of clinical staff to develop mindfulness. The potential impact upon patient engagement has been identified but further research into this area is indicated.

Application of a self-practice self-reflection (SP/SR) framework to clinical training programmes for those learning cognitive behavioural therapy (CBT) have demonstrated positive outcomes. These programmes have typically resulted in reports of enhanced learning, improved clinical skills, heightened empathy, improved interpersonal skills, increased self-awareness, and self-development for those undertaking such training. However, the utility of specific activities within this framework for enhancing trainees’ learning still requires exploration. This study sought to explore the use of a low frustration tolerance (LFT) exercise to enhance trainee’s learning around issues relating to frustration and discomfort tolerance. It also further explored the possible application of SP/SR as a form of competency-based assessment. The study was based on 41 student trainees that engaged in a self-directed LFT exercise. Written reflections on these exercises were then thematically analysed. From a competency basis, the exercise provided an approach for observing the trainee’s competency with formulation skills, intervention planning, and self-reflective capacity. Participants reported both personal and professional development outcomes from the exercise. These included a ‘deepened’ understanding of cognitive behavioural principles related to their experiences, both in terms of principles relating to maintenance of dysfunction and to creating change. Increased self-awareness and learning outcomes relating to the development of interpersonal skills were also commonly reported by trainees.

Hoarding disorder is a surprisingly common problem which impacts on most areas of life. People who hoard typically have multiple agencies involved in their care due to the complex health and safety impact and risks associated with hoarding. ‘Treatment’ involves finding ways of supporting discarding large amounts, typically underpinned by CBT principles. We evaluated the impact and outcomes of a conference designed to boost professionals’ confidence and understanding in working with hoarding problems, both individually and with other agencies with a view to improving inter-agency service provision. Changes in professionals’ confidence and understanding were evaluated immediately before and after the conference. Conference participants’ qualitative responses related to service improvements were analysed using content analysis. People with personal experience of hoarding issues subsequently participated in a focus group where the results of the conference were presented. These data were analysed using thematic analysis. Confidence and understanding in working with hoarding problems substantially increased from pre- to post-conference. Professionals identified a range of possible improvements, most commonly working more closely and improving communication with other agencies. People with personal experience suggested improvements across three over-arching themes: developing an improved understanding of hoarding, the need for improved resources, and improved multi-agency working. A multi-agency conference increased confidence and understanding in professionals working with hoarding problems, and improvements specified by both people with personal experience and professionals provide a useful guide to service improvement. Results provide a framework in which CBT approaches should be embedded.

Multi-morbidity, having more than two diagnosed health conditions, is becoming increasingly common within healthcare services. Approximately one third of these patients are likely to have a mental health condition. Those with multi-morbidity with physical and mental health conditions have poorer outcomes in terms of their health, increased mortality rates, and higher usage of healthcare services.

This paper presents a case of a patient with multi-morbidity, with associated mental health conditions of anxiety and depression. She was seen as part of an integrated service which provides psychological support at home alongside the nursing team. The intervention used was based on transdiagnostic cognitive behavioural therapy (tCBT), provided over nine initial sessions and two additional booster sessions. Self-report measures were completed at intervals throughout the intervention and at follow-up. Improvements on the depression and anxiety measures were seen over the initial nine sessions, followed by a relapse at the 3-month follow-up. This was the result of a deterioration in physical health which led to a deterioration in mental health. The booster sessions mitigated further deterioration in mental health, despite the physical health worsening during this time.

This case suggests that tCBT can be helpful in reducing anxiety and depression in people with multi-morbidity. However, additional booster sessions may be required as further physical deterioration can re-trigger core beliefs and result in further mental health problems.

The lifetime prevalence of OCD in the UK is estimated to be between 1 in 100 and 1 in every 50 people. It is therefore necessary to explore innovations in practice to expand the reach of the gold standard therapeutic approaches of exposure with response prevention (ERP) and cognitive behavioural therapy (CBT). The COVID-19 pandemic has facilitated such innovations with several services accommodating changes to routine practice by utilising digital platforms to provide videoconference-delivered therapy. Despite a growing evidence base demonstrating efficacy and scope for the use of videoconference-delivered CBT for obsessive-compulsive disorder (OCD), there remains qualitative research collated from clinicians which suggests that a lack of practitioner confidence and a low belief in positive outcomes are barriers to adopting remote therapy practices for clinicians. Therefore, this structured case report describes the assessment, formulation, intervention and outcome of an 11-week videoconference-delivered therapeutic intervention. Reflections are made regarding the use of the digital platform throughout the intervention, alongside the strengths and difficulties of applying videoconference-delivered CBT for OCD.

A range of clinicians (n = 72) were asked to provide a definition of a schema. The participants were selected from different parts of the broad church of the CBT community, with all having received some training in CBT – although only 26.4% had a formal CBT qualification. Fourteen themes were identified, suggesting that the concept is perceived to be complex. However, the mean number of themes identified per clinician's definition was small: 2.86 (mode = 2). We consider this finding reflects a problem concerning a lack of clarity with respect to the use of one of the key concepts in CBT.

The main aim of this research was to investigate the effect of the 8-week group therapy intervention based on the integrative cognitive model (ICM) of bipolar disorder. The sample was composed of 10 patients with bipolar I and bipolar II diagnoses. The group sessions were held once a week for 1.5 hours. For the quantitative measures, the group participants were assessed during pre-test, post-test and 3-month follow-up using the Turkish versions of the Beck Depression Inventory, the Hypomanic Attitudes and Positive Predictions Inventory, the Psychological Well-being Scale and the Satisfaction with Life Scale. Quantitative analyses revealed that a reliable change was seen only in pre-test and post-test depression scores. However, this change could not be maintained at 3-month follow-up. For the qualitative analyses, data collected during semi-structured interviews were used. The thematic analyses results showed that the 8-week ICM-based group therapy was found to help participants make sound observations about their behaviors, decrease their feelings of loneliness and increase self-acceptance, and acceptance of the role of mood swings in their lives. Moreover, the results showed that participants found the following activities very beneficial: describing their emotions, evaluating the intensity of their emotions, identifying their life goals, coping with interpersonal conflicts, evaluating resources and going over strengths. In conclusion, the 8-week ICM-based group therapy had a positive impact on participants’ self-awareness, self-acceptance and self-perception.

Scotland and Wales share the opportunities of devolved government as well as challenges such as urban deprivation and remote rural communities. Such commonalities make a comparison of their approaches to psychological therapies relevant. The Scottish and Welsh governments have both published guidance concerning improved access to psychological therapies and these reveal different approaches. The Scottish Government has provided clear and concrete guidance for services, retains a close overview of progress, and plans training from the centre. The Welsh Government has published guidance which is unspecific, has largely devolved responsibility for implementation to local health boards and has no central plan for training. Scottish guidance provides clear information about who can expect to receive specific evidence-based therapies, the number of sessions they can expect to receive, and crucially the level of training and competence required for therapists. Welsh guidance documents have not yet specified which patient groups can expect to access formal psychological therapies, which psychological therapies are considered to have a sound evidence base, the number of sessions patients can expect, or the level of training and competence required for practitioners. Welsh policy documents make no reference to competence frameworks for therapists.

In the UK there has been a drive towards facilitating swift access to psychological therapies. Groups are an efficient way to provide psychological interventions to a wide range of people and are recommended treatments for mild depression and anxiety, presentations commonly seen in primary care mental health teams. Group cognitive behavioural therapy (CBT) has been shown to be clinically effective, but less is known about the acceptability of groups to patients. This study evaluated patient satisfaction with CBT groups running within a primary care mental health team in Scotland. Data from a routinely administered patient satisfaction questionnaire were collected. Likert-scale responses were analysed via frequencies and percentages, and free text responses were analysed via thematic analysis. Among those who completed a group, overall satisfaction was high. The qualitative analysis revealed that for many a group environment was therapeutic in itself, and the intervention provided service users with a range of skills with which to tackle their difficulties. However, others indicated that a group environment was unsuitable for their needs, and perceptions around the accessibility and relevance of group content were mixed. Indeed, drop-out rates were high, and perceptions of groups among those who did not attend the final session are not included in this analysis. Group dynamics may be both a facilitator of and a barrier to therapeutic benefit, depending on individual factors. Future studies could evaluate satisfaction among service users who drop out of interventions in order to inform future service delivery.

Due to the growing evidence base supporting the hypothesis of common processes across different mental health problems, transdiagnostic interventions are receiving increased research attention. Transdiagnostic approaches have the potential to produce better outcomes, to reduce waiting times and to increase cost-effectiveness in stretched mental health services. Research into transdiagnostic cognitive behaviour therapy (CBT) in group format has demonstrated positive results in participants with anxiety disorders, with some studies extending the inclusion criteria to secondary and comorbid symptoms. This study evaluates a transdiagnostic CBT-based intervention, delivered by a secondary-care mental health team and includes participants with a range of diagnoses typical of this population. The real-world setting and lack of exclusion criteria based upon diagnosis provides an ecologically valid evaluation of a transdiagnostic CBT-based intervention. The results suggest that the intervention was associated with reductions in self-reported symptomatology and improvements in social functioning of individuals who attended in a secondary-care mental health service.

Self-reflection can aid therapist development, particularly interpersonal skills. It can be achieved through using cognitive-behavioural therapy techniques, for example, formulations of the therapist's cognitions and behaviours have been used to aid self-reflection. As interpersonal skills may be an area that benefits from self-reflection, an approach to formulating the interaction between client and therapist may be beneficial. This study reports the use of simple ‘antecedent-belief-consequence’ (ABC) formulations for the client and therapist to conceptualize their interaction. This description of a treatment failure focuses on cross-cultural work with a survivor of torture, where self-reflection may be particularly indicated to promote cultural competence and address the impact of the content on the therapist. ABC formulations for the client and therapist were completed and through this structured self-reflection, the therapist was able to identify the impact of her own beliefs on the process of therapy. This method identified areas for further development and generated hypotheses for how to continue therapy with this client. Using ABC formulations then may provide a useful and structured way to conduct self-reflection with explicit focus on the interaction between client and therapist.

Borderline personality disorder (BPD) is a mental health condition characterized by emotion dysregulation, interpersonal impairment, and high suicidality. Dialectical behaviour therapy (DBT) is the most widely studied psychotherapeutic treatment for BPD. To date, the vast majority of DBT research has focused on cisgender women, with a notable lack of systematic investigation of sex and/or gender differences in treatment response. In order to encourage effective, equitable treatment of BPD, further investigation into treatment targets in this population is critical. Here, we employed a systematic strategy to delineate gaps in the DBT literature pertaining to sex and gender differences and propose directions for future research. Findings demonstrate a significant discrepancy in measurement of sex and gender, particularly among gender-diverse individuals. Exploring DBT treatment response across the full spectrum of genders will facilitate the provision of more tailored, impactful care to all individuals who suffer from BPD.

Wales has not adopted the English IAPT system and has no centralized training plan for developing cognitive behavioural therapy (CBT) in Wales. However, Welsh Government policy expresses an ambition to improve access to evidence-based psychological therapies for people in Wales. This study focuses on one Welsh Health Board's plan to improve access to CBT. The study aims to benchmark support for effective delivery of CBT in the Health Board against NICE and Department of Health standards, and to establish whether the Health Board's plan is succeeding in developing staff capability and access to evidence-based CBT. Mental health staff funded by the Health Board to complete accredited training in CBT were asked to complete an online questionnaire asking about their training, accreditation, use of CBT, and experience of workplace support for delivering CBT. The standards were taken from the Department of Health competency framework for CBT, NICE guidelines and BABCP safety and confidentiality criteria. The Health Board performed well across seven standards of workplace support for the delivery of evidence-based CBT. Staff funded to undertake accredited CBT training continued to develop and to use CBT in their everyday clinical practice. The study indicates that the Health Board is succeeding in offering good standards of workplace support for CBT, including access to accredited CBT training. A recommendation is made that this be shared with other Welsh Health Boards and that a comparable study be undertaken within an IAPT service.

The term schema is often used to describe core beliefs, both functional and dysfunctional, developed in childhood. We believe that this view is rather mono-dimensional, and that by taking a broader perspective lessons can be learned from other fields. In this paper we examine the various theories of schema with a particular focus on the memory perspective to examine the acquisition of skills in sports. In terms of memory theory, performance of a set of actions (running a race, jumping a hurdle, playing chess) creates neural activity in the body across numerous domains (motor, visual, psychological), and repetition lays down a neural network that can be built upon and altered over time. We believe that the examples discussed in the context of sport can be used to help clinicians reflect on the concept of schema, and thereby re-examine assessment and treatment options.