There is a paucity of research exploring the validity, reliability and impact on clinical outcome of Cognitive Behavioural Psychotherapy (CBP) case formulations. This review considers a variety of literature that relates to formulations and their use, it also draws on other types of psychotherapy where there appears to be a more established and robust research base. The literature review explores the research that has taken place within CBP and considers the themes that emerge from this research. Several themes were identified and these relate to decision-making and experience, specific guidelines to aid quality of formulations and a significant lack of understanding of clients' views on the formulation process and its outcome. It is unclear whether formulations do influence the successfulness of therapy. Recommendations are made as to what further research is needed and the form this should take.

There is an increasing evidence base for the effectiveness of Behavioural Activation in treating adult depression; however, there has been little investigation of using this approach with adolescents. This article reports on the adaptation of brief Behavioural Activation for Depression (BATD) for adolescents (BATD-A). A case study is reported to illustrate the brief structured approach, treatment response as indicated by routine outcome measures, and the family's view of the intervention. The adaptations made to the adult BATD manual are discussed including parental input, adapted values and activities, and engagement issues. It is hoped that following further evaluation, BATD-A could be successfully delivered as a low-intensity intervention for depression.

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.

Six clients in cognitive behaviour therapy (CBT) or metacognitive therapy (MCT) were interviewed about their experiences of therapy with a focus on helpful elements. Clients in both CBT and MCT mentioned the positive and informal relationship with the therapist as helpful. However, while clients in both therapies emphasized insight into the causes of depression and modification of negative maintenance patterns as helpful, the understanding of depression and the remedies for the condition differed. Clients in CBT focused on previous negative experiences as the cause of present maintenance patterns and mentioned changing negative thought patterns as helpful. Clients in MCT stated that the realization that rumination was their key problem and that they could choose not to engage in negative thinking had been crucial. Furthermore, clients in CBT tended to describe increased personal strength and self-confidence as the main gain from therapy, whereas MCT clients mentioned improved ways of coping with thoughts or problems. The importance attributed by the clients to technical factors differs from previous qualitative studies conducted across various therapeutic approaches, which have typically concluded that common therapeutic factors are more important than specific factors. It does, however, correspond with conclusions from other qualitative studies focusing explicitly on CBT.

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.

Implementing change in organizational systems is challenging, and implementing a new psychotherapeutic approach is no different. A literature exists on issues in implementation across a wide range of domains (technological, healthcare, justice). However, little of it is utilized in endeavours to implement innovations in psychological treatments. This paper draws on the implementation literature and on the experiences of the British Isles DBT Training Team (BIDBT) in implementing Dialectical Behaviour Therapy (DBT) in mental healthcare systems in the UK over the last 13 years. This paper describes principles and strategies of ‘organizational pre-treatment’ as a necessary prerequisite to implementation.

This study examines the effectiveness of a group CBT (CBGT) intervention in reducing a variety of symptoms and problem areas associated with social anxiety disorder. A longitudinal cohort design assessed changes in standardized psychological scales assessing general mood and specific aspects of social anxiety. Questionnaires were completed pre-programme (time 1, n = 252), post-programme (time 2, n = 202), and at 12 months follow-up (time 3, n = 93). A consistent significant pattern was found for all variables: pre-intervention scores were significantly higher than both post-intervention scores and 12-month follow-up scores. Large effect sizes were found and rates of clinical significant changes varied, with over half of the participants recording clinically significant changes in general mood. Individual CBT can be translated successfully into a group format for social anxiety. Given the high completion rate, the intervention is acceptable to participants, feasible, and effective in a routine clinical service.

Co-morbid mental health diagnoses present challenges for services structured to provide disorder-specific models of treatment, such as those structured around Improving Access to Psychological Therapies (IAPT). Intolerance of uncertainty (IU) has been identified as both disorder specific and transdiagnostic, although little research explores transdiagnostic approaches to treatment of IU alone. A cognitive behavioural therapy treatment targeting IU previously established for individual therapy was adapted for a group within an IAPT primary care service: the ‘Making Friends with Uncertainty’ (MFWU) group. Twenty patients presenting with symptoms of a range of disorders including generalised anxiety disorder, obsessive compulsive disorder and depression completed the intervention in three groups. Measures of IU, anxiety and depression administered in the first and final sessions of the group have been analysed as well as examining common themes in participant feedback and facilitators’ own reflections. The results showed that nine participants (45%) showed reliable change in IU following the group and 16 (80%) showed reliable change on a measure of depression or anxiety. A thematic analysis identified universality, tolerance and acceptance and the manifestation of IU in the group process as key. The results suggest that the MFWU group provides an effective and feasible option for individuals presenting to IAPT services, including those reporting co-morbid difficulties. Implications for future practice are discussed as iteration and evaluation of the framework and content will continue.

This paper focuses on the Black minority ethnic population (Black British, Black African, Black Caribbean) and uses the term BME in reference to this group. Only 6.2% of BME people access psychological intervention for common mental disorders. In provision of cognitive behavioural therapy (CBT) the diversity in global majority populations1 requires culturally specific informed and responsive approaches. The Improving Access to Psychological Therapies (IAPT) programme needs to be accountable, culturally congruent and strategic, to ensure accessibility and improve outcomes for BME people. According to the Mental Health Foundation (2019), a higher percentage of Black, Asian and other minority ethnic populations (BAME) are diagnosed with common, severe and complex mental health disorders. Despite the weight of literature on this, little has changed. The NHS Implementation Plan outlines trajectories for increased access and reduced attrition within mental health services, addressing inequalities for BAME populations.

Evidence-based guidance and audits for provision of culturally sensitive and adapted therapies are presented in the pioneering (IAPT) BAME Positive Practice Guide (PPG). However, there are no funding arrangements or formal integrated frameworks to support implementation. The COVID-19 global pandemic and the high-profile death of George Floyd tragically exposed and highlighted the consequences of systemic racism. Understanding of the importance of service and clinical anti-racist practice is imperative for CBT therapists. Implementation of the BAME PPG audit tool ensures review of race equity in access, engagement, adaptation and workforce within IAPT and other mental health services. This could transform lives.

Māori are the indigenous people of New Zealand and in 2006 comprised approximately 15% of the country's population. Epidemiological data suggests Māori experience rates of depression that are higher than the general population and are less likely to engage in treatment for mental health issues. The main aim of this study was to evaluate the effectiveness of an adapted approach to psychotherapy with Māori. The broad goals of which were to provide empirically grounded guidance for therapists aspiring to provide best practice to their Māori clients. This paper documents the evaluation of a cognitive behavioural therapy (CBT) treatment protocol specifically designed and adapted for delivery to adult Māori clients with a diagnosis of depression. The treatment protocol was administered to 16 Māori clients with a primary diagnosis of depression. The adapted treatment incorporated Māori processes for engagement, spirituality, family involvement and metaphor. The intervention exhibited considerable promise with large significant reductions in depressive symptomatology in the participant group. Furthermore, significant reductions in negative cognition were observed. This is the first piece of applied clinical research that has examined the effectiveness of an individual psychological therapy exclusively with Māori and the first to examine individual psychotherapy outcomes with an indigenous population using an effectiveness study. The findings have a number of implications for the treatment of Māori clients with depression. This study provides useful guidelines for clinicians providing psychological treatment to Māori and provides strong support for the cultural adaptation of psychological treatment with ethnic minority groups.

Adolescence is associated with heightened vulnerability to symptoms of depression and anxiety. In-person and computerised cognitive behavioural therapy (CBT) are effective treatment options, yet uptake and engagement remain low. Smartphone delivery of CBT offers an alternative, highly accessible method of delivering CBT. However, there is no freely available CBT smartphone application (app) specifically designed to reduce depression and anxiety symptoms in adolescents. The aim of this study was to design a new CBT smartphone app (ClearlyMe) that targets depressive and anxiety symptoms in adolescents. We engaged in a rigorous co-design process with adolescents (n=36), parents (n=15), and mental health professionals (n=32). Co-design involved: (1) discovery of users’ needs, views and preferences by conducting focus groups, (2) defining app features through ideation workshops and user consultations, (3) designing therapeutic CBT content and visual features, and (4) testing prototypes. Users were involved at every step and the process was iterative, with findings carried forward to ensure continued refinement of concepts and features. We found a preference for vibrant, cheerful colours and illustrations and non-endorsement of gamification and chatbots, which contrasted with findings from other studies. Preferences were largely consistent between the three user groups. However, adolescents preferred an app that could be used autonomously without professional support, whereas mental health professionals desired a product for use as a therapy adjunct to support CBT skill development. The importance of co-design, and particularly the inclusion of all stakeholders throughout the entire co-design process, is discussed in relation to the design of ClearlyMe.

Returning to the scene of the trauma is often recommended as part of trauma-focused cognitive-behavioural therapies for post-traumatic stress disorder (PTSD). Many clinicians avoid site visits due to lack of confidence or practical constraints; however, recent research suggests this is a valuable part of treatment. This article summarizes a rationale for including the site visit as part of cognitive therapy for PTSD, as well as the main considerations about when to carry it out in treatment. A practical framework for planning and implementing site visits is described.

It is widely recognized that psychological factors play a central role in the adjustment process and subsequent management of chronic pain. The role of anxiety, and specifically pain-related fear, has received particular attention. Paralleling developments in the anxiety disorders literature, psychological models of pain-related fear now highlight the importance of cognitive processes in its maintenance and treatment. However, theoretical and treatment advances in the anxiety disorders literature have not been widely applied to the pain field. In particular, certain cognitive processes, specifically safety-seeking behaviours and imagery, which appear to be involved in the maintenance of pain-related fear. This paper explores how these concepts may apply to pain-related fear and demonstrates how they may aid conceptualization and be used to guide a more cognitively orientated and efficacious treatment.

Method of Levels (MOL) is a form of cognitive therapy based on Perceptual Control Theory (PCT). This paper presents the initial steps towards four methods of establishing the validity of MOL. First, the session was rated by two independent experts for its adherence to MOL using a newly developed 6-item scale based on the Cognitive Therapy Rating Scale. Second, each therapist utterance within a session of MOL was coded and categorized in terms of the therapist's goal to test for adherence to the two specified goals of MOL. Third, a macroanalysis of a MOL session utilizing interpretative phenomenological analysis hypothesized the control hierarchies involved in a client's presenting problem and their zones of conflict. Fourth, a microanalysis of a brief interchange between the therapist and client explored its adherence to PCT. These methods of establishing validity are introduced and explored for later use in larger scale studies. The limitations of the present study and suggestions for future research are discussed.

Emerging adulthood (age 18–25 years) is a distinct developmental phase, characterized by multiple life changes, transitions and uncertainties, associated with significant risk of mental ill health in vulnerable individuals. Identity exploration and development is key during this phase, and the development of an eating disorder during this time can significantly impact on this process. This single-case study details the treatment of an 18-year-old female outpatient with first episode, recent onset anorexia nervosa. Using the Maudsley Model of Anorexia Nervosa Treatment in Adults (MANTRA), focus was placed on identity exploration and development as a tool to reduce the dominance of anorexia nervosa and increase recovery focus. Outcome measures at end of treatment and 6-month follow-up showed significant sustained improvement in BMI and EDE-Q scores. The patient gave detailed positive feedback suggesting that this was a highly acceptable and effective intervention. The case study is discussed with reference to limitations and some reflections on the utility of incorporating identity work in the treatment of anorexia nervosa in emerging adulthood.

Problem-solving and coping skills deficits have been shown in adolescents who experience suicide-related behaviours, including suicidal ideation. Little evidence exists about effective interventions for this population. We undertook a pilot study of an Internet-based CBT programme that included problem-solving skills training to investigate its impact on skills deficits. The study employed a pre-test/post-test design. Outcomes of interest were negative problem orientation, emotion- and task-focused coping, and adolescents’ perception of helpfulness of the intervention. Participants, recruited via the school wellbeing team, were assessed at baseline, at weekly intervention sessions and immediately post-intervention. Twenty-one adolescents completed the intervention. Over the course of the intervention, negative problem-solving orientation improved and students relied less on emotion-focused coping strategies. Because there was no control group, we cannot be certain that the changes seen between baseline and post-intervention can be attributed to the intervention. Adolescents rated the problem-solving and cognitive restructuring modules as particularly helpful. Interventions that include enhancement of problem-solving skills, as well as cognitive restructuring to address adolescents’ appraisal of problems and their ability to solve them appear promising for adolescents with suicidal ideation. Further investigation is warranted.

Helping service users to return to work has emerged as a key therapeutic objective of the Improving Access to Psychological Therapies (IAPT) initiative. IAPT programmes implement National Institute for Health and Clinical Excellence (NICE) guidelines, especially cognitive behaviour therapy (CBT), for people suffering from anxiety and depression. However, relatively little research has been conducted to date into whether, or how, cognitive behavioural interventions can help individuals return to work. This paper reviews literature and research into CBT and occupational outcomes and considers whether a return-to-work agenda may jeopardize the therapeutic alliance which is suggested to be necessary for effective CBT. Moreover, through the use of clinical examples from our practice, we suggest ways in which employment issues might be integrated into CBT for depression and anxiety disorders. We conclude that a return-to-work agenda can be utilized during therapy while maintaining a collaborative and secure therapeutic relationship, especially, perhaps if work issues are embedded within the formulation. However, further research is needed, not only to determine whether CBT can help individuals return to work but also how CBT might best integrate a return-to-work agenda.

Attention to client metaphors has been asserted as a way of enhancing cognitive behaviour therapy. Metaphors can be part of the shared language that is co-constructed between clients and therapists. Recent advances in cognitive linguistics have provided the most clearly operationalized method yet to identify metaphors in conversations, allowing analysis of how shared language develops. This study aims to explore how metaphoric shared language develops in early cognitive behaviour therapy sessions. Based on 12 transcripts of early cognitive behaviour therapy sessions, an iterative process led to the identification of a range of therapist and client responses to each other's metaphors, and identification of whether therapists or clients initiated metaphoric exchanges. Types of responses to therapist or client metaphors within three speaking turns were found to be: repetition, rephrasing, exploration, elaboration/extension, or agreement. Bursts of metaphoric exchange were initiated and taken up by therapists and clients at a similar rate. To conclude, therapists need to attend to the occurrence of metaphors and be aware of the range of potential responses that can engage the client in the ‘metaphoric dance’ (co-construction of shared metaphors). This has the potential to enhance engagement and outcomes though more salient reformulating of the problem for the client.

Cognitive behavioural therapy (CBT) for major depression is an effective treatment, but outcomes for complex cases, with co-occurring biological, psychological and social factors, are variable. Complexity factors can cause treatment to become diffuse, disorganized and over-complicated. At Step 3, disorder-specific protocols should be provided with therapy kept as simple as possible and delivered responsively, e.g. barriers to treatment should be tackled, ensure the client is well-prepared and seek to form a strong therapeutic alliance. At Step 4, if disorder-specific protocols have been ineffective, the priority is to formulate how complexity factors are interacting with the client's depression. An individualized formulation is used to carefully target these interactions. The treatment is still evidence-based and simple at the point of delivery, but there is greater emphasis on case-level interactions that are unique to each individual. Case examples are used to illustrate both approaches.

Using 16 non-clinical adults from the community, this study examined the effects on well-being of a group intervention consisting of a 4-week behavioural activation component followed by a 3-week mindfulness component, finishing with an integrating closure session. Results from intention-to-treat analyses showed moderate and significant improvements in psychological distress and several indices of well-being after the behavioural activation component. These improvements continued through the mindfulness component of the intervention such that effects were greater after participants had received the complete intervention. Half of the participants reported reliable and clinically significant improvement in the amount of time they felt happy after the intervention and a quarter of participants reported improvement at follow-up. Behavioural activation and mindfulness interventions may provide a useful framework for further research with non-clinical populations who wish to enhance their well-being and learn skills that may protect them against depression and other mental health problems.