Attachment theory may develop understanding of the occurrence and maintenance of persecutory delusions. This study investigates the role of dispositional attachment and contextually primed secure base attachment representations in the occurrence of paranoid thinking. Sixty participants were randomly allocated to one of three conditions: a secure attachment priming condition, a positive affect condition, or a neutral control condition. Following priming, all participants were exposed to a paranoia induction. State paranoia was measured at baseline and following the paranoia induction. Dispositional insecure attachment was associated with both trait and state paranoid thinking. Contrary to predictions, the secure attachment prime did not appear to buffer paranoid thinking and had a negative impact for participants with high levels of attachment anxiety, highlighting the potentially aversive effects of exposure to secure attachment material in those with existing insecure attachment styles.

The Improving Access to Psychological Therapies (IAPT) programme started in 2008, but it contained little provision for specifically meeting the needs of Black, Asian and minority ethnic (BAME) groups. The purpose of this evaluation was to describe the experience of transition from BAME community mental health worker (CMHW) to IAPT low-intensity psychological wellbeing practitioner (PWP) in order to identify possible gains and losses for the former communities served, and the factors that might contribute to successful training of people with BAME expertise. Four former CMHWs who had transitioned into working as PWPs were interviewed. Semi-structured interviews were used. The data were analysed using thematic analysis. Six major themes were identified with the benefits of training emerging as an important factor for the participants in enhancing their role. Three of the themes interconnected and focused on the impact for BAME communities in terms of access to service and barriers. Evident in the interviews were descriptions of adaptations that were made as a result of CMHW having access to both new and old skills. Finally, two themes focused on the participant recommendations as to how IAPT services might become more culturally responsive. The findings suggest that there can be significant benefits for services to provide IAPT training to people already providing culturally specific services. The participants reported that low-intensity cognitive behavioural therapy (LICBT) was effective, but only when cultural sensitive adaptations were made. The evaluation has some clear recommendations as to how IAPT services might seek to offer culturally responsive CBT. Suggestions for carrying out further practice-based evaluations are made.

We describe the results of a randomized controlled trial to assess effectiveness of an anger management group programme, employing a cognitive behavioural framework that was run by the Psychology Service. The treatment group was compared with a control group on a waiting list. The trial was performed at the Southampton CBT Service. The treatment group received a cognitive behavioural anger management programme, initially based on Novaco's approach, but with further development of the motivational components. The control group received no treatment and was on a waiting list. The Novaco Anger Assessment Scale (NAS), State-Trait Anger Expression Inventory (STAXI), Evaluative Beliefs Scale (EBS), Hospital Anxiety and Depression Scale (HAD) and the Clinical Outcomes in Routine Evaluations (CORE) were used to measure anger, belief about self and others, anxiety and depression, and physical and psychological wellbeing. Clients in the anger management group showed statistically significant changes on STAXI, NAS, CORE and EBS subscales at the end of the therapy. The change in depression and anxiety on HAD (depression and anxiety) was not statistically significant. It was not possible to carry out analyses at follow-up due to high dropout rates. We concluded that an anger management programme using CBT was helpful in reducing anger and overall psychopathology.

Cognitive behavioural therapy (CBT) is the most efficacious and effective psychological intervention for treating anxiety disorders. Behavioural techniques, in particular exposure-based techniques, are fundamental to positive outcomes. However, research suggests that these techniques are either not used or are under-used when treating anxiety disorders. This study assesses therapists’ reported use of CBT techniques in the treatment of anxiety disorders, and explores which therapist variables influence technique use. A total of 173 CBT therapists completed measures on their demographics, routine therapy practices in treating anxiety disorders, and internal states (e.g. self-esteem). These data were analysed to see how often therapists employed particular techniques and the correlates of the use of those techniques. Behavioural techniques (e.g. exposure) were the least utilized set of core CBT skills, being used less often than non-CBT techniques. The under-utilization of these key techniques was associated with greater levels of increased inhibitory anxiety amongst therapists. Supervision and therapists’ self-esteem were both positively associated with the use of non-CBT techniques. While this study established what CBT therapists purport to use in routine practice with anxious populations, further research is needed to assess the association between adherence (or lack thereof) and client outcomes, and the factors that drive non-adherence.

A first empirical study into group schema therapy in older adults with mood disorders and personality disorder (PD) features has shown that brief group schema therapy has potential to decrease psychological distress and to change early maladaptive schemas (EMS). Effect sizes however were smaller than those found in similar studies in younger adults. Therefore, we set out to adapt the treatment protocol for older adults in order to enhance its feasibility and outcome in this age group. We examined this adapted protocol in 29 older adults (mean age 66 years) with PDs from four Dutch mental health institutes. The primary outcome was symptomatic distress, measured by the Brief Symptom Inventory. Secondary outcomes were measured by the Young Schema Questionnaire, the Schema Mode Inventory, and the short version of the Severity Indices of Personality Problems. Contrary to our expectations, the adapted treatment protocol yielded only a small effect size in our primary outcome, and no significant improvement in EMS, modes and personality functioning. Patients pointed out that they were more aware of their dysfunctional patterns, but maybe they had not been able yet to work on behavioural change due to this schema therapy treatment being too brief. We recommend more intensive treatment for older patients with PDs, as they might benefit from more schema therapy sessions, similar to the treatment dosage in younger PD patients. They might also benefit from a combination of group therapy and individual treatment sessions.

Large-scale cognitive behavioural therapy (CBT) training and implementation programmes, such as the pioneering Improving Access to Psychological Therapies (IAPT) initiative in the UK, aim to develop a workforce of competent therapists who can deliver evidence-based interventions skilfully. Self-awareness of competence enables CBT therapists to accurately evaluate their clinical practice and determine professional development needs. The accuracy of self-assessed competence, however, remains unclear when compared with assessments conducted by markers with expertise in CBT practice and evaluation. This study investigated the relationship between self- and expert-rated competence – assessed via therapy recordings rated on the Cognitive Therapy Scale Revised (CTS-R) scale – for a large sample of IAPT CBT trainees during training and, for the first time, at post-training follow-up. CBT trainees (n = 150) submitted therapy recordings at baseline, mid-training and end-of-training. At 12+ month follow-up, a subset of former trainees (n = 30) submitted recordings from clinical practice. There were positive relationships (r = .27 to .56) between self and expert CTS-R scores at all time points. The proportion of tapes demonstrating significant agreement between self and expert ratings (CTS-R difference <5 points) increased significantly across training and remained stable at follow-up. Findings indicate that accurate self-awareness of competence can be developed during structured CBT training and retained in the workplace. These outcomes are encouraging given the importance of self-awareness to CBT practice and accreditation. Future investigation into the development and maintenance of accurate self-awareness of competence is warranted.

Low self-esteem is widely acknowledged to be associated with the phenomenology of a number of mental health diagnoses, including those which are treated under the umbrella of Improving Access to Psychological Therapies (IAPT) services. To evaluate the effectiveness of group Cognitive Behaviour Therapy (CBT) based on the work of Fennell in treating low self-esteem 50 participants attended a 10-week group programme. Pre- and post-group measures of depression, anxiety and self-esteem were compared using Mann–Whitney U tests. The results indicated that there was a statistically significant and clinically meaningful change across all pre- and post-group measures. Mean post-group measures indicated levels of depression and anxiety which were below caseness and a healthy level of self-esteem. Results indicated that gains were well maintained at 3-month follow-up. The results from this study highlight the effectiveness of group CBT for low self-esteem and thus contribute to the limited evidence base in this area. Results are discussed with consideration of the existing evidence base, implications for clinical practice, and future research.

This paper is an introduction to adaptations to make cognitive behaviour therapy (CBT) more accessible to people with intellectual disabilities. It is intended to inform therapists who may work with people with intellectual disabilities in mainstream services.

The paper describes adaptations that consider neuropsychological processes, such as memory, and executive functions, such as planning, problem solving and self-regulation, and identifies that these factors are not unique to people with intellectual disabilities. We describe adaptations based on a review of literature describing CBT for people with intellectual disabilities (Surley and Dagnan, 2019) and draw on clinical experience to give examples of adaptations where possible. The paper particularly emphasises the generalisability of adaptations used with people with intellectual disabilities to therapy with wider populations and suggests that CBT therapists working in mainstream services will have the skills to be able to adapt therapy for people with intellectual disabilities.

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.

There is a national drive to increase access to psychological therapies across England, with a specific focus on under-represented groups such as Black, Asian Minority and Ethnic (BAME) groups. Although prevalence rates for common mental health conditions such as depression and anxiety in Orthodox British Jews are less than those of the generic population in the United Kingdom, accessing services to help treat these conditions within this group are considerably less than other groups. This paper seeks to consider reasons for this, as well as what adaptations, both from a therapist and service perspective, can be made to increase access within the Orthodox Jewish community with lessons to be made to other BAME groups.

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.

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.

Infectious disease outbreaks have occurred sporadically over the centuries. The most significant ones of this century, as reported by the World Health Organization, include the EVD epidemic, SARS pandemic, Swine Flu pandemic and MERS pandemic. The long-term mental health consequences of outbreaks are as profound as physical ones and can last for years post-outbreak. This highlights the need for enhancing the preparedness of pragmatic mental health service provision. Due to its magnitude, the novel COVID-19 pandemic has proven to be the most impactful. Compared with previous outbreaks, COVID-19 has also occurred at higher rates in frontline staff in addition to patients. As COVID-19 is more contagious than earlier outbreaks, there is a need to identify infected people quickly and isolate them and their contacts. This is the current context in which mental health services including IAPT have had to operate. Evidently, Improving Access to Psychological Therapies (IAPT) services are a major mental health service provider in the UK that have demonstrated variability in their response to COVID-19. While some IAPT services quickly adapted their existing strengths and resources (e.g. remote working), other services were less prepared. To date, there are no clear unitary guidelines on how IAPT services can use their pre-existing resources to respond to the long-term effects of outbreaks. In light of this, the current paper aims to reflect on the lessons learned from past outbreaks in order to consider how an enhanced remit of IAPT might integrate with other services to meet the long-term needs of patients and staff affected by COVID-19.

Physical health outcomes for patients with long-term conditions can be significantly affected by their psychological wellbeing; those experiencing psychological difficulties are less able to manage symptoms, have a poorer quality of life, and more frequent hospital admissions. National guidance recommends the assessment and treatment of psychological difficulties secondary to respiratory disease, but implementation of this across services is inconsistent. Here, we describe the process and findings of a 9-month study integrating psychological assessment and intervention into an acute respiratory department. The aim of this provision was to provide appropriate interventions for both in-patients and out-patients with identified psychological needs, and to evaluate the impact of these across a range of outcome domains. Psychological assessment and intervention was flexibly implemented as clinically appropriate within the context of the wider multidisciplinary team. Hospital admissions data were collated, and feedback obtained from both patients and staff. Results highlighted that psychological provision was well received by both patients and staff, and was associated with improved patient experiences and a greater focus on holistic care. Of the 73 patients receiving psychology input with at least 1 month of follow-up data, 75% showed a reduction in their admission frequency following intervention. The estimated savings to the wider NHS exceeded the costs of providing psychology input. In light of existing literature, national guidance, and the present findings, we highlight the need for those commissioning and managing respiratory services to consider the various potential benefits of integrating psychological provision for a patient group with high levels of psychological need.

Hearing voices is a distressing and trans-diagnostic experience. Cognitive behavioural therapy (CBT) is an effective psychological treatment for distressing voices, but is offered to only a minority of patients. Limited resources are a barrier to accessing CBT. Evaluations of brief forms of CBT for voices have offered encouraging findings, but the ability of briefly-trained therapists to deliver these brief therapies has yet to be explored. We evaluated the outcomes of a brief form of CBT (Coping Strategy Enhancement, CSE) for voices when delivered by highly-trained and briefly-trained therapists. This was a service evaluation comparing pre–post outcomes in patients who had completed brief CSE over four sessions, within NHS Mental Health Services, delivered by highly-trained and briefly-trained therapists. The primary outcome was the negative impact scale of the Hamilton Program for Schizophrenia Voices Questionnaire. Data were available from 92 patients who completed a course of brief CSE – nearly half of whom received therapy from a briefly-trained therapist. Modest benefits across the sample were consistent with previous evaluations and did not seem to be influenced by the training of the therapist. This service evaluation offers further evidence that brief CSE can begin a therapeutic conversation about distressing voices within routine clinical practice. The usefulness of this initial conversation does not seem to be reliant upon the extent of therapist training, suggesting that briefly-trained therapists may play a role in increasing access to these conversations for patients distressed by hearing voices.

Many children with autism spectrum disorder (ASD) exhibit difficulties with negative affect. Cognitive behavioural therapy (CBT) has been successfully adapted for individuals with ASD to treat these difficulties. In a wait-list control study, for example, group analyses showed promising results for young children with ASD using a developmentally adapted group CBT approach. This report examined response to group CBT in terms of individual-level change in young children with ASD. Eighteen children with ASD, aged 5–7 years, and their respective parents participated in treatment. Parents completed pre- and post-treatment measures of negative affect and related behaviours. Treatment responders and non-responders were grouped based on significant treatment outcomes as assessed by statistically significant change for lability/negativity and 20% decrease in intensity, duration or frequency of emotional outbursts. Results indicated that 67% of children met criteria as a treatment responder, showing meaningful improvement in at least two outcome measures. No significant group differences emerged for initial characteristics before treatment. Wilcoxon signed rank tests determined pre-/post-treatment change in parental confidence for each treatment responder group. Results indicated statistically significant increase for the treatment responder group in parent-reported confidence in their own ability and in their child's ability to manage the child's anger and anxiety, but these results were not significant for the treatment non-responder group. Results provide additional evidence that CBT can significantly decrease expressions of anger/anxiety in children with ASD as young as 5 years, yet also suggest need for further improvement.

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.

Self-practice/self-reflection (SP/SR) allows cognitive behavioural therapists (CBT) to self-experience the techniques they use clinically. However, it is difficult to find published first-hand accounts of CBT therapists’ SP/SR experiences. This may be because CBT research is primarily positivist and objective, while SP/SR is intrinsically subjective. Borrowing from the principles of autoethnography may offer a subjectivist qualitative methodology, allowing CBT therapists to write up their SP/SR experiences as rich, first-hand research material, potentially impacting theory and practice. This novel personal case study of SP/SR borrows from autoethnography, adapting it to analyse the self-practice of the CBT model of worry, in order to understand my own experience of worry as well as the model itself.

Compassion focused therapy (CFT) is rooted in an evolutionary view of the human mind as formed of a multitude of contrasting, and often conflicting, motivations, emotions and competencies. A core aim of the therapy is to help clients understand the nature of their mind in a way that is de-pathologizing and de-shaming. The approach is also focused on the cultivation of compassion to work with these difficult aspects of mind. CFT includes the ‘multiple-selves’ intervention which involves the differentiation of threat-based emotion and an exploration of their conflict. Compassion is then applied to the client’s affective world to aid regulation and integration. This paper focuses on clients’ experiences of a chairwork version of multiple-selves, wherein clients personify their emotions in separate chairs. Nine participants with depression were interviewed directly following the intervention and the resulting data were analysed using interpretative phenomenological analysis. Three interconnecting themes were identified: appreciating emotional complexity; the role of chairwork process; and compassionate integration. The results highlight the importance of emotional differentiation in understanding internal multiplicity and conflict in depression, and the role of compassion in creating a sense of personal coherence. The embodied and enactive nature of chairwork was found to be of benefit in identifying and separating emotion, and in developing new forms of self-relating. The paper discusses the clinical implications of such findings for the treatment of depression.