Recently there have been a number of developments in cognitive behaviour therapy (CBT) that have led to cultural adaptations of specific interventions and a greater awareness of how in general CBT might be adapted for Black and Minority Ethnic (BME) service users. These developments, however, involve change at the level of the individual therapist and particular treatment approach, but involve very few considerations of what needs to happen at the levels of teams or services in order to best meet the mental health needs of British South Asian and other BME populations. This paper summarizes the way that services need to understand how minority populations use services and how to involve those populations in developing services in order to ensure their needs are best met.

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.

Vaginismus in one of the most frequent causes of non-consummation of marriage, and of infertility, in Arab-Muslim societies. Cognitive behavioural therapy (CBT) proved to be effective, but it is important to consider the cultural context of the patient attending CBT for vaginismus. The aim of our study was therefore to draw attention to the belief systems and behaviours linked to female sexuality and couple relationship in the Arab-Muslim culture. We present a series of four patients representative of the local culture and show how treatment strategies were adapted to fit these behaviours and belief systems, as well as environmental factors. We found that excessive closeness of family members, allowing the family to be intrusive and exercising pressure on the couple, a strict education which highly values virginity, transmits fear of ‘the male’ and fear of sex, and which links sex with pain, were the common denominator of all patients of our case series. We adapted the classical CBT strategies for vaginismus to our cultural context. The educational component was enlarged. Cognitive techniques were used to modify specific traditional beliefs. The integration of the family, and not only of the partner, into the treatment process proved uniquely beneficial for the patients.

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.

Current work in multicultural competency has emphasized factors such as race and ethnicity, age, disability status, socioeconomic status, sexual orientation and gender. For those clinicians who work with military and veteran populations, grounding in military cultural competence is also critical as a prerequisite for providing quality care. We believe that engaging these populations from a specifically cognitive behavioural orientation allows bridging of cultural gaps and that there is a natural alignment between cognitive behavioural therapy (CBT) and many aspects of warrior culture. This paper outlines several factors related to the values of military culture and strategies of the CBT therapist to better understand and use these values effectively in clinical practice, including lessons learned from an intensive outpatient program providing speciality care to veterans and military service members.

The use of transdiagnostic mental health treatments in low resource settings has been proposed as a possible aid in scaling up mental health services. Modular, multi-problem transdiagnostic treatments can be used to treat a range of mental health problems and are designed to handle comorbidity. Two randomized controlled trials have been completed on one treatment – the Common Elements Treatment Approach, or CETA – delivered by lay counsellors in Iraq and Thailand. This paper utilizes data from two clinical trials to explore the delivery of CETA by lay providers, examining fidelity and flexibility of element use. Data were collected at every therapy session. Clients completed a short symptom assessment and providers described the clinical elements delivered during sessions. Analyses included descriptive statistics of delivery including selection and sequencing of treatment elements, and the variance in element dose, clustering at the counsellor level, using multi-level models. Results indicate that lay providers in low resource settings (with supervision) demonstrated fidelity to the recommended CETA elements, order and dose, and occasionally added in elements and flexed dosage based on client presentation (i.e. flexibility). This modular approach did not result in significantly longer treatment duration. Our analysis suggests that lay providers were able to learn decision-making processes of CETA based on client presentation and adjust treatment as needed with supervision. As modular multi-problem transdiagnostic treatments continue to be explored in low resource settings, research should continue to focus on ‘unpacking’ lay counsellor delivery of these interventions, decision-making processes, and the level of supervision required.

The aim of this study was to conduct a systematic literature review to ascertain whether cognitive behavioural therapy (CBT) for social anxiety disorder (SAD) can be successfully used in non-Western contexts and demonstrate sufficient effectiveness. This area is largely under-researched with conflicting evidence presented in quantitative studies, with virtually no qualitative studies published. This review utilized realist review methodology and focused on qualitative case studies presented by clinicians. A systematic search of EBSCO HOST, The Cochrane Library Database, Google, Google Scholar and reference mining, using various combinations of terms relating to: (1) CBT, (2) social anxiety and (3) cultural diversity were employed. Seven case studies of cultural adaptations of CBT treatment for culturally diverse SAD sufferers were included. The treatment outcomes were generally promising in all cases (reporting significant decrease of SAD symptoms, maintained over time) and the success of therapy was often attributed to culturally specific modifications introduced. CBT can be an acceptable and effective treatment for culturally diverse SAD sufferers with ‘modest’ modifications, without major diversions from the original CBT models and protocols, but this finding must be treated with caution and more methodologically rigorous research (qualitative and quantitative) is needed to more fully understand what works, for whom and in what circumstances.

Experiences of racism can be a cumulative risk factor for developing mental health problems. Cognitive Behaviour Therapists working with Black and Minority Ethnic (BME) service users should be confident in their ability to establish the necessary rapport to ask about these experiences and be able to incorporate this information into longitudinal formulations and as part of maintenance cycles. This paper sets out guidelines as to how to do this as part of a wider engagement process.

Delivering research-supported intervention is increasingly important, given the growing emphasis on evidence-based practice in mental health treatment. When working with clients who hold marginalized identities, however, therapists may have questions about how to best tailor interventions, as treatments may not yet have demonstrated efficacy with under-represented populations. This paper describes potential strategies for using dialectical behaviour therapy (DBT) skills to help LGBTQ+ clients, guided by a theoretical model for understanding sexual stigma. Joining these two paradigms, suggestions are made for applications of skills that can help LGBTQ+ clients who are in DBT effectively interact with invalidating environments characterized by structural stigma. DBT-based strategies aimed at buffering clients from environmental invalidation and enhancing their skills in self-validation can help provide them with pathways towards affirming their own sexual orientation and gender identity. Examples from clinical cases are used to enhance understanding of skills application in practice.

Cognitive behaviour therapy (CBT) in its current form might not be applicable in non-Western cultures. Differences between Western and non-Western cultures have been reported widely. Most psychotherapeutic interventions have been developed in the West and are underpinned by the values that might be specific only to Western culture. To adapt CBT, we need to understand whether the concepts associated with CBT may conflict with cultural beliefs, identifying barriers to the success of the therapy using the views of experts by experience, public and practitioners. This paper discusses the process, foci and framework of cultural adaptation of CBT. We describe an evidence-based framework for adapting CBT for individuals from non-Western cultures that will benefit clinicians who practise CBT and individuals from different cultural backgrounds.

This paper outlines a psychological skills group for unaccompanied asylum-seeking young people with a focus on cultural adaptations in the context of a UK mental health service. Unaccompanied asylum-seeking young people have typically experienced multiple losses, traumatic experiences, significant disruption and psychosocial stressors. These experiences occur during a key developmental period and outside of the context of a supportive family environment. Mental health difficulties are estimated to be present in 41–69% of this population. Prevalence rates are higher than among children seeking asylum with their families or children who are not from refugee or asylum-seeking backgrounds. Cognitive behavioural approaches were considered to be applicable and useful when working with this client group. Group approaches may offer unique benefits for this population through peer support and normalization. The group described was planned around three key themes: physical health needs, emotional wellbeing and resilience-building. A number of adaptations were made to meet the needs of this population which included engagement, considering physical health needs, sleep, language needs, issues related to power, race and status, and thinking about the needs of the group as young people. Attendance ratings, session rating scale outcomes, preliminary effectiveness data and qualitative feedback from young people identified that this is an acceptable approach for these young people. Unaccompanied asylum-seeking young people require a broad package of care; however, making adaptations to routine practice allowed access to evidence-based interventions to support mental health and wellbeing.

Homeless girls suffer labour and sexual exploitation, abuse, discrimination and social exclusion at a higher rate than the rest of the population. However, worldwide information on homeless girls and intervention programmes for this group are scarce. This study examined the preliminary efficacy of a brief cognitive behavioural group therapy tailored to Mexican homeless girls. The intervention targeted subjective well-being and these determinants: symptoms of anxiety, symptoms of depression, assertive behaviours and functional emotion regulation skills. Results revealed statistically significant differences in symptoms of anxiety and depression, assertiveness, emotion regulation strategies and subjective well-being with treatment effects that ranged from moderate to large. Symptoms of anxiety and depression, and dysfunctional emotion regulation strategies decreased. Assertive skills, functional emotion regulation strategies, and subjective well-being increased. Outcomes were clinically relevant. At 2-month follow-up, participants showed improvement from pre-treatment on all measures. The current study provides unique findings in terms of a promising preliminary intervention that helps restore homeless girls to a healthier social/emotional developmental path especially in the context of Latin American cities. As a result, the clinical implications of this research highlight the urgent need to design effective interventions based on the observed characteristics and identified needs among homeless girls.

Computerized cognitive behavioural therapy (cCBT) has been developed to address economic and clinical issues around limited access to evidence-based therapy. Supported cCBT (variously termed iCBT or eCBT) has been developed to address issues with the effectiveness of, and engagement with, cCBT. There has been no in-depth qualitative exploration of the patient experience of eCBT within the UK, which might aid improving its effectiveness. The aim of this study was to explore patient experience of eCBT in one inner-city National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) service using a semi-structured interview and Thematic Analysis methodology. Ten patients took part. Six main themes were identified: (1) Being Offered eCBT; (2) How eCBT Compares with Self-help; (3) The Patient's State of Mind; (4) The Relationship with the Supporter; (5) Preferring to Talk; (6) eCBT's Value as a Treatment. Participants in this study indicated a preference for face-to-face talking therapy, but were clear that they could form a therapeutic relationship via asynchronous messaging. They reported clinical benefit from the eCBT programme and online relationship, and acknowledged that accessing this immediately was valuable. Issues around the process of selecting patients for eCBT, including with regard to acknowledging or mitigating any negative emotional effects of eCBT, and how to offer and support users with it, are discussed.

This paper is clinical practice-based, and examines the Greek cultural linguistic schema of Politeness Plural in the application of the Schema Therapy mode model. The philosophical principles of Schema Therapy and the importance the model ascribes on creating a warm therapist–client relationship as a pre-requisite for schema healing are discussed. We further explore the need for the therapist to be culturally sensitive to the linguistic use of Politeness Plural in Greek-speaking populations. We are looking into the reasons of why, whilst culturally sensitive, a schema therapist needs to remain inquisitive of potential maladaptive and/or internalized dysfunctional coping mechanisms of inter-relating that are masked by the use of the Politeness Plural linguistic schema. The implications the cultural linguistic schema of Politeness Plural can have in the therapy outcome are considered. Specifically, we argue that holding on to the Politeness Plural cultural linguistic schema may reinforce emotional distancing and compromise schema healing. The authors identify the need for more research to further understand the issues that are raised in this article. Although the focus of the article is on Greek populations, the matters under consideration may be valuable to other cultures.

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.

There is a very high prevalence of post-traumatic stress disorder (PTSD) within refugee populations and survivors of torture. Refugees, asylum seekers and survivors of torture who access IAPT (Improving Access to Psychological Therapies) can present with unique clinical challenges for cognitive behavioural therapy (CBT) therapists. The use of reflective practice can be beneficial particularly when there is added complexity in the client's clinical presentation. The aim of this paper is to provide an overview of how reflective practice can improve clinical work with this patient group and to identify some of the challenges that refugees, asylum seekers and survivors of torture may present with during therapy. The paper sets out how the use of the critical incident analysis model and clinical supervision can assist to develop reflective practice skills and improve the clinical practice of IAPT CBT therapists who work with diverse populations.

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.

Trauma and dissociation may be important factors contributing to the experiences of distressing voice hearing. However, there is scant mention of how to target and treat such processes when working with people with psychosis. This case study reports on an initial attempt to work with dissociation and trauma memories in a person with voices. A single case approach was used, with standardized measures used before, during and after 24 sessions of cognitive therapy, and at 6-month follow-up. In addition, session-by-session measures tracked frequency and distress associated with voices and dissociation. The participant reported significant improvements in terms of reduced frequency and distress of dissociation, and voice hearing, as well as improvement in low mood at the end of treatment. At follow-up there were enduring benefits in terms of dissociation and trauma-related experiences, as well as broad recovery but not of change in voices. This case illustrated the potential benefit of targeting dissociation and exposure to trauma memories in producing general symptom improvement and specific reductions in dissociation and voice hearing at end of treatment.

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.