Written guidance is part of a coherent support system for CBT supervisors, consistent with general developments in evidence-based practice. In theory, training manuals can help by specifying educational procedures and providing support materials so as to foster fidelity, expertise and effectiveness among supervisors. Supervision guidelines can help by offering supervisors the fruits of research and expert consensus. Together with related resources, such written guidance promises to empower professionals and to benefit patients. But progress with written guidance is very limited within clinical supervision, particularly in controlled research. In marked contrast, locally developed guidance appears to have been implemented successfully within pragmatic studies, a marked achievement when also contrasted with the general healthcare literature. Using eight criteria, the available supervision research is reviewed and conclusions drawn on developing written guidance so as to better fulfil its promise.

Treatment goals are considered a vital part of therapeutic work, and their role is often emphasized in cognitive behavioural therapy (CBT). However, the attainment of goals is rarely accounted for in terms of treatment outcome. In this study, we set out to investigate a structured format for goal assessment and goal attainment in CBT delivered as routine care. We were especially interested in the sensitivity to change in perceived goal attainment. Patients completed a self-administered version of the Bern Inventory of Treatment Goals (BIT-C) and rated their perceived attainment on a maximum of five prioritized goals before and after 12 weeks of treatment, along with measures on anxiety, depression and health-related quality of life. The results indicated that the prioritized goals only partially correspond to disorder-specific concerns, and that perceived proximity to treatment goals is clearly associated with improvements following treatment. The results are discussed in terms of the BIT-C being a promising tool for use in clinical settings in assessing treatment goals as well as in evaluating the attainment of these goals.

Autism spectrum disorders (ASD) including high-functioning types such as Asperger's syndrome (AS) are diagnosed when there is evidence of a triad of qualitative impairments in social interaction, communication, and stereotyped/repetitive behaviours. It is not uncommon for these impairments to be accompanied by social anxiety. The present single-case study investigates the use of cognitive behavioural therapy (CBT) to treat a 47-year-old man who was assessed as having difficulties with social skills and social phobia in the context of a late diagnosis of AS. He received 20 h of CBT adapted for his AS in 15 sessions including a 1-month follow-up. Following a highly individualized formulation, treatment included modelling, role-playing, reinforcement, thought challenging, and behavioural experimentation. Results from five self-report measures showed continued improvements from the start of therapy to follow-up in social anxiety, global distress, depression and self-esteem. The client gave positive feedback about his experience of treatment. The case study is discussed with reference to limitations and some reflections for CBT in ASD.

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.

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.

Accurately evaluating how competently one is performing can be a precursor to seeking training and supervision, therefore contributing to safe, effective practice. Little is known about what predicts accurate self-evaluation. Prior research findings are inconsistent, with overestimation of self-rated competence in some studies and underestimation in others. We aimed to explore the relationship between therapists' reflective ability and the level of agreement between self-rated competence and competence rated by an experienced CBT assessor. Thirteen trainees undertaking a postgraduate CBT diploma submitted a series of recordings accompanied by self-ratings using the Cognitive Therapy Scale – Revised (CTS-R) and related written reflective analyses. Independent assessors marked the written analyses using a standardized marking scheme and rated the therapy sessions using the CTS-R. Trainees tended to overestimate or underestimate their competence in comparison to the independent assessors. The level of agreement between the assessors' ratings and self-evaluation of competence tended to improve during training, while reflective ability did not. Reflective ability was significantly related to level of agreement between self-rated and assessor-rated competence. Trainees do not consistently demonstrate the bias for overestimating their competence previously found in qualified therapists. During training, the tendency of an individual to over- or underestimate their competence may not remain stable, but tends to become more consistent with ratings undertaken by an experienced CBT assessor. Trainees who were rated as more reflective, tended to agree more closely with independent assessors on evaluation of competence. Therefore, enhancing reflective ability may help therapists to more accurately self-evaluate their competence.

Body-focused repetitive behaviours (BFRBs) including trichotillomania, skin picking, and nail biting, are non-functional self-destructive habits, which have a severe negative impact on everyday functioning. Although BFRBs cause distress, they are maintained by both negative (relief) and positive (stimulation) reinforcement. The emotional regulation (ER) model proposes that people with BFRBs have a general deficit in ER and, as a consequence, engage in BFRBs to alleviate affect and reinforce the behaviour. The current study was designed to explore differences in ER between people with BFRBs and controls to identify specific emotions triggering BFRBs. Forty-eight participants (24 BFRB, 24 controls) completed questionnaires measuring Difficulties in Emotional Regulation (DERS), a Triggers Scale and an Affective Regulation Scale (ARS). Significant differences in people with BFRBs and controls were reported principally on the DERS subscales of lack of emotional clarity, difficulties in impulse control, and access to ER strategies. On the ARS, the BFRB group reported overall difficulty ‘snapping out’ of emotions. The majority of BFRBs were reported to be triggered by anxiety (78%), tension (70%), or boredom (52%). The clinical implication is that ER could be beneficially targeted in therapy for BFRBs.

There is growing evidence regarding the effectiveness of mindfulness-based interventions offered to diagnostically diverse groups of participants. This study examined the feasibility and effectiveness of adapted Mindfulness-Based Cognitive Therapy (MBCT) groups offered to NHS patients in a secondary-care Psychology and Psychotherapy Service. The group was run as an adjunct to individual therapy and accepted referrals from all therapists in the service, so participants had experienced a range of therapeutic approaches prior to attending the group. The nine groups run during the project also included staff participants, as part of a capacity-building strategy. Results indicate high levels of acceptability, with low drop-out rates. Standardized outcome measures were used to examine the effectiveness of the group, and patient participants demonstrated improvements which were statistically significant. Qualitative feedback from group participants and referrers was positive. The findings support implementation of MBCT as part of a package of psychological therapy interventions. Further research regarding this form of MBCT is discussed.

Although individual cognitive behavioural therapy for psychosis (CBTp) is a recommended treatment in the UK, studies evaluating participant experiences are limited, particularly in high-security (HS) conditions. Traditional methods of participant evaluation disadvantage HS patients. Individual chief-complaint orientated CBTp (C-Co CBTp), a variant of CBTp, is offered in a HS setting. The paper aimed first, to evaluate participant experiences of individual C-Co CBTp within HS conditions, and second, to evaluate collaborative group game design as a means of evaluating participants’ experiences. Collaborative group game design was used as a novel method of participatory action research to evaluate patient and practitioner experiences of C-Co CBTp. Fifteen participants (10 inpatients, five staff) developed a life-size game representing their experiences of C-Co CBTp and offered feedback on the process. The game comprised of 24 squares, each depicting and describing a therapy experience, and a set of game-play cards. Collaborative group game design is a viable means of evaluating participant experiences. Findings corroborate and add to the current evaluation literature. Participants placed particular emphasis on collaboration, the therapeutic relationship, therapy as a nonlinear process and vulnerability and hope.

Trauma-focused cognitive behavioural therapy (TF-CBT) is beneficial for individuals with post-traumatic stress disorder (PTSD); however, a subset of clients struggle to engage with traditional methods, due to high levels of avoidance and dissociation. This paper aims to describe an adapted approach to imaginal reliving and prolonged exposure, to facilitate subsequent cognitive updating. The paper demonstrates the technique with veterans, who are a client group that may struggle with some aspects of traditionally implemented TF-CBT. Two case studies are described, both with PTSD symptoms stemming from traumatic military experiences. An adapted exposure technique is utilized to address the barriers of high dissociation, poor access to trauma-related cognitions and fixed intrusive imagery. The approach involved three stages: (1) reliving the trauma outdoors, (2) manipulating the perspectives of the imagery, and (3) restructuring the narrative with new perspectives. Both clients showed decreased dissociation and improved toleration of their traumatic imagery. Improvement of PTSD symptoms and quality-of-life functioning was observed for both clients on objective measures. Adapting TF-CBT to have a stronger emphasis on grounding and allocentric processing may be helpful for a subset of patients with PTSD that present with high levels of dissociation and avoidance. Further research and investigation into alternative populations is needed.

Despite efficacy and effectiveness evidence, and recommendations from the National Institute for Health and Care Excellence (NICE), use of CBT self-help materials remains inconsistent in UK mental health services. Since 2006, the Improving Access to Psychological Therapies (IAPT) programme has provided standardized training and mandates routine use of CBT self-help materials by their trainee psychological well-being practitioners (PWPs). This study tested whether the main constructs of the theory of planned behaviour (TPB; attitudes, subjective norms, and perceived behavioural control), past use, prior training and demographic characteristics, would predict PWPs’ intention to use self-help materials routinely in their clinical practice. Stage 1 utilized a standardized procedure to create measures for the constructs of TPB, before the design and testing of a web-based, cross-sectional questionnaire. In stage 2, the questionnaire was administered to a convenience sample of trainee PWPs (n = 94). Data was analysed using multiple linear regression, mediation analyses, and content analysis. TPB constructs predicted intention to use self-help materials, with only direct attitude contributing significantly to 70% of the variance in intention. Past use of materials predicted intention, via direct and indirect mediation. Qualitative data from 43 trainees highlighted clients’ experience of self-help materials as positive, albeit with some practical constraints. The results suggest that the main constructs of TPB have some utility in predicting trainee PWPs’ intention to use self-help materials routinely. Future prospective, longitudinal research could investigate actual use of self-help materials to elucidate cognitive factors involved in trainees’ clinical decision-making post-qualification.

Although clinicians have used cognitive behavioural case formulations (CBCFs) to guide treatment for many years, the validity of the case formulation (CF) is rarely evaluated. Given the central role of the formulation in treatment planning, particularly for complex or comorbid cases, a straightforward method to empirically evaluate the validity of the CBCF could increase the effectiveness of a treatment plan tailored for a particular client. This article describes a step-by-step, person-specific approach to evaluating a CBCF that can be used for appropriate cases in a clinical practice or especially a clinical training setting. The evaluation focuses on discriminant validity of person-specific scales and constructs and patterns of predicted functional relationships between idiosyncratic cognitions and distress. The approach is illustrated with an adult seen in a training clinic who was diagnosed with generalized anxiety and recurrent major depressive disorders and who completed 28 brief end-of-day, individualized questionnaires. The clinician's CBCF hypotheses were empirically evaluated using mostly simple statistical analyses available in readily accessible worksheets. Intervention implications of the CF evaluation are discussed.

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived flaw in one's appearance, and is often emotionally linked with early adverse experiences. Cognitive behavioural therapy (CBT) is effective but may not resolve shame and anger that can be at the emotional root of BDD. This paper presents a single-case study of a 25-year-old man with a history of treatment-resistant BDD characterized by a preoccupation with facial skin linked to a developmental history of sexual abuse and bullying. He was treated at a national residential specialist unit for 16 weeks during which time he received three individual 1-hour weekly CBT sessions (42 sessions overall), and participated in the residential group programme and therapeutic community. CBT was enhanced using imagery rescripting, compassion-focused therapy and family work to specifically target shame and anger-based past experiences. Severity of BDD was assessed with the BDD-Yale–Brown Obsessive Compulsive Scale (BDD-YBOCS) at pre-, mid-, post-, 3-month and 18-month follow-ups; a weekly self-report measure (Appearance Anxiety Inventory), and a client-drawn self-portrait of his perceived skin flaws at pre- and post-treatment. Treatment outcome was positive. The BDD-YBOCS dropped 94% from the extremely severe range pre-treatment to the sub-clinical range post-treatment. BDD symptoms improved progressively throughout treatment, and when the emotions of anger and shame were resolved (as reported by the client) fell to the non-clinical range. Gains were maintained at 18-month follow-up. We conclude that enhancing CBT for BDD using emotion-focused techniques is to be recommended, particularly when emotional memories continue to affect body shame.

Obsessive compulsive disorder (OCD) is a debilitating mental health disorder, with prevalence in adults of around 3.1%. The social and economic consequences of OCD are high for patients and their families. It is unlikely to improve without treatment. Help-seeking for treatment is often delayed and studies have found an average treatment gap of up to 17 years. This study aimed to explore the factors that influenced how, when and why people sought help and to identify any issues that they faced during help-seeking. Individuals experiencing OCD were invited to complete a web-based survey hosted on a national OCD charity website over a 3-month period. Eighty-eight individuals took part. Most had sought help from their general practitioner (GP), while others accessed websites and private services. Lack of awareness and understanding by health professionals was reported as a problem, as was the speed of referral or getting the right treatment. There is a need for further training and education for health professionals and GPs. Education and awareness campaigns for the general public, with more focus on how help can be sought, and on the different types of OCD may contribute to improving recognition of symptoms and accessing timely help.

Few studies have explored therapists’ views on computerized cognitive behavioural therapy (cCBT) and this study aimed to provide an in-depth understanding of accredited therapists’ views on cCBT's role in treating depression. Twelve therapists constituted this self-selected sample (eight female, four male). Mean age was 52 years (range 46–61). The data obtained from a semi-structured questionnaire were analysed using thematic analysis. Three themes were identified and discussed: (1) the standardized nature of cCBT for depression, (2) the importance of the therapeutic relationship in cCBT, and (3) the pros and cons with cCBT as an alternative to CBT. The therapists in this study emphasized that innovations in CBT delivery formats (e.g. internet-based, computerized) show promise. However, participants expressed some views that clash with the evidence-based viewpoint. More work is needed to improve the implementation of evidence-based practice and policy.

Ways of coping with stressful situations can be categorized as problem-focused, emotion-focused, and dysfunctional. Methods of controlling intrusive thoughts, which are frequently associated with psychological distress, have also been classified into different subgroups. This study assesses associations between methods of coping and thought control, and how these relate to distress. Sixty-eight participants were recruited from outpatient psychology services and completed measures of distress, coping, and thought control. Problem-focused coping strategies and both distraction and social thought-control strategies were associated with each other and with lower distress. Conversely, dysfunctional coping strategies and both worry and punishment thought-control strategies were associated with each other and with higher distress. Future research and the clinical implications are discussed.

Welcome to this Special Issue of tCBT. Our focus in this special edition of the journal is on supervision. Few would argue the vital role of supervision during CBT training and beyond to ensure treatment fidelity to evidence-based protocols. I would like to take this opportunity to thank Professors Derek Milne and Robert Reiser for kindly acting as guest editors. In addition, we are grateful for their fine contributions to the supervision literature in this particular edition of the journal. Thanks too to Professor Cory Newman from the tCBT editorial board for contributing to the overarching paper provided by Professors Milne and Reiser. Thanks also to all the authors for their fine contributions and to our reviewers who gave so generously of their time to comment on the submitted manuscripts. Our intention is to publish one Special Issue a year, next year we look forward to a special edition with a focus on ‘complexity’ with guest editors Dr Claire Lomax and Dr Stephen Barton from Newcastle University.

Supervision is probably the single most effective method for helping therapists to develop competence, capability and a professional identity (Falender & Shafranske, 2004; Callahan et al. 2009; Watkins & Milne, 2014). Supervision is also perceived by supervisees as the main influence on their practice (Lucock et al.2006), and has been recognized by governments as an essential component of mental health services in the 21st century (e.g. Care Quality Commission, 2013). Paradoxically, supervisors themselves may receive inadequate support and guidance. This is an unacceptable strategic and moral oversight, one which presumably undermines the fidelity of CBT while increasing burnout: in one survey, 82% of participating supervisors expressed dissatisfaction over their support arrangements (Gabbay et al. 1999). Recent surveys of CBT supervisors indicate that despite an overall sense of satisfaction with supervision, considerably more can be done to support supervisors in terms of developing improved supervisory and training materials (Reiser & Milne, 2016). The phrase ‘something does not compute’ sums up this paradox succinctly (Watkins, 1997, p. 604).

In this Introduction to the Special Issue of the Cognitive Behaviour Therapist on clinical supervision we start by highlighting the unmet and overdue need for coherent organizational systems to support, guide and develop clinical supervisors. We identify a seven-step, cyclical model that describes how such a system might work, with particular reference to CBT supervision. These steps start with conceptualization (e.g. definition of CBT supervision) and complete the problem-solving cycle with evaluation (e.g. corrective feedback). We provide an overview of typical research and development activity for each part of this model to illustrate how a sound supervision infrastructure might best be developed. The SOS model provides a systematic approach to indicate the organizational conditions under which CBT supervision might flourish.

Internationally, clinical supervision has been increasingly recognized as a core competency and an essential requirement for clinical training. Over the past 10 years, frameworks for supervision competencies have been developed and promulgated in several countries, notably the UK, USA and Australia. But what is the current status of the actual practice of CBT supervision in the UK? We conducted an internet survey with a purposive sample of n=110 accredited British Association for Behavioural and Cognitive Psychotherapy (BABCP) supervisors and trainers (a 44% response rate), selected for their assumed expertise. The results were consistent with past surveys of Townend et al., indicating that the most frequently reported supervision methods tended to reflect many of the recommendations in widely disseminated supervision competency frameworks and recognized best practice statements. Overall, these CBT supervision leaders reported using an impressively wide range of methods, including much more frequent use of role-play, therapy recordings, and direct observation than reported in the Townend et al. surveys or in observational studies. Although satisfied in their supervisory role, respondents indicated the need for improved CBT supervisor training resources, with significant interest in developing competence instruments and group supervision methods. In conclusion, at least for this small sample of CBT supervision leaders in the UK, practice reflects international progress, but training resources are sought to maintain momentum.