Action-based methods such as behavioural experiments, role-play and (by extension) ‘chairwork’ are powerful techniques recommended in core supervisory texts for cognitive behavioural therapy (CBT). Despite this, experiential methods are seldom used by supervisors, suggesting that supervision often drifts from a ‘doing process’ to a ‘talking process’. A number of factors contribute to this divergence from best practice, including limited confidence and a lack of familiarity with experiential procedures amongst supervisors. To address this, the current paper presents a variety of action-based techniques for enhancing supervisees’ technical, perceptual, interpersonal, reflective and personal competencies. Behavioural experiments, empty-chair, multi-chair and role-playing exercises for maintaining treatment fidelity, enhancing empathic attunement, repairing therapeutic ruptures, resolving impasses and working through negative countertransference are described, amongst others. Further research is needed to establish the nature and extent of supervisory drift, as well as the efficacy of action-based methods.

Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, culture can influence engagement and treatment efficacy of CBT. Several attempts have been made in Asian countries to develop a culturally adapted CBT for depression. However, research in the Indian context documenting the views on cultural influence of CBT is limited. The present study is an attempt to explore the views of patients and therapists in India by following an evidence-based approach that focuses on three areas for adaptation: (1) awareness of relevant cultural issues and preparation for therapy; (2) assessment and engagement; and (3) adjustments in therapy techniques. Semi-structured interviews with three consultant clinical psychologists/therapists, a focused group discussion with six clinical psychologists, and two patients undergoing CBT for depression were conducted. The data were analysed using a thematic framework analysis by identifying emerging themes and categories. The results highlight therapists’ experiences, problems faced, and recommendations in all three areas of adaptation. The findings highlight the need for adaptation with understanding and acknowledging the culture differences and clinical presentation. Culturally sensitive assessment and formulation with minor adaptation in clinical practice was recommended. Therapists emphasised the use of proverbs, local stories and simplified terminologies in therapy. The findings will aid in providing culturally sensitive treatment to patients with depression in India.

I have been asked to describe how Perceptual Control Theory (PCT) and Method of Levels (MOL) came into being, and as I approach the age of 82 that seems a prudent request. Some parts of the following should probably be taken more as a reconstruction than a verifiable record of the past, but I will strive for realism.

This article describes a clinical protocol for supporting those presenting with post-traumatic stress disorder (PTSD) and dissociative symptoms, particularly dissociative flashbacks, based on a cross-culturally applicable model. The protocol is discussed from the perspective of working with a refugee and asylum seeker population, although many of the principles will be applicable to clients from any background presenting with these dissociative symptoms. The protocol addresses the assessment and formulation of a client’s dissociative symptoms. It includes guidance on sharing psycho-education with clients regarding the evolutionary function of dissociation and developing practical strategies to monitor and manage dissociative symptoms. The strengths and limitations of this protocol are also discussed.

Dismantling studies are used in psychotherapy in order to understand the important components of treatment. Typically, this has occurred so that people could understand the unique contributions provided by cognitive versus behavioural techniques. Recently, mindfulness-based approaches have apparently added a third dimension to the dismantling enterprise. Dismantling is seen as an important way of understanding the change process in psychotherapy and, therefore, clarifying how we might most effectively promote change. The way in which an entity is dismantled, however, exposes assumptions about the nature of the entity and its organization. In this paper we argue that dismantling studies in psychotherapy have perhaps generated more confusion than consensus and have provided little practical benefit for clinicians. We suggest that the phenomenon of control might provide a unifying perspective from which to approach the integration of behavioural, cognitive, and mindfulness approaches. In one sense all these seemingly different approaches are doing the same thing and it is this ‘thing’ we highlight in this paper.

Can a cognitive behavioural approach offer a fresh understanding of the maintaining processes in burnout? This paper considers the enduring nature of burnout symptoms over time. It examines the hypothesis that some of the actions associated with ‘coping’ in burnout may conversely serve to perpetuate burnout symptoms. This model is considered in the context of mental-health workers and is discussed in the light of current research. It implies the need to adopt an approach to burnout that incorporates the challenging of burnout-related cognitions and the elimination of safety behaviours, rather than having a sole focus on self-care strategies.

Although cognitive behavioural therapy (CBT) is recommended for the treatment of a number of mental disorders among the general population, the ability of individuals with learning disabilities (LD) to understand CBT concepts and engage in CBT has been questioned. Aims: To examine whether specific prerequisite skills for CBT can be taught to people with LD using a newly developed training intervention and to investigate the acceptability of the intervention. Method: The study adopted a within-subjects case series research design. Quantitative assessment methods were used to evaluate the CBT skills of six adults with mild to moderate LD pre-intervention, following intervention and at 1-week follow-up. Participants were also asked to provide some qualitative feedback about how they had experienced the intervention. Results: The cognitive mediation skills and the ability of most participants to link activating events to emotions increased following intervention training and this improvement was maintained for four of them at follow-up. The feedback of participants regarding the process and content of the task demands was positive. Conclusions: The findings suggest that people with LD can learn some of the skills considered necessary to participate in CBT, such as cognitive mediation. However, further and more robust research is required to substantiate these findings.

The Method of Levels (MOL) shares many similarities with other therapeutic approaches and is perhaps most distinguishable by what it does not include rather than what it does use in sessions. MOL has two basic steps which are followed in an iterative procedure until the patient/client experiences a change or shift in their understanding and experience of a problem. This article explains the steps and uses examples and suggestions for practice to promote understanding.

Brief cognitive behavioural therapy (CBT) is effective in working with non-underweight eating disorder patients across transdiagnostic groups. However, it is not clear whether it will be as effective in the treatment of binge-eating disorder, where emotional eating is likely to play a larger role than starvation-driven eating. This case series tested whether brief, 10-session CBT (CBT-T) would be effective in a case series of 53 patients with binge-eating disorder. Attrition rates were comparable to previous research. Eating attitudes, binge frequency, anxiety and depression were measured. Remission was measured comparing different categorical methods: ‘cut-off’; reliable change index (RCI); and clinically significant change (CSC). CBT-T was effective for binge-eating disorder patients, at comparable levels to other non-underweight patients. All measures of pathology were significantly reduced, with large to moderate effect sizes. When categorical changes were used to indicate remission, RCI and CSC levels were more appropriate than existing cut-off methods, potentially because of the lower levels of initial restrained eating in this clinical group. CBT-T’s effectiveness in transdiagnostic groups is replicated in binge-eating disorder patients, despite their greater level of emotionally driven eating. More stringent definitions of remission (CSC and RCI) should be used more widely, to ensure realistic estimates.

The construct of cognitive errors is clinically relevant for cognitive therapy of mood disorders. Beck's universality hypothesis postulates the relevance of negative cognitions in all subtypes of mood disorders, as well as positive cognitions for manic states. This hypothesis has rarely been empirically addressed for patients presenting bipolar affective disorder (BD). In-patients (n = 30) presenting with BD were interviewed, as were 30 participants of a matched control group. Valid and reliable observer-rater methodology for cognitive errors was applied to the session transcripts. Overall, patients make more cognitive errors than controls. When manic and depressive patients were compared, parts of the universality hypothesis were confirmed. Manic symptoms are related to positive and negative cognitive errors. These results are discussed with regard to the main assumptions of the cognitive model for depression; thus adding an argument for extending it to the BD diagnostic group, taking into consideration specificities in terms of cognitive errors. Clinical implications for cognitive therapy of BD are suggested.

The aim of this pilot study was to test whether a future-oriented expressive writing intervention is able to reduce post-traumatic stress disorder (PTSD) severity and associated symptoms such as depression and unhelpful trauma-related beliefs. In an uncontrolled pre-/ post-design participants attended 8 weeks of manualized therapy. Assessment was undertaken pre- and post-treatment, and participants also completed a 3-month follow-up assessment. Of the 17 participants who began therapy, 13 were treatment completers. Results indicated a significant decrease in PTSD severity, depression and unhelpful trauma-related cognitions from pre- to post-treatment and at 3-month follow-up. Clinically meaningful change was more modest; however, three participants reported PTSD remission at 3-month follow-up. It is concluded that expressive writing with a focus on achieving future goals and personal change may have some utility in reducing post-traumatic stress but future research will need to investigate this with greater methodological rigour before firm conclusions can be made.

The Children and Young People's Improving Access to Psychological Therapies (CYP IAPT) programme emphasizes the meaningful contribution session-by-session routine outcome monitoring (ROM) can make to clinical practice and its importance in highlighting services’ effectiveness. Two studies on issues related to the implementation of ROM in children's services were conducted. Study 1 was qualitative; 12 Child and Adolescent Mental Health Services (CAMHS) professionals participated in focus groups. Themes identified included the idea that ROM could provide objectivity, could be collaborative and empowering. Concerns included how measures may adversely influence therapeutic sessions and how the information may be used by the service. These themes were used to develop a questionnaire about professionals’ experience of and views on session-by-session ROM. In Study 2, 59 professionals from four CAMHS teams completed the questionnaire. It was found that only 6.8% reported ‘almost always’ utilizing session-by-session ROM. Detailed analysis of questionnaire responses suggested two subscales reflecting the perceived negative and positive impact of session-by-session ROM. It was found that clinicians who currently use session-by-session ROM hold stronger positive and negative beliefs than clinicians who do not. This study suggests that session-by-session ROM is not currently routine practice within CAMHS and highlights the importance of considering how this practice can be best implemented within this setting with reference to clinician attitudes.

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.

Far from being a monolithic approach to psychotherapy, cognitive behavioural therapy (CBT) is in fact an umbrella term to describe a family of psychological therapies that share many common features but also have nuanced differences. Of the CBTs, two are often conflated under the ‘CBT’ moniker, namely cognitive therapy (CT) and rational emotive behaviour therapy (REBT). In this article, we explore some of the key differences and similarities between CT and REBT, touching on philosophy, practical implementation, and literature. We provide a brief hypothetical case study to demonstrate the different ways a therapist using CT and REBT might tackle the same client problem. We do not declare either approach superior, but suggest each might have their advantages in certain contexts and acknowledge that skilful practitioners could, and often do, integrate both approaches. As CBT continues to evolve and move into new areas, it is important that psychology practitioners and researchers are clear about which specific approach to CBT they are delivering, measuring and/or reporting on.

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.

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.

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.