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.

Cognitive behavioural therapy (CBT) is an evidence-based psychotherapy and one of the most widely used treatments for mental health problems. It is generally acknowledged that supervision improves the quality of treatment although systematic descriptions and empirical evaluation of supervision have been sparse. Moreover, there are relatively few valid and reliable instruments to evaluate supervision. Based on a comprehensive review of the supervision literature, six competency domains were identified to cover the scope of CBT supervision: Theory, Focus, Learning strategy, Techniques, Structure, and Interpersonal style. The Moeller, Moerch, Rosenberg Supervision Scale (MMRSS) was developed to evaluate supervisor performance within each of these domains after observation of supervision. The present study examined the psychometric properties of the MMRSS (inter-rater reliability and construct validity), the clinical utility, and satisfaction when using MMRSS to evaluate CBT supervision. CBT supervisors (n = 8) were recruited for the study and provided videos of group supervision. A total of 21 videos were rated using the MMRSS and the Supervisory Competency Scale (SCS) by two independent raters. Supervisees and supervisors completed a satisfaction questionnaire to capture their experience of using the MMRSS during supervision of supervision. The MMRSS showed acceptable internal consistency and validity. Several domains in MMRSS (Structure, Learning strategy, and Interpersonal style) correlated significantly with the corresponding domains in the SCS for cognitive supervision. Preliminary results indicate that the MMRSS may be a valid and clinically useful tool to evaluate CBT supervision, although further systematic evaluation is needed.

Compared with the traditional face-to-face format, therapist-guided internet interventions offer a different approach to supporting clients in learning skills to manage and overcome mental health difficulties. Such interventions are already in use within IAPT (Improving Access to Psychological Therapies) and other routine care settings, but given their potential to deliver treatment more efficiently and therefore increase availability and access to evidence-based interventions, their use is likely to increase significantly over the coming years. This article outlines what is meant by therapist-guided internet interventions and why an online format is thought to be advantageous for clients, therapists, services, and communities more broadly. It reviews the current evidence in the context of common therapist beliefs about internet-based treatment. It aims to identify gaps where further research is required, particularly in relation to the broader implementation of these treatments in IAPT and other routine clinical services. Specifically, it emphasises the importance of choosing the right programmes, providing adequate therapist training in their use, and considering practical and organisational issues, all of which are likely to determine the success of implementation efforts.

Behavioural experiments (BEs) are a major cognitive ingredient in the cognitive behavioural therapy (CBT) model which can be applied in-session or between-sessions. In-session BEs are particularly effective and widely demonstrated in anxiety disorders, yet they remain under-utilised in depression. Clients presenting with persistent depression are often difficult to engage due to the chronicity of their symptoms and their learnt self-perpetuating demoralised states. Research to date demonstrates the effectiveness of in-session BEs in engagement and treatment in depression. This case study details the treatment of a client presenting with persistent major depressive disorder (MDD) with hopelessness and how in-session BEs effected engagement and treatment. This case study is discussed with reference to strengths, limitations, clinical implications and recommendations for practice and development.

Cognitive behavioural therapy (CBT) is generally defined as a short-term, problem-oriented psychotherapy that focuses on modifying dysfunctional emotions, thoughts and actions. In clinical practice, CBT consists of a number of cognitive and behavioural techniques that aim to help patients suffering from psychological disorders. The practice of CBT is well established in Western countries. In non-Western countries, CBT is still in the process of being established as the evidence-based psychotherapy. Despite being the heart of the Arab world, the development and practice of psychotherapy in Egypt in general, and CBT specifically, is still emerging. The training and practice of CBT has received a mixed response in Egypt. In practical settings, evidence-based CBT is subject to individual and cultural variations and adaptations. Many local studies examining the efficacy of CBT in psychiatric disorders among different population groups in Egypt have been conducted. Unfortunately, many of these studies have not been published and therefore have missed the opportunity for international recognition. The current review aims to explore the practice of CBT with a specific focus on national research of efficacy and adaptability of CBT for different populations in Egypt.

In this paper, rational emotive behaviour therapy (REBT) is presented as the most comprehensive cognitive behavioural therapy (CBT) to date, with over-arching influence on most of the other therapies that came after it. However, despite REBT’s comprehensiveness and the limitations inherent in other CBT approaches, REBT has its limitations. Limitations in REBT theory are explored and an argument is made in favour of rectifying these limitations by incorporating other approaches into REBT (namely cognitive therapy and compassion-focused therapy) to create a more complete integrative psychotherapy model. It is then argued that psychotherapy integration is the future of CBT mainly due to the fact that it reflects how most therapists practise, and due to its utilization of the common factors theory. Finally, the integrative model – which I call Assimilative Integrative Rational Emotive Behaviour Therapy – is presented and demonstrated using a clinical case example.

In the UK there has been a drive towards facilitating swift access to psychological therapies. Groups are an efficient way to provide psychological interventions to a wide range of people and are recommended treatments for mild depression and anxiety, presentations commonly seen in primary care mental health teams. Group cognitive behavioural therapy (CBT) has been shown to be clinically effective, but less is known about the acceptability of groups to patients. This study evaluated patient satisfaction with CBT groups running within a primary care mental health team in Scotland. Data from a routinely administered patient satisfaction questionnaire were collected. Likert-scale responses were analysed via frequencies and percentages, and free text responses were analysed via thematic analysis. Among those who completed a group, overall satisfaction was high. The qualitative analysis revealed that for many a group environment was therapeutic in itself, and the intervention provided service users with a range of skills with which to tackle their difficulties. However, others indicated that a group environment was unsuitable for their needs, and perceptions around the accessibility and relevance of group content were mixed. Indeed, drop-out rates were high, and perceptions of groups among those who did not attend the final session are not included in this analysis. Group dynamics may be both a facilitator of and a barrier to therapeutic benefit, depending on individual factors. Future studies could evaluate satisfaction among service users who drop out of interventions in order to inform future service delivery.

Multi-morbidity, having more than two diagnosed health conditions, is becoming increasingly common within healthcare services. Approximately one third of these patients are likely to have a mental health condition. Those with multi-morbidity with physical and mental health conditions have poorer outcomes in terms of their health, increased mortality rates, and higher usage of healthcare services.

This paper presents a case of a patient with multi-morbidity, with associated mental health conditions of anxiety and depression. She was seen as part of an integrated service which provides psychological support at home alongside the nursing team. The intervention used was based on transdiagnostic cognitive behavioural therapy (tCBT), provided over nine initial sessions and two additional booster sessions. Self-report measures were completed at intervals throughout the intervention and at follow-up. Improvements on the depression and anxiety measures were seen over the initial nine sessions, followed by a relapse at the 3-month follow-up. This was the result of a deterioration in physical health which led to a deterioration in mental health. The booster sessions mitigated further deterioration in mental health, despite the physical health worsening during this time.

This case suggests that tCBT can be helpful in reducing anxiety and depression in people with multi-morbidity. However, additional booster sessions may be required as further physical deterioration can re-trigger core beliefs and result in further mental health problems.

Exposure therapy is consistently indicated as the first-line treatment for anxiety-related disorders. Unfortunately, therapists often deliver exposure therapy in an overly cautious, less effective manner, characterized by using their own ‘therapist safety behaviours’. Cognitive behavioural models postulate that beliefs about therapist safety behaviours are related to their use; however, little is known about the beliefs therapists hold regarding therapist safety behaviour use. The present study aimed to identify the beliefs exposure therapists have regarding the necessity of therapist safety behaviours and to examine the relationship between this construct and therapist safety behaviour use. Australian psychologists (n = 98) completed an online survey that included existing measures of therapist safety behaviour use, therapist negative beliefs about exposure therapy, likelihood to exclude anxious clients from exposure therapy, and use of intensifying exposure techniques. Participants also completed the Exposure Implementation Beliefs Scale (EIBS), a measure created for the present study which assesses beliefs regarding the necessity of therapist safety behaviours. Beliefs about the necessity of therapist safety behaviours – particularly in protecting the client – significantly predicted therapist safety behaviour use. Findings suggest that exposure therapy training media should aim to decrease therapist safety behaviour use by addressing beliefs about the necessity of therapist safety behaviours, especially in protecting the client.

In slow-open groups as well as therapies of less than ten sessions, each group session holds importance. Patients, therapists and co-therapists have different perspectives and may gain different experiences from a group session. This study investigates the perspectives of patients, therapists and co-therapists on alliance, new insights and therapist techniques in the same group session. Do the three actors perceive these group aspects similarly or differently? Which group aspects are related with the outcome coping? One hundred and forty-nine sessions of a cognitive behaviour therapy group have been investigated. Patients, therapists and co-therapists gave ratings on their perceived alliance, group topics and insights as well as therapists’ technique competency. Concerning new insights, there was concordance between patients and co-therapists (r = .211, p < .05). Concerning alliance, there was a concordance between patients and therapists (r = .327, p < .01). Therapists focusing on alliance building was associated with lower patient outcomes in terms of work coping (β = –.391). The quality of therapeutic techniques was the same in groups with higher and lower outcomes. Patients’ perception of whether they felt good in the group session was explanative for session outcome, while therapists’ perceptions and context conditions (supervision, number of participants) was not. Patients, therapists and co-therapists have different perspectives on the same group therapy session. Patients’ perceptions are associated with session outcomes. A lower session outcome must not be associated with a poor technique performance of the therapist. Therapists should not only be aware of alliance building and correct technical performance, but they must also be aware of patients’ perceptions of the group process and outcome.

The Coronavirus (Covid-19) pandemic is exerting unprecedented pressure on NHS Health and Social Care provisions, with frontline staff, such as those of critical care units, encountering vast practical and emotional challenges on a daily basis. Although staff are being supported through organisational provisions, facilitated by those in leadership roles, the emergence of mental health difficulties or the exacerbation of existing ones amongst these members of staff is a cause for concern. Acknowledging this, academics and healthcare professionals alike are calling for psychological support for frontline staff, which not only addresses distress during the initial phases of the outbreak but also over the months, if not years, that follow. Fortunately, mental health services and psychology professional bodies across the United Kingdom have issued guidance to meet these needs. An attempt has been made to translate these sets of guidance into clinical provisions via the recently established Homerton Covid Psychological Support (HCPS) pathway delivered by Talk Changes (Hackney & City IAPT). This article describes the phased, stepped-care and evidence-based approach that has been adopted by the service to support local frontline NHS staff. We wish to share our service design and pathway of care with other Improving Access to Psychological Therapies (IAPT) services who may also seek to support hospital frontline staff within their associated NHS Trusts and in doing so, lay the foundations of a coordinated response.

Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioural therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD, and describe their application to treating patients with PTSD following ICU.

In the past few weeks, coronavirus disease 2019 (COVID-19) has dramatically expanded across the world. To limit the spread of COVID-19 and its negative consequences, many countries have applied strict social distancing rules. In this dramatic situation, people with eating disorders are at risk of their disorder becoming more severe or relapsing. The risk comes from multiple sources including fears of infection and the effects of social isolation, as well as the limited availability of adequate psychological and psychiatric treatments. A potential practical solution to address some of these problems is to deliver enhanced cognitive behaviour therapy (CBT-E), an evidence-based treatment for all eating disorders, remotely. In this guidance we address three main topics. First, we suggest that CBT-E is suitable for remote delivery and we consider the challenges and advantages of delivering it in this way. Second, we discuss new problems that patients with eating disorders may face in this period. We also highlight potential opportunities for adapting some aspects of CBT-E to address them. Finally, we provide guidelines about how to adapt the various stages, strategies and procedures of CBT-E for teletherapy use in the particular circumstances of COVID-19.

Group cognitive behavioural therapy (gCBT) is commonly used in Increasing Access to Psychological Therapies (IAPT) services. However, there is limited knowledge of the efficacy of gCBT as a delivery format for generalised anxiety disorder (GAD). To address gaps in literature, this study aims to explore the efficacy and attrition of individual and group CBT interventions, respectively, at Step 3 for GAD using data from a routine IAPT service over a 24-month period. Data were retrospectively derived from a routine serviceʼs IAPTus database, separating those eligible for comparison into group (n = 44) and individual (n = 55) CBT for GAD. Outcomes were differences in pre–post self-reported anxiety (GAD-7) and depression (PHQ-9) scores, clinical recovery and attrition for gCBT and individual CBT. Both gCBT and individual CBT yielded significant reductions in self-reported anxiety and depression scores over time. Results indicate that 53% of patients attending individual CBT achieved clinical recovery, with similar but less competitive rates of 41% in gCBT. Attrition rates were similar between gCBT (29.5%) and individual CBT (27.3%), respectively. Preliminary results suggest that both individual and gCBT are effective interventions for GAD patients in IAPT, offering symptom alleviation and comparable recovery and attrition rates post-intervention. This observational design offers credibility and insight into a pragmatic evaluative and explorative comparison. gCBT may offer an acceptable and potentially economical alternative.

Treatment outcomes across Improving Access to Psychological Therapies (IAPT) services in England have improved year-on-year, with the national average proportion of patients in recovery at the end of treatment now exceeding the 50% target. This is despite the number of referrals and numbers of treated patients also increasing year-on-year, suggesting that services have evolved local practices and treatment delivery to meet needs whilst improving performance. This study explores whether there have been changes in clinical practice with regard to: (1) the number of sessions and length of treatments; (2) the number of cancellations and non-attendance; and (3) the recording of problem descriptor information, and the association with treatment outcomes in IAPT. Routinely collected data from seven IAPT services involved in the North and Central East London (NCEL) IAPT Service Improvement and Research Network (SIRN) were brought together to form a dataset of nearly 88,000 patients who completed a course of IAPT treatment. Results showed that there was a slight increase in the average number of sessions, and decreases in the length of time in treatment, as well as decreases in both the number of non-attended appointments and the use of inappropriate problem descriptors. These findings highlight a number of areas where potentially small changes to clinical practice may have had positive effects on patient outcomes. The value of using IAPT data to inform service improvement evaluations is discussed.

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.

NHS Education for Scotland (NES) plays a lead role in training the NHS Psychological Therapies workforce across Scotland. Ferguson et al. (2016) outlined the challenges, opportunities and proposed evaluation of the NES Specialist Supervision Training in Cognitive Behavioural Therapy (NESSST-CBT). The aims of the training were to provide an evidence-based, flexible and learner-focused training in CBT specific supervision competencies. This paper will provide an update on the evaluation of the training using Kirkpatrick’s Impact Evaluation Model (1967, 1987). Results indicate that: (1) delegates rated the training experience positively in various ways; (2) delegates described increases in their confidence and competence in using structured measures of CBT and supervision; (3) a majority of delegates completing a 3-month follow-up questionnaire described continued use of a structured CBT measure in supervision and for self-reflection; and (4) 392 psychological therapists in Scotland have now been formally trained in CBT specific supervision skills. NESSST-CBT continues to adapt and improve as a resource for staff as NES moves forward in its Digital Strategy for Scotland’s NHS and partnership staff. Further implications of this are discussed, as well as limitations of the study.

The recent COVID-19 pandemic has triggered a surge in anxiety across the globe. Much of the public’s behavioural and emotional response to the virus can be understood through the framework of terror management theory, which proposes that fear of death drives much of human behaviour. In the context of the current pandemic, death anxiety, a recently proposed transdiagnostic construct, appears especially relevant. Fear of death has recently been shown to predict not only anxiety related to COVID-19, but also to play a causal role in various mental health conditions. Given this, it is argued that treatment programmes in mental health may need to broaden their focus to directly target the dread of death. Notably, cognitive behavioural therapy (CBT) has been shown to produce significant reductions in death anxiety. As such, it is possible that complementing current treatments with specific CBT techniques addressing fears of death may ensure enhanced long-term symptom reduction. Further research is essential in order to examine whether treating death anxiety will indeed improve long-term outcomes, and prevent the emergence of future disorders in vulnerable populations.

Problems most frequently reported by young people in school counselling relate to family difficulties. During adolescence, conflict between parents and young people increases as young people move towards independence whilst still being reliant on parents. The quality of communication during this period has implications for young people’s well-being. The current study explored how the principles of perceptual control theory (PCT) could be used to develop a structured activity aimed at helping young people to talk to their parents about their goals and goal conflicts.

PCT proposes that individuals function well when they are able to control things that are important to them. Every individual has numerous goals/wants and if two or more are incompatible, conflict arises. The current study focused on supporting young people to explore conflict that might arise due to incompatible goals held by them and their parent. Six families (child and parent/carer) were recruited to try a goal-setting and monitoring activity. The activity was facilitated by a Method of Levels researcher over a 10-week period. There were two follow-up appointments at 2 and 4 months. Two families were retained for the entire study. On completion, four families provided qualitative feedback. On the basis of participants’ feedback, the activity was modified to incorporate discussions on incompatible goals. Two families piloted the modified activity and provided feedback. Both families completed the study. Results suggest that a parent–child activity using the principles of PCT is feasible and acceptable among parents and young people.