Research shows high levels of complex co-morbidities within psychiatric populations, and there is an increasing need for mental health practitioners to be able to draw on evidence-based psychological interventions, such as cognitive behavioural therapy (CBT), to work with this population effectively. One way CBT may be utilised when working with complexity or co-morbidity is to target treatment at a particular aspect of an individual’s presentation. This study uses a single-case A-B design to illustrate an example of using targeted diagnosis-specific CBT to address symptoms of a specific phobia of stairs in the context of a long-standing co-morbid diagnosis of schizophrenia. Results show the intervention to have been effective, with a change from a severe to mild phobia by the end of intervention. Clinical implications, limitations and areas for future research are discussed.

Cultural factors are influential in the prevalence, diagnosis and treatment efficacy of mental health conditions. Although the literature has advanced substantially towards the development of cultural adaptations of cognitive behavioural therapy (CBT) for various minority cultural groups, research into cultural adaptations of CBT for the Orthodox Jewish community has been scarce. This qualitative study interviewed five CBT therapists about their experiences working with clients from the London Orthodox Jewish community and uncovered several key practical implications for the clinical practice of CBT with this client group. This study indicates that CBT is a culturally appropriate psychological treatment for this client group that accords with Orthodox Jewish teachings and religious beliefs. CBT therapists are encouraged to become familiar with Orthodox Jewish cultural practices and beliefs and adopt a culturally sensitive approach to treatment. Despite the reduced mental health stigma within the community, this study recommends that CBT therapists normalise mental health conditions and therapy with Orthodox Jewish clients. Due to the close-knit nature of the community, it is suggested that CBT therapists display heightened confidentiality with this client group. To overcome the mistrust of their Orthodox Jewish clients, CBT therapists are advised to display cultural sensitivity and genuine respect for the Orthodox Jewish way of life, in addition to building a strong therapeutic alliance. Further qualitative research exploring different perspectives is necessary to produce evidence-based guidelines for the cultural adaptation of CBT for the Orthodox Jewish community.

In a previous feasibility trial, we found that transdiagnostic cognitive behavioural therapy (T-CBT) showed promising results in improving emotional disorders in adults from Saudi Arabia. The primary aim of this study was to replicate these findings and compare T-CBT results with results for counselling sessions. The overall sample consisted of 276 patients (175 in the T-CBT group and 101 in the counselling group). Of the overall sample, 110 patients (39.9%) completed the treatment plan, and 166 (60.1%) disengaged from treatment. The pre- and post-assessments of the clients who completed the treatment showed large effect sizes for almost all outcome measures for both the T-CBT and counselling groups. For patients who decided to disengage from therapy, T-CBT had medium effect sizes for all three measures (depression, anxiety and function), while counselling sessions had medium effect size for the anxiety measure only. This study provides additional evidence that T-CBT is suitable for patients from Saudi Arabia with emotional disorders. The study also provides information regarding when and why T-CBT or counselling was applied in a real clinical setting. Implications and recommendations are discussed.

Worry is a common symptom that can become excessive and is related to several negative health outcomes. Our research group recently developed an online treatment for teenagers with excessive worry with a parallel programme for their parents. The treatment is characterized by a specific focus on exposure to uncertainty and other avoided stimuli, and includes a substantial amount of parental involvement. The aim of this study was to explore how teenagers and their parents experienced the treatment, especially how they perceived working independently with exposure tasks, parental involvement in the treatment programme, and a fixed treatment format. An experienced, independent clinical psychologist interviewed eight teenagers and nine parents in total. The verbatim transcripts were analysed with thematic analysis and two main themes emerged: ‘Seeing the worry in a new light’ and ‘Changing within a set format’, which both consisted of three subthemes. Based on the analysis, we concluded that teenagers can work actively with exposure and experience it as helpful even though it can be difficult and strange at first, and that parental involvement can be perceived as beneficial by both teenagers and their parents. While the online format placed a substantial responsibility on the families, and some would have wanted additional therapist support, working independently with one’s difficulties was acceptable.

Therapist beliefs have been identified as a contributing factor to ‘therapist drift’ in cognitive behavioural therapy (CBT). Scales have been developed to measure therapist beliefs, but none explicitly measure ‘therapy-interfering cognitions’, and there is no research on their usage. The aim of this study was to explore how best to conceptualise such a scale’s content and usage, based on clinicians’ perceptions and experiences of current scales. Three focus groups were conducted, involving 12 participants who were either qualified or trainee CBT therapists. Transcripts were analysed using thematic analysis. Four main themes were generated: (1) The Awareness and Importance of Cognitions, (2) Factors Fuelling Therapist Cognitions, (3) Addressing Therapist Cognitions, and (4) Using the Scale. Participants thought it important to be aware of and address therapist cognitions (not underlying beliefs). Participants emphasised that therapist cognitions are not just products of the individual, but are influenced by external factors. A scale could enable therapists to do better work through reflective practice, as long as it was used not just to identify cognitions but also to support changes in therapist behaviour. A scale could also meet a perceived need for making this part of routine practice. However, participants discussed how therapists might have reservations about disclosing cognitions in this way. Recommendations for current practice, and future research developing such a scale, are made.

Moral injury is the profound psychological distress that can arise following participating in, or witnessing, events that transgress an individual’s morals and include harming, betraying, or failure to help others, or being subjected to such events, e.g. being betrayed by leaders. It has been primarily researched in the military, but it also found in other professionals such as healthcare workers coping with the COVID-19 pandemic and civilians following a wide range of traumas. In this article, we describe how to use cognitive therapy for post-traumatic stress disorder (CT-PTSD) to treat patients presenting with moral injury-related PTSD. We outline the key techniques involved in CT-PTSD and describe their application to treating patients with moral injury-related PTSD. A case study of a healthcare worker is presented to illustrate the treatment interventions.

Many parents of children with anxiety tend to engage in varying levels of family accommodation (FA) in order to alleviate anxiety symptoms. This can exacerbate anxiety symptoms and have adverse effects for psychological treatments. A small number of general and specific interventions have been developed for FA but treatment research is at a nascent stage. Acceptance and commitment therapy (ACT) may be an effective treatment for FA. This article reviews the potential advantages and uses of ACT and how ACT’s six core processes can help target particular features of FA. The theoretical support for ACT is reviewed relevant to FA. The article concludes by conjecturing how ACT may be a useful and adaptive treatment in targeting FA.

Despite the understanding that unaccompanied minors’ (UAM) experience high rates of post-traumatic stress, the provision of evidence-based trauma-focused therapies is low for this population. Narrative exposure therapy (NET) is an effective short-term intervention for treating post-traumatic stress disorder (PTSD) after multiple traumatic experiences, such as those experienced by UAM. Within the existing literature, there is a lack of research investigating unaccompanied minors’ experiences of NET or any trauma-focused therapy. Participants were four UAM experiencing PTSD who formed part of a pilot delivery of NET within a dedicated child and adolescent mental health service for refugee children. Semi-structured interviews were conducted and transcripts were analysed using interpretative phenomenological analysis (IPA). This project identified five themes that encapsulated unaccompanied minors’ experiences of receiving NET, including the process of preparing for this therapy, what it was like to receive it, and the differences they identified at the end of treatment. The significance of this taking place within a safe therapeutic relationship was explored within the context of the attachment losses experienced by UAM, and the impact this has on emotion regulation was considered. The potential of a reduction in PTSD symptoms facilitating a positive spiral in adolescence was reflected on within this paper.

Individuals with subthreshold borderline personality disorder (BPD) are commonly encountered in primary care settings, yet the psychological treatments they receive are rarely tailored to their needs. In an effort to capture and treat this group of individuals in a targeted and meaningful way, some primary care settings offer Systems Training for Emotional Predictability and Problem Solving – Emotional Intensity (STEPPS-EI). This evaluation sought to assess the feasibility of STEPPS-EI within NHS primary care services. Employing an uncontrolled design, the evaluation examined recruitment, retention, effectiveness and group appraisal. Findings supported three out of four evaluation objectives for feasibility: uptake of the group was high at 74%, the group was well received by the group and significantly effective at reducing symptoms of BPD, depression and anxiety. However, retention rates were low, with only 43% classed as ‘completers’ of the programme. The results indicate preliminary evidence for STEPPS-EI as a potentially feasible intervention with possible modification to enhance retention and avenues for further study.

Treatment recommendations for mental health are often founded on diagnosis-specific models; however, there are high rates of co-morbidity of mental health presentations and growing recognition of the presence of ‘transdiagnostic processes’ (cognitive, emotional or behavioural features) seen across a range of mental health presentations. This model proposes a novel conceptualisation of how transdiagnostic behaviours may maintain co-morbid mental health presentations by acting as a trigger event for the cognitive biases specific to each presentation. Drawing on existing evidence, psychological theory and the author’s clinical experience, the model organises complex presentations in a theory-driven yet accessible manner for use in clinical practice. The model offers both theoretical and clinical implications for the treatment of mental health presentations using cognitive behavioural approaches, positing that transdiagnostic behaviours be the primary treatment target in co-morbid presentations.

Worry is common among individuals with psychosis and has been found to be a causal factor in the development of paranoia. Previous research has shown that a cognitive behavioural therapy protocol targeting worry helps to reduce persecutory delusions and associated distress in a population experiencing longstanding psychotic symptoms. However, there has yet to be a published adaptation of the protocol for individuals experiencing a recent onset of psychosis. The current study aims to examine the feasibility of adapting the worry intervention for recent onset psychosis in a group setting. Six young adults with a recent onset of psychosis, aged 18–32 years, participated in a pilot study of an 8-week group intervention covering cognitive behavioural strategies for managing worry, including worry periods, worry postponement techniques, mindfulness and relaxation, and problem solving. Pre- and post-intervention data were collected on worry, anxiety, depressive symptoms, psychotic symptoms, and perceived recovery from psychosis. In addition, qualitative feedback from group members was gathered during a post-intervention focus group. Feasibility of the group appeared promising, despite high participant attrition. All components of the intervention were successfully implemented, and group members provided positive feedback regarding acceptability of the group. Contrary to prediction, there was not a consistent decrease in worry from pre- to post-intervention. Findings from secondary symptom measures were mixed and may have been related to participants’ subjective experience of the group. Specifically, participants who experienced high levels of group cohesion seemed to benefit more from the intervention.

Rumination has been shown to play a part in post-traumatic stress disorder (PTSD), but its relation to the intrusions characteristic of PTSD has mainly been investigated experimentally. This proof-of-concept case study explored the occurrence, personal experiences, and possible relation between rumination and intrusions in two PTSD patients in their daily living using a mixed method approach. A novel wearable self-tracking instrument was employed which provided fine-grained temporal resolution of observation data and could eliminate recall bias. Furthermore, quantitative and qualitative data were collected on participants’ symptoms, rumination and experiences of using the self-tracking instrument. First, without distinguishing between the two phenomena, the participants tracked both for a week. After receiving psychoeducational training for distinguishing between rumination and intrusions, the differentiated phenomena were tracked for a week. Both participants reported being subjectively able to distinguish between rumination and intrusions and made observations with high adherence during the project. Data hinted at a possible temporal relation between the phenomena in line with theories posing rumination as a maladaptive coping strategy as well as an exacerbator of PTSD symptoms. However, relations to mood were inconclusive. Furthermore, by using the self-tracking instrument, participants gained a heightened awareness of the characteristics of rumination and intrusions and contextual cues for occurrence, as well as a greater sense of momentary agency. Results reveal promising prospects in using the wearable self-tracking instrument for further investigation of the relation between rumination and intrusions in the lived lives of PTSD patients, as well as potential for incorporating this method in clinical treatment.

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

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.

Limited research has directly addressed the challenges of higher education for students with autism, who face additional difficulties in navigating social, personal and academic obstacles. With more students experiencing mental health difficulties whilst at university, therapeutic interventions on offer need to be suitable for those accessing support. Cognitive behavioural therapy (CBT) is widely used to support university students, as it is firmly established as an effective treatment for a range of issues, including social and generalised anxiety in typically developing populations (NICE, 2013; NICE, 2019). However, the efficacy of CBT for individuals with autistic spectrum condition (ASC) is less well known, despite the high prevalence rates of anxiety in this population. This paper seeks to address a gap in the literature and uses a single-case (A-B) experimental design over 16 sessions to reduce co-morbid social and generalised anxiety in a university student with high-functioning ASC. Clark’s (2001) cognitive model of social anxiety and Wells’ (1997) cognitive model of generalised anxiety were employed to formulate anxiety experienced in this case. Standardised outcome measures were used for social anxiety, i.e. the Social Phobia Inventory (SPIN), and generalised anxiety, i.e. the Generalised Anxiety Disorder-7 (GAD-7), in conjunction with idiographic ratings to assess the impact of therapy. Findings indicate that CBT was an acceptable and useful intervention with mixed results; discrepancies were found between clinical change recorded on standardised measures compared with idiographic ratings. This paper discusses the use of standardised measures of anxiety for individuals with ASC and identifies directions for further research.

Nearly half of patients with non-cardiac chest pain (NCCP) experience significant complaints after a negative cardiac evaluation, at considerable costs for society. Due to the lack of treatment capacity and low interest for psychological treatment among patients with somatic complaints, only a minority receive effective treatment. The aim of this study was to assess the feasibility and usefulness of internet-assisted cognitive behavioural therapy (I-CBT), including encouragement of physical activity for this condition. Ten patients with NCCP received a six-session I-CBT intervention with minimal support from a therapist. Questionnaires assessing cardiac anxiety, fear of bodily sensations, depression, interpretation of symptoms, frequency of chest pain and impact of chest pain symptoms were collected at baseline, post-treatment and at 3-month follow-up. Semi-structured interviews employing a phenomenological hermeneutic approach assessed the participants’ experience of the intervention. Quantitative results showed clear improvements in several measures both at end of treatment and at 3-month follow-up. The retention rate was 100% and client satisfaction was high. The intervention was feasible to implement in a cardiac setting. This setting made it easier for patients to accept a psychological approach. Qualitative interviews revealed that the participants felt respected and taken care of, and they obtained a better understanding of their chest pain and how to cope with it. This pilot study yielded promising results regarding feasibility, clinical effect and patient satisfaction from a brief I-CBT intervention for NCCP in a cardiac setting. These results indicate that a randomized controlled trial with a larger sample size is warranted.

For more than a decade, Improving Access to Psychological Therapies (IAPT) has been training a new workforce of psychological therapists. Despite evidence of stress and burnout both in trainee mental health professionals, and qualified IAPT clinicians, little is known about these topics in IAPT trainees. Consequently, this systematic review sought to establish the current state of the literature regarding stress and burnout in IAPT trainees. Electronic databases were searched to identify all published and available unpublished work relating to the topic. On the basis of pre-established eligibility criteria, eight studies (including six unpublished doctoral theses) were identified and assessed for quality. This review identifies that research into the experience of IAPT trainees is under-developed. Existing evidence tentatively suggests that IAPT trainees may experience levels of stress and burnout that are higher than their qualified peers and among the higher end of healthcare professionals more generally. The experience of fulfilling dual roles as mental health professionals and university students concurrently appears to be a significant source of stress for IAPT trainees. More research regarding the levels and sources of stress and burnout in IAPT trainees is urgently needed to confirm and extend these findings. Recommendations for future research in the area are given.