Survivor guilt is a common experience following traumatic events in which others have died. However, little research has addressed the phenomenology of survivor guilt, nor has the issue been conceptualised using contemporary psychological models which would help guide clinicians in effective treatment approaches for this distressing problem. This paper summarises the current survivor guilt research literature and psychological models from related areas, such as post-traumatic stress disorder, moral injury and traumatic bereavement. Based on this literature, a preliminary cognitive approach to survivor guilt is proposed. A cognitive conceptualisation is described, and used as a basis to suggest potential treatment interventions for survivor guilt. Both the model and treatment strategies require further detailed study and empirical validation, but provide testable hypotheses to stimulate further research in this area.

NICE Clinical Guideline no. 78 recently identified Dialectical Behaviour Therapy (DBT) as an appropriate treatment approach for the effective treatment of suicidal behaviours in the context of borderline personality disorder. Uniquely among the cognitive behavioural therapies DBT is a team-based treatment. This paper focuses on the task of selecting and training a team before considering issues in the training and supervision of therapists learning this approach.

There is growing evidence that Behavioural Activation is an effective treatment for older adults with depression. However, there is a lack of detail given in studies about any adaptations made to interventions or efforts made to remove treatment barriers. Factors such as co-morbid physical health problems, cognitive impairment and problems with social support suggest there may be specific treatment considerations when developing interventions for this group. This article aims to describe adaptations made to a general adult Behavioural Activation manual using literature on treatment factors for older adults as an organizational framework. This information may be of use to mental health workers delivering behavioural interventions to older adults with depression and documents the initial phase of developing a complex intervention.

The development and conceptual relationship of the constructs of threat appraisal (TA) and intolerance of uncertainty (IU) are explored in the context of anxiety disorders. A narrative review tracking the development of these constructs and their relationship is undertaken. There is some evidence to suggest that the interaction between the components of threat appraisal (probability × cost) may partially account for or provide a theoretical framework which explains presenting levels of anxiety. Furthermore, research suggested that IU is a construct which contributes to a broad range of anxiety disorders. It was concluded that distinctive cognitive biases linked with IU – such as interpreting ambiguous and uncertain (both positive and negative) information as highly concerning – suggests that IU is interpreted negatively independent of threat appraisal. These findings mean a number of issues remain unclear, including whether IU in anxiety-provoking situations is sufficient in itself – independent of threat appraisal – in eliciting high levels of anxiety. Additionally, it is unclear whether threat appraisal and IU act as independent constructs, or more in an interactive manner in anxiety. To achieve further clarity on these issues, methodological recommendations for future research are made.

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.

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

At the very beginning of our lives we have similar needs, but as we get older the ways of maintaining our wellbeing will vary greatly. Quite simply, we get more different and complex as we age! Hence, attempts to both meet older people's needs and treat their psychological difficulties often require comprehensive assessments and biopsychosocial formulations. It is relevant to note that many of the latter formulations are informed by CBT theory, even when dealing with people presenting with dementia and challenging behaviour. Despite the conceptual complexities, there is increasing evidence to suggest that the most effective interventions for this ‘challenging’ population are basic communication strategies. This paper outlines the key principles of effective communication under the heading of Communication and Interaction Therapy (CAIT). The concepts underpinning CAIT are illustrated via a number of case studies of people living in 24-hour care. It will be argued that an implication of this approach is the judicious use of therapeutic lies, but only as a last resort.

Despite the acknowledged importance of clinical supervision, controlled research is minimal and has rarely addressed the measurement or manipulation of clinical supervision, hampering our understanding and application of the different supervision methods. We therefore compared two related approaches to supervision, cognitive-behavioural (CBT) and evidence-based clinical supervision (EBCS), evaluating their relative effectiveness in facilitating the experiential learning of one supervisee. Drawing on a multiple-baseline N = 1 design, we gathered mostly qualitative data by means of an episode analysis, a content analysis, a satisfaction questionnaire, and interviews with the supervisor and supervisee. We found that the EBCS approach was associated with higher supervision fidelity and increased engagement in experiential learning by the supervisee. This case study in the evaluation of supervision illustrates the successful application of some rarely applied qualitative methods and some potential supervision enhancements, which could contribute to the development of CBT supervision.

Increasingly, evidence suggests that computerized Cognitive Behavioural Therapy (cCBT) is effective at reducing adolescent anxiety and depression for young people in the general population or those ‘at risk’. However, less is known about the acceptability, feasibility and effectiveness of cCBT for adolescents with clinically significant levels of impairment. This study aimed to investigate the feasibility of using a novel cCBT intervention, ‘Pesky gNATs’, with adolescents aged between 13–18 years with anxiety and/or depression who met the criteria for specialist mental health services. Eleven participants were recruited from a Tier 3 child and adolescent mental health service (CAMHS). Recruitment, attendance and retention rates were recorded and qualitative feedback about the benefits and disadvantages of completing cCBT were obtained during the final session. In addition, a number of outcome measures were completed pre- and post- intervention to assess reliable and clinically significant change. The intervention was very brief comprising of just seven sessions. Participants showed high recruitment and retention rates. All participants who started the intervention completed it. All described the programme as useful and the majority identified several benefits. Four of 11 participants demonstrated reliable reductions in symptoms of depression and anxiety and six of 11 showed decreases in parent-reported symptoms of anxiety and depression following the seven-session intervention. This study demonstrates the acceptability and feasibility of using cCBT in a Tier 3 CAMHS setting. Further research is required to investigate the effect of Pesky gNATs on anxiety and depression in other Tier 3 settings.

While clinicians have described the benefits of using formulations within therapy, little is understood about the client's experience of the formulation process. Cognitive behaviour therapy (CBT) is currently the treatment of choice for many adult mental health difficulties. However, research exploring clients’ experiences of CBT formulation is very limited. The present study set out to explore experiences of CBT formulation in clients with depression. Seven participants were interviewed and the data analysed using Thematic Analysis. The analysis identified key themes such as: ‘Feeling trapped or restricted by depression’, ‘The development of the formulation – from coming to my own conclusions to something the therapist developed’, ‘From negative to mixed feelings: emotional reactions to the formulation during the therapeutic process’ and ‘A new journey: towards making a new sense of oneself’. The results of the study highlight the personal and emotional challenge of the formulation process for clients.

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.

Therapist cognitions about trauma-focused psychological therapies can affect our implementation of evidence-based therapies for post-traumatic stress disorder (PTSD), potentially reducing their effectiveness. Based on observations gleaned from teaching and supervising one of these treatments, cognitive therapy for PTSD (CT-PTSD), ten common ‘misconceptions’ were identified. These included misconceptions about the suitability of the treatment for some types of trauma and/or emotions, the need for stabilisation prior to memory work, the danger of ‘retraumatising’ patients with memory-focused work, the risks of using memory-focused techniques with patients who dissociate, the remote use of trauma-focused techniques, and the perception of trauma-focused CBT as inflexible. In this article, these misconceptions are analysed in light of existing evidence and guidance is provided on using trauma-focused CT-PTSD with a broad range of presentations.

Despite an emerging evidence base for the efficacy of supported computerized cognitive behavioural therapy (eCBT), uptake in services has been slow. Therapists’ beliefs about eCBT may constitute a barrier to offering eCBT to clients, but little research has investigated this topic. The aim of this study was to investigate therapist attitudes towards eCBT in one inner-city Improving Access to Psychological Therapies (IAPT) service using a survey design. Data were analysed using descriptive statistics. Thirty-three therapists took part in the study. Although 97% of participants reported that they knew ‘what eCBT involves’, and 62% reported that they were ‘confident to offer eCBT to clients’, only 10% endorsed that ‘there is a strong evidence-base to support the use of eCBT’. Two-thirds of the sample believed that eCBT ‘could be effective for mild and moderate mental health difficulties’, but most participants believed that eCBT would perform ‘worse’ or ‘much worse’ than face-to-face interventions for a range of disorders. Barriers to offering eCBT related predominantly to assumptions about client expectations of therapy, and perceived lack of a therapeutic relationship. Participants identified the provision of training on eCBT for those recommending treatment options to clients as a potential solution. Results from this study highlight therapists’ attitudes to eCBT that might contribute to low uptake rates of eCBT. Particularly, misperceptions about the evidence base for eCBT may be prevalent. Appropriate training and ongoing supervision for therapists are considered as interventions that may increase acceptance of eCBT as a valid treatment option.

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

There is increasing evidence that mindfulness techniques can be used safely and effectively in the treatment of psychosis, but the potential benefits of these techniques for individuals during the early stages requires further exploration. This study investigated whether mindfulness training in a group setting is associated with a reduction in distress and an improvement in mindfulness skills for people who have psychotic experiences. Data are reported from eight participants who completed measures before and after attending a mindfulness group. There was a reduction in CORE and DASS scores and an increase in mindfulness skills following participation in the group. These findings suggest that mindfulness training can be beneficial for reducing distress and negative emotional states associated with early psychotic experiences during the critical period.

This paper reports from a study of an intervention aimed at strengthening mental health nursing staff supervision. We developed and tested a short-term group-based meta-supervision intervention as a supplement to usual supervision. The intervention drew on action learning principles to activate and inspire supervisees to develop strategies for influencing their own supervision practices. The core ‘meta-supervisory’ process was organized round participants’ reflections on the possible benefits of supervision, their perceived barriers to realizing the benefits, and the articulation of concrete actions to overcome the barriers. In this paper, we introduce previously reported findings from the study and present two novel supplementary analyses of data from the meta-supervision process. First, we analyse a transcript of an audio recording made during the intervention, which illustrates how supervisees generate empowering psychosocial resources through the group processes. Second, we analyse supervisees’ paraphrased accounts of barriers to effective supervision and their accounts of personal projects to overcome the barriers. Barriers ‘outside’ the supervision setting primarily inspired projects aimed at creating structural change, whereas barriers ‘inside’ the supervision setting inspired projects aimed at creating individual change. The meta-supervision intervention was effective in increasing participation in supervision, but it shared the same problems of resistance and reluctance as often observed in supervision in general. In the discussion, we compare our ‘bottom-up’ approach to activating supervisees and implementing supervision practices with ‘top-down’ approaches. The meta-supervision intervention illustrated the importance of engaging supervisees in their own supervision and suggested how it can have both individual and organizational benefits.

Six clients in cognitive behaviour therapy (CBT) or metacognitive therapy (MCT) were interviewed about their experiences of therapy with a focus on helpful elements. Clients in both CBT and MCT mentioned the positive and informal relationship with the therapist as helpful. However, while clients in both therapies emphasized insight into the causes of depression and modification of negative maintenance patterns as helpful, the understanding of depression and the remedies for the condition differed. Clients in CBT focused on previous negative experiences as the cause of present maintenance patterns and mentioned changing negative thought patterns as helpful. Clients in MCT stated that the realization that rumination was their key problem and that they could choose not to engage in negative thinking had been crucial. Furthermore, clients in CBT tended to describe increased personal strength and self-confidence as the main gain from therapy, whereas MCT clients mentioned improved ways of coping with thoughts or problems. The importance attributed by the clients to technical factors differs from previous qualitative studies conducted across various therapeutic approaches, which have typically concluded that common therapeutic factors are more important than specific factors. It does, however, correspond with conclusions from other qualitative studies focusing explicitly on CBT.

The third wave of cognitive behavioural therapies has a developing evidence base and there is an increasing demand for specialist training. However, methods for training clinicians have not yet been evaluated in terms of effectiveness and usefulness. This evaluation seeks to assess: (1) the effectiveness of one-day introductory Acceptance and Commitment Therapy (ACT) workshops for clinicians in a NHS setting in terms of increasing knowledge of ACT; (2) the impact of experiential techniques as a method for delivering ACT training. A total of 73 participants took part in the workshops and completed questionnaires were administered pre-workshop and post-workshop; a further 29 participants completed follow-up questionnaire after 12 months. Participants demonstrated an increase in ACT knowledge, indicated that their interest had been stimulated, viewed the workshop positively and reported that their clinical work had been influenced by the workshop. In terms of the training process, experiential techniques are integral to ACT practice and training. Participants reported that their training experiences and engagement with the training group had not been aversive. Moreover, there was no evidence that participants’ own levels of experiential avoidance had affected training outcomes.

Implementing change in organizational systems is challenging, and implementing a new psychotherapeutic approach is no different. A literature exists on issues in implementation across a wide range of domains (technological, healthcare, justice). However, little of it is utilized in endeavours to implement innovations in psychological treatments. This paper draws on the implementation literature and on the experiences of the British Isles DBT Training Team (BIDBT) in implementing Dialectical Behaviour Therapy (DBT) in mental healthcare systems in the UK over the last 13 years. This paper describes principles and strategies of ‘organizational pre-treatment’ as a necessary prerequisite to implementation.

Clinical supervision is key to the delivery and governance of effective psychological work. We place increasing emphasis on the evidence base in our clinical decision making, and yet there is no comparable body of information to inform our supervisory practice. This is a serious problem for psychological therapists; there is an urgent need for theoretically driven and empirically evaluated approaches to supervision, and the training of such skills. This preliminary evaluation examined the impact of a 5-day training designed for Improving Access to Psychological Therapies (IAPT) supervisors new to the role. A within-subject, repeated-measures design was used to compare self-assessed supervision competencies over the course of training. Twenty-eight IAPT supervisors completed 5 days’ training based on the Supervision Competencies Framework and IAPT Supervision Guidance. Significant improvements were found in ratings of generic, specific, applied and meta-supervision competencies, as well as overall competency. This evaluation gives preliminary support for the impact of training on supervisory competencies. There are clear limitations, particularly the lack of objective measures and comparison training. Nevertheless, in the context of a very limited evidence base to date, the study contributes to a more robust approach to developing supervisory competence in clinical practice.