The far-reaching impact of post-traumatic stress disorder (PTSD) on a person's life is well documented, yet PTSD often goes undetected and untreated. Previous literature suggests that there may be particular challenges in assessing PTSD in children and adolescents. There is evidence that once PTSD has been identified, a trauma-focused cognitive behavioural therapy (TF-CBT) approach is effective at treating PTSD in young people. Where PTSD in adolescents presents in response to multiple traumas it may be necessary to make some modifications to treatment protocols. This might include offering more sessions, extending the stabilization period, addressing common trauma themes, and tackling additional issues that may arise beyond a simple PTSD presentation. This single-case quasi-experimental design (n = 1) details the assessment (phase A) and treatment with individualized TF-CBT (phase B) of previously undiagnosed PTSD in response to multiple events in an adolescent girl who had been seen by several mental health professionals previously. The paper is also a clinical case report, paying particular attention to how PTSD was assessed and what other factors, for example emotion regulation, self-esteem and relationships, were found to be important. Trauma, anxiety and depression were measured with the Child PTSD Symptom Scale and the Revised Children's Anxiety and Depression Scale. Scores reduced from clinically significant to non-clinical levels by the end of treatment, with these gains being maintained at 3-month follow-up. Suggestions are made around assessing and treating trauma responses in young people, especially where PTSD exists in response to multiple traumas.

This study aimed to demonstrate proof of concept and acceptability of a brief acceptance and commitment therapy (ACT)-based guided self-help intervention for improving quality of life (QoL) and mood for people with muscle disorders (MD). A case-series with an AB design was used to assess changes in primary (QoL) and secondary (depression and anxiety) outcome variables across the period of study. Change in the psychological process targeted by ACT – psychological flexibility – was also investigated, to allow insight into possible treatment mechanisms. Post-intervention, participants also completed a brief free-text evaluation. Relative to pre-intervention scores, four (of seven) participants showed varying degrees of improvement in all primary and secondary outcome variables and were thus considered responders. However, consistent concomitant improvements in psychological flexibility were not apparent. Participants reported a mostly positive experience of the intervention; all appeared to complete the intervention, and no adverse events were reported. Nonetheless, there was evidence that those with compromised concentration or who report good initial QoL and low levels of distress may derive less benefit. Although several methodological weaknesses limit the strength of our conclusions, this ACT-based guided self-help intervention shows encouraging utility for improving QoL and mood in MD.

Clinical supervision is regarded as one of the most important components of psychotherapy training. In clinical practice, it has been found that the implementation of clinical supervision varies substantially and often differs from the recommendations made in the literature. The objective of the current study was to investigate the frequency of topics (e.g. ethical issues) and techniques (e.g. role play) in the clinical supervision of psychotherapy trainees in Germany. To this end, we considered supervisions in cognitive behavioural therapy (CBT) and psychodynamic therapy (PT). A total of 791 psychotherapy trainees (533 CBT and 242 PT) were asked via the internet to provide information about their current supervision sessions. We found that clinical supervision in psychotherapy training addressed topics that are central for the effective treatment of supervised patients (i.e. therapeutic interventions, therapeutic alliance, maintaining factors, and therapeutic goals). However, the most frequently used intervention in clinical supervision in psychotherapy training was case discussion. Rarely were techniques used that allowed the supervisor to give the supervisee feedback based on the supervisee's demonstrated competencies. For example, 46% of the supervisors never used audiotapes or videotapes in the supervision. Differences between CBT and PT were rather small. Current practice regarding the techniques used in clinical supervision for psychotherapy trainees contradicts recommendations for active and feedback-oriented clinical supervision. Thus the potential of clinical supervision might not be fully used in clinical practice.

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.

Physical health outcomes for patients with long-term conditions can be significantly affected by their psychological wellbeing; those experiencing psychological difficulties are less able to manage symptoms, have a poorer quality of life, and more frequent hospital admissions. National guidance recommends the assessment and treatment of psychological difficulties secondary to respiratory disease, but implementation of this across services is inconsistent. Here, we describe the process and findings of a 9-month study integrating psychological assessment and intervention into an acute respiratory department. The aim of this provision was to provide appropriate interventions for both in-patients and out-patients with identified psychological needs, and to evaluate the impact of these across a range of outcome domains. Psychological assessment and intervention was flexibly implemented as clinically appropriate within the context of the wider multidisciplinary team. Hospital admissions data were collated, and feedback obtained from both patients and staff. Results highlighted that psychological provision was well received by both patients and staff, and was associated with improved patient experiences and a greater focus on holistic care. Of the 73 patients receiving psychology input with at least 1 month of follow-up data, 75% showed a reduction in their admission frequency following intervention. The estimated savings to the wider NHS exceeded the costs of providing psychology input. In light of existing literature, national guidance, and the present findings, we highlight the need for those commissioning and managing respiratory services to consider the various potential benefits of integrating psychological provision for a patient group with high levels of psychological need.

Many National Health Service (NHS) Trusts in England have invested in dialectical behavioural therapy (DBT) for mental health service users. The experiences of NHS staff delivering DBT were explored using semi-structured interviews with six dialectical behaviour therapists working in secondary mental health services within the NHS. The aim was to consider the impact on staff of adding the DBT therapist role onto their existing job role. Interview data were analysed using thematic analysis. Six themes were inductively generated from the data: DBT as a useful framework; DBT as the most satisfying part of the job; ‘Worzel Gummidge heads’– conflicts in roles; ‘DBT buddies’– the importance of informal support; uncertainty about the future; and recursivity – using DBT skills personally. Interactions between themes, implications for the service and future research directions are discussed. Key findings suggest that the addition of the DBT therapist role, as well as the recursive nature of DBT, has a positive impact professionally and personally. However, the service context within which participants were working can lead this additional role to cause increased demands and therefore stress, reducing that positive impact.

The purpose of the present study was to explore the experience of being asked for reassurance from the perspective of carers of obsessive compulsive disorder (OCD) sufferers, and to examine its relationship to sufferers’ reassurance seeking by a direct comparison with data obtained from the person they normally offer reassurance to. Forty-two individuals with OCD and their carers completed alternate versions of the Reassurance Seeking Questionnaire. Result suggest that carers report most commonly providing reassurance when asked to do so, and the frequency of their reassurance provision is associated with how carefully sufferers seek reassurance, rather than their OCD symptom severity. The carer's perspectives on the impact of reassurance provision was accurate; both sufferers and carers perceive that reassurance works only temporarily, but even if the anxiety-relieving effect of reassurance decreases in the medium term, it is likely to be perceived as beneficial because carers accurately perceived that sufferers would feel much worse if they refused to provide reassurance. The present study is the first to quantitatively investigate carer's experiences of reassurance provision, and elucidate why carers feel the need to provide it.

Anorexia nervosa (AN) is a notoriously costly and challenging psychiatric illness to treat. Despite an accumulating evidence base, psychological treatment fails to achieve symptom abstinence in many patients with eating disorders, a shortcoming that is likely to be further pronounced in AN. The case study reported here describes how a mutually agreed break in a course of psychotherapy following an initial lack of progress might have influenced outcome for a client with a severe eating disorder. The patient received 26 sessions of CBT and results, consistent with those of larger studies, showed significant improvement on primary symptom measures. These results are discussed in the context of relevant psychological theories and an exploration of the client's motivation. Consideration is also given to other factors that may have influenced outcome.

Psychoeducation courses have gained some empirical support as effective early intervention strategies. Many of these courses reflect traditional cognitive behaviour therapy (CBT) thinking but psychoeducation courses based on other approaches are beginning to emerge. One such course, ‘ACTivate Your Life’, is based on acceptance and commitment therapy (ACT). The aim of this preliminary investigation is to evaluate a four-session (eight-hour) ACT psychoeducation intervention delivered within the Abertawe Bro Morgannwg University (ABMU) Health Board. Participants were invited to complete four outcome measures (assessing depression, anxiety, self-esteem and life satisfaction) and two process measures (assessing mindfulness self-efficacy and psychological flexibility) at pre- and post-intervention. Statistical analysis indicated that participants’ scores across each of the measured domains showed highly significant changes. These results suggest that a brief psychoeducation ACT course may be useful in helping people in need of early psychological intervention, and that further research is now needed to provide a definitive evaluation of its effectiveness.

There has been limited application of cognitive behavioural therapy (CBT) to the treatment of distressing visual hallucinations (VH) in people with psychosis. Preliminary research applying interventions to a novel presenting issue are enhanced by utilizing designs that allow strong inferences to be made about the effect of the intervention. Hence, this study aimed to measure change in appraisal, affect, and behaviour as a consequence of CBT VH, to improve understanding of the process of change. A multiple-baseline experimental single-case design methodology was used with five participants who received a CBT VH treatment package. Participants used daily diary measures to record appraisals, affect, and behaviours related to the distressing VH. Standardized measures were completed at each phase change. Four individuals completed therapy. Formal visual analysis of the data supported by statistical analysis indicated significant changes for appraisal and affect, with replication across three participants. Changes in frequency of VH were reported in two cases. Change was not evident on the standardized measures. This study replicates and extends the findings in showing potential value of CBT VH. Further research should consider alternative methods of capturing behavioural change. Attempts should also be made to replicate across therapists and centres.

Socializing a client to the cognitive behavioural model is advised in almost every cognitive behavioural therapy (CBT) textbook, but there is limited evidence for whether socialization is measurable or important. The aim of the study was to pilot a written and interview-based measure of socialization to investigate whether socialization to the model can be measured in a sample of young people who have completed CBT. Sixteen participants (mean age 14.9 years, 75% female) completed a semi-structured socialization interview and a novel written measure of socialization. Treating clinicians were asked to provide subjective ratings of participant socialization. The structure and content of these measures was examined. A moderate but non-significant correlation was found between the novel written measure of socialization and clinician rating of socialization (r = .37). The concept of ‘socialization’ is not well understood and the socialization interview presented mixed, unclear results. This may be due to issues with the design, but may also be that socialization, as currently understood, is more complex than can be captured in this way. The important aspect of this study is introducing the concept of measuring socialization and factors that may be important in future research. Socialization to the model is an important construct within CBT but at present is a challenging concept to measure. Future research will need to focus on operationalizing the concept further and refining measures so that it can be accurately captured. Understanding which therapist and client behaviours contribute to the process of socialization could conceivably improve outcomes, but this cannot be done until this area is understood more fully.

Cognitive behavioural therapy (CBT) has been shown to be an effective treatment for anxiety disorders in children. However, the majority of studies conducted to date have included heterogeneous samples of children combining social anxiety disorder, generalized anxiety disorder and separation anxiety disorder (SAD) together. Few studies have examined the efficacy of CBT to specifically treat SAD. Moreover, research on the impact of CBT for SAD in children younger than 7 years old has been very limited. To address these issues, we examined the effects of a CBT parent training programme with six children with SAD aged between 4 and 7 years using a non-concurrent multiple baseline design. Parents completed semi-structured interviews, questionnaires and daily diaries to assess their child's anxiety symptoms, parental practices and parental stress. Results indicated that five of six children no longer met the criteria for SAD diagnosis after treatment and at 3-month follow-up. Moreover, the daily diaries showed that four of six children presented a systematic favourable change of the total weekly frequency of SAD symptoms. Finally, four mothers reported a decrease in overprotection, but we observed no changes in parental stress.

As therapists we frequently use and hear the term ‘complexity’ in relation to clients, situations and settings. Although we may assume there is a shared understanding of what is meant by complexity, is this true? Do we really know what we mean by describing someone, or something, as complex? If we define complexity as ‘consisting of many different and connected parts, not easy to analyse or understand’ (Oxford English Dictionary, 2017), then we are probably describing intersections and interactions between different elements that can influence each other. Interestingly, the origin of the term derives from the Latin past participle plexus, meaning braided or entwined, which captures neatly the sense of the term ‘complex’ as meaning literally braided together. The breadth of this definition therefore may help to account for the diversity of the ways in which the term complexity is used in clinical settings. Continuing with the idea of the plait or braid, it also gives a sense of the number of threads or strands that could be incorporated within such a system. Complexity can derive from any source, and can interact with any part, so it can derive from the patient, the therapist, the therapeutic relationship or the healthcare setting; and each of these may interact with one or more parts. So from any source, complexity can affect processes and outcomes of care.

Eating disorders are commonly regarded as complex psychiatric conditions, although this perception might be a product of the high levels of physical and psychological co-morbidity that are present in many such cases, rather than being about complexity in the eating disorder per se. This paper will consider the reasons that eating disorders are seen as complex, and whether or not that perceived complexity should be seen as a genuine reason to deviate from existing evidence-based cognitive behavioural therapy (CBT) protocols. Case examples will be used to illustrate how complex presentations can require clinicians to work skilfully with relatively simple formulations to achieve the best outcome, rather than using unnecessarily complex formulations and treatments. The importance of clear supervision is also stressed, as it can play a role in clinicians’ perception of the need for a complex or simple formulation, it can support the clinician in developing a collaborative, focused and efficient formulation, and it can keep the clinician on track with an evidence-based CBT approach.

Obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD) can take many different forms of presentations. The term ‘complex’ is common and inconsistently used in both OCD and BDD. Practitioners often refer to complex OCD or BDD when patients present with severe co-morbid problems, often in the context of personality difficulties, dissociation, difficult early relationships and trauma; or when the illness is chronic and debilitating with previous multiple treatment failures. Current best-evidence treatment protocols for both disorders focus heavily on exposure and response prevention (E/RP) but with moderate success, particularly in patients who are deemed ‘complex’, and often those with relevant shame and/or disgust-based past experiences. The aim of the present paper is to (a) describe factors that contribute to complexity in OCD and BDD, and (b) link these with theory and practice. We emphasize the importance of understanding both the function of OCD and BDD-related behaviours (rather than the content of obsessions or compulsion), and the context in which they occur such as the family. We illustrate complexity in OCD and BDD using real case material, using a functional and contextual approach to formulate the client's difficulties, and demonstrate how E/RP can be enhanced successfully with imagery rescripting, family work, and compassion-focused therapy.

Persistent complex bereavement disorder (PCBD) has been included in the appendix of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders as a condition for further study, and a new diagnostic category of prolonged grief disorder (PGD) is likely to be added to the International Statistical Classification of Diseases and Related Health Problems (ICD-11) (Maercker et al., 2013). Whilst there is increasing evidence that prolonged grief has distinct characteristics (Bryant, 2012), there are clinical features that overlap with post-traumatic stress disorder (PTSD), such as intrusive memories, emotional numbing, and avoidance of trauma or loss reminders. Here we describe how the cognitive model for persistent PTSD (Ehlers and Clark, 2000) and trauma-focused cognitive therapy for PTSD (Ehlers et al., 2005) have been helpful in treating persistent complex grief.

Cognitive behavioural therapy (CBT) for major depression is an effective treatment, but outcomes for complex cases, with co-occurring biological, psychological and social factors, are variable. Complexity factors can cause treatment to become diffuse, disorganized and over-complicated. At Step 3, disorder-specific protocols should be provided with therapy kept as simple as possible and delivered responsively, e.g. barriers to treatment should be tackled, ensure the client is well-prepared and seek to form a strong therapeutic alliance. At Step 4, if disorder-specific protocols have been ineffective, the priority is to formulate how complexity factors are interacting with the client's depression. An individualized formulation is used to carefully target these interactions. The treatment is still evidence-based and simple at the point of delivery, but there is greater emphasis on case-level interactions that are unique to each individual. Case examples are used to illustrate both approaches.

People with epilepsy are significantly more likely to have a mental health disorder than those without a chronic illness. The reasons for this are multiple but may include the mental health difficulties being perceived as complex due to the presence of a chronic illness. In part due to the apparent complexity of the co-occurring physical and mental illness, many are not offered evidence-based treatment (EBT) for the mental health disorder. There is little guidance to inform clinicians about the interventions to use to treat mental health disorders in people with epilepsy. The present paper reports a case of treatment for depression using a standard EBT in a young person with epilepsy. The patient also had clinically significant symptoms of anxiety and an eating disorder and would be considered ‘complex’ according to standard criteria. The intervention, however, was relatively simple and was delivered as guided self-help via 10 weekly telephone calls of approximately 30 minutes duration, and two follow-up calls at one month and three months post-intervention. Self-report and parent-report questionnaire measures were completed before and after the intervention, and at both follow-up time points. A blind-rated online diagnostic interview measure was also completed before and after the intervention. The young person and her family also completed a qualitative interview of their experiences of the intervention. This simple intervention was effective in working towards the client's goals, although pre–post measurement on standard measures was variable. This interesting case raises questions about whether patients with mental and physical comorbidities are complex, or just perceived as complex.

Cognitive behavioural therapy (CBT) is widely acknowledged as a treatment of choice for a range of psychological disorders, including those that affect criminal offenders and mentally disordered offenders. Meta-analyses of multiple studies provide evidence of CBT's efficacy and have led to its recommendation as a first line treatment for anti-social personality disorder (ASPD; NICE, 2009). However, there is comparatively little evidence about the effectiveness of CBT in relation to complex problems faced by offenders in prison and secure psychiatric services. The aim of this study was to examine how clinicians conceptualize and respond to complexity in the practice of CBT treatment with high-risk mentally disordered offenders. Using a qualitative methodology, semi-structured interviews were conducted with six practitioners. The interviews were analysed using thematic analysis. The first main theme was ‘critical challenges and issues’ which included subthemes addressing patient characteristics, the therapeutic context, ethical challenges, and treatment challenges. The second main theme was ‘overcoming obstacles’ which included subthemes on promoting safety, an emphasis on non-specifics, how to create an enabling space and creative practice in the application of CBT. The study emphasizes the importance of creating an enabling safe space by being ‘responsive’ to the patients’ needs and also emphasizes the importance of working to establish a baseline for ‘safety’ in all alliances wherever possible.

More than half of college students endorse experiencing at least one traumatic event. Consistent with other populations, the rate of post-traumatic stress disorder (PTSD) for college students has been reported at around 12%. Despite this, empirically supported treatments for PTSD have not been widely disseminated in University Counselling Centers (UCCs). This study examines outcomes using cognitive processing therapy (CPT) with a sample of n = 26 college students in a UCC setting. This study also examines therapist experience, length of degree and symptom severity on outcome. After completing training, n = 8 therapists completed CPT consultation and certification. Students who participated in individual CPT during this process were administered the PCL-5 and PHQ-9 at weekly sessions. A retrospective chart review was completed. PCL-5 and PHQ-9 scores were separately examined as outcome variables using linear mixed models where session, therapist experience, length of therapist degree, and severity of symptoms were included as fixed effects, and subjects were assumed to have a random effect. Significant reductions in PCL-5 and PHQ-9 scores were observed across treatment. In this sample, 84.6% of students were treatment responders. Results were unchanged when adjusting for therapist level of experience or training. CPT shows strong potential for UCC settings. CPT can be successfully implemented with novice therapists.