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.

The paper forms part of a series of papers outlining the theoretical framework for a new model of uncertainty distress (this paper), treatment implications arising from the model, and empirical tests of the model. We define uncertainty distress as the subjective negative emotions experienced in response to the as yet unknown aspects of a given situation. In the first paper we draw on a robust body of research on distinct areas including: threat models of anxiety, perceived illness uncertainty and intolerance of uncertainty. We explore how threat and uncertainty are separable in anxiety and how we can understand behaviours in response to uncertainty. Finally, we propose a clinically, theoretically and empirically informed model for uncertainty distress, and outline how this model can be tested. Caveats, clinical applications and practitioner key points are briefly included, although these are more fully outlined in the treatment implications article. While we outline this model in the context of novel coronavirus (COVID-19), the model has broader applications to both mental and physical health care settings.

Misophonia is a condition of unknown cause characterized by atypically intense negative physiological and emotional reactions to hearing certain sounds – most often those associated with oral functions. Individuals with misophonia often report high levels of psychological distress and avoidance behaviours that seriously compromise their occupational and social functioning. As of yet, no effective treatment of misophonia has been identified, and health care providers often struggle when they encounter clients who have it. This case report describes the assessment, case formulation, and treatment of a client with misophonia using cognitive behavioural therapy (CBT), and serves as an initial contribution to the evidence base for the efficacy of CBT in the treatment of misophonia.

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.

Cognitive behaviour therapy (CBT) in its current form might not be applicable in non-Western cultures. Differences between Western and non-Western cultures have been reported widely. Most psychotherapeutic interventions have been developed in the West and are underpinned by the values that might be specific only to Western culture. To adapt CBT, we need to understand whether the concepts associated with CBT may conflict with cultural beliefs, identifying barriers to the success of the therapy using the views of experts by experience, public and practitioners. This paper discusses the process, foci and framework of cultural adaptation of CBT. We describe an evidence-based framework for adapting CBT for individuals from non-Western cultures that will benefit clinicians who practise CBT and individuals from different cultural backgrounds.

Clinical supervision is central to evidence-based practice (EBP) and continuing professional development (CPD), but the evidence base has made little impact on supervision, a major form of CPD. We unite the two by developing four evidence-based guidelines for cognitive behavioural therapy (CBT) supervision. The guidelines were designed to address the supervision cycle (i.e. collaborative goal-setting; methods of facilitating learning; evaluation and feedback) within the context of the supervision alliance. Guideline development followed the National Institute for Clinical Excellence approach, including a representative stakeholder working group (with local service users and supervisees), a national group of supervisors and supervisor trainers, plus an expert reference group. A total of 106 such participants completed an ad-hoc guideline evaluation tool, designed to provide a multi-dimensional reaction evaluation of the guidelines. The guidelines were all rated favourably, satisfying the key initial criteria of accuracy and acceptability, and were judged to represent a CBT approach to supervision. It is concluded that the use of the guidelines might help CBT supervisors to better meet demands for CPD (including specialization in supervision) and EBP.

Clinical supervision plays a recognized role in facilitating practitioner development and in promoting therapeutic fidelity, but instruments that can support such activities by measuring competence in supervision are rare and often psychometrically compromised. As part of a research programme intended to raise the empirical status of supervision, we describe the initial psychometric development of a new instrument for observing competence (Supervision: Adherence and Guidance Evaluation; SAGE). This instrument is suitable for measuring CBT supervision, and can be administered by self-rating or by an independent observer. Preliminary tests of the reliability and validity of SAGE suggest that it is a promising tool for evaluating supervision. In addition, SAGE can be applied readily and has good utility. In these respects, SAGE appears to have some advantages over existing instruments, and may therefore provide a basis for enhancing research and practice in CBT supervision. Suggestions for future research on SAGE are outlined, particularly the need for a generalizability analysis.

To contribute to a model of CBT supervision, we interpreted supervisees' understanding of the processes involved in their receipt of supervision. Second, we assessed the utility of a Grounded Theory Methodology (GTM) to study supervision. Supervisees were interviewed about their experiences of supervision, within a cross-sectional, qualitative design. In-depth, face-to-face individual interviews were conducted with seven trainee clinical psychologists. Their perceptions of supervision were analysed by means of a constructivist revision of GTM. A conceptual model is presented, to show the learning process from the perspective of the supervisees. This suggests that the receipt of supervision was experienced against a developmental backdrop involving a progression along two continua: competency and awareness. A set of core processes (Reflection, Socratic Information Exchange, Scaffolding, Supervisory Alliance) were thought to interact, enabling appropriate learning across developmental stages. This was thought to facilitate movement through individualized Zones of Proximal Development (ZPD). The fidelity construct of ‘receipt’ is complex and does not lend itself to quantification and measurement using a positivistic approach. By contrast, GTM was a useful methodology to use in this context. Further research using a similar methodology may further contribute to a model of CBT supervision.

Conversations around improving access to psychological therapies for BAME (Black, Asian and minority ethnic) service users have been ongoing for many years without any conclusion or resolution. BAME service users are often under-represented in primary care mental health services, and often have worse outcomes, leading to them being portrayed as ‘hard to reach’, and to deterioration in their mental health. They are over-represented in secondary care mental health services. The authors of this article argue that more resources are required in order to understand the barriers to accessing mental health services, and improve both access and recovery for BAME service users. This paper examines concepts such as race, ethnicity and culture. It aims to support service managers and therapists to develop their confidence to address these issues in order to deliver culturally competent psychological therapies to service users from BAME communities, with a focus on primary care. It is based on our experiences of working with BAME communities and the feedback from our training events on developing cultural competence for CBT therapists. The paper also discusses the current political climate and the impact it may have on service users and the need for therapists to take the wider political context into consideration when working with BAME service users. Finally, the paper stresses the importance of addressing structural inequalities at a service level, and developing stronger ethical guidelines in the area of working with diversity for CBT therapists in the UK.

The Oracle of Delphi's admonition to ‘know thyself’ may be more difficult than it seems, when it comes to self-assessment of competence in cognitive behaviour therapy (CBT). This paper investigates the accuracy of self-rating of competence in relation to other measures such as ‘direct’ assessment of videotaped sessions or supervisor ratings. Self-assessment of competence is something most of us do and arguably has an important role in professional development, but it may also be biased and unreliable. Two measures were developed, based on the Cognitive Therapy Scale – Revised, to assess student and supervisor assessments of competence at the start and end of a CBT training course. Competence data across a range of measures from a 5-year audit of a postgraduate CBT course is presented and the relationship between self-rated and other-rated measures explored. Results are discussed and it is suggested that trainee self-assessment, while not found in this study to be correlated with other measure of competence, may provide important information about confidence development, and areas where a trainee perceives they have strengths and weaknesses.

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.

‘Cyberchondria’ describes the phenomenon of searching for health information online exacerbating health anxiety. This study explores health anxious individuals’ experiences of searching for health information online to further understand ‘cyberchondria’. Semi-structured interviews were used to explore participants’ (N = 8) experiences of searching for health information online. Transcripts were analysed using Interpretative Phenomenological Analysis. Four themes emerged: ‘information is power’, ‘novelty of Internet searching’, ‘need for strategies to navigate the search: Google, authority and cross-checking’, and ‘cyberchondria: short-term gain but long-term pain’. Participants’ accounts suggested they sought health information online as a form of problem solving: to understand their problem and decide on a strategy for solving it, to feel better about having the problem by having ‘done something’ about it, or to share others’ similar experiences. Seeking online health information was prompted by negative expectations of healthcare professionals, yet was not seen as a replacement for medical consultations. Participants noted the accessibility of the Internet and were aware that information is sometimes inaccurate or irrelevant. Thus participants used strategies to filter and validate information. The findings are considered in relation to what they tell us about the purpose, methods and impact of seeking health information online among individuals with health anxiety.

Individuals working for the emergency services often bear witness to distressing events. This outcome study examines therapeutic interventions for Fire Service personnel (FSP) experiencing symptoms of trauma, depression, anxiety and low levels of self-compassion. This study aims to investigate the effectiveness of using Compassion-Focused Therapy (CFT) as an adjunct to Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) in reducing symptoms of trauma, anxiety and depression and increasing self-compassion. A convenience sample (n = 17) of participants, referred for therapy following a traumatic incident, were allocated to receive 12 sessions of either TF-CBT or TF-CBT coupled with CFT. The study employed a repeated-measures design. Data were gathered pre- and post-therapy, using three questionnaires: (1) Hospital Anxiety and Depression Scale; (2) Impact of Events Scale-R; (3) Self-Compassion Scale – Short Form. TF-CBT combined with CFT was more effective than TF-CBT alone on measures of self-compassion. Significant reductions in symptoms of depression, anxiety, hyperarousal, intrusion and avoidance and a significant increase in self-compassion occurred in both groups post-therapy. The study provides some preliminary evidence to suggest that FSP may benefit from therapeutic interventions aimed at cultivating self-compassion. Further research is warranted using a larger sample size and adequately powered randomized controlled trial, to detect statistically significant differences and to negate the risk of confound due to low numbers resulting in significant differences between groups at baseline. Using CFT as an adjunct to TF-CBT may help FSP, who bear witness to the distress of others, cultivate compassion for their own suffering.

Theevaluation of supervisor training has featured weak measurement and lacked a coherent framework, limiting effectiveness. A literature review was first conducted to clarify the current status of supervisor workshop evaluations, related to the promising fidelity framework. This consists of five criteria: the workshop's design, the training (competence of the trainer), the delivery of the workshop, the learning of the participants (receipt), and the clinical practice outcomes (enactment). Second, we applied this framework to the training of supervisors (n = 17) in a cognitive-behavioural therapy (CBT) approach, by analysing one trainer leading two successive supervisors’ workshops. The review of the literature indicated that there were significant psychometric and conceptual deficiencies in the current evaluation of supervisor training. The data from the case-study analysis suggest that the manual-based workshop could be delivered with high fidelity by this trainer (e.g. the CBT approach to supervision received 89% approval). The fidelity framework provided a systematic, feasible and coherent rationale for the evaluation of supervisor training. Our preliminary findings indicated that the workshop was successful. To fulfil its promise as an improved way of evaluating supervisor training, the framework should be piloted with other trainers, instruments and workshops, using controlled designs.

This article summarizes the current knowledge and treatment for a specific phobia of vomiting (SPOV). It is relatively uncommon compared to other specific phobias but may have been misdiagnosed in catchment-area surveys. The differential diagnosis of SPOV includes obsessive–compulsive disorder, hypochondriacal disorder and anorexia nervosa. I discuss the following: a model that is linked to past aversive experiences of vomiting; conducting a clinical assessment; making a formulation; psycho-education, engagement and therapy. The strategies employed depend on the formulation but are likely to include: exposure in vivo to cues of vomiting, exposure in imagination and role-plays of vomiting, imagery re-scripting, behavioural experiments; and dropping of safety-seeking behaviours.

The psychological treatment offered to clients is important. However, an equally important consideration may be the way the treatment is delivered. Reducing waiting lists and improving access to services are priorities for many health services. So is increasing patient control over their own health-care outcomes. While waiting times and access to services have typically been addressed by increasing the numbers of clinicians available, our work suggests that a strategy of providing patients with the ability to determine the frequency and duration of their treatment may be an option that is simpler, more effective, and financially more attractive. After describing policy and ethical guidelines as well as empirical and theoretical information, we provide data from our work in one GP practice about the improvements in waiting times and access to services that occurred when we adopted an approach that allowed patients rather than clinicians to decide how the organization of treatment would occur. There seem to be many benefits to this approach; however, it may also raise dilemmas for clinicians when patients' preferences differ from their own. Ultimately, these conundrums can only be reconciled by the individual clinicians based on their attitudes to mental health problems and service provision.

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.

People with obsessive compulsive disorder (OCD) are likely to be more susceptible to the mental health impact of COVID-19. This paper shares the perspectives of expert clinicians working with OCD considering how to identify OCD in the context of COVID-19, changes in the presentation, and importantly what to consider when undertaking cognitive behaviour therapy (CBT) for OCD in the current climate. The expert consensus is that although the presentation of OCD and treatment may have become more difficult, CBT should still continue remotely unless there are specific reasons for it not to, e.g. increase in risk, no access to computer, or exposure tasks or behavioural experiments cannot be undertaken. The authors highlight some of the considerations to take in CBT in light of our current understanding of COVID-19, including therapists and clients taking calculated risks when developing behavioural experiments and exposure tasks, considering viral loading and vulnerability factors. Special considerations for young people and perinatal women are discussed, as well as foreseeing what life may be like for those with OCD after the pandemic is over.

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.

Interpersonal dynamics are a recurring impediment to effective clinical supervision and can lead to phenomena like collusion between the supervisor and supervisee. Collusion involves both supervisor and supervisee engaging in safety behaviours that serve to conveniently avoid and escape from difficult topics and challenging methods. Whilst minimizing the short-term threat to supervisor and supervisee, collusion will tend to undermine the effectiveness of supervision and limit significantly its long-term value to patients. In order to consider how best to address collusion, we review the cognitive-behavioural therapy (CBT) and related literature on collusion, focusing on how it has been formulated and managed. We then provide a case study featuring a supervisor who was colluding with the supervisee's avoidance behaviours (i.e. filling supervision sessions with superficial reflections on his casework) by not challenging these reflections or moving to another learning mode (e.g. experimenting). We develop a CBT formulation of this pattern of supervision as part of the self-reflection process, led by a consultant. Self-reflection appeared to be a useful tool for improving the supervisor's understanding of this dysfunctional process, and strengthened the supervisor's confidence in utilizing relevant skills in the future.