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Published by Rachel Handley for BABCP
The podcast for therapists using Cognitive Behavioural Therapy to help shape and inform their practice.
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In this episode of Practice Matters, Rachel Handley is joined by Dr Antonia Dittner, consultant clinical psychologist and lead author of "A Therapist's Guide to CBT to Support Adults with ADHD," to explore what CBT has to offer this often misunderstood client group. Together they unpack the diagnostic picture, the overlap with anxiety and depression, and why a formulation driven, transdiagnostic approach can help therapists feel more confident with this client group. Antonia walks through the four core elements of therapy: behavioural work on routines and habits, thinking patterns, managing emotions and impulses (including how procrastination often develops as a way of avoiding difficult feelings), and longer standing beliefs and coping. She also shares practical tips for structuring sessions, addressing shame and self-criticism with compassion, and what services can do to support access for neurodivergent clients. Further resources: A Therapist's Guide to CBT to Support Adults with ADHD by Antonia Dittner and colleagues Find out more about training and support from NAAAPS (National Adult ADHD and Autism Psychology Service) Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review, and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Practice Matters, Rachel Handley is joined by Dr Scott Waltman, president-elect of the US Academy of Cognitive and Behavioural Therapies, to explore what Socratic questioning really is and why it matters. Scott describes it as thinking with our clients rather than for them, comparing it to Socrates' own idea of being a midwife for thought. They discuss the evidence behind Socratic questioning, the difference between guided and provided discovery, and how Scott's research reshaped Padesky's well known four step model. Scott also shares practical advice on focusing questions, and on working with a client's own definitions to shift stuck beliefs. Further resources: Find out more about Scott's work here Socratic Questioning for Therapists and Counselors can be bought from Routledge here Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Practice Matters, Rachel is joined once again by Professor David Veale, this time to explore emetophobia, the specific phobia of vomiting. David explains why this is the most common specific phobia presenting for treatment, despite being largely overlooked by researchers for years, and the devastating impact it can have, from avoided pregnancies to missed medical care. Together they unpack what drives the fear, how it differs from OCD and eating disorders, and why tolerating uncertainty rather than seeking reassurance is at the heart of effective treatment. David also shares his "vicious flower" formulation, practical tips for therapists who might be squeamish themselves, and exciting developments in virtual reality treatment. Further resources: David's self-help book, Free Yourself from Emetophobia , co-authored with Alexandra Keyes, is available here Find out more about David's work and publications here Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autumn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Practice Matters, Rachel Handley is joined by Professor David Veale, consultant psychiatrist and cognitive behavioural therapist, to explore body dysmorphic disorder (BDD). Together they unpack what BDD really is, how it differs from vanity, social anxiety, and OCD, and why so many people suffering with it end up seeking cosmetic solutions rather than psychological support. David shares the CBT formulation for BDD and explains the key maintenance processes that keep people locked in distress: self-focused attention, comparing, ruminating, checking, and safety behaviours. He also discusses imagery rescripting, the challenges of engagement, and why targeting processes rather than the content of beliefs is so important in this work. The episode also covers what effective therapy looks like in practice, who is most likely to benefit and why persistence matters, the current evidence base, and where David hopes future research will take the field. Further resources: Find out more about David's work and publications here More information on BDD can be found via the BDD Foundation Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autumn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Practice Matters, Rachel Handley is joined by Professor Alicia Meuret to explore anhedonia, the reduced ability to feel pleasure, and the development of Positive Affect Therapy (PAT). Together, they unpack why so many clients struggle not just with feeling bad, but with a profound absence of positive emotion, and why traditional CBT approaches may not fully address this gap. Alicia explains the science behind the brain's reward system, breaking it down into three key processes: wanting, liking, and learning. She also introduces PAT, the evidence-based treatment she developed with Professor Michelle Craske, and shares what the randomised controlled trial evidence tells us about its effectiveness compared to more traditional CBT approaches to treating depression. The episode also offers a practical overview of what PAT looks like in the therapy room, including behavioural activation with a positive focus, savouring, gratitude practices, and building a richer emotional vocabulary. Alicia addresses some of the trickier clinical questions too, including how to present a positive-focused rationale without invalidating clients' very real distress, and how these ideas might just change how you look after yourself as a therapist. Further resources: Find out more about Alicia's work here - including links to all the trials mentioned in the podcast Alicia's most recent trial published in JAMA Network Open can be found here Positive Affect Treatment for Depression and Anxiety: Therapist Guide can be bought from Oxford University Press here Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Let's Talk About CBT- Practice Matters , Rachel Handley is joined by Professor Paul Farrand to unpack the theory and practice of low intensity CBT. They explore what low intensity really means, challenging common misconceptions and clarifying its evidence base, including its focus on single-strand interventions and stepped care delivery. Paul discusses how low intensity approaches improve access, efficiency, and patient empowerment, while maintaining clinical rigour through strong practitioner competencies in engagement and risk assessment. The conversation also highlights adaptation for diverse populations, evolving delivery formats, and future directions, including digital innovation and applications in physical health settings. A great listen for anyone wanting to learn more about low intensity CBT or thinking about applying it in different contexts. Further resources: Find out more about Paul and his work here Paul's publications, including the systematic review he mentions can be found here Find out more about the Cognitive Behaviour Therapist Low Intensity special issue here The Sage book in which Paul's chapter on low intensity CBT is included is: Farrand, P. (2024) Low-intensity CBT Skills and Interventions: A Practitioner's Manual. London: SAGE. More information about NHS Talking Therapies can be found here Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Let's Talk About CBT: Practice Matters , Rachel Handley speaks with Professor Shirley Reynolds about behavioural activation for depression in children and young people. Shirley reflects on what we know about depression in adolescence, the challenges of access to effective treatment, and why brief, values-based approaches may be particularly well suited to this developmental stage. Drawing on findings from large clinical trials, she explains how young people often attend fewer sessions than are offered, prompting important questions about engagement and the design of therapy. The conversation explores how behavioural activation helps young people identify what matters to them and gradually increase meaningful activity. Shirley outlines what a course of BA looks like in practice, from early psychoeducation and activity monitoring through to parent contracting and relapse prevention, and discusses the importance of supervision, system support and therapist wellbeing. Further resources: Find out more about Shirley and her work: https://www.drshirleyreynolds.com/about More information about the online training with Shirley and Laura Pass can be found here: https://www.cbtreach.org/pass-reynolds The IMPACT trial: Goodyer, I. M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J., Holland, F., Kelvin, R., Midgley, N., Roberts, C., Senior, R., Target, M., Widmer, B., Wilkinson, P., & Fonagy, P. (2017). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. The Lancet Psychiatry , 4 (2), 109–119. https://doi.org/10.1016/s2215-0366(16)30378-9 Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
How do we make effective therapy for depression more widely available without losing quality or compassion? In this episode, Rachel Handley is joined by Professor David Ekers, a leading researcher and clinician specialising in behavioural activation (BA). David shares the story of how his clinical experience with long waiting lists led him to focus on scalable, evidence-based approaches to care. The conversation explores the development of behavioural activation, the evidence underpinning low intensity delivery, and key findings from major trials including the COBRA and BASIL studies. David explains why behavioural activation is a robust, practical intervention that can be delivered effectively by a range of practitioners, without losing therapeutic depth or compassion. David reflects on common myths about low intensity work, the importance of supervision and therapeutic relationships, and the challenges services face when balancing access, outcomes, and relapse prevention. Further resources: David's University of York webpage can be found here which details all his publications and research projects Papers and links to further information about the trials mentioned in this episode are listed below: COBRA: Finning, K., Richards, D. A., Moore, L., Ekers, D., McMillan, D., Farrand, P. A., O'Mahen, H. A., Watkins, E. R., Wright, K. A., Fletcher, E., Rhodes, S., Woodhouse, R., & Wray, F. (2017). Cost and outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA): a qualitative process evaluation. BMJ Open , 7 (4), e014161. https://doi.org/10.1136/bmjopen-2016-014161 Richards, D. A., Rhodes, S., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Barrett, B., Finning, K., Ganguli, P., Warren, F., Farrand, P., Gilbody, S., Kuyken, W., O'Mahen, H., Watkins, E., Wright, K., Reed, N., Fletcher, E., Hollon, S. D., & Moore, L. (2017). Cost and Outcome of BehaviouRal Activation (COBRA): a randomised controlled trial of behavioural activation versus cognitive–behavioural therapy for depression. Health Technology Assessment , 21 (46), 1–366. https://doi.org/10.3310/hta21460 Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., Barrett, B., Farrand, P. A., Gilbody, S., Kuyken, W., O'Mahen, H., Watkins, E. R., Wright, K. A., Hollon, S. D., Reed, N., Rhodes, S., Fletcher, E., & Finning, K. (2016). Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority Trial. The Lancet , 388 (10047), 871–880. https://doi.org/10.1016/s0140-6736(16)31140-0 BASIL : Gilbody, S., Littlewood, E., McMillan, D., Atha, L., Bailey, D., Baird, K., Brady, S., Burke, L., Chew-Graham, C. A., Coventry, P., Crosland, S., Fairhurst, C., Henry, A., Hollingsworth, K., Newbronner, E., Ryde, E., Shearsmith, L., Wang, H.-I., Webster, J., & Woodhouse, R. (2024). Behavioural activation to mitigate the psychological impacts of COVID-19 restrictions on older people in England and Wales (BASIL+): a pragmatic randomised controlled trial. The Lancet Healthy Longevity , 5 (2), e97–e107. https://doi.org/10.1016/s2666-7568(23)00238-6 Littlewood, E., McMillan, D., Graham, C. C., Bailey, D., Gascoyne, S., Sloane, C., Burke, L., Coventry, P., Crosland, S., Fairhurst, C., Henry, A., Hewitt, C., Baird, K., Ryde, E., Shearsmith, L., Traviss-Turner, G., Woodhouse, R., Webster, J., Meader, N., & Churchill, R. (2022). Can we mitigate the psychological impacts of social isolation using behavioural activation? Long-term results of the UK BASIL urgent public health COVID-19 pilot randomised controlled trial and living systematic review. Evidence-Based Mental Health . https://doi.org/10.1136/ebmental-2022-300530 More information and publications related to the study can be found www.BASILStudy.org CASPER: Gilbody, S., Lewis, H., Adamson, J., Atherton, K., Bailey, D., Birtwistle, J., Bosanquet, K., Clare, E., Delgadillo, J., Ekers, D., Foster, D., Gabe, R., Gascoyne, S., Haley, L., Hamilton, J., Hargate, R., Hewitt, C., Holmes, J., Keding, A., & Lilley-Kelly, A. (2017). Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression. JAMA , 317 (7), 728. https://doi.org/10.1001/jama.2017.0130 Lewis, H., Adamson, J., Atherton, K., Bailey, D., Birtwistle, J., Bosanquet, K., Clare, E., Delgadillo, J., Ekers, D., Foster, D., Gabe, R., Gascoyne, S., Haley, L., Hargate, R., Hewitt, C., Holmes, J., Keding, A., Lilley-Kelly, A., Maya, J., & McMillan, D. (2017). CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness. Health Technology Assessment , 21 (8), 1–196. https://doi.org/10.3310/hta21080 DiaDeM: More information and publications related to the programme can be found here Insika Yomama: Rochat, T. J., Dube, S., Herbst, K., Hoegfeldt, C. A., Redinger, S., Khoza, T., Bland, R. M., Richter, L., Linsell, L., Desmond, C., Yousafzai, A. K., Craske, M., Juszczak, E., Abas, M., Edwards, T., Ekers, D., & Stein, A. (2021). An evaluation of a combined psychological and parenting intervention for HIV-positive women depressed in the perinatal period, to enhance child development and reduce maternal depression: study protocol for the Insika Yomama cluster randomised controlled trial. Trials , 22 (1). https://doi.org/10.1186/s13063-021-05672-0 MODS: More information and publications related to the study can be found www.MODSStudy.org Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Let's Talk About CBT- Practice Matters , Rachel is joined by Dr Alasdair Churchard, clinical psychologist, CBT therapist and NIHR pre doctoral fellow at the University of Oxford. Alasdair's work focuses on ethnic inequalities in psychological therapies, and together they explore why historical context matters in CBT practice. The discussion covers the importance of addressing ethnic inequalities in mental health services and explores practical considerations for therapists, including how to broach difficult historical topics, the balance of asking versus self-education, and the need to focus on histories of strength and self-empowerment alongside trauma. Further resources: Language used: Talking about race and ethnicity at work | The Law Society , Writing about ethnicity - GOV.UK RHO report: Ethnic Inequalities in Improving Access to Psychological Therapies (IAPT) MHA detentions: Detentions under the Mental Health Act - GOV.UK Ethnicity facts and figures Marmot report: Structural Racism, Ethnicity and Health Inequalities in London - IHE Bansal meta-ethnography: Bansal, N., Karlsen, S., Sashidharan, S. P., Cohen, R., Chew-Graham, C. A., & Malpass, A. (2022). Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography. PLoS Medicine , 19 (12), e1004139. Some culturally-adapted CBT links: Williams, M. T. (2020). Managing microaggressions: Addressing everyday racism in therapeutic spaces . Oxford University Press. Rathod, S., Kingdon, D., Pinninti, N., Turkington, D., & Phiri, P. (2015). Cultural adaptation of CBT for serious mental illness: a guide for training and practice . John Wiley & Sons. Beck, A. (2016). Transcultural cognitive behaviour therapy for anxiety and depression: A practical guide . Routledge. Iwamasa, G. Y., & Hays, P. A. (2019). Culturally responsive cognitive behavior therapy: Practice and supervision (pp. xi-348). American Psychological Association. Lawton, L., Thwaites, R., & Warnock-Parkes, E. (2025). Using cognitive therapy for PTSD when racism was part of the traumatic event (s): case illustrations and practical considerations for therapists and supervisors. the Cognitive Behaviour Therapist , 18 , e31. What is metacompetence?: Whittington, A., & Grey, N. (2014). Mastering metacompetence: The science and art of cognitive behavioural therapy. How to become a more effective CBT therapist: Mastering metacompetence in clinical practice , 1-16. Helen Kennerley on the working relationship: Kennerley, H. (2014). Developing and maintaining a working alliance in CBT. How to become a more effective CBT therapist: Mastering metacompetence in clinical practice , 31-43. Ian Andrew James on kitchen sink formulations: James, I. A. (2010). Cognitive behavioural therapy with older people: Interventions for those with and without dementia . Jessica Kingsley Publishers. Ken Laidlaw on formulation: Laidlaw, K. (2014). CBT for older people: An introduction. Source for Seamus Heaney quotes: Heaney, S. (2014). Crediting Poetry: The Nobel Lecture . Farrar, Straus and Giroux. DPR model: Churchard, A. (2022). How can psychotherapists improve their practice with service users from minoritised ethnicities? An application of the Declarative-Procedural-Reflective (DPR) model of clinical skill development. The Cognitive Behaviour Therapist , 15 , e1. Thwaites, R., Churchard, A., Mofrad, L., Wood, D., & Brooks-Ucheaga, M. (2025). Considering the whole self: integrating identity (s), context and power into the declarative procedural reflective (DPR) model of CBT practitioner development. The Cognitive Behaviour Therapist , 18 , e35. SP/SR for therapists from minoritised ethnicities: Chowdhury, S. S., Churchard, A., Lawton, L., Malik, Z., Thwaites, R., & Clements, H. (2025). A novel self-practice/self-reflection programme for CBT therapists from minoritised ethnic backgrounds: a multiple baselines single case experimental study. the Cognitive Behaviour Therapist , 18 , e15. Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Practice Matters, host Rachel Handley speaks with Dr Christopher Martell, a leading expert in behavioural activation (BA) for depression. Christopher shares his journey from early training in CBT to becoming a key figure in the development of BA, describing how behavioural strategies can help people move toward a more meaningful life when depression keeps them stuck. Rachel puts common myths to him, including whether BA is too simplistic for complex cases or ignores thoughts and emotions, and he explains how BA works with both private and public behaviour to support change. They explore the importance of values, small steps, and compassionate coaching, as well as new research into biological mechanisms involved in recovery. Christopher also reflects on therapist challenges, resilience in clients, and why activation sometimes means slowing down. Further resources: Behavioural Activation for Depression: Second Edition: A Clinician's Guide A Darkness Visible - William Styron The Noonday Demon - Andrew Solomon Find out more about Christopher and his publications here: https://christophermartellphd.com/ Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode, Rachel talks with Professor Zindel Segal, Distinguished Professor of Psychology in Mood Disorders all about Mindfulness-Based Cognitive Therapy. (MBCT). Zindel discusses the origins of MBCT, detailing how he and his colleagues transitioned from traditional cognitive therapy to integrating mindfulness as a core mechanism for preventing depression relapse. The conversation explores the fundamental concepts of mindfulness, the challenges therapists face when shifting from goal-oriented CBT to mindfulness inquiry, and the empirical evidence supporting MBCT's efficacy, particularly concerning the neurobiological findings about sense foraging and the role of sensation in recovery. Further resources: Mindfulness-Based Cognitive Therapy for Depression – Segal, Williams & Teasdale Better in Every Sense – Segal & Farb MBCT website Stay Connected: Follow us on BlueSky and Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode, Rachel Handley talks with Professor Ed Watkins, Professor of Psychology at the University of Exeter a world-leading expert in Rumination and its impact on mental health and wellbeing. Professor Watkins talks about Rumination-Focussed Cognitive Therapy, an evidence-based approach he has developed and trialled to target these specific processes in depression. They discuss: What is rumination What might be the different between adaptive and maladaptive rumination How rumination can become a habit that can maintain low mood, anxiety and depression The development and application of Rumination-Focused CBT (RFCBT) to depression Practical techniques to shift clients from ruminative abstract, self-critical thinking into concrete, experiential, and compassionate approaches When RFCBT may be especially helpful, including with complex or chronic depression Resources & Further Learning: Find more information about Ed and his publications here Find out more about The Calming Minds Project here Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow
In this episode of Practice Matters , Rachel is joined by Professor Judith Beck, President of the Beck Institute for Cognitive Behaviour Therapy and one of the most influential voices in the field. Judith discusses her personal and professional journey into CBT, the legacy of her father Aaron T. Beck, and the evolution of cognitive therapy from its traditional roots to recovery-oriented cognitive therapy (CT-R). Judith also shares insights on the importance of the therapeutic relationship, strategies for validating clients, managing hopelessness, and adapting CBT across cultures and how therapists can look after themselves, continue learning, and stay connected. Resources and links mentioned in this episode: Beck Institute for Cognitive Behavior Therapy Subscribe to the Beck Institute newsletter Cognitive Behavior Therapy: Basics and Beyond (3rd edition, 2021) by Judith S. Beck Beck Institute social media channels: Facebook: https://www.facebook.com/beckinstitute LinkedIn: https://www.linkedin.com/company/beck-institute-for-cognitive-behavior-therapy/ X: https://twitter.com/beckinstitute YouTube: https://www.youtube.com/user/BeckInstitute Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using cognitive behavioral therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today, I'm really delighted to be joined by Professor Judith Beck. Professor Beck is president of the Beck Institute for Cognitive Behavior Therapy and clinical professor of psychology and psychiatry at the University of Pennsylvania Perelman School of Medicine. She has published prolifically on CBT, including key texts that are to be found on the bookshelves of almost every CBT therapist with a desire to hone their craft. And they really do guide us through the basics and beyond. Judy, welcome to the podcast. Judith Beck: Thank you for having me. Rachel: I'm fortunate to have met you previously during a brief period of study at the Beck Institute many moons ago now. However, I imagine that I feel about spending time talking to you about CBT the same way normal people might feel about chatting to celebrities, given that of course your CBT royalty, your father being Aaron T. Beck, also widely regarded as the father of CBT and that you've worked so closely with him to develop the field. It might perhaps seem inevitable given that background that you would end up in this work, but you clearly could have chosen any number of career pathways. Can you tell us a little bit about your personal and professional journey to where you are now? Judith Beck: So I've always loved children. And when I was probably six or seven, I decided that I wanted to be a teacher. And so when I went to the University of Pennsylvania, I studied education to become a teacher, but I took a lot of psychology courses as well. And I taught kids with learning disabilities for a while and then decided that if I wanted to have a career or met my career as a teacher, I really had to go back and get a professional degree, a master's degree. And so I went back to school and got a master's in educational psychology. Then worked as a supervisor for a little while and decided that I should really probably get a PhD. And it was toward the beginning of my PhD program that I became more interested in psychology and in my father's work. And I really think that I must have been at least subliminally influenced by my dad when I was a teacher and when I was a supervisor. At the beginning when I started to consider going into this field, I had kind of a naive idea and it was an automatic thought. I thought, I just don't know if I'm cut out to be a psychologist because I've always been such an intuitive teacher. I didn't really need someone to teach me how to teach, especially when it came to teaching kids with learning disabilities. It was just quite natural for me to know how to take something that was complicated and break it down and speak to my young students in a way that they could understand. So I thought, how could I learn to be a psychologist? I'm not intuitive at all about how to do that. Rachel: So if it requires some learning, then it can't be for me. Judith Beck: That was my thought at the time. And fortunately it turned out to be wrong. And then I started to learn really in detail about my dad's work, and it all made so much good sense to me. And what's interesting is that I've really come full circle. For a while, especially at the beginning, I was primarily a CBT therapist. But then I really became a CBT teacher. And most of my activities now, or many of my activities at the Beck Institute have to do obviously with training and teaching other people to use CBT. Rachel: So you started by integrating psychology into your education and you've come full circle in now you're integrating education into your psychology. Judith Beck: That's right. You sometimes people draw interesting conclusions. More than a couple of people have said, well, you probably didn't go into psychology initially because that's what your father was doing. And I said, no, no, no, it wasn't a reaction to my father. It was just that I was always drawn to working with young children. And that's what I did as a teacher. Rachel: When talking about families, I've often spoken on this podcast previously about how as both a psychologist and a mother, I hope that my professional skills give me skills and insights as a parent that I might not otherwise have. But mostly it feels like I'm just more aware of the many, many ways in which I'm failing as a parent and setting my kids up with all kinds of dysfunctional assumptions about how the world works. I wonder how it was growing up in the Beck household. Was there lots of practice and reflection on CBT principles? Judith Beck: Well, I grew up in the late 1950s and 1960s and I didn't go to university until 1971. And it was really through the later 60s and into the 70s that my father was developing cognitive therapy. But my parents had a very traditional marriage. My father worked all of the time and my mother who actually went to, did something extraordinarily unusual. She went to law school when she had four kids under the age of 10. There were three women in her very large class. Women just didn't do that in those days. It was starting in probably 1961 or 62. Despite the fact that she was in school and then developing her own career, she really had probably 90 % of the care of the kids and the household and organization and so forth. We did have dinner every night, though, as a family. My father stopped work long enough to do that. But we didn't really talk about his work very much. There was one memory that I have that I've told a number of people about, that's when I was someplace around 10, 11, 12 years old. And my father said, Judy, I have a new idea I'd like to run by you. And then he described the cognitive model. That's not a situation that directly influences your reaction, but rather your interpretation of that situation, the thoughts that go through your mind. And so he told me that, and he gave me an example. And he said, what do you think? And what I said out loud to him was, well, yes, that makes sense. But in my own mind, my automatic thought was but that's so obvious. So I think I probably began thinking like a cognitive therapist fairly early on, although we really rarely discussed his work. I knew my both parents were unusual, my mother being in school and becoming a lawyer. And I knew my dad was unusual because he wrote books. And I didn't have any friends who's fathers or mothers wrote books. Rachel: To be fair, I think I've got teenage boys and most of what I say either seems extremely obvious to them or totally ridiculous. I mean, at the other extreme, but it's lovely to hear about your mother as well. Cause obviously we all know so much about your father's work, but obviously two very inspirational, hardworking parents who, you know, work with a love of learning and an interest in doing things in the world. So fantastic. Well, glad he got past you, Judy, because if you'd said it sounds like rubbish, maybe we never would have had CBT. So I'm glad you were one of the first audiences. Now, regular listeners to the podcast will by now be familiar with our podcast challenge. We love a good formulation here at Practice Matters in good CBT style, but because we're an audio podcast, it has to be done unlike almost everything we do in CBT without boxes or arrows or other visual aids. So here's your challenge. Can you give us a brief explanation of how the cognitive model explains psychological distress develops and is maintained without any of those aids. Judith Beck: Sure, so the first thing I want to say is that automatic thoughts do not cause depression. Depression is caused by so many different factors and it's important to take a biopsychosocial view of the development of depression. Automatic thoughts are probably an important precipitating factor among others that ultimately lead to the development of depression. I'm just gonna use depression as an example. But the automatic thoughts don't themselves cause depression. Okay, so the easiest way to talk about a formulation is by presenting a case. So I'll do that very quickly. I had a patient who lived in the Midwest in the United States and her husband got a job in Philadelphia. So they moved a thousand miles away to Philly and she was really struggling. She had so many losses. She lost the physical and emotional proximity to her parents and her sisters to whom she was really close. The same goes with her small but tight-knit group of friends. She lost her church and her church community. She obviously lost her job because she had moved. She lost the kind of the comfort and the safety of the apartment that they had been living in and the neighborhood. And then she moved to Philadelphia where she doesn't know anybody, where the neighborhood isn't nearly as safe, where she doesn't have a job, where she doesn't have family nearby, where she doesn't have a church in that community. And she really feels the losses very deeply and becomes very sad and is overwhelmed by the thoughts of what she has lost and how she can't regain them. She makes a few attempts to integrate into her new community. She gets a job at a nearby shop, but she gets fired after a couple of months because it really was a poor match for her skills. She and her husband look around but can't really find a church that they feel comfortable in. She tries a little bit to meet her neighbors, but they just seem very unfriendly to her. And then she begins to really isolate herself. She begins to avoid things like going out. She even starts avoiding going to the grocery store, so she doesn't feel quite safe leaving the apartment without her husband. And then ultimately she becomes depressed. Once she's depressed, these maintaining factors of avoidance and isolation keep the depression going. So when I first started to see her, of course I do a thorough evaluation and in the very first session and in part of the evaluation as well, I start to hear her automatic thoughts. So her husband comes home and says he has found out that there is another store nearby where she might be able to get a job and she thinks, but if I get that job, I'll just fail at it. And she felt very sad and then her behavior was not to get the job. Why did she have that thought? Well, she had that thought because when she lost the first job that she had tried in Philadelphia, and in fact, she had had some similar experiences when she had lived in the Midwest, her belief of incompetence got activated. And this is a very painful belief to have. And so it makes sense then that she would avoid activities where she thought that she might fail. And the way that we understand the connection between these core beliefs and these coping strategies, these unhelpful patterns of behavior are in our intermediate beliefs, especially her assumptions. One of her broad assumptions was if I try to do anything challenging or difficult I'll fail at it because I'm so incompetent. Another kind of key automatic thought this is the last one that I'll get because you said to be brief. Her husband and she get invited to a dinner by one of his co-workers and when he tells her about it, she thinks Well, what's the use of going? I have nothing to offer other people. I have nothing to say. I won't fit in. I'll just have a terrible time. Again, she felt very sad, and she really wanted to avoid going. Why did she have that thought? Well, it's because she really had some very deep doubts about herself. She had a core belief of unlovability that got activated when they moved to Philadelphia. And again, we could see some just roots of how this started given some childhood and teenage experiences that she had. So her belief that she is unlovable gets activated. Her specific belief was, I don't fit in. But once that belief got activated, then you saw again a lot of avoidance and isolation. And her belief was if I try to interact with other people, they'll just see that I'm so unlikable or that I have nothing to offer them, that I just don't fit in. So in this way, the depression gets maintained when she's even aware of these automatic thoughts, which is sometimes before treatment starts, but certainly much more after treatment starts. When she even became aware of her automatic thoughts, she didn't think to question them, she just accepted them as valid. And then they had a really profound effect on her emotions, on her behavior, and also on her physiology. She described how when she was feeling very depressed and sad and hopeless, her body just felt so heavy. Rachel: So when those core negative ways in which we can view ourselves get activated by, as you said, in that situation, huge loss, we can get stuck in these patterns of thinking that just keep us there and maintain and those behaviors that maintain that. Judith Beck: That's right. Rachel: In preparation for talking to you, Judy, I invested in the third edition, as you know, of your seminal book, Cognitive Behavior Therapy: Basics and Beyond. Perhaps unfairly assuming that I would be almost over familiar with the content because, you know, I've read the first edition, you know, maybe for the first time about 20 years ago, genuinely have gone back to it time and time again. But what I actually found was there was so much more to digest and learn, particularly with respect to shift from what you term in the book, traditional CBT to recovery oriented cognitive therapy or CTR. Instead of going back to basics, it felt a little bit more like sort of back to the future. I was learning all the time reading through that. And I hope we'll dig into this throughout the podcast. But as a starting point, I wonder if you could articulate for our listeners the basics that have stayed the same. Are there immutable principles of the cognitive model and CBT that are sort of set in stone. Judith Beck: Before I start, I think I should make a distinction between cognitive behavior therapy that's carried out by psychotherapists, psychologists, other mental health professionals, and CBT interventions, which are programs usually that use cognitive and behavioral techniques but don't necessarily do the whole therapy. But for now, I'll stick to what is immutable about cognitive behavior therapy. So there really are two things. One is you must have a very strong therapeutic relationship with the client. And if you don't, they may not come back to the next session or they may get very little from treatment. The other is you must conceptualize patients according to the cognitive model. So those two things are immutable. And because we don't limit ourselves to cognitive and behavioral techniques, if we're using a cognitive conceptualization, there may be a rationale for using techniques from any evidence-based treatment. So, for example, I will often use techniques from acceptance and behavior therapy or from dialectical behavior therapy, especially when clients engage in a dysfunctional thought cycle, such as rumination and depression or obsessive thinking or worry and anxiety disorders. So CBT is not defined by its use of cognitive behavioral techniques. It's defined by its reliance on the cognitive model as an organizing theory to help guide treatment Rachel: So it's formulation or conceptualization driven techniques rather than technique driving therapy. Judith Beck: within a strong therapeutic relationship, exactly. Rachel: And we're going to return to the therapeutic relationship later on in the podcast. We're looking forward to talking a bit more about that. One of the most obvious changes between the additions of your Basics and Beyond book is the title change from cognitive therapy to cognitive behavior therapy. What's developed do you think in our understanding of the importance of the B in CBT? Judith Beck: Well, actually the B appeared in the second edition of Cognitive Behavioral Therapy: Basics and Beyond. And we were very much influenced by the term CBT as it was being used in the UK and in other places. And we realized that people were so much less familiar with the term cognitive therapy than cognitive behavior therapy. So I want to say two things about this. One is behavioral techniques were essential from the very beginning of cognitive therapy. And in fact, in one of his books in the mid-1960s, my father describes what we would now call behavioral techniques. And in his first real book about how to practice cognitive therapy of depression, he also very much emphasized behavioral activation and behavioral experiment. So the B is nothing knew. You know, I think if we had it to do over again, we probably should call it cognitive behavioral emotional therapy because so many people think that emotion is not an important part of the treatment when actually the whole reason we have the treatment is so that people can have an improved emotional response. Rachel: It's often sort of an accusation here leveled at CBT. It's not really about the emotions. And as I mentioned earlier, there's a noticeable shift in what you explained in the overall emphasis of CBT. So it appears to have largely changed if I'm right in my reading in terms of time orientation. In fact, you make that quite explicit in how you describe that move from traditional CBT to recovery oriented cognitive therapy. So for those listeners who have yet to encounter that distinction, can you explain a little bit about the difference? Judith Beck: Sure, let me just start with saying what recovery-oriented cognitive therapy is. So it was originally developed by my dad and Paul Grant, who's now our director of cognitive therapy recovery-oriented programs at the Beck Institute. And they developed it as a treatment for people with a diagnosis of serious mental illness, such as schizophrenia. And while they developed the treatment for individuals with schizophrenia of any severity, they really have focused a lot on how to adapt CBT so that it's appropriate for people who have been hospitalized. And they recognize that with this kind of patient, you obviously couldn't use more standard
In this episode of Let's Talk About CBT- Practice Matters , host Rachel Handley is joined by two leading experts in perinatal mental health- Professor Heather O'Mahen and Dr Sarah Healy. Together, they explore the unique challenges, adaptations, and opportunities that come with providing effective CBT for individuals during the perinatal period. Heather and Sarah draw on their clinical experience, policy work, and research to discuss why perinatal-specific approaches are needed, the prevalence and impact of perinatal mental health difficulties, and how therapists can adapt CBT to meet the needs of diverse parents and families. The conversation also covers access to care, the role of identity and stigma, supporting culturally diverse and neurodiverse parents, and therapist wellbeing when working in this emotionally heightened period. Whether you're working in NHS Talking Therapies, secondary or specialist care, private practice, or simply want to deepen your understanding of this vital area, this episode offers compassionate insights and practical strategies for helping parents during this transformative time. Resources & Further Learning: · Find out more about the Pearl Institute here · Access the Perinatal Positive Practice Guide here · Take part in the Jame Lind Alliance perinatal mental health survey here · Listen to the our previous episode on OCD in the perinatal period with Dr Fiona Challacombe Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to Let's Talk About CBT-Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today, we have the pleasure of being joined by not one but two experts in perinatal mental health, Professor Heather O'Mahen and Sarah Healy. Professor O'Mahen is Professor of Perinatal and Clinical Psychology at the University of Exeter and world leading expert in treatments for depression and anxiety in the perinatal period. Her work focuses not only on improving treatments, but also on improving treatment access, for example, through digital delivery. Heather is also currently National Clinical Advisor to NHS England's Perinatal Mental Health Policy Team. And Dr. Healy is a leading perinatal clinical psychologist with over 20 years' experience in the field. She co-led with Heather the development of the Talking Therapies perinatal competency framework and contributes regularly to the development of perinatal mental health policy. They've also founded together the Pearl Institute, which provides evidence-based training for clinicians working in the perinatal period. You're both so welcome. Thank you so much for making time in your busy schedules to come on the podcast. I think the fact that from the first planning to recording this podcast has taken us about 10 months is probably a good indicator of just how busy you are doing this brilliant work. Heather: Thanks for having us, Rachel. Rachel: Now, I know you're both hugely committed to working in perinatal mental health, and I'm wondering how you came to work in the field and what's kept you fascinated by it personally and professionally? Heather? Heather: Well, I came to it accidentally. I applied to do a post-doc at the University of Michigan when I was living in the States and it was in primary care. But they had rejigged things and then said, we have this other one in perinatal mental health, would you be interested? I had a long-standing interest in women's mental health so that sounded really great to me and I said, yeah, I'm definitely interested. Then I started doing therapy with women, parents from the perinatal period, and also doing research in the area, and I just couldn't stop. It's such an incredible, transformative period in people's lives. It's such a meaningful time to get to work with folks. There's so much that's going on, but there's so many opportunities to walk alongside people during this period of change. And then of course I had my own children and that fed it further. And so here I am. Yeah, yeah, yeah. Then you learn like, wow, it really, really, really, really is important. Rachel: You learn what it's really about. Fantastic. And how about you, Sarah? Sarah: Yeah, I guess I came a bit of a roundabout way into perinatal. My early kind of career was more on the research side of things, but I started with a master's in the psychology of early development. I was really interested in that early mother-infant relationship. So I did my PhD in that area and I kind of been moving towards clinical psychology. Thought I would end up in CAMHS because I really liked working with children and that kind of parenting piece and then have the great fortune of having an assistant psychologist post in a mother and baby unit. And I just really found the work fascinating and as Heather kind of said, such a transformative time to be working with. So that kind of started me on my perinatal path. And since then, I've really just found the work so rewarding. And similarly having my own, my son, obviously now eight, he just turned eight. The perinatal period is a little bit a while ago, but I think I learned a lot from the work that really helped me as a parent and then being a parent really, I guess, added to my knowledge and passion for the area. Such an exciting, interesting area to work in and you get such variability in the type of difficulties people are having and the outcomes are so rewarding. I get emails from clients I saw years ago, of pictures of their children that are now eight, nine, ten, and you feel you've been really part of that process. Rachel : Wow. So it sounds like you both really have a deep commitment to women's mental health, to parents, to babies, to seeing kids develop and thrive. And that you've really enjoyed working in this joyous, but also incredibly vulnerable and challenging period with people where you can really make a difference. Now, certainly my experience, I've got three kids and experienced postnatal depression after two of them and I remember look back at it being such a precious, incredible time, really special time in my life despite that, but also all these challenges that are piling in. And yeah, at eight, the challenges continue don't they Sarah, but there's a little bit more sleep maybe. Sarah : The sleep is nice. Rachel : But it sounds like you also both had an excitement about bringing together research and practice around multiple areas like physical and mental health and adult and child developmental psychology in ways that can make a big difference and you both obviously live and breathe this work at home as well. But people who haven't worked extensively in the area might ask if we need a special approach to perinatal mental health, you know, can't we just apply what we already know about the evidence-based practice and approaches to depression and anxiety, for example, for the adult population and adapt those where we need them in line with our individual formulations. Heather: I think that's a really good point. And the evidence would suggest that we can adapt many of the interventions that we do have, but that it's really important to understand what's going on for perinatal parents during this period of their life and to be able to, in those formulations and in those adaptations, make sure that you're addressing the key issues that are important for them. I think this has been for some and maybe historically challenging to get their heads around maybe a little bit. Back in the day, back before there was this lovely investment in England in perinatal mental health care, i t was certainly the case that I would talk to some clinicians or service leads and they go, ah, but we don't really see that many perinatal parents in our service. I don't think there's actually really much of a need- and nothing could be further from the truth. The need is just as great, if not greater and we know that we see an increased incidence around issues like say OCD during this time and also that there are real problems around birth trauma and issues around loss as well. So it is that parents do experience problems during this time. They do want support, but they want the support that's really family focused, that really understands that the baby is so integral in their lives at that point, and that can address it. And we can do that, but we need to get it right. And if we don't, we don't see the parents, just like the service leads said, we won't see them if we don't get them what they need and want. And I think we can compare this to other significant problems that people might be having and very intensive or transformative parts of their lives, like veterans, for example, or people with long-term medical conditions. And we definitely see the priority there that we need to adapt for those problems as well. So likewise let's do right by perinatal parents. Sarah: I think just to add to that Heather, I completely agree with all those points there, but also thinking about looking at services that are doing it well. And when you have services that really are adapting their interventions to be specific to clients in the perinatal period that are doing lots of outreach, that are liaising with other perinatal colleagues, other health professionals, they are getting the clients. They are seeing a lot more perinatal clients and they are getting the positive outcomes. And similarly, most of my clinical work now is in private practice and people are sometimes coming having had not so great experiences of much more generic interventions where they didn't feel people really understood what they were going through, weren't taking into consideration, say, preparing for birth or timings of interventions, didn't really understand the demands of having a small baby or some of the physical issues that might come up at that time. And so we're looking for something that really could take that consideration in time. And often that's the feedback I get as a clinician. It felt like you really understood my journey. You knew what was coming up for me or what may be challenging or difficult. You're really able to help me prepare or link in with other services. So I think the feedback both from clients and you know from services that are doing a really good job about being responsive to perinatal clients, and not just the birthing person, but to the wider family. The feedback is always really positive. Rachel: So we need this specific approach because there's something different about the context we need to take into account. There are specific issues that people are dealing with. And I'm really struck by what you say that if we get it right, people come. If we're not getting it right, we're not going to see these folk and you can draw that faulty conclusion that that's because we don't need it. But that probably applies across the board to lots of different diversity issues and specific issues at different times that people experience in life. And you mentioned, Heather, that there is an increased prevalence of some problems around this time. How significant a problem are the psychological disorders in the perinatal period? Heather: So overall, the problems in the perinatal period, and we've just got new data out on this. So the Mental Health Intelligence Network has worked with NHS England to produce new prevalence with regional data as well on perinatal mental health. So, we know that mental health problems are about 25.8 %, just about, have perinatal mental health problems. Outside of the perinatal mental health period, you're probably talking about a similar slightly lesser prevalence rate across all of the problems. But some of those differences that you're going to find are, say for example, in OCD where we do see a higher prevalence rate. And I think what's also really interesting is that if you ask women who have had OCD at any point in their life, when did it start? A significant number up to about 50 % of them will say during the perinatal period. And also we have sadly high rates of birth trauma and PTSD associated with difficult childbirth experiences. Rachel: And if listeners haven't heard it already, we did a great podcast with Fiona Challacombe who talked a lot about OCD in the perinatal period, which was really so informative and so helpful. So we can see that there are these particular issues which may be raised in this period, but you're all saying that there's also the case that there may be, it may be the genesis of some problems that continue for people much longer than that. And then we may see them later in their life, but this is the period where it perhaps if we got in there and nip things in the bud, we might be able to make a really significant difference over time. And thinking about trauma, which you've spoken about, I provide supervision to folk in Talking Therapies and other secondary mental health settings, delivering trauma focused cognitive therapy for PTSD. And I've noticed that there has been a huge number of cases of perinatal loss coming through. I know this is an area that often culturally wasn't spoken about in the past. What does the data tell us about the prevalence of perinatal loss and outcomes for women and their wider family? Sarah : Yeah, it's interesting. We've been doing a lot of training to kind of increase awareness of the impact of perinatal loss and the prevalence of perinatal loss. I know that it's unfortunately a very common phenomenon, one in five pregnancies will end in miscarriage. We also have to think about the prevalence of ectopic pregnancies, around one in 90 pregnancies, tradition of pregnancies, stillbirth, neonatal deaths, a lot of areas in which one can experience a perinatal loss and that we do know that that can have a significant impact on people's mental health and that's reflected in the research with higher rates of PTSD so the prevalence of the research in this area is growing, but there is some evidence that the incidence of PTSD is higher than what you would expect following say childbirth in the general population. So anywhere between 7 and 20 percent. And also we see higher incidences of anxiety and depression following perinatal loss. We really need to be able to think about how we're offering evidence-based treatments. It's lovely to hear that that's coming up in some of the trauma-focused CBT work because I think one of the things that when we're doing training, we have to talk about is, we need to make sure we're treating the right difficulty or problem. And sometimes when people come with a lot of distress, which is so understandable, following a perinatal loss. They can get immediately signposted to bereavement counselling and that type of support, which may be absolutely appropriate, but we don't want to miss the PTSD, OCD, anxiety or depression that we might need to be supporting with someone with following perinatal loss. So lovely to hear that that's being kind of brought up in your supervision and people are being supported with that. And I think it's one of those areas that actually you do need a little bit of perinatal specific kind of training or information that you really need to inform yourself, kind of what that might have been like for somebody, understanding the physical implications of some of those losses for someone that had to birth a baby or maybe may have been producing milk after birth and have the kind of physical recovery and all of those areas that could have been quite traumatic and might be part of what they're struggling with in the present or they may be struggling in a subsequent pregnancy or contemplating future pregnancies. So thinking about actually having a good grounding and understanding about the different implications of all these different types of losses and ongoing investigations that they might have to be kind of considering or thinking about implications for future pregnancies. So it's a really big area that it's lovely to see getting more attention. So I think this is an area that wasn't really thought about much historically. And anyone who's experienced any of these losses really knows from a very personal place, the kind of impact of it. And we really want to help people be able to kind of process and accept and understand that it's normal to be grieving in this period, but we need to also be addressing any mental health difficulties that might be there. Rachel: Yeah. So it's really good we're seeing these come through and hopefully rewarding for both of you as well, having led on the good practice guidelines, you know, to see people and services following that and picking up on these cases early on and intervening. And I guess that leads us to think about, you know, the access issue that people have. What are the challenges people face in accessing good support in this period of their lives? What makes getting support difficult if indeed it is so. Heather : So I think we have to recognize from the perspective of people who are seeking support, it can be challenging just in general. But I think during this period of life, when there's so much that's going on, so you start off in pregnancy and you've got a lot of appointments that you have to go to, a lot of people are still in work, or they have other children. And so they're juggling all of that and appointments. There can be stigma. We would like to think that we've gotten far with stigma. But there is still quite a lot of stigma that people feel and that can vary across different kind of cultural or economic backgrounds as well and people's willingness to talk about those problems. And sadly, although it is rarely, very rarely the case, but sadly, a lot of women will say that they fear that if they say anything about their mental health problems, that their child will be removed from their custody. And a mental health problem alone should never be the reason to remove a child from somebody's care. So all of these things can be barriers and then there's trying to get into the treatment. If you tell a healthcare professional that you have a problem, you hope that they hear you and that they recognize those problems and that they appropriately refer you on and you get a smooth transition into service. But we know that can sometimes have difficulties and challenges as well. It can be challenging in part because it is normal, say, for example, in pregnancy to have a slight increase in anxiety. And from a healthcare practitioner perspective, and we've seen this data in large scale epidemiological studies that we've analysed, from a healthcare practitioner's perspective, that could be, oh well, it's normal to be anxious during this time period. But it's not normal to have problems that are causing you a lot of distress, most of the days that are impairing on your functioning that are kind of taking over your life. And so it's really healthcare practitioners understanding the difference between what's a little increase in anxiety and what's not a normal experience for somebody and where they do need a bit of extra support and then getting onto that support. Rachel: And I'm hearing that there are these practical barriers, and it does feel like sometimes you're taking on another full-time job, doesn't it? Whe
In this episode, Rachel talks with Professor Barney Dunn, clinical psychologist and researcher at the University of Exeter, about his work on Augmented Depression Therapy (ADepT) a novel approach to treating depression that targets anhedonia (difficulty experiencing pleasure) and aims to boost wellbeing. Barney shares personal and professional insights into why and how traditional CBT might be augmented to actively help people rediscover joy and meaning in life. He explains how ADepT, based on systematic research, integrates cognitive behavioural principles with techniques from ACT, mindfulness, strengths-based CBT and more, all aimed at helping clients live well alongside depression rather than simply reduce symptoms. Whether you're a therapist working with depression or simply curious about new directions in CBT, this episode offers a thought-provoking and inspiring conversation about what it really means to get better- and stay better. Resources & Further Learning: Find more information about Barney and his publications here Find out more about ADepT here Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today, we're joined by Barney Dunn, a highly renowned research and clinical psychologist specialising in therapies to improve wellbeing and functioning in depression and related mental health conditions. Professor Dunn is based at the University of Exeter, and he has a finger in many interesting pies, but today he's here to talk particularly about his work developing and implementing treatment for depression with a particular focus on symptoms of anhedonia. Thanks so much for joining us, Barney. Barney: Thank you very much for having me, delighted to be here. Rachel: And just as a starter, we want to think about how you got into this area of research. And as I said, you're interested in lots of different things, but you've devoted a lot of your time and effort to thinking about anhedonia. There's so much to fascinate in clinical psychology. I wonder what got you interested in the field of depression and specifically this anhedonia area personally and professionally? Barney: Professionally, when I was doing clinical training and learning to cut my teeth with a lot of depression cases, hitting a point where I felt like I'd done quite a lot of work reducing the negative and reducing symptoms, but the job was only half done. And clients were saying things like, at the end of therapy, well, I'm not depressed anymore, but I'm still not quite sure what life's for and I'm not enjoying stuff. And I felt...Well, maybe I'm not doing CBT correctly, or maybe there's a bit of a trick missing about how we can do that stuff better. So that was the kind of professional route into it. The personal route into it was a bit more growing up with my dad. So I lost my mum when I was little and was very well supported by my family but seeing my dad in my eyes never quite get back to life, never rediscovering joy and connection and meaning and grinding through and turning the wheels, but not getting pleasure back and thinking there's a missed opportunity there. Even after the difficult, there's possibility for the good. And so that's the kind of personal motivation is thinking of clients like my dad, how could I help them get back to life when they've been through some difficulty and rediscover wellbeing and joy? Rachel So that really meaningful connection for you from your own lived experience with being alongside someone who never got that meaning back. Those are big questions. And I hear what you say, you working in depression, you get good results with your clients in terms of their symptoms improving, but you talked about a job half well done or half done. Currently, how well are these symptoms targeted in mainstream treatments? I mean, it's a brave man who takes on, you know, Beckian cognitive therapy and thinks, right, we need to do better. Barney: Well, I mean, we should follow the data. So if you do Beckian cognitive therapy and indeed any other evidence-based treatment for depression under ideal circumstances, really good therapists who are really well supervised, you basically get about 60 % of clients who will meet diagnostic remission at the end, half of whom will relapse within the next two years. So that's ultimately a 30 % proper response rate. And that means we leave a lot of people with a lot of distress afterwards, you know, 70 % of the people that are coming through our doors. If you look at NHS Talking Therapies reliable recovery rates for depression lag a bit behind anxiety recovery rates, and they're a bit below 40%. So more than 60 % of the folks coming through NHS Talking Therapies with depression will be depressed again within a couple of years. So there's definitely still a problem to solve and it feels like a really interesting and clinically important question to work on but one to be humble about because lots of really great minds and really hardworking people have thrown themselves at it, and what we've done is proliferated a lot of equally partially effective treatments but we haven't made any stepwise gains since Beck who did make that massive stepwise improvement in the late 70s. Rachel: Yeah. So it's great that there's evidence-based treatments are out there, but there's still a lot of people that find that there's something lacking at the end of therapy or even don't improve. So if we treat the sort of negative feelings, so there's negative symptoms of depression. Doesn't that automatically also address some of this anhedonia or positive valence system? And if not, why not? Barney: So I think that's the assumption we all came from to start with, which is there's a continuum of affects, which you go from being really negative, you get to this middle point where you've been meh, and then you move to this position where you're feeling really positive. So if you bring down the negative, the positive will inevitably increase. But then there's been some interesting other ways of thinking about that and recognising that they're at least partially dissociable systems, which means positive affect can move when negative affect doesn't move and vice versa. And again, just to come back to my dad as a case example, when my dad was dying of cancer, there was a lot of distress and difficulty and pain. And there wasn't a way to make that go away. He was dying of cancer, but that didn't mean there weren't things we could do to find wellbeing within the midst of that. One of my favourite memories with my dad in the last few months was he wanted to drive his car again, but he was on too much morphine to drive safely. So we put him on the sit on mower and drove around the garden, kind of destroying my mum's prized flower beds and my stepmother's prized flower beds. And that's one of my favourite memories, like chuckling with my dad on morphine, driving badly around the garden, amongst a whole lot of negative affect. So I think it's quite useful to realise even in the midst of depression, you can find joy and pleasure. There's also an increasing basic science argument here, which is the systems of the mind and brain that regulate negative emotions and avoidance of threat are partially dissociable from the systems of mind and brain that regulate positive emotions and approach towards things. So you can move one without moving the other. And my view is you need to do both in therapy. Bring down the negative, push up the positive. Rachel : Does everyone experience, I mean, you've just spoken about an example of your dad experiencing lots of negative emotion, but still having that positive emotion. Does anhedonia develop for some people and not others in the context of depression? Barney: I think it's like most ways of thinking about depression, things fall on a continuum. Estimates of how many clients have clinically significant anhedonia ranges from 30 % of them having really severe and profound anhedonia to 70 % having significant anhedonia. It's one of the, along with elevated negative affect, it's one of the two cardinal symptoms you need to get a diagnosis of depression. So it's pretty prevalent, but it isn't there for everyone. And it isn't there for the people that have it all of the time. Its just sometimes people need to develop the skillset when anhedonia is with me, how can I step away from it and get back to wellbeing and joy? Rachel : And is there a differential pathway? I mean, will it be some people who are more likely to develop anhedonia than others or circumstances that are likely to lead to that? Or as you say, is it just likely to be there or not at different times than that pathway? Barney: Well, so my view again is like most symptoms, there are many ways into it and many ways out of it. So it's dangerous to put hard and fast generalisations onto it. But I would say there definitely is a kind of genetic, biological basis for your reward system to be more or less reactive for better or for worse. So some people are just born with a capacity that reward washes over them and they really enjoy it. Others have to work a bit harder. I'm increasingly struck that in people's developmental histories, an absence of early positive experiences then makes it hard to understand and be able to lean into positive emotions. I love the move towards trauma-informed practice, but I think we also need to have just as much focus on clients who've missed the positive and how we can grow that system later from scratch when it wasn't developed during childhood. There is also a pathway from chronic exposure and stress and trauma that alters the reward system. So I'd say there are those three groups of biological predisposition to anhedonia, people through complex trauma have kind of what we'd call neuroendocrine scarring, the kind of hormonal and biological systems that regulate, change the positive affect system, and then people who just weren't exposed to reward and didn't learn how to play with it when they growing up. Rachel : And this for many people is kind of quite a new language and a new way of thinking. Lots of people listening to this podcast will have started their training in CBT, either as CBT therapists or within other professional trainings with the Beckian model of depression and learning their skills. And if we say the words, core beliefs or dysfunctional assumptions, they'll already be mapping out in their minds a longitudinal maintenance formulation. What would a formulation of depression look like taking into account these systems of positive effect and reward processing these kinds of perspectives? And before you start Barney, I need to make you aware of our Practice Matters podcast challenge. So we like a good formulation, but there can be no boxes or arrows or other visual aids because we're an audio podcast. So just a brief explanation about how the problem develops and is maintained without repetition, hesitation, deviation, power point, whiteboards or flip charts. Barney: I like the challenge, Rachel, and you also know me, I'll ignore the rules as we go along slightly. So I'm to give you a narrow formulation of what might get in the way of a client enjoying potentially rewarding experiences. In the therapy ADepT. we've developed, we think about psychological mechanisms of mind that when people are exposed to potential opportunities, get in the way of that leading to sustained and ongoing positive emotions. The first thing is behaviour avoidance, people don't put themselves in situations that are potentially rewarding. The second thing is behavioural shaping. So they're not choosing activities and refining activities in the best way they have to land. So if I'm going to a party, arriving with friends and making sure the music I like is playing. The third one is intentional. When they're in a potentially rewarding situation, they're noticing the bits they don't like rather than the bits they do like. So maybe I'm out for a beautiful meal but don't like peas, so I focus excessively on the peas on my plate, not the beautiful prawns I really like. Rachel : My kids need this. I'm just saying. Barney: The fourth one's kind of cognitive. So what we're realising is a lot of clients who are depressed have a set of appraisals when positive emotions start to switch on that dampen them or crush them. It's because they're a bit alien and scary and weird and uncomfortable. And the appraisals are things like, this is too good to last, I don't deserve this, people will think I'm too big to my boots. So what those kind of appraisals do is they instantly extinguish the positive emotion. And it's a bit like a candle snuffer in a church. The flame is instantly squashed. And what you're left with is the smouldering flame that isn't very pleasant afterwards. There's also a nature of how experientially engaged in the positive activity people are. Are they being very heady and evaluative? A bit like Barney going to a party and wall flowering at the edge and not really being part of it, watching it, versus Barney going to a party and really connecting to the sensory experience. So in ADepT, what we're doing is we're spotting all of those patterns that get in the way of positive affect, triggering and sustaining, and we're getting clients to take a step in the opposite direction. So when they want to avoid, we get them to approach. When they're focusing on the negative, we give them skills to focus on the positive. When we're having dampening appraisals, we give them skills to come up with realistic positive appraisals that can help them engage. When they're being very stuck in the head, how can we get them back into the mindful everyday moment and so on. Rachel : So that was a brilliant summary, Barney. And I know you've talked about high ADepT. You like to keep things short and punchy. So you're obviously well practiced at that. But you've said that there's key factors of behavioural avoidance, behavioural shaping, attentional processes and cognitive processes that are maintaining the model. And you've talked already a little bit about how your treatment focuses on that. Can you tell us a little bit about ADepT? What ADepT stands for and what that means. Barney: Well, so ADepT stands for Augmented Depression Therapy, which was basically an attempt to get better at treating anhedonia in depression. And the broad formulation model in ADepT goes something like this. We think people get depressed for good reason, usually because life isn't going in the way that they'd want it to. So what we're trying to do is help clients clarify what's important to them and makes them tick. So that's values work. Then we try and behaviourally activate them towards getting more of that stuff in their lives. And we fully expect that when that happens, depression is going to try and trip them up as they go. Life will throw them challenges and depression finds ways to make those small hills turn into mountains. How can we take a step away where clients have resilience to challenges in life? Life also simultaneously throws us opportunities and depression is really good at snuffing those out, how can we help clients instead lean into those opportunities? So we're trying to create a virtuous circle where clients clarify and move towards what's important to them and act opposite to their depression so that they get the full potential out of these life situations they're engaging in. And I guess the flip from CBT is actually producing depression isn't the goal here. By the time most people are coming to see us, certainly for high intensity CBT, they're usually on their third or fourth or fifth or sixth episode, if you look at the epidemiology of depression, we know it is a kindling condition that people are likely to have an ongoing vulnerability for. And in some ways it's an unrealistically optimistic model to say, I can cure you, I can get rid of this thing. In ADepT, we're instead saying, how can we support you to live well alongside your depression so that you can have wellbeing? And by wellbeing, we mean getting meaning, getting pleasure, getting social connection. And we frame depression as a barrier to achieving those goals. And we say to people, there'll be times in life when you are in a depressed episode, how can we help you get as much wellbeing at those times as you can? There'll also be times when you're not in a depressed episode, how can we really help you lean into wellbeing at those times? So it's ultimately learning to live well alongside depression, befriending the naughty black dog that's tripping you up and trying to turn it into a bit more of friendly house pet that you trust in your living room. Rachel : And I was struck by what you said at the top of the podcast around, you know, patients getting to the end of treatment for depression and maybe feeling less low, but saying, actually, this hasn't addressed this huge important aspect to me of where's the meaning in my life and where's the positivity at the front end of treatment when you're engaging them in this idea of, of not maybe targeting the depression or, or the goal not being to be depression free but rather one of wellbeing. How do folk engage with that? Barney: I mean, this was one of the really interesting empirical questions when we talk, because I guess the standard view was you can do this well-being work at the end once you've got people better. And surely it will be profoundly invalidating to say to people right at the start of the work, let's really think about what will make you tick and make you want to get out of bed. And what we've found is the opposite. If you clarify what's important to people and help them move towards it, it often helps give them the motivation to keep pushing through when their depression is saying, all I want to do is lie in bed, stay on the sofa and withdraw. Having that, this is what my mind is telling me now, but what's important to me at a higher order level is I want to be a good father or maybe I want to be a marathon runner or maybe I want to do a good job at work. That can give me enough distal motivation to keep me pushing through the avoidance. Rachel : It sounds like as in standard cognitive therapy with depression, would expect trip ups, we would expect ups and downs and we might often formulate those in therapy as an opportunity to test things out. It sounds like those are not only formulated as an opportunity to test things out or put strategies into practice, but actually almost quite essential to the ADepT process that people are experiencing those trip ups to be able to kind of implement what they're learning. Barney: Yeah, one of the things I found in my early CBT practice was I was thinking, well, these people are struggling to get back to reward. So thinking all I've got to do is give them a massive hit of reward. So they used to like parties, let's throw the best party ever so they can get back there. And people were trying it, and they were finding it really quite aversive and saying, I don't like that anymore. And then I was at a kind of talk by Paul Salkovskis, he was being really entertaini
In the second part of this episode with Professor Steve Hollon, we go beyond theory into the heart of applying cognitive therapy for depression in real-world settings. Steve shares what therapy really looks like across the spectrum from relatively straightforward to deeply complex clients and how therapists can stay grounded and effective, even when things feel messy. Resources and links Cognitive Therapy of Depression (Second Edition) Find out more about Steve and his research here OXCADAT: A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/ Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel Handley: Welcome to Let's talk about CBT- Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Welcome back to part two of our conversation with Professor Steve Holland, international expert in cognitive therapy of depression. In our last episode, Steve gave us some fascinating insights into the development of the cognitive model and how we can understand the development and maintenance of depression. In this episode, Steve talks in detail and with lots of examples about how to apply the therapy to really help people with all sorts of complexity in their lives without fear of getting it wrong. So let's dive straight in. Rachel Handley: And so, if you had to put in a sentence the main task of therapy, and I know asking any researcher to put anything into one sentence is a challenge, right? But what would you say is the purpose of therapy that we need to keep foremost in our minds to guide therapy? Steven Hollon: I'll say two things if I can Rachel Handley: I'll allow you two. Steven Hollon: Then I'll say two things. The first component is, when in doubt, do. If you're depressed, don't wait to feel like doing something. You're not going to feel like doing anything. Do the stuff you would do if you weren't depressed. And then the desire will come back, but don't wait to feel like it. And the second thing is don't believe everything you think. And the most powerful way to disconfirm an existing belief is to test it in a situation that your therapist can't control. Therapists get paid to tell people they're okay, or in some cases, dynamic, tell people they're not okay and if you've got kids to put through college, that's a nice, long term life lifestyle. But, what I'll do with the client when we start out and I learned to do this with Tim Beck and Maria Kovacs and others is in the very first session say, l ook, we can do this a couple of ways. There's some things I'd like to teach you how to do. And I can either do them for you or I can teach you how to do them. My goal is to make myself obsolete. Is that okay with you? And usually then people say, yeah, I'd prefer that. Usually, occasionally they won't, but usually they'll say that. And I'd say, now, if we were going to help you learn how to do these things, how can we do that? Say, well, can I work on this stuff between sessions? That's a great idea! So let people reinvent the therapy each time coming through. Then you'll end the session and have something for them to do between this and the next session. And by the way, every major study that has shown an efficacy for cognitive therapy has always seen people who are clinically depressed at least twice a week in the beginning. If I have to wait seven days to meet somebody, to work with somebody who's deeply depressed, they're going to forget who I am. I mean, their hippocampus is turned over. It's a, you have to reintroduce yourself. I get a little momentum going over that first session. Give me two or three days later I can keep the momentum going like Sisyphus pushing the rock up the hill. I don't know what things are like in the UK, but I would always want the depressed client to have twice weekly sessions in the beginning. It doesn't have to be an office, one could be over the internet and then I'll space it out later on. Maybe we get a couple of weeks in, then we'll drop back to every other week. Rachel Handley: And certainly that kind of frequency of therapy is one where we have fallen into habits of, the routine is once a week for an hour on the same day and not one that a one that services often struggle with implementing logistically in terms of this, but certainly, looking at the evidence and the good clinical practice, it seems to be a point that bears reiterating. Steven Hollon: Its for the benefit of the convenience of the therapist, not for improving clients. Rachel Handley: So in terms of therapy, then it's don't think about it, do it. And don't believe everything you think. Steven Hollon: Well, yeah, in terms of the behavioural components, don't wait to feel like it. Do it. But when you do, do a test that tests your beliefs when you do it. With the sculptor, if you don't think anybody's going to hire you, then put applications in. Let's see if you're right. You might be, in which case work on a career change, but don't your problem is right now not that you're incompetent. You might be. Well, we don't know that yet. What we do know is you're not sending out your portfolio and until you send your portfolio out, we don't know how competent you are. So let's find out. Rachel Handley: So let's test the strategy. So keeping in mind that you've said in the manual, which is a brilliant revision, the second edition of Cognitive Therapy for Depression, that therapy is not just a set of strategies or techniques, however, it's helpful to know what a typical course of therapy might look like. Can you tell us what an episode of therapy might look like for someone coming in for cognitive therapy for depression Steven Hollon: I mean, yeah, that's a great question. I think it depends very much on what the client walks in the door with, like the sculptor, nothing much going else going on for him, except he had lost his job, probably no misfortune of his own, but he was going about getting the next job the wrong way. I mean, he was working, but something he didn't consider work and it was just a relatively simple matter of pitting his Theory A, which is I'm incompetent versus Theory B, which is he's going about it the wrong way, which is take a big task, break it into small steps, take it one step at a time, rather than getting overwhelmed with the magnitude of the task. Easy for him. Another client that I talk about is a woman that came into one of our trials that Rob DeRubeis and I were doing, and she ended up drawing me as a therapist. She knew some of the graduate students already. She'd done her training at Vanderbilt several years earlier. And when she got back to town at this point, on the way to getting divorced, real things have blown up for her in her personal life. She's absolutely devastated. Gets back into town, talks to some of her graduate student colleagues, hears about this study, decides I'm going to be in that, goes on clinicaltrials.gov, looks up what the inclusion-exclusion criteria were, sees that we were referring out people with borderline because they could get DBT in Nashville, they're going to do better with that than with what we had to offer. She borrows a copy of DSM, looks up what criteria are for borderline, knows what to deny when she comes in for interview, gets screened into the trial, gets me as a therapist, to her misfortune. In the first session, I start the thing about saying what I prefer to do is teach you how to do this as opposed to simply do it for you. And she said no, you don't understand. I am flawed. I am deeply flawed. Something happened to me as a teenager. I don't want to talk about it. I don't think we need to, but it changed me forever. I tear up anybody I get close to. I would like to have relationships with people that I care about. But anybody I get romantically involved with, I just tear them to shreds. I become this dragon lady, tiger lady. And she said, no, don't worry about that cause I'm 29. I turn 30 in six months and I don't plan to live past 30. And the third thing she said was now I'm an incorrigible liar and you can't believe a word I say, will be a problem for therapy? And of course it won't be, and it won't be a problem for therapy because no matter what story she makes up, it's going to have coherence. Evolution constrains that if she comes and tells a story about something that got her angry, then she's going to have cognitions that are consistent with somebody did something they shouldn't. The physiology is going to be aroused, and the behaviour is going to be want to attack, which is what she did in context of her relationships. So you can work with all that stuff. I never worked with somebody quite like her before, we were 3 years and in the beginning, because she was able to coerce me into it, we were meeting daily and we're meeting pretty much daily for the 1st year. And then we drop back to a couple of times a week in the 2nd year and then spaced out beyond that time. She made a marvellous return recovery, but it was slogging and I didn't know what we were doing half the time, so we're making it up as we go along, more complicated minds are going to take longer. Now, I know from some of the training with IAPT folks, they don't necessarily get longer. However, those folks are going to show up in the service again, as Marsha Linehan would say, you can either pay us now for DBT which is going to be a couple of years, or you can have them showing up in your emergency room, bleeding on the floor, you know, how you want to set up your systems? And what I'll encourage the folks in IAPT to do is, if you get what, 10, 12, session, however many sessions you get, go as far as you can go, but for goodness sake, lay out a cognitive conceptual diagram. So they have a roadmap. The next time they show up with a therapist, they can say, can we start here? I've covered all of this stuff. I'd like to pick up with you and, you know a new therapist, but we don't have to go through all the same ground, do we? I can show you this. I know how to do that. Rachel Handley: And what would that cognitive conceptualist diagram look like? Steven Hollon: Oh, yeah. For the sculptor, there wouldn't be much there. Just his dad used to favour his younger brother when he was younger, so he came to believe he was incompetent. And he did have a lot of other problems going on, just when he got in a tough situation, he would give up too soon. So instead of giving up, let's break it into smaller steps, make it easier to do. It's like walking up a hill. You're more likely to get up a hill if you have steps than if you have to go straight up the icy stream. For the architect, gee, this terrible, awful thing, which no great mystery was involved a gang rape when she was about 15 and her father totally blew her off. She'd already lost her mother about six months earlier. She developed the belief that nobody could ever possibly love her or meet her halfway. So in a relationship, she developed a host of compensatory strategies, what people treating anxiety disorders would call safety behaviours. And her compensatory strategies, when she got close to somebody, she wouldn't ask for what she wanted because she would assume they would turn her down. She couldn't be very direct with somebody she was starting to get close to. And she would be provocative without meaning to be because if they didn't give her what she wanted, she would then act out. And, yeah, she stayed basically 15. And those strategies were the things that were screwing up a relationship one after the other, but she thought they were protecting her from being rejected. And they weren't, they were just the thing that was causing the rejection and until she started to test some of that out we- it was Anke who had to walk me through, it was my first time walking through the reliving of the traumatic experience and Anka had to give me some guidelines on how to do that. We did. It took me about an extra month to get around to doing it, three months to talk her into it, a month to talk me into doing it. My graduate students shamed me into doing it because of course they all learned how to do that in the sexual assault centres before they ever get their degrees. At any rate, it was revelatory. She not only had this notion that she was damaged property, that no decent male would ever want to have a relationship with the thing that happened to her. She also had this notion that, which she didn't have a clue about, which was that it was so scary to think that something so awful could have happened to somebody that didn't deserve it. She wanted to wrap herself up in this really tough, film noir model role. And that was the image of herself she presented the world. What she had to do is drop that stuff and get somebody she was really getting close to, have some night where she would let down the guard, tell them everything that happened to her and see what happened. She wasn't going to do that with the current boyfriend, but she would do that with me as a therapist. She would do that with an old girlfriend that she hadn't seen for years. She invited her up to have a long weekend in Nashville, pleasant, etc. And then she told the girlfriend about what had happened to her. The girlfriend commiserated for about 30 minutes and said, you want to get something to eat? The girlfriend didn't care. Took her a while longer. We had a couple of additional pieces of information she wanted collected by people other than me. And, so we ran some surveys and the like, tape recorded. And then it turns out most people, most eligible males wouldn't be the least bit concerned. One or two would, but she blew them off anyway. She's not ready to talk with the current boyfriend but has a revelatory experience, conversation with him. He commiserates for about 20 minutes. Males aren't as good at that as female friends and said, you wanna get something to eat? He didn't care. What he didn't like was when she picked on him when she was mercurial in the relationship. When if she wanted something instead of asking where he could either decide whether he would give it to her or not, she would try to manipulate him that he didn't appreciate. So when she got past that, she was able to start dropping the compensatory strategies which she thought was protective from being rejected, that's why she was getting rejected, but it took us a while to get there. Now, maybe, having had more experience with that, of the 10 patients I worked with in the Penn-Vandy trial, five of them had histories of sexual abuse, which I do think is a diathesis. And, for four of the five, we got through stuff a lot faster than we did, but she was the first person I worked with. And I was learning how to do this for the first time. Rachel Handley: Wow. And it sounds like there's a huge range in what you say from your sculptor example to this lady who had three years Steven Hollon: That's right. And again, I think we probably could have knocked it out in a year or less with this lady, maybe even less. But the sculptor didn't need the cognitive conceptualisation diagram, wouldn't bother doing it with them. This lady until we got that on paper, that was the, we had a couple of sheets of paper. We always had on the desk every time we had a session, and we'd be talking about what could you do with this new boyfriend? What would you try? Is that risky? What's on the line? How would you like to behave? What would you like to be able to do? And if you were, the new you, and then she would go from that. Rachel Handley: So it sounds like in both cases, at both ends of the extreme, if you like, if we wanted to conceptualise it as a continuum, you're working with cognitions, that your sculptor had thoughts about his part in that he was flawed that it was a problem with him rather than a problem with strategy. But you are getting him in a very behavioural practical way to break down those strategies to test them out to do something different. With this lady there was a lot more involved in understanding why her compensatory strategies might have evolved why her beliefs what and what are maybe we might talk about core beliefs or what are quite fundamental beliefs about herself that there's a lot more working out to do in that, and a more prolonged period of understanding those strategies and testing those out Steven Hollon: Yeah. That's a great summary, next time we revise the manual, if I can, I'd like to borrow your summary. Yeah. The sculptor didn't need the heavy artillery. The architect did. And she wasn't going to take the leap in a relationship that she was with somebody who's interested in easily because it scared the daylights out of her. She was so sure that it was going to blow up on her. She wasn't willing to take that chance. So having the stuff in front of her, gave her a little extra. Rachel Handley: And this really illustrates to me something I've often noticed working with depression. I work a lot with anxiety, with trauma and social anxiety and these kinds of presentations. And often that feels like you're engaged in a kind of sniper fire. You've got a very clear set of cognitions that you go out and you test out, about blushing or about beliefs about the over generalised sense of danger in the world, you know what you're dealing with, you know what the trauma is, you know what the social anxiety is, what the panic cognition is. In contrast, sometimes working with depression feels more like guerrilla warfare. You don't know what's going to pop up when the patient comes in, what situation they're going to bring. The manual talks about being patient led in content, but therapist led in structure and that can lead to some therapist anxiety is like anything can come up any situation, shifting targets, thoughts. You've described a very beautifully illustrated, a kind of very complex piece of work that went on for a long period of time with someone who said they might, I might not even tell you the truth when I'm here, you've got some work to do to understand how things are for them. So what holds this all together when you're engaged in this guerrilla warfare and you don't know what's going to come up and you're preparing for a session? What holds it together? Steven Hollon: Well, yeah, a couple things. Number one is, I always think the patient brings the content, we bring the process. So whatever content they walk in the door with, we're going to put that into our process. And they're not that, this is where we come back to the principles, they're only a couple things we want a client to learn and if they're depressed, it's don't wait to feel like it 'cause your dopamine is not working quite yet, but then the cognitive component of that is don't believe everything you think. Let's see what you believe and let's see how accurate that is. And the most powerful way to find out if what you believe is really true is to set it up in the real world and see what happens. The architect was not going to believe, that, somebody she was interested in wasn't going to reject her until she heard a fact she was interested in. I could say anything I wanted to, the old girlfriend could say that, but you k
In the first instalment of this special two part episode, Rachel Handley talks to Professor Steve Hollon, international expert on the prevention and treatment of depression and co-author of the second edition of Cognitive Therapy of Depression about how we understand and treat depression. Steve shares what first drew him to the field, his early encounters with Aaron T. Beck and the rise of cognitive therapy, and how insights from evolutionary biology, psychology and neurobiology can enrich our understanding of depression. Next time: In Part 2, Professor Hollon discusses how CBT can be applied to a wide range of presentations, from more straightforward to highly complex and even tries his hand at devising a brief intervention for the President of the United States. Don't miss it! Resources and links Cognitive Therapy of Depression (Second Edition) Find out more about Steve and his research here OXCADAT: A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/ Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel Handley: Welcome to Let's talk about CBT- Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. My guest today is Professor Steve Hollon, who had so much fascinating information, theoretical and clinical insights and stories to share that we just had to produce a special two part episode. In this first part, Professor Hollon shares the reasons for his fascination with depression, the story of Beck's development of the cognitive therapy for depression model and insights from psychology, neurobiology and evolutionary biology that can help us understand the development and maintenance of depression. Professor Hollon is an international expert on the prevention and treatment of depression and co-author of the long awaited second edition of Cognitive Therapy of Depression , the definitive and groundbreaking psychotherapy manual, first published by Aaron T Beck and colleagues in 1979. Professor Hollon is professor of Psychology at Vanderbilt University in the US but is no stranger to us in the UK and supporting the dissemination of evidence-based therapies here as he regularly provides training to services in the UK and teaches on the Talking Therapies Program at the IOPPN annually. So welcome to the podcast, Professor Hollon. Steven Hollon: Thank you very much. And Steve, please. Rachel Handley: So Steve, you've been working in this field for quite some time now, you might not want to tell us how long, but can you recall for us who or what got you invested in the field of depression personally and professionally? Steven Hollon: Yeah, I can't tell you exactly why I got interested in depression, but that goes way, way back. We have some family history that I got my own personal history of episodes of depression, but to make a long story short, I was in graduate school in Florida State which was good, strong program, but I was reading Aaron Beck and Marty Seligman and Jerry Claremont, the fellow that generated IPT and I was showing up, in those days we had libraries, we had stacks. And I was looking at some of the same journals that my then graduate student colleague Judy Garber, now 50 years now we've been together looking at the same kind of things and we just decided that we weren't getting the kinds of training that we absolutely wanted, as good as the program was in Tallahassee, we want to work with some of the leaders in the field. So she wrote to Marty and cut a deal with him to run his research labs while he was off on sabbatical at the institute in London. And I was finishing up my dissertation collection data and I followed her up about six months later, with the notion that I would work for Beck. Of course, Tim Beck didn't know me from Adam and couldn't get in to see him. And his cognitive therapy approach hadn't taken off yet, but we ended up seeing that his group was going to be presenting at a conference, Society for Psychotherapy Research in Boston. So we drove up the coast and went to the meeting there and I spent the next three days getting to know the other people in this research group and, talking with Maria Kovacs, really first rate psychologists who ended up becoming a leading figure in developmental psychopathology, Hungarian and wanted to go back to Hungary for an extended visit that summer and Tim was reluctant. They had a research grant going on. She was interviewing people that survived suicide attempts. I'm just hanging out on the fringe of the group, and I said, well, I'm a psychologist, I'll stand in for it. So I stood it on a volunteer basis and spent the next three weeks trying to make myself indispensable. We ended up negotiating my first year in Philadelphia as my clinical internship. Second year, with Tim's blessing, I went over to the psychiatry residency program, continued working with him, and then ended up going off to Minnesota for a job I was thoroughly unprepared for. Nonetheless, things went well, I got an offer and went out there. Judy graciously finished up her doctoral training at Minnesota and eight years later, we were left eight years and 16 winters later, we left for Nashville Vanderbilt and where we've both been on faculty for close to 50 years. Rachel Handley: Wow, that's quite a trajectory. I'm old enough to remember what it's like to go down into a basement of a library and roll the stacks along and actually have to find a physical journal paper, not just type it in on the internet. Right. But from there to working at the heart of the revolution, really, of cognitive therapy with Beck and his team must have been quite something. Steven Hollon : It was something, but it was not a thing yet. Tim Beck, Philadelphia Penn was heavily psychodynamic, he was heavily ostracized. He'd been dropped by the Philadelphia Psychoanalytic Society. Every year they'd have the various psychiatry faculty meet with the residents, and when he met with the residents, virtually nobody showed up. It became a thing with the publication of the first outcome trial, the Rush et al study that suggested that cognitive therapy not only held its own with medications, it was actually better than turns out. It only looked better than because we did a terrible job with the medication comparison, but everything since that's done a good job with cognitive therapy, done a good job with medication treatment suggested they're about comparably effective and cognitive therapy has an enduring effect that cuts subsequent risk by about half something medications can't do. Rachel Handley: And as you hinted there, that was the journey for Tim Beck as well. He came from this psychodynamic background training team, anyone with a passing interest in cognitive therapy now knows about or has started by training in the principles and practice of cognitive therapy for depression. But can you tell us a little bit about his story and the development of the approach? Steven Hollon: Yeah, he was, although he was marvellous fellow, a marvellous human being, but originally wanted to be a pathologist because you could get definitive answers, but he ended up getting diverted into psychiatry. And in those days, the late 40s, early 50s, everybody was trained dynamically. He was trained by some of the best. And of course, the dynamic explanation for depression was it was anger turned inward. These were unconscious motivations laid down in early infancy, to be angry with your parents about something, some kind lack of sexual gratification and the notion was you had to, the patient himself or herself couldn't be aware of what their true motives were because there were defence mechanisms that got in the way. So you had to sneak up on them. You had to rely on free association. People would take the couch and just say, first thing that popped into their head, or you would interpret dream content, and you might spend two or three years exploring the underlying motivations without ever approaching them directly. The therapist might go, certainly better part of a session without saying anything. So it was a very long term, expensive therapy form of therapy. Tim was interested with his interest being a pathologist was interested in doing some research as well. And he was struck by the fact that the things his clients to him and their free associates in their dreams, which is like what they told him when they were walking into the office. I'm an addict. I'm unlovable. I'm a loser. I never do anything right. As, and they weren't screens for underlying, sexual and aggressive drives, They were just what they believed. He did some research where he investigated dream content, investigated free associations, and as hard as he looked, he could not find evidence of anger turned inward. It just wasn't there. He did an experimental study with colleagues across the street in psychology at Penn where they manipulated outcomes on a performance task. And it turns out if you want to get somebody who's not depressed really activated and motivated to try harder the next time, give them a failure experience. Rig it so they don't win. If you want to get somebody who's depressed activated the next time, give them a success experience, contrary to what they expect that then gets them mobilized. And on the basis of that, he started, I think, in '63. he was writing those things up in the late 50s, but a '63 article in what was then the Archives of General Psychiatry, laid out the basic notions of the theory. And in '64, he came back and described some of the things he was doing therapeutically, which were really almost common commonsensical, if you take your client's beliefs at face value, you have them exactly the accuracy of their beliefs, and it got him dropped by the Philadelphia Psychoanalytic Society, ostracized by his colleagues, but the last laugh, he wrote his '67 book on depressions now considered a modern classic an things took off from there. Rachel Handley: Well, that's the kind of failure we can all live with, right? Steven Hollon: Exactly. The one thing Tim would always say is it much like, working with people who are depressed is you always want to turn adversity to advantage. Something goes wrong, find out a way to get something out of that. Rachel Handley: That's what he did. And it sounds like, very much took that, that, that pathology approach. He was dissecting the presentation, what was in front of him and understanding it rather than the bringing theory a priori to the presentation. Steven Hollon: Yeah, absolutely. He was always driven by data, which is again given a psychiatric background, you wouldn't necessarily have expected that, but he did and he was. He also spent at least a year at Oxford in the early 80s. Michael Gelder picked up on this growing phenomenon fairly early on and invited Tim over for a year sabbatical and he did, and that's where he had contact with people like David Clark and Paul Salkovskis. And, just, in some respects, England moves a little closer to Beckian Cognitive Therapy than we do in the States. We have a lot of folks that came to cognitive behavioural approaches from a more behavioural background, and they still have a little trouble thinking about the meaning behind the belief, for them, but a cognition is just another behaviour. You reinforce that in you replace negative thoughts with positive ones, as opposed to getting people to examine the accuracy of their beliefs. So there's a bit of a contrast. And I would think nowadays, David Clark, Paul Salkovskis and Anke Ehlers are closer to Beck in spirit than the states and depression. But, most of the rest of the folks over here, particularly anxiety, stress, et cetera, are more nearly behavioural with cognitive over than are you guys are in England. Rachel Handley: So there's that difference of emphasis and approach, but depression is a worldwide problem where we're used to thinking about and hearing about the statistics and figures like one in five, often quoted in terms of what lifetime prevalence is a big burden on the health of the world population. But it's been suggested that even those high figures might be an underestimate. How significant, Steve, is depression as a problem? Steven Hollon: Yeah, I do a undergraduate class. I'll go and do another meeting later on this afternoon where the whole focus of the class is everything we were wrong about a decade ago, and one of the things we were most wrong about is, we've always thought of depression as the single most problem with psychiatric disorders, and it is, but it turns out it's about 4 to 5 times more prevalent than we realised. And our estimates were based on good retrospective epidemiological surveys, the kind of thing we did in the States with the National Comorbidity Study. Ron Kessler, superb epidemiologist, did that but the methodology is to interview a large number of people over the course of a year, and they range in age from their late teens up to the 80s. And when you do that, about once a year, you'll start getting calls from journalists that say, I noticed that people in their 80s have fewer episodes than people in their 20s. Is there an epidemic? No, there's no epidemic. Just people in their 20s remember an episode of their 20s. People in their 80s don't. So it's a memory problem. If you look at the birth cohort studies that follow people from birth on, like the marvellous Dunedin sample that Terrie Moffit and Avshalom Caspi have inherited and followed, where the sample is now in the mid-forties, you get estimates of depression which are at least 3 to 5 times higher than what we get from the retrospective surveys. And the biggest proportion of extra cases that we hadn't realised are single episode patients. We've always assumed that depression was quite common, about, as you say, about one person in five but highly recurrent. Turns out it's much more common than that. The Dunedin sample, over half of those folks have now had at least one episode of depression, but the bulk of them don't go on to have a second. And what it turns out is that, what it looks like is what an evolutionary biologist would call a species typical behaviour. Any one of us could get depressed if something bad enough happens. Now, there's a subset of folks that go on to have multiple episodes. We don't have a good explanation as for why that is. Scott Monroe and Kate Harkness did a terrific pair of articles, 2019, in Psych Review, and then 2022, I think, in Annual Review where they suggested a dual pathway model that some folks hit adolescence at elevated risk which sounded very compelling. I thought they're really onto something. I remember writing very positively about that. But when you check in the distribution of episodes, in the Dunedin sample it's purely linear. Most folks that have an episode only have one, the next largest group of people have two, next larger group of three, et cetera. But there's no bimodality and that were something like intelligence where there are a large number of factors, no one of which counts for much of the variance. You got a nice normal distribution with a small number of people, genetic anomalies, birth, trauma, et cetera, at the low end, get a little bump. We don't get anything like that. Or if you think of gender or height is normally distributed within women, normally distributed in men, but the two together make a bimodal distribution. If there were really some kind of diathesis that accounted for a large number of cases of recurrent depression, you would expect bimodality, and we just don't see that in the data. Rachel Handley: And so when we look at current reports of increasing incidents of depression since COVID, for example, would your perspective be that's more likely to be measurement area error? Or is that just something so bad has happened that we can get depressed from that. Steven Hollon: yeah, I mean, things happen. We had increases during the depression and increases in suicide, usually suicides, a hard index, and more people jumped out of windows in the 1930s than before or after. I do think when bad things happen, more people are going to get depressed, so it wouldn't surprise me if we have an excess, I would be surprised if they go on to become recurrent. Rachel Handley: Okay. So it doesn't necessarily mean in the longer term, we're going to see an increase in of people presenting for therapy, but we don't know. Steven Hollon: We don't know. I'll be curious. My wife's a developmental psychopathologist. And what she would say is that the thing you don't want to do to 12, 13-year-olds is not let them be in classrooms with other 12 and 13 year olds and make them go through social media, feel criticised, et cetera, that's a recipe for generating angst in young adolescents. Rachel Handley: Absolutely. And given this huge prevalence that you're talking about of single episode depression and then these other presentations where people have recurrent depression, when you see a presentation like that, so pervasive across the species, it might lead you to speculate about is something adaptive about this? And when we look at anxiety, for example, it can seem obvious that being alert to threat would have some adaptive functions, perhaps even things like anger, the function around seeking justice or restoring kind of normal social norms. What might be the value of a depressed mood? Steven Hollon: We thank God for first responders, they keep the rest of us alive. But in our ancestral past, if you didn't walk up to the edge of a cliff, you're more likely to live and have offspring than if you did. So anxiety does serve a function. We've never had a problem with that. Pain serves a function, and pain keeps you from doing additional damage to injured tissues. We've never thought about depression as having a functional advantage. Paul Andrews, the evolutionary biologist at McMaster in Canada, has I think really come close to nailing this. The number of good evolutionary biological theories of depression, any one or all of them might be true to greater or lesser extent. The thing I like particularly about, Andrews and Andy Thompson, his colleague, in a paper they published back in 2009 in Psych Review. When I first read it, I thought, hey, these guys, lovely, but they have no idea what they're talking about, they just got it wrong. And over the last decade of arguing with the two of them, I'm now convinced they were more right than I was. The thing I like about that, what they say is that depression evolved because it gets us thinking very hard and long about social, complex social problems. And in our ancestral past, the one thing young primates couldn't afford to do was be thrown out of the troop. If you were, you're going to get picked off by predators. And if you're a young adolescent female, who's probably already been impregnated, it's going to be a double whammy evolutionarily because you and the offspring are going to be lost to posterity. Now the problem with, you can avoid falling off a cliff if you don't walk near the cliff. but if you've offended the elders in the troop, you got to sort out how you're going to deal with that. Now we know,
In this episode of Let's Talk About CBT- Practice Matters , Rachel Handley talks to two expert guests – Professor Kim Wright from the University of Exeter and Associate Professor Tom Richardson from the University of Southampton – about bipolar disorder and the role of CBT in supporting people with this diagnosis. Tom and Kim share their extensive clinical and research experience, alongside insights from Tom's own lived experience of bipolar disorder. They discuss common myths, the importance of timely and accurate diagnosis, and how CBT can support people with bipolar in a meaningful and collaborative way. They explore what CBT for bipolar looks like in practice, including work on relapse prevention, mood stabilisation, routine regulation and addressing beliefs about mania. The conversation also covers important systemic issues such as gaps in service provision, barriers to access and the need for more widespread training and implementation. This episode is released to mark World Bipolar Day and aims to raise awareness and improve understanding of this often misunderstood condition. Resources & Further Learning: · Richardson, T. (Eds). Psychological Therapies for Bipolar Disorder: Evidence-Based and Emerging Techniques. Spinger-Nature, 2024. · Bipolar UK Commission · Find out more about Kim Wright's research and publications · Find out more about Tom Richardson's research and publications Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to. Let's talk about CBT Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today I'm delighted to be joined by not one, but two expert guests, my wonderful friend Kim Wright, Professor of Clinical Psychology at the University of Exeter, and the equally wonderful Tom Richardson, Associate Professor of Clinical Psychology and CBT at the University of Southampton. Both of our illustrious guests specialise in researching, treating, teaching, and training others in psychosocial interventions for bipolar disorder. Welcome guys. Tom: Thanks for having us. Rachel: I know you've both been working in this field of bipolar for many years. Kim, when I first met you, you were doing a PhD in bipolar, even before embarking on your doctorate in clinical psychology. And Tom, I know you have personal as well as professional reasons to be so committed, and passionate about the area. Can you tell us a little bit about your pathways into this work? Kim: Yeah. Hello Rachel. It's really good to be here. So, I, started out quite a long time ago, when it was possible to finish your psychology degree and go straight into a research associate job and I was very fortunate to be able to do that and work with Dominic Lamb on his trial of CBT for people with bipolar, for relapse prevention. And that is at the, or was at, Kings College London and it was one of the early CBT trials in the area and it was really exciting to be involved in it and as part of that, again, this is a bygone era, it was possible to do a part-time PhD that was heavily subsidised for members of staff of the institution. So I did my PhD part-time with Dominic alongside my role, and that gave me the opportunity to meet hundreds of people with bipolar disorder and hear about their experiences. And then, after I finished, I did clinical psychology training and then worked in a community mental health team for a bit. And then I had a really wonderful opportunity to join the clinical research group at the University of Exter where I am now. And back then it was led by Willem Kuyken and Ed Watkins, who work in the area of depression. And they liked the idea of broadening out the team to include a focus on bipolar. So that was a great opportunity for me to return back to research in the area of bipolar and also to work in the research clinic that we set up in the university not long after. Rachel: What a brilliant opportunity to work with such amazing people, but also to be in there from the ground up, working on that first CBT trial in the area. Really exciting. How about you, Tom? Tom: Yeah. Well, as you said, my research interests really has come a lot from my own experiences because I have Bipolar disorder type I. I haven't always been completely open about that. It's taken a few years of qualified life for me to feel comfortable with that, but yeah, I ended up having a manic episode just after my A levels, just before I started my degree, my undergraduate degree. I ended up in a hospital with a manic episode, so that got me interested in it. And then, when I was doing my undergraduate degree, actually I started doing a little bit, I started doing some stuff for kind of student journals and my thesis was actually about hypomania and how it relates to impulsivity and risk taking in the general population. So I actually became hypomanic about my dissertation, about hypomania. So, and then I was working as a research assistant on sort of computer-based CBT at the University of Bath with children. But I did a little bit of stuff, a few bits of research and kind of papers around bipolar disorder, around like letters to the editor and reviews and that kind of thing. And then when I started my doctorate here in 2010, and that's when I started to get my kind of first real clinical experience, my first placement, I worked with a couple of people with bipolar disorder. And then, I was working in the NHS in Portsmouth community mental health teams for eight years. And that was a whole range of problems, but I did a lot of bipolar work there. I set up and ran a bipolar group, which was, which I really love doing. So it's gone from there. And then I joined the university in 2021, and this is a big part of my research here is about psychological therapies for bipolar. So influenced by my own experiences a lot of the time, as well as my service users. Rachel: And I know that's naturally and rightly a very personal choice to share that information about your own mental health, but incredibly helpful, I think, for other mental health professionals as well as I'm sure your research to de-stigmatise that area and to be able to think about it from the inside out. Tom: Thank you. Rachel: We've recorded a number of podcasts recently on unipolar depression, and in fact, we've got a whole series of podcasts on depression coming out. This will probably be the first one because we've got World Bipolar Day coming up, but those conversations really underlined to me how common unipolar depression is. And our listeners will be not only aware of that, the massive numbers of people suffering from depression, but also probably seeing them in their practice's day in, day out. But bipolar is perhaps a little less well recognised and understood. So, can we start with some of the basics? How might we recognise bipolar disorder or bipolar spectrum disorders outside of sort of dramatic portrayals, like the likes of Claire Danes on Homeland? Kim: Yeah, so you're absolutely right. Bipolar is quite a lot less common than unipolar depression. I would say if you're seeing someone with recurrent depression and they report periods of consistently elated or irritable mood that go on for, say around four days or so, as well as some heightened energy and activation that's pretty persistent over that period, you could ask them a bit more about that time. A key thing is often sleep, people often talk about dramatically reduced need for sleep, but still feeling rested. They might also talk about that their mind's racing, that they're talking a lot more than normal and importantly, if they're around other people, noticing that they're different at those times and there isn't another obvious explanation like stimulating drugs or an overactive thyroid, for example. And I think it can be a tricky one because I think a lot of clinicians are quite reluctant to pursue diagnosis for the, supposedly the milder, subtypes of bipolar. But there is this concern in the prescribing community about the potential for SSRI drugs, antidepressants, to increase vulnerability to mania. So it can be important for people to know if they do have that tendency to periods of hypomania, in terms of treatment choice, in medication. Rachel: Why? Why do you think clinicians are reluctant to pursue those diagnosis? What do you think is driving that? Kim: I think it's partly to do with maybe concerns about people getting a stigmatising diagnosis, concerns about people being, particularly young people, being prescribed what are often seen as quite heavy medications with a considerable side effect profile. And also, the difficulty that there can be if people have quite a rapid cycling, mild or subtype of bipolar with distinguishing that from other potential explanations. So that can make people, some clinicians, maybe more reluctant to diagnose. Tom: I think it's also worth saying that it also just gets missed a lot of the time. I was part of the Bipolar UK Commission, so we wrote some reports as part of that and that one of the key, really shocking findings was it was nine and a half years average to diagnosis. And nine and a half years after you'd been in touch with a mental health professional. Most people are originally diagnosed with unipolar depression, they're diagnosed with a depressive episode, but the hypomanic/manic side often gets missed because you're not likely to go and get help for that unless it's really severe. And then you might end up in hospital or contact with criminal justice or something horrible like that. But actually, a lot of the time people won't go and get help. So it does get missed for a long time because these episodes of hypomania/mania, they go on for a long time, they go on for weeks. That's an important distinction, we're not talking about daily ups and downs here. These go on for a long time, but they still don't go on as long as depression, people are depressed for months, people are hypomanic for a few weeks. So it's very easy to get missed even if you're under a mental health team. Rachel: And Tom, Kim mentioned stigma and that being a barrier sometimes from a professional's point of view to diagnosing these problems. Do people suffering from these issues want diagnosis? What do you think about the whole issue of stigma for people who are presenting in services? Tom: And I know there, there might be some therapists and clinical psychologists who, maybe don't agree perhaps with the term, but actually the research we did with Bipolar UK I think it was 85%, 87% that they found the diagnosis helpful. So we need to listen to that and we need to respect that. Yes, some people did say it increased feelings of stigma, but that was a real minority. And actually, other people were saying positive things like it got me the help I needed, it got me the medication, and it gave me an understanding from my experiences. Maybe there's a small risk of stigma, but I think it's improving. I think the awareness about bipolar disorder in the general public is better than it was a few years ago. And actually what the Bipolar UK Commission found people saying it, it helped make sense of my experiences, I think that's counteracting shame and internal stigma about this because the consequences of bipolar, how people act when they're manic in particular, spending money and changes in sexual behaviour, there's a lot of shame and stigma that can come with that internally, people being very hard on themself and that fuelling depression. So actually people having an understanding and knowing that, and if they're not alone with this and this is part of a condition, can be really helpful. Rachel: I think at risk of finding very circular, diagnoses in general are helpful if they're helpful. So if they help people understand and also help them access appropriate help and treatment for the issues they're facing, which we will come on to, won't we? Is there anything that's helpful for people to know about distinctions between subtypes of bipolar disorder or a spectrum of bipolar disorders? Tom: Yeah, so there's the two main types are Bipolar I and Bipolar II disorder. Now this wasn't always made as a distinction and a lot of people who are listening to this with bipolar might not be aware if they are Bipolar I or Bipolar II, a letter from a doctor might just say Bipolar Affective Disorder. They might not be clear. The main difference is mania versus hypomania. So Bipolar I, which is probably a little bit less common than Bipolar II. It's the more severe mania, full mania where these changes in energy and impulsivity really do get quite extreme and it causes all sorts of problems, people might end up in hospital. So Bipolar I is the more severe mania. Usually with depression, not always, there are some people who just get manic, but most of the time it's depression as well. Bipolar II tends to be sort of more severe depression and then hypomania, which is less severe than full mania, won't cause as many problems, you're not likely to go into hospital with hypomania, but it still causes problems. I think that's important to say, I think hypomania can be dismissed as, oh, it doesn't cause any problems, but it does, and you don't meet the criteria for a hypomanic episode. So that's the main distinction, is mania versus hypomania. Sometimes people may get a diagnosis of cyclothymia, which is where people have these sort of milder hypomanic episodes and depression episodes that don't quite tick those boxes. So I'd consider them people who are high risk for bipolar disorder. Rachel: Okay. That's really helpful. I wonder if there are any other, or any myths about bipolar and how it presents or is often understood that you'd like to bust that might be barriers to clinicians understanding or engaging well with people in this area. Kim: I think a big one for me is the portrayal of the high periods as being times of extreme happiness or extreme positive feelings. Whilst they can be for many people, one of the kind of key symptoms of mania can be irritability rather than a kind of happy, high mood. And that can mean that it can be missed because it's the person isn't saying, wow, I feel really joyful and elated. It's more like this huge level of frustration often that things aren't happening quick enough, that people are getting in the way, the world isn't letting things evolve and goals to be met as quickly as the person might like. And also, even if people do start out feeling quite high and elated for some people, that it can become quite unpleasant. People talk about feeling I'm overactivated. I'm not even sure I really want to be, but there's nothing I can do to put the brakes on. Yeah, so that's one myth I would want to bust. Another one would be that some, and this is really important, that there can be a portrayal in the media that someone with bipolar is always up or down, when in fact lots of people with bipolar have very long periods of being feeling pretty stable, being well, and only occasional episodes. Rachel: Yeah. I'm reminded of a recurrent dream. You know, we all have these recurrent anxiety dreams from time to time. One of mine is being in a car and not being able to put the brakes on. When you were talking about that feeling of just speeding up and not being able to stop, that's what that reminded me of and that horrible feeling of being out of control. Kim: Yeah. Tom: I agree with Kim. It's not all pleasant when people are manic people, it can feel very unpleasant, it can feel very distressing, out of control. I think a big one for me is, as I suggested a little bit earlier, a big misunderstanding is that this is daily ups and downs, which might be seen more with something more emotional sort of dysregulation. And when people are manic, they can have this dysregulation where the moods are quite up and down. But these episodes we're talking about are like weeks at a time. We're not talking about it changes one day to the next. We're talking about your hypomanic for a few weeks, and like Kim said, then you can be stable for a long time and then you might have an episode of depression that goes on for kind of a couple of months. So that's a really important distinction. Rachel: Brilliant. Thank you so much for, enlightening us in those areas. What's the place then for psychological treatment with bipolar disorder? I guess we hear a lot about the biological vulnerabilities to bipolar disorder, or there's a sense that this is something that's genetic or biologically driven and I'm sure we'll talk more about that. Is it a presentation that really requires primarily or exclusively a pharmacological intervention, or does that differ depending on what stage you're at in terms or phase you're at in terms of the symptoms or you're experiencing. Kim: So you're right, pharmacological treatment has historically been the main treatment offered to people with bipolar and in the NICE guidelines there are certainly plenty of recommendations about pharmacological treatment and there are differences depending on the phase of bipolar, but psychological therapies are also recommended and those include CBT. And they're recommended really for two main aspects; so one is for relapse prevention and the other is for acute bipolar depression, at least within the NICE guidelines. I think it's really important to say that unlike maybe with some other conditions, we don't have much in the way of trials of psychological therapy without medication compared to medication. Instead, it's usually psychological therapy in addition to medication or usual care compared to usual care. So the evidence base for psychological therapy as an alternative to medication is not well developed. However, what I would say is, I would hate to see a situation where somebody who can't take medication for bipolar, or chooses not to, is denied psychological therapy because there are just really good reasons to expect it will be potentially really helpful for people. So I would want to see that being an offer to people, who can't or don't want to take medication. Tom: I think a lot of people might underestimate just how effective psychological therapies can be for bipolar. The biggest meta-analysis that's been done, it showed that CBT, group-based psychoeducation, which is often very sort of CBT informed and family interventions, family therapy, nearly halve the risk of relapse, Rachel: Wow. Tom: Which is really impressive. My take on the kind of literature so far is that if you add in medications like lithium, it halves your risk of relapse and then you add therapy on top, it halves the risk again. Which is pretty huge really. It really is. And I think that there, there's sometimes an issue about, maybe there's a little bit of, it's not as clear how much it reduces acute manic symptoms, but I think the evidence suggests maybe it does. And the same with acute depression symptoms. I mean, it is hard to do therapy with someone if they are really acutely manic and really acutely unwell. But actually, the evidence does say, well, it still might reduce kind of manic symptoms. So yeah, there's sometimes an issue about when you do it and what the motivation is cause it's really good for relapse prevention work. Sometimes I pe
In this episode of Let's Talk About CBT: Practice Matters , Rachel Handley is joined by Dr. Rebecca Murphy, a clinical psychologist and researcher specialising in Cognitive Behavioural Therapy (CBT) for eating disorders. Together, they explore the complexities of eating disorders, effective treatment approaches, and ways to improve accessibility to evidence-based interventions. Resources & Further Learning: Visit cbte.co for information on CBT-E, training, and resources. Learn more about Rebecca's research at the Centre for Research on Eating Disorders at Oxford (CREDO) . The CREDO Contributors' Group is for individuals who are interested in our work, including people with lived experience of eating disorders, members of the public, and professionals with an interest. People in our Contributors' Group may be invited to participate in future research and consultation if they wish. Join our Contributors' Group by emailing credoenquiries@psych.ox.ac.uk . Please contact: Lisa.debrou@credotherapies.com if your clinical practice is interested in using Digital CBTe Rebecca's research ad publications can be found here: https://www.psych.ox.ac.uk/team/rebecca-murphy Follow Rebecca on Twitter/X: @rebeccamurphyox for updates on her work. Read Overcoming Binge Eating by Christopher Fairburn – a key resource on CBT for eating disorders. Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: podcasts@babcp.com Subscribe and leave a review – and don't forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today, I'm really delighted to say we're joined by Dr. Rebecca Murphy, clinical psychologist and senior research clinician at the University of Oxford, specialising in CBT for eating disorders and its dissemination. Welcome, Becky. It's really lovely to have you on the podcast. Thanks so much for joining us. Rebecca: Thank you so much, Rachel. It's such a pleasure to be here, and to be part of this really interesting series that you've put together. Rachel: Becky, we go back a few years, right? We probably even unknowingly crossed paths in the psychology department when we were undergraduates overlapping. But ever since I've known you properly when we embarked on our clinical psychology training, you've been really interested and passionate about eating disorders. I'm wondering what got you interested enough in the field, personally, professionally to pursue this as essentially your life's work? Rebecca: Yeah, thank you so much, Rachel and it's lovely to be speaking with you, as we have known each other for such a long time. So, I guess my interest started with mental health generally, and probably I had an interest from a very early age compared to most people, because my father was actually director of a therapeutic residential community for people with severe and enduring mental health difficulties. And as a director, he actually had to live on site, so I actually grew up surrounded by people with various mental health problems, seeing the impact it had on people's lives and being able to observe the difference that support and care made. I carried this through and that's why I studied psychology as an undergraduate. And within my course, we looked at different areas of mental health and I was very interested in eating disorders and what I especially loved was their complexity and the multifactorial elements. So as with many other areas, they're sort of no single cause. Yeah, you're thinking about biological, psychological, social factors. But I think with eating disorders, it's a really nice example of how all of those elements come together. So that was kind of my early interest. And I wanted to do something that would really make a difference, and I felt as if eating disorders as a field is actually still relatively young compared to some other psychological disorders so I really thought, Oh, I've got an opportunity potentially to make a big difference, as a researcher and clinician, in terms of thinking about new approaches, new ways of understanding eating disorders. And when I started to work with people, I also loved seeing how much people could change. So I really felt that it was an area in which there's so much hope because most people do get better and that was really rewarding to be part of. So yeah. That's where it all started. Rachel: And do you think that desire to make a difference, and that sense of hope was rooted in those early experiences that you had of living in that community? Did you see people's lives change, impacted there? Rebecca: Yeah, I think I did. I suppose I saw two things. One, if it's part of your everyday environment, it's very de-stigmatising, so you just see how normal it is for all of us at some point in our lives to have various difficulties, and I think I didn't really see it as something separate or that it was something that made people fundamentally different. I just saw it as part of a sort of continuum, that maybe we're all on. And I did, I saw people change. I mean, not necessarily the parts of them which they appreciated and valued but I could see that when people were really suffering, that was something that if you provided people with care and support, they were able to come out of and then they were able to make changes in their lives in terms of what they wanted, in terms of living independently or no longer being in such a state of distress. Rachel: So you could say that mental health has been part of your experience in terms of your genetics, your social environment and your psychological interest yourself throughout your life then. Rebecca: Definitely. So for me it was an everyday conversation from a really young age. Rachel: And I know you're interested not only in the what or process of treatment for eating disorders, but you're also interested in how we deliver therapy to make treatment more accessible and widely available. And we'll get into some of the great work you've been doing in that area. But given this is a young field as you've alluded to and there's probably still a lot of work to be done, how easy is it for folk who need access to good evidence-based treatment for eating disorders to access that? Rebecca: It is such an important question and unfortunately there is, as is the case in other fields as well, but there's a huge treatment gap between the number of people who could really benefit from treatment and the number of people who actually receive it. And perhaps there are two, two major sources of this treatment gap. One is that often people with eating disorders, they feel a sense of stigma or shame surrounding the problem so people may delay seeking help or never seek help because they don't feel able to disclose it to someone and so that's sort of an internal barrier. And then externally other barriers include that there is really only a limited number of trained therapists to be able to help people with eating disorders. So even when people do come forward and seek help, there aren't enough specialists to meet demand. And I mean, that's true even in kind of wealthy developed countries, and we know that only a small percentage of people with eating disorders receive recommended treatments. Rachel: So it's that double whammy of actually, it's really hard to get yourself to therapy because of that stigma, because of those barriers, and then you get there and you might not even be able to access it, so a lot of work to be done there. Rebecca: Yeah, absolutely. So it's a really difficult journey for people. Another barrier is often that people might present for help, but due to a lack of training, quite often primary care staff, so people sort of GPs and other individuals at the first point of contact, they aren't trained well enough to easily be able to recognise eating disorders as well. So people can get missed, misdirected or dismissed and if they even make it through that barrier, they might have to wait years to get treatment if they're even offered any, many eating disorder services are so limited that they can only offer treatment to people that are considered to be at very high risk, so other people just get turned away. Rachel: And the term eating disorders covers a really wide range of clinical presentations. I wonder if you can tell us a little bit about maybe some of the unifying characteristics of eating disorders and also aspects that might differ diagnostically, and what we know about typical presentations our listeners might see day to day in clinical practice. Rebecca: Yeah, that's a great topic to consider and I really liked how you started with asking about unifying factors because it's something that our research group at the Centre for Research on Eating Disorders at Oxford, our position is that we're more interested in features or characteristics of eating disorders rather than diagnoses. And quite often you do have these shared or unifying characteristics, which are quite specific to the eating disorders, but are shared across the group. And one of those characteristics is what we call an over evaluation of shape and weight and eating, which is where people's sense of self-worth depends largely or exclusively on their ability to feel like they're doing well in the areas of eating, weight and shape. So often people might be feeling bad about themselves as a person because they feel that they're not able to do well in those areas, which are very much informing their sort of sense of self-worth. So this is quite a unifying characteristic across most eating disorders, but not at all. And quite often this characteristic drives other features of eating disorders that we see. So for example, if you are feeling that in order to be worthwhile as a person that, in terms of the areas of, for example, weight and shape, it quite often means that people end up developing strict rules about their eating. So this is where perhaps they have certain foods, which they do not allow themselves, they may set calorie limits. And these rules need to be followed, because they are rules, and that leads people sometimes to go on to actually eat a restricted amount of food which may mean that they develop being a lower weight or in some cases what can happen as well is because the rules are so strict, it actually causes them to have episodes of binge eating, where they lose control and eat an unusually large amount of food. And that's through a couple of mechanisms, including feeling as if they've broken the rules because often these rules are so difficult and demanding that it's almost inevitable they get slightly broken and that can trigger a "well, I've sort of messed up a bit, I might as well give in completely". And also people get very hungry and in a state of psychological deprivation. So they're sort of craving and drawn to the very foods that they've banned themselves from having and people often feel incredibly distressed and guilty, as a result, and this reinforces their desire to want to diet more and be more concerned about their shape and weight, and they get stuck in that cycle. And so that's kind of one element and then we also have another sort of feature around eating disorders is that people are using eating in some way to try to cope with difficult or intense mood states or problems in their life as well. So that's another kind of characteristic feature amongst eating disorders. Rachel: And, in terms of the kind of labels we might put on these kind of presentations diagnostically, and I hear what you're saying, kind of there are these trans diagnostic features, these unifying features, what are the kind of presentations people might hear about, see, be intervening with in clinical practice? Rebecca: So probably the three most well-known eating disorders are Anorexia Nervosa, where people restrict their eating and become a low weight. Bulimia Nervosa, where people also judge their self-worth in terms of wanting to control eating shape and weight, and they will also diet, but at the same time they have episodes of binge eating and they may make themselves sick as well. And then there is Binge Eating Disorder which is where people have regular episodes of binge eating, feel very distressed about that, but they don't engage in the set of compensatory behaviours we see in bulimia nervosa, and the compensatory behaviours are fasting or making themselves sick those sorts of things. So they're the three most well-known. But then there's a group of what we might call other or atypical, which are still above the clinical threshold, but they don't quite meet the exact set of criteria of the other disorders. Rachel: So they're still distressing, they're still interfering with people's lives, and they're focused on these kinds of behaviours, but maybe don't quite fit the mould. Rebecca: Yeah, absolutely. Rachel: And what do we know about how significant a problem these eating disorders are population wide? Rebecca: Yeah. so actually eating disorders are, as well as sort of being severe, they are relatively common as well. There was a systematic review in 2019, which estimated that over 100 million people worldwide are currently experiencing an eating disorder. And in terms of kind of population estimates or how often over the course of somebody's lifetime they might experience an eating disorder, the most common eating disorder is binge eating disorder. So that affects around sort of 2-5% of the population of people over their lifetime, many cases go undiagnosed. Bulimia nervosa has a lifetime prevalence of around 1-2%. And the rarest eating disorder is anorexia nervosa, even though it's often the most well-known and the most perhaps visible on the surface level and that affects around half to sort of 1 percent of the population. And that's in terms of eating disorders above a clinical threshold whereas we also know that many people have disordered eating or eating problems below that threshold as well. Rachel: And I imagine there's a bit of overlap and people move from maybe one presentation to another over the course of their lifetime or the period of their eating related problems. Rebecca: Absolutely, yes and that diagnostic migration, where people may perhaps begin their eating disorder journey, meeting the criteria for anorexia nervosa, which could evolve over time. And another time that you see that person, they might be experiencing criteria, which is consistent with bulimia nervosa. That diagnostic migration is common and that's one of the reasons that our research group take a more transdiagnostic approach to understanding and treating eating disorders, because it doesn't really make sense to us if we were to see someone one week and it looks like they meet the threshold for one disorder and we seen them a week later, they meet the threshold for another disorder, to suddenly change our treatment approach based on that kind of fluid progression. It makes more sense, in our view, to take a trans diagnostic approach where we're really interested in what are those kind of unifying features which tend to be quite specific to eating disorders and we match and map our treatment onto those features rather than a diagnosis. Rachel: And potentially much more meaningful and helpful to those individuals as well. We're coming up to Eating Disorders Week in the UK towards the end of February and I've seen statistics on the BEAT website where they talk about the theme of the week is anyone can be affected by an eating disorder , and really those statistics do speak to that. And they talk about 1 in 50 perhaps in the UK experiencing these kind of presentations at some point in their life, which is really, it's huge isn't it, and speaks to the importance of the work you're doing. And in our culture, in Western culture, there is such a strong emphasis on the importance of weight and shape. It is actually hard to fathom sometimes why any of our young people grow up with a healthy, happy body image. We were just catching up on our kids, before we started recording and talking about my youngest, my seven-year-old daughter. And I was really shocked in this last week when she suddenly announced that she was fat and had a fat tummy. I'm really taken about where that come from, as it didn't come from chatter or talk around the house. And you hear these narratives so quickly in young people's lives. But obviously there's something about the kind of presentations you've been talking about, that some folk go on to really get trapped into this very single minded focus on weight and shape. Given the range of presentations, you've talked about these fluid presentations, the overlapping presentations, is it possible to identify a typical pathway into eating disorders? How does someone go from a feeling that they've got a fat tummy to this kind of overvalued sense of identity in their weight and shape? Rebecca: Yeah, that's a good question and I appreciated your lead up to that in terms of thinking about, how common it is and how worrying it is as parents and members of society to see our young people just start to exhibit essentially eating disordered type behaviours and thoughts, from such an early age, even if they don't meet the sort of diagnostic threshold. And actually studies have found that it could be sort of around one in five children and adolescents worldwide do exhibit these sorts of eating behaviours, which is really very common. In terms of the sort of pathway I guess every individual's journey is different, but there will be contributing factors. So there are certain risk factors that make some people more vulnerable to developing eating disorders, and essentially one of the biggest risk factors for eating disorders is something which many people engage in which is dieting. And for some people they can navigate that, they can sort of diet in a way that it doesn't dominate and take over their lives. But for some people, what starts as perhaps less sort of harmful dieting can really develop into something where people start to feel that the eating disorder is controlling them rather than the other way around. And sometimes you get a perfect storm of factors, so it might be, for example, I mean it's different for everyone, that somebody starts dieting, maybe they feel that generally other elements of their life are not in their control, so they get quite a sense of control because they're eating and perhaps early on is something they feel that they can control and change. Maybe they have an influence on the number on the scales, maybe they've had times in their life when they've been bullied or treated in a way or exposed to some kind of trauma which makes them feel bad about themselves, which makes them feel bad about their body. Maybe they get some positive feedback, sadly, from people on sort of you know, dieting or losing weight because of the weight stigma and our culture which values restriction. And maybe they then also have some difficulties in their life, which they then turn to controlling eating disorders to cope with. The sort of dieting pathway is quite a common pathway and perfect storms are created by maybe having some other things in the background, perhaps some triggering factors, perhaps there's a relationship breakup, loss of a job, s
In this episode of Let's Talk About CBT – Practice Matters , host Rachel Handley speaks with Andrew Beck, consultant clinical psychologist, CBT therapist, and author of Transcultural Cognitive Behavioural Therapy for Anxiety and Depression . Andrew is a leading expert in culturally adapted therapies and a former president of the BABCP. Together, they explore the importance of culture, language, ethnicity, and identity in therapy and how these factors influence mental health, therapy engagement and treatment outcomes. Andrew shares his personal and professional journey into transcultural CBT and he and Rachel discuss practical strategies for therapists to approach conversations about culture and difference in therapy, as well as the evidence supporting culturally adapted approaches. Andrew encourages therapists to engage with these topics, step outside their comfort zones, and take a flexible and collaborative approach to transcultural CBT. If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on Instagram, @babcppodcasts.bsky.social on BlueSky or email us at podcasts@babcp.com . Resources & Further Reading Transcultural Cognitive Behavioural Therapy for Anxiety and Depression : A Practical Guide by Andrew Beck The Cognitive Behaviour Therapist Special Issue on Being an anti-racist CBT therapist IAPT Black Asian and Minority Ethnic Service User Positive Practice Guide Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to Let's Talk About CBT- Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who share insights that will help you understand and apply CBT better to help your patients. Today I'm going to be talking to Andrew Beck, consultant clinical psychologist and CBT therapist. Andrew is a former president of the BABCP and author of the influential book, Transcultural Cognitive Behavioural Therapy for Anxiety and Depression . He's also a leading expert nationally and internationally on culturally adapted therapies. So we're so delighted to have you, Andrew. It's one of the great joys of hosting this podcast, having the opportunity to read and reread the work of world experts in different areas of CBT, like yourself, and to talk to them about their work and having dipped into your book a few years ago over the years, it's been wonderful to have an opportunity to read it from front to back as there's such a rich, wide ranging and thought provoking and practical information in it. I'm also really curious, cause at first glance, not necessarily the obvious choice of a topic for a white British therapist to write. And I'm wondering how you got engaged in this work. What's motivated and informed your interest in it personally, professionally? Andrew: Yep, it's a really good question, Rachel. And first, thanks for letting me know that it was a helpful book to you and something that was readable. It's one of those really difficult things about putting a book out there that you never know how it's landed and how it's landing, really. Because people pick it up, but you seldom hear from people about what it was like as a resource. I mean, how I came to be interested in it was through a couple of strands, really. One was quite personal, going right back to, I suppose like my early political life. I was born at the end of the 1960s. By the time I was 12, 13, the National Front who were kind of overtly racist political party were quite active in the area that I was growing up. And I think I was probably 13 when I first went on a kind of anti-Nazi league march and was listening to The Specials who were a band who really articulated the need to push back against that kind of growing tide of racism. And that was really formative for me as were some of the friendships and relationships I had during my teens and twenties, and being close to people who'd experienced discrimination at the sharp end. Really, as you say, I'm a kind of white English man, I'd never really experienced any kind of discrimination or hardship as a result of my characteristics, but politically I was interested in getting alongside people who had. So that was where it came from a kind of values point of view, I think, but in terms of how I ended up doing that as part of my job as well, is, so I was quite late to psychology. I graduated when I was around 25 and one of the first jobs I had was a research job in Nottingham, looking at how and why people used acute psychiatric beds. I was really lucky in that part of the team who were doing that work was a trainee psychiatrist called Swaran Singh, who's now Professor of Social Psychiatry in Warwick, but at the time he was just sort of finding his feet as a psychiatrist. And he said to me one day, have you ever noticed how nearly everybody who comes into these wards on a section of the Mental Health Act is a young black man? And I said, no, I hadn't noticed because, you know, I was a young white man. I didn't need to notice things like that. I didn't need to recognise those inequalities because they didn't really affect me, but Swaran as someone from a minoritised background had noticed. And what he was able to do was tack onto the study that we were doing, an additional study, looking at the rates of sectioning and who got sectioned and why. And with the statistical help of Tim Croudace, we wrote a paper that showed that young black men were massively disproportionately admitted under sections, despite the fact that the severity of their presenting problems was no greater than anyone else's. So that got me really interested in inequalities in mental health care. So I was really lucky that I had someone who opened my eyes to that really at a formative stage in my career. And then I spent three years as an academic, a research assistant, research associate. The professor in charge of my department told me that I'd never be a very good academic, but I'd probably be okay as a clinician. So then I applied for clinical psychology and began to practice clinical psychology in East London, where the patient group we were working with was diverse. So from the moment that I began to learn how to be a therapist, it was learning how to be a therapist with people from different backgrounds to myself. So that's how I became interested in that quite early on in my career, really. Rachel: So it sounds like you found yourself in a time and place in your life where there are these movements going on around your natural interest and inclination to stand up against racism and discrimination. But then also these key figures that drew you in and were generous with their time and thinking and their experience to help you think about ways in which you could really enact that in your work. Andrew: Yeah, that's absolutely right. I was so lucky in that, that there were a number of people who took the time to kind of help my thinking develop really. And that was generally people from minoritised backgrounds themselves who could see I probably had some kind of enthusiasm or interest and who sort of put the time and effort into bringing me along. And I'm really grateful for that really, I was very lucky to have those experiences. Rachel: And it's evident from your own history of your involvement in this work. This isn't a new conversation. It's not something that we're arriving to just now in terms of a therapy community. However, the way in which we discuss these things often feels quite tentative and people are coming to it often quite new and without kind of fully formed ideas. One of the things that might be helpful to think about upfront as we're having this conversation is what kind of terminology we might use in this podcast and maybe more generally that is helpful, rather than alienating for folk as we talk about transcultural therapy. Andrew: Yeah, that's a really good question, Rachel. And it's one of those things that I think when I think back about how we had those discussions, in the kind of mid to late nineties, the language that we use then was very different to the language that I would use when I first started writing about this in publications and the language that we use now is different again. And it's a constantly evolving language. And I think that's great because as therapists, we know that the way we describe the world helps us understand the world and so refining our language is really helpful. But there's a downside to that, which is, I think worrying about getting the language right can be a little bit paralysing for people and people can be so worried about saying the wrong thing that they say nothing. And I think one of the helpful positions to take is that if people are trying to do the right thing, trying to talk about things from a position of good intent, but whose language isn't quite up to date, what I think I've learned over the years is not to kind of really overtly correct them, but to just use language that I find more palatable and see if that kind of rubs off to give people that different opportunity to talk in different language about these kind of issues, because I would rather people had a go and got it a bit wrong than didn't have a go at all. But in terms of the language that we currently use, I mean, it's in a state of flux, I think, So, when I published the book Transcultural CBT , I used the term BME, Black and Minority Ethnic, because that was the most useful phrase around at the time. By the time it was published, that phrase was out of date and the preference was for Black Asian and Minority Ethnic. And so when we did the Positive Practice Guide, myself and Michelle, we used the term BAME because it seemed like the most useful, but we knew then that term was on its way to changing. And I think we even acknowledged that in the writing, that the language that we use at this moment in time will seem old fashioned by the time you read this almost. And so, the terms used now, that there's several that are competing in a way to become the definitive one. And so the terms people use, like from a minoritised community, is quite a useful one and why people prefer that to, say, being from a minority community, is that there's an idea that being minoritised is something that's done to you, to your community, it's about being excluded. But of course, that term has been flipped on its head by some academics in this field who prefer the term global majority. And why that's useful in some ways is it recognises that most people in the world are from a non-white background. And I think there are some settings where that's clearly quite useful to articulate an idea. But I always use what I call the mum test. And that's my mum is really bright, she left school at 15 and worked, when she did work, in a shop on the checkout until she was in her forties. And then through a friend of mine went into care work and was a really good care worker and worked with kids from diverse backgrounds. And I sometimes think the language that we use to talk about these things needs to make sense to my mum. Which is, you know, someone who's a frontline worker who gets on with doing the job and who wants to do the job, isn't discriminatory, but needs a language that they can make sense of. And so I always ask myself when we're thinking about these new terms, how would that land with my mum? Would she be able to make sense of it in order to do a better job by the people that she's supporting and looking after? So, I'm not entirely sure where I'm going with that other than to say that it's quite complicated and coming up with the terms that are going to be most useful is by no means an easy thing. And of course, it's not my role as a middle-aged white man to come up with them either, it's sort of, I listen to what people are saying and prefer and kind of get alongside that when I can. Rachel: I loved where you started there where you talked about defining our language helps us define our thinking, which is important in therapy, but it sounds like what you're saying is it's not a final statement, it's an iterative process. In therapy we define our thinking, we have Socratic dialogue to understand what we're thinking so that we can then test that out and change that thinking or modify that thinking if it's helpful and useful and helps us communicate to ourselves and others in different ways. So it sounds like if we inhibit ourselves from speaking about these issues, we inhibit ourselves from learning and changing. Andrew: Yeah. And you've got to have that willingness to get it wrong. I've got it wrong so many times in my career, both as a therapist in the room, as a writer on this topic, you know, giving it a go means that at some point you're going to make mistakes, but you just fail again, but fail better next time. Rachel: Yeah, I can identify with that, and I can also identify with the idea that language can really challenge us and hit us in different ways. I remember the first time I heard that phrase you mentioned, global majority. It really stopped me in my tracks for a moment because suddenly you realise the inherent comfort in being part of a majority and that was just a helpful moment to, you know, have a little mini tiny insight into something, a baby step along the way to developing my understanding. Andrew: Yeah. That's a really nice example of just how a switch can go on. Rachel: Hopefully folk will forgive us if we are clumsy in this podcast and we can use language that people find helpful and not destructive. And given all that you've already said, it seems blatantly obvious that factors such as culture, language, ethnicity, religion, these things that are important parts of our identity as human beings would impact on the way mental health problems manifest in individuals and society at large and how people engage with and benefit from therapy also. But we're always interested in the evidence here that, that seems self-evident, but what is the evidence that these factors are important in mental health and the application of CBT? Andrew: I would say of the evidence that's out there, I'm probably on top of and able to articulate about a tenth of it, if that. So it's very much a kind of highly selective take from my point of view. Rachel: 10 percent is pretty good, Andrew, we'll go with that. Andrew: We'll go with that, it's a start. So emotional distress and what we might consider to be mental health difficulties occur in all cultures, in all contexts. People struggle with their feelings, with their experiences. But the frameworks within which they understand those can vary considerably, and the nature of those problems can vary too. So we know that in some communities at some points in time, certain kinds of distress will be greater, and that may be due to environment and what's going on, or it may be to do with how a particular community articulates and thinks about unusual experiences, or the things that are happening to that community at any one point in time. So all of our experiences are understood through the framework of our current culture. I can give an example of that from say panic, which is a fairly common problem that many people work with therapeutically. Now, whatever your cultural background, if you experience something as threatening, your fight or flight system will be activated and your heart will begin to beat faster amongst most other things. Now, if you're from a white Western background where we've had 30 or 40 years of really good public information about the risk of heart attacks and what to do if you have a heart attack, chances are you'll understand what's happened to you as a heart attack. This feels like a heart attack. This must be what a heart attack feels like. So then that, that burst of adrenaline is experienced as a potential heart attack and you'll act accordingly or kind of safety behaviour may be to call 999 or lie down on the floor or whatever seems sensible to you. But if you're from a culture that hasn't really experienced heart attacks, doesn't really talk about that as a kind of pressing health problem, but that may talk about particular kinds of supernatural forces that could act on the heart. When you get that burst of adrenaline and your heart starts to beat quicker, out of the blue, you'll interpret it through that lens. So you're still misinterpreting a bodily phenomena. So something about the underlying structure of what's going on is the same, but the phenomenology is different because the framework that you have for understanding is different. Does that kind of make sense? Rachel: Yeah. So I understand the world's going to influence how I understand what's happening to me. Andrew: Yeah. And then the thing that you do to fix it will vary. So if your belief is that's caused by a supernatural phenomena, the thing you do to make yourself safe would be probably to seek some kind of help that is supernatural in origin. Whereas if you believe it's a heart attack, you'll call 999. So it's your kind of, your subsequent behaviours are shaped by your cultural framework too. Rachel: So the way these problems present, the way they manifest for individuals can be quite different based on the culture and how they respond. And what's the evidence that the needs of these different communities, minoritised communities, are met well or otherwise in our mental health services in this country? Andrew: So we're really lucky in the UK and in England specifically that we've got the IAPT or NHS Talking Therapies data set. So that's unique, I think, in the world in giving us the ability to look at really large numbers of mental health consultations and see what happens. And we've known, from the IAPT data sets that in the early days of IAPT, so looking at the kind of new and pilot site, for example, people from minoritised backgrounds had as good an outcome as people from white backgrounds in therapy, probably because that team in the pilot site was multicultural in itself, had chosen to work in Newham, which was a famously multicultural area and had the kind of expertise to do that work. But we also know from that pilot is the access was lower for people from minoritised backgrounds. So some things were changed, including self-referral that enabled people from minoritised backgrounds to get better access. So we know that in some instances, at some times, access and outcomes can be as good for people from minoritised backgrounds, but if you look at the national picture in NHS Talking Therapies, we can see that both the access and the clinical outcomes have been worse for people from most, but not all minoritised backgrounds. So people from a Chinese background in Britain had as good a rate of access and outcomes as white service users right from the start, but compared to people from, say, a Bangladeshi or Pakistani background whose access rates were much lower and whose outcomes once in therapy were much lower. So we know that it's very uneven picture both between different teams and different ethnic groups. And that's the same for, look at, for example, psychosis services. And we know that you need to be much more unwell to get a service if you're from, for example, a black British background in psychosis services and the less likely to get kind of wraparound care and are more likely to be admitted still 30 years after Swaran and I's work highlighting this, still more likely to be admitted under the Mental Health Act. I think there's a lot of evidence from within England and the wider United Kingdom, that there's still these gaps. But the good news is, over the past few years within NHS Talking Therapies, the gaps have closed and
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