Let's Talk about CBT- Practice Matters

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 [email protected]. Please contact: [email protected] 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: [email protected] 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, some kind of trigger which presses people's buttons in terms of feeling bad about themselves and feeling like their life's out of control. And for other people, it could look quite different. They could be younger or older. I mean eating disorders could happen at any age. They could be older, they could be middle aged, and they could be someone who has always perhaps turned to food when they felt low, or as a way to deal with difficult feelings, but they start to do that more and more and maybe they sort of feel that they're trying to diet as well, that sort of out of control binge eating could happen. So yeah, there are lots of different ways into it. Rachel: I'm really struck by that as a getting older woman myself, that even in those environments where when you were younger, you might get positive feedback for losing weight, but also there might be some sense of, oh you don't need to diet or we shouldn't be dieting, whereas you get to sort of a certain age and it's completely normal to be on a diet or to be talking about time restricted eating or different types of whatever the latest fad is. I wonder, do you see interactions with other sort of fads and trends, like for example, we see the new sort of generation of weight loss drugs, like Ozempic, it’s all over the news and in celebrity chats. Do these things affect, interact with eating disorders in the presentations you see? Rebecca: Yeah, absolutely. So these kind of new weight loss drugs are having quite a major impact on eating disorders. Probably not clear exactly, how much at the moment, but I think they definitely are having an impact. These sort of types of drugs tend to work by reducing appetite, slowing down digestion, which essentially means people eat less and lose weight. But for people with eating disorders or a history of disordered eating, these medications can be potentially quite risky. If you think about the appetite suppression risk, so if people have reduced sense of hunger, it makes it easier for them to skip meals, easier to eat little and that can have quite negative consequences in terms of increasing people's risk of going down that pathway around strict dieting and not feeling that they can eat normally. And that can trigger binge eating cycles, especially when with quite often with these drugs, people are not able to take them for a sustained period of time, kind of forever, they're taking them for a period of time and then they're coming off them so that, can be really difficult in terms of triggering problems. Rachel: You've said about the importance of control often in these presentations, you get a sense of this is under control, I can do this, I can go further and then the drug goes. Rebecca: Exactly. And then there's a change in people's weight, which can be quite distressing for people. So I think it's very difficult. And I think the other way in which I see harm is because they turn the conversation essentially onto the topic of eating, weight and shape. And I mean the conversation in terms of what we talk about in our real life, what's spoken about on social media, the attention, the kind of space that is given to these topics, the amount of coverage of celebrities who've lost weight. We've got such a narrative now around what I think already was a really harmful idea, which is that this idea that anyone can just change their sort of body shape and size dramatically and that's kind of a really unhelpful fallacy. But sadly, I feel like these drugs are just reinforcing that. Rachel: Really unhelpful, isn't it? And I can imagine it's so much harder to convince someone that really the world isn't judging them on the basis of their weight and shape when that's so much of the narrative that's out there. And some of the best developed work in CBT for eating disorders that your group has done historically has been with bulimia nervosa. And that work, as you've alluded to, has been extended and enhanced to provide an understanding of the maintenance of and treatment of eating disorders across the board in this kind of overlapping picture we've been speaking about. Can you tell us a little bit more about this journey and our understanding? Rebecca: Our research group has been around for longer than I've been working in this role, and I want to acknowledge Christopher Fairburn and Zafra Cooper who played such a major role in really developing these psychological treatments. Originally, the treatment that we specialise in called Enhanced Cognitive Behaviour Therapy, or CBT-E, started life as CBT for bulimia nervosa back in, I think, sort of 1981 or something. And so that model was essentially a theoretical model and treatment approach for one eating disorder, bulimia nervosa, and the characteristics involved in that eating disorder. And that treatment was pretty effective, but I think it was probably around half of people who received it didn't get better and Chris Fairburn and Zafra Cooper, Roz Shafran and colleagues, what they did was took the approach of really trying to understand why it was that some people didn't get better. And, as a result of that investigation and exploration, they added more to that original model and expanded it. So one area that was very interesting is they found that for some of the people who didn't get better with that original version of the treatment, they actually had some difficulties almost sort of outside of the eating disorder, outside of that very kind of focused model and that included clinical perfectionism, core low self-esteem, we definitely see low self-esteem in people with eating disorders, but a really sort of deep seated core belief about feeling bad, interpersonal difficulties and essentially they expanded the model so as to allow for the inclusion of these broader, more external factors. So that was one way that they increased the potency of the treatment. They also expanded diagnostically outside of bulimia nervosa to take this transdiagnostic approach. So what they did was created a treatment that was suitable for people with all types of eating disorders, including anorexia nervosa, by adding in additional modules that were needed to be able to expand the treatment and create more of a sort of general trans diagnostic template understanding, that could then be applied to anyone with an eating disorder. And they also sort of really looked carefully at some other aspects which weren't originally considered in the treatment. And that included, for example, body shape checking which is something that often people who are very concerned about their shape and weight engage in behaviours to try and sort of check their weight, maybe looking in the mirror or pinching or feeling their bones. And actually, in the expanded version of the treatment, enhanced version, they included a therapeutic procedure dedicated to addressing shape checking, as it's quite a major maintaining mechanism or feature which tends to contribute to people's concerns that they have about their body. Rachel: So thinking then about the factors drawing together what we've been speaking about the development, the vulnerability, the risk factors, these factors that keep the disorders going. You may or may not know we have a challenge on this podcast. I know you do know that we love a good formulation in CBT, usually it has boxes and arrows and is drawn up in a whiteboard or similar or online. But this is an audio podcast. So here's our challenge. Can you give us a brief explanation about how eating disorders develop and are maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids. Is this possible, Becky? Are you up to the challenge? Rebecca: I will accept the challenge and I will hope that I can deliver. I would like to start by saying that the approach that we tend to take when we actually work with patients is that we don't use jargon, so we actually prefer to call the  formulation a diagram and we tend to always start drawing the diagram collaboratively with our patient by, first of all, beginning with what it is that someone most wants to change. So this means that everybody's diagram maybe starts in a different place and it would start with their own kind of words to describe it. But I can give you one kind of version. So, it's quite common that people say that they would like to perhaps change their binge eating, if they're binge eating but if someone isn't binge eating, they may often begin by saying they'd like to change how upset and distressed they are about their body, for example. So, if we imagined we started there and this is what we often consider quite a core factor, almost a driving factor behind many eating disorders is the way in which people judge their self-worth in terms of their ability to succeed in or control their eating, weight and shape. We could imagine that this begins at the start of the journey. So people are very concerned about their shape and weight and they really feel bad about themselves as a person if they're not controlling or doing well in those areas. And naturally leading on from this, you might see that this could lead to strict dieting; in order to control my shape and weight and eating, what I must do is follow this set of rules. And perhaps these are things that you've been told in the media that you shouldn't eat, or calorie limits you should stick to if you want to lose weight. And so people might start restricting their eating, that might get more extreme, which could mean that people develop being a low weight. And when people are a low weight that often comes with certain side effects, such as being preoccupied with food, feeling incredibly full from eating a small amount of food, losing interest in the outside world and quite often these side effects serve to really reinforce the concerns that someone has about their shape and weight and the need to diet. They think, well, I'm feeling full, I've only had a tiny amount I must've overdone it. Or I'm not really that interested in anything else in the world anymore, except what’s going through my mind about eating, shape and weight so that, that's what I'll focus on. So people can get stuck in a sort of vicious cycle there. And, or, if this might also happen, they might find that because they're really trying to control their eating and engage in this strict diet that they lose control of their eating and start to binge eat in the way that I described earlier, either through kind of hunger and cravings or through feeling like inevitably they break their rules, they feel they've failed, they give up control. And then when this happens, they think, wow, I need to really double down on my rules. I must be even stricter. Makes them even more concerned about the shape and weight and they get stuck in that cycle. And binge eating doesn't just come out of the blue, typically it happens in response to difficult or intense feelings that people have or things that happen in their life. And so there's a sort of another pressure, and that pressure can also put people under pressure to want to diet more in response to difficulties in their life. It could make people want to make themselves sick. Different eating behaviours can help to modulate or change people's mood. It can distract them, it can take their mind off things that they don't want to deal with in their life. But then of course those problems build up because people aren't dealing with them in their life. They're perhaps using these sort of unhelpful coping strategies, so you get another kind of vicious cycle there. So I hope that's illustrated some of what we believe is relevant to understanding eating disorders. Rachel: That was an excellent summary of lots of very complex processes there. And as you say, lots of different cycles going on. But with this kind of core idea, this over evaluation of weight and shape leading to these kind of behaviours around restriction and restraint, which then have this cascade of effects; the preoccupation with food, with how our weight and shape is doing, and the kind of narrowing of focus, which then, you know, kind of feeds back in or maybe we fail and we double down and maybe there's external pressures ramping up the pressure to control and creating further preoccupation with that and leading to other behaviours that might again be having sort of negative feedback into the loop. A lot of different directions I can see that people can go, but all cascading from this central preoccupation. And as we see across the disorders, I guess, these often self-defeating strategies to try and achieve those central goals. Rebecca: Yeah, absolutely. I mean, dieting is often seen, for example, as a solution to binge eating but in fact it's a major perpetuating factor. It's actually driving a lot of binge eating. Rachel: And given these factors that are, these drivers and these common factors that we're seeing, what are the key elements of enhanced CBT for eating disorders and how do they link to these maintenance factors? Rebecca: Yeah. So we could think of, and this isn't my analogy, I think this is an analogy of Chris Fairburn and his other colleagues, but eating disorders as being a bit like a house of cards. If you've ever sort of made one of those as a child, where you try to create this kind of structure with playing cards. And if you think of an eating disorder as a bit like that sort of structure, what you're trying to do in therapy and our sort of CBT-E therapy is you're trying to take out the key cards that are keeping the eating disorder in place. So you're mapping your treatment strategies and procedures onto exactly those maintaining mechanisms and you're trying to quite strategically pull those cards out. The first thing that you do in treatment, we call it starting well, which is stage one and essentially that's a bit like laying the foundation, I think, for a lot of the rest of treatment because you help people to have a better understanding of their own eating disorder, to become more aware of what they're doing in real time so that they can make changes. And you pull out quite a major card and that is, use an intervention which sounds simple but is quite complex in terms of the repercussions and what it changes in the structure and that's where you introduce regular eating. Quite often people come to treatment with large gaps as they're skipping meals or skipping snacks, or they might have quite chaotic eating habits or ways of eating. And they don't have a kind of structure of times when they eat and when they allow themselves to eat. So one of the sort of key elements that we put in place is trying to change that, and that seems to pull out some quite key cards in the eating disorder. So you're disrupting that long period of time people are going without eating, and essentially helping people to be able to eat which is the kind of major part. Rachel: You say Becky, that sounds simple, but I imagine I'm coming to treatment, I am literally petrified of what goes in my mouth and the impact it's going to have on my body. It doesn't sound at all simple. Rebecca: No, it's it sounds simple as a procedure if you sort of just say, oh, regular eating, it sounds like, what do you do in regular eating? You eat at regular intervals. But exactly as you say, it's certainly not simple for people to do. It's incredibly hard because eating is exactly the reason they've come to treatment because that's something that they find difficult. So it's not something thats easy to do. It's something that we have to help people to be able to build in that kind of structure and that has often has such a powerful effect in terms of, for example, often a rapid reduction in binge eating when people do that. It builds a foundation for people who are lower weight to then be able to add in more kind of energy into their diet. So that's kind of part of the starting process as well as people really understanding what's keeping their own eating problem going and becoming more aware of what they're doing. Quite often they might be on sort of eating disorder autopilot, just sort of going through the motions of restriction, dieting and so on but without really being aware of decisions that they might make or behaviours that they might engage in. So once we've started well, hopefully, we then move into the second stage which is where you kind of take stock and review progress. And you think, what have we learned about eating sort of so far together? What do we now need to do in the rest of our treatment to be really sure to treat together what it is that's keeping your particular eating problem going. So you plan on the basis of this sort of taking stock stage, and you plan stage three, which is where you really try and tackle the major elements that are keeping somebody's eating disorder in place. And that part of treatment is more kind of personalised, what you do and the order of what you do would depend on the person. Quite often you're addressing body image, dietary restraint, people's rules about their eating. You might be looking at how people cope with events and moods and helping people to problem solve or find other more helpful ways of coping with mood states. If somebody's a low weight, you would be helping people to make an informed decision to regain weight and then helping them with weight regain. So that's kind of Stage three. And then at the end, you want to help somebody to stay well in the long term. So you dedicate the final part of treatment towards really trying to empower people with what they would need to know in order to stay well in the long term. Rachel: So that's a brilliant summary of those four stages, an overview. Is it unfair to ask what a typical good course of therapy might look like? Typically, what do you do? And I'm thinking, you've spoken about getting people into regular eating. How do you persuade someone that's a good idea? And how do you address some of these other maintaining factors that we talked about? Rebecca: Yeah, establishing regular eating, what we're doing with people is helping to perhaps be able to take a step back from their eating disorder instead of perhaps kind of living it and being in it. It's being able to kind of step back and observe it from a distance. And that's why we do draw this diagram together because we want people to be able to kind of look at their eating problem and be curious and interested in it and try and understand some of the ways in which they're behaving and thinking about things which are keeping the eating problem going. And we also engender that curiosity and kind of distance perspective through helping people to self-monitor in real time. So that's where people write down in the moment, really anything to do with their eating problem and that might be a lot of things that actually are not eating- but that could be how people are feeling, what's happening in their life, what they're thinking about, which might be a consequence of what they're doing with their eating, or they might be things that trigger difficulties with their eating. And so when they've got that sort of curiosity and that stepped back perspective, it enables them to see with you, what sorts of patterns are actually holding them back and creating problems. And so at the same time as us suggesting that they experiment with doing things differently and eating in a kind of regular planned way, they're also recognising that the way that they've been doing it, which is often by skipping meals, maybe going the whole day and then perhaps losing control later or just feeling really tired and unable to concentrate and all those sorts things and kind of recognise that, that's not really helping them. And you're coming in and you're saying, I'll be here to support you but how about doing things differently, experimenting with doing things differently? And I'm going to give you some advice on something which really does help most people with eating disorders. Why not give it a go, see if life is any better doing it this way, at this point what have you got to lose? Now for some people, they feel like they've got a lot to lose and you do have to spend time in treatment really helping them to think about whether or not they want to get better and those sorts of things. But even with regular eating, people can choose what they want to eat. It's not about saying you have to eat certain things. It's about the timing. So they're starting off by perhaps spreading out, in some cases small amount of food, but it's actually giving them that structure, and you're kind of giving people permission to eat which can be really difficult for people.And we also at this stage would involve significant others. So really quite often recommend that people invite people close to them who have an influence on them and their lives into the end of one of our sessions. And so we can think about how other people can really support them and create the best environment that will help them to be able to make the changes that we're talking about in the therapy session. In terms of a typical stage one, it would look like quite often people making some changes like eating more regularly, binge eating would usually might go down, it's different for everyone, people starting to feel like they understand their eating disorder better. It’s not easy. I don't think with anyone, I wouldn't say it's kind of straightforward or easy and that's usually why, again, we see people twice a week in stage one, because they need that extra support to build therapeutic momentum, to not get stuck. And then, usually they have actually made some progress in stage one. There are still things that are difficult, but they can see a little bit that things can change. They're feeling a bit more hopeful but often even at that stage, there's still a lot of work to do. So we plan the rest of treatment, usually during that taking stock stage you kind of think, well, what's been difficult and everyone's different, it might be that they've had difficulties attending sessions because they have childcare issues or something external to them. Maybe they've had difficulty talking about things in the session because that's something that they find hard to do. Maybe you as a therapist think, Oh, actually, perhaps I've been doing things that haven't been that helpful. And so that taking stock stage is an opportunity for you both to put your heads together and think what do we need to work on? What might be getting in the way of change? What do we need to do for the rest of treatment? So usually that's a really important informative stage. So for most people that still coming to treatment, they're making changes. And then the third stage can look quite different for different people, but most typically we would start by thinking about how people judge their self-worth largely in terms of shape and weight. And there are different ways that we do that. I think of it a bit like, imagine that your sense of self-worth is shown in a pie chart and each slice in the pie chart is a reflection of an area of your life that informs your sense of self-worth. So for some people it might be work that dominates, if I give an interesting talk like this podcast, if people think this is a great podcast, maybe I feel good about myself, or if it goes terribly badly, I think maybe I feel awful about myself if that's a major area on my pie chart. Rachel: I'm sure you'll come away feeling good Becky Rebecca: If I don't really mind and I'm not too bothered, maybe that's because there are other areas in my pie chart, which help to balance things out, which I can think, oh, well this went badly but at least I'm still doing all right, with being, I don't know, being a wife or mother or engaging in my hobbies or something like that. But for people with eating disorders quite often, it's very much, that they've got all their eggs in one self-evaluative basket, like sort of weight or shape and when they feel like that's not going well, it’s really difficult. So we get people to try and bring in other slices to their pie chart, by engaging in areas of life outside of eating, weight and shape, maybe taking up hobbies they used to enjoy, maybe thinking about what other people they know do and really trying to build a life outside of eating, weight and shape. So it's a bit like, if you're a gardener and you put a plant in like mint and it starts to dominate and take over the garden, you've kind of got different strategies but one strategy is to surround it by other quite kind of vigorous plants which can help to squeeze it out. And that's what you're trying to do when you help people build up other areas of your life.   The other way to squeeze mint out is to sort of deprive it in terms of no longer feeding and watering it. And that's another approach we take, which is where we think, what is it that people are doing which is a natural consequence or expression of their concerns about shape and weight, but which are actually serving to keep them concerned about their shape and weight. And that might be frequently checking their body, scrutinizing themselves in the mirror, looking at parts of their body that they don't like, those sorts of things. How can we try and stop engaging in that behaviour? So sort of stop feeding and watering the over concerned slice so as to really shrink that slice of the pie char or limit the growth of that plant. So that's one approach we take with body image. And then there are the other areas, which, I've gone on now, so you might not want those, but we talked about dietary restraint, helping people regain weight, there's other elements of treatment. Hopefully, again, usually it sort of goes well to the extent that people find therapy helpful, they find change and benefits in those areas and then they stay on for the last part of treatment, which is how to stay well in the long term. And normally, at the end people maybe feel ready to end treatment. Which is great, or they feel a bit sad about ending treatment and that's okay too and we help them to feel confident about going forward and using what they've learned in therapy on their own Rachel: That's so helpful, and I love the, where you started, you talked about stepping back, you talked about the formulation with the diagram, you joined up, and it seems to me there's this kind of overall stance of almost like zooming out, stepping back from this very narrow focus of where my identity self-worth derives from, to just seeing that bigger picture, that bigger pie, that more variegated garden. I love the mint analogy, as someone who can grow very little, but has had limited success with mint as the only plant that actually does reproduce in my garden. I can see how one might overvalue one's identity as a good mint grower, but it seems that might lead to limited positives in one's life more generally, so this is a really helpful metaphor. And you talked about how people hopefully are getting benefit from this. What do we know about the effectiveness and efficacy of CBT- E? Is it effective? Is it equally effective for everyone? Rebecca: So I think, if we look at the research, when the CBT-E is well delivered by people who know how to deliver it, around half to two thirds of people who start, CBT-E experience significant improvement and though that sort of improvement is sustained, in the longer term, a year or so, later. So most people get better and it is one of the most well supported evidence-based treatments for eating disorders. However, having said that, that's still telling us that there are some people who don't get better, we have work to do. And we also know that eating disorders affects many different types of people. There is a stereotype that it's sort of young teenage girls, white, cisgender, there's this whole kind of stereotype. But of course they affect lots of people and so we probably do need to make sure that we do more work in making sure that we research how to deliver CBT-E in a way that benefits people, with the whole diversity of factors which exist in eating disorders. We might need to think about how best to adapt it and work with people who have eating disorders and other co-occurring conditions, and so on. But I guess the take home is that I guess, most people do get better but we still want to get more people better. Rachel: If you can get the right therapy from the right people, there's a good chance you're going to improve and get well. In recent years, you've been very much focused on that kind of accessibility to treatment. You've been focused on digitalisation of CBT-E. Given those issues you've talked about, the challenges that people face in accessing therapy that sounds really important. So what are you doing and how is it going? Rebecca: So the starting point here was that even though we have really good therapists delivered psychological treatments, only a small fraction of people receive them. And this is especially true for people with recurrent binge eating so because of the shame and sort of not being enough therapists. So what we've done is we've taken our therapist led CBT-E, and we've taken a printed program led version, and what I mean by this is a, sort of like a self-help book, Overcoming Binge Eating. It's the printed program led version of CBT-E, so you have a program delivering the therapy or the advice rather than a therapist but it's using the same kind of principles and ingredients from therapy. We've taken the printed program, we've taken our therapist led program and from that we've derived a digital app, a smartphone app and website-based program led treatment. So we've made some adaptations in terms of what we know about how people use digital treatments but we've used our tried and tested active ingredients to develop this treatment. We've involved people with lived experience, experts by experience. We've listened to them about what they found helpful, integrated their feedback and being through many cycles, iterative cycles, of development. So we do now have the treatment, it is available, but it's, even though it's on the app store, sadly you can't really do anything with it unless you are in the process of working with, for example, some NHS trusts that are using it now. But it's not available to everyone at the moment, but we are starting to run some pilots in the NHS and think about how to roll it out and implement it more widely. Rachel: Fantastic. So addressing those questions of whether it works and in whose hands it works. And across the sort of face to face and digital packages you've got right now, you've been teaching, supervising, applying that, developing it. I know that development of the digital space has been a labour of love for you. What are the most frequent issues that come up for therapists? Where do they get stuck? What kind of questions do they ask when using CBT-E? Rebecca: Probably the biggest struggle that people have is with how to apply CBT-E flexibly, but within a framework. And I think that's where quite a lot of the time therapists get stuck because, and this is partly our responsibility as trainers and supervisors to try and convey the message that the treatment itself isn't a set of, kind of, if/then rules; if the patient does this, then you must do this, because then in reality everyone's different. So nobody does exactly how you might describe in a training manual. So what we need to try and do is to do what I found very helpful in my training and supervision that I had from Chris and Zafra, which was think more about what are the principles underlying and guiding our decisions. So CBT-E is very much a formulation driven or diagram driven treatment. One principle is that you start with thinking really trying to understand something before you change it, trying to understand what's keeping it going, another principle is sort of doing a few things well, rather than many things badly, maybe staying focused as a therapist which people often find hard because typically, and this is only natural, when things get tough you tend to sort of drift away. You think, oh well, I don't know what to do about this within this framework, which perhaps you've internalised as a set of if/then rules. So you perhaps drift and bring in something else. I think that's probably the biggest area that we need to work on in terms of training and supervising, which is to help people to build in flexibility from the position of understanding a framework, but then still staying within an evidence-based approach rather than perhaps making up something new or trying to combine elements from a very different therapeutic model. Rachel: So we often talk in CBT, don't we about sort of fidelity with flexibility and of course when you're learning something new, it's terribly reassuring to have a series of tick boxes that you can tick off and procedures you can do. But if we're being truly formulation led and person centred in a way, thinking about the individual that's in front of us whilst adhering to that model and the evidence-based principles, we're not just ticking off boxes and doing the next thing or grabbing something that we think might work. And this area is one that can be personally taxing to work in. It can be challenging. I had the very great good fortune many years ago to work briefly with some of your more longstanding colleagues, Roz Shafron and Chris Fairburn. And I remember touching base with Roz after conducting a series of interviews with young women with anorexia nervosa for a study she was running. And being wonderfully empathic and thoughtful as she was, conscious of the impact it might have had on me sitting for the first time with a series of women who so undervalued their well-being that they were pursuing this path of self-starvation really. And so she asked me something along the lines of, do you feel ten years older? And in those moments, I think I did, actually. There was something so very sad and shocking about these amazing young women with so much potential and so many gifts and talents with so much to offer the world, working so hard just to take up less space in that world. And something else I noticed working with colleagues is how hard it is for those working in the field not to become very focused on food and weight and shape themselves in one way or another. I wonder what your reflections might be on looking after ourselves as therapists in this area and how we might be challenged by the work and how we might have to reflect on, modify our own assumptions and rules or how we look after ourselves generally. Rebecca: I quite like that expression of putting your own oxygen mask on first. And I think as therapists, we do have a responsibility to look after ourselves, not just because we've got a responsibility to ourselves, we are people too and we need to look after ourselves. But also if we aren't looking after ourselves then we risk not being the best therapist that we can be to help other people. So I think when I entered the field, I was mindful of the fact that, and this would be true for other areas as well, but you become vulnerable potentially to being kind of sensitised by or sensitive to the sort of topics of conversation that dominate your time with patients. And of course, one of the qualities of being a therapist is being empathetic and entering people's worlds. And sometimes you enter them so deeply that you kind of, you don't have that benefit of that distant kind of kind of perspective, which you really need in order to be helpful so it can be easy to get drawn in and then become almost enabling of the eating disorder because you're so on the patients side that they take you into their kind of world. I think as therapists, what we need to do is be reflective as we go on, that we’re not taking those perspectives and integrating them into our views. And, in supervision, I do raise this issue and I think it's important if people feel able to be able to talk to their supervisors about this, and to be reflective, so that we can be the best therapist that we can be, because I think people with eating disorders are understandably able to listen so carefully to what we say as therapists, they listen so carefully to anything we reveal in terms of our views of people's bodies, of how people eat and unless we are really unambiguous about, for example, valuing people of all shapes and sizes. And unless we're unambiguous about valuing flexibility and eating, then people will hear even the tiniest little bit of drift that you might take as a therapist towards internalising weight stigma or any of those sorts of things. I think we have a responsibility, not just in terms of looking after ourselves, but have a responsibility to our patients to be mindful about that. Rachel: And I guess the flip side of those challenges that we face and things that could be taxing are also the tremendous privilege that we have, having these windows into lives of people who are extraordinarily resilient, folk who really are surviving on so little, or cycling around these really self-defeating cycles of self-loathing. I'm wondering what you've learned from the people you've worked with, and how this works maybe made a personal difference in your life or the focus of your work. Rebecca: Yes, and I think that's absolutely true what you've said. I suppose when you start off training and entering this world, you can read in the literature about how effective treatments are and so on. But I think unless you actually see it for yourself it's quite hard to really believe the research. I mean, we know it's sort of there, but I think you need to see people being able to make changes, to really believe it to be true, which you then need to go on and be able to kind of inspire and encourage other people with their recovery. So I suppose that's one of the things that I think I have learned which is that, for many people, change is possible and I think that's something as a therapist that you need to see to believe. So I think that has been important to me. And I think the other thing that you see is you see, exactly as you said, amazing people with such skills and resources that perhaps they are very much putting into kind of perhaps the areas of weight, shape, and eating but what you're trying to do in therapy is encourage them to take a massive risk away from what feels safe and what feels, it might even feel the right thing to be doing, and you're trying to get them to step into a very unknown, scary world, trusting that things could be different, and I think maybe what I've learned from people is that taking those risks can be really worthwhile. And I don't think I'm a big risk taker myself, so I'd probably find that really quite hard to do so I'm quite impressed when people do that. I'm quite impressed by how many changes they make in their lives. But I don't think that's easy. It's quite inspiring for me. Rachel: And we've spoken about how the therapy is doing really well, half to two thirds of people seeing improvement getting better. The digitalisation, hopefully going to take it further in terms of access. What are the next big challenges, do you think? Can the therapy outcomes be improved further? What do we need to know more about? What don't we know and what are the big next steps to the field? Rebecca: Yeah.so I think, I mean, we're probably in the middle of this, but we spent a lot of time trying to develop really good evidence-based treatments and, naturally, we wanted to improve their potency or effectiveness. We wanted to take people from 60 percent of people getting better, we want to take it to 75 percent and so on. We spent a long time on that, which, is right. But at the same time, we didn't spend much time thinking about how do we actually disseminate these and scale them up to the many people who need it? How do we actually reach people other than the tip of the iceberg, which is what we see in clinics- we didn't really spend much time thinking about that. And we didn't spend a lot of time thinking about implementation. So again, when we carried out our research, which typically was pretty inclusive in terms of we had a lot of people with different co-occurring conditions, and all sorts of things, but there were certain things that we did in a research setting that were probably really important to the outcomes we achieved, such as, for example, in our treatment at the start, we see people twice a week. Now when our therapy from kind of research gets translated into everyday clinical practice, Rachel: That's not the normal model, is it? Rebecca: Its not! And they say, Oh, we can't do that in our service. We're only allowed to see people once a week, which is not a criticism of the individuals, but it's quite a problem when you can't translate it. And that wouldn't be acceptable in kind of drug treatments or heart conditions, Oh, well, sorry. Yes. Your heart medicine, we've changed it a little bit. Don't worry. We just took out one of the ingredients. You may get another one as a surprise. But somehow it’s considered to be acceptable to have a poor translation, and we also, as kind of researchers and clinicians leading these developments, we have a responsibility to try and think about that implementation, how is it going to be translated in everyday practice? How are we going to do that? What do we need to do? How do we talk to commissioners? How do we make sure that the implementation is achieved because otherwise we've spent so long developing these treatments but it's all a bit pointless if we don't reach anyone with them. If we don't implement them in the same way that we did them. So I think those are really important questions that we need to answer. I'm not saying we can't continue to do things that we've done before, try and understand why treatments work, identifying mechanisms of change and those sorts of things. But I do think we need to, yeah, really think about reach in terms of impact, we need to think about implementation as well. Rachel: So again, it's not just about what, it's about how we do this and the leadership and implementation of these brilliant treatments you've been developing. If people want to learn more about your work, where can they access training? How can they get involved? How can they become one of those therapists that's going to give this gold standard treatment in a way that people are really going to benefit from? Rebecca: Yes, we have a website, in collaboration with my colleague in Italy, Riccardo Della Grave. We've created a website called, which is cbte.co and that is full of information about CBT-E, including, training that we do and that training is free for some individuals such as NHS and certain organisations worldwide and you can find lots of information there. You can look me up in our research group if you put in psychiatry and CREDO, you'll find our research group which has some details. You can become a contributor, we have a group of people with lived experience and professionals and researchers who are interested in our research that we stay in touch with, so you can join our group. And I am currently on X as @rebeccamurphyox, and I need to explore other platforms because I know people have left to maybe abandon that platform. But if you follow me there, I'll then try and take you somewhere else when I find out where else I should be, maybe Bluesky and these other areas. Rachel: Fantastic. And we can put those various links in our show notes so people can follow those through and to any papers and books that Becky would recommend as well, we'll pop those in the show notes. So have a look there if you want to see where you can follow this up. Becky, in true CBT fashion, we like to summarise and think about what we're taking away from each session. I’m going to ask you to summarise and tell us what key message you would like to leave folk with regarding this really important work with folk with eating disorders. Rebecca: I think that change is possible, I suppose I think that is an important, area, and that in order to bring about change it's worth experimenting with doing things differently. And that's true for patients and therapists, so if you're somebody who hasn't yet experimented with delivering an evidence-based treatment like CBT-E, maybe now is a good opportunity to consider doing that. Rachel: Becky, you said early on in the podcast that you set out to make a difference in the world and I think from what you we've heard and what you've said and about the real change that has been facilitated for so many people, I think you can safely say that's what you're doing. So thank you for the work you're doing. I'm off to go and check on my garden, see how the mint's doing. Think about some strategies maybe to squeeze it out, maybe I'll just make myself a nice mint tea and have it with something that breaks the dietary rules. Rebecca: Brilliant. well, it's wonderful to have been here today and been given this opportunity. Lovely to chat with you as always, Rachel. And I appreciate people listening to this and I hope that what you said is true, that I have been able to help make a little bit of difference. So thank you so much. Rachel: Thanks so much, Becky. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    

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 [email protected]. 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 so you can see that, for example, if you're from a black British background, your access and outcomes are now as good as people from a white background when accessing NHS Talking Therapies. So it is possible to close the gap, but it needs resources and effort, but there's still a long way to go for some other communities, like, for example, the Bangladeshi and Pakistani communities, but the Indian community has really closed the gap and it's almost equitable now. We've still got a way to go. Rachel: And what have the major initiatives been that have closed those gaps? What's changed, do you think? Andrew: I think we're lucky in, in both SMIs, Serious Mental Health Services in the UK and in NHS Talking Therapies, in having had really outstanding leadership around this. And I know more about NHS Talking Therapy, so it's probably better I talk about that more than the SMI field, but the kind of leadership who set national strategy and policy, recognise these gaps and put resources into closing them by getting people the training that they needed, giving people the kind of feedback from the data sets that we've got about what was going on, by ensuring there were frameworks available to help improve services. So that's been a real success story over the past few years in NHS Talking Therapies. And I know that there are similar initiatives going on in the kind of serious mental illness field, for example. And one of the reasons that's been the case is that it’s sort of outstanding leadership within the psychiatric professions, actually, who've really done a lot of that work in the SMI field. Where I think there's still a really big gap is in CAMHS. I think so little is known about whether children and young people from minoritised backgrounds get their mental health needs effectively met in CAMHS, because there aren't those kind of big data sets available that we've got in NHS Talking Therapies to monitor that closely, but small bits of research have shown that there are gaps but I'm not sure there's a national strategy to close them, really. Rachel: So like the whole issue of discrimination more broadly in our culture, it’s a huge issue, no one can say job done, but there are encouraging signs that these gaps can be closed if we focus on them if there's good leadership and a real sort of sense of energy and motivation to address those issues. Andrew: Yeah, absolutely. And one of the things I think has really helped as well is, if you look at workforce data, NHS Talking Therapies has a diverse workforce. So it's going to be much better placed to close those gaps than services, for example, traditionally clinical psychology services, which haven't been particularly diverse. I mean, that's changing slowly, but I do think one of the reasons for the success of NHS Talking Therapies, as well as the leadership, is that there's been a diverse workforce who've taken up those challenges and the same in SMI fields as well. I think, psychiatry has always been a very diverse field of medicine and that's really helped psychiatry to an SMI service to get the house in order. Rachel: So bringing this all into the therapy room, if you like, you have a really wonderful, practical, helpful chapter in your book about how to discuss ethnicity and culture with individuals we work with in therapy. I guess I'm not alone in having some anxieties that sometimes hold me back from attempting to adequately broach these areas of difference in therapy. And I'm wondering from your work and your experience, what you think it is holds therapists back in having conversations around these issues. Andrew: I think it's probably the same kind of thing that makes therapists avoidant of all sorts of things that would be helpful for their patients, like experiential learning and exposure and things like that. We're anxious about getting it wrong and because as cognitive behaviour therapists, we know that what we do when we're anxious about something is we avoid it, and we put a lot of effort into avoiding it. But I would say if people are a bit avoidant, do a bit applied practice and see what happens when you drop your avoidant behaviour a couple of times, and notice what happens to the therapeutic relationship, the engagement and how the session goes. And then you can compare, if I ask about these things and if I don't ask about these things, what difference do I notice and check it out experientially. But actually what we know from asking patients- I was involved in a bit of small-scale research some years back, just ask patients in therapy, do you want your therapist to ask about your ethnic background? And these were all patients who are service users from a kind of minoritised background themselves, unanimously said, I want to be asked, and it would improve the therapeutic relationship. So we know that's what patients want, but if you're not sure, and it's understandable people might be a little bit avoidant, drop your avoidant behaviour, be a good cognitive behaviour therapist and see what happens. Rachel: I think that’s really interesting what you said about it potentially improving the therapeutic relationship because I think that's possibly what often holds people back, they're worried about damaging the therapeutic relationship in some way if, as you said, they get it wrong and that can often drive that avoidance can’t it?. But actually the patients are saying, no, this is what we want. Andrew: And you might get it a little bit wrong, but it's better than getting it totally wrong by not asking. And I suppose, what's that phrase? Don't let the, don't let the good be the enemy of the great or the great be the enemy of the good. Something like that. But you know, give it a go. Give it a go. Rachel: And if we are to give it a go, if we are to, you know, try and get our mouths wrapped around some of these conversations in therapy. What is most helpful? What are the ways that you’ve found, or research and studies have found that there are helpful? You know, is it something we went to broach early on in therapy, or is it later on when we've got more of a trust built up, or do we need to ask permission to have these conversations, or is there anywhere in therapy it's particularly important to bring this up? Andrew: Yeah, I think it's a bit layered. Early on, the first time you're in a room with someone, you want to establish that good working relationship using all those non-specific therapy skills of active listening, unconditional positive regard, non-verbal skills to put someone at ease to build a degree of trust. But then I would say within the first sort of one or two sessions, and often within session one, as someone's begun to relax into it, just a simple question like, is it okay if I ask a little bit about who's at home? Now that enables you to start to draw out a genogram. So I'd recommend a genogram, whether you're working in adult or child services, as a way to map who's at home. And then you could say something like, I would say because I'm white, I'd describe my ethnicity as white. How would you describe yours? How would other people in this genogram describe their background? And so you begin to add to the genogram a sort of a bit of cultural mapping on that as trust is developed. And I would say in the first session, you might just ask about broad ethnic categories and you might begin to explore a little bit as trust is a bit more apparent, something about, for example, faith background, migration histories. So things that are a little bit more of a challenge than just, you know, I describe myself as British South Asian, or I describe myself as Jamaican, into a bit more about how people identify the individual you're working with and some family members. And then once you've really developed a richer relationship of trust, you can go on to more challenging topics like experiences of discrimination or Islamophobia or the kind of aspects of marginalisation. So you're building trust over time and taking more risks in terms of what you talk about as that trust and that therapeutic relationship grows, that's the kind of rough approach I would take. Rachel: It sounds like you're talking about early on really opening the door to those conversations and a nice sort of graduated approach to that. But I guess if the door is open, if people know that you're comfortable talking about those things, they can push the door open much wider if they want to at any point. You mentioned genograms, now a lot of therapists, particularly working in with children and in environments where we're thinking a lot about the system, the family system or wider system might be really familiar with using those. Some CBT therapists may never have used a genogram in their life. How would you describe that sort of simply as a tool? Andrew: So I suppose a genogram is a bit of a family tree, really and it's just a way of representing who's who in somebody's life and typically with genograms, there's some sort of introductions to genograms on YouTube you could take a look at, but you use lines to represent relationships between people and there's a sort of format for doing that, how you would show a kind of romantic relationship, how you would show children and siblings, and then shapes to represent people's gender. Now that's an interesting one because, when genograms were developed, it was a square represented male, and circle represented female. But now the way that people talk about their identities become much more kind of multifaceted and complicated. And there's a whole bunch of additional genogram shapes to represent, for example, trans, nonbinary identities. There are ways of doing genograms to show gay relationships that's all easy to find on the tutorials that are out there. One of the things I would say around doing that is, don’t assume heterosexuality when you're doing genograms and assume that someone's relationship is someone of the opposite sex and so just ask a little bit about who are they in a relationship with, can you tell me a bit more about them and try not to make those assumptions. Because if you do make those assumptions about heterosexuality, it then closes down discussions about sexuality as well, which is quite important or gender identity. It's quite simple, but it's also quite complicated, but start simply and start with the kind of ABCs of genograms and then develop your practice from there. Rachel: And it can be a lovely collaborative and pictorial tool that you can really share and get a lot of information out of. And as you're talking, it's reminding me of intersectionality in our identities and who we are and how actually a lot of what you talk about in your book on Transcultural Cognitive Therapy gives us hints and tips and clues as to how we might approach some of those other aspects of identity, like gender identity and other aspects that we often fumble around in therapy as therapists. When it comes to assessment and formulation of presenting problems in CBT, most CBT therapists or people using CBT as part of their therapy, usually have a list of assessment areas, you know, a couple of decades in, I still have my kind of prompt sheet when I'm doing the assessment, cause I forget things routinely, you know, they might be thinking about presenting problems, predisposing issues, precipitating, perpetuating, maintaining factors, goals, aspects of personal and family history and things like that. Are there ways in which we might need to adapt our assessments to provide us with important information about culture and ethnicity that might usefully inform our formulations for therapy? Andrew: Yeah, I think on the whole the things that people are already doing don't need much adaptation once you've started a discussion about difference, because those sort of predisposing, precipitating, maintaining factors, are there for most people's struggles, but what we include in those probably needs to be adapted. And I give one example of that, it's a topic that I didn't write enough about in the book, but that we wrote a little bit more about in the Positive Practice Guide, but that I've sort of tried to write about and think about more since, which is people's experiences of racism. And because the reason I didn't write about it in the book was that, you know, I'm a white man and I didn't need to have it forefront in my mind and it's only while I've been going out and doing training on this that, that people from minoritised backgrounds have pointed out that I needed to think more about it and do more about it in the therapy room. But if you think about experiences of racism, we know from the research that someone's from a minoritised background, or someone's from a LGBT background as well, for example, the more discrimination that you experience in your life, that's a cumulative risk factor for developing a mental health problem. So that experiences of racism can be a predisposing factor. But from our formulations, it might be that a particular incident of discrimination is the precipitating factor. So, it might be the thing that set off the thing that's got someone struggling and coming to see you. But actually, ongoing discrimination might actually be part of the maintaining factors. So those struggles that people have because of their characteristics can be predisposing, precipitating or maintaining. And one of the ways I sometimes formulate that is using a bit more a narrative formulation of why me, why now, why still, and so discrimination can fit into either of those kind of spheres really. So I think the basic stuff that everybody does well, still stands, it's still genuinely useful. And if you just add to that a kind of sensitivity to and willingness to think about people’s worldview, experiences, and the marginalisations. It just kind of enriches it really, rather than needing to reinvent it. Rachel: And we think a lot in therapy, don't we, about being curious and asking people and not making assumptions about people's experience, which all of this really, you know, points towards and then some, you know, asking those questions of people and being willing to hear about their experience. But I'm wondering, is there a line to walk between burdening a person with educating you about their ethnicity and culture and how it might inform their problem and empowering them to tell you and actually just educating ourselves? Andrew: It’s a great point, so I've been really influenced by systemic family therapy in the way that I've thought about adapting CBT. I got to do some systemic training early on in my career and really value the way that as a model, it was way ahead of CBT in its adaptation. But one of the things I think in systemic practice that they talk about is almost a relentless curiosity. I get the impression in some of the research or some of the practice literature, it's sort of relentlessly asking about someone's family life and dynamic. And I think that is potentially over intrusive. Actually, what you need to know about is just enough to help someone get better and if you want to learn about another culture, there’s loads of ways of doing that, that aren't in the therapy room. The therapy room is just for learning enough about that particular person and that particular moment in time to help them make some shifts. And the additional learning is what you do in your own time through books and films and getting involved in community associations and getting out into the world. Rachel: And I know that I've had colleagues and friends and even trainees on programs I've been involved in running that have at times, because they've come from a minoritised background, have felt burdened in providing that sort of expert advice to their white middle class therapist friends. Is that something we need to be cognisant of as well do you think? Andrew: Yeah I think that’s a really good point because if you think about the power structures within most mental health teams, it's usually people with my characteristics who are the most powerful, the best paid, the ones in the most senior positions, drawing on the expertise of people who are less powerful and less well paid within the organisation, who may not have the time and the capacity to educate everybody. And so I do think there's a sensitivity needed there that our colleagues and friends aren't resources to draw on. But if we are going to ask people's advice or thoughts or reflections, I think getting permission to ask is really useful. And one of the many things I've sort of taken from family therapy is not asking questions about something directly. So, to not say, can you tell me about how racism impacted on you when you were at school, for example, but to say, is it okay if at some point I ask about your experiences of racism at school and let me know when might be a good time? And so to shift the power dynamic away from you demanding a resource from someone, to checking if it's okay and giving them the choice about when that might take place and a choice not to do that at all. So I think that sort of shift in the way you might seek it out is useful. But ofcourse there are people in our networks who would very much see that as part of their role to do that as well and part of their job. And I'm thinking specifically about chaplaincy services. So, if you're lucky, you’ll work in a trust that's got a multi faith, multiethnic chaplaincy service and my experience is generally they see their job as in part helping staff in the hospital or in the trust understand the communities that are served. So that might be a resource that's a more kind of reasonable one to draw on because they absolutely see that as what they're there for. Whereas a colleague who's another therapist doesn't come to work to do that. Rachel: So again, some really fantastically practical ways to ask questions and who to ask them of as well that are really helpful there. You said that we just need to know enough to help folk. We don't need to keep going to be massively intrusive. So once we've established the problem presentation and informed ourselves around the kind of aspects we've spoken about, is it then just okay to roll straight ahead with the disorder specific evidence based models we have for the particular problem presentation? I'm thinking of, there was a quote in your book, Andrew, which hit me quite starkly when I read it. You said that there's no evidence to support the idea that because someone from a different culture meets the diagnostic criteria for a particular disorder, the problem can be formulated in the same way as it would be for a white service user in a Western context. That seemed like quite strong and potentially quite anxiety provoking statement for your average CBT therapist trained in the UK. I know the model, I've got to apply it. Can you say a bit more about that? And I think that example you gave about how the panic disorder, for example, might be experienced differently by an individual already started to suggest ways in which you may or may not apply some of the same strategies and approaches. Andrew: Yeah, we've got to be really modest about the limits of our knowledge, I think. And there's a whole world of research about the cross-cultural applicability of diagnostic categories, first of all, but because as cognitive behaviour therapists, we're not tied to diagnostic categories that closely, but we are tied to disorder specific models. And there's lots of thinking about the degree to which these are useful or not across different cultures, because we've got to be honest about the fact that most of the diagnostic categories and disorder specific models were developed by white researchers from their work with white patients. However, we also are beginning to realise that many of the patterns that we see, you can see in other cultures, perhaps not all cultures at all times, but in some cultures at some times. So you wouldn't want to throw out the models that we've got. But you'd need to hold them lightly, and I think what I mean by that is to have a kind of modesty about the models that we offer to patients and say, well, if we think about it in these terms, what am I missing? What might we need to add for this to make sense. What bits don't fit your experiences? And so be prepared to, even when someone looks like a real kind of real barn door case of a particular model that we're keen on, confident with and think we're going to use, to be prepared to modify or even fully abandon that if the patient doesn't have a sense of it reflecting their own experiences and the patterns that they've noticed. Now that's true for working with white service users as well. That willingness to hold our ideas lightly is important, but it's even more important when we're taking a particular model across cultures or into different faith groups or people with very different worldviews and experiences. So start with what you know, I guess, would be my advice but hold it lightly because we do know there are really good trials of CBT for OCD from lots of different cultural groups that have been effective. Great work done in North African Muslim communities using OCD that's had some modification to take into account faith and spirituality but is largely like we recognise CBT for OCD. So we know that these models travel fairly well, but with that person in the room at that time, just be prepared to be a little bit flexible. Rachel: You know we don't want to engage in a different kind of discrimination of not offering evidence-based treatments to people and assuming somehow that they're not going to be applicable. But I really liked that phrase, it's one my mum used to use a lot, hold things lightly. And it reminds me of that phrase we often use about CBT being collaborative empiricism, you know, this idea that we're finding out together and often I think when we adapt for difference of whatever sort, what we're doing is we're just refining our CBT to be better with all the people we work with. Andrew: I think when we step into that willingness to be flexible, and I like that phrase, kind of really collaborative and really empirical, all of our CBT gets better, doesn't it? You know, that flexibility, that willingness to get alongside people's lives, just makes us better therapists in general. Rachel: And I guess on that, you know, we've been thinking about how we discuss difference with individual clients. Is that only an issue when the person sitting in front of me is of a different cultural background or ethnicity or gender? Or is that something we should be thinking about with apparently very similar folk to ourselves? Andrew: Yeah, it is, isn't it? I mean, one of the reasons that we might want to hold that in mind are things like socioeconomic difference. It can be really helpful when we're working with service users who are really poor, you know, who missed appointments because they don't have the bus fare to get there, who are struggling to pay their bills to say, I recognise I'm in a steady job in the NHS, and some of those struggles you're having financially are ones that I don't currently have. I wonder how I can get alongside you to better understand what that's like? And likewise, around issues around sexuality, I think it can be equally useful to acknowledge difference and similarity when we're working with service users. But of course, all of us will have different levels of comfort with self-disclosure as well. And of course, self-disclosure is not something we're obliged to do, but nor is it something we're forbidden to do in CBT. We, all of us will be a different way along a spectrum of how useful we find disclosure and I think as long as we can rationalise that and have checked in using supervision, that the level of self-disclosure we're using is in the best interest of patients, you know, that can also be a kind of useful tool. And if I could give an example of that from my own life, I've married into a Punjabi family. Now, I don't talk about that routinely with patients, but there are sometimes in therapy when it has been useful for me to let someone know that I've had that experience and that it's sort of enhanced the therapeutic relationship. There is a sort of benefit to a level of disclosure of difference or similarity. But I don't think anybody is obliged to bring that as a therapist. Rachel: No. And presumably gives you lots of insights as you just live life with your family into the experiences people can have from multicultural backgrounds? Andrew: Yeah, I mean, it's more giving me insights into how little I know, despite what I think I might know. It’s been a good lesson in cultural humility. Rachel: So once we're then thinking about what we don't want to withhold CBT, we want to adapt, we want to hold it lightly, we want to do this curious and collaborative process. So how can we go about thinking about adapting CBT then without throwing the baby out with the bathwater or just entering a perpetual state of therapeutic drift? Do we have handrails? Are there best examples of how we can take a robust approach to adapting CBT in transcultural contexts? Andrew: I think on the whole, the models you will have been trained in and used will be useful. And the thing that needs adding is the willingness to think about different phenomenology, and what I mean by that, is different views about what things mean and how they impact on people's lives. And that can take all sorts of forms, it can be around the degree to which and the importance of other family members thoughts, feelings and behaviours so something that's a little bit like a systemic approach to CBT. Because in some families, the beliefs and behaviours of others can be as important as the beliefs and behaviours of the person that you're working with. Ofcourse that can be true in white service users and their families too. But for some minoritised communities, it's really important to be able to hold that idea that the problem exists within a system and there's a kind of collectivist approach to thinking about it that you might not be used to with the more individualised CBT. But other adaptations are, I mean, many of us from white backgrounds are from either sort of atheist, agnostic or fairly lightly religious worldviews. And I think being able to recognise that you'll be working with people who have very strong views about the world that are informed by faith, spirituality and the supernatural. And that's quite a different perspective on the world to the one that you might have. And just that willingness to get alongside that, to not see that as a sort of a faulty worldview that perhaps needs correcting or that can be safely ignored, but to just see it as one that a richer understanding of that will help you understand the dilemmas that people bring to therapy, or the stuckness they may find themselves having or why particular thoughts are especially abhorrent to them. And then I think lastly, it's just being willing to recognise that, as I said earlier, that those sort of predisposing and precipitating factors might be to do with discrimination of many kinds in a way that we're not trained to necessarily think about in mainstream CBT as usual. But that actually can be very readily incorporated into the models that we use. So they're the kind of, as you say, the handrails to bear in mind, really. Rachel: And there are different models of adapting CBT, aren't there? So you speak in your book about culturally adapted CBT and culturally sensitive CBT. Could you say a little bit about how those might differ? Andrew: Yeah. And it's one of those areas I keep changing my mind about, in the sort of five years, six years since I wrote it, it might even be longer now. So it's probably 10 years since I wrote it then, cause it takes a couple of years to get it out there into the world. What I think is that there are some examples of CBT that were, where researchers and clinicians from a particular ethnic or religious group took CBT and translated those ideas into a different language, and in a way that reflected the values and beliefs of their particular group. And then delivered CBT in that language with that framework and that's what I consider to be culturally adapted CBT. It's been done from the inside by people who are within a particular community, for people in that community. And we know that's effective and that works. But in a UK setting, most typically you'll have therapists from any one of a number of backgrounds working with service users from any one of a number of backgrounds. And so that culturally adapted approach may be of limited use, and what you need is a kind of an approach that I call culturally sensitive or culturally responsive that enables you to flex your use of the model to take into account that the kind of whole experience of the person that you're working with, but that's very flexible and adaptive. So I suppose one of those approaches, culturally adapted, is for a particular community by a particular community. Culturally responsive or culturally sensitive has that kind of wider applicability and it's probably more useful in more settings in the UK. Rachel: That's really helpful. And again, I know you've given examples of how that's been applied in PTSD, for example, in different settings and really usefully used. At risk of getting very esoteric and philosophic, are there any even more fundamental problems with the underlying assumptions of CBT that we need to engage in? For people out there that are thinking, well, you know, CBT largely formed in Western individualistic culture, the strong cultural norms or widely held assumptions about the locus of therapy being addressing the individual thinking and behaviours that are key in their maintenance. And that it is their responsibility to change that or within their power to address that, can that apply transculturally or are there other things we need to consider? Andrew: That's a really tough question. I'm going to, I'm going to have a go at it, but I probably won't have a very good go at it so apologies in advance. I think, you know, the therapies that we provide, and it's as true of any other kind of therapy as it is of CBT assumes that, that come in, meet in a kind of, health services setting for 50 minutes a week and thinking about your difficulties and what you might do differently is a kind of universally understood way of overcoming problems. And of course, we know that a lot of the problems that people come with are to do with things that are outside of their immediate control, which may be about housing, poverty, discrimination, climate collapse is another area that people are increasingly interested in. So making that assumption that the responsibility for change can be wholly with one individual and that 50 minutes a week thinking about it is enough to empower them to do that is a bit naive, isn't it really? And that's probably one of the reasons why not everybody gets better in therapy, you know, even the best trials with the most straightforward cases, 30 percent of people show no improvement. Within NHS Talking Therapies, if a service is getting a 55 percent recovery rate, it's doing really well. And I think that is a little bit about all those other factors. But I would say, and I really want to empower therapists around this, as a therapist, you can help someone have an impact on some of those other factors too. And that might be just as simple as someone who's in really substandard housing that's impacting on the health of themselves and their kids, in an unsafe neighbourhood whose mental and physical health is deteriorating as a result. You writing in a really clear and strongly worded letter to the housing authority about that can make a material difference to those processes. And you may not feel like you're particularly powerful sitting in a therapy room on your own, but a letter on headed noted paper that's sent to the right people and perhaps even copied to some other people can shift some of those other factors that aren't just about unhelpful behaviours or being over engaged with your thoughts. So actually, there's stuff that we can do as therapists that is effective. Now it's not to say that we ought to be social workers because we'd be poor social workers. We're not trained to be good social workers, but there are things that we can do that still might make a difference. And that includes things like liaising with the immigration services if someone's mental health is to do with uncertain immigration status and threat of being detained. Or referring them to someone who can do a benefits review if poverty is a big part of what they're struggling with. So there are things that we can do around the edges that might nudge things in the right direction, but I'm very much sympathetic to the idea that a lot of it is other things that takes political will to change in the long run. Rachel: Yeah. And that is an encouraging idea that, you know, we do have potentially some power. We can use what power we have in the face of what we see, often feels like, you know, growing picture of discrimination and poverty, et cetera. And I guess that kind of leads quite nicely to thinking about how this work can be personally challenging for us as therapists, because we can encounter shocking prejudice in the world as we're talking to our patients. We can also encounter shocking prejudice in ourselves as we do this work and that we are unaware of as unconscious biases that we bring that sometimes this work highlights to us in very stark ways. The mistakes we make in therapy can feel very high stakes, as we talked about, you know, not one even wanted to broach some of these conversations in case we get it wrong. If we're, whether we're recently trained or really experienced, it can still be hard to learn to adapt our practice or change our practice. So it strikes me that good supervision must be really important in this area. And I'm wondering what the role of supervision is in this work for the therapist. Andrew: I'm really glad you highlighted that this work can be a challenge therapist in all sorts of ways, including just being exposed to how tough people's lives are. And because we're a bit used to that in terms of being exposed to say people's trauma history and their experiences of, I don't know, childhood sexual abuse, violence and neglect. We're a bit trained for that, but we're less well trained for exposure to people's experiences of discrimination. And that can take a toll on us. And I think it's, you know, talking to colleagues from minoritised backgrounds who I think find this particularly painful when they're working with service users whose experiences of discrimination mirror their own so much, but also, you know, therapists from white backgrounds can find it difficult to be exposed to this world of discrimination that they've maybe been able to ignore up until that point. And I think having a supervisor that you trust, is a really good starting point, but very few supervisors have been trained in working with this kind of material. And what I would say is if you've got a supervisor who isn’t that comfortable in having these kinds of discussions, it's better to be upfront about that and to recognise and say, I noticed that when I brought that, that seemed quite a difficult topic for you. I wonder if there's ways that we can work together to make this a more kind of useful topic. Because responsibility for supervision going well is both the supervisors and the supervisees, and it's okay for you to raise that with the supervisor if they're not managing it very well. But I do think supervision is important and supervisors can help you recognise vicarious trauma and when that may be impacting on you and to help you do something about that or reduce its impact. But I think it is important to find supervisors who are capable of having those discussions or to nudge them towards doing better if they're not. Probably particularly important if you're a therapist from a minoritised background yourself, and if you don't feel like you get that kind of support in supervision to look for other ways of developing kind of peer support networks around that kind of work that might help sustain you. So we've got a long way to go, I think. Rachel: Yeah. Are there ways in which supervisors can access training or think differently, upskill that might help them in these areas? Andrew: Yeah, we've done bits within BABCP before. So myself and Michelle Brooks both do some supervisory training on thinking about difference and diversity, both how to help supervisees do better in this work, but also specifically how to support supervisees from minoritised backgrounds. So, keep an eye out on the BABCP's CPD program. We sometimes run things at conference as well. There are few opportunities, I'm afraid, probably there's more these days within clinical psychology training because many of the courses now as part of their push to have more diverse trainees include some training for supervisors on that. So if you're clinical psychologist and you have trainees, you probably got a good route in there. But for many cognitive behaviour therapists, just watch what BABCP is offering. Rachel: And I know from the clinical psychology world, there's lots of evidence emerging around both the negative impacts that people have had from poor, transcultural supervision, but also the positive effects that there can be when these things again are broached and made normal to speak about, that emotional processing is part of these things as part of supervision, as is a space in a non-shaming, non-blaming way to reflect on our own biases and assumptions that we come face to face with sometimes in this work. Andrew: Yeah. And good supervision can really help with that, can't it, in a way that sort of supports and challenges. Rachel: And you mentioned earlier on that an important aspect of culture for many people is their faith, their religious faith or their spirituality. And I think this is a huge topic and hopefully we'll do some further podcasts in this area, but it often isn't brought to the table explicitly in therapy. And you said one of the reasons might be because there may in the Western culture be sort of less strongly held or less commonly held faith beliefs. But I think even as therapists with faith, as I would identify, it can feel like a no-go area in therapy. Do you have thoughts about why we might be reluctant as CBT therapists to engage in conversations about faith? Andrew: Yeah. Cause we certainly are reluctant, aren't we? And yet if you're working with someone with a faith background, your faith shapes the way you see the world. It shapes your values, your actions, what you consider a good life to be, the things that you will want to do more of and not want to do at all. And I think to miss this misses an important part of many people's identity. But I think the kind of origins of psychological therapies and yeah, going right back to Freud is a world where God was considered to be not that important anymore. And so it's not been built in to our kind of any of our psychological therapy models. But if we think as cognitive behaviour therapists, we're interested in people's views of the world, then our views of the world is shaped by our faith and spirituality. So understanding that can be really useful. And I think understanding it can be a helpful way on people's pathway to recovery as well, because people's faith may give them very clear expectations of how they will live, what they will do. And if they're not able to do that as a result of their mental health difficulties, identifying the kind of barriers towards living a desired life can be a really useful therapeutic tool and a real motivating tool to help people make some shifts. But I would say, one of the things I do when I do training on this is I get people to work in pairs and ask your partner, what do you believe? Do you believe in God? What are your beliefs about what happens when you die? What do you believe about the supernatural? And it's usually one of the noisiest parts of the day, because people absolutely love being asked those questions. Because how often do even your closest friends say to you, what do you really believe? And why I do that is for two reasons. One, it helps people get used to asking that question. But the other is, it helps us understand our own position a little bit, because I think if we're working with someone and asking about their faith background, it's useful to just be able to recognise our own and recognise how our own faith background might shape the way we ask someone else about theirs and how we might see theirs as well. So I would recommend, if you don't get a chance to go to training on this, just find someone at work and say, look, I want to do this exercise. I just want to spend five or 10 minutes asking you about your faith. And then you can ask me about mine and see how it feels. Rachel: If nothing else, it'd be a wonderful behavioural experiment in the limits of Britishness and no-go topics in the workplace. Andrew: Yeah, I think it was Alistair Campbell who said, when he was working in Tony Blair's team, and someone asked about Blair's faith and Campbell said, we don't do God. Rachel: We don't do God. That's right. Yeah. And as a therapist with a faith myself, I think there is a sense of which often there are assumptions that faith of all different types can actually be a negative influence in people's life and experience. And we think about, you know, the kind of rituals and things people have sometimes in OCD or sort of perfectionistic standards, often faith is seen as feeding in a negative way. And it's really important, isn't it? To think about actually how these aspects might be positive, motivating, really goal enhancing aspects that we are working with as someone in therapy and that's true also, if they've got no faith at all, that they will have a worldview that is in a sense of a faith and informs how they want to live their lives and how they'll reach those goals. Andrew: I think we need to begin to think about faith and spirituality as an asset and something that's not problematic. That's something that can be, I think we can draw on, in order to help people make positive shifts. And also someone who has no faith, is an atheist, as you say, they'll still have a value system that's that shaped by other things and how we understand that and help them use that to make some positive shifts- I don't know if it's still the case, Rachel, but I remember reading research about general happiness as well. And I say this as someone, I'm an atheist and I'm really kind of quite a sort of, I'm very clear in my atheism, but the research evidence is that people who have a faith background are much happier than people who are atheist. Rachel: Well, that must explain why I skip into work every day, Andrew. Andrew: Yeah. And why I'm so grumpy. Rachel: Yeah, I think we both accept it's probably a bit more complex than that. So you obviously love this work, told us a story really how this has been personally important to you. It's been part of your professional life since way back. And I'm wondering what you've learned in that journey from the people you've worked with, because it's often how this work has the most impact on us isn't it? Through the individuals we sit with, we talk to, that we learn from. Andrew: Yeah. I think I've been really lucky. So I'm a middle aged white guy who got interested in this field fairly early on in its development. And I suppose I have really benefited from patience and willingness of both colleagues and patients from minoritised backgrounds to explain things to me and to help me understand life from their perspective and the challenges they face and the way that things need to be done differently to enable them to do better in mental health services. And, I think the things I've taken from that is realise the patience that others have shown me and that I want to pay that back a little bit by, you know, being available to people who are interested in this field, to give encouragement for people to step up and take on roles of developing expertise within it, as I was encouraged to do that by people, I think from a professional point of view, it is that kind of appreciating the patience of others and the encouragement of others and wanting to pay that forward a little bit. From, the kind of service users I've worked with therapeutically, it's a bit about how people have thrived, even in immense adversity and thinking about what it is that, that people have been able to draw on what kind of personal and familial and community resources have enabled people to do okay. And even sometimes really well, despite huge barriers to them doing okay. And that's really inspiring. It's been lovely to be alongside people's journeys and just see how they've drawn on resources to do well. Yeah. I've been really lucky. It's great being a therapist. Rachel: And can you tell us a little bit more about the work you're doing now, what the horizons are for you in terms of research, writing, training people? Andrew: Yeah continue to do training. I've stopped writing now. I think there's a new generation of people in this field who've got more to say and whose voices need to be heard. So, if anything, I'm encouraging people to write and I've had some opportunities to do that through, the Cognitive Behaviour Therapist Journal, and a few other forums. I've just sort of, I don't think my voice is the one that needs to be out there now, really. It's those, it's that next generation. Rachel: Okay. We're going to cancel the podcast. Cancel the podcast. Andrew's voice is not supposed to be, oh no, hang on. You still might have something to say. Andrew: Yeah, because it, and what I've got to say is listen to those new voices. Right, you know, through the BABCP journals and CBT Today, those voices are getting a platform and they're really vital and important with very new perspectives. So part of what I'm doing is actually stepping back, shutting up and encouraging others. Cause I think I'm at that stage in my career where that's the right thing to do really and, I’ve probably said most of what I'm going to say that's of any use. But the best thing I can do is give those other people a leg up to say it now. But I still get asked to do training, which is a real pleasure. And, just recently, been with my local NHS Talking Therapies team, spent a couple of days with them thinking about adaptation and supervision issues. I’m still involved in some training courses and doing small bits with the BABCP as well. I can safely say I'll never write anything else again. I think I've enjoyed writing while I've written, but I think it's the next generation's turn now and I'm really sort of at that point of worrying about the next generation and supporting, supervising that next generation and kind of waiting for them to fully take over and looking forward to seeing the next stages of this work that won't be by me you know, it will be by younger people from minoritised backgrounds mainly who will really who are already doing a great job of carrying it forward Rachel: And is there any work you would like to point people in the direction of already? And we can put some links in the podcast show notes as well? Andrew: Yeah, I mean absolutely no hesitation in saying look at the special issue of the Cognitive Behaviour Therapist on anti-racist practice. I think there's great papers being collated there. It's a fantastic resource, many of which is written by that next generation of writers. I think CBT Today always features something of interest in each issue that I recommend people take a look at and, I think they're probably the two most useful places for people to start. And I would say if you look at those resources and think that you've got something to add to that. Both of those publications are really welcoming of new voices. And even if you've got an idea that's a little bit half formed, get in touch with the editors and say, I'm thinking about this. What do you think? And you'll get encouragement and help to get it in a publishable form and get it out there. I'd really recommend people do that. Rachel: Fantastic. And I know Steph Curnow our host of Research Matters podcast and Managing Editor of the journals would echo that wholeheartedly. And maybe that's somewhere people might want to listen into the Research Matters podcast to get some ideas about the kind of research that is, is going out there. Andrew, in true CBT style, we like to summarise and think about what we're taking away from each session, but I pass the buck, you know, and I'm not a very good therapist in that sense, I force you to summarise. So, in time honoured fashion, what key message would you like to leave folk with regarding the work? Andrew: It can be a little bit uncomfortable doing this work, but the rewards for the people that you're working with and for you as a therapist are considerable. And so be in approach mode, not avoidance mode when you're thinking about diversity work, and you may not get it perfectly right, there may be things when you look back, you think, Oh, I wish I'd done that differently, but to try and to do your best is far better than not doing this work at all. And my guess is if you've got to the end of this podcast, then you are committed to this kind of work. You want to give it a go and so I would really encourage you to step into trying some of these ideas and see what happens. Rachel: That's so encouraging and inspiring. And I know you said you don't have much more to say, but I think people will really value what you've had to say today and learn loads from that, Andrew. So thank you so much for sharing all your wisdom, experience and knowledge in this area. thank you so much. Andrew: It's been a real pleasure. Rachel:  Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    

In this episode of Practice Matters, host Rachel Handley is joined by Dr. Eleanor Leigh, Clinical Psychologist and Associate Professor at the University of Oxford to discuss social anxiety disorder in young people. Eleanor shares her journey into this field, highlights the challenges of recognising and treating social anxiety in young people, and offers hope through emerging evidence-based interventions, including tailored cognitive therapy for adolescents. Resources Mentioned: OXCADAT Resources: Free therapy resources, manuals, and videos for cognitive therapy. CAMY Website: Learn more about Dr. Leigh's research group focused on young people's mental health. Overcoming Social Anxiety and Building Self-confidence: A Self-help Guide for Teenagers (Helping Your Child) Papers mentioned: Carruthers SE, Warnock-Parkes EL, Clark DM. Accessing social media: Help or hindrance for people with social anxiety? Journal of Experimental Psychopathology. 2019;10(2). doi:10.1177/2043808719837811. Evans, R., Chiu, K., Clark, D. M., Waite, P., & Leigh, E. (2021). Safety behaviours in social anxiety: An examination across adolescence. Behaviour research and therapy, 144, 103931. https://doi.org/10.1016/j.brat.2021.103931 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 X and Instagram or email us at [email protected]. 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 we're joined by Dr Eleanor Leigh and we'll be talking about social anxiety disorder in children and adolescents. Eleanor is a clinical psychologist, an Associate Professor at the University of Oxford and Honorary Associate Professor at University College London. Her research and clinical work is focused on improving our understanding and treatment of adolescence anxiety disorders. Her particular expertise is in social anxiety and she's widely published in the area and has done some really fantastic work deepening our understanding of the application of cognitive therapy in this population. Welcome to the podcast, Eleanor. Eleanor: Hi, Rachel. Thanks for having me. Rachel: It'd be really great. just as a starting point to hear what got you interested in this area, how did you get into looking at social anxiety in young people? Eleanor: So I was very lucky to do my clinical psychology doctorate many moons ago at the Institute of Psychiatry at King's, and I had my final placement at the Centre for Anxiety Disorders and Trauma, and which sort of specialised in the treatment of anxiety problems in adults using cognitive approaches, which have been set up by David Clark and Anke Ehlers. And I remember being really nervous about being there because there's a great reputation. And I got there and I had the most amazing supervisor in Debbie Cullen. And I had this really exciting six months of going deep into a therapy and feeling like I was delivering treatments that seemed to make a real difference. I was treating adults with Post Traumatic Stress Disorder and Social Anxiety Disorder. And I found it just really fulfilling and I thought, wow, this is amazing. And then I went and did a placement in a service for young people with anxiety problems, which was equally dynamic and exciting. But also made me really aware of how much kind of further behind the curve the research was, and treatment development was, with children and young people. And I'm sure we'll come on and talk about this in a little bit, but I was particularly struck by how the treatments for young people with social anxiety, which seemed to be the bread and butter that was coming through the clinic, just weren't as useful or helpful. And that was, I suppose, the real catalyst for where I've gone. And where my career has taken me so far. Rachel: So you had this experience of seeing stuff that really worked, that was really satisfying, but then also seeing this gap in the market, if you like, this area that we were under helping folk with. And it makes sense that this was the bread and butter of what you were seeing because adolescence can be an excruciatingly self-conscious time for many, but not all young people. And I guess lots of young people must suffer from social anxiety, but what do we know about how many actually suffer from this as a disorder? What the sort of typical age and onset and course of social anxiety is at this stage of life? Eleanor: Yeah, I think you've just pulled out two really important things. One is about what tends to happen to most of us in our teenage years, and the other is about thinking about the scale of the problem of social anxiety. Maybe if we just start off by thinking about what happens in the teenage years. I don't know, Rachel, about you, but when I think back to my kind of progress into being a teenager, I have like a particular memory that I find excruciating, which is of going shopping. I always tell this when I'm doing teaching, of going shopping with my mum, and I remember asking her to walk slightly ahead of me so we could pretend that we weren't actually together because I didn't want to be seen by my friends hanging out with my mum. My dearest mother, though, still carried on and bought me a really nice pair of jeans, despite my like abominable behaviour. And I suppose what this really makes me think about in retrospect is how we all get very self-conscious during the adolescent years, and there are all these changes going on with our kind of social, emotional, cognitive processes in adolescence, and that's all I suppose in the service of trying to help young people shift away from their family unit and towards their peer group, learning how to make, break and repair relationships because that's what we need to do to be able to become independent adults, functioning ourselves. Rachel: So what you're saying is it's normal that my teenage sons want to spend all their time in their bedroom and not with me. Eleanor: I know, painful as it is, and I've got a, my daughter is moving into the adolescent phase, and I can feel her pulling away as I endlessly try and hug her, I realise that this is a very normal thing. And so what we see, the research seems to suggest that there is this very predictable uptick in social worries as you sort of pre adolescence move into the teenage years and that's based on both parent report and child self-report. For most kids what we then see is that sort of just eases down naturally without any particular intervention. Rachel: So I can really identify with that. I remember my teenage years feeling like a long tunnel of feeling dull and boring and generally socially unacceptable. But you're saying that part of this is normal as a process of kind of individuating, separating from our parents, wanting kind of work things out, feeling awkward, feeling uncomfortable, self-conscious, but how does it develop into a problem that impacts people like social anxiety? Eleanor: Yeah, and I think, so this is a really critical point, isn't it? It's that for most people, all of these processes are recurring and increase in susceptibility to peer influence, self-consciousness, and there's this kind of perfect storm that sets the stage for social anxiety or social concerns. But why is it that some young people will then go on to have this kind of much more distressing and problematic social worries compared to others. And I suppose there are a few answers to that. Most likely there are going to be genetic vulnerabilities. And so some young people temperamentally, but more sort of behaviourally inhibited, tend to hold back, tend to be those kids who take a bit longer to engage in a party or play or a game or something novel. But there's also likely to be sort of particular experiences that some young people have been through that might make them more likely. So we know that, for example, from twin studies it seems to be this combination of genetic factors, but also non shared factors. So environmental factors. So things most likely to do with what's happened to that young person that's not in their family home. So peer experiences might be the kind of best candidate we could consider. And one of my colleagues did a really lovely meta-analysis looking at the relationships between peer problems and social anxiety in young people and found really clear indication of a two way link. But so it does seem to be that problematic peer relationships and peer victimisation in particular, contributes to social anxiety over time. Rachel: So it's a significant problem then for young people is it? I mean, how many young folk actually do develop this as a disorder as opposed to a normal self-consciousness? Eleanor: Yeah, exactly. So estimates vary but lifetime prevalence rates suggest it's between sort of five and 8%. But when you think about that sort of around 90 percent of cases will have their onset before early adulthood, before about the age of 20 ish. So most cases will first occur in that kind of adolescent period. So if you think about an average classroom of about 30 kids, you could expect to see a couple of kids, one to two kids in the classroom. Yeah. And if you speak to clinicians, it is the most kind of common problem coming through the doors. Rachel: So it’s a really significant problem. We see it really frequently in services, thinking back to where you started with saying there was this gap in treatment for it and evidence-based treatment and treatments that really helped. How well recognised do you think it is now generally in services or generally in the population and how easy is it for young people to get evidence-based treatment now? Eleanor: I think recognition has improved probably for all mental health problems. I think there's been great strides in how we talk about mental health and how we recognise it. And with the development of mental health support teams in schools, I think there has also been a great improvement. I think there's something particular about social anxiety that brings with it some challenges in terms of the stigma and shame that young people would often feel about their difficulties, which can be a kind of inbuilt obstacle to young people asking for help. And so many young people, I think, who are socially anxious will feel like it's not that they have a problem that could be treated. It's that there's something wrong with them inherently as a person. It's sort of, it's a sense of social anxiety. A bit like depression is sort of disorder of oneself. The other thing that I think can impact on detection rates is that many people in the system, parents, families, or teachers will see it as a normal part of being a teenager that many young people will grow out of. It's just the kind of awkwardness of being-just like we were speaking about a moment ago, Rachel. And yet we know that there are levels of social anxiety, which really get in the way and are really debilitating and actually don't go away on their own. And that's the other thing. When young people, are intensely socially anxious, they will get caught in cycles which mean that actually the social anxiety is perpetuated, and we see from longitudinal studies that social anxiety is one of the most chronic of the common mental health conditions. Rachel: And it sounds like it can be quite difficult doing this sort of peeling apart what's normal developmentally from a sort of disorder pathway. How difficult is that to do? How do you know, right, okay, this is no longer just this kind of teenage normal development, and it's actually spilling into something that needs an intervention right now. How do you decide that when someone presents in clinic? Eleanor: I think it's such a good question. And there are lots of different views on the utility and rights and wrongs of diagnosis. But I think at the core, what we want to do is talk to the young person, talk to the family and understand from their perspective the way that social anxiety is impacting on their happiness, on their well-being, on their ability to do the things that we know they should and could be doing. And I think that's one of the other really key aspects of thinking about intervening in adolescence is that there are these absolutely critical milestones that young people will be moving through, and that we know that problems like social anxiety can really impact on. For example, some big studies in Sweden have suggested that social anxiety disorder can really impact on kids’ academic attainment. So young people who are seeking clinic treatment for social anxiety disorder were less likely to progress through to tertiary education like university and they tended to do less well in their final year exams. And that's not because of IQ, it's not because of ability, it's because likely a range of things, but social anxiety will make it hard to put your hand up in class and ask the question and have that kind of query resolved. It will make you less likely to do well in that presentation which might be part of your final assessment. But also, some work that I've done with colleagues indicates that it also might affect how able you are just to concentrate on what the teacher is saying. Because instead, all of your attention, as we were saying earlier, is preoccupied on, oh my gosh, is someone going to ask me a question? I feel like I'm really red and I'm looking really silly. Instead of something to do with Henry VIII, or something to do with photosynthesis, or whatever else is on the topic. Rachel: So both in terms of the prevalence at this age and the onset being a huge statistic, isn't it? 90 percent of folk having their onset at this stage in life, and in terms of the impact it has on people and the longevity of that disorder and the huge impact that can have on the trajectory of their lives, it sounds like it's really important to try and stem this tide to get in there at this stage. Eleanor: Absolutely, and I’m always minded that I give this very bleak kind of picture, and it is a really impairing disorder, but I also think for any clinicians or researchers thinking about working in the adolescent space, it's also a really exciting opportunity to think about how do we deliver an effective treatment in a timely way? Because that can really nudge young people in a different direction. So, I think a smaller, sort of tighter intervention can have a bigger effect at these early stages is my kind of optimistic take on it. Rachel: Well, we're all about hope here and that's what these treatments offer, isn't it? And David Clark was recently on the podcast and talked through the Clark and Wells model of social anxiety, which you might, as you might expect, he's pretty familiar with having developed that himself. And it seems that has a lot of relevance to adolescents. And I know that you've been applying that model for many years and adapting that model. I wonder, given what you've started to say about what's distinct, or additional factors in young people if you could talk us through a model of social anxiety as applied to young people. Now we're a podcast, so you can't use boxes or arrows or any other visual aids, so this is your challenge. Can you tell us what a formulation of social anxiety looks like in adolescence without any of those aids? Eleanor: Rachel, it's still early in the morning. I haven't even finished my first coffee, but I will try. And I will also feel very glad to come in the wake of David because I think anyone can probably go and listen to his amazing description of the model. I will try and do my second best, I think. One of the things just to say that I found so interesting in the work that I've done with David thinking about how the model might apply to young people, it's just how many parallels and similarities there are to how many findings we replicated in young people, as were found in adults. And so just thinking about it, a young person with, who's socially anxious, will be going into a classroom. Going into the lunch hall, for example, and there'll be a sense of something's going to go wrong, something bad's going to happen. That kind of threat signal is going to be coming up. It's going to be an anticipation of social demands that a young person feels unable to manage. And when they go into that lunch hall and they see the table they're going to join, they sit down, they’ll start thinking everyone's looking at me, perhaps I've got nothing to say, and they're all going to think I'm the kind of boring one. So the whole kind of range of negative thoughts that will be different for each young person will be running through their minds. And as a result of all of those kind of negative thoughts that will impact and create a cycle of effects on what young people pay attention to, what they picture in their mind's eye and what they tend to do. So the first thing that will often happen is something to do with their attention. And if we think about attention a bit like a spotlight, you and I will be in a conversation and I'll be thinking about you, Rachel, I'm focused on you. and then sometimes thinking, what am I going to say next? But generally I'm absorbed in the to and fro of our chat. Whereas a young person who's socially anxious, that spotlight will be absolutely on themselves and on how they're coming across and that has negative consequences, it has a knock on effect. It means that, firstly, they aren't attending to how the other kids are, what they're doing on the lunch table. They're not noticing that the person opposite them is smiling, perhaps that someone else is not even paying any attention to anyone, they're eating their ham sandwich. And so then the next part is that they are not attending to the other people, but they're attending to themselves. They're attending to their physical feelings. And internal information. And that is what becomes the source of information about how they're coming across to other people. So feeling sweaty in the armpits becomes information that actually I must look sweaty in my armpits. Feeling red in my cheeks means I must look like I'm blushing. And then the other source of information are those mental images and impressions. So picturing in one's mind's eye the kind of worst case scenario of how one looks. One young girl told me that she looked like a kind of red blushing tomato and that's a clear image. But obviously the worst case negative distorted sense of how she looks. But other young people have described more impressionistic like, sense of how they come across. So one young girl said it was like she was a kind of a lump, like a stone in the room. So everyone else was moving around and she was just this lump that no one was interested in. And because these images or impressions tend to be seen from the outside in, so as if you can see yourself, they feel quite believable, feel plausible. And so again, these are used as further information for how one's coming across. And so this kind of self-focused attention and these internal images become data or information and it's how one processes oneself as a social object. And then of course, because people are concerned about messing up, because they have these horrible senses of coming across badly, it will trigger a whole range of safety behaviours, things people will be doing to try to prevent or mitigate those kinds of horrible concerns. And these will vary. They will be the classic sort of avoidant behaviours, looking down, speaking less but also those more sort of sophisticated strategies of trying to come up with good stories, having a joke ready that always lands, asking lots of questions, laughing along to every joke. And these may be sort of work in the moment at some level, but they keep those fears going. And they also have a whole range of other negative consequences like they can actually directly cause the feared symptoms, they increase that self-focused attention. And really importantly, they can actually impact on the social interaction. That's the social setting, because if you're not looking at someone and not asking questions, that's giving a pretty clear signal about whether or not you're interested, even though it's the opposite to what's intended. Now, at this point, I might just pause if that's okay, Rachel, and just comment briefly on some of the findings we've had in relation to young people and this model because that's the sort of, that's the core aspect of the model, I suppose, as we might be thinking about it with adults. Rachel: It sounds very familiar in terms of that adult model. I'm really curious to hear what pieces might be a bit different or might be additional to that. Eleanor: Yeah, so just in terms of what we know from our work with young people, firstly, there's some really interesting findings that we’ve picked out in relation to safety behaviours. One of my colleagues did some really nice work looking at the types of safety behaviours and how they might vary across development. And so we seem to have these kind of two clusters of safety behaviours, these avoidant safety behaviours and impression management safety behaviours. And when we looked at this in young people, we sort of replicated that. So we seem to find these two factors. But what was really interesting is that we seem to find, when we looked at younger adolescents, so the kind of Year 7s, the just starting high school, compared to our college students, so 16 to 18s, we seem to find that younger kids used relatively more of the avoidance safety behaviours compared to impression management safety behaviours. So I think what's interesting about that is that it makes sense because probably when you're trying to use impression management safety behaviours, they're sort of more cognitively sophisticated. You have to be thinking about what the other person might be thinking about you in order to this is going to be a good story. Rachel: So in terms of cognitive development, younger kids might not quite be there yet. Is that right? Eleanor: Yeah, so that's what we seem to see at a kind of group level. But then this is very interesting when we think clinically because the other part of the finding about safety behaviours is that both types of safety behaviours make you feel more anxious, they perpetuate those negative beliefs about yourself, but it seems to be that it's the avoidance safety behaviours that are particularly problematic in terms of that contaminating effect on other people. So impression management behaviours affect you if you use them, but they don't seem to affect the interaction. Whereas in contrast, avoidance safety behaviours also affect the interaction. So when we sort of zoom out and imagine our year seven students starting secondary school in lots of quite complex social environments, feeling very nervous, but tending to use more of these sort of avoidance strategies hunkering down, they're going to be more vulnerable to having that kind of negative impact on their social environment. And then if we add another layer and think, what are the peer processes going on normatively? Well, normatively there's this whole hypersensitivity to peer rejection. There is this kind of really febrile environment socially. All the kids are worried about being rejected at this time. So then if you're this young person with social anxiety, bringing in their worries and being very avoidant, that may well be picked up particularly negatively by a peer. And so one gets locked in these cycles very early, that can then be quite hard to break. Rachel: So the environment seems to confirm your fears, where the environment is one that's all about fitting in. You only have to watch a group of teenagers walking down the road to see they're all wearing the same trainers, the same haircut, the same clothes. It’s all about conforming in many ways, isn't it? Eleanor: Yeah, it's so interesting. I feel like I've been this kind of, not a bird watcher, but a sort of watcher of teens for a while. Because you're absolutely right, there are these sort of tribes, these groups, and at first glance they all look identical. But then there are these very subtle differences between them. And actually, so one might be wearing their grey trackies at a particular length, the other's wearing like black trackies, and they've got very similar Nikes, but one's got a green tick and the other's got a blue tick, there are just these sort of little differences. And when I speak to my young people in clinic, they'll often talk about trying to get it right. And just sort of often mimicking or doing the same thing as my peers, but then being criticised or rejected for that because they haven't quite got it correctly because they copied too much. They haven't got the social rules right because they've just been so desperate to fit in. Rachel: And it sounds exhausting trying to fit in all the time, trying to manage your impression. I know that certainly adults who speak about a long life of social anxiety talk about that a lot, don't they? It's just so draining and exhausting always trying to come across well. Eleanor: Yeah, absolutely. And we've just done some work with looking at quite a big data set, with a large community sample, and that's really borne out with that data in that what we see is that, over time, social anxiety is associated with persistence of depression symptoms, but also it seems to be associated with suicidal ideation over time through a pathway through depression symptoms. And in fact, that's what we often find is that it's depression that will bring young people to clinic. I think that's the same problem with adults as well. It's often not the social anxiety. And I think it's that, what young people and what most of us, many of us want more than anything is social connection. And that's what brings us most pleasure and most meaning in our lives. And that's no different for a young person with social anxiety, and actually it's acutely true for teenagers. And yet, kids who are socially anxious just fundamentally don't feel like they're acceptable and feel like if they show themselves then they will be rejected. Rachel: So you have summarised that beautifully. Is there anything we've missed in terms of additional sort of factors that influence young people in terms of our social anxiety formulation? Eleanor: I suppose the other dimension that we've been thinking about in addition is thinking about the kind of parent system. So I mentioned earlier that young people as they're moving through adolescence or it's a process of individuation, but of course, the majority of young people will be still living in the family home and parents will still have considerable sway and influence over their day to day lives and over their decisions that are made around them. And it's quite interesting in the kind of evidence around the relationship between parents and young people anxiety is not hugely compelling. It seems that if there is an association between parental behaviours and beliefs and young people anxiety, it's pretty modest, and the dimension that seems to be most relevant is that of sort of being overprotective or over intrusive. As parents, and I feel like I'm learning this all the time, we don't just put on our parent hat, like, we come to parenting with all our own concerns, worries, beliefs, like, I feel like I'm constantly doing it wrong. Rachel: I'm convinced it's worse if you're a psychologist. Eleanor: I know, because you do it and then you realise you've done it wrong, I think, probably, something like that. Yeah, so parents will bring with them their own anxieties and we think that those parents who are particularly worried about their child, like my child's is not going to be able to cope with their social, new social environment, my child's going to get treated badly by their peers. That may well encourage a sort of over control, over involvement in their child's social world in a way that potentially is developmentally inappropriate. And I suppose that can impact in a range of ways. It can mean that young people are less willing to try things and test out ideas. But it can also mean that young people are more susceptible to unkind reactions from others. Because I remember a young person whose mum would take them to the gate every day and pick them up, even though that just wasn't happening anymore in year seven. So that young person was then sort of singled out somewhat for some unkind treatment by their peers. So in some cases, it can be useful to think about the role of parents as potentially a sort of feature of that's keeping the social anxiety cycle going. Of course, when we're thinking therapeutically, parents will also very often be an absolutely critical resource and support to help the young person develop confidence. But sometimes, inadvertently, parents despite the best will in the world, can be getting caught up in the cycle a little bit. Rachel: So thank you so much for describing that. That really helps put it in context an helps us think about those factors which are really specific to young people. Is the treatment for social anxiety and CBT specifically for social anxiety with young people effective? Is equally effective as it is for adults? You started out by saying there was lots of developmental work to do there. Is it there yet? Is it equally effective in the real world as in treatment trials? How's it working? Eleanor: So CBT is a broad church, and maybe we'll do a brief history lesson for CBT for anxiety in young people. But for a long time, whilst treatments were being developed for kind of particular anxiety problems in adults, in children and young people, it was a different approach that was being taken where CBT for all kinds of anxiety was one intervention. And so these treatments tended to focus on anxiety, sort of a generic model of anxiety, and then there'd be psychoeducation and anxiety management skills, and then there would be graded exposure based on habituation model. And probably one of the best well known ones of those is Coping Cat or the Adolescent CAT Project, but there've been a whole, there's a kind of now very wide family of these that vary in terms of like, with parents, without, in groups, one to one, via digital delivery and so on. And broadly, there've been so many treatment trials with this intervention and broadly, when you look at loss of primary diagnosis, or when you look at reduction on a broad measure of anxiety, the outcomes seem to be good. So effect sizes are around 0. 8, which is really great. But what's been exciting is that as there've been so many treatment trials, data accrues and that allows us to begin to ask really important questions around what are the kind of moderators of treatment outcome? What things predict who does well in these treatments and who doesn't? And a really consistent finding from these studies is that the presence of social anxiety disorder, is a kind of significant predictor of poorer outcomes. So we did a meta-analysis of this a few years ago, led by a really fantastic colleague of mine. And what we found is that young people with social anxiety disorder were about 50 percent less likely to recover from these broad-based CBT interventions. So about, I think, well, about 55 percent of those with other anxiety problems recovered from broad based CBT. Only about 35%, with social anxiety recovered. And this is a finding that's been replicated by various other groups. So there's a really nice paper out, a couple of weeks ago by our colleagues in Norway. And they found this seems, this effect persists up to about 4 year follow up. Rachel: Wow. So that's a really big discrepancy between those groups, isn't it? 55 down to 35%, Eleanor: Yes, so this is this is what's so brilliant about bringing findings of lots of trials together, being able to ask these really important nuanced questions like what works for whom. Those kind of broad-based CBT interventions are probably good for lots of anxiety problems, it just seems there's something particular about social anxiety that means that those kind of exposure-based techniques aren't so helpful. And then when we think back to what we were talking about a moment ago, in terms of the sort of social anxiety Clarke and Welles model, this starts to make sense, doesn't it? Because if a young person is repeatedly facing social situations, but still very much caught up in their head doing safety behaviours, then it's going to be very hard for them to learn anything new, learn that actually they came across just fine. And so what this suggests is that we need to do something with those attentional and behavioural processes in the moment to help young people make the most of those learning opportunities, and to discover that they don't need to hide, they come across just fine as they are and that's where we've been moving in the last few years thinking about the applicability of cognitive therapy, which is the treatment that David and others developed to target those core processes in the social anxiety model. And we've been adapting that for young people. And we're obviously not the only group. So others have been involved in doing similar evaluations and we're still at a sort of early stage, but findings are really promising. For example, Jo Magne Ingul in Norway, who undertook a trial comparing one-to-one face to face cognitive therapy to group based Coping Cat or a version of Coping Cat to an attentional control, found that individual cognitive therapy outperformed group Coping Cat and outperformed attention placebo up to six months follow up, which is really exciting. I mean, there are questions around, well, you've got a one-to-one treatment compared to a group treatment and maybe a kid with social anxiety doesn't want to be in a group treatment so there are some questions, but it is really exciting preliminary findings. And then we've run a preliminary trial, we actually took a bit of a leap, so we decided to test the treatments, not just as cognitive therapy, but delivered in digital format, so an internet delivered version. Rachel: Which intuitively makes a lot of sense if we're talking about a digital generation. Eleanor: Well it's very interesting. So Chris Hollis has done lots of really, MindTech has done a really nice review looking at this and actually preferences are mixed I think amongst young people towards digital treatment. So I think we do need to think about choice for young people as well as for adults. But what digital therapies provide, which I think is really crucial, given the sort of constraints on services, is the opportunity to deliver rich, high content therapies in a brief format. So with no loss of all the kind of core treatment elements, which is so important. And what we found with that trial that came out last year, it was a waitlist-controlled trial, we found, that about 77 percent of young people had recovered at the end of treatment compared to 14 percent in the waitlist, and then when we looked at six months follow up that had increased to about 90%. So young people did really very well. Rachel: Wow. That must have been really exciting. Eleanor: Yeah, it was really exciting. I was also really delighted that we tested an internet delivered treatment because it's during covid. Yeah, it felt really exciting, and it was sort of the preliminary demonstration of the sense that we'd got from our early development work of the potential for the treatment. But obviously, really big questions are now there ready to be tested. So are there specific treatment effects that we can demonstrate? So in other words, is internet delivered cognitive therapy, which we've called OSCA for young people, Online Social Anxiety Cognitive Therapy for Adolescents. Is that better than an active comparator or treatment as usual?  And also in our first trial, treatment was delivered by me as a kind of someone who lives and breathes social anxiety. And we really want to be able to find out what are the outcomes like when it's delivered by clinicians working in routine services, who are doing a whole range of other things with their day to day working life, not just social anxiety research. Rachel: So we want to know it's not just an Eleanor effect? Eleanor: Yes, exactly. Rachel: Although I imagine being with you Eleanor would just be very therapeutic in and of itself, but fantastic results. I mean, thinking about even just what you were saying about good, more generic treatment across disorders. We were looking at sort of 55 percent recovery rates, weren't we? And you're not talking about 77 percent at the end of treatment, going up to 90 percent later. So there's must be some of the best treatment response rates we're seeing across the board in young people. Eleanor: Yeah, I think we need to remember this is a small trial. It's preliminary so I think it's now about increasing our sample size, feeling greater confidence in our results and then starting to think about implementation and rollout and improving access to the treatment if our findings are supported. Rachel: And are there any sort of diversity factors we need to be aware of there? So do we know yet is the research there to tell us that this treatment- and I hear what you're saying is preliminary results from small trials- but do you have a hunch around this treatment being equally accessible to everyone? Or do you think there might be cultural or other issues that might make it more difficult for some people? Eleanor: Yeah it's a really good question. In terms of cultural diversity so we actually recruited through, it was primarily, it was in the South of England but from lots of South London secondary schools we were working with. We had quite a diverse sample, primarily female, and I'd like to boost our mix of genders in our next trial. We've also been working with the Born in Bradford project, looking at is our internet program acceptable to people from different parts of England and also people from different ethnicities that weren't captured in our first trial. I think the big area for us which we're currently working on with colleagues in Bath, and with some of us here in Oxford, is thinking about neurodiversity. I think is the kind of big area which I do have more questions about, is the treatment as it stands going to be helpful or are there things that we need to adapt? So for example, recent work we did was looking at the kind of construct overlap between safety behaviours. So these are those things, the kind of things people do to try and keep themselves safe, in relation to their social worries on the one hand, and then camouflaging and masking behaviours on the other, which are things young autistic people will do in order to hide or conceal aspects of their autistic identity or autistic selves. And what we find is that, that these camouflaging and safety behaviours can often look the same from the outside, despite having functional differences. So this is an area where, for example, we might want to think about, are there in our clinical techniques things we need to do a little bit differently? Because it may be that although camouflaging and masking are associated with stress and burnout, they're quite protective and important for judicious use in certain contexts for a young person, or at least we need to know when and if a young person chooses to use them or not. Rachel: Thats so interesting and such important work because we know that social anxiety is really raised along with other anxiety problems in those folk that are on the autistic spectrum. Eleanor: So we know like 50 percent of young autistic people will have social anxiety disorder. It should be something that clinicians are seeing routinely and so the other dimension of it, I suppose, is thinking about all different autism specific processes or traits that might interact with social anxiety. So sensory sensitivity, for example. And so we're doing some work at the moment which is hoping to get at this question. So we're going to start with, as well as some observational experimental studies, we're also beginning a multiple baseline case series design just to learn some lessons before we hopefully move into a bigger evaluation of what would this treatment look like if we evaluate it. Rachel: Fantastic. And given what you've been saying about thinking about so closely developing the interventions, whilst looking very closely at the mechanisms that are underpinning the presenting problems and the perpetuating factors. Can you tell us a little bit about sort of the nuts and bolts of what treatment looks like, typically what do you do in therapy with a young person? Eleanor: Yeah, I now feel like I'm a digital native and I spend a lot of my time doing internet delivered treatment, but why don't I talk about the kind of more traditional way of doing it, which I think might be more familiar to listeners. This is a phrase that David used once, and now it kind of echoes in my head, but he says, treatment sticks like a limpet to the model which, I don’t know if that means anything to you, but I find that really helpful. So if you, if one has a good understanding of the model, then the treatment flows from that because everything one does in treatment is in service of targeting those maintenance processes. What treatment looks like is, we will start by thinking with the young person about their own social anxiety and developing a personalised version of that Clark and Welles model with them. It's almost like a snapshot of when they are anxious in a social situation, what tends to happen to their thoughts, to their attention and to what they do to keep themselves safe. How do they tend to picture themselves in the moment? We might also just check in on those kind of processes that are around it. So is there worry and rumination? Are there issues around high self-criticism that we might want to think about? What about the peer environment, parental factors, just holding those but always think about the core aspects of the model which we're going to be really focusing on. So that's the sort of first step. It can often be helpful to ask a young person to do another few models over the week so that as all social situations are different, particularly sort of performance situations compared to a social interaction. The next step is the self-focused attention and safety behaviours experiment. This is all following, hopefully if people know the adult treatment, it's following a very familiar predictable course. So the next step is the self-focused attention and safety behaviour experiment, which is that experiential exercise where we want young people to discover for themselves the unhelpful effects of being internally focused and using safety behaviours. So one of the criticisms that would be historically be levelled at, I was thinking about cognitive therapy for young people as well, but it's all talking and surely young people aren't going to like that. And actually cognitive therapy is learning through action. That's how I see it. And that's why I think it's such a great match for young people because here in session two, we have this experiment where really people find out for themselves, Oh, so this thing that I thought was helpful is really not working for me. And I don't think very often one gets a sort of penny drop moment in with therapeutic procedures whereas I think this is one of those techniques that really is can be pivotal, so we do that in session 2. Very often young people, which I think is more of an issue with young people compared to adults, will say yeah but it was an adult I was talking to, they were friendly, this is not how it works at school. So we really need to think about that bridge to okay let's test these ideas in your everyday life. Let's see if these principles hold when you're at school, when you're at your football club, when you're going to drum. And then this then sets the stage for the next clinical technique which is video feedback so young people can watch back with that kind of careful preparation in advance that Emma Warnock-Parkes has written so beautifully about in her paper with David. And really helping young people to see themselves in a more objective and positive light. And then following that we give some systematic training in getting out of one's head and getting better at engaging in the external environment, social environments, so that young people can gather real information, real data from the outside world about how they're coming across rather than relying on their feelings. And then that sort of sets the stage for behavioural experiments. And that's really where we go, testing out one's fears in social situations whilst dropping safety behaviours, getting out of one's head in order to really hopefully learn that young people are acceptable, that they are liked, that they are fine just as they are without safety behaviours. That's the message that we want to convey and help them to discover about themselves. Rachel: So it sounds a world apart from that sort of generic exposure type treatment you were talking about that often got delivered to young people in the past, because that just gave people the opportunity to learn and learn again that actually this feels awful in my head, to be exposed to those awful images and that felt sense that they had of themselves. This is quite different, isn't it? Eleanor: It is and it's really interesting. Some other groups have done some really lovely work where they've sort of taken the generic approach and they've tried to add in elements of attention training or of imagery work and see whether that is better than the generic sort of standard broad-based treatment. And they don't seem to find these effects. So I wonder whether there's something about being very model driven and really bringing in those kind of core techniques early on that seems to be very helpful. So I think the kind of key things I'd be thinking about for clinicians is just making sure that you develop that model early and that is what's driving the techniques subsequently, and also that one doesn't hold back from doing, for example, the self-focused attention and safety behaviour experiment, which I think does make therapists a bit nervous and I think there can be a tendency to leave that till a bit later, spend longer on psychoeducation, but I think it's really valuable to do it very early on. And I think, in fact, that's sort of something that David and Adrian discovered, when they were testing out the treatment, some time ago. Rachel: And I'm conscious that when we were speaking earlier, you mentioned that teenagers can be quite cruel about difference. They can pick up on these things. We tend to hope when we're running these experiments that people are going to come back with really positive data. Is there a risk when you're sending a young person off to their environment to experiment and behaving? Maybe not in this kind of net within those narrow tram lines, they might believe they have to behave that actually they might have some of their worst fears confirmed. Eleanor: Yeah, this is an absolutely critical point, and this is a question I think I get asked at every training that I do, and it is certainly a reality and a difficulty. So our job as therapists is to try to ensure that young people go and do experiments and discover something helpful and positive for themselves that's also more objectively accurate, I suppose, but it's about making sure they make helpful discoveries about themselves. We need to think about, in that initial assessment, what is their social context? What are their peer relationships like? Even that is not easy to find out, so I've got an amazing PhD student at the moment who's trying to get at this question of the links between social anxiety and peer relationships. And she's going to be using something called social network analysis to try to strip out that layer of, well if you've got social anxiety you actually are more likely to rate people being unkind to you, you're going to inflate these associations. So she's trying to get at this question using different study techniques. So I suppose tracking back, what I mean by that is thinking about even asking a young person about their social relationships when they're socially anxious, it's quite hard to unpick what is it that's perception and what is it that is how people relate to them. I think if a young person with social anxiety perceives a certain environment that they're in as victimising or bullying, that's how you read it. That's how you take it. And then what I would normally do is think, let's try to in the first instance produce or help form some alternative social settings that feel safer, that feel more benign in which they can undertake those behavioural experiments and start to test out some of their ideas. And then whilst we're doing that, also just very gently trying to start unpicking some of the mechanisms we think link social anxiety and peer problems. What happens when you go into a social situation and you're using those kind of avoidant behaviours and not looking up? What might be the message that someone else is picking up? So just starting to pull out and test out the ideas around actually, there might be some things that a young person who's socially anxious does in social situations that might elicit less friendly reactions. Rachel: How do you go about creating those opportunities to interact with those more benign situations? It's a long time since I was trying to decide what to do with my social life as a teenager, where do you start? Do you go hang out with them, Eleanor? Do you go in the bowling alley? Eleanor: I think I'd make that worse. It's definitely about in vivo experimentation, for sure. If you're spending a whole session in the clinic room, I think one should be going out and doing behavioural experiments together, so that's part of it. The other part of it is, what I tend to do is, very much engage with parents as a resource. Where, who, which of the friendship, is it cousins? Is it, for example, can we get them connected to a drama group? Can we get them connected to a dance group? Joining those groups that feel more manageable. It’s very much a kind of, there's some practical work that's often done there with parents or carers or people in the system to support that. Another way of doing it is get engaging with a member of school staff, finding those lunchtime clubs that might be more manageable, for example, and a kind of safer setting. So it's sometimes getting those kind of key adults around to scaffold, to support environmental shifts so that behavioural experiments can happen. Rachel: And that leads nicely to thinking about that other piece that you mentioned that's a little bit different for adolescents, so the parental interaction. How do you engage parents? Do you engage directly with parents around that? Do you engage through the young person? How does that look in your therapy where it's necessary to address that? Eleanor: Thinking about how we work with parents, it's different with each young person. In terms of working with parents, it can vary from almost never seeing the parent, to them to spending some time directly doing some one-to-one work with a parent. And that will be determined by a range of factors, the kind of developmental age or stage of a young person, the preferences of a young person, the ability of a young person to engage independently with therapy or the extent to which they need help. And then thinking about whether there is a reason to engage with a parent because we think there might be parental behaviours that are kind of part of or feeding into the difficulties. In terms of that kind of last strand, which I think is where your question was going, I would always exercise a bit of caution around intervening with parents because, what we tend to see is that anxious parenting behaviour is often in response to parenting an anxious child, it's a sort of dyadic process, it's not one way or the other. And I think by really focusing initially on the young person, hoping to get some symptom relief, and then seeing actually what happens to how the parent is engaging. We often see just spontaneous resolution of those parenting behaviours when a young person feels better. If that doesn't ease, even though the young person is engaging in therapy, and we're also seeing, for example, a parent allowing avoidance of behavioural experiments. Perhaps there's a little bit of parental avoidance that is impacting on the child's experimentation then it might be, that might be some signals to think about working with parents. And there it's quite light touch typically, maybe 20 minute phone call and some kind of back and forth emails. And it's absolutely using the principles that we have been using with a young person. The first step is often about helping a parent to spot their own beliefs and concerns about their young person's ability to cope, the potential threat that they're facing socially. Identifying that belief, but then also getting a sense of where that's come from, understanding the parent's perspective, because parents will often be feeling blamed. They feel like they are to blame, we all feel a sense of responsibility for our children. And so that's probably particularly the case when your child is receiving a treatment. So thinking about walking alongside a parent. Saying, of course, let's make sense of where these concerns come from, that your daughter's going to get bullied. It's often from somewhere really understandable. I was really socially anxious as a child and I had a horrible time, or they were bullied in primary school and I don't want it to happen again to them. Understanding the story in the background. Well, that makes absolute sense that you have that belief and that you feel like that. Now let's look at how that belief impacts on how you relate to your child and what you do. So you start to move to thinking about, well, because I'm concerned that they're going to get bullied, for example, I will walk them to school. I don't allow them to use social media, or I track their social media. And we look at them and then we look at the pros and cons of those behaviours, the intended, the unintended consequences. And that then sets the stage for some, often some kind of research work that we encourage parents to do. Benchmarking. What are other parents doing in their cultural group, in their community, in their age range? Working out for them what is actually probably where they should be compared to where they are. And then behavioural experiments. So let's test out those ideas and see, find an alternative and it can be helpful to engage a young person sometimes in those moments so that they know what's coming and, it depends I think on, from a case by case basis how much you involve the young person in the parent work. Rachel: And it does sound like a really understanding, respectful process where, there's nothing more basic and human is there for us as parents to want to protect our children from harm, but also tapping into that piece of what we want most of them is to flourish. And those two things, the way we go about those two things don't always marry up. Eleanor: No, and I think often parents are busy, often they have many competing demands, and parenting can often just be driven by quite quick emotional habits. And so it's helping a parent explicitly think about the pathway through to what they're doing and is that how they choose or want to do it and giving them that space to test out doing things a bit differently. Rachel: So Eleanor, that's been a really helpful description of how the model might be applied, how it looks very much like what we might expect in terms of sticking like a limpet to the model, but also thinking about these additional factors that are play a really important part in how you might need to address those more broadly, the sort of systemic factors that are supporting or maintaining the problem. In your vast experience of teaching this work, supervising, applying the therapy with young people, where do therapists get stuck? What are your most frequently asked questions or trickiest issues that come up? Eleanor: I think we might have just been speaking about it actually. I think the most challenging thing is, particularly in the kind of work with young people, is thinking about the reality of that social environment. I was talking about this with colleagues the other day in that there's something very specific about the school environment which is not only all these adolescents having all their social concerns and feeling kind of sensitivity to peer reward and peer rejection, but it's also like a locked system, so to speak. So as adults, we have agency, often we have much more choice about how we interact with our environments, our workspace. Not everyone will feel that to a certain, to a greater extent, but that is much more so than young people who need to be in school all day. And so then I do think it becomes a challenge to think about how do we help young people make positive discoveries about themselves when their social environment can be quite unkind. And actually one of the things that we've recently developed are virtual classrooms. So these are sort of filmed classrooms of differing sizes and it's a way for young people to test out and do behavioural experiments and video feedback, giving speeches or reading aloud or just sitting in a classroom that generates the feeling of being in a classroom, but in a slightly safer setting. So then you have a kind of staggered way to then move to experimenting in a real classroom, which potentially does feel more challenging. Rachel: I love this idea, but I've got to check out- is there someone throwing something at all times? Another child in these videos, because if the stories that come out from my kids schools, if you believe that it wouldn't be authentic otherwise. Eleanor: We did, we asked, we got a range of classroom scenes. So some we've got some good students in quotes, and then we've got some other scenes where we've got disinterested students. So they're all looking over their shoulders and whispering and passing notes. So we've tried to get a range. Rachel: the teacher tested, brilliant. And what about another question or issue I hear people talking about is sometimes about starting off on the right foot in terms of diagnosis or problem presentation. So with young people, as I understand it, there's often quite a lot of comorbidity or sometimes it's hard to say what the main problem is as it still emerging or there's seems to be more sort of nonspecific anxiety around this. Is that a thing that people struggle with? Eleanor: Yes, absolutely. and I would say, I mean, social anxiety brings with it a risk of a whole range of other anxiety problems and depression. It's rare to see social anxiety in isolation. And certainly, I think that problem of sort of specification of anxiety disorder is even harder in pre adolescence and it gets a little bit easier, as kids move into the teenage years. And I think that was very much the motivation historically for those kind of broad based approaches, because it was often tricky to identify the primary problem. But I think, I suppose there's a few strategies that can help us to do that and to tease out if there is a social anxiety that seems to be the kind of core problem, then how we do that. And part of that's about using good measures which I think is something that we still need to improve our use of in child and adolescent mental health services. So thinking about making sure we have a comprehensive battery of good, valid, reliable measures for young people to complete at the beginning, so that we can actually quantify and understand the kind of picture of their problems. And I think that's particularly important, I suppose, thinking about social anxiety where sometimes young people wouldn't say that their main problem was about other people and how they came across, but on a questionnaire it comes out really clearly and that then opens the door to ask these questions. And then the other thing is about, if there are a range of problems, which there typically are when a young person has social anxiety in the mix is thinking about asking questions around if we could treat your social anxiety and you weren't worried about how you came across to other people, what effect would that have on the other difficulties we've talked about so far? How are the, we've got these different problem areas that we've talked about. How do you think they relate to one another? Which would be the thing that would have the biggest impact on you if we could target that? And I think, there is value in focusing in a single-minded way on a particular problem to gain traction, because I think otherwise there can be a risk of therapist and young person getting lost in the, not seeing the wood for the trees, so to speak. Rachel: So a useful response to complexity can often be to simplify? Eleanor: Yeah. And there are different approaches to that, aren't there? I think it's about thinking, my approach has been to think about mechanisms. So what do we understand are the modifiable processes that seem to be driving this young person's problems and how can we target those effectively and acceptably for them? Rachel: and they may be in common across the different issues that they're dealing with. Eleanor: Yeah. Rachel: You've talked about how you've been working really hard to harness the digital world in your work. I'm wondering for young people though now, what impact life lived online is having on them. And we read about it all the time in the newspapers, any parent I speak to is always obsessing about how much time their kids are spending online and which social media apps they're using and when and how often and with whom. Are you seeing in data, in clinics and presentations, an impact on young people of this online life? Eleanor: So this is a big question and I feel like perhaps it might be one that you could do a whole podcast on. Rachel: Great. We'll have you back Eleanor: No, well, I don't think I'm an expert in any way. I think that the research is a little bit messy. And what seems to emerge from, there've been a number of umbrella reviews and so on. What seems to emerge from the studies that have been done is that there does seem to be an effect. In general, it seems to be that there is it’s a negative effect, but on the whole, it's pretty modest. So someone who's been a real trailblazer in this area is Amy Orban up in Cambridge, and she's done some really interesting work, mainly in the kind of wellbeing space rather than the kind of, the kind of more severe end, I suppose, of the spectrum. But she has found, for example, that young people who tend to use more social media than others there are some links with poorer wellbeing across certain domains, but also when young people tend to use more social media compared to when they would usually, that then is linked to a slight decline in wellbeing. So that's, I think, really interesting. She also seems to find two particular sensitive periods, which I think probably needs replication. But for, and it's different for girls and boys. So there's, in the early phase of adolescence, it seems around 11 for girls and 14 for boys. Think about when puberty might be happening. So very interesting. And then there's a subsequent sensitive period, which is coincides for girls and boys of around 17. In other words, a time when social media, the strength of the association seems to be a little bit stronger. So that's there in terms of looking across the population. I think potentially it's different when we think clinically and Emma Warnock-Parkes, just to mention her again, has done some nice work thinking about how social anxiety, safety behaviours and so on might translate online. And really what we see is that what young people, individuals, tend to do in real life, so to speak, will move and migrate on the online interactions. So people who are socially anxious will tend to do more passive scrolling than interaction. They will be posting less. They'll spend a lot of time preparing posts before they do it. So these are things that you can see sort of analogue parallel, so to speak. And this makes sense, when we talk to young people about their social world, they don't see a distinction between a real world and a social world. And many of the people that they interact with overlap. I suppose what's potentially different is the rate at which people, you can connect with people, they can react in kind or unkind ways. And one can quantify, literally, with one's likes how well you've been received and that's so potentially it could be that you, it amplifies any effects received about social rejection or acceptance. Rachel: That makes sense. A human behaviour is human behaviour wherever it occurs, but it may be amplified in certain contexts, in certain, medium, that's really interesting to, to see what comes of further of those studies as we learn more about that. Eleanor: Yeah, and I have to say, like, although I mentioned all of that with Amy Orban I still, as a parent am very reluctant to, and I'm always having debate, I'd say debates with my daughter about, whether or not she can have a phone. Rachel: This is good. I can quote the expert to my kids. We know that CBT isn't just a process of clinically applying techniques and tools, we bring ourselves as therapists with all our assumptions and life experience. And we spoke earlier about how many of us may have had negative experiences ourselves in childhood, in social situations, sometimes I feel, albeit working clinically with adults who are presenting with various different anxiety disorders and other presentations, it feels like everyone was bullied when they were a kid, everyone's got a story about what was going on. You start to wonder who were the bullies, but, I guess we might have to challenge some of our own assumptions, some of our own preconceptions about how childhood, adolescence and peer interactions in that period work, or maybe some of our own standards or beliefs about what's acceptable, what's not. Does that play out do you think in therapy? Eleanor: I think what's really interesting is, and I've been learning about this recently and thinking about it quite a lot, is our language around bullying, teasing. What I find really interesting is that we've just been doing qualitative interviews with young people who have experienced difficulties with peers and social anxiety, and we decided not to use the word bullying. Because when you ask young people if they've been bullied, most of them will say no. And then you ask, then you list a whole range of behaviours and they'll tick many of the things that we would think absolutely constitute bullying. And I think there's something particularly for those individuals who have had or are socially anxious, to tend to minimise unkind behaviours from other people, internalise and take on the blame and responsibility for those behaviours. And I also think that you mentioned like, who are the bullies? I also think there's not always completely clear lines about how, you know, relationships are very complicated things. And there are often times when people can go between both sides of that bully/victim dynamic and times when one can be a bystander as well. So I think it's also partly about thinking how do we ask people these questions to get good data and also how, what methods do we use to try to interrogate the associations between peer relationships and various mental health outcomes going beyond self-report, which is just going to inherently be problematic when we're looking at these sorts of associations. Rachel: And it sounds like it might be important to explore some of my own assumptions as a therapist about what is going on in this peer interaction. As you said, if people have had those negative experiences, they may have internalised those have thought that it's something about them and they may therefore also minimise the young person's experience or think that it's all about them learning some more social skills rather than testing the veracity of their perception of themselves. Eleanor: Yeah, absolutely. And I think the other thing is when we work with young people is remembering that I mean, it's hard, it's trying to tap back into how it feels and how it felt when you were young, but also just coming from a position of you need to tell me, you're the expert on all of it. You tell me what it's like for you and what your school is like. Coming from a position of curiosity, I think, and while you can try and tap into what it was like as a teenager for yourself, also just saying, you need to tell me this bit. We need, we can't, I can't do this on my own. I might know this stuff about CBT, but you know what it's like in your school and in your, in your kind of landscape for now. So let's come together to try and boost your confidence and help you feel better. Rachel: And we often learn as much from our patients and our work, don't we as our patients learn from us. I think it's one of the joys of doing this work. You get to see the inner workings of people's lives and their thinking and how that plays out. Have you learned from the young people you've worked with, how has that work made a difference to you and your life, do you think? Eleanor: Oh my gosh, that's a good question. And lots of things are coming to my head at the moment. Firstly, and the first thing I was thinking is like, it's just been, it's such a privilege all of it. But that, I mean, that sounds a bit of a nicety, but it does genuinely. I always feel so privileged that people trust one enough to do the work together. And I think, that is a role one shouldn't underestimate the importance of. I've had a really nice experience. Recently we have, so with Emma Warnock Parks and David Clark and we were commissioned to write a self-help book in the Overcoming series for young people with social anxiety. And we were really lucky to have a young person with a lived experience of social anxiety join us as a co-author. And that has been a fantastic experience in how to write properly for young people. So she would go through and say, this is patronizing. This is patronizing. You don't need to speak down to teenagers. And she just guided us to think about making sure that we had an authentic voice that was respectful to young people, but also always thinking about accessible language, and that's a hard balance to find. And I was really grateful to have her on our team guiding us. And the other thing she talked about, which was so interesting is the importance of weaving throughout our book, this notion of speaking to oneself with kindness, trying to counter self-criticism throughout, because she said she experienced, and actually many of the young people I've worked with, just that kind of self-critical voice that seems a really common thread. Rachel: Yeah. So what can look like stroppy and difficult behaviour from an adult perspective, actually, when you get dig underneath that, there's often so much self-doubt and self-criticism isn't there for young people that's going on and that's maybe coming out in a way that doesn't help. Eleanor: Absolutely. And make sure you make me think that, I think one of those cognitive techniques that has been talked about is asking patients to have a second thought if they've had a kind of negative automatic thought, if they're depressed and actually we as clinicians need to do that as well, take a second thought, particularly when working with adolescents is that stroppy reaction actually an anxiety driven response, for example. Rachel: And I'm guessing that as a mother of a 12-year-old, when you're being marched down the street, three paces behind her on a clothes shopping trip, you may have some compassion and want to buy that pair of nice jeans for her. Eleanor: If I have half the compassion and loveliness of my mum that she had towards me, then I'll be doing okay. So I just got it. Yeah, exactly that. Rachel: As we move towards the end of the podcast, Eleanor, I wonder if you can tell us a little bit more about some of the exciting horizons in your research. You've mentioned so many different things that are going on. You sound like a very busy person, with fingers in lots of pies, but it sounds like it's a really exciting burgeoning field. What, what's happening? What are the next big steps? Eleanor: Yeah, so we're really delighted that the NICE early value assessment in their recommendations of digital CBT for anxiety and depression in young people gave a provisional recommendation for our OSCA online treatment last year, which was fantastic, really great. They also published some evidence generation plans. So sort of clear, description of the evidence they would like to see down the line in order to provide full recommendation and actually that aligned quite neatly with our existing plans. So we are about to start a randomized control trial comparing OSCA to treatment as usual, which we've operationalised as graded exposure based CBT, delivered by clinicians working in routine children and young people's mental health services. So that will be with 220 young people and that's going to be starting very soon. So that's really exciting. And then another track of work is looking at understanding the treatment for autistic young people with social anxiety and then another big strand of work is implementation and thinking about making sure from the beginning we're thinking about how best to roll out and implement OSCA in services so it's acceptable to clinicians except service managers so that's another important part of the work. Rachel: And so for people listening who are really eager to learn more about this and they, they don't want to wait for a dissemination study 10 years from now, they want to know what they can do right now to learn more about this, to implement this and to help the young people that are sitting in front of them overcome this really challenging problem. Where can they learn more? What can they do? Eleanor: Yes so there are lots of ways really so there's a couple of websites that people might find helpful, so the first which is OXCADAT Resources and that is where people once they've registered it's a free resource and people can find lots of videos and therapy resources and our questionnaires that we use to support to guide and support our therapy can all be accessed. So that is, I think, and there's our manual is on there as well. And another website is for our group, focused on young people's mental health. And that's, our group is called CAMY, so Cognitive and Behavioural Approaches to Mental Health in Young People. And I can give you the link to, to share, afterwards. And that just gives an introduction to our team members and what we're doing at the moment. And then the other thing, if people are interested, is our young people's self-help book will be out, I think in a couple of weeks, published by Hatchette and it's in the Overcoming series. Rachel: Fantastic. We'll put all those links in the show notes so people can get to those directly. Okay. In true CBT fashion, we like to summarise and think about what we're taking away from our session. So, I wonder if there is a key message that you would like to leave folk with regarding this really important work. Eleanor: So I think what I would say is social anxiety many people feel is a hard problem to treat, but it's actually, I think one of the most rewarding problems to treat. And it's very likely that you will, if you're working with young people, it will be something that you see. And if we can deliver a good treatment early, we have this amazing opportunity to really shift a young person's trajectory and their journey. They might be going on to university when they weren't going to go to university, getting that job in a cafe when they weren't going to, choosing to leave home. These kinds of moments in life that really can make a difference. And it's well, the evidence really is pointing to the potential value of considering using cognitive therapy for this problem in young people. Rachel: That really does sound like a very hopeful place to leave it. I know you said at the beginning, make it sound so huge and difficult, but to know that these treatments are available, that we can stem that tide is really exciting. Amazing to hear about your work and all the work that's ongoing. Thank you so much for talking to us today, Eleanor. Eleanor: Thanks so much, Rachel. Lovely to speak to you. Rachel: And to our listeners, thank you so much for joining us until the next time, please look after each other and look after yourselves. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on X and Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    

This episode, Rachel talks to Dr. Stirling Moorey about the role of CBT in supporting individuals with cancer. Dr Moorey is a consultant psychiatrist and a leading expert in psycho-oncology as well as the new BABCP President. He has worked extensively in the field of CBT and cancer since the 1980s, contributing to research, clinical practice, and supervision. They discuss how not everyone with cancer will need r want psychological interventions but how CBT and learning coping strategies can be effective for those who do and how therapists can look after themselves when working in this emotionally demanding area. Useful links: Books: Moorey, Stirling, and Steven Greer, Oxford Guide to CBT for People with Cancer, 2 edn, Oxford Guides to Cognitive Behavioural Therapy (Oxford, 2011; online edn, Oxford Academic, 1 June 2015) Papers: Serfaty, M., King, M., Nazareth, I., Moorey, S., Aspden, T., Mannix, K., Davis, S., Wood, J., & Jones, L. (2020). Effectiveness of cognitive-behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial. British Journal of Psychiatry, 216(4), 213-221. https://doi.org/10.1192/bjp.2019.207 Serfaty, M., King, M., Nazareth, I., Moorey, S., Aspden, T., Tookman, A., Mannix, K., Gola, A., Davis, S., Wood, J., & Jones, L. (2019). Manualised cognitive–behavioural therapy in treating depression in advanced cancer: The CanTalk RCT. Health Technology Assessment, 23(19), 1-106. https://doi.org/10.3310/hta23190 Serfaty, M., King, M., Nazareth, I., Tookman, A., Wood, J., Gola, A., Aspden, T., Mannix, K., Davis, S., Moorey, S., & Jones, L. (2016). The clinical and cost effectiveness of cognitive behavioural therapy plus treatment as usual for the treatment of depression in advanced cancer (CanTalk): study protocol for a randomised controlled trial. Trials, 17(1), Article 113. https://doi.org/10.1186/s13063-016-1223-6 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: Today I'm so pleased to welcome Dr Stirling Moorey to the podcast to talk about CBT and cancer. Dr Moorey is BABCP president elect and a recently retired consultant psychiatrist who's been practicing CBT since 1979 when he visited Beck Centre for Cognitive Therapy in Philadelphia for a medical student elective. He's a highly acclaimed clinician, researcher, and teacher, and has specialised in several clinical areas, including psycho-oncology. Stirling is particularly known for his research and work on the application of CBT for individuals with cancer. So thank you so much and welcome Stirling. Thank you for joining us. Stirling: Thank you. Thank you very much for inviting me. It's great to be on the podcast and really lovely to be contributing to what is the growing CPD offer of BABCP to our members. Rachel: And on our agenda today is an understanding of if and how CBT can be helpful to individuals with cancer and how we might apply CBT in this context. To start us off, I wonder if you could tell us a little bit about your journey into this work and what got you interested personally and professionally in working with CBT and specifically CBT with cancer. Stirling: Well, it's interesting. I think that this all began in about 1986 when I passed my membership of the Royal College of Psychiatrists and was looking for what the next job would be as a Senior Registrar. And looking for what might be research opportunities and Dr Stephen Greer, who was a wonderful clinician, but also a pioneer of research in psycho-oncology had received a large grant from what was then the Cancer Research Campaign, is now, Cancer Research UK to look at the effectiveness of psychological treatment in cancer and so he developed, was developing, what he called Adjuvant Psychological Therapy, which was a bit of a mix of some emotional support and CBT type components. So, because I was interested in and had some experience of CBT at that time, he was quite keen for me to come on board and be a member of the team. So that's how it started and really led to us doing some research but also producing our book, which was originally Adjuvant Psychological Therapy. It's gone through I think three or four editions now and has become the Oxford Guide to CBT for People with Cancer. So I got into it through really a research interest and my time at the Royal Marsden meant that we were doing quite a lot of clinical work in the liaison service as well as the research project. Rachel: And just to ask, briefly, Stirling, some people might not be familiar with that term adjuvant. What does that mean? What does that refer to? Stirling: So he called it Adjuvant Psychological Therapy because at that time, adjuvant chemotherapy was a treatment, that is still used, alongside what might be say a surgical removal of a cancer, and alongside that people would have a chemotherapy treatment. So he said, well why don't we sell this in a way to the oncologists by calling it Adjuvant Psychological Therapy, might make it more acceptable. Rachel: And do you think the fact that you had a medical background rather than, a sort of psychological background in terms of a psychology degree, that sort of pathway into psychological therapies, prepared you, drew you in particularly into this kind of work? Stirling: Yes I think I agree. I think that, having a medical background, I think gives you some advantages. It doesn't mean that many psychologists can't be very proficient at working with people with physical illness, but it does give you a different angle. I mean, I think one of the things that perhaps is unfortunate in the CBT world is that I think that biopsychosocial approach that doctors can bring, and nurses can bring is perhaps undervalued a little bit. So yeah, I think that adds a component to the psycho-oncology. Rachel: Perhaps I wonder if you can go places with your patients that perhaps psychological therapists might fear to go for that the fear that maybe their patients might think there's telling them it's all in their mind or, you know, being reductionist about what's going on for them. Stirling: I think that's right. I think that, to some degree, I don't know that being a medic necessarily comes up that often as an issue for patients. I think where the areas where it can be helpful is that you perhaps speak the language of the medical staff, doctors and nurses. So sometimes actually sort of interpreting in both directions, interpreting for the patient what some of these things mean, and vice versa, helping the doctors to understand. And sometimes we would have joint meetings with the oncologist or the nursing staff and again, that, that translation can be helpful, which perhaps is a little bit more difficult from someone who doesn't have a physical, medical background. Rachel: So you had this interest in CBT, this training in CBT, there was this momentum behind this particular area, there was funding for research into cancer. And we know now as then, but increasingly so cancer is undoubtedly a huge global concern. It's one of the most incurable diseases with, I understand, the second highest mortality rate after cardiovascular disease. Macmillan Cancer Support estimated in 2022 that there were approximately 3 million people living with cancer in the UK alone, with that number anticipated to rise exponentially up to sort of 5 million by 2040. And the NHS reports that one in two people will develop some form of cancer during their lifetime. So in that context, the context of the high mortality rates and the high prevalence of cancer, can you tell us a little bit about why we would be thinking about psychological interventions with cancer? Stirling: Yeah, I think that the good news on the psychological front is that we know that about 60 percent of people who go through a cancer diagnosis are going to be coping pretty well. They don't meet criteria for anxiety or depression, and I think that's very encouraging that there's a lot of resilience that we have. But, you know, 20 to 30 percent of people will experience symptoms of anxiety, depression and adjustment problems and that's a significant burden, I think for themselves and for health services in the past was largely unrecognised, but I think it's much more becoming recognized. People experience a whole range of reactions to cancer. The thing about cancer that I think makes it differ from other long term medical conditions is the threat to survival, is, is in our culture, associated very much more with cancer than with other conditions. But someone, say, with heart failure may actually have a much poorer prognosis than someone with cancer but in terms of the psychological impact because of the way in which we stigmatise and see the disease, that threat is often very profound. So fear of recurrence and progression is a big component of the psychological burden of cancer but then alongside that, there's also the impact of physical symptoms. There may be side effects from treatment, such as going through chemotherapy and losing your hair, having nausea, side effects from surgery, which may be major physical changes impacting body image. And also, often in later stage disease, physical symptoms such as fatigue and insomnia really impairing your capacity to cope. And plus the social impact of cancer for people losing, say their, their livelihood, losing their role, and the stigma that is still around. People don't quite know how to talk to someone with cancer. So a whole range of biological, psychological, and social impacts of cancer, that, as I say, fortunately, most people don't need psychological interventions beyond the usual support that might be necessary for any physical illness. But some people really do benefit from having a bit more of a of a look into how they're coping and how we might help them. Rachel: And that figure, you said that 60 percent figure is really striking because it's really not that long ago, as you say, so culturally cancer wasn't even spoken about, you know, it was the C word, wasn't it? People didn't even use it almost from sort of superstitious perspective, if I say it, it might get me, and to realise that, you know, 60 percent of people can adjust and cope, with respect to their psychological wellbeing seems quite extraordinary. I realised hearing that myself, you know, I have maybe some assumptions about how if this were to happen to me, it would be absolutely catastrophic and I might not be able to deal well with it. But also, easy to understand, given that sort of broad range of impacts that not only the problem itself brings, but also the treatment for the problem brings that people would need some support, potentially. So, you know, along those lines of, you know, ideas that are around and myths that we might want to bust or things that may or may not be true, we have a set of true/false statements that we often include in this podcast, which might open up some of those discussions for you. So first up, a majority of people who are diagnosed with cancer will die as a result of the disease? You may have addressed this a little bit. Stirling: Yeah, so that's no. So current figures are that something like 50 percent of people who have a diagnosis of cancer will survive for 10 years or more. And in an illness like, say breast cancer, actually the figures are that people are going to be likely to die from other causes before breast cancer causes them to die. That doesn't mean that actually there are an awful lot of people who will die from the disease, but it isn't inevitably a death sentence as people used to fear and increasingly more and more treatable, but with huge variation in survival rates. So if you're a young man and have a testicular tumour, you have an approaching a 98 percent chance of surviving. If you have pancreatic cancer, unfortunately, figures are really down still around 1 percent of people surviving five years or more. Rachel: That’s a huge variation as you say. but again, cause to pause when we think it's inevitably a death sentence when we hear those words. And how about, the next statement to people with cancer generally do not want psychological support, they just want their physical symptoms to be addressed? Stirling: I think probably on the balance, no, but it is a more nuanced sort of answer because, as you see in that figure of 60 percent of people not meeting criteria for any psychological disorder, those people may not necessarily want to have help. They may benefit from some support because there are still lots of issues that you need to be dealing with, even if that doesn't mean that you have a psychological morbidity that we would say requires sort of professional intervention. But for instance, in the first trial that we did, it was a sort of a screening trial in a way, looking at people who scored high on the health anxiety and depression scale. And they were offered either treatment or treatment as usual or Adjuvant Psychological Therapy and quite a percentage of them would say Oh, well, I’ll help with the trial. But as long as I’m in the control group because I don't really feel I need psychological support. And also looking at the outcomes of studies of CBT and other therapies in cancer, when you offer this to everyone, actually your effect sizes are quite low. If you target it for the people who have significant symptoms, then you get much better effect. So we don't have evidence that it's harmful to offer treatment when people are not hugely distressed, so that's where the nuance is that actually I think everyone would probably appreciate support, understanding, good communication but not necessarily a psychological treatment. Rachel: So psychologically informed approaches may be helpful for everyone, but it makes sense, doesn't it? If you didn't have depression, you wouldn't expect to see a huge impact on your depression if you had a depression treatment would you? So that, that makes perfect sense. So how about this one then Stirling with your passionate commitment to CBT over the years. CBT is too superficial an approach to have anything to offer the kinds of key existential anxieties and questions that people with cancer present with. Stirling: No, I would say to that, that CBT isn't an existential therapy per se, but, I think in terms of the threat to survival and the cognitions that we have around prognosis and the meanings of death are things that can be really can be addressed with a CBT approach. For instance, the sorts of existential concerns that people with incurable cancer have would be say around the process of dying, the pain that might be associated with that and the distress that might be associated with that. And I think that from a traditional CBT perspective can be examined in terms of the evidence and very often people have catastrophic fears, often based upon past experiences, with loved ones at times when perhaps pain control was not so good. So we can examine those beliefs. We can put people in touch with the palliative care team who are excellent at reassuring them about the ways in which pain can be controlled, etc. We can also, I've worked with the imagery that people have around dying and their own deaths, and I might share a little bit later, a very moving experience in using imagery work with one of my patients around that. And then the other area, other areas around projection into the future, what will happen to my family, again, what might I be able to do right now to maybe project into the future memories that I can leave with people. So all of these are very much within the CBT frame. In terms of what happens after death, maybe because we're not primarily an existential sort of therapy, there are other approaches that may address that. But we can work with fears about the consequences of if you believe in an afterlife of what that might mean for you by actually working together with sympathetic and compassionate rabbis, priests, imams to set up a sort of almost like a behavioural experiment that I'm fearing that something that, that I will go to hell. Well, let's actually get you talking to someone rather than just ruminating, being stuck in that guilt. Let's get you talking to someone who might be able to give you a compassionate view of what the future might look like. So all sorts of different things that can be taken from our CBT toolbox, even in this area. Rachel: So working with the patient's own cognitive and spiritual outlook in terms of things that are meaningful and valuable to them. So next statement. If people with cancer simply take a positive attitude to their illness, they'll be more likely to recover. Stirling: The answer to that is no. That first trial that we did, Stephen Greer was very interested in the sort of psychophysiological aspects of psycho-oncology because he'd done a study that had found that women with who'd had a mastectomy, who had a fighting spirit, were lot likely to survive longer than those who didn't. And so this trial was in part aimed at to seeing if we could improve prognosis. In fact, it was quite underpowered in terms of numbers. It did show that we could improve psychological adjustment, but no impact on disease. And subsequent studies have really showed that actually having an optimistic, positive approach doesn't have any impact on your prognosis but does have an impact on your well-being and your coping. Rachel: It's an idea that I think is so prevalent in our culture that somehow there's something that individuals can do just about how they fight cancer or how they, as you say, that, that term fighting spirit, how they man or woman up to it is going to affect the outcome. And that's very interesting to hear what the research says about that. Stirling: Again a sort of just a little also a caveat is there probably is some research that people who are depressed may have poorer prognosis, but whether that is a psycho-immunological effect or whether it's a sort of simply the fact that you perhaps engage less with treatment if you're depressed I don't know, but there's some suggestions that the helpless, hopeless stance may not be,so good. But not that if you think positively, you'll beat this. Rachel: Yeah, you can't think it away. Stirling: Yeah Rachel: So final statement for our true and false section then, treating people with cancer is unrelentingly depressing and difficult as a CBT therapist. Stirling: Very definitely no. There are strains and costs, I think, to working exclusively in this area, but I think one of the things that is most obvious when you're working with people with cancer is that an awful lot of people will have very good coping strategies but have decompensated as a result of the threats of the disease. So actually they can regain those strengths, they can remember those strengths, they have the resilience so they bounce back quite quickly with some brief treatment. There will also be other people who perhaps have longer term problems who already have a history of depression or mental illness who will be more like the patients we usually see in secondary care and so on but actually in many ways the patients that we're seeing are going to be easier to treat in a way and very rewarding to see that rebuilding of their skills quite quickly. Rachel: So, in contrast to what we might think, it's not a depressing prospect treating someone with depression where it's just a kind of downhill process. Actually, you can see this bouncing back, these rewards, these positive outcomes despite the picture of the illness. Stirling: And I’m not sure if this is on your list of myths, but a related myth I can tell you is that if you have incurable cancer then you're inevitably going to be depressed And actually, there's a meta-analysis that showed that the levels of anxiety and depression in people in palliative care who have cancer that can't be cured are around the same as those in people going into an oncology service. So actually, again, it's that resilience but our job is to help the people who perhaps aren't so resilient to cope better with the illness, whether it's either through fear of recurrence or through a knowledge that they are going to die and the negative impact of that on them. Rachel: So I think we've established quite clearly that when we're talking about CBT with folk with cancer, we're not talking about treating the cancer per se. We're not necessarily looking at the outcomes of the cancer diagnosis, but we're thinking about providing treatment for these associated psychological, but also social, and psychosocial functional changes, et cetera. Can you tell us a bit about evidence base and clinical recommendations for the application of CBT with cancer? Stirling: There have been a lot of studies of cognitive behavioural type interventions in cancer. They range from sort of more coping type strategies, often delivered in groups, delivered to people across the board, whether they have distress or not to more focused individual CBT in both second and third wave sort of approaches. And so generally, the finding is that CBT does have an impact on anxiety and depression. We know also that it can be helpful particularly with the insomnia in cancer and with pain and fatigue so lots of studies demonstrating that so overall the evidence is that CBT is an effective treatment and with suggestions that results can be there at least a year after the intervention. When you compare it, head-to-head with other treatments there isn't really evidence that it's more effective for people with cancer with their depression and anxiety. Rachel: So what other therapies has it been compared with? Stirling: So compared with more supportive type therapies, sort of emotional expressive supportive therapy, which is another sort of slightly more humanistic approach. So it's as with I think we could say with a great number of things, particularly depression not possible when you do head to heads to show benefit of CBT as being particularly more effective. Though with the cancer studies the effects, the sample sizes are often quite small, so it's quite difficult to show necessarily a more beneficial effect. We'll talk a little bit more, I think, about the study we did at St. Christopher's Hospice, where we trained nurses to, do CBT, first aid CBT, in patient’s homes when they were visiting them as clinical nurse specialists. And what we found there was an effect for anxiety but less of an effect for depression, but no more than the group who received usual support. And I think there is something about the support that you receive in a clinical setting, or if you have a controlled treatment that is supportive that is really important for people with cancer that actually then means that specific techniques like CBT are added in to that it's not really a placebo effect, but it's a basic effect of having a supportive relationship is a big component of what people benefit from when they're dealing with a serious physical illness. Rachel: So it sounds like there might be slightly different benefits across different treatment targets. So whether that's depression, anxiety and who it's delivered by and in what context. Stirling: I think of the impacts of physical symptoms like insomnia and pain that we would see a benefit of CBT. There have been a lot of studies that have actually compared CBT for insomnia, say, with an active treatment but my, my, my guess would be that for those, sort of more specific problem type areas, we would have some benefit. Yeah. Rachel: And is there a sense of differentiation in effectiveness across different types of cancer or different stages of cancer? Stirling: Again, this is, I think, not clear. There've been a number of studies that people with advanced cancer that have showed an effect. The study that we did, the CanTalk study that we did within IAPT, had some rather disappointing and surprising outcomes. And here, what we did was we helped clinicians who were working in IAPT to have one day a week training in CBT for people with cancer. And then the study took people with advanced cancer who were currently depressed and allocated them to treatment as usual or 10 sessions of CBT within IAPT. And it was a flat line, neither group actually showed any improvement. So we didn't even get a placebo type of CBT. So that was a large study of 200 people. It's not quite clear why there wasn't any effect there, but I think it does, it does tell us that it may be that the skills that you need for working with people with more advanced disease might need a bit more specialist sort of input. So that sort of brings us, I think, to the recommendation. So recommendations are that people with cancer should get a sort of a stepped care approach. That's the professionals in working in oncology services and so on should have some training in communication so that they can give appropriate support. But at the next level, we're talking about perhaps more telephone type support and input of group support and so on. Moving up to the next level, which is psychological treatment services within the cancer setting.  I think that there are lots of reasons why treating people with active cancer or with more advanced disease in IAPT is not appropriate. And I think in the, in the guidelines, really cancer is seen as a chronic illness, a long-term condition but Talking Therapist services are going to be focusing more on people who've recovered and the fear of recurrence problem. And we know that, for instance, if you follow up people after a successful treatment for their cancer, over time the incidence of depression is no different from that in the normal population, the healthy population but the incidence of anxiety disorders is four times as high. So I think this is where IAPT can offer something with perhaps some support from psycho-oncology services. but people with active cancer are probably best treated by psychological services embedded within the hospital because of those, you sort of started to talk at the beginning about what being a medic can bring to it. I think that actually working within that setting, can probably be more helpful than going out to a psychological treatment service separate from that. Rachel: So that multidisciplinary approach can really enhance and support the treatment. Stirling: Exactly. Yes. Absolutely. Rachel: So, given these recommendations, we have said that not anyone, not everyone by a long stretch will need psychological intervention. But for those who do or have some of these issues that might benefit from this kind of approach how widely available is psychological therapy for them? You know, would someone your typical individual diagnosed with cancer in the UK, for example, be likely to be offered psychological support at some point in their cancer treatment pathway? Stirling: It's very variable. Pathways sort of are now being developed in most areas, most regions and, and certainly, most hospitals would have, clinical nurse specialists who are working in cancer, who have some of those basic support skills and counselling skills, and some of them have CBT skills too but it's patchy still. It's patchy and many places don't have liaison psychiatry or psychological therapy services. So it's a I think still a little bit of a postcode lottery. Rachel: So it sounds like this is an area where dissemination is really important to enable people to have that equal access to that treatment that, that can, in the right circumstances with the right presentations be really helpful to them. Stirling: That's right. Yes, Rachel: In many areas in CBT currently, there've been really big developments in dissemination around offering self-help or supported self-help or technology assisted CBT to improve that. Is that something that's happening in cancer? Stirling: It is. There are sort of brief interventions, both more general ones and more specific ones for things like insomnia and fatigue and so on. Telephone based, computerised, all sorts of things. It makes sense to provide that, whether just how effective it is, I think, is still, in question and the meta-analyses that I've looked at, I've read, suggest that there's not enough data yet to know how effective those low intensity interventions might be. We would hope that they would be, for instance, if you take people who've recovered and have fear of recurrence, one meta-analysis found that it was more face to face treatment over a period of a month or more had a better outcome than the briefer telephone based treatments And so on. So I think it's early days, but you know, our hope is that we'll find that way of disseminating Another way of doing it is that Kath Mannix, who is a CBT therapist and palliative care consultant has developed is what she calls first aid CBT and this is an approach where we train physical health professionals, so clinical nurse specialists, but also a lot of oncologists have come on the training in basic CBT principles that they can use sort of generically in their work and these include really being able to develop a problem focus, being Socratic in their questioning, using some basic behavioural, maybe mainly behavioural activation, but some behavioural experiments and some simple cognitive restructuring. So the trial that we did at St. Christopher's where we randomly allocated nurses to either getting training or not, and then following up their patients, we found that for anxiety there was a significant reduction when the nurses who'd been trained were working with that. So that's another way as of actually trying to embed some of this in the work that, that the physical health professionals are doing. Rachel: And it does speak to, doesn't it, that importance of training and, evidence-based skills because those nurses are fantastic. I can imagine just having those folk involved in your lives would in itself have a positive effect, but the fact that there's that additive effect of this training really tells the story, doesn’t it? Stirling: I think probably the take home message from the nurses and from the study with that is that they are already trained in listening and supportive counselling skills. But what they found was that actually learning to step back and to do a five areas diagram, either on paper or just in their head, stopped them from doing what they, I think they hadn't realised that they were doing, which was reassuring, and which was problem solving. So simply creating that space and teaching people Socratic questioning, allowed them to maybe hold some of the anxiety that they were feeling in the situation. And we would think these are very experienced professionals who wouldn't be doing that. But we found what they were doing was automatically saying, oh you're feeling a bit anxious Well, I’ll get the social worker to see you or oh you've got some pain and you're really worried about that, let's think about how we might increase your pain control and they learnt to actually sit back And ask a little bit more about what the thoughts and feelings are around the pain, looking then at some of the safety behaviours they might be using or not jumping in straight away to reassure. Rachel: So allowing individuals to build that resilience to internalise those coping strategies to take charge of their own journey, if you like, rather than jumping in and trying to solve everything. Stirling: Exactly. Yes. Rachel: I'm guessing given what we've spoken about the multitude of problems that can present and presenting issues that we might be working with a CBT therapist in cancer there probably isn't such a thing as a generic CBT with cancer formulation. Are there key maintenance factors you might be targeting in this work across presentations? Stirling: Yeah. Yeah so, this is a whole day's workshop really… Rachel: Excellent. I'll give you five minutes. Stirling: in five minutes. So thinking about the sort of the adjustment model that I would use is, to think in terms, if you're formulating someone with cancer, to think in terms of two major threats. So the first one is a threat to survival, which is unique, not unique to cancer in terms of a life threatening illness, but it’s different from, say, something like diabetes or other long term conditions. So, what is the threat to survival? And we can understand that in terms of an adaptation of Lazarus and Falkman's model. So how do I understand the diagnosis? Is it something that I see as a death sentence? Is it something I see as a challenge? Is it something I see as a huge uncertain threat? And then how do I see my capacity to cope with that? So can I rise to the challenge? And if I feel that I can rise to the challenge and I have an optimistic view then that promotes a fighting spirit or what you might call a resourceful spirit to be able to deal with it. But then other people might be focusing very much on this is a loss or a harm, I can't do anything about it and therefore, I'm helpless and hopeless. So, firstly, understanding the threat to survival and then the second threat is really the threat to the self, the self-image. So threat to the image of yourself, maybe as a competent person who can be in control of your life, maybe threats to your perception of your body image which may be important to you. How is that changing? Threats to your social role and so on. So I think understanding generically the cancer in those terms is important and when we talk about maintenance factors, I think we have to remember that we're dealing here often not with a steady state which we would be in traditional anxiety or depression. We're dealing with a process of adjustment that is changing over time. So the threats will be changing as maybe the disease progresses or you experience treatment or you end treatment and so on. And again, in terms of maintenance factors, the difference between a coping strategy and a safety behaviour is less clear cut so, taking an example, any form of avoidance, we would want to get rid of in traditional CBT for anxiety or depression, but sometimes actually making a choice to focus your attention on something else is going to be an adaptive strategy. So in terms of what we know about effective coping. I've been quite impressed by a simple three C's mnemonic that someone has developed for coping with disasters, but it works very well with cancer. So it's about control. So if you're coping, you maybe have can exert control over the disease through complying with treatment, etc. But also control over other aspects of your life that you still can exert some control over by making sure that life goes on. Second C is coherence so it's giving meaning to your experience. We know that people who are able to actually make sense of the cancer in terms of how this fits into their life experience sometimes actually grow from it, sometimes even see benefits that they find in this horrible situation. And then the third C, which we have a lot of evidence for is that social support, connectedness really makes a big difference. And so if we think about the sorts of non-coping behaviours, they're very similar to what we see in anxiety and depressive disorders. So, avoidance is not generally not good, rumination and worry are generally not good. On the more interpersonal front then Actually, people can get stuck in reassurance seeking or over dependency but on the other hand, they can also get stuck in excessive self-reliance. So, actually, the beliefs that they have about it being a weakness to ask for help can prevent them from getting that connectedness and getting that social support. And so, I think, in terms of how we might formulate it, thinking about those threats to survival and to your self-image. And then looking at how those threats are processed and the coping strategies that may be using or you may not be using, that might be adaptive or maladaptive, but there isn't a single sort of statement about what the best way to cope with cancer is cause it's unique for every person. so that's. That's, yeah, we could go on, but that’s a brief overview. Rachel: That's very clear. I know we normally have a challenge to ask people to do that without boxes and arrows being an audio podcast and you did it beautifully, even without being without giving the challenge. And I guess, you know, there's lots that will be familiar to our listeners in there as therapists around thinking about those coping strategies in life that are seem to be ubiquitously unhelpful, like, you know, rumination and worry and avoidance or isolating oneself, et cetera. But again, in common with other problems that we might be intervening with the key factor of formulating the individual. So understanding whether avoidance is actually a positive or a negative coping strategy for that individual depend, I guess, on the function that it's having for them. Stirling: I think that I see that one way of thinking about the function is this something that is moving me towards something that's important or valuable or useful? Or is it something that I'm doing to try and move away from my emotional distress or from something else? So actually, if we're moving towards, sort of think about this in sort of ACT sort of terms, if it's moving towards a valued goal then that is going to often be more effective as a strategy than doing something just to actually reduce your distress if that makes sense?. Rachel: Yes, that makes a lot of sense as I'm thinking about how someone might, for example, be perceived as avoiding certain social situations that they feel a sense of discomfort in. And we might want to say, well, this is not furthering your connectedness. This is, you know, putting you in an environment where you might be more likely to ruminate and worry, but actually they might be exerting some control over how they're choosing to spend their time and how they're spending their time meaningfully and valued activities. Stirling: Exactly. And I think that, when you have relatively sort of reduced energy levels, if you're going through say a chemotherapy or radiotherapy, which we know makes people very fatigued, then actually making decisions about what's a wise thing to do here. And I think, as you say, but it also depends to some extent on whether that avoidance is driven by an anxiety about how you're going to come across to people, what they'll think of you versus is driven by actually it's I don't have the energy to see these people and perhaps use some of my coping strategies to deal with them not knowing what to say to me, not knowing how to ask about my situation, right now, I don't think I have the resources to do that, and that's fine. Rachel: So having asked the impossible question of you to condense a whole day's workshop on maintenance factors and models into a few minutes on this podcast, I wonder if I can ask yet another impossible question, which is there sort of a typical approach to then treating these issues, you know, given these key maintenance factors, what are the main cognitive behavioural strategies one might be using? Stirling: Well there isn't a typical approach and it depends, to some extent on the circumstances and the time you have. So working in palliative care and sometimes also working with people who are undergoing treatment, you have relatively short space of time. And so actually being much more problem focused can be really helpful and again, as I was saying that people have that capacity to cope already. So, if they're not, sort of very decompensated, then focusing on, oh, you've got some avoidance because of those social anxieties like you mentioned. Let's plan, map that out with a five areas model. Let's look at what the maintaining factors are. Let's get you going. With other people, if you have a little bit longer, I do find it really helpful to look at the developmental model to understand what the meaning of cancer is for you, why often it's around people having beliefs about needing to be in control and cancer par excellence is the threat that takes control away from you because you don't have control of your body, you don't have control of your treatment, etc. And so helping people to understand how that their past experiences, their current beliefs, how cancer sort of pulls the rug from under them, I think can be really helpful. And one piece of advice I think I would give to therapists is, if you can find some time to understand the meaning of cancer for the person, that can really help to engage them, I think more and it may be one of the things that perhaps was a bit lacking in the CANTORC trial. I don't know, because I think that talking therapies therapists, may not be so familiar because they go in with a problem descriptor, what's going on, what's the diagnosis, what's the model, let's get on with it. Actually creating that space to understand what does cancer mean to you, and therefore understanding why you're trying to cope with it in the way that you are is going to be helpful. In terms of strategies, I think, behavioural activation for people who are helpless and hopeless or depressed is really an effective treatment strategy because very often people sort of throw out the baby with the bathwater. Because I can't do some of these things I used to do, there's no point in doing anything. Because I can't be the person that I used to be, I've given up. So simple behavioural activation is often very helpful. As I've said, sort of behavioural experiments around the particular focus of something like social anxiety or fatigue leading to reduced activity and then cognitively the challenge really is what do we do when we're working with realistic negative automatic thoughts. How do we help people to evaluate whether thoughts are helpful or not, as well as whether they're realistic, which requires maybe a little bit of thoughtfulness around and sensitivity to how you deal with the cognitive elements of the response to cancer. Rachel: I wonder, we've talked a lot about sort of meaning and values and understanding. This is a dynamic process in which people are not in control of there's a reality of that. I wonder is there any place for an integration of or even indeed intention between sort of second wave and third wave approaches in CBT to these kinds of presentations. Stirling: Very definitely. I think firstly, we’ve always been using some of these third wave techniques. I think I'm going to be writing something for tCBT, for the Cognitive Behaviour Therapist updating the article I wrote on coping with adversity some years back and I’m thinking of calling it where coping with adversity where second and third waves meet because I think there's a danger that we throw out the second wave treatments, and just go for things like sort of mindfulness or ACT or something with people with sort of serious physical illnesses. And the second wave treatments can still help us because we know that, in terms of coping strategies, problem focused coping is one of the most effective coping strategies that people can use. So still being able to look at what are the problem areas that you're bringing, how can we help you do effective problem solving is going to be good for many people with early-stage disease and a good prognosis. We can do a lot of work around their catastrophic misinterpretations of what's going on and the possibility of they're coming to the conclusion that they're inevitably going to die when we have a lot of evidence against that. So all of those second wave can still be very helpful. And bringing in third wave things where you're facing, here's a problem that that can't be solved so how do I then manage this? And, I think there is sort of this rather false dichotomy between the two approaches and a treatment like Dialectical Behaviour Therapy very overtly actually deals with both. So the dialectic is actually we're about change and we're about acceptance. So bringing acceptance methods, I would be using mindfulness with most of the people with cancer. I introduce them to it as a way of accepting thoughts can be really helpful with the ruminations and worry and I'm increasingly using imagery as sort of based methods, which, now are they second wave or are they a third wave in the sense that I see them as more constructivist? They're not really about challenging the evidence, they're not about as sort of the positivist view of is this true or false, they're about can we create new realities here that are helpful to you. So yeah, so I would say yes, I think we can bring the two together. Rachel: And perhaps we've talked about, haven't we, another podcast which talks more in depth about this integration of second and third wave and there are all sorts of false dichotomies made and put out there. The idea that you can do second wave CBT without attending to someone's meaning and values seems to me like very bad CBT full stop but the idea that you wouldn't also formulate what things people can change in the third wave approaches also seems a very simplistic approach to helping anyone. I'm reminded of the serenity prayer as you're talking, this idea that the courage to change things I can, and the serenity to accept the things I can't. There's something about working across that space, isn't there? Stirling: Yeah, absolutely and the wisdom to tell the difference and that I think really sums up this this line of work. Rachel: And many of our listeners will be experienced at working with working with depression, anxiety using CBT, and you've talked about how perhaps the sort of direct treatment of this kind of area in transplanting that into Talking Therapies services might not be effective. There might be lots of reasons for that particularly around kind of understanding and pursuing the meaning of the cancer to individuals. Are there things that therapists should be aware of if they're trying to formulate and work with these presentations in the context of cancer and just trying to sort of wholesale transplant their skills across? Stirling: Yeah, so I think that the good news is that you have all the skills that you need. It's not that different working with someone with cancer and even someone with incurable cancer. So those as we've said those sort of maintenance factors are still there. You have this the skills, you have the Socratic questioning skills and so on. I think the first step is to really try to understand the person. So there's a danger that we get too caught up with the problem and get into problem solving too quickly. So firstly, really properly understanding what cancer means for this person and validating that experience for them that I think is a slight difference from how maybe you might be approaching some of these things in IAPT services sometimes. I think good therapists inevitably always treat the person. But, but remember that, this is a person who's going through a really often traumatic life experience, so that's one tip. The second one is really around empathy, and we'll talk a little bit more about this perhaps when we talk about how we look after ourselves, but you mentioned the existential issues in cancer and this is an area where actually we all have that existential issue of sorry to tell you Rachel, but you're going to die. Rachel: Now that comes as a shock to me, I thought I was the exception to the rule. Stirling: So that's universal and we spend a lot of our time pretending that we're not although intellectually we know we are, but when we're face to face with someone who perhaps is going to die or for whom that threat is very real, that can both activate our own issues about death, but we can also when we respond and relate to the person, we can get rather caught in thinking that we do understand what it's like for them. And so it's actually asking the silly question, what's so bad about dying? Because unless we understand that person what it's like, we can jump to the conclusions that we know. So that's one another area looking at your cognitive empathy. Are you really properly understanding what this person's experience and similarly in terms of a more emotional empathy. Am I getting dragged down by the sadness of this person's life because I can relate to it so well. Another tip is really thinking about how your behavioural activation work might need to be adapted if someone is physically less well. But again, this is something that in working with long term conditions people will be very familiar with. And then final tip on apparently realistic negative thoughts. And, I would suggest, a threefold approach to this. So, we can, first of all ask the question, to what extent is this true? What evidence do you have? So, that's our standard CBT question. That’s a more, that's a sort of a rational perspective on it. But another way that we also use a lot is to ask the question, is this helpful? So even if this thought is realistic, actually, is it helpful to you. So it may be for the person who's had thoughts about dying and is ruminating actually, those may be very accurate thoughts, but not that helpful. So can we help you to explore the pros and cons of this particular thought process or behaviour? And then the third approach is what I call the sort of more constructivist approach is, which regardless of if this is true or not, can we create alternative perspectives that might be more helpful for you? And, and there it's more being aware of perhaps times when the patient says things like, well, you know, it's brought my husband and I closer together and just asking that. Oh, well, how was that? How is that's happened? What have you learned there? And what's that told you about what’s important to you in life? How has that helped you to develop your strengths? which sort of steps outside of that Oh, I’ve got to find a negative thought and challenge it and actually we create new alternatives, it's building on people's strengths and the meaning that they give to life. Rachel: So it sounds like, you know, finding and amplifying the positives, not Pollyanna sort of, you know, invalidating way, but actually allowing people to, to notice in a sense, those things that are positive and meaningful to them, even in this negative place. I'm really struck listening to you about how every therapist might do well to do some of this work Because I'm often think when I'm, when we do these podcasts across different areas, there are lots of lessons to be learned that just make us better therapists. You know, there's things you've talked about, about really focusing in and understanding and validating the experience that the individual, whatever their problem is sitting in front of us, the thinking about, you know, how we empathise and not getting caught in kind of a false sense of cognitive empathy where we think we understand what they're doing, but really, searching for the individual meaning, and not getting caught up in our own thinking. And working on all those levels with negative thoughts, you know, is it realistic? Is it helpful? And are there other perspectives, other ways of looking at this even beyond that? And you did, you intimated that, one of the things, you know, we're concerned about on this podcast is about therapists looking after themselves for their own sake, as well as for that of their patients. And people might worry about their own emotional responses and resilience to this kind of work, particularly working with people who may be terminally ill or really in dark places and how that might interfere with their therapy. So being able to support those more balanced thoughts or helpful thinking or finding those positives or, you know, knowing that this is very real tragedy ahead for the individual getting lost in that. What's your advice for people approaching this work but concerned about their ability to contain the emotional content? Stirling: I think first thing really is to make sure that you're getting good supervision and that you feel safe to bring these issues to supervision. I think that having the third person's view on the relationship in therapy and what you're doing can help you to get that little bit of distance as well as support, noticing when you are getting sort of dragged in a bit too much to identifying. It’s always good, we don't do it very often, do we? But it's always good to actually look at our own negative thoughts sometimes and do a thought record and then I think if we do find ourselves getting very caught up with how terrible this person's experience is there might be some third wave strategies that might be quite helpful. There's a distinction that people sometimes make between empathy and compassion and between the idea of feeling with or feeling for and there's an interesting study that was done in which people were asked to imagine that they were experiencing the same thing as someone who was in a disaster or some traumatic event on the one hand. And then, as an alternative, people were asked to imagine what might it be like for that person. So there's a subtle difference, but even though those two sort of instructions were only subtly different, it made a difference to the extent to which the person, the imaginer, was distressed. So, when the subject was imagining I am this person, they had good empathy but they were also distressed. When they were imagining what might it be like for that person, they had pretty good empathy but were less distressed. And I think when we're using compassion type techniques to help people to do maybe a compassion meditation on the person's experience and helping them to sort of feeling for that person, that's what we're doing. There's also, sort of, an equanimity practice too that you can do in terms of imagining or just simple statements like, you know, I can't experience or change your pain. All I can do is what I can do to help relieve it. No matter how much I want,your pain is your pain. So it's actually helping people to separate out. And the third, that another, sort of third wave type technique, that you might use actually in the session is a brief sort of meditation that Kristin Neff, who's a self-compassion teacher uses which is breathing for yourself and for the other. So we recognise that I'm here with someone who's really in a very sad state. They've just got been given news that there's no more active treatment, for instance. Yeah. And so we simply do, one breath for them and then one breath for me, because actually I'm suffering too in being with you because I'm a human being. I relate to you. I understand to some degree how horrible that must be and so that's horrible for me too. So we say one for me and one for you So it might be breathing in one for me and one feeling for you, one sense of compassion for you helping to both ground you and recognise that it's okay to be upset in this situation rather than trying to force yourself to be always a therapist who is unmoved by the people you're working with. Rachel: And that word you just used moved is quite moving, even hearing about those, there's different approaches actually, and how they might help us both hold that empathic space but hold our own space so that we can be there for the client and not stepping too far into their pain so that we can't actually help them, support them with that pain. In other ways these problems can affect us. We know as we stand up at the top of the podcast, you know, one and two people, suffer or will suffer from cancer at some point in their life. Therapists are very likely to either suffer themselves or have friends, family members, colleagues, acquaintance who are suffering from cancer at any given moment. How would you advise therapists working with patients with cancer whilst also potentially dealing maybe with their own symptoms or in relationship with people in their personal lives with cancer and they're finding that challenging? Stirling: I think we have to look after ourselves. So it may be that if you have someone close to you who has cancer and that is very upsetting for you, it may be it's wise not to take on a cancer patient and obviously if you're working in a cancer setting that's not possible. But if you're working in other settings, I think that you know, we need to set some boundaries sometimes for ourselves. So that's one thing to bear in mind. If you're working in a cancer setting or, you have to take on the patient who has cancer, then I think from a cognitive perspective, it can be helpful to really do some sort of what you might call stimulus discrimination. So discrimination between how their experience is not the same as my experience. So it may be, so again, we jump to those conclusions that this is the same that if they've got a poor prognosis, then my family member has a poor prognosis. Well, it may be the case, but let's actually check that out so that we remain with a rational perspective of just how much is this resonating, that's another way. I think that, it’s about, then also this, I think, for, anyone working with cancer is being able to maybe compartmentalise a little bit and to say actually, when I'm going back to the home situation, that's going to be different from what I'm doing in the therapy situation which and that means sort of looking after ourselves because as a therapist we have responsibility for the other person, as a family member we don't have the same responsibility and we maybe have to be clear about what is my role here. I'm not necessarily I may be in a position of having to look after this person, but I may not be and I shouldn't make the assumption that I have full responsibility for this person's well-being. Rachel: And I’m just aware of a couple of really inspiring colleagues who sadly in the past, recent history have passed away with cancer themselves, you know, notably Hannah Murray, who I know was celebrated at the most recent BABCP conference, who did such amazing work in PTSD through her diagnosis and a colleague of mine in the Ministry of Defence, Jonathan Young, who gave some very inspiring talks and insights into his own experience with cancer as he was going through it was really drew a lot of meaning and value from what he could give the insights that he could provide and the reflections that he had during that time. And a real gift of that to his colleagues. And I know both of those individuals as will many more that we maybe don't know of go unsung, do work through these difficult scenarios and find tremendous value in continuing to do the work that inspires them. And that has so much meaning for them in terms of helping other people. Stirling: Yes and I think a lot of people a lot of people do that. As we've said it depends, everyone has their own way of coping and so I think. For many, therapists and professionals actually continuing to work, that, when we started our, we started our work Beck came and gave us a, a sort of a, an informal seminar. And I always remember one of the phrases he says is you can't control your death, but you can control your life. And so I think that many people continue working because that gives their life meaning, it's valuable but some other people may choose actually not to. They may say actually what I value in life is something different and so I’m going to give up work and do something different. So we again, it's that it's finding the meaning for you that is most helpful and as we've said that people may find that having the diagnosis of cancer makes them re-evaluate what's important to them. I think that often people in the helping professions recognise that actually helping people is what's important to me. So I'm going to continue doing that. But if you were working as a hedge fund manager, you might have a different attitude towards your work if you had cancer. Rachel: Not that we would like to suggest on this podcast that isn't a very valuable role in society. One of the wonderful things about being a therapist that we often reflect on in this podcast is the opportunity we have to see into the very intimate details of individuals lives. And, you know, at this moment where people are taking stock of what is important to them or grappling with these big questions in life, I'm wondering what you might have learned from the people you've worked with over the years or how that might've made a personal difference in your life. Stirling: Yes. I think working with any patients, we can find things that are inspiring but it's I think the courage that people with cancer has that is always, most I know it's quite moving that when the chips are down, people rise to the occasion. They may not have thought that they would, but they do. And seeing that, I think, for me, has always been very inspiring. I'm thinking of the, I don't see many patients individually now. I've mainly doing supervision and teaching, but the last person I worked with who was had incurable cholangiocarcinoma and what I found really very, moving about was that he was able to, actually say, I've lived my life. I've got no regrets about the way I've lived my life. I've achieved the things that I wanted to achieve. Maybe there were other things that I wanted to go on to achieve, but that he said that having cancer, actually made him, grateful for everything he had and jokingly he said that for the first time having been a cis-white male, he was experiencing what it was like to be in a minority, in a minority group. And the fellow feeling he had sitting in the waiting room with other people that we're actually, we're all in this together. And he was so positive that he- I asked him and he made a whole list of ways in which cancer had enriched his life which you know was absolutely incredible and he felt that by using one of the biggest shifts that he felt that he wasn't you know, particularly it was more of a meeting from time to help him with coping strategies rather than a treatment for a psychological disorder, but we did some mindfulness together and the key shift for him, I think, was in thinking that he said that, by being in the present moment, I can appreciate what I have now with a recognition that actually things are going to change in the future. So it brings an even greater appreciation of being pain free right now, without then ruminating about the pain that might come. So, that was very inspiring. And, I think I'm sure, I think he would be okay about me sharing one of the interventions that we used, because he was okay about me sharing these things, but He had a memory of his mother's death and of her being in pain, he wasn't sure whether she was conscious or not, and he wasn't so his interpretation was that she was in great distress. She was also very frail and had lost a lot of weight and this was sort of feeding into his own fear of his own death. And that he would inevitably die in a distressed state, and he had considered, if he could go into Dignitas or something like that because of his family. So first of all, we did some, more straightforward cognitive work around what evidence he had that actually she was in distress. And the fact is that it's much more a mind reading, we don't know if that person is aware or conscious or not, but we make the assumption that actually they're suffering. And so it’s difficult to hold that uncertainty, but we don't, we don't know that. And then we did some imagery work around his mother and the image that he chose was He had a memory of her being lost a lot of weight. He carried her somewhere and he had an image of lifting her and holding her in his arms and loving her and amazingly that image then transformed his own view of his own death. So his fear of death he said just went, I don't know how much that's true, but I think that's sort of illustrates you know just the power of imagery but also his capacity to engage with and use that to really transform, so I think he was a very inspiring man. Rachel: absolutely sounds like an inspiring man and, you know, really, it's really inspiring hearing about that work and understanding even that, you know, the worst things we can imagine, or the things that have the worst meaning for us can be transformed in terms of their emotional content when we get that different perspective on them and get what we need in those moments. I'm almost struggling to move on from that. I'm so, so, so struck by that image, but we have done a whistle stop tour of this today, Stirling, at many points, we've said that these would be whole days of workshops, lots to learn. If people do want to learn more about this work, where can they access training? Stirling: Well there aren't sort of formal training programs. I think that Kath Mannix is doing some training, but it's it tends to be more around professionals working in palliative care. So, looking up her name, you'll find stuff on that. I do periodically workshops for BABCP and if you're in a Talking Therapy service, then quite often I will do a one day top up for people on the long term conditions services. If services want to commission me to do an online or face to face workshop, they could always do that. And although our book is quite old in some ways now, it's about 12 years since we published the last edition. people still find it quite helpful; I think. So that's, I would, direct them to have a look at Cognitive Therapy, Oxford Guide to Cognitive Therapy for People with Cancer, still. Still in print, I think. Rachel: And we'll put that link in the show notes for people to be able to access us. I guess one of the things we've, that has been a theme of today is the fact that there is so much more to learn, so much more research to be done around the specificity of what helps, what those effects are and also in terms of training and disseminating this treatment, you know, and hopefully, you know, where we started was with you saying that you got interested in the area because there was some momentum and impetus behind researching this, but it sounds like that, that needs to keep going, that there are lots of future avenues to explore. So thank you so much, Stirling. And in CBT we like to summarise and think about what we're taking away from each session. So in time honoured fashion, what key message would you like to leave folk with regarding working with CBT with cancer. Stirling: Well, I think the key message is you have all the skills already, they just need to be perhaps tweaked a little bit for working with people facing a life-threatening illness. The important thing is to really understand the person in front of you rather than the problem they're bringing. And if you have that at the forefront of your mind then I think it will make it much easier to engage with and work with them. And two don't make assumptions about what they're feeling, how they're feeling it, how terrible their life might be, find out, and you often find that people have the strengths and resources to cope with this. But you just need to help them unlock them. Rachel: Wow. So, CBT is about working with people, not problems and meaning is key. Thank you so much for your time today it's been really fascinating talking to you and I think, whether people are working in this area or really quite unconnected areas in CBT, I think there's something to learn from what you've told us about the processes, the understanding, the interventions and these wonderful examples from working with your patients as well. So thank you so much. And to our listeners, thank you as always for the work you do. And until next time, look after yourself and look after each other. Thank you. Stirling: Thank you Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. 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In this episode, host Rachel Handley sits down with Dr. Fiona Challacombe, a leading expert in perinatal anxiety and obsessive-compulsive disorder (OCD), to explore the impact of OCD on new and expecting parents. They discuss why new parents are particularly vulnerable to intrusive thoughts, how CBT techniques can effectively treat perinatal OCD, and the importance of dispelling myths around maternal mental health. Fiona also offers practical advice for therapists working with clients presenting with perinatal OCD, including how to approach and adapt exposure therapy sensitively during pregnancy. 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 X or email us at [email protected]. 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 Useful links: Maternal OCD website- https://maternalocd.org/ Perinatal Positive Practice Guide can be found here: https://babcp.com/Therapists/Perinatal-Positive-Practice-Guide A list of all Fiona’s published papers can be found: https://www.kcl.ac.uk/people/fiona-challacombe Books: Challacombe, F., Green, C., & Bream, V. (2022). Break Free from Maternal Anxiety: A Self-Help Guide for Pregnancy, Birth and the First Postnatal Year. Cambridge: Cambridge University Press. Bream, V., Challacombe, F., Palmer, A., & Salkovskis, P. (2017) Cognitive Behaviour Therapy for Obsessive-compulsive Disorder. Oxford: Oxofrd University Press. Challacombe, F., Salkovskis, P. M., & Oldfield, V. B. (2011). Break Free from OCD: Overcoming Obsessive Compulsive Disorder with CBT. Vermilion. Transcript: Rachel and Fiona Challacombe 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 we're joined by Dr Fiona Challacombe, lecturer and researcher at King's College London and Oxford University. Therapist, author and leading expert in perinatal anxiety and in particular obsessive compulsive disorder or OCD. Over 20 years, her research has examined the impact of perinatal OCD on women and children, including the first randomised control trial of CBT for postpartum OCD, and treatment effects on anxiety and parenting. She's developed and leads a service for parents with anxiety disorders at the Maudsley Centre for Anxiety Disorders and Trauma and is the author of a number of excellent books and manuals on CBT for OCD, and we'll put some links to those in the show notes for people later on. Welcome Fiona. Fiona: Thanks so much for having me. Rachel: It's really, really great to see you, genuinely great to see you, not least because we're long overdue as we've just been talking about pre-recording for a catch up. We go back quite a long way to our, our training days at the IOP with a bunch of brilliant people. Actually, I'm hoping to get some of the others on this podcast. Becky Murphy hopefully will come and talk to us at some point about eating disorders, but loads of great folk that we were really fortunate to train with. And then I feel a certain pride when I read all the things that you've done, it's not really justified, but it's just kind of like a family connection when you've trained together, isn't it? You feel that connection. So, it's just brilliant to have you here and you've been so committed to this work and I know you're really passionate about it. What got you hooked in this field of OCD, personally and professionally? Fiona: Well, I came to training, which does really feel like yesterday, having worked with Alan Stein on this incredible treatment trial for mums with eating disorders, so that really got me very interested in the early parenting field. And I was really lucky when we started training to train with Paul, I think the first person, one of the first people I ever saw had OCD. And, of course, applying the model as a new trainee, it was just miraculous. It works so well. And getting this understanding of the cognitive model and how responsibility works in this context, putting all of these things together has been an amazing journey really, so starting to understand more about OCD, how well the treatments work, and then thinking about parenthood in that context, it makes so much sense that it's a time of increased risk. So I was very lucky as a trainee to do my doctoral research with parents with OCD, and it was mums with OCD with slightly older children, and understanding a little bit from their point of view about the impacts on parenting and so on. But in talking to those mums, and doing their SCID, and asking them about how their OCD started, when it started, really, one after another had said, well, it started during when I had my baby, it started during the perinatal period. And after about the fifth person had said this, I really thought, this is very interesting. I hadn't really heard of perinatal OCD. It wasn't something that was kind of on the radar. Perinatal mental health services were at a completely different point. It just really was before all the transformation stuff. And whilst most of us were aware of postnatal mood changes and so on, the idea that other things could occur at this time was like a really a not well understood idea, but it was really striking. So that's really all of those things together, what kind of brought me to this topic. Thinking about this early stage, why would it be that this perinatal period would be such a time of kind of onset, really, and risk for this problem? Rachel: And you mentioned there, Paul Salkovskis, who I've just recently recorded another podcast with on OCD more generally, which will hopefully be available to folk at the same time as this. And he's been such a great figure in this field, hasn't he? And someone fantastic to work with in your training and we know from him that OCD is a really widespread problem. It's a smaller problem in sense, statistically, than maybe other, mental health problems that people experience, but nevertheless really significant. And when it afflicts women in that perinatal period, it comes at a really vulnerable time for them, doesn't it? And their children. Can you tell us a bit about how significant a problem it is in that period, how often people have that problem, how it impacts them. Fiona: Yeah, so again, we haven't had good data on this really until very recently, there just aren't those big studies, but it does make sense that it's a time of increased risk because I think if you had to make a sort of cocktail for anxiety problems, you would put in a high dose of kind of responsibility, uncertainty, feeling kind of de skilled, and it has all of those elements and all the physical changes and things that kind of make life a lot more challenging. But really the studies hadn't been done. So, we know OCD affects sort of one to two percent of people at any time, a bit more over a lifetime. But there was a fantastic study by Nichole Fairbrother, which gave full kind of diagnostic interviews to a whole cohort of people, as they went through pregnancy into the postnatal period. But what Nichole did was to be really kind of, specific about asking them not only about our common understanding of obsessions and compulsions, and do you check doors and taps and things like that, but also to ask them about infant specific perinatal thoughts, so are you kind of checking the baby excessively and so on. So that study found a very high prevalence, particularly postnatally, so over the whole perinatal period, the whole prevalence I think was about 7%. So, whilst there are, I think, really interesting issues about what's normal and adaptive over that period because most parents can relate to kind of a time of excessive checking and feeling uncertain about things, and all the things that we're very familiar with in terms of the concepts related to anxiety. For a proportion of those people, it clearly is very troubling and impairing and persistent. So, I think there is this genuine increase in prevalence around this time but it can be hard, very hard to sort of distinguish exactly what's what and I think health anxiety probably is fuelling that as well. But it's definitely a time of increased risk. I think we can say that quite confidently, and particularly in the postnatal period and particularly for intrusive thoughts of deliberate harm in that area really is quite distinct to OCD in the sense of it being a very common presentation. You do get in those horrible intrusive thoughts in the normal population in the context of other problems, but that's quite a common presentation postnatally. Rachel: So it sounds like, it's such an important area to be researching, to be thinking about and offering treatment in. And I can really identify with what you're saying about that anxiety around the perinatal period and becoming a parent. I mean, everything else that you have to step up to in life in terms of responsibility like that you normally have to do an exam or, you know, at very least go to a class or someone gives you a job interview and says, yes, you're competent to do this. Suddenly you've got this little person in your arms and you're thinking, who is crazy enough to trust me with this huge responsibility. And people like ourselves, who like to study, probably read lots of books and go to classes and do all of those things. And the advice is often conflicting, isn't I and challenging. And then you add in disturbed sleep and plenty of time to worry and ruminate while you're with this little person who doesn't talk back in the middle of the night. It's not hard to understand why people might be anxious and as you say, what might be normal as well as, more challenging for that. And are there reasons why some people might be more prone to developing OCD, even in that context than others? Are there particular experiences that might lead to particular vulnerability or interpersonal factors that are there? Fiona: Yeah so I think the general vulnerabilities for OCD are of course come into play. So kind of, beliefs about the world, being quite kind of rule bound, ideas about responsibility and those things in that particular situation, as you say, you can imagine why that might be quite tricky. And having had a history of course, is probably the biggest predictor, because I guess, it's a demonstration that those vulnerabilities can be activated in particular situations. But I think, you know, in terms of the characteristics of the pregnancies, I think if you have more complications, if you perhaps have a baby who's got increased vulnerabilities, spending time on the NICU or something like that, it's those factors that you just talked about, but then they're looming even larger. Rachel: For folk that might not know, NICU. Fiona: Yeah, so neonatal intensive care, so it's actually very common for babies to spend a little bit of time, if they're born prematurely or have other complications at birth and so on. I guess it, it's an indicator that there’s a bit of extra help needed, but of course really tricky for parents because you're right in the middle of that medical situation. As I was saying, it's a tricky time to transition to parenthood. But of course, if you're having to go through that and the care is having to be managed by a medical team more extensively. You may have also had a difficult time during birth and labour yourself and all of that. So that's a particularly vulnerable group of parents for all sorts of things. But our research has also indicated that intrusive thoughts are very common in that group, which makes perfect sense as well. Rachel: Absolutely. And then I guess there's other contextual factors which may or may not influence this. So recently there's been a lot of media and news coverage about risk in the perinatal period from risks due to shortages and shortcomings in neonatal care. And then you get the stories about abuse and neglect from parents and carers. Do you find that the frequency and volume of those kinds of stories in any way interacts with maternal anxiety? Fiona: I think inevitably, doesn't it? I think maternity systems are very stressed and understaffed and really difficult places for maternity staff to provide the care that they wish to. At the moment, we're all very aware of those, of those issues, and of course the very difficult situations that have occurred, so there is an underpinning kind of reality to that, of course, but I think in terms of anxiety, those notions do filter through and people, of course, worry about things going wrong, that's very normal. But, again, very hard for us to kind of navigate likelihood and risk as, with our human brains and going into that situation, if you're a pregnant person, you're going to give birth. For many those stories can influence the present in terms of kind of worrying about things going wrong. So, pregnancy kind of related anxiety is very common. It's sometimes called fear of childbirth, it's sometimes called pregnancy related anxiety. Those terms can be used a bit interchangeably and there's also kind of an interaction with OCD as well. And it's also a perinatal concept that unsurprisingly if you have other anxiety problems, it goes along with those too. But yes, I think having lots of exposure to the idea of horrible things happening can, of course, make you feel that those things are much more likely and make your current reality much more scary. That definitely can happen. Rachel: Even if they are the exceptions or at least not as common as they sound like they are? Fiona: Yeah, yeah, exactly. Of course, most people go through birth and labour, and whilst it's might not be the sunniest picnic, it's usually okay, and so on. And, yeah, being a little bit sort of forearmed that things might be challenging can be helpful. There's some really fascinating new work from Pauline Slade that actually, just in the general population, if you in antenatal classes just make people aware of the possibility of complications. If people do experience those things, that can be psychologically quite helpful. So to some extent, knowing that is helpful, but of course, reading about awful things doesn't mean those things will definitely happen. So there's a balance to be struck in terms of that level of information, I think. And of course, things really stand out when horrible things happening into the postnatal period. I mean, going back to the concept of intrusive thoughts of deliberate harm. So most of the women that I've worked with that have read a story or been aware of a horrible case where a mum in particular has perhaps harmed their child in the context of a very severe illness. And that feels like it's very likely and that's very much fuelled their OCD in terms of trying to understand how things like that could happen. Could I do that? And so on. That's quite a common occurrence in terms of worrying about it, whilst the actual events are very rare. Rachel: Yeah, absolutely. I'd like to ask you about some myths, potentially, facts, potentially, that are kind of out there about OCD and the perinatal period, bit like what we've been talking about, all this information that people get kind of thrown at them and also how they might kind of also seek out pieces of information when they're feeling anxious about of what's going on, but also for therapists working with this. Let’s start with, perhaps a straightforward one. Perhaps they might all be a little bit more subtle than that, but how about the idea that everyone gets a little bit OCD around this time? Can you be a little bit OCD in the perinatal period? Fiona: I mean, I think the phrase is inherently unhelpful, and I think most people with OCD would feel quite annoyed to say the least. It's not great to actually kind of minimise what is real distress and suffering. Whilst it's fine, I think, to say anxiety is understandable, phrases like that are completely unhelpful in helping us kind of recognise where people are truly struggling so it's the language I would want to modify in that sense. Rachel: Absolutely. That's really helpful. And how about the idea, which I know, can worry clinicians, that when a mother expresses thoughts of harming their baby or child, this is likely to present a very significant safeguarding concern and should always be reported. Fiona: Yes, this is one of the most common issues that come up in terms of how to navigate what will, you know, 99 times out of 100, will be intrusive thoughts to normalise. And it's all about how you follow up a disclosure. And understanding from clinicians’ point of view that actually there is this spectrum and whilst as clinicians it's really important for us to assess risk properly, it's also important for us to not take that at face value because that can cause harm as well. And that certainly has happened and still does happen, unfortunately, that people are automatically referred for safeguarding processes when it is very clearly unwanted, intrusive thoughts of harm that do not fit in any sense within the person's intention. And there are people that are clear about that themselves, but asking questions, for example, like, are you completely sure you won't act on your thoughts? For a person who's experiencing an unwanted intrusive thought, that's not a helpful question. So, understanding and asking follow up questions about what does it mean to have these kind of thoughts, what do you do when you get them, can give you the right information to understand what course of action to take. I do understand that as clinicians we don't want to get that wrong, and it can feel like the stakes are very high and it can be really alarming if people are disclosing these kinds of thoughts, but it is super important to understand that these thoughts are really common. We think almost all parents will get thoughts of accidental harm. And in most of the studies, about half of parents will say that they have thoughts of deliberate harm, including sexual abuse and violent harm. And these thoughts seem very normal, but it's very important for us to understand, and ask those follow up questions before we know what the right course of action is to take, because it can be as I said really harmful for people if the system almost acts as part of the OCD, kind of like a systemic sort of safety behaviour that, as with all safety behaviours, will stop that person actually gaining confidence that these are just thoughts and they don't mean anything about them. You can absolutely be a wonderful parent and still have horrible, intrusive thoughts because that's all they are. Rachel: And the last thing we want to do is just underline or reinforce that awful shame and distress that people are feeling. And related to that, what about the idea that anxiety in mothers in particular will automatically lead to poor attachment or poor outcomes for their childcare and their relationship with their child? Fiona: Yeah, again, it's really important to be evidence based. Anxious attachment is not the same as being anxious as a parent. And certainly, I think my study is the only one that has used the strange situation, a really robust measure of attachment for mums with OCD. And we found absolutely no difference in terms of secure attachment for mums with OCD and mums who didn’t have OCD. Rachel: And for people who don't know, that's kind of paradigmatic study where parents are with their children and then they leave and then they come back and there's really systematic ways of looking at how the child responds to the caregiver in that situation. Fiona: yeah, so it's a really robust test because it's all about rating the behaviour of the baby. Babies aren't brilliant actors, it’s considered the real sort of gold standard. Whereas if you ask parents about their perceptions of the impact on parenting, that will often be very high. And that's also been replicated in another study I was involved with where mums with various anxiety presentations filled out a bonding questionnaire, really commonly used bonding questionnaire and they were videoed interacting with their babies and in terms of kind of sensitivity, which is one of the precursors and underliers of secure attachment. And whilst the parents with anxiety felt that there might be bonding difficulties that wasn't borne out with the observation at all. So I think it's a really important lesson that we need to think about perceptions as being different from what's actually going on. And certainly my experience with mums with OCD is that their primary concern is about bonding with their baby and their baby's welfare. And sometimes the anxiety and OCD will sort of skew things towards focusing on safety and so on, but the underlying bond is there and what's driving it. Sometimes we're very worried about parents for whom they're much more ambivalent and you know that's where the issue is, but I would say generally speaking parents with anxiety are just trying to do their utmost and so actually that's why the therapy can work so well because it's about trying to utilise that bond to do things in a more helpful way Rachel: So these are the parents that, that love their babies so much, almost to their own detriment because they're loving them in ways that maybe they don't need to because of these distorted perceptions about the harm that might come to them. Fiona: Yeah, I think there's nothing wrong with the love, but it's the behaviours and the way the OCD is, getting them to do all of the checking, not having any sleep and so on, and it's about gradually trying to understand that with the person, using all of your CBT techniques to test out changes and what really happens if I just do that a bit less. But really, the wonder of the work is that the bond is so strong actually, having the bond there is the real sort of glue for the whole work. Rachel: And how about sort of taking that step further beyond that sort of immediate bond? Is it true that children of anxious mothers will inevitably, and that's very labelling, isn't it? Anxious mothers, but children of anxious mothers will inevitably grow up to have an anxiety disorder, or that they will be damaged in some way? Fiona: Yeah, and there's absolutely no inevitability about that. There are undeniably studies showing increased risks of anxiety and depression for kids of parents with anxiety and depression- and the reasons for that are going to be complex, but there's no inevitability. I think that's really important. So we're looking at a kind of a relative increased risk. And I think some of that will be a sort of overall genetics vulnerabilities and so on. But some of that will be perhaps parenting style and so on. And that's so actually engaging with parents at the earliest stages because often parents will come into treatment for that reason and being very worried about the impacts on children and so on. Again, a lot that we can do and getting treatment for your anxiety will teach you the skills to understand anxiety in your children. It's very cool. That's kind of a real double benefit there, I think, and that often is quite an explicit part of the work that parents actually do want to be able to kind of better, create a better environment for their kids. So I think there's still, there's no inevitability about things, but the longer that you can be free of your anxiety problem, I think that's likely to be the best for you as a parent and for you as an individual, and for your kids too. Rachel: Perhaps what we need Fiona is a RCT on whether it's more damaging for children to have a clinical psychologist as a parent or someone with an anxiety disorder. But I keep telling my kids I'll pay for the therapy if it comes to that. Fiona: Yes, no, maybe let's not look into that too closely. Rachel: so final myth or fact that does occupy therapists a lot, I think in this kind of work is, is it irresponsible to do exposure therapy when someone's pregnant? Fiona: Right, this is a very recurrent topic at this point. Therapist anxiety is a real thing, right, and we do all experience it, and we're now working with our patients, even outside pregnancy, and they say, oh, I hope this thing doesn't happen. Sometimes there is a little echoing thought there as well, it's like, oh, I hope the bad thing doesn't happen as well, but doing this is has a different purpose and as with as we were talking about lots of things are heightened in pregnancy so I think those therapist beliefs can loom a lot larger. And there's anxiety from therapists points of view and sometimes from system points of view that if we kind of get people to do exposure, that might somehow cause harm. And it's really important for us to engage with that and think, well, that's an important consideration always, isn't it? So we do actually need, again, data on that. What could be the mechanisms of harm? What do we actually mean by exposure therapy? And I think when we're sort of getting into it, there's an assumption there that exposure is getting people to do awful things that make them feel terrible and then we just make them go home and hopefully our therapy isn't like that. We're setting a framework, aren't we, that people are kind of doing things to experience life as it is. And the idea of that is that will then help them with the anxiety that they are bringing. They're coming to our sessions to do an evidence-based treatment because they're already anxious. There's already a high level of anxiety there, and that's often a neglected part of the argument, even though it's very key that people are coming for help because they're already anxious. We're not actually picking people off the street and asking them to do these things for no reason. I've recently completed a trial of exposure based treatment in pregnancy and the participants responded to the treatments really as you would hope and expect, that they felt apprehensive about doing some of the exposures, but did it, learnt, some of the quotes from the participants were really a textbook in terms of kind of, it was by doing that, that I really found out that my sensations were safe and they were just part of my anxiety. Reliving in PTSD, that was really difficult, but it was like, I'd gone back in time. I understood new things about the experience and that helped them then to have a better pregnancy and less anxious pregnancy as they went through. And so we asked them a lot about that experience, of course, to understand whether there were any negative effects and so not finding it aversive, not wanting to do it. I mean, that's our job as therapists working with anxiety, isn't it? We kind of need to approach that. Rachel: No one comes to our session skipping with joy because we're going to ask them to do exactly what they want don't want to do… Fiona: Exactly. And it was mirrored from the therapist as well, those little voices were there of kind of, I knew that I needed to be confident delivering this, in order to demonstrate that for my person. And really having to remind oneself of the model and so on in order to do that. And I think that's okay. That's part of our, you know, we have to keep self-correcting and reflecting as therapists. And these were incredibly skilled and experienced therapists, and it was a good kind of, again, lesson that these things, we're human too, and these things do happen. I think we can say that it's safe and it's really important to do and it's effective as long as the person wants to do these things and are motivated and feel like it's the right time. Often there's a lot going on for people in pregnancy. I think that was more of an issue in terms of delivering treatments that often people are dealing with work or there's housing difficulties and can we actually book in sessions for the next few weeks in order to be able to do this properly and well. These are the real considerations, I think, having enough time and they're looking after the little ones, how do we do this, do we do it online? All of the logistics are really key to delivering treatment well. And we've got to pay attention to those issues which are more prominent in pregnancy. But I think when the person is motivated and able to do it, it works really well and we shouldn't withhold a treatment because the person is pregnant and we are gaining evidence that it's helpful and it's an evidence based treatment during this time as others. Rachel: I think that sounds like a really helpful corrective as well, as you said, that these people are suffering anyway. I know we often talk about OCD as a kind of bully, don't we? And we would encourage people to stand up to bullies. And that doesn't mean it's not going to be hard, but you don't stand up to them they're still in the playground every day and you're still facing that distress and that uncontrolled exposure and distress in your daily life. Fiona: Yeah, and if someone says, look, I would really like to work on this now before my baby comes and we just, we say, no we're withholding a treatment. We need to have a really good reason for that, and I don't think we do. It’s in some services that I've encountered they’ve, we don't do any treatment in pregnancy, we don't do exposure in pregnancy. Sometimes exposure is getting the person to be able to sit on a seat so that they can use a train. It's like, I think we just really do need to kind of dig into what we do mean by these things and whether it's ethical to withhold a treatment that works for someone that wants it. Sometimes we do modify things. So we might not do the full kind of anti OCD experiments with a pregnant person. I think that's okay as well, interesting what where to stop and so on. But it is a negotiation. We need the person to be on board. So I think thinking about what would a pregnant person at this stage of pregnancy be able to do, that's what we're aiming for. What's going to help you with where you're at now, so I know, I've talked a lot about this because it's such a key issue, it still comes up all the time, we need better guidance.   Rachel: Absolutely, it sounds like your trial is a really big step forward in that as well. You may be aware that on this podcast we have a challenge, so we ask our guests to give us a brief explanation about the particular presentation they work with, how it develops and is maintained, without repetition, hesitation, deviation, boxes, arrows or other visual aids which can be tricky for CBT therapists. So we've recently asked, as we've mentioned already, your longtime colleague and collaborator Paul Salkovskis to do this for OCD. So he did it pretty well, as you might expect, having written the model, but maybe you can do a better job, and maybe, there are some sort of specific factors you want to add in around mums in this perinatal period and OCD. Over to you, challenge extended. Fiona: Right, so just to make sure I've understood, giving you an overview of an entire formulation of a particular presentation. Without hesitating or referring to any boxes and arrows. Rachel: Yeah, but what the listeners don't know is that we can edit out hesitation, so don't worry too much. Fiona: Well, I will go with what is the key presentation of intrusive thoughts of deliberate harm in the postnatal period. It’s not uncommon for a person to experience these seemingly out of nowhere. As the baby is handed to them in the delivery room. Because OCD is a brilliantly apt detective for knowing what is the worst possible thought that a person could have at this time. And that's what makes it so devious because it's a time of joy and a time where you might not be expecting these kind of thoughts. You might have gone through a horrible birth, but you might be there with your baby and an OCD thought will pop in. But of course, that makes perfect sense to us in understanding the model because due to those situational vulnerabilities, that's what makes that thought really stand out, and of course it really does. So we know, of course, the thought itself is no problem at all. These thoughts are very normal and very common in the perinatal period, amongst birthing parents and non-birthing parents, they're super common. But if you're not aware of that, that thought might stand out even more. And if you think that thought means, my goodness, I am about to do something awful, this is it. What sort of a person has this type of thought? Who could I even say about this? I'm going to hand the baby back over to my partner. That's where the problem can really begin. And OCD becomes very pernicious like this and surrounds the problem with shame. And we know that there's lots of that going on for new parents, you're learning on the job, you're often being told by all sorts of people what to do and how to be. It can be very difficult to find your ways, it's another vulnerability factor. So having these horrible thoughts, and having that now your radar going round for, well, I better look out for these kind of thoughts, more of them tend to pop up. It then reinforces this idea that, my goodness, perhaps I am an awful parent. What kind of parent does that? Perhaps I need to go away and think about all the terrible things I've done because there must be some kind of reason for this. And so on and so on. There's much more sort of fuel. Better not spend time with the baby. Perhaps I'll let my partner do that all important first bath because, gosh, if I was to do it, I might do something terrible. Now I've got this clue that in this new situation I've never experienced before, something has been activated from my deepest, darkest soul, and poor people are left stuck with these horrible thoughts. You can see how then the behaviours would reinforce it. Super upsetting. Where do you go to with this type of idea? Can you talk to your antenatal group? It can be all a bit tricky. So lots about the situation can be in the ways we're very familiar with how devious OCD is. In this particular situation, it makes sense that this is very common because we don't talk about these things in our antenatal groups more generally, although we could, that would be a very helpful and very cheap way, I think, of, perhaps preventing for some people the onset of these problems but actually having that information would be super helpful, and of course the treatments can work so well because we tackle these, all the avoidances, we tackle that meaning and help people move on from this. Rachel: That was brilliant, and not only was it very clear, but also actually, genuinely, that was, I find myself quite moved when you're talking about that first bath because it really highlights to me as a parent what this can rob from you as a parent. There are really small but absolutely precious moments in life that add up to the joy of parenting. Fiona: That's right. That's a really important point. And I think that's why it can take people a long time to recover from these experiences, not in terms of intrusive thoughts and feeling that you might act on them because in a way the treatments work so well for those kind of things. But there's this sort of legacy of this was a really special time and opportunity that has been robbed from me in various ways. And so quite often we're working with people in the medium and longer term to help them come to terms with some of those moments. And often it hasn't robbed everything. I think that's an important point to make. And also, if you haven't got OCD, sometimes those moments are a little bit tricky as well. And things are in more of a spectrum too. Rachel: I’m forgetting all the screaming that went on with the first bath. I'm sure this is what selective memory does. It's fortunate that I was sleep deprived probably at the time. Fiona: that's the thing, isn't it? It's generally, there are moments, but there are definitely other moments as well. So, but yeah, that's where talking about things can, I think, help process all of that too. Rachel: And we know, as you said that, the treatment for OCD is very effective, clearly not for absolutely everyone. there's always places to go in developing these treatments, aren't there? But it's a really effective treatment for OCD. In perinatal OCD, is it as effective and is it equally effective for everyone across diverse groups and populations? Fiona: These are really good questions. As I said, there are not loads of treatment trials, but the one that I did show that was it's as effective in terms of, I mean, it was a pilot trial, but the effect sizes were similar to kind of OCD at other times. Research has a diversity issue, I think, and that's OCD, perinatal OCD is no different from that, so we need better answers to that question as to whether it's as helpful for people across groups. I think there are differences, in terms of how appealing services are, so who's coming to services is a big issue. So whilst we have this effective treatment potentially, I don't think it's being, it's as accessible across diverse groups. So we do need to do better within perinatal OCD and within general mental health services to fully answer that question. Of course, good practice is to adapt treatment as much as possible to the person in front of you and work together to, or work as a therapist to understand and bridge any difference and kind of think about the context the person is in. But yeah, it would be great to have more information about that. One adaptation so that in the trial was to do intensive therapy postnatally and in the pregnancy trial, I did intensive and weekly therapy and they both worked well, but I would say in the postnatal period, so intensive treatment, it's the same as the regular treatment but doing it in a shorter period of time. So essentially, we had four sessions of about three hours each that were spread over two weeks, and that worked really well for postnatal women in that context. So as we have been talking about, it's a busy time. It's very hard to find time for yourselves. And I was, reflecting at the time of that trial on our standard treatment model, which is where we ask someone to come to a particular place- this was pre covid. I asked them to be at this place at this particular time with their baby, or not, for an hour a week for three months. And the idea of that when I was at that stage would have made me want to cry, really. Rachel: The idea of being able to wash my hair at the same time once a week at that stage. Fiona: yeah, exactly. So we got really good feedback for that trial because we tried to do as much as we could at home, and it's not always possible, but that is the ideal or a mixture of at home and in the office. But having these long sessions, it felt manageable for people. They could organise childcare for four afternoons, or as opposed to for three months. So I think thinking about the delivery and implementation is really important for the perinatal period, but for OCD, where getting momentum is really key to change that model worked really well, so I'd highly recommend that. Rachel: Those intensive treatments and remote treatments as well and all these innovations are, seem really important across the board in lots of different problem presentations. I guess I wonder how this, if you've got any thoughts about how this might translate into your average psychological therapy service that isn't doing a trial, isn't resourced to do it in that way. Do you think this is possible in the future? Fiona: Yeah, so the pregnancy trial we ran through Talking Therapies but it is an issue in terms of the model. You have to do lots of negotiating, and it wasn't, always easy because I think there's an anxiety if that person cancels, that's three hours contact hours that are then not filled and so on. It's something that needs a bit of thinking about. So the Perinatal Positive Practice Guide is a wonderful document that sort of highlights some of this implementation stuff in terms of needing more flexible cancellation policies within perinatal and so on. And obviously within specialist perinatal services, that's the bread and butter, it's more configured around that, perhaps there's more sort of flexibility to do that, but yeah, it's an ongoing question, it's not easy, so easy for these, they're wonderful services but to do, to be a bit more idiosyncratic and adapt in that way is genuinely more tricky, I think, so that’s the challenge. Rachel: And I think, we're just, we're so socialised into thinking about therapy is once a week for an hour a week, aren't we? And really there's not necessarily a legitimate reason why that is the best way to deliver any therapy. Fiona: Yeah, and there's an increasing evidence base for time intensive models. And I think that there are pros and cons. I think they work as well, but I suppose it's having more choice for people. That's the ideal. I think there's no point sort of forcing people into an intensive model where that wouldn't work for them with their other commitments or so on. But it seems like it's a good adaptation to have available, if possible, particularly in this context. Rachel: Talking about adaptations and therapy, so what does a, what's a typical course of therapy look like? What are the core elements? And you've already mentioned a few things that we might adapt for this period, but what are the core elements? What might be the typical/ atypical pieces if you like around perinatal OCD? Fiona: Yeah, so it’s always context dependent, isn't it? So I think very familiar in terms of CBT for OCD, but the parenting element is usually weaving that through and through. So the majority of people, their OCD will be interacting or be orientated around the baby, but not for everybody. So there are certain, certainly a very small subgroup of people for whom, their OCD is just really nothing to do with it. But because OCD is very consuming, there is an impact. So I think being very sort of sensitive to that in terms of goals and what the person's sort of wanting to achieve is really key. There is a question about how much to involve babies in treatment. It tends to be, I think, really helpful if you can have the first few sessions without the baby there and getting the person really clear with the understanding the model, theory A, theory B, getting things kind of set up. But then after that, trying to make everything as integrated with real life as possible, which for most people will be about looking after the baby or doing tasks with the baby or going to places with the baby, it's just really putting things into the current context, really. Rachel: And theory A, theory B for those who are new to this, the idea that OCD or the problem is, Fiona: Yeah, so it's a key tool in the armoury, but this kind of real paradigm shift, it really, I think it's the kind of basis for the whole treatment, really. So once you've kind of done your formulation, and as we were talking about in the little vignette there, so understanding the problem and what's at the heart of it is really important, or gaining a shared understanding of what's currently driving it, but then you as a therapist are offering an idea to test out in the rest of the treatment that perhaps, rather than theory A, the problem is that you are a horrible psychopath, actually the problem is that you're terrified of that idea. And understanding the difference between those two is treatment in itself, I think, and really understanding and then absorbing the idea that if this is an anxiety problem, that probably does make sense of why instead of trying to do harmful things, I'm actually trying to do the opposite. So it really gives you such an important structure for a new understanding, taking things through behaviourally, so that makes sense that if you're terrified of this, it's an anxiety problem, what you need to do is actually less of that, because that's what will help with your anxiety which is the key problem here. And getting the person to explore that themselves and, in various ways, thinking about why they believe what they do, what's in their history that might fit better with that and then, what are they doing that might be kind of making that anxiety worse? And then therefore, what do they need to do to make it better? Everything sort of flows from that. So it's a good question, Rachel. That basically is the whole treatment. Rachel: and then you're piling in the usual behavioural experiments. Fiona: Yeah, absolutely. So it's really important to use that understanding to do things differently. Sometimes it's curious, I think, especially perhaps interacting with our stateside colleagues where they have a slightly different model. We do ERP within the context of CBT, but it is about belief change and how we integrate those things. It's really important to actually do things differently. It isn't just about challenging thoughts in an abstract way. Rachel: So not just ERP, Exposure Response Prevention, but actually thinking about those cognitions. Fiona: Exactly. So theory A, theory B really lays the foundation for what we're then going to do next behaviourally. If theory B is true, that this is an anxiety problem, then you can be next to your baby, you can have all the knives drawers open in your house. You can change your baby there and that will ultimately seem probably a bit absurd. But OCD will have perhaps stopped that person from doing that. So, it isn't just about kind of habituated to anxiety. Paul has this wonderful phrase, Paul Salkovskis says, it's finding out how the world really works. And that's a cognitive process. That's a cognitive affective process because it really kind of gives people that lived experience, and that sort of aha moment, ideally, that actually, oh, what I believed then, it was too scary to even test out, but in doing that, its fine. Rachel: And you mentioned earlier something about maybe not going to the anti OCD piece. Do you want to say a little bit more about, about what that means? Fiona: Sure, in order to feel confident about things, we usually probably want to go a bit further than opportunities might present themselves in life. And given that we can't prove that we won't do something, let's go with that example, a person who might be worried about stabbing their baby or what have you, it's really hard to prove that something won't happen. But of course, generally in life, we're not trying to do that but because we don't feel it's necessary. So we're trying to get to the person to a point where it's like, this doesn't really feel necessary because I just know in that way that I know I'm not going to push someone into the road when I cross the road. It's not something I need to sort of process. So, we ask people to do a bit more then they might do on average, so sometimes it's very common for parents with this particular problem to say, avoid chopping food near the baby, what if I did something impulsively? So whilst we definitely want them to be able to do that, we want them to feel really confident so we're like, okay what we're going to do with this? We’re going to chop food right next to the baby and when I say, get all of the knives out, get the absolutely massivest one, even though you're only cutting a little tiny carrot or something like that to build on that confidence. So we, what we call anti OCD experiments are really kind of pushing back against the OCD and just saying, right, okay, what I'm going to do is take this to such a level that I'm showing up OCD for what it is. It might be very inconvenient to use this knife, so I'm not going to do it on the regular, but I can if I want to. And so on. And sometimes maybe that would be the only knife there. So we really want to make sure that whatever life chucks at us we feel we are able to do it. In contamination OCD, it might be not washing your hands after going to the loo would be a really common one in general, that's probably not a bad thing to do. But every now and then you might be in a situation, I don't know if you go to festivals or perhaps you're in a service station and the taps aren't working and it's like, you're just going to have to live with that situation and it's okay. So you want people to know that there isn't this line, OCD says, right. All right, okay, you can have that one, but you can't use the really big knife, or ooh, this is where the line is, and life isn't like that, so we really encourage in the opportunity of therapy, people to go as far as possible. And that's within common sense grounds, as it were. So we're not ever doing anything harmful, of course, to a baby. But we might say, it's really important that you're able to, like change your baby when you go outside. And probably us parents have all been in that situation where it's not optimal. You might find yourself in, probably in similar, in the motorway service station. Or, actually they're usually quite good actually. But some other equivalent where you just have to get on with it. And so we want people to have as much experience in the bank that's generalisable that they can just get on with it, if they have to. And then it makes it much more straightforward to choose the path that you want to be on, rather than OCD choosing it for you. Rachel: Bit like exposure to that massive spider in spider therapy that you might not normally be coming across in your day-to-day housecleaning. Fiona: yeah, exactly. Rachel: But you said that you might, there might be occasions in the perinatal period where we wouldn't go to the nth degree on the anti OCD sort of pathway. Fiona: possibly. I mean, particularly things like contamination experiments in pregnancy. I mean, again, having been pregnant or knowing pregnant people, you modify things a bit, you might wash your food a bit more and that's okay. And I think it's fine to do those kind of experiments where, not washing something, but going and kind of doing a full kind of toilet contamination experiment. It would be quite in the negotiation with people. Probably isn't totally necessary at that point. And, there are, there is a special context, so I think that's what I mean of kind of there are slightly different parameters on it, but you might want to say, this makes sense for now, we want to, you to be doing what your friend is able to do within your group, the average person, but actually postnatally, we'll save some sessions to do some of this stuff so that, as said, you can deal with whatever service station that you're at. Rachel: So see, you'll be lurking in the delivery room, Fiona, with your hand down the toilet. Fiona: I don't know, I'll give them a few weeks off at that stage, but something like that. Rachel: So we may have talked about a few of these particular issues that come up most frequently, but you've been now doing this for a while. I'm not going to age us, Fiona, but we've been at it for a while now. And you do have extensive experience of teaching, supervising and applying the models in this perinatal period. So where do you find therapists get stuck? What are the most frequently asked questions or the trickiest issues that come up? Fiona: I think, yeah, contamination stuff can be really tricky. Sometimes the versions of OCD where it's very internal and ruminative and unverifiable. So, there are some, within perinatal ones, they're less common, but they do come up. So things like, have I given my baby the wrong name is relatively a common one, so that, really trying, getting into those concepts of what's right and wrong and so on, and people worrying about having done something which might cause damage years down the line. So again, it's very ruminative, and it's not uncommon within OCD, but everything is ramped up because of that responsibility piece, and people can get really sort of distressed and it can be quite difficult to get at some clear blue water with people in terms of the treatment of theory A, theory B. So those are quite, they are quite tricky forms of OCD, I think, when it's very internally referenced and, and driven. So yeah, I think those are common ones. And then ones where the person is very contamination focused, there's been a few that I think have been really sort of fuelled as well by the pandemic. It was a very difficult and strange time for us all, where people have been, it's been obviously very kind of reinforced in terms of external threat and needing to keep things safe but actually then people still being stuck within that. So there being difficulties in delivering treatment to people because of the overall situation, but also that sense of threat and probably less dissonance, I guess, to work with in terms of kind of, I need to keep my baby safe against the world. And kind of maintaining those beliefs that the world is a hugely threatening place and of course, at a very extreme end, that's really difficult and really problematic, babies not people not going outside, there's being lots of stuff going on at home. Rachel: And in that kind of brings to the table, this is wider system that people are kind of part of, aren't they, dads, birthing partners, family, and those kind of pressures that can be reinforced by the people around them as well. But also I guess we have talked a lot about mums, or, birthing people in this podcast, but I guess there's a lot of stress around also for birthing partners, for dads in that perinatal period. And I think you've looked a little at this and how this can be impactful within the family system. So, do dad's/partners need any special help or consideration in this period? Fiona: Yeah, absolutely. it's a time of increased risk as well for Dads. Intrusive thoughts are very normal in birthing and non-birthing parents because of the way services and so on are kind of configured, there's less detection, I think, amongst, the non-birthing parent and it can be more difficult to plug in and sort of understand that context as well. Whilst it does happen, yeah, I think dad's non birthing parents are less well served. But yeah, of course, because of the context, it's similar for both parents and there's anecdotal evidence, not so much research also about grandparents as well. But, probably to a lesser extent because of the being a step removed and not having all of the biological factors as well but absolutely, I think because of the vulnerability piece and because of the responsibility piece and so on and how common intrusive thoughts are at the time of increased risk, as well. Rachel: So we need to not forget the others Fiona: Yes. Rachel: So then thinking about, ourselves as therapists and self-reflection, the stuff we bring into therapy sessions, there can be challenges around this work, I guess. And sometimes we have to challenge our own assumptions about what we're doing. Sometimes we have to look out after ourselves at particular vulnerable periods. What about therapists treating OCD, for example, whilst they're pregnant themselves or they've got a partner who's expecting or they're co-parenting small children. What kind of things might therapists need to consider with respect to self-care and also kind of managing their own assumptions and how they might impact on therapy. Fiona: Yeah, I think it's always important to check in with those things, but I think something particularly heightened about perinatal period. There's so much lived experience, and as we've kind of talked about throughout, it's all so relatable, I think. It's why it's such a wonderful area to work in, that, all of that makes sense. And I think, if you are pregnant or trying for a baby, it does bring up things for you and, if one of the kind of main drivers of OCD at this time is about causing harm, allowing harm, these things can really chime. So I think it's really important to reflect on whether things are coming up for you, how comfortable do you feel taking on this case or working with this particular form if it chimes with your own experience either present or past. I think it's always fine as a therapist to say, actually, I just, for this particular person, I'm going to take a pass on this one and work on the next case that comes in. And I think sometimes we can be surprised, and I think it's good to be reminded of ourselves as human beings as well, it's not, you can be the most kind of hardened therapist, but sometimes certain experiences will just get to you and often, with our perinatal OCD clients, there are very good reasons why people are very tuned in to harm and loss and so on. And sometimes it's those background factors that can really chime with us. And so we need to be able to think about that whole picture. And I said, it's really fine if for whatever reason that's just not for you right now because although we have talked about the formulation and so on, we're actually talking, it's the whole picture that is very important of making sense of things, why is this person feeling as they do right now? Rachel: Yeah. And I guess on that theme of that bridge from the professional to personal, I guess we learn a lot from our patients too, don't we? Kind of what we take away as professionals, but also as human beings. And I'm wondering if there are things that you've learned from your patients that have made a personal difference in your life or the focus of your work. Fiona: I think, again, it's one of the great privileges. You learn from absolutely every person that you work with, I think. And that's why it's just such a wonderful job. And in terms of specifics, like how to deal with things, when the worst happens. I'm often really in awe of the people I've worked with. Whether I could translate that to things that I can do differently is perhaps another question, but understanding how amazing people are, even in the depths of very difficult experiences, it's very humbling. And I think gives you hope when things aren't going your way for whatever reason. I find that a great source of comfort actually just to think there are ways and having that privilege of connecting with people and trying to understand with them their strengths, is a great source of hope, I think. Rachel: And you've got two gorgeous daughters yourself. Has being a mum changed how you've approached the work? Or has the work changed how you've approached being a mum? Fiona: I actually became pregnant during my trial. And so at the beginning of the trial with the first few people I was working with there, I wasn't a parent and became one during that process. So that was really interesting in itself. It's helpful for behavioural experiments as well but of course, gave me such a lot of insight, I think, that I could see from afar, of course you don't have to have experienced everything that your client group has. But when I was normalising, like, this is really hard, I really knew that up to the depth of my being, in a way that I didn't before, I think. So I think it gave me more authenticity, perhaps, and solidarity, and understanding the nuances of what's it actually like to be awake at four in the morning trying to work out breastfeeding and in the context things. So I think it just gave me more, even more, respect for the parents that I work with, as well, and having more anecdotes to draw on, and I got intrusive thoughts as well. I often mention that in teaching. Having spent the preceding several years kind of researching and thinking about intrusive thoughts, I was very pleased to actually get some really terrible ones myself as I brought my baby home. I thought, hang on a minute, I know what's going on here. These are really awful, but yeah, I'm very lucky that I've got a context. Rachel: You, you were forearmed in, in that case. Fiona: Yes, yeah, still, it's interesting. Still have, you have that emotional reaction because they're horrible images, but I didn’t have the awful meaning Rachel: I can identify with that. Absolutely. 100%. yeah. And I guess, well, we're not implying that you need to be a parent to do this work, obviously. There are phenomenal therapists who don't need to share our experience that our clients have, but it can add a different dimension, can't it, to the work. And as you say, some useful anecdotes, perhaps on a more superficial level for me being pregnant and doing therapy, just managing toilet breaks was it was an issue. Fiona: Yeah, exactly. And then, I think appreciation of all the logistics as well. I think it's very hard returning from maternity leave and having, there's multiple roles and even just being in the right place at the right time. Rachel: You're very active still, obviously, in your research, and you've talked in this podcast a lot about different pieces of work you have ongoing at the moment. What are the next big challenges, do you think? What are the horizons for the research, the therapy, for dissemination of the therapy? What's going on in your world? Fiona: It would be really good to have more evidence about treatments, particularly in pregnancy, so we've made a start with that, but kind of more definitive trials, and say more sort of diverse groups as well, and I think, yeah, trying to address some of these issues that we touched on earlier about access to services, I think is as important as the kind of what, obviously it's very important that the treatments that we deliver, but there are issues with that in perinatal. So I see that as the biggest challenge and that these inequalities, across maternity and mental health. As mentioned earlier, there are some really tricky forms of OCD and, well, CBT works beautifully for many people, but not for everybody, so I think kind of continuing to try and refine the models and treatments for those who don't get as much benefit would be really important. There's still lots to do, and I think working on the parenting piece too, so that's the other main thread that I'm following at the moment as well, as to whether we can help people, support people and enhance their early parenting skills, as well as treatment for their kind of OCD and difficulties, because it's so intertwined with becoming a parent. I think that's a very fruitful, potentially really fruitful area. If we can support the parenting, we might actually then be able to indirectly address a lot of the things which are driving the OCD. So that lack of confidence and feeling, I might be a bad parent, if we can actually give people some concrete skills to enhance what they're already doing. Because I said they're usually incredible parents. I should have said, that's one of the things I've learned from my parents. How to do things really well actually, but helping them realise that more could I think again really enhance our current treatments in the perinatal period. That's always been a question or, how do we really integrate treatment for the parents own mental health as well as treatment and to support their early parenting. Rachel: I can hear from what you're saying just why it's such an exciting place to work because you're influencing life, not one person, but a whole family system there. Fiona: Yeah, hopefully, yeah, it's really warming when things go well and people are putting things into practice and sometimes they'll email you back with, pictures or things that they're able to do with their new little one and it's just wonderful. Rachel: So if people want to learn more about your work, access training, et cetera, or want they get involved, how can they learn more about that? We'll obviously put links to your books and any papers you can recommend and the show links, but what steps forward would you recommend for people who want to get more into this sphere? Fiona: So there are lots of resources. One of the first ports of call would be the maternal OCD website. So that has lots of research resources and lots of patient facing resources, including an infographic that we co-produced together. And there's also an animation coming out about intrusive thoughts that we have worked with Maternal OCD with. So just to give a bit of background on them that’s Maria Bavetta and Diana Wilson who are people with lived experience who set up this charity to raise awareness. So as I said, when I started working in this field, it was a very little known problem and they've done absolutely fantastic work in raising the profile of maternal OCD. And we've actually produced lots of training events and things together. So that's a great port of call. There are also formal trainings available, things like OCTC run workshops on perinatal OCD and other perinatal mental health problems. If you are coming in as a practitioner in specialist services, there's an upskilling program as well to access, which is highly recommended that also has formal training and supported clinical work as well. So that's a wonderful resource, but there's more and more coming through to train the perinatal workforce. So the Talking Therapies Competencies and Positive Practice Guide are just fantastic summaries of where we are with the evidence too. So loads of things to access if you're new or very weathered within perinatal, there's always, stuff going on in excellent training. Rachel: I often find a good old self-help book is one of the great places to start. And of course, you've got one of those, went on with Victoria and Paul Salkovskis and various books you publish, which are so well written and so accessible and just really insightful. Both for patients and for therapists, I think. Fiona: Thanks Rachel. That's very kind to say, it feels like those kind of things, even though they're obviously not the academic kind of products, but I think you could make a case of those make the most difference. And it's really nice when people get in touch or come up to me at a conference or lived experience event. And they say your book really helped. And it's a team effort. It's Paul's model but yeah, that's a really nice experience. We do have a perinatal specific one on maternal anxiety, which covers OCD and lots of other presentations, which, as said, often kind of go together as well, so another self-help one in the arena there.   Rachel: So in true CBT fashion, we're going to summarise and think about what we're taking away from this session. I guess the question is, what key message would you like to leave folk with regarding this work and the perinatal period? Fiona: Perinatal OCD is, can be a really tricky problem for people, really impacts on parenting, but the treatments are very effective and it's a wonderful time to work with people and as I said you can benefit or you can support people to be the best parents they can be and as a therapist you get so much from that too. Rachel: Fiona, thank you so much. It really has just been a delight to talk to you about this work that you're invested in and done so much amazing stuff that will really help people. I'm sure lots of people listening to this will have taken loads away. So thank you so much for your time. And as always to our listeners, thank you for all the work you do and until next time, look after yourself and look after each other. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on X and Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    

In this episode, Rachel talks to Professor Colin Espie about cognitive behavioural interventions for insomnia. They discuss the importance of sleep, common misconceptions about sleep and the importance of trusting in the body's natural sleep processes.  Colin highlights the high prevalence of sleep disorders and comorbidity with other mental health conditions that CBT therapists will commonly be treating. They discuss factors that maintain sleep problems and key evidence-based and effective approaches to addressing these obstacles that might help you and your patients to get a good night’s sleep! 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 X or email us at [email protected]. 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 Useful links: Books: The Clinician’s Guide to Cognitive and Behavioural Therapeutics (CBTx) for Insomnia: A Scientist-Practitioner Approach (2024) by Colin A. Espie. Overcoming Insomnia and Sleep Problems: A self-help guide using cognitive behavioural techniques (2021) 2nd Edition, by Colin A. Espie. Papers: Espie, C.A. (2023). Revisiting the Psychogiological Inhibition Model: a conceptual framework for understanding and treating insomnia using cognitive and behavioural therapeutics (CBTx). Journal of Sleep Research https://doi.org/10.1111/jsr.13841 Link to further papers: https://www.ndcn.ox.ac.uk/team/colin-espie Training links https://www.scni.ox.ac.uk/study-with-us   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 Professor Colin Espie about Cognitive Behavioural Interventions for Insomnia. Professor Espie is a Professor of Sleep Medicine in the Nuffield Department of Clinical Neurosciences at the University of Oxford. Since qualifying as a clinical psychologist in 1980, he's accumulated decades of research and expertise in the relationship between sleep and mental health and the understanding and treatment of sleep disorders particularly using cognitive behavioural therapeutics, a term we'll return to later in the podcast. He's also internationally recognised as a leading expert in the field and his work has been disseminated widely, not only through his many journal articles, books, and training programs, but also through his Sleepio app, which has supported improved access to evidence-based help. So welcome Colin. It's brilliant to have you with us Colin: Rachel, thank you very much for inviting me. It's great to be here. Rachel: So, I'm going to start with a question that I've heard you say you always get asked in these interviews. So, we're going to get it right out of the way up front. You're an international sleep expert. How well do you sleep? Colin: It's the journalist question, Rachel, isn't it? They usually ask at the end of the interview just when you're finishing up, Oh, by the way, how do you sleep? I'm actually a pretty good sleeper. I wake me quite early in the morning, you know, so I'm not a late night person. Rachel: So, you haven't had to apply these techniques extensively to yourself, or is that something you do? Colin: Well, the interesting thing, Rachel, is that I, and I'm sure it's true for everyone who's listening to the podcast, thinking about your own life, never mind the life of your clients and your patients that we all at times have difficulty sleeping. It's a normal experience, just the same as we all at times feel a little bit worried or anxious or have a period of feeling a bit depressed. And in some ways, the techniques that we use with our patients are kind of similar to what we try and do ourselves. Except we just need to apply them particularly rigorously, to help to remove more reluctant problems, shall we say. So I try not to lie awake in bed, for example. I try to, I better get up and go back to bed when I feel sleepy again, although it's not the easiest thing to do. Rachel: So you've practiced what you preach Colin: I, well, I try. I try. Rachel: and you've been interested in sleep from very early in your career. So I believe you're only a few years qualified as a clinical psychologist when you organised your first international conference on sleep. And then later you carried out the first control trial in insomnia patients in 1989. Colin: Yes. Rachel: And so what got you interested in the field of insomnia personally, professionally? Colin: Well, I think like, as with most things in life, its curiosity, isn't it? I started work, qualified in 1980 and I worked in primary care, seeing patients referred by general practitioners. That was very new at the time, getting direct referrals from GPs. And after a few months, one of the GPs said to me, “Colin, don't suppose there's anything you can do to help these people who can't sleep?” And I said, I don't know. Because we've never been taught anything really about sleep or its relationship to mental health. I'd been seeing lots of anxious people with depression and so on. So I said, send me a few patients. And I went to a thing called a library. And read some books, and some papers. Rachel: libraries, what are they like? Colin: I know, I know, so I, I tried to just find out as much as I could and discovered there was an emerging literature on behavioural therapies for insomnia. But mostly they'd been conducted in student populations and not with patients. So, in the mid-80s, I designed, as you said, kindly, the first trial of referred patients, and of course CBT had never been invented as a term then. Rachel: So it was, it was all brand new and on many levels. Colin: yeah, what I looked at initially were relaxation-based therapies and therapies based on something called stimulus control, which is, it's a behavioural approach if you like to try and help reestablish a good pattern. And I looked at something called Paradoxical Intention, which is a cognitive therapeutic, designed to overcome performance anxiety, in other words, to stop you trying to sleep. So these are the three interventions, which when I looked in the papers I could find, these were the three approaches that seemed to have some evidence base but hadn't been tried with patients. And I mounted a placebo-controlled trial as well. Pretty bold stuff, really, I think, back in the day, Rachel. Rachel: Fantastic. And as you said, this is whole raft of interventions that you now have developed and gone forward to, and we'll talk a bit more about that as we go through this podcast today. I guess you're not the only person who was curious about sleep. I mean, it seems at the moment that we're all pretty obsessed with sleep. I can't scroll through my news app or a Sunday supplement without encountering at least one article on how to sleep better or on sleep problems, which does suggest that it's a problem, or at least a perceived problem for a lot of people. And anecdotally, my friends who work in higher education with undergraduates tell me that Gen Z is absolutely fixated on getting their eight hours sleep and they're in bed before their parents and their professors. So, so perhaps a good place for us to start talking about sleep problems is defining what good or normal sleep looks like, how we would define that, what it's for? Colin: Yes, absolutely right, Rachel, sleep's everyone's business, it's not just the business of professionals. And in many ways sleep is nature's medicine, its what nature has provided, for us to give us quality of life and we wouldn't be able to function at all without our sleep. And when one thinks about it, we imagine ourselves to be highly evolved species, which I think we are, but we haven't evolved to do without sleep. In fact, we need rather a lot of it. If we spend a third of our life asleep, that's in service of our quality of life. But then what is sleep? I think a lot of people think of it as a kind of oblivion. Yeah and that's what it should be, that you just kind of conk out kind of thing. And that's you for the night. Rachel: it's the switch off button. Colin: it's a switch off button, but it's actually really the switch on button. Because there's a lot of research evidence now that, if you were to ask the brain, what's your preferred state, they would say sleep. Because that's when I can go on with my work, when you're out of the way. Because during sleep, a lot of the repair restoration work is done in terms of regenerating cells, in terms of clearing toxic waste from the brain, in terms of infection control and signalling. We need sleep to recover and rest, of course, but there's all these much more sophisticated processes going on. And of course, as people interested in psychology, it's sleep that gives us cognitive recovery. It's during sleep that memories are consolidated, not during wakefulness, or not efficiently during wakefulness, much more efficiently during the night. And it's during sleep that emotions are regulated and reset. So, it's a very complex set of processes and phases and stages, and people will be aware to some degree of REM sleep, Rapid Eye Movement sleep, or dreaming sleep, which occupies about a quarter of a night. and then non-REM sleep occupies about three quarters of the night. And it’s all beautifully architectured if you like, across the night. Rachel: So those different types of sleep have different functions? Colin: Yeah, absolutely. And I think one of the difficulties nowadays when one buys some kind of smartwatch or whatever, and it's going to track my sleep and tell me how much sleep I've got, and then tell me how much sleep is in different bins. And you look at the different bins, one of them called deep sleep, and you'd rather, you wish, well, I hope my whole nights in deep sleep. But in fact, from a scientific perspective, deep sleep occupies somewhere between 10 and 20% maximum of your night. And in later life, maybe five to 10%. Deep sleep's quite a rare commodity. But that tells us also that, that all the forms of light sleep are just as important, but we're more likely to waken out of those and dreaming sleep is light sleep, of course. Rachel: So as psychologists, we really like to measure things and we often are asking our patients to record and monitor and measure things, but it sounds like some of these measurement processes can be oversimplified and lead to sort of negative outcomes in terms of people thinking they're not getting the right kind of sleep or that their sleep isn't directioned in the right way. Colin: That's right. I mean, I think that's an unfortunate side effect of people's best efforts to look after their health but sleep is not designed to be monitored like that and good sleepers don't do it. In fact, good sleepers have no idea how to sleep. Rachel: They just do it. Colin: But just like you breathe, Rachel, I've noticed you're breathing pretty well, but you've probably been unaware of that. Have you noticed that you're breathing? Rachel: I have not been focused on it. Colin: Yes, and that's the way our basic physiological functions are designed to work. So breathing and sleeping are designed to be totally automated behaviours. This is why sleep is so interesting from a psychological perspective because I've never met anyone who's able to get to sleep in my career thus far. I've never met a single person who can get to sleep. I've only ever met people who can fall asleep. Rachel: The difference being an automated versus an intentional process. Colin: Yes, exactly. That psychology, trying to actively control the sleep process tends to disturb it. Just in the same way as trying to actively control the breathing process can lead to hyperventilation. Now of course one can take deep breaths and, and so on. But one can't switch on your sleep. You can amplify your breathing rate and reduce it, but you can't do that with your sleep. It belongs to a highly automated, regulated system that's done largely automatically. So this is one of the reasons that, that insomnia can be such a difficulty. Either if we have an acute difficulty, I can't get to sleep tonight and I'm struggling. Oh no good. I'm speaking in a podcast tomorrow. What if I need to be properly slept, or, you've got an insomnia difficulty. Then you get caught in this vicious cycle, don't you? Rachel: So it sounds like, what you're saying is sleep is an automated process, not something we need to actively do. It's something that should happen naturally. It's something that is very active in itself. It's not a switch off button. It's a switch on button for our brain. These cycles of different types of sleep are important. So we don't just want to be in deep sleep, as our sleep apps might tell us, but we actually want to have these variety of functions that the brain is carrying out throughout the night. I'm going to put a few questions or statements to you about sleep that might sort of tap into some of these myths or maybe true and informative statements so that you can tell us whether they're true or false. So here goes. Colin: Here we go. Rachel: Adults require 8-hour sleep to function well cognitively. Colin: Probably, not quite as much as that, but that would be the average figure, somewhere between, say, seven and a half and eight hours. The difficulty is that 50 percent of the population is always below average. In everything. And that a lot of that proportion is normal. So therefore, we're not all the same. And the best way I can explain this to people is to think of your shoe sizes. We may have an average shoe size for the adult male population or the adult female population. But that doesn't mean we should all hobble around in the same shoes. We should really try to figure out, what shoe fits my foot? What's comfortable? And we do that by trial and error. And that's how we find out how much sleep that we actually need. And I think one of the difficulties is that when you convert sleep into the five fruit and veg kind of thing, well, five fruit and veg, eight hours sleep, the eight-hour sleep is really, it can only be a guide. You try to get to prioritise and value your sleep but try to personalise it and to establish the amount of sleep that you require. And sometimes people spend too long in bed, and they can't sleep through that period and end up having difficulties. Other people have got such busy lives that they're running short and not getting enough sleep. And of course, when we've got mental health difficulties, sleep can be elusive. So it's a complex answer to what seems like a simple yes or no question, Rachel. Rachel: But actually that complexity is important, isn't it? Because if we're all trying to shoehorn our sleep into a particular amount of time or worried about it being less than that, then that can create problems in and of itself. Colin: Yeah, because we know, don't we, we know that sleep matters. That's one of the reasons that we get very anxious when you can't sleep, not just because of the horrible experience, but we know it matters. We know deep down in a primitive way that it matters and our response to not being able to sleep well or sleep enough can be very alarming, the same way as if we can't breathe. There's not enough food. There's no drinking water. Because it's one of the basic ingredients of life; sleep, oxygen, food and water. The basic ingredients for survival. So therefore, when one's in shortened sort supply or when we feel it's in short supply where instinct is then to try to control the solution and of course people want to take active set steps to solve a problem that's understandable, but we can take steps that actually make it worse. It's such an important commodity but yet we can't just commoditise it. We have to trust it. Rachel: And you hinted there, sometimes people worry about getting enough sleep because of particular things they need to do or functions they need to have. So here's another statement, less than eight hours sleep will mean that we're unsafe to drive. Colin: No, that's not true. Again, it would relate to the amount of sleep you've had. But I think the thing to monitor in relation to safety is your level of sleepiness, not the amount of sleep you had the night before. So, for example, if somebody said, well, I had my eight hours sleep, so I'll just continue driving even if I'm sleepy, that would be a very reckless thing to do, and the courts would agree with that, and you'd be found guilty. If you're falling asleep at the wheel and causing accident or injury, it can be a criminal offence because one has to be responsible. So we need to monitor our sleepiness. And I think the main thing to differentiate there, and I think this is important in our clinical work, too, is to differentiate between experiences of sleepiness and experiences of fatigue. They're not the same thing. Rachel: So how do those differ? Colin: Well, sleepiness is a behavioural tendency to fall asleep. When one knows that your head's nodding, that you're yawning, your eyes are closing, you're stretching, your eyes are itchy, you've had some warning signs, you've already had a momentary microsleep, your partner's dug you in the ribs, you spilt the tea on your sweater- and of course people are aware of this driving and it's very dangerous indeed. Whereas fatigue is a sense of weariness and doesn't necessarily mean that we're about to fall asleep. In fact, people with chronic fatigue syndrome often have difficulty sleeping, so it's not inevitable that when you're fatigued, you're going to fall asleep. And fatigue is, to some degree, a good countermeasure to fatigue is activation. If we get up and do something, then we can take the edge off fatigue. Whereas with sleepiness, you really have to have a nap if you're very sleepy. Rachel: And you've already mentioned that people sometimes spend too much time in bed. So the next statement is in order to get sufficient sleep, we should go to bed and stay there until morning. We should just spend more time in bed if we're not getting enough sleep. Colin: Well, I think we should experiment. You know, to find the amount of, let's call it the sleep window. That's often the way I think of it. What is the best window for me to sleep? In other words, how long should I be in bed? When should the window be positioned? Some people are more naturally morning people, larks, and will tend to have their sleep window early. The and the gate, the circadian gate as we call it and we can talk about the circadian system a little bit- the times that are sleeping wakefulness. But people who are morning larks will tend to feel sleepy in the mid evening and then a would have a natural sleep period that would wake them up at three, four in the morning. Five in the morning, whenever. And night owls are the opposite. The gate doesn't open till later. So, it's really about figuring out the timing of your sleep as well as the amount of sleep. And experiment. I think one of the difficulties, and of course we find this with clinical practice too in general, that what we do with cognitive behavioural therapeutics is we encourage people to experiment, to try things and if they're unsure whether it would work and if they're unsure whether they could do it, then we encourage them to experiment with it. But we also encourage them to experiment because we're trying to test a formulation to see if there's evidence for it. And this is a bit like that. What is the best time for me to sleep? But I think what people often look for from the therapist is just tell me the answer. Tell me exactly what to do and they want it off the peg whereas we know that's not what works best for people. That's not part of a collaborative approach, but it's not really formulation driven. That's more just a technician approach. Rachel: So experimenting is good, collaborative empiricism, heart of CBT and I shouldn't be worrying that my teenage sons, we're currently in the summer holidays, are experimenting with getting up long after the sun has arisen, but we'll maybe come back to those issues later on. Colin: Well, it's a natural experiment, Rachel and it's actually what happens in teenage years, that the body clock is set to delayed phase position. So, so teenagers find, struggle to get to sleep and they struggle to get up in the morning. And of course, when you take away the time givers, the zeit givers, like you've got to get up to go to school, when you take those away you release the break at the end of the circadian period so they tend to be even more phased delayed. That's a biological norm, unfortunately, in some ways. But you said we'll come back to it. We can come back Rachel: Yeah. Yeah. And it's one that's going to be interesting when they start school again this week. So one that our listeners might have something invested in here. We should never drink alcohol or caffeine if we want to sleep well. Colin: It's generally a good thing to avoid caffeine as you approach bedtime. A lot of people will go into decaffeinated drinks in the evening. Because caffeine is a stimulant and can delay sleep onset, but in experimental studies it does so just by a few minutes. It's not really accounting for insomnia, unless your caffeine intolerant and of course most people build up some tolerance to it. So, it's much overstated, but that's not to say that we shouldn't pay some attention to it. And of course, caffeine can be found in chocolate and diet aids and lots of other things and it's good to encourage people to experiment again. But sometimes if they hear the psychologist saying, starting the treatment insomnia with sleep hygiene, talking about caffeine levels and beds and comforts and new pillows, mattresses, they might quite rightly think this isn't really going to be therapy. We don't have a good relationship with alcohol in the UK. And alcohol modifies the structure of our sleep. So quite a lot of alcohol in the evening will obliterate your REM sleep. It will remove your REM sleep. It’s a REM suppressant and as the alcohol wears out of your system during the night, you may have more dreams towards the morning and sometimes more disturbed dreams and nightmarish dreams if people are drinking a lot of alcohol. So, alcohol, although it's a sedative, a drug, a depressant drug in the central nervous system, it does have unwanted effects on the structure of your sleep. Rachel: So it may initially help us potentially fall asleep or it may hasten sleep onset, but it doesn't help our quality of sleep. Is that right? Colin: Yeah. And may cause some retrograde amnesia so you don’t know whether you've slept or not, in extreme cases. I'm not saying it's an anaesthetic, but there's a different, there's a different kind of structure to your sleep. So you know, it's not sleep at all costs. So usually the first cycle of REM sleep occurs after about 60 to 70 minutes into the night, you have your first cycle of REM sleep, and that's there because it's meant to be there. But alcohol, if taken in excess will obliterate that altogether. And often an alcohol fuelled sleep doesn't feel like it's a good, had been a good sleep even if you've slept for quite a while. But I don't believe in the ministry of no fun, Rachel. You know, I'm not saying that, we shouldn't be walking a tightrope with our sleep and it's often the way that patients feel with their anxieties or worries or depression, the trauma and with insomnia that they feel very vulnerable. I think one of the things we need to do is to learn to trust that sleep is a highly evolved biological imperative. It won't let us down. We have to kind of try to keep it in a good position and good shape. We need to look after it and one way to look after it is by not regularly drinking too much. Not using alcohol as a sleep aid but that's not to say that I've never had a malt whiskey. Rachel: So we're not encouraging, total abstinence or black and white thinking when it comes to things that people get some pleasure or enjoyment from, but we're thinking about how that does have impacts, particularly when used and abused.   Colin: People often underestimate how much they've been drinking and tell you, and tell themselves they've not been drinking much, and tell themselves also that they don't have a problem. So, it can be one of those things that for some people, for some patients, we should encourage them to experiment with that, that it could actually be a factor and perhaps inadvertently alcohol has become a sleep aid for them. Rachel: And so another statement then for our true and false section. In order to catch up on a bad night's sleep, we should go to bed super early the next night. Colin: No, there’s a natural homeostasis to our sleep drive. And homeostatic functioning is about, it's a pressure system that creates a balance, drives towards balance. So, leaving aside the alcohol question, let's suppose you're parched and you know you need a drink. Your dog knows, he or she needs a drink, insects know they need a drink. It's not a smart thing to know it's just that you gravitate towards needing to recreate a homeostatic balance, where your fluid intake is concerned. When we're hungry, we seek food and when we're sleepy, we seek sleep. And the drive for sleep, the biological drive for sleep is stronger the night following a poor night. So, so, and interestingly, this is often what people do with pills, don't they? I slept badly last night, so I'm going to take a sleeping pill tonight because I can't afford another one of those. That's the very night they are likely to sleep better anyway, because they had a bad night, because there's a natural recovery. So the best thing that people can do is to establish the pattern and to retain their pattern, rather than to switch it back and forth reactively to poor experiences and to bad nights, because that tends to create a situation where it's hard for the homeostatic system to find its balance point again. Rachel: So you don't need to actively sleep more to catch up. Actually you need to trust that your body will respond to that, that you will sleep well the next night and that over time, that homeostasis will be reached again. Colin: Usually if people have slept badly, it's either because they didn't have enough sleep opportunity that night because they were busy, they were doing things, they were up late, they had to get up early, whatever, things in their mind, they catch the flight, so reduced sleep opportunity plus some anxiety about it, or it could have been just one of those nights when they couldn't settle. But either way, the sleep loss accrued, accumulated from that night will help to drive a better sleep the subsequent night. So reasons to be confident in sleep's ability to do its best for you. If you end up going to bed the next night for an even longer period, for example, than you would normally spend in bed then there may not be sufficient sleep drive to carry you through an extremely long sleep period. And then you go, hey, what's happening here? I've went to bed at eight o'clock. I had such a bad sleep last night and I can't get to sleep. And that's possibly because you, well, do you ever normally fall asleep at eight o'clock? What's your normal time of sleep onset? But again, when I talk about experimentation, I'm talking about experimentation towards habit formation. You know, what we do with young kids is we experiment to get them into patterns of behaviour. We support them when they're trying to walk and then we experiment, see if they can walk three steps instead of four steps and fall only two out of five times instead of five out of five times but eventually, they walk, so even things that are going to happen need to be supported by experimentation. But they're in aid of automation, of it becoming just a natural pattern. Which is not really overthought. Rachel: So final one of our true and false statements. There are good sleepers and bad sleepers, and you just are what you are. You're stuck with it. Colin: There's some truth in variation in almost everything. So there are some people who seem to be better sleepers. It's often more to do with some people have greater vulnerability to downregulate arousal, for example. Because sleep, to fall asleep, you have to be able to downregulate your arousal level. And some people have higher set points in arousal. Other people had experiences which to some degree have contributed to them being somewhat hyper aroused. Rachel: Like a lot of our clients. Colin: yeah, and those things then become the target for what we can do to help people to manage those situations, and I guess psychological therapy is on a bridge between managing a situation to live with it better and curing it, solving it. What I would say is that a lot of insomnia problems can be solved. Don't just live with them. I think this is one of the reasons a mindful approach has not been that successful as a treatment for insomnia disorder. Because the insomnia problem can be sorted. Rather than, you don't need to live with it. But you really have to experiment behaviourally to get the positioning of your sleep right. Rachel: So it's not just a position of acceptance. Colin: No, sometimes people say to me about, well, you use the paradoxical approaches and say, is that not just mindfulness and is that not just acceptance? I mean, there's an element of acceptance in every world, religion, philosophy, and creed and it's integral to a lot of psychological therapy, but it's not sufficient to solve a problem that can be solved. For example, if you're afraid of an animal, you can solve that problem, you can overcome it, you don't need to accept the fear of it. One thing I would say though about good and bad sleepers is I've never met anyone who's good at sleeping. It's not something you're good at, you're not a good breather, you're a great breather, what a great breather, great walker. It doesn't make sense to be good at it. In fact, if you try to be good at it, you're more likely to be end up having difficulties with it. Rachel: So, I think you’ve really clearly stated there that sleep is an automated process, an automatic process. We don't have any more control of that really than we have over breathing. And you've talked about the need to be sleepy, and, and also the need to be able to get downregulate to feel safe and I've heard you say those are the two things that really need to be in place to feel sleepy and feel safe to fall asleep. You've also just spoken about the homeostatic sleep drive so this kind of builds up this pressure for sleep. Are there other processes that govern automatic processes that govern our sleep, other cycles, rhythms, patterns? Colin: Yes. So people will have heard of the circadian system. And of course, in relation to sleep, the circadian system regulates the timing of sleep and the timing of wakefulness. But the circadian system is present at cellular level. So if I was to take a one cell out of a strand of your hair, Rachel, and to put that one cell in a little Petri dish, that one cell would follow a 24 hour rhythm all on its own, assuming it had enough energy to survive. But one can demonstrate what's called a molecular clock at cellular level. So this is an intrinsic rhythm. This is integral to our system and all the major organs in the body follow a circadian oscillator system and, you'll have been jet lagged, I'm sure. Yes, and it's a terrible experience, isn't it? It feels like it's got general malaise, isn't it? It's not just about not sleeping well, or at the wrong times. Our digestive system is out of sorts, our light sensitivity is out of sorts, everything is out of sorts. And jet lag is actually what's called internal desynchrony in circadian science and what that means is your bodily systems, your bodily oscillator clock systems are out of sync with each other. It's not just you being out of sync with the clock on the wall and not being able to sleep at night, it's to do with your different clock systems, being out of sync with each other and recovering at different rates. And sleep science and circadian science are coming more closely together in recent years, and at Oxford I'm involved with the Sleep and Circadian Neuroscience Institute where we're interested in basic animal models of sleep and circadian function as well as the clinical human and societal levels, because these are clocks that time us, that time our lives, and time the seasons of our lives at a different kind of seasonal rhythm. So, what happens is that, when you wake up in the morning, and I've just checked my watch, it's 10 o'clock, right? So I think it's 10 o'clock. So let's suppose you got up at 7 this morning, Rachel, maybe you get up early, I won't ask you a personal question, but 3 hours, right? So in a normal homeostatic system on its own you'd be three hours into your sleep debt. You'll have accrued three hours of sleep debt. You're owing three hours to the sleep banker. And what would happen you would expect is as you gradually go through the day, you get sleepier and sleepier. If you didn't eat anything, you'd get hungrier and hungrier. You didn't, if you didn't breathe, you wouldn't last three hours, right? So the homeostatic system on its own would just accrue debt and the main symptom of that would be sleepiness and danger. The circadian system operates to keep us alert during the day in opposition to the accumulating sleep drive. So it's an alerting system and then, as night falls the circadian system begins to orient towards opening the sleep gate to allow it to flood through and the main hormone that helps us to measure this is something called melatonin. And melatonin's expression is suppressed by light and increased during the dark phase. So these complex bits of neuroscience are all part of the design, if you like, to enable us to sleep at night, to get the recovery that we need, and to maintain an optimal alertness during the daytime. Rachel: So on the one hand, we have this sleep debt that's rising through the day. And the other hand, we have these kind of body clocks operating. And it's incredible to think on that cellular level, that's a really fascinating example you give about a cell from a strand of hair, it has its own clock regulating Colin: Yes, and there's a lot of evidence that, circadian disruption is a very common factor in a bipolar illness, in schizophrenia and psychosis and so on. There's a lot of what we do as psychologists and therapists, which we're doing, we think, at the level of the mind is actually having direct effects on behaviour and the brain. Our interventions are really psychobiological even if they're primarily at the operational level, psychosocial, what you're actually doing is you're modifying our adaptation to the world. I think we need to recognise more the fundamental science connection that we need in psychology to take things to the next level, just in the same way as it's happened in medical science, broadly speaking. Rachel: So it's not just, it's not just psychobabble. We're not just talking about nice stuff and making people feel better. Actually, that body mind connection, interconnection is really fundamental to what you're achieving when you're working in this Colin: Yeah, I sometimes kind of laugh. I find myself chuckling when I see something in a newspaper about scientists have discovered that there's a relationship between the mind and the brain, kind of thing. What is the mind, if not the brain? Do you know what I mean? Or surprised that some real science behind psychological interventions, it's not all just questions and questionnaires. And it actually makes a difference to how our body functions and how we operate as human beings. Psychological interventions are a lot more powerful than many drug interventions and, if you look at insomnia, for example, cognitive and behavioural interventions are recognised internationally as the preferred first line interventions having effects that are greatly superior to any sleeping pill. And that's not because they're operating just at the level of kind of emotion. They're actually making a difference to people's actual functioning in day-to-day life as well as their sleep at night. Rachel: And you've spoken about how in certain psychological or problem presentations sleep rhythms can be disrupted. Clinically speaking, how widespread are sleep disorders and what are the issues people with insomnia typically struggle with and seek treatment for? Colin: well, if you pick up the DSM or ICD and just flick through the classification of mental diseases, you won't find any that don't have sleep disruption as part of them. And I think historically, we've taken the view, quite incorrectly, that sleep is a piece of collateral damage that's associated with mental health problems. The real thing is the bipolar illness. The real thing is the depression. The real thing is the anxiety. And a symptom of all these things is your sleep gets disturbed. I think it's much more of a bidirectional relationship than that, and sleep is much more fundamental than that. So, therefore, the advice nowadays is that you should actively treat the sleep difficulties as part of the disorder you're managing, and that you're likely to get a better outcome if you take a 24-hour perspective on the individual, than just taking a daytime perspective, which is often what we do. So the night time is just a consequence of the daytime, the brain doesn't believe that. The brain would prefer you to think differently, that actually sleep is the engine. And therefore, when people aren't sleeping well, the supply isn't there to live your life well so therefore, addressing both. Because I've got a research background and am a clinical psychologist and others involved in research, you tend to get involved in doing something specific, you become an expert in something, and I think we need more of that research expertise, but equally, I’m a strong believer in the generalist approach that all clinicians should become skilled in understanding the role that sleep and wakefulness play in the presentation of my patients, whoever they are, wherever they are, they will be grateful to you if you ask them about their sleep. If you think, does it really matter? Is this an important thing? They'll tell you it is, and it does, but you know often we don't quite know what to do to help them. And this idea that in insomnia clinic, it's where people have got isolated insomnia, 80 percent of these people have got comorbid difficulties, physically and mentally, and these other disorders aren't the main problem. They need help with both those things. Rachel: So is it possible to put your finger on a sort of statistic around the prevalence of sleep problems or insomnia? Colin: Generally speaking, we think of insomnia as a disorder, which is a difficulty initiating and maintaining sleep three or more nights per week for a minimum of six months as being an insomnia difficulty, and if you take that more rigid definition, then you're probably talking about somewhere between 8 and 10 percent of the population, or between, depends on the surveys, between 10 and 12 percent of the population has an insomnia disorder, and that the prevalence of insomnia increases with age, and tends to be a little bit higher in women than in men. If you look at insomnia symptoms, then you're probably talking about 20 percent of the population has got chronic insomnia symptoms. So it's a very common difficulty. Rachel: Yeah. And if we had those kinds of statistics in almost any other mental health presentation, we would be hearing about it even more probably in terms of our therapy. So it sounds, as you say, there's this, focus of attention isn't always on the sleep problems whilst it may be one of the big issues that our patients are presenting with. Colin: Yes. We did a study with one of the IAPT services, in Buckinghamshire, I think it was, a number of years ago and CBT for insomnia was added to the standard care, and of course, there's a control group and what we found in that is not only did you, could you treat the insomnia symptoms in these people attending IAPT, but their remission rates of depression improved by somewhere around five or 6 percent, depression remission improved when you actively treated the insomnia. So insomnia intervention is not just to address sleep difficulties, it's to address difficulties that present in terms of mental health, emotion regulation, but also in terms of other outcomes important to people like, workplace productivity, things like that are very important to people as well in terms of their functioning. Rachel: And so regular listeners to this podcast will know we often have a, a particular challenge for our guests. We love a good formulation in CBT but being a podcast, it's an audio medium and you can't have boxes and arrows and diagrams on this medium. And I guess what I'm hearing from you is that this is a broad range of problems and problem presentations we're talking about, not one particular problem presentation; it might be different for different people. Is it possible to have an explanation about how insomnia develops and is maintained? Colin: it's the same for kind of every disorder, really, and people use different models of thinking, the five Ps model or other things to understand that these are generic models that have been used in medicine, as well as psychology and adopted pretty much that one is, you're going to be more predisposed to have a difficulty and maybe various factors that lead to predisposition. There could be genetic factors, predisposition, factors in terms of early experiences, adverse, life events, some people constitutionally are very hyper aroused relative to others. So there might be some people who have got a predisposition to find it difficult to downregulate arousal, to establish patterns in their behaviour. And then of course, we're familiar with the acute exacerbation of symptoms during a second P- the precipitating phase when something is triggered and that's usually the point at which somebody would become symptomatic or syndromatic and might seek help and that may be more of an acute episode. And obviously the extent to which that event is going to express itself depends also on the degree of protective factors the individual may have against something causing difficulties. But what we're often doing with cognitive behavioural therapeutics is that we're addressing the other P, the perpetuating factors, the things that are keeping it going. We often think of as secondary factors. They're not secondary in terms of importance, but they're secondary in relation to, they're the things that drive the vicious cycle of the difficulty, as the person tries to resolve the problem and one thinks of that in terms of anxiety disorders, perpetuating factors might be avoiding the situation, for example, safety behaviours or things like that may come into it. So for insomnia, it's the same types of things, if you like, and this is one of the reasons why people should not be afraid to venture into exploring sleep difficulties with their clients and their patients, because you've got the core skills associated with evaluating a problem. We're looking at, how did this problem, there must be a way that this problem makes complete sense. Why is it logical as a person to have an insomnia difficulty just now? And then you explore the formulation using that kind of three, four, five-piece model, like you're doing at the moment with other problems and often it can be the same kinds of predispositional factors, precipitating factors, perpetuating factors that are maintaining the insomnia as are maintaining other difficulties. Rachel: What would be some of the sort of major maintenance factors that you see with these kind of sleep difficulties? Colin: Well, well, I think one of the things that's particularly important with insomnia is that the active attempts to solve the problem are often making the problem much, much, much worse. I wrote some model on this a number of years ago called the Attention Intention Effort Pathway. And we know from a lot of research done over many decades, that the purpose of human attention, selective attention is action. That's why you pay attention to something, to act on it. And therefore when someone reaches a threshold of threat and is causing us concern, we act on it. We want to do something about it. But this is also a little bit of an amber flashing light for insomnia because just be careful what you're doing here because you could be making the situation much worse. You can't get in the driving seat of your sleep. Sleep operates a fully automatic vehicle, there's no manual gears, right? You can't drive it, you can't decide to sleep, you can't decide, you can decide to waken up, you can set an alarm, but you can't set an alarm to fall asleep. It's really about getting things into a pattern. So I think, one of the key maintaining factors, perpetuating factors is intentional behaviour and active efforts to control and manage the sleep process. Now this is true for other difficulties as well, but I think that's one of the crucial ones here. Rachel: what kind of things do people do to try and intentionally control their sleep that gets in the way of that automatic process? Colin: Well, they get involved in self-monitoring, thinking about “I think I feel sleepy now, I feel sleepy now, I better get to bed, or what if I don’t feel sleepy, I’m not sleepy anymore...” so their heightened sense of awareness then they need recipes. They approach things like a recipe. They say, “what should I do?” And they read something out some guru's written or they try some device, or they try something they hope it works. Then they think it works, then they think it doesn't work, and then they think it's useless. Then they try something else. They cast it around, feel desperate. They're always looking for solutions. Whereas the good sleeper, falls asleep almost accidentally, they fall asleep in the context of trying to stay awake, pretty much, they abandon wakefulness. And this is why a lot of the behavioural therapeutics, like sleep restriction therapy, which is a way of reducing the amount of time you spend in bed in order to drive up the homeostatic pressure for sleep, so it's a struggle to remain awake, helps you to recognise again that sleep is something you abandon yourself to, it's not something you engage yourself in. Rachel: Yeah. So I'm hearing you say that a lot of the same precipitating, predisposing factors exist for insomnia as for any mental health presentation including things like anxiety. But the perpetuating factors, similar to other problems, are those things people try desperately to do to fix the problem. In this case, it might be very much attention focused on sleep, and then doing whatever they can to try and make something come under their control. It's actually this automated process and that be the things they're doing to try and get to sleep become a problem in themselves. Colin Yes. I mean, there are several pathways to go down in, in your formulation with the individual and things to consider. And I've explained a lot of this recently in a book that's coming out shortly. I'm trying to un offload, I suppose a lot of my experience over the years and how best to manage insomnia, not using CBT as a thing, but using the therapeutics within it in a thoughtful way to apply them to the barriers and obstacles that this particular individual is facing. So it could be, for example, the difficulty the individual have is that they struggle to down-regulate their arousal level so we can address it that way. And one can look at relaxation therapeutics for that. And there are a whole variety of different ones, that one can use there. Another approach may be that the difficult they're having is with sort of mental events, at some level their mind is preoccupied in racing, but there's five or six different cognitive therapeutic techniques that can be effective there. So I think once what one is doing with the formulation approach is moving into what's the domain of interest and then what is the technique that’s most likely to chime or address the nature of the presenting material, thoughts and emotions that the person's having in bed at night. And then, of course, the other piece is the kind of more behavioural domain, which is really based upon stimulus control theory, and the use of sleep homeostatic and sleep circadian functions to drive sleep back into its correct position. And those are actually the most effective techniques of all of them. And often people, at the time they see me or other people who see people with sort of chronic sleep difficulties, by the time they come along, they've often had a sleep problem for a long time, years and years. And their sleep pattern, well, you say, what's your sleep pattern? And they say “what pattern?” so you immediately see that it's a sleep pattern problem, but we tend to calculate something called sleep efficiency, which is very simply how long would you spend in bed on the average night? And how much of that time do you think you're asleep? And you get a figure that you can convert into percentage. So, if somebody says “well, I spend about eight hours in bed, but I'm only sleepy about six”. Then say, well, that's you, so your sleep efficiency is 75%. And one can use simple tools like this which probably we don't have time to go into them all, but you can use them to then say, well, that would suggest this technique is a very effective therapy for that and it's called sleep compression therapy or sleep restriction therapy or stimulus control or we would often use as you, as we all do, more metaphors. Metaphors for explaining things to people in simple language like trying to get your sleep pattern into proper shape or let's try to put the day to rest, if you use a cognitive control technique and so on. Rachel: And this might be where we're sort of encouraging people to stay up longer to try and sort of organize their sleep into a shorter, more efficient window of time. Colin: Yes, that's right. It's a bit of like a reset button you're pressing to see that it can be a struggle to fall asleep and the struggle to waken up and that you feel sleepy again. And that the patient again differentiates between sleepiness and tiredness. And thinks, oh, I do feel sleepy and allow the sleep drive then to dominate and dictate your sleep pattern, rather than you trying to steer it. But these are techniques that we need to learn. There are some important differences, I think, here between some of the things that we use in general psychological practice to manage many conditions with exposure therapies, for example, EMDR is an exposure therapy, is desensitization kind of approach. These are kind of generic things I would say, as there are a lot of relaxation therapeutics and cognitive techniques, but the ones that we use, that are most powerful for insomnia in the behavioural domain, like sleep restriction therapy, sleep compression symbols, control therapy are things that one really needs a little bit of help with learning and training. And they're also rather counterintuitive. There's also a technique in the cognitive domain called Paradoxical Intention, which comes from the work of Viktor Frankl prescribing the symptom, kind of thing, where you encourage people to try to remain awake rather than to try to fall asleep, and to overcome the performance drive to try to get to sleep, and to realise, begin to realise that sleep is an involuntary process. So Paradoxical Intention Therapy can be one of the cognitive therapeutics that one might select depending upon the formulation you come to around a particular individual. And of course, some people find it difficult to get to sleep and some people find it difficult to get back to sleep and some people awaken early. So, you need to take account too of the circumstances, the timing of things and what you could suggest to try. Rachel: so I'm hearing what you're saying, the reason why you're so keen on this term, cognitive behavioural therapeutics. It sounds to me and correct me if I'm wrong that it's about being first of all, formulation and problem presentation led for the individual. And it's about matching the intervention to the presentation and the particular maintenance factors, which may be very diverse. When we think about CBT for sleep, it's not one thing. It may be very much focusing on a behavioural domain. It may be focusing much more in a cognitive domain, and it may very much vary even within those domains, depending on the particular pattern of sleep problem that the individual has. Colin: Yes, if one draws a parallel, with pharmaceuticals just for a moment, a lot of the drugs that we have that we use for common mental health conditions, are actually quite similar to each other. But they've got different names. They’ve got different sites of action. They've got different uptake rates, different dynamics and kinetics and so on, but there's a number of different SSRIs, for example, and when a patient goes along to see a medical doctor and they're prescribed an antidepressant, they're prescribed a particular drug. And that may be changed to a different drug, and it is a different drug, and of course the dosing regime may change as well. And these are all different therapeutics and therapeutic options, and we're familiar of thinking of that there's a formulary of drugs and there are formulary of hypnotic drugs, sleeping pills, Z drugs, different kinds of Z drugs, and recent drugs that have come out, which are dual receptor agonists, But we see there's all these different drugs, but actually these drugs are kind of similar to each other. And then there's CBT. So you've got all these different things, and then there's CBT, or there's evidence based psychological therapy. We need to begin to see that CBT is not a thing. That CBT is got an and in it. It's cognitive and behavioural therapeutics. And within that, there are scores and scores of different techniques. So, it really should not be CBT versus mindfulness or CBT versus EMDR or behavioural activation versus CBT, because behavioural activation is part of CBT. Mindfulness is part of CBT. EMDR is part of CBT and CBT doesn't exist. CBT is just a family name. Rachel: I think we may have to rethink the podcast, Colin, Colin: well, I don't know. I think you Rachel: maybe the podcast shouldn't exist…. Colin: Well not at all. I think the podcast should exist, it’s just really about celebrating the diversity of things and I think it's just to do with the way that therapies have emerged over time. We had behavioural therapies, but there were different ones of those, and then cognitive behavioural therapies, cognitive therapies, so we ended up with multi component therapies, and then the term CBT was invented. We're early days, right, in this journey, but I think a range of therapeutic options and how to deliver them, will take us away from this technocrat approach of, well I just deliver CBT, this is what I do, to thinking what is it we're doing, for whom, and how, and what does, and to what, against what outcome and it will really simplify, I think, a lot of our treatment journeys, and will encourage patients to understand and believe that they haven't, when they say they've tried CBT and it didn't work, that actually you can begin to adjust the interventions and refine them and select from them in such a way that we create a much greater diversity of therapeutic pathways for individuals. Rachel: you've mentioned that CBT for insomnia is recommended in NICE guidance and across the world in, in, in guidance that therapists draw on suggests that. It's effective, but it also, you've also said that there are different elements to this. What are the most effective elements of CBT for sleep problems? Will it help everyone? Does it help everyone equally if we're thinking about diverse groups and populations? Colin: The most effective components within CBT, and where I would tend to go initially are something called stimulus control therapy, and sleep restriction therapy which are behavioural therapeutics. These are the most powerful techniques according to the outcome studies. There are also a range of cognitive therapeutic techniques that can be helpful, one of those I mentioned is paradoxical intention. Cognitive restructuring approaches can be helpful as well for some people and the crossover between the cognitive and the behavioural is something called cognitive control. It's really a cognitive form of stimulus control. If you think about, worry time, for example, that people will be familiar with, that's a behavioural technique, really, but what you're doing is setting aside a time to worry, so you're not reacting to each worry as it occurs. And in cognitive control with insomnia, what you're doing is telling the person put the day to rest before they go to bed at night. So all these techniques can be effective. Relaxation type, techniques can also be quite effective. And there's a whole range of those ranging from progressive muscle relaxation to autogenic training, biofeedback approaches. They're probably a bit less effective than the cognitive ones, and a bit less effective again than the behavioural ones but the relaxation approaches in general tend to be more associated with lifestyle and philosophy of life so therefore, there's other different kinds of benefits from those. And mindfulness, I guess and ACT can fit a bit between cognitive and relaxation. And there's an emerging evidence base for mindfulness and ACT techniques as well, perhaps particularly for people who don't respond to the more active techniques, where it then becomes a case of more accepting and living with the situation rather than trying to resolve it. So these are the kind of range of techniques that are out there, and that are evidence based. But as I was saying earlier on, I think it's very often a case of helping people move away from just the kind of simple it's all in the mind kind of approach. Because often when you go for therapy, it may seem that, well, you're just encouraged me to relax. You should relax a bit more. Stop thinking about it so much, or get things into pattern, or stop worrying, or face up to it or think more positively. A lot of psychological therapy, unless it's delivered well, can be very trite. So therefore, I encourage everyone listening to develop their therapeutic skills at the level of helping people to engage with tough stuff. Because the power of cognitive behavioural therapeutics is not just in the techniques themselves. It's in the motivational system enabling people to implement things in their life that are actually quite difficult to do, to face up to things that are very difficult, to deal with them differently when they've not been successful in doing that before, and to stick at something that you don't really believe will work or they don't think that they deserve to be helped. These are really where therapy can be transformative, and it's not because you're a great therapist in the sense of, you'll be warm and kind. It's really to do, in some ways, with you being supportive of the person implementing things. Because implementing things is the key to all therapeutics. Rachel: And I imagine, particularly in some of these interventions when, for example, you're asking people to get out of bed when they've not been asleep for 15 minutes, or you're asking them to stay up way beyond they would normally go to bed. These are things that are quite difficult to shift or, you know, I think of myself lying awake in bed at night and the last thing I want to do is drag myself out of bed. Colin: They're very difficult, they're very difficult to do, and I say to patients, I wouldn't do it. What? They say- well it's difficult, isn't it? I've tried that. I'm asking you to get up, go to bed at this time, get up at that time, or get up during the night. And it's hard. It's going to be very hard to do that. But many patients would say to you with a whatever difficulty they have that, if there was a surgical procedure that would fix this, I would take it. I would do it. I would do anything to overcome this problem. And I think sometimes we just need to be straight with them and say, therapy can be as hard as that. It can be as hard as that but the evidence is that it can be effective. And there's some aspects of restructuring, the way you're thinking or restructuring your pattern of sleep at night that is quite invasive. It’s stripping out an old way of doing things, an old way of thinking, establishing a new one with a lot of disciplines involved, often not for an immediate gain, but then that's why people do surgery, right? They think, well, I trust the outcomes, trust the science and present things openly and plainly to people and say, I'm going to support you to do this difficult thing. And then they begin to say, okay, see the sleep hygiene stuff I read, or this is different. Rachel: And ofcourse with surgery they get an anaesthetic, so they get a good sleep. So, you know, Colin: well, exactly. Rachel: maybe a secondary motive there, Colin: Yeah, there might be. Rachel: but given that challenge that your patients face, you know, when you're, I love that honesty- I wouldn't do it. What have you learned from the people you've worked with? How has this work made a personal difference in your life or the focus of your work as you've been working with people over the years with these kinds of problems? Colin: No, that's a good question. I guess that's why we do it, to some level to try and make a difference. The thing that comes to mind to, to share here is actually about someone who came along and took part in one of our research studies, a woman with cancer. And it's a study we did in the Beatson Oncology Centre in Glasgow, many years ago, early, well, the study was published, I think, in 2008, and we were looking at nurse delivered cognitive and behavioural therapy for insomnia as an adjunct to cancer care. And that tells you something immediately that even in situations where you think, well, we know what the problem is, why are we focusing on insomnia, that insomnia really matters? Now, I got a phone call, one day from the professor of oncology, who was a co-investigator in the CRUK grant, and he said, “Colin, I had to phone you, I've just seen one of the patients in the trial, coming along clinically and she's not very well.” And I said, “Oh, right. Do you think she shouldn't be participating in the trial? Or is there, are you concerned about, you want to withdraw her from the study?” no he said, I've never had a conversation like this in my life. And I said, what happened? And he said, she told me that your CBT for insomnia knocks my chemotherapy into a cocked hat and I said “what do you think she meant by that?” He said “I have no idea, but I mean, she's, this woman's got cancer. She needs her chemotherapy.” And I said, “Jim, I think she's telling you that her sleep really matters to her and that she's grateful that we're addressing that. We're not just focusing on what seems to be a primary illness or model.” “Well”, he said, “I think that might be right”. That woman had to withdraw from the study a bit later, and she phoned and left a message on the answer machine, apologising for dying, really, apologising that she wasn't going to be able to finish the study because it meant so much to her. And we say to our patients or students, we're teaching them that intermittent reinforcement is very powerful, and I think what's kept me going over the years is intermittent reinforcement; a lot of working life is hard, not all of it is exciting. We don't go down the corridors of the university or the hospital high fiving people about our successes and it's a lot that's tough. And sometimes we don't know. A lot of people never come back. They don't fill in the outcome measures. They say they got better, and we don't know why. We don't always know what's going on. Once in a while, you get something that's a very powerful, a reinforcement. I think in a way, the triggering factor for me at the beginning with the GP saying that curiosity led me to think, I don't know if I can help. I tried to find out, was stimulating. And I think these intermittent kind of bits of feedback that we get encourage us. Don't they, that, yeah, this was a good choice. Rachel: What a beautiful story and how incredible that  in those dark times, undoubtedly dark times, dying from cancer can be no fun for anyone, that there was some light in there and hearing that it was focusing on the thing that really mattered. Colin: yes, that's right. And so I think whatever you're working, if people are listening, whatever you're doing with older adults, with kids, with people in health and mental health settings, community hospitals, or whatever, sleep is going to be relevant to your work and you can broaden the base of what you're doing by taking a greater interest in people's 24 hour lives, not just their waking lives. Rachel: And if people want to learn more about your work, about this work, I mean, it's such a huge area, Colin, we could talk on and on, and I know you need to go. But if people want to learn more, what training opportunities, how can they get involved in this work and your research and where can they go to learn more? Colin: Well at Oxford, in this particular week is a residential week, for our program in sleep medicine. we've got people from all over the world here, from America, Canada, India, Jamaica, Australia, various European countries, South America and they're studying with us as part of an online program in sleep medicine. And you can do that as a course, as a diploma, you can do it as a master's degree, or you can take modules from it and it's all online, but they do get a chance to come in the summertime for a week and spend some time with us. So that's one thing that I’ve been interested in trying to establish things that are kind of scalable, if that makes sense. I do workshops and so on BABCP and other workshops are available. I try and pass on skills. I wrote a self-help book a number of years ago in the Overcoming Insomnia Series, a second edition come out 2021. There's a book coming out this month. The Clinicians Guides to Cognitive and Behavioural Therapeutics for Insomnia: a scientist practitioner approach. Often you get books, don't you, that you think are going to tell me how to do this. So I vowed I'm not going to write a book like this unless it actually tells people how to do things. So, it's my distilled knowledge of how to assess and treat people with insomnia. And that's published by Cambridge University Press, which should be out later this month. Rachel: we'll put a link to that in the show notes, as well as the self-help other papers that you can recommend. Colin: And the, and the other piece is you meant, you were kind enough to mention Sleepio earlier on. I get involved in developing a kind of digital approach to treating insomnia. And Sleepio was given a Nice guideline in May, 2022. It's available in the NHS in Scotland and I hope shortly will be England at no cost. It's just part of a funded healthcare package. So, and that can integrate into services. I'm very much a believer in a kind of step care approach and that we should have a range of different ways of doing things with different levels of expertise and skill there. But if we've got a situation as we have that the treatment of choice for insomnia is cognitive and behavioural therapy. We've got a responsibility somehow to make it available to everybody and so hopefully some of these tools or ways of just closing the gap that there's been historically there. Rachel: That's wonderful. And it is brilliant that you're doing all this work just to get that out there to the people who need it. And thank you for doing today and allowing our listeners to benefit from hearing about the work, a broad area but some really good ideas and thoughts in there for people to take away In true CBT fashion, we like to summarise and think about what we're taking away from each session. So what key message would you like to leave people from this work? If they were to go home and talk to, folk about what they've done in, in, in the podcast today, what would be that couple of sentences that they would bring home from this Colin: Well, I think, just, your, believe your Gran was right. She always said what you need is a good sleep. Sleep on it. Things will feel different in the morning. Sleep is nature's medicine. It's there to provide for us, for all of us, so we can do our best work and so that our patients can have the best quality of life. So I just encourage people to steadily improve your skills in helping people with their sleep difficulties. It's often a question you don't want to ask because you don't know the answer. So is it, how are you sleeping kind of thing? Because you don't, I don't quite know what I'm going to suggest next. I was curious enough to find out and to figure out ways of it's become really interesting to me. If a little bit of that passes on to a few people on the podcast, then I'll be delighted. Rachel: And there'll be a lot more in their toolbox and just a little bit of sleep hygiene, if they pursue this plus they're also allowed the occasional malt whiskey which is good news. Colin: And many brands are available. Rachel: Thank you so much, Colin. Colin: Pleasure. Thanks, Rachel. Rachel:  Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on X and Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.  

In this conversation, Professor David Clark discusses his work using Cognitive Behaviour Therapy to treat Social Anxiety Disorder. He and Rachel talk about the Cognitive Behavioural model of Social Anxiety Disorder, considering the factors that contribute to maintaining this debilitating problem experienced by many people and the evidenced-based approaches to treating it. The conversation also delves into the economic impact of evidence-based psychological therapies and the importance of delivering high-quality, evidence-based care. 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 X, babcppodcasts on Instagram or email us at [email protected]. Useful links: Papers: David has published numerous papers in the field and a full list can be found here: https://bit.ly/3zjxcNy The paper mentioned authored by Emma Warnock-Parkes is published in the Cognitive Behaviour Therapist and can be found here: https://bit.ly/3XzVsEq Clark, D.M. (2018) Realising the mass public benefit of evidence-based psychological therapies: the IAPT program. https://pubmed.ncbi.nlm.nih.gov/29350997/ Clark et al (2023) More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder. https://www.cambridge.org/core/journals/psychological-medicine/article/more-than-doubling-the-clinical-benefit-of-each-hour-of-therapist-time-a-randomised-controlled-trial-of-internet-cognitive-therapy-for-social-anxiety-disorder/ED618AA69204AABD5C5691ABC454F5BE Ehlers et al (2023) Therapist-assisted online psychological therapies differing in trauma focus for post-traumatic stress disorder (STOP-PTSD): a UK-based, single-blind, randomised controlled trial. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(23)00181-5/fulltext OXCADAT: A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/ 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 and produced 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, we're talking about Social Anxiety Disorder, and we're really privileged to be joined by Professor David Clark, who's devoted his long and distinguished career to cognitive approaches to understanding and treating anxiety disorders, and also to disseminating these treatments so that help can be made available to as many people as possible. In addition to his work in social anxiety, David's work has led to the development of effective NICE recommended cognitive therapy treatments for panic disorder and PTSD. David is well known for pioneering and tirelessly working to advise and steer the IAPT program in England, and he continues to work towards wider and wider dissemination of therapy through digitalisation and through his training, teaching, and political engagement worldwide. Welcome to the podcast, David, David: Oh, thank you for having me, Rachel. It's lovely to chat again as we've worked together so closely in the past. Lovely to see you. Rachel: and there can be a few therapists working in the field of CBT and beyond who aren't aware of the enormous contribution you've made to social anxiety, but not everyone will know about your journey. So, it'd be great to hear about what got you interested in psychology, psychological disorders, and specifically social anxiety, both personally and professionally. And as a starting point, is it true that as a young man, your choice of study might've had rather more to do with the gender balance on the psychology program rather than the subject matter? David: Well, that had an element to it. I think I've always been interested in mental health problems since I was a child, my mother was someone who people would come to when they were distressed, and she gave them obviously very supportive chats. But you often don't feel that just following your mother is the right way to go. And so I felt that maybe one could do better, and I was good at chemistry. So, I started really as an undergraduate as a chemist with the idea that we could develop some improved drug treatments for mental health. But I soon realised that drug treatments were quite limited and were likely to have pretty high relapse rates. I was also studying on a course where there were just four women in an intake of 200 first year students at Oxford, but I had bumped into a few members of the opposite gender at parties and one of them was wandering past chemistry one day and said, why don't you come down and have a cup of coffee in experimental psychology? where I found, it was a wonderful department, with lots of senior people just sitting down with the undergraduates talking through ideas over coffee, and of course, a much more even gender balance. So, I moved fairly quickly to the experimental psychology department. Rachel: So there was a real motivation to help others right from the beginning, but maybe a small iota of self-interest there amongst that. David: and an interest in social interactions of all sorts. Rachel: And social anxiety then, what took you in that direction? David: Well, the first sort of clinical problem we worked on is panic disorder, and that was at the time that we started working on it in the mid-1980s considered to be the most difficult to treat anxiety disorder. So, there's lots of research showing that those people with agoraphobia who also had panic attacks got least improvement from behaviour therapy. And similarly, those people with what we call generalized anxiety who had panic attacks also got least improvement. So it seemed a really good topic to work on. Of course, things worked out well for us in developing a cognitive model in the treatment. And I think nowadays people tend to think it's easiest to treat of all the anxiety disorders. So in the sort of mid 90s, we started looking around for another problem and social anxiety is the most common anxiety disorder in the community. But what really fascinated us was that it is also the one with the lowest natural recovery rate. It starts in childhood for most people, and in the absence of treatment, it is often lifelong and it really interferes with your life. So it seems a really good challenge Rachel: So an area where you could really make an impact in research and having had such success with the panic model and having such an elegant approach to that, that was really making a difference it felt like let's extend this, let's look where people are really suffering. David: Yeah, and there was already a very respectable, psychological treatment. Group CBT was the dominant modality, the gold standard. But when you looked at the sort of outcomes in the best trials, it was rarely the case that you got more than 40 percent of people fully recovering from their social anxiety and that seems a real sadness for a condition that's so chronic and so common. Rachel: And as you said, the largest, most widely prevalent problem in terms of anxiety disorders, but many of us can also identify with feelings of social awkwardness or shyness at some point in our life. But how does social anxiety develop then into a problem that impacts people more significantly as you've described? Who typically suffers from social anxiety and how does that come about? David: Yeah, so you're obviously right. Many of us feel rather shy in some new social situations. And there are some events which pretty reliably make us anxious, like job interviews, particularly if you want the job. But that's sort of normal so we only think of people having an anxiety disorder if the anxiety is out of proportion to the situation. So it's not just in job interviews, for example, and it also really holds you back in life. You have a lot of avoidance and you can't do the things that you would like to. And so that's a real distinction between normal social anxiety and Social Anxiety Disorder really how much it interferes with your life. Rachel: And I can reflect on my first job interview with you, David, and it gave me some insight, but also working with you subsequently gave me some insight into how those techniques that you have come across and developed have been, could be so helpful. So we have a bit of a challenge on this podcast, David. We love a good formulation in CBT, as you know, ideally with boxes and arrows and pictorial ways of describing things, but this is an audio podcast. So here's the challenge. Can you give us a brief explanation about how social anxiety develops and is maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids? David: Well, the development is like most anxiety disorders. It's a mixture of genetic vulnerability, social learning, and adverse life events. That's not the interesting point from therapy. The interesting point from therapy is what keeps it going. And there's a really big puzzle because modern life is such that we all have to meet other people more or less every day. And at least when in adulthood, people with social anxiety, when they're meeting other people are not getting unambiguous negative feedback from them. So they seem to be having naturalistic exposure and we know that exposure therapy is a sound principle. So, the big puzzle for us as therapists is to work out why don't people benefit from naturalistic exposure? And being a cognitive therapist, I think the answer lies in getting into people's heads. And so, Adrian Wells and I interviewed a lot of people with social anxiety, tried to work out three things; what are they thinking? How does their thinking change what they pay attention to? And also how does it change the way they behave? And we found that if you can understand those three points and how the things interlock, then you can really understand why this is such a persistent problem. Rachel: So it's something about thinking, about attention and about behaviour.  Shall we start with the thoughts? what do they look like in social anxiety? David: Well, the thoughts are often pretty self-evaluative. Thoughts like, I'm being boring, I'm being stupid, I look very anxious and of course, the idea that people have is that other people will be thinking similar things. It's almost like a projection of your own negative self-evaluation into other people's minds. And you're fearing you'll be rejected. Rachel: Which sounds pretty scary…so what do people typically do when they have these kind of thoughts? David: Well, the first thing is a shift in attention. Because people are worried about how they're coming across to other people, they focus a lot of their attention on how they think they appear. So, they may be talking to someone else but a lot of their attention is on themselves, thinking how am I coming across? And that shift to an internal focus of attention in itself is a problem, because if the conversation goes fine, the chances are you won't notice, because you're lost in your head. But when you get lost in your head, unfortunately, that gives you access to a lot of internal information, which people take as really good evidence for their worst fears, although actually it's not. Rachel: How does that work in practice? David: Well, the most common thought is that other people can see you're anxious and then they'll think badly of you because of that. So, of course, Adrian Wells and I asked lots of people, well, have people said to you, Golly! David, you looked really anxious when we were having a drink in the pub on Friday evening. And some patients say yes, someone has said that to me. But to our enormous surprise, most patients said, no one's ever said that. So of course, we then ask the obvious question, well if people haven't said that? Why do you think it? And the answer was always the same; I feel very anxious and therefore I really must look very anxious. That sounds logical but research shows it's a bad strategy. It's not that someone with social anxiety doesn't look at all tense, but the difference between how they think they look based on their feelings and how they really look is enormous and gets bigger the more anxious they feel. So, the more anxious you feel, the more you overestimate how anxious you look. So that's point one; people are using their feelings to decide how they appear. Rachel: Over and above those anxious feelings, I know a lot of your work has focussed on other types of internal information that also play a role??? If you're worried about how people see you, you won't be surprised to hear that people with social anxiety often have images in which they see themselves from someone else's perspective. That would be great if those images were how they really look, but sadly they're not. The images are really their worst fears visualised. So if you're worried about sweating and your lips shaking, what you see is big globules of sweat on your forehead and a quivering lip. Whereas the reality would be nothing like that. But because the image is observed from outside, it has a ring of truth to it and people just assume it's true. We use the word image and that conjures up an idea that it's a bit like a sort of 4k video. It is for some people, but mostly what people say is it's an impression they have. It's not like there's a video playing in the back of their head all the time, but if you ask them to describe how they look, they can generate it very quickly and it'll be like that. The other source of information is maybe a bit more difficult for people to understand, it's what we call your felt sense. So, someone might be in a group of people in a conversation. And they may be standing really close to them. But they have the feeling that they're very distant from them. It’s almost as though space grows and they feel there's that group of people and they're all together and I'm separate and apart and I don't fit in. And that felt sense of being separate and apart and not fitting in is further evidence that people think you're boring, uninteresting and it is really like space grows for these people. It’s simply a consequence of self-focused attention; if you're watching yourself all the time, it makes you feel distinct from everyone else. Whereas if you're not watching yourself all the time, you're lost in the conversation. You feel part of the group. Rachel:So that’s two factors you’ve mentioned already – shifting attention onto yourself so you can’t really take in what’s actually happening in the social situation and at the same time getting access to misleading internal information that seems to confirm your fears… Yeah, the third thing, which is really destructive, is changes in behaviour. And there, in all anxiety disorders, people do what we call safety behaviours; things you do in order to prevent the thing you're afraid of from happening. But if, as in social anxiety, your fears are unrealistic, the problem is that if you do the safety behaviour and nothing bad happens, you'll think that's just because I saved myself that time. It's because I did the safety behaviour. But if I was just myself, let people get to know me, then they would think badly of me. So doing the safety behaviours maintains your anxiety. Rachel: It makes perfect sense that you wouldn’t want to run the risk of rejection or humiliation…What kind of safety behaviours do you tend to see in social anxiety? David: Well, if I was worried that you think what I'm saying is boring, I might engage in a couple of safety behaviours. I might have carefully prepared in advance this morning all the answers I was going to give to you in this podcast, which actually I haven't, but I might've done that, just to make sure I came across really good, better than I really am. And I also, as we're talking now, I might be memorising everything that we've already said and checking whether what I'm about to say makes sense, whether it's clever enough. And I probably go quiet every now and again because I think, oh, it's not clever enough, I'm not quite sure what to say. Those two safety behaviours might get me through this interview. But afterwards, I'd still think, Oh God, I'm going to be caught out. People are going to think I'm really boring. So my fear wouldn't change if I was someone with social anxiety. But they have other consequences, which are really problematic. And one of them is it really interferes with the social interaction because if you're doing all this memorising, then the person you're talking to gets the impression you're not really interested in them. You're mind's somewhere else. Which it sort of is. And so the conversation doesn't flow so well, and the chances are the other person may not be so interested in talking to you again. They're picking up the cues from you that you don't seem to be interested, so why should they be interested? They don't want to be rude by pushing themselves on you too much. So this is a special situation, where unlike many other anxiety disorders, the safety behaviours actually make some of the things you're afraid of actually happen. They make people less friendly to you. At least, the sort of safety behaviours that we call the avoidant ones. So, in that example, I would be avoiding saying certain things because I thought you'd think I was stupid. There's another set of safety behaviours which maintain your fears, but don't necessarily impact other people. And they're what we call the impression management safety behaviours. We see them a lot with actors but also some people who are in professional roles that are well practiced. They will have lots of stories to tell people. They'll go to a party and they'll run through their funny jokes and their funny stories. And everyone sees them as the life and soul of the party. But they're doing this to avoid really talking about themselves, and as soon as they run out of their jokes, they'll move on to someone else because they're terrified that you might discover what they worry, which is that you might think they're boring if you just get to know them, or stupid, or uninteresting. So people tend not to notice that someone with social anxiety has social anxiety if they use a lot of these impression management safety behaviours, but they're still very destructive for the person because they prevent them from discovering that if they just were themselves, people would accept them in any case. Rachel: Brilliant. David, if there are any fears lurking here, you know, I can give you some immediate stooge feedback that there wasn't an iota of boring or stupid in any of that. Really, as we would expect, articulate description of the model. And in common with other cognitive therapy models that we have, there's definitely something about how people think, the unhelpful and inaccurate thinking they have. Also how, what they're attending to that's bringing about that thinking and what they do in response to that information, but some very specific and particular mechanisms in social anxiety that you've spoken about. And we describe CBT as an evidence-based approach to psychological problems, not only because the therapy is tested and trialled, as you've done many times with this model, but also because the assumptions on which the models are based emerge from cognitive and behavioural science and are tested experimentally. And that gives clinicians and patients alike a confidence in the approach we're taking. It's not just sort of psychobabble. It doesn't just sort of feel like it works, but actually we've tested it out. So how have you and your colleagues systematically tested the assumptions about their maintenance of social anxiety and the model you've just described? David: I guess there's two things. Firstly, obviously, we've tested the treatment that's derived from it in lots of randomized control trials. Thankfully, people in other countries have expressed interest as well. So there are now about a dozen randomized control trials in the UK, in Norway, in Sweden, in Germany, in Japan and in China, and the treatment is being compared against lots of alternatives, exposure therapy, group CBT, psychodynamic therapy, interpersonal psychotherapy, medication, psychiatric treatment as usual. It has always beaten whatever it's compared with. So it has a very solid evidence base in terms of the treatment package. For the mechanisms, what we've tended to do is try and bring them into the laboratory and manipulate the processes in the lab and see whether that influences people's social anxiety in the short term. And we've also done sort of mediation analyses where we've measured the key processes and then looked at whether in a clinical trial when cognitive therapy is more effective than an alternative treatment, is it at least partly due to its greater ability to change those mechanisms? And there's a lot of research that has worked out positively using both types of experimental approach. So, for example, there's a nice experiment by Colette Hirsch, where Colette got people with social anxiety to have a conversation with a stranger. And, during that conversation, unbeknownst to the stranger, the patient switched in their mind between their habitual negative observer perspective image of themselves, or a more realistic one based on video feedback, and what was the consequence of that mental switch turning on one of the key processes? Well firstly, not surprisingly, when you turn on the negative image, you feel much more anxious. You think you come across looking much more anxious. And that's, as the model would predict, partly a distortion because the other person actually views you more positively. But there's also partly a reality in it in the sense that the difference that when you're doing your negative image, the other person still does view you less positively than when you haven't got the negative image, even though in both cases you're putting yourself down. So how does this mental image that you have in your head unbeknownst to the other person sort of leak and change the other person's perception of yourself? Well, it turns out that is because when you turn on the negative mental image, you also turn on the avoidant safety behaviours and those are what influence the other person. So, you see in this neat little experiment, the whole system has a tight interlocking of mental images, safety behaviours, self-perception and other people's responses. Rachel: That's a really elegant study, isn't it? And it mirrors what we see clinically. Often we're trying to get our heads around these models as therapists, but when you ask those questions of someone who's truly suffering from social anxiety, it's like a light bulb moment when they, they say, yeah, I absolutely, I have that image of myself and yes, it does feel like I'm distanced from the people around us. So, so we know that in the therapy sessions, but it's really good to know that there's this experimental evidence underpinning that we can be confident in. You've described really well the mechanisms, the model, and some of the evidence behind it. What does treatment built on this model look like then typically? David: Yeah, so the treatment, as with our other treatments, really closely focuses on the maintenance product processes in the model. It's a very tight sort of intervention based on those. So, it starts where patients are at. They are using their feelings to decide how they appear to other people, and they're very self-focused as they do that. So, rather than just giving them a bit of psychoeducation, explaining the model to them, we like them to feel it. And so we start with a little experiment in the therapy session, where we often get them to talk briefly to someone they haven't met yet. Doing it twice, once while focusing on themselves, thinking about how they're coming across and doing their safety behaviours. And once while trying to get out of their head, just lost in the conversation, focused externally. And to their immense surprise, they find that when they don't focus on themselves and do their safety behaviours, which is, of course, what they're doing to manage their social anxiety, when they don't do that, they do the opposite, they feel less anxious, and they think they come across better. So this really hooks people in on the therapy because you've done something which makes them feel better. It's not just a chat. It's not just a bit of psychoeducation. You've demonstrated in a social interaction that we have a way of making you feel better. So that hooks people in on the therapy. And of course they can start now experimenting a bit with trying to focus externally and drop some of those safety behaviours. So they're already on a roll early in therapy. We then look at these really distorted images people have and help them discover that they are distorted and therefore misleading, and best avoided paying attention to. Rachel: So you’ve already said people are pretty convinced by these images and they may well have had them for a long time – how do we convince them they are worth reconsidering? David: Well, we don't do that by nice reassurance from the therapist, saying, actually, I know you were feeling very anxious when we were talking earlier on but you came across pretty well. Because patients may not believe that. They may think, well, you're a therapist, you're paid to be nice. But maybe that's not like the real world. So instead, we like patients to see things with their own eyes. And so we use video feedback, where we video some social interactions, we get them to predict how they think they will appear based on their feelings and set up things in a very structured way. And then we get them to compare their predictions with what they actually see on the video. And when set up carefully, this is a really good way of helping people discover their perceptions of themselves are excessively negative. So you're now on a roll, and people are inquisitive. They think, well, the evidence I've been using so far to decide how I'd come across isn't good evidence. So, let's find out how I really come across. And that's when you get into doing a lot of what we call the behavioural experiments, where you get people into social situations and get them to drop their safety behaviours. So they give the world a chance to get to know them, participating more in the interactions. And they're focusing externally so they can see how people respond. And that process helps them to discover that if they give the world a chance to get to know them, not hiding away or using all the impression management safety behaviours to hide themselves in a different way, then they are generally accepted. And that's an incredibly positive experience. You're always wanting to test particular fearful predictions. And if they don't come true, you want to know, why is that? Is it because the person thinks they were lucky that time? Or because they did those safety behaviours? Or is it because they've truly learned that actually they will be accepted if they let people know them? So you're often refining these experiments whenever you repeat them. You don't just do the same thing twice, you refine it in a collaboration with the patient to find the most convincing evidence for them. Rachel: So lots and lots of behavioural experiments to test out those fears… David: And there's a last component to the treatment which, we developed over time, which is that although people are not getting really negative feedback from other people as adults, some people have had socially traumatic events in the past; they’ve been bullied or teased at school and things. And in some cases, those socially traumatic events do impinge on the present. They influence the sort of images people have of themselves. And sometimes also the feelings are very similar to the past event. Even if in the past event, they were physically attacked or bullied and in the present in the adults there's no possibility anyone's going to do that but there's a similar feeling of physical threat. When we get those touchstones, showing that the past is intruding on the present, in terms of the nature of the images and the feelings, then we also do some work that we take from our PTSD treatment to help break the link between those trauma memories and present perception. And that gives us an extra bow in our arrow, which we find, helps to further really give people full confidence. Rachel: So it's really active therapy, isn't it, David? And I think right from that very first pivotal experiment that you spoke about, where people are manipulating their safety behaviours and their focus of attention through all this real world finding out how the world really works, how people really perceive us is very active on the part of the therapist. And some of these experiments can be tricky to learn when you're starting out, but so useful and they are, they're really the gift that keeps on giving throughout therapy as you build this dossier of evidence about how the world really works, how people really respond to you. And for that reason, I remember I never dared come to supervision without having done at least one behavioural experiment with a client or perhaps a bit of imagery rescripting as we, as we got towards the end of therapy. But you really see how people's view of themselves changes and what a wonderful gift to know that actually you can be in the world as you are, and that is acceptable and worth a lot of work. David: Yeah, and, and of course, what you did in preparation for supervision was absolutely the right thing to do because the research supports what you did. So, I've mentioned that there are clinical trials in lots of different countries, and the treatment has always beaten the competitor, but sometimes it beats the competitor by miles, sometimes by not quite so much. And, in the not quite so much, which has been some of the German studies, when we've looked with the investigators at what happens in the treatment, we've found they're doing very few of the behavioural experiments and they're not scheduling time to do that. So there's quite a lot of evidence that the more of these behavioural experiments you do, the better the outcomes you get. But quite a lot of them involve leaving the office with the patient to do things. And that is quite a problem in NHS services where our diaries are scheduled in such a way that it may be quite difficult to do it. So this is a problem that we still need to crack in routine practice. Rachel: And I, I hear that a lot from therapists working in talking therapies and in other NHS settings that you've spoken about that the idea of doing a 90-minute session seems like a mountain to climb. How do we fit that into our service organisation? Or how do we get stooges into a session? And we talk about stooges just bringing people who are naive to the therapeutic set up to what the particular issues of the individual are to have a conversation and give some feedback in. What would your message be to services around the value of that and, and how they might think about building that into their organisation? David: Well, I think I'd say, the NHS mental health services exist not for the convenience of the managers, they exist in order to transform the lives of our patients, and the evidence is really clear that you get much better outcomes if you organise a face to face therapy to do these things. And it's also very clear that wherever you get a patient to at the end of therapy, the gains are really well maintained over the next five to ten years in the follow up studies So, you're really changing someone's life, if you effectively treat their social anxiety disorder. People are coming in for treatment on average in their late 20s, early 30s. Life expectancy is 80 something. So you will give someone a different life for the next 50 to 60 years. They will do so many more things with their life. They'll meet so many more people. They will really be an enormous asset to society. So why wouldn't we want to organise our clinical diaries to transform someone's life for the next 50 years? Rachel: So we do it because it helps, but it sounds like there's also an economic argument there as well, that people aren't going to be coming back for more therapy. Then they're not going to be suffering on a long-term basis. David: There's an enormous economic argument and I guess you see the data for this most clearly with the data sets we've now developed in the NHS Talking Therapies program, and copies of the program that are done in other countries like Norway. So, for example, recently, in a Norwegian study, they showed that people who were treated in their version of NHS Talking Therapies, randomized to that versus treatment in standard treatment and primary care, including access to psychologists and psychiatrists, by the way, they had much better clinical outcomes, about twice the recovery rate. But interestingly, from an economic point of view, if you then followed them up for three years post treatment, the people who had had the talking therapy service had a higher personal income than the people who didn't, who were treated in primary care. And that difference in income is so large that it's four times greater than the cost of the service. So this data and other data we have in the UK, and in Spain, led Jeremy Hunt to invest an extra £590 million in expanding the talking therapy services in the autumn statement. Because he was convinced that this is solid data; that evidence based psychological therapy, when organised well in coherent services, actually helps grow the economy. So that's what the Chancellor is interested in, of course. In the NHS, we're also interested in saving money. And there's lots of good evidence that if you can effectively treat people's anxiety and depression, then over the next few years, they have less physical healthcare costs. A really nice example of that is a data linkage study from UCL recently, where they looked at people who were successfully treated in a Talking Therapy service and followed them up for the next three years and found they had significantly less adverse cardiovascular events, including heart attacks and strokes. So, there's an enormous impact that you can achieve from well delivered psychological therapies that have a higher recovery rate. But it is all to do with getting people better. So if you look at the Norwegian data, the benefit to cost ratio in terms of the economy is 4 overall compared to treatment as usual in primary care. But for those people who recover, it's 10. And for those people who don't recover, it's 0. So we really need to focus on making sure we deliver our psychological therapies in a high quality evidence based way. Rachel: So when done well, it works and it pays and to do this treatment in particular, it's not just about talking therapy, it's doing therapy. And we've talked about how the behavioural experiments getting out there, testing and are so critical. And you've talked about the evidence base generally with this kind of care, thinking about social anxiety specifically, what’s the efficacy of this treatment, effectiveness of this treatment? And is it both effective and efficacious in the real world? Does it treat people the same? Does it work for a diverse population? Where's our evidence at in terms of that right now? David: Yeah, so if you look at the randomized controlled trials, and with, delivered by research therapists but with NHS Talking Therapies patients, you get about 70 percent of people fully recovering from their social anxiety and significantly more, in the high 80 percent showing reliable improvement. You don't at the moment get such high recovery rates in routine care in NHS Talking Therapy services. And we think that is for two reasons. One is because some patients, contrary to NICE guidance, are given low intensity interventions rather than this type of face-to-face therapy. The other reason seems to be that people get less sessions than you see in the trials. And the last reason, which is really interesting, is that often therapists are not using a measure of social anxiety each week to guide practice. So, the recommended measure in talking Therapy services is the SPIN, but quite a lot of people don't seem to use it. And we have very good evidence from an analysis from UCL that when therapists do use the SPIN to track progress in therapy, they get much higher recovery rates. And why is that? Well, when you look closely at the data, one reason is that people get much more like the expected dose of therapy. When people are using the SPIN, I guess because they're more sensitive, the GAD may have improved, but they can see with a spin, but a lot of the social fears are still there. So they carry on. So that's really good for patients. But, and this is really interesting, even if you statistically control for that, you find that every hour of therapy is more effective if you're using the right measure. So, it just seems to be a way of helping us as therapists really focus on what matters and keep that tight focus. Rachel: and not just using measures for measure's sake. It sounds like using them very actively is an important ingredient in what you're talking about. David: oh, incredibly, it's not for measure's sake, it's really to focus your therapy. The other really interesting development recently is, as we've developed an internet version of the treatment, which has all the key components in it, but most of the work is done by the patient accessing the program online but with support from a therapist. And we find in the clinical trials that you get as good results with only about a third as much therapist time compared to sort of expert delivery. We've also found recently, in some pilot studies, in six Talking Therapy services that we can actually train up routine therapists in Talking Therapy services to get the same high recovery rates with the internet treatment as research therapists. So over 60 percent recovery, full recovery, which is a lot better than we currently get in the routine treatments face to face in Talking Therapies. So why is this? Well, I think because the internet program always develops, always delivers the full treatment content, and it does get patients to do an enormous number of behavioural experiments. And it does this by lots of videos which illustrate people doing behavioural experiments for different fearful beliefs in the real world. And so, patients can look at the video and then try it out in action. And that seems to hook people in. If people would like to see some of those videos and also get them as tips for designing their own behavioural experiments, you can see them all in the social anxiety section of the oxcadatresources.com website. That's a free website that the clinic created for therapists, and it's got an enormous amount of material about how to deliver our social anxiety treatment and our PTSD and panic treatment. And it's currently being used by therapists in a hundred and seventy-five countries around the world. So, if you log in and it's free, then you'll be joining a worldwide community of psychological therapists. There are apparently 195 countries, so we've still got twenty to go. Rachel: It really is a wonderful resource, and your team has always been so generous with their research and materials and support of good therapy out there in the real world. Every corner of the real world, it sounds like, or almost. And for those that maybe aren't so clear about the distinction between low intensity and high intensity ways of working, we've become very used to this kind of language, certainly within Talking Therapies services. How does your internet program differ from supported self-help that people might have at a low intensity level and how would you distinguish that? David: Yeah, it's a very good question. So I think the sort of supported self-help, low intensity intervention that people get from for social anxiety is basically some psychoeducation about social anxiety and encouragement and exposure therapy. Neither of those are actually components of cognitive therapy for Social Anxiety Disorder but the internet treatment has all the components of the high intensity treatment. So it has almost no overlap with what's currently given as low intensity interventions. But the interesting thing of course is it does require a lot less therapist time because the patient is doing a lot of the work. So you, you could say in that way, it is a new type of low intensity intervention but it's not what has been offered so far in Talking Therapy services. I should also say that although it was designed to be used by high intensity therapists, in our most recent research with Talking Therapy services, we find that PWPs can be trained to get just as good outcomes with it. But what the patient is doing is not the equivalent of reading a self-help book on social anxiety, psychoeducation and exposure therapy. It's got video feedback of your social performance, it's got lots of experiential exercises, it's got specialised modules for all the different social fears, it's got ways of working with your trauma memories. They're all there in the program. Patients spend a lot of time in it, although the therapist's time is modest, about six hours over the full course of treatment. On average, we found in our most recent study that patients were spending approximately 40 hours on the internet treatment, and much more time in behavioural experiments. So, it sucks people in, they're really interested in it, because they recognise themselves. They can see, the program seems to know what they think, they recognise their thoughts. The program seems to be good at spotting these very subtle safety behaviours they have, including all the things they're doing in their head, which people can't just see, but the program alerts them to them, and they recognise from the case examples, people just like them, but then it just gives them so much more guidance in how to test things out in action with all these video clips. Rachel: That's fantastic. It sounds like it's brilliant as we've spoken about for dissemination, getting the treatment out there to more people, but also sounds like there's some really interesting workforce developments there with PWPs being able to deliver this, our highly skilled PWP colleagues, with the right training and support. David: Yeah, just one other point to say about it in that one of the strengths of internet programs is that if you get the content right, the program will always deliver the correct content. It doesn't have a day off. and it also will deliver it anywhere in the world. So we've now done trials with the program in China and in Japan. And really interestingly, with almost no modification, the program gets just as good outcomes with Chinese and Japanese residents. Rachel: So is this a step towards artificially intelligent therapists? David: Well the program is written to rely on help from real therapists who are familiar with the program and understand it well. It's possible that in the future with some of these online programs, you might find that you're guided through the therapy program with an avatar but that's not where we're up to. Rachel: So we're not discouraging people to take up therapy as a career just yet. There are secure jobs still in the system. David: Oh, absolutely. I mean society's growing understanding that psychological therapies don't only transform people's lives and the lives of people's families, but also are good for the economy means that without doubt, throughout the world, society is investing more in these evidence-based therapies. Obviously, the Talking Therapies Program has expanded job opportunities for therapists enormously. We've got an extra 11,000 therapists there. I anticipate that something similar will happen in community mental health for people who have conditions other than anxiety and depression. And I'm working with governments in many other countries to expand access to evidence based psychological therapies. Rachel: All that said, we are human, and therapy can be challenging at times. And you've been in this in this game, in this system of working with social anxiety for many, many years. In your extensive experience of both delivering the therapy yourself, teaching, supervising. Where do therapists get stuck with social anxiety? David: Well, I think, that the first issue is not really quite understanding the transference issue or the relationships issues. So social anxiety has a rather special relationship problem. It’s because you as a therapist are a stranger. So, you're a phobic object when you start the therapy, in fact when you start your assessment. It's a bit like saying to a spider phobic, we've got a really wonderful therapy for you and by the way, your therapist is a tarantula. That would interfere with the therapist process quite a bit, wouldn't it? And exactly the same thing happens in social anxiety and if you're not aware of that, you'll fall into lots of traps because of you being a phobic object. So quite a lot of our training is making people aware of what those traps are so they don't get sidetracked by them. And so what classic examples, well, there's one that happens in the initial assessment interview. People with social anxiety are worried about other people seeing they're anxious so they often try and hide the fact that they feel anxious. So if you're, doing your assessment interview and you feel you're making good progress, you're getting lots of details about the problem, you're starting to develop the model, the chances are your patient won't look very impressed. Because they're trying to stay in control, they're trying to stay a bit distant, so they don't look too anxious. And, if you're not aware that that's a safety behaviour that they've turned on because you're a phobic object, and so you're not really seeing the real person. You might mistake that as them having a lack of interest in your therapy and what you're doing. There's a good chance that will trigger lots of negative thoughts in your own head about your own performance, which will distract you from the therapy. So, the relationship issues start even in that first interview, but they carry on throughout therapy. So, because people are very focused on their feelings, when you're asking them, what were their thoughts, they often don't seem to answer immediately. They just say, well, I felt very embarrassed. And they don't say anything much more. And they look uncomfortable. And what do we normally do when people look uncomfortable in therapy? We sort of lean forward in our chair, look them in the eyes as I'm doing with you now and try and be very warm and empathic. But when we do that to someone with social anxiety, it's spotlighting them. It's making them centre stage, and they hate it. And so they're likely to, their minds are likely to go completely blank and they'll feel uncomfortable. They may even have a panic. So we have to adjust our interpersonal behaviour. So we're still very friendly, but not in their face in the way that you might do with some other people who are distressed. There are other sort of things that can go wrong in the relationship, like believing the evidence of your own eyes, if you're a therapist. So say someone says, Oh, well, my worst fear is that I'll blush. And as they say that they start to go red. And you might think, Oh my God, their fears are realistic. It's really true. I don't know that I can do much about this. But you're in the wrong place, you're observing what you see in front of you. You need at that point to get into the patient's head and find out, well, what do they think they look like at that moment? And if you do that, you'll find they think they look enormously worse than that. So, you can be misled by the evidence of your own eyes. And there are quite a few of these other therapist-patient relationship issues that people need to understand. Rachel: So you need to be very reflective as a therapist and taking that presumably also to supervision and thinking about how that's working its way out with your interactions in therapy. David: Yeah and you'll also find them covered in the workshops and things. So on the OXCADAT Resources website, for example, there is a full day workshop of me showing how to do the cognitive therapy for social anxiety, and it does cover these interpersonal issues. Rachel: And what about David when there is a grain or even more than a grain of truth in some of people's beliefs and I'm thinking here not about, for example, their blushing being very obvious. I'm thinking about groups that do face social prejudice. So, for example, people from global majority, people that face discrimination based and other protected characteristics. How do we adapt the therapy to this when there also is social anxiety in that picture. David: Yeah, well, I mean, the first thing to say about all cognitive therapy is that you don't challenge facts. So, there are situations where people are subject to discrimination and bias and things like that. The therapy isn't going to challenge that. That's the truth. The therapy works on the sort of added meaning that people put on those things and the distortions, and also of course helps people to be more assertive in standing up to these things. Rachel: and another issue that comes up, certainly I find in supervision is people thinking about either comorbidity or really entrenched negative views of the self that people might describe as, self-esteem problems or depression related problems. David: Yeah, so this is a really good question, and I think, quite a lot of the thinking here has sadly, been sort of over influenced by the structure of Beck's original cognitive therapy for depression book where there the argument is that early on in therapy, you deal with behavioural changes and negative automatic thoughts, but you leave what is called assumptions or your basic beliefs about yourself until late in therapy. That is completely the wrong thing to do in social anxiety. Everyone with social anxiety has some fairly substantial negative self-perceptions, or what Chris Padesky would call core schemas, like, I'm unlikable, I'm weird, I'm different from other people and those are a lot of the action. And people can mistake them for low self-esteem, but there, there are a lot of the core of social anxiety and the treatment works incredibly well with them. As long as you bring them into play right from the beginning of therapy. So, if someone has a thought like, a belief like I'm unlikable, bring it into play in the early behavioural experiments, in the video feedback and all these other things. And when you bring it into play, then it changes very well. So, we would say there's quite a misunderstanding of the distinction between low self-esteem and social anxiety. There's a very nice paper by Emma Warnock-Parkes recently in Cognitive Behavioural Practice, which really outlines this point clearly and shows you how you make sure you bring these very negative self-concepts onto the table, right from the start. Rachel: I really valued reading that paper recently and we'll make sure that's in the show notes along with the other great resources you've signposted us to, David. David: I should however say, having made a bit of a criticism of the original Beck Cognitive Therapy for Depression, or at least the impact he's had outside of depression, that this autumn the second edition of Cognitive Therapy for Depression will be published just 45 years after the original and posthumously, of course, because Tim Beck recently died. But it's a very welcome update and I would certainly recommend people have a look at it. Rachel: That's wonderful. It certainly has stood the test of time, hasn't it? But an update is probably overdue. And you've spoken David about some of the misperceptions therapists can have in therapy about the personal interpersonal interaction with their clients. And that sort of speaks to another issue that we talk a lot about on this podcast that CBT isn't just a process of clinically applying techniques and tools- we bring ourselves as therapists and all of our assumptions and life experience with us to therapy. So for example, when I was working in your team in London, I found myself doing some things that I might never have dreamt of doing deliberately otherwise in busy shops and cafes and train stations. I think I hopped across a train station platform at one point in London, and they've stuck with me for a very long time. Now I remember your story of spraying water under your arms, into your armpits and going into news agents and pointing at shelves and things like that, but it does speak to how we might be challenged ourselves. By this work as therapists might we have to challenge some of our own assumptions, our own excessively high standards of social behaviour or concerns about judgment, those kinds of things. David: Yeah, I think one of the very nice things about cognitive therapy is it allows you to take many of your own beliefs as hypotheses, just like your patient’s beliefs, and can encourage us as therapists to test out in action some of the beliefs that make us a bit worried in some situations or a bit inhibited in some situations. And it's a really good thing for therapists to do themselves because it helps them understand the difficult journey that their patients are on. If you do something that you find challenging, it gives you a better insight into how hard it is for the patient. But it also helps you really internalise the whole treatment approach. And so maybe I could ask you for our listeners to tell us about maybe one or two of those things that you did that were challenging and what you learned as a therapist from doing them. Rachel: So I think it's a truism that we're often drawn to bits of therapy where we have some personal investment or some sneaking kind of cognitive distortions of our own to test, aren't we? But certainly, I remember spending a lot of time in Camberwell where we worked at the time, in cafes, spilling drinks and dropping, in the days when we still used cash, dropping coins on the floor or going up to the nearest busy station in London and behaving slightly oddly on train platforms as people walk past without a care in the world, not looking at me for one second, because they were just on their way to their train and looking at their watches and getting on with their lives weren't they? So lots of things. I do feel slightly sorry for the cafe owner. So we'll go back someday and offer to clear up. David: But would I be right in saying that you were genuinely surprised by the lack of people's interest in those things when you essentially broke some of your own personal rules about social behaviour. Rachel: Absolutely, it's astounding really what, in a sense you can get away with. And I guess you often call these sorts of widening the bandwidth experiments, don't you? And we all have this internal sort of narrow highway. Or, or perhaps not highway, narrow path that we tread often in our lives. I think my teenage sons might not thank you for the fact that my bandwidth is quite as wide as it is David, that my social behaviour might gotten a bit out there, but you know, people expect strange things from psychologists, don't they? David: Well, yeah, I think you can, never be fully admired as a, as a parent in these situations. And it's not uncommon for parents to occasionally embarrass their children. Rachel: Not just me then. So what have you learned then from people you've worked with? I think we often do learn from our patients, don't we? Are there stories that stand out from your experience? David: Well, I think in social anxiety, the main thing I've learned is that the person you meet at the start of therapy is not the real person. The person you meet at the start of therapy is hidden away behind these various safety behaviours. And if in the course of working with them, you can get them to drop these and let the world know them. Without exception, they're all really interesting people. And it's just so wonderful to see them be themselves and contribute to the world. And so that's the most fundamental thing I've learned. And I think this has been a change in the way we thought about therapy. So, in the sort of 1980s and 1990s in anxiety disorders, there's a lot of talk about anxiety management training. The idea that anxiety is something that we teach people's skills to manage. It was sort of relaxation training or distraction, coping techniques, social skills and things. And, the cognitive revolution has been to say. No, that's not what you do. You really focus on people's fearful beliefs and work with them to help them to discover that they're not realistic. These things aren't going to happen, or if they do happen, they're not as catastrophic as you think. And once you get that fundamental understanding, there isn't anything to manage. You don't need these techniques. And I think this, this does change the way we as therapists think about anxiety. It's not, this is an anxious person, we've got to teach them a few coping techniques. It's more, this is someone who is the victim of their fearful beliefs and we can, working with them, help free them from being the victim of those beliefs then they can have a very normal life. Rachel: It's always really heartening at the end of therapy. We do a therapy blueprint, don't we, to summarise people's learning. And I don't think there's a feeling like it when you leave work at the end of the day, and someone has written on their therapy blueprint. It's okay to be who I am. I can be me. That's a good day at the office. And David, you are sort of retired. You've retired from at least one of your roles, but that doesn't seem to be slowing you down or observably reducing your output and productivity. Can you tell us a little bit more about horizons for you, your research, the field, what's going on in social anxiety more broadly? David: so I have retired from my university post at Oxford. when you get to a certain age, Oxford requires everyone to retire. We have a compulsory retirement age but that has sort of freed me up. I don't have the sort of teaching duties and administrative duties I had before, and I don't have to follow term times. So it's certainly given me more time to support the Talking Therapies program, and I hope also lobbying for an equivalent of that in community mental health, where at the moment, less than 2 percent of people seen in community mental health services get a course of psychological therapy. I mean, it's just appalling. So, I hope we can change that. And thankfully, around the world, our governments are getting interested in trying to make psychological therapies more widely available to the public. I think a lot of it from the politician's point of view is the economic argument that sucks them in. But of course, the economic benefits only occur if you do good therapy and you have good recovery rates. So, there's also an interest in designing your mental health services with that in mind and recording outcomes. So I find myself having the opportunity to support psychological therapists in many different countries as they strive to make psychological therapies more widely available for their public. In the last couple of months I've been, working in Iceland, in South Korea, in Nova Scotia, in Spain, in Norway, and Finland. Oh and Hong Kong. Rachel: but we still need to hit those 20 countries that aren't yet on the OXCADAT website, David, that that's your target for the next 10 years. We're recording this podcast in the run up to general election. It will probably go out after that time so I should say that having given a plug for Jeremy Hunt today, that other chancellors may be available. David: Well, I think, I think what I'd say about that is that, one of the great things about the Talking Therapies program is it was initially developed by the Labour administration. It was, cherished and further expanded by the coalition. And has been cherished and further expanded by the current administration with further investment from every Prime Minister other than perhaps the one who didn't have time in office to do that. So it's been a cross party thing. And why has it been a cross-party thing? I think it's largely been because of the extraordinary willingness that everyone in the program has to recording patient outcomes and allowing them to be reported. Because it means whatever government you have, of whatever political persuasion, they can see that patients get better with the psychological therapies. And so they can see it's worth investing. And that's really all down to the extraordinary work of people in these services and their willingness to be transparent about what they do. And it's very different, difficult for any politician of any political persuasion, not to support you when there is no doubt that you're doing a lot of good, a lot of people recovering and you're saving society a lot of money. And that's true for these Talking Therapy services. If we can get the rest of psychological interventions to also go for that sort of transparency, I'm sure we will find further support across the board. Rachel: And it's also due in no small part, David, to your championing and your communication and your skills in delivering that message and telling those in power, who seem to come with, an open-door people want to invest in and are committed to this, this cause, but actually the cause needs championed as well. And that's what you've done so incredibly well. David: But it would get nowhere without the wonderful workforce. Rachel: And David. In CBT, we like to summarise and think about what we're taking away from each session. So in time honoured fashion, I'm going to ask you what the key messages you would like to leave folk with regarding this work with social anxiety, David: Well, I think the key message I'd say is that this is a very treatable condition, which it's worth investing your time in because in the absence of treatment most people won't recover. But if we get it right, you completely change their lives, and this is one of the greatest gifts that we can have as psychological therapists, the chance to help someone change their life. For the very long term, there's very little relapse, people just are different for the next decades. Rachel: which takes us really nicely full circle to your mum and the help that she gave people that inspired you into this work in the first place. David, thank you so much for spending this time with us. So grateful for your time, your wisdom, and also all your work in this area. And we hopefully will welcome you back at some later date to talk about some of the many other pieces of work that you've done, that we can learn from. Thank you so much. David: Well, thank you for having me on and it's lovely to be able to catch up with you again after all the work we've done together in the past. Rachel: Thank you, David. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team at [email protected]. That's [email protected]. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that new episodes are automatically delivered to your library and do please share the podcast with your therapist friends and colleagues.  

In this episode Rachel talks with Professor Paul Salkovskis about using CBT to treat people with OCD. They discuss the Cognitive Behavioural model for OCD and how OCD develops and is maintained, debunk some common myths about OCD and the effectiveness of CBT in treating OCD. Paul and Rachel also chat about some of the more unusual techniques they have used when helping patients with OCD… Whether you’re a seasoned therapist or new to the field, this episode offers a wealth of knowledge about OCD and its treatment. Paul’s decades of experience and his ability to explain complex concepts in a relatable way make this a must-listen for anyone interested in understanding OCD and improving their therapeutic practice. 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 X or email us at [email protected]. Useful links: Paul has published numerous papers on OCD and hoarding (amongst other things) all of which can be found listed here: https://bit.ly/4dIpBqi Books: Bream, V., Challacombe, F., & Salkovskis, P. (2011). Break Free from OCD: Overcoming Obsessive Compulsive Disorder with CBT. London: Penguin. Bream, V., Challacombe, F., Palmer, A., & Salkovskis, P. (2017). Cognitive Behaviour Therapy for Obsessive-compulsive Disorder. Oxford: Oxford University Press. Articles: Lomax, C. L., Oldfield, V. B., & Salkovskis, P. M. (2009). Clinical and treatment comparisons between adults with early- and late-onset obsessive-compulsive disorder. Behaviour research and therapy, 47(2), 99–104. https://doi.org/10.1016/j.brat.2008.10.015 Rhéaume, J., Freeston, M., Léger, E., & Ladouceur, R. (1998). Bad luck: an underestimated factor in the development of obsessive-compulsive disorder. Clinical Psychology & Psychotherapy, 5(1), 1-12. doi:10.1002/(SICI)1099-0879(199803)5:13.0.CO;2-J   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 we're talking about Obsessive Compulsive Disorder, or OCD, and we're delighted to be joined by world leading expert in the area, Professor Paul Salkovskis. His cognitive behavioural model and treatment for OCD is probably the most widely taught and applied in clinical practice. He's an expert in CBT for anxiety disorders and has a huge impact on developing interventions and improving therapy outcomes, not just in OCD, but also in panic, agoraphobia and health anxiety. Without him, we might not have the formalised concept of safety seeking behaviours or be nearly so unconcerned about the bizarre and intrusive thoughts that we all have on a frequent basis. All of which means that Paul is more likely to be found with his hand down a toilet or licking his shoe than washing his hands. So I'm really delighted to be welcoming you remotely, Paul, to this episode of Practice Matters to talk about OCD. Welcome. So clearly, Paul, you've got a really wide range of clinical and academic interests, other than a predilection for the taste of the sole of your shoe. Is there a reason you got particularly interested in OCD professionally and personally? Paul: By the way, the sole of my shoe is salty during the winter, but not during the summer. I can't tell you why. Why did I get interested? Well, well, I mean there are two intersecting reasons. One of which is that when I was training, I was trained with something called David Clark, you've probably heard of him and we had a mentor who's called Jack Rachman, who was professor extraordinaire, in just about everything, but particularly OCD. So that was part one. So Jack inspired me, and I've kind of followed his mould, or been in his mould for a very long time. And then the other thing is, having met a lot of people with OCD, just the fact that they were the most fabulously nice people. And I don't really have any OCD that I'm aware of anyway, but I really like and identify with people with OCD because they're so nice and that probably links to one of the reasons they, of course, have OCD. I think it is possible to be too nice. Rachel: So something about these figures in your career, which you've actually become for many people throughout your career. I know you've inspired loads of people to, to follow in your footsteps and do this kind of research, but that just real connection with the patients, with the folk that are struggling with these and that human connection has inspired you. So, to get us started, I have some true or false questions. First of all, true or false, everyone has a little bit of OCD. Paul: That's true and false. Because the kind of basis of OCD, intrusive images, thoughts, doubts, and so on, is there in everyone but not everybody suffers from OCD. So, so it kind of starts with something we all have. Rachel: Brilliant. Secondly then, OCD is simply about being a little too focused on cleanliness or organisation. Paul: 100% false. Rachel: The brains of people with OCD are different to those with normal brains. Paul: Brain is the organ of the mind. Therefore, in very small ways, different. But not in a way that you can detect in any kind of biological test or scanner or whatever. So, so they are, they work in the same way, but the workings can be different. Rachel: Okay, excellent. OCD is untreatable by psychological interventions? Paul: You're joking, right? Okay, no you're not. Okay, no, okay. So, so I think that I could reasonably say that's 100 percent false. Rachel: Just your life's work. In order to treat OCD, you need to start with the root causes in a person's childhood. Otherwise, it will just come back in another way. Paul: Yeah, the old symptom substitution myth. Completely false, but it's not that childhood is irrelevant. And we'll probably come back to that. Rachel: OCD is harder to treat than other disorders for which CBT is a recommended intervention. Paul: It's false, but it's also true again. And that's because a lot of people are not properly trained in how to treat it. So it's harder if you don't have the tools but it shouldn't be. It really shouldn't be. Rachel: Okay. So starting at the basics then, what is OCD and how big a problem is it for people living in the UK and beyond? Paul: Lots of discussions about how much it is. Everybody who specialises in problems says, My problem is more common than everybody else's problem. But that's not true. It's probably sitting about 1 percent lifetime prevalence. which is lower than a lot of places will tell you. How big a problem it is? It's as big a problem as any other severe mental health problem. There are people who have mild OCD, and people who have severe OCD, and people with mild psychosis, and severe psychosis, and so on. So, what is it, its obsessions which can be intrusive thoughts, images, impulses, or doubts, and compulsions, which are related to it to those in terms of the meaning, which should take you to things like cultural issues and clearly there are cross cultural differences in the way OCD, kind of sets itself up. But then there's the disorder and that's the living hell that many people with OCD have. It really is awful for many people. And it can completely destroy people's lives for year upon year, shortens lives for some people and soon. So it's a really big problem but it's not the most common mental health problem. But the thing that bothers me about it, what, why it being a big problem is that I regard OCD as an unnecessary illness, nobody should suffer from it. When I'm working with OCD, when I'm working with people with OCD, and I tend to work with people who are more severe, these days, they've had the problem for a long time. Treating the OCD is the least of what I do. And generally, I'm dealing with the thing that I've sometimes referred to as collateral damage, that the way in which the people's lives have been eroded, destroyed, stolen from them. And then, when you've dealt with the OCD, you're left with people whose lives have been devastated by it and then helping them rebuild and reclaim their life. Now that is not unique to OCD. It's just because of the chronicity, severity and the poor treatment that people are offered we see it particularly commonly. Rachel: So do you feel that treatment isn't accessible enough yet? Paul: Not by a long way and that takes us to the whole issue of parity of esteem. I was talking with some therapists the other day, and we're talking about the way that people are offered sort of like short terms of treatment, you know, sort of six sessions or whatever. And it just goes completely against the whole parity of esteem thing. The idea if you've got, if you've got cancer and you need chemotherapy they don't say, well, that's three sessions of chemotherapy, you should have 12 but we're going to give you three or we're going to give you a quarter of the dose because it'll help a little bit, and so on. And we would never do that. It would be an absolute scandal. And the idea that we can take people with severe OCD and then say, oh, here’s a stress management group, and then here's four sessions with somebody who probably isn't actually able to formulate because they're not trained in formulating because that's not done. And then that's it off you go. That's not good and it's not appropriate, in my view. Rachel: And at worst, I guess, it's not just getting less than the appropriate dose, it's actually doing harm. Bit more akin to doing half a heart transplant than half the medication. Paul: Yes exactly and the harm is palpable. One of the things you have to remember is as a clinician, I don't see the people who did really well when they had early treatment and then went off and lived happily ever after. We see the people who've failed in treatment and so on. But within that context, for example, I’ve seen young people in their late teens, who as a child were held down by a couple of nursing staff while they were contaminated against their will and that person had been utterly traumatised, has no trust in services, obviously and was made so much worse by that. So that kind of stuff can also go on and it's, in my view, it's a scandal. It shouldn't happen, but it's done and noted as therapeutic. Rachel: And absolutely devastating for those individuals. And I guess 1 percent doesn't sound that huge, but when you scale that up to the millions and millions of people who are suffering with this problem, you know, more or less severely, it's huge, isn't it? And how does it develop? Who typically suffers from OCD? Is there a type? Paul: Nice people, nice people. We don't really know how any psychological problems develop. You know, there are clues about triggers and so on, but we don't really know. But we've speculated about this, and generally it's holding up in terms of research. So, it looks like, it starts from normal intrusive thoughts. Thoughts, images, impulses, doubts, the thing that we know 90 to 100 percent of people get. So you start with an intrusive though and if you then believe that this thought's popped into your head, meaning that you may be responsible for harm to yourself or other people, then you try and fix it. And that might involve checking, it might involve neutralising, saying a prayer if it's a blasphemous thought or whatever. And then you're caught in that loop and then the whole series of vicious circles that kind of develop from that. And people get increasingly trapped in that. They become stuck in a particular way of seeing the world in terms of harm. And they do it because they're nice. I mean, one of the things we'll say is, you know, if you have terrible thoughts about harming strangers in the street and you're a serial killer, you might have OCD. But because people with OCD have those kinds of thoughts, they think it means that they're a serial killer, which is deeply ironic. You know, they’re the safest people in the world, in terms of if you want somebody to babysit your kids and somebody says, Oh, I have these terrible intrusive thoughts of being a paedophile, well you should be pretty safe there, actually. And there's this issue of risk. It's one of the things that therapists get very hooked into too, the idea of risk. People get worried. Well, if somebody says, Oh, I'm going to, I'm going to throw my baby on the floor, really hard, or I'll stab them with a knife or whatever. It's, wow, safeguarding. If somebody has OCD there's zero risk they will do this thing they're worried about, what we call the primary risk, that's zero. There's a secondary risk, and that's a hundred percent, and that's that actually the untreated OCD is going to interfere with your relationship with the child. Because you're worried about harming the child, when the baby cries, you can't pick the baby up and cuddle them. You can't change their nappy. You can't do pretty much anything. So, you have to call somebody to come over and look after them and so on. Then they get older, you can't let them crawl on the ground and so on, that's a secondary risk. And that's the really bad thing. And that's a risk of untreated OCD. And that's one of the things we have to really bear in mind that people get very hooked into this whole idea of primary risk. I'll tell you one thing. I put my money where my mouth is here. So one of the things I have in a drawer somewhere over here is a very sharp Sabatier knife, and it's something I'll use in a behavioural experiment. If I've got somebody who's worried that they're going to, they're going to stab people and so on, then with appropriate preparation after formulation and so on, then I might ask them to hold that sharp knife at my throat while they stand behind me, make sure they're holding it tightly and so on. Now, I'm very careful about my diagnosis because if that person's got command hallucinations, that would be a bit of an issue, wouldn't it? But I'm absolutely confident that if somebody has OCD, then I'm a hundred percent safe. Rachel: I remember Paul, working for you very early in my career and very recently married heading off to work one day. I was cycling to work and having a slightly strange conversation in the kitchen with my husband as I looked at our knife block and I said, which of these knives do you think is the sharpest and biggest? And he said, well, odd question, but I think it's probably that big meat knife. I said, okay, I wrapped it up, put it in my bike pannier and cycled off to work. Or I would have done if he hadn't stopped me and said, Rach, why the knife? Why are you taking that to work? As I said, I was working for you thinking he might have been fearful for your safety. You know, we were getting along fine, but you never know. And when my answer was, well, I'm just going to get my patient to hold it against my throat, the concern escalated rather quickly and I learned very quickly to explain the model of OCD to my husband that day. And interestingly, that is the next challenge we have for you, Paul. It's our podcast challenge. So we're not a visual format, we're an audio format and in CBT we love our boxes and arrows, don't we? But what I'd like you to do now, if possible, is to step up to the challenge and give us a brief explanation about how OCD develops and is maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids. Paul: Okay. So, I'm going to start what we do in therapy, which is you start with the maintenance and then you later might then pop back to development. There's a man that we both know called Mark Freeston. He wrote a really nice paper, which is called Bad Luck, Neglected Causal Factor in Psychiatry, something like that in which he basically said that one of the main reasons that people develop psychological problems is through bad luck. Okay, so about half the people we see with OCD, there's no obvious precursor, nothing that led to it, it's just that they were in the wrong place at the wrong time, had the wrong thought, responded the wrong way and so on. Okay, so, formulation, without hesitation, or the other things that you mentioned because I don't want to repeat them. Okay. So, people have what would not for most people be a normal intrusive thought. They notice it and they think either the thought itself means something that harm could happen that they could cause or prevent, or actually the fact that thought occurred means, that harm could occur if they don't prevent it and so on. And that meaning, the thing sometimes called a negative automatic thought, but I think meaning is a better way of thinking about it, then leads to a set of reactions. and those reactions include things you can't control. Like, you know, if you thought that you're, that someone you love is going to die as a result of having a thought, and you really believe that in your heart, then that makes you feel frightened and miserable and guilty and so on. You can't actually suppress those, but it might also lead to things like saying a prayer or trying to picture them alive and so on. It's something you choose to do. So, there's two types of responses, from the meaning in terms of responsibility and harm. One of which is, things which are driven and which you can't actually do anything about. And then there's things that you try to do. And that would include neutralising, it could also include thought suppression, trying not to think about something, which has of course, the paradoxical effect- it occurs more. And then there's also things like checking. Did I actually close the door or whatever? And then you get into what Adam Radomsky talks about as the checking trap. So, the more you try to make sure of something, after a few goes, a few checks, then you become less and less confident in the eventual outcome. So, these are all feeding back into the meaning. Some of these things are feeding back into the actual intrusion. So because you feel miserable, guess what? You get more intrusive thoughts because if you're frightened, then you get more frightening thoughts and so on. And so these things then lock into a way of looking at the world, a way of responding to the world, and people become stuck in that. And of course, what you're going to be doing in therapy is giving people a different perspective on that. But going back to the developmental issue, so, so the question is how do these things start? And sometimes we'll pick up that there's really two things that can make people more likely to misinterpret intrusions as a sign of responsibility for harm to themselves or other people. These two things are critical incidents so, these are like, like accidental stuff that happens. The example that sticks in my head is the little girl who took her neighbour’s dog. She loved this dog, took the dog to the park and did it day after day and then one day the dog runs around the pond in the park, jumps at the pond, doesn't come up again. And then she has to go back and the neighbour says, why did you let him go in? and she basically felt that she was responsible for that and then became super sensitive to the idea she could cause harm without meaning to. And so then started taking precautions. So that'd be a critical incident. The other thing is beliefs, sort of general beliefs and there are, I don't want to target a particular religion, but the notion of, the notion that thinking something is as bad as doing it, sometimes known as sin by thought or whatever, that you can break God's law by thinking something, yeah, is very problematic. So general beliefs about that, general codes of moral conduct, you must never cause harm under any circumstances and so on. So general assumptions or beliefs, which are too rigid, and which mean that then people, when they have an intrusive thought then interpret that as a sign they've got to act to prevent it, which gives them compulsions, then locks them into all these other components. There we go. I didn't breathe during that. I also repeated a lot though, but nobody buzzed. So it was okay. Rachel: It's great and not breathing gives you extra points. So fundamentally you're saying stuff happens to us combined with standards and beliefs that we may have when we have these thoughts of harm lead us to do paradoxical things, actually make those thoughts of harm worse, or at least not go away. Paul: Sounds familiar, doesn't it? It reminds me of something called CBT. I can't remember what that is. But it's something. Rachel: I know. And fortunately you did pretty well on the model because having written it, you know, that would be embarrassing if you didn't understand it, wouldn't it? fantastic, brilliant. Thank you for that. As we've noted before in this podcast, we describe CBT as an evidence-based approach to psychological problems, not just because it works to treat them and the therapies tested, but also because the assumptions on which the models are based emerge from cognitive and behavioural science and have been tested experimentally. And that's something, again, you've been committed to for many years, decades, even. Not that I want to age you, Paul, and that, that can give clinicians and patients confidence in the approach we take. It's not just sort of psychobabble. It seems to work. Let's keep doing it. How have you and your colleagues systematically tested the assumptions about the maintenance of OCD? Paul: By doing a kind of range of experimental strategies. So, things like testing out thought suppression. In fact, thought suppression is an interesting one because I actually think, and the evidence we have is that, that it may be not just the thought suppression, it might also be just the fact of looking for it. So, if you look for a thought then you experience it more. And then on top of that, if you try to suppress it then it'll occur more. But there's also things like, testing out assumptions around, say reassurance seeking, which is one of the things picked up on. So recently one of the people I was working with looked at what happened when you ask people to imagine getting reassurance or getting support as an alternative to reassurance, and then picking up that actually people with OCD who have not actually had treatment, you know, have worked out that if they seek reassurance, it's going to make them more anxious. And if they seek support, meaning that they say, you know, I'm feeling anxious, can you help me with my anxiety, that makes them less anxious and less inclined to seek more reassurance and so on. So, it's unpicking the components. But in the end, the important science is not that actually. The important science, in my view, is the science we do with each individual case. So another of the people that I kind of go back to is a guy called Monte Shapiro, who actually pretty much invented the idea of single case experiments. He called it the intensive investigation of the single case. He basically said that you should treat people with psychological problems as kind of partners in a scientific enterprise where you work out how things work for them, how the world really works, actually, in modern parlance, and then get them to try it out. So if you try not to think, not to think thoughts, just in the single case, and then you get this big surge, then you know that's causing it. If you don't get the big surge, it's probably not actually causing it. So you can do the science at the level of the individual. It's also, of course, why we've got to evaluate what we do because one of the things we know is that people that we work with, I mean these lovely people with OCD work with will tell me as I try and help them that they're doing super well. But if I measure it, in some instances, if they're not doing super well, they're just trying to be kind to me. So actually systematically measuring both the processes that are driving things in any particular individual, but also whether or not what you're doing is helping or harming is a really important part of what we do. So I would take it away from the sort of the laboratory science or the experimental stuff that we do with groups of people, which is important. But say in the end, in CBT, what matters is the science we do with a particular individual. Rachel: And you've, you've talked really clearly about the various maintenance cycles and you've alluded to this sort of stance of therapy, this sort of collaborative empiricism. What do the typical elements of therapy for OCD look like? What would you typically be doing with a patient? Paul: Well, you start, as a therapist, you start with an assessment, right? But you've got to be a bit stupid if you think it's just an assessment. It's a two-way assessment. So the really important thing that happens is not what I think of the patient, but what they think of me, actually. So, and that's going to take you into the issue of engagement, because essentially therapy is going to go well if the patient looks in your eyes and sees the possibility you can understand, that you're trying to understand and so on. That's part of their assessment of you. So, helping people feel understood, getting to know the person before you get to know the problem. And then looking at what it is that's keeping the problem going, what's maintaining it and doing that through the thing we call guided discovery, which is rather than me sort of going verbal psychoeducation, more psychoeducation. So what happens if you do that and so on. So, so the person essentially tells me how their problem works and then I'll reflect it back and help them structure it and see it in that way. So the other thing about this is that I do not believe that as a CBT therapist, I treat people. I support people in bringing about change so it's kind of, it's not, you don't do something passively. You help people discover how things work, and then try things in a different way and then see if that is helpful. So, so it's this idea that it's actually, you know, we've often, as cognitive behaviour therapists, we artificially divide behavioural techniques from cognitive techniques. Cognitive techniques is where you get, look at the meaning and you help people understand sort of what's going on and we get them to draw on their past experience so they'll be able to tell you about what happened when their OCD was really bad, and you describe it and you, you draw arrows and so on and you help them understand how that works. And then you'll ask them questions from their past experience about whether that's true or whether the way that you've drawn it out might be a better way of thinking about it. And at some point, the person says, well, I don't know, you know, I don't have the answer to your question, Paul, you're a very clever therapist, but actually I don't really know what to say about that. And that's when you use the behavioural experiment. So you've run out of past experience. And so you help people get new experience. And that new experience feeds back into the discussion and the whole enterprise is directed towards this really key phrase, which I drum into my trainees on a regular basis, which is good therapy is about helping people understand how the world really works. It's not about thinking positively. It's not about thinking logically. It's actually making sense of their world. Which might mean, you know, that there are some things you can't do anything about. You know, if someone is, for example, in an abusive relationship, say intimate partner violence or whatever that you're trying to make them think differently about it. On the other hand, you don't, you can't completely walk away from it and say, there's nothing I'm doing about it. So, so you have to help them negotiate that, think about their options and so on. So understanding how the world really works, including taking into account issues like stigma or adversity or trauma with a small T, or even trauma with a large T, for your sake, Rachel, and bringing all that together in a way that empowers the person who's stuck in a particular way of relating things. And in the end, good cognitive therapy is about empowering them to bring about changes. We don't do the change. They do the change. So good CBT is self-help with me or you as therapists standing back in admiration that somebody has the courage to take control of their life. Rachel: And I always loved the way you explained to me many years ago, just the concept of behavioural experiments and just let's find out, let's find out together. But you're asking people to take a big leap there from, you know, we think it could be this, it could be that to let's find out, let's do stuff different. Is it, is there some quite important work that needs to be done to, to help people take that leap? Paul: Well, that work is, we've already talked about that really, that's the formulation because these essentially, you know, people come in with a particular view that they have horrible thoughts, and they think they're a violent killer and then in the assessment, you work out that they're actually a really kind person who's afraid of being a violent killer. So, so then when they get that and that makes sense and they draw on their past experience to say, well, actually, you know, I'm generally quite a nice person, I do look after people and so far I haven't done anything violent at all. But that's when they're going to need to take the leap, which might involve the Sabatier in my drawer (other knives are available by the way) but anyway, there's the sharp knife in my drawer, you know, held to my throat as part of the behavioural experiments and so on. Now, the other component of that. And this is a good example of it, is also that people will take that leap of faith if they believe that you truly understand. And that you can be trusted, you know, and the fact that I'm asking the patient to hold a knife to my throat does suggest that probably that I'm pretty confident in what I'm doing. But, in general, it's the notion that if the person feels understood by you and then you ask them to do something to confront their fears, then they're going to  do it for you. Now, that's an enormous burden on us actually, you know, in a sense it gives us a responsibility and we have to rise to that. And I think that's one of the important things that we have to reciprocate that, we have to then offer the trust in the other direction and so on. Rachel: We've talked a bit about what the therapy involves and this journey that we take people with us on, and, you know, all the time kind of trying to imbue that sense of trust through understanding, through formulation, through connecting with where they're at. I guess we also need to be confident in what we're doing, that it's going to be helpful. So, so is CBT for OCD effective? Where's the evidence base? Paul: The evidence is really strong, and it's been synthesized by NICE. The evidence for CBT for OCD is really strong. The extent to which there are people who don't respond, is complicated. In 2013, DSM 5 took hoarding out. Hoarding was always the odd one out of all the subtypes of OCD, it didn't work. But there's another subgroup, which again, Jack Rachman, towards the end of his life, he has sadly, as you know, gone now but towards the end of his life, he highlighted the importance of mental contamination, which related, now you'd be really happy about this, Rachel, because it did relate to a particular type of traumatic event, which is betrayal events. So, you know, we're able to identify people who don't do quite so well, and we can therefore refine treatments in those areas. But overall, it's absolutely clear, it's the first line treatment for OCD, pretty much across the piece. It's boringly, consistently effective. Rachel: Is it for different minority groups, for example, or people from different religious backgrounds, cultural backgrounds? Paul: Yes, again, there's no evidence that it's ineffective in those things. It's certainly been trialled across the world in a range of ways. The important thing is that it's adapted. I mean, you don't translate therapies, it's a really bad idea to just translate them. You adapt them. So, and again, if you think of some of the things in OCD, for example, if you take the unlucky number 13, which some people want to avoid, and could get quite obsessed with. That doesn't happen in China, but the numbers four and 14 on the other hand are really horrific and again, if you think of religious OCD, then clearly big differences across the range of different religions you see across the world and so on. So, so yeah, it's important that it's adapted rather than translated. And the adaptations should be done by people who understand it locally. It's not a matter of, you know, white haired professor from Oxford turning up and telling them, this is exactly how you do it according to this manual, and so on. It's about actually working with people to say, well, here's the kind of things we'll be doing, and here's, you have to tell me how it would adapt and translate, which I've done in various countries. Rachel: So there's no evidence that the mechanisms are different or the underlying processes are different. It's more of the epiphenomenon and how those might be expressed within different cultures? Paul: Well, that's right. I mean, there's a generality of processes, but the specificity of the behavioural outcomes. I mean, the type of prayer or religious rituals, you do will be different according to a particular religion. Also, we have beliefs about germs and so on, but 300 years ago, you know, before that, that annoying Pasteur woman invented germs, you know, then we weren't worried about the way we washed our hands and so on. And that's one of the clues that OCD is fundamentally a psychological problem because the way it's evolved historically, that the invisible menace of today is not the invisible menace of 50 years ago. 50 years ago, people worried about radiation from luminous watch dials. Rachel: So, and I guess it's also not about dismantling someone's culture or someone's religious beliefs because there's people in every culture in it with every, you know, with fervently held religious beliefs in different ways that don't have OCD. It's not about dismantling those. Paul: Well exactly right because essentially we do not try and remove people's basic values. You know, I see a lovely, a loving mother, who’s doing OCD around her, around her children. Okay, I don't then want to turn her into a child abuser. That would not be a good outcome. What you do is you help her be a more effective loving mother. By the same token, if somebody has religious OCD, I don't want to take their faith away from them I want them to be able to connect with their faith in an appropriate way So if you take somebody say with blasphemous obsessions, they're unable to go to the mosque or the church. Which means they get disconnected from the religion because of their fears about religion. I want them, you know, you're quite likely to be encouraging people to go along to the place of worship and defeat the OCD in that context so they can pray better They can pray more effectively and be closer to God. I'm not religious, but I recognise the importance of religion to people, and it's really important that we don't undermine their values in the same way as we wouldn't turn that loving mother into a hateful, abusing mother. Rachel: We've already alluded to the fact you've been doing this for quite some years. You've got a lot of experience to say the least of teaching, supervising, applying the therapy. Where do therapists get stuck, Paul? What are your most frequently asked questions or the trickiest issues that come up, and this could be for people starting out or for people who've been doing this for a very long time and maybe working in more complex areas. Paul: I think where they get stuck is formulation, that people don't do a good formulation, they don't understand what's going on. I mean, one of the things that if you're a sufferer, if you have OCD and you look in the eyes of the therapist and blanking comprehension looks back at you. Then there's a lot of trouble going to happen in that therapy. Patients are very kind and helpful to us, and they'll forgive us to a degree, but ultimately, it's not going to work fantastically well. There's a really simple rookie error that a lot of people make, which is they try and formulate from a page in a book or something they got on the internet and so on, rather than doing it from the particular person or even that persons experience. Rachel: So back to our boxes and arrows?   Paul: But not actually using preset boxes and arrows. And then there's another mistake that people make is that they say, well, I'm going to make, I'm going to do an individualised formulation. So let's talk about your OCD and what usually triggers it off and what does it usually mean when that, and the clues in the usually. Yeah, that's wrong. What you do is you say, okay. When was the last time your OCD was really bad? And then what was the first sign of trouble on that occasion at two o'clock on Wednesday? And then what was the next sign of trouble? And so you get people's memory of what happened rather than their really helpful guesses as to what might be going on. And that's one of the big errors that people make, that they don't go really specific and then try several different examples and then pull it together and then share it with the person. One of the things I'll do after a formulation usually is look at it and say well this could be right, but it could be complete nonsense, please tell me if you think this is just wrong. And typically people will tell you that it's not wrong or they'll tell you that it's wrong in a particular bit and you have a discussion. So you're actually responding to the person in that way. So helping people feel understood requires understanding and requires you to build that understanding. And then the other mistake that people make is they get the formulation, hopefully not from a book or an internet site, and then it stays that way. And of course, you know, you and I both know that formulation is a dynamic thing. As you learn more, you'll scrub things out, you'll elaborate, and so on. And it belongs to the person. And they have ownership of it. Therefore, to stick to it for 12 sessions having done it in session 2, is foolish. Basically. Rachel: So the formulation isn't another unhelpful, rigid belief system Paul: Exactly that, yeah. And the formulation is in the service of helping the person choose to change. Because again, you don't make change, they choose to change. And when they choose to change, that's when things really get going. Rachel: and one of the things people sometimes talk about when they're trying to formulate OCD is issues with particular presentations. So people that seem to have compulsions without apparent obsessions or obsessions without compulsions, how does that fit within the model? Paul: Okay. Well, well, it fits beautifully. I mean certainly for the, for what's called rumination sometimes, the obsession about compulsions. Dave Westbrook and I dealt with that way back in the nineties, wrote a lovely paper about it. It's an old problem. Well, and in fact, we drew on Joe Wolpe's 1958 stuff where he talked about anxiolytic obsessions and anxiogenic obsessions, by what he meant the anxiogenic obsessions are the intrusions. You know, I'm going to murder my baby or whatever. The anxiolytic obsessions are, oh, I love my baby very much. And so it's actually the ritual. It's inside the person's head. Why would that be worse? And well, it's because it's portable. Because, you know, if I'm contaminated, I've got dirty hands, or I think I'm contaminated, I've got to find a bowl to wash my hands in the soap and the rest of it and so on. Whereas if I'm ritualising my head, if I'm say saying a prayer after having a bad thought, I can just pause briefly now, say a quick prayer and carry on and it's portable and therefore more intense and so on. So, ruminations I think are that, well, it's clear they are the same as other types of OCD. Compulsions without obsessions are the thing we call proceduralised. So you just get very good at it. It's like driving your car home. You just, you don't have to think about it and so on. And so, you get into the groove and as soon as you actually ask the person to perhaps not do the tapping or the washing or the prayer they say or whatever, then typically you'll then get the obsessions coming back in. So the obsessions are there. They've just gone underground. Rachel: And that’s not uncommon in people who've had OCD for a very long time, is it? Which is again where people can often struggle at the assessment phase. Paul: Well, safety seeking behaviours essentially remove the idea of threat, but it's still there. So, the example I sometimes use, as you know I'm quite fond of metaphors, the example I use there is why would something you're doing to make yourself safe make you feel in danger? So, if you come to visit me, Rachel, which you'd be more than welcome to do, and I greet you at the door and say, oh, thank you very much for coming, please wear this hard hat while we're in the building to keep you safe, right? and then we carry on talking. We sit with hard hats for a couple of hours. Do you feel safe because you're wearing a hard hat? Rachel: Well, maybe with you, Paul, but not usually. Paul: So, so, you know, it says that the things that people are doing to make themselves safe are actually a constant reminder, of a threat. And because it's just a joke, you know, I'm just joking over this, but you were never in danger, but you're going to be pretty nervous at the ceiling tiles by the time you leave the building. Rachel: is it harder to treat people who have sort of decades long histories of OCD, do you have to adapt? Is it just the same and more? Paul: Here the thing, isn't it? I mean Claire Lomax, mutual friend of ours. Yeah, and I did various studies on this. And yeah, Claire and Victoria and I did the thing, the things we call tales of the unexpected. And one of the things, one of the studies we did when we were working in the Maudsley in CADAT was we looked at people with long duration versus short duration. And what we found is that when people have long duration problems, they started more severe than the people that have short duration problems. Yeah, short duration, like, this is like 40 years versus like 15 years or something like that. And so, so it looks like it is worse. And when you treat them, they end up in the same place because the people who have the more severe problems show a bigger decrease. Now it doesn't mean they're necessarily doing better, it's just that they're doing just as well, and they end up in the same place. We have the same thing for age of onset. So because there were people who were saying oh, well you know, if you start OCD when you're a kid it's completely different. It's a neuropsychiatric problem blah blah… and so we looked at people as adults whose OCD had started before the age of puberty or after the age of puberty, and then again, we looked at the outcome and the same thing happened. You know, they start off more severe, but they all end up, they all end up in the same place. So the people who had an early onset, you know, improved significantly more than the people who had the late onset. Similarly, the third unexpected finding was people in addition to OCD had OCPD. Now, this is. This is a little bit funny because I was working with a, with a researcher, but they brought me the data, so we, people had OCD and OCPD, and people who just had OCD, and we just wanted to see how they did in treatment, and so, the person brought me the data, and I said, you're going to have to go back and check it, I think you've got it wrong, you've got it the wrong, the group's the wrong way around. And they came back a little later, a little anxious, I think, and said no, it is the right way around. And what we found was that people who had Obsessive Compulsive Personality Disorder, as well as OCD, were improving significantly more, than the people who didn't have obsessive compulsive personality disorder. And initially we're thinking, why is this? And then I think we understand it. Because OCPD, is, you know, it's about perfectionism. So those people we had with OCD who had OCPD were doing the homework. They were listening to the recordings of sessions, which we always ask people to do. They were completing the questionnaires. They did the tasks, and they did the therapy perfectly in that way. I'm not able to confirm that at this particular point but I think that's very likely. And what it tells you, again, that your expectations get violated. I did not, we did not expect to find that. You get that at an individual level. Somebody walks through your door and I think, Oh no, this is, you know, this is going to be a really hard case. And the number of times you get wrong on that, and then you think something's really easy and they're not that easy. We should not have strong expectations when people walk through the door because that can actually interfere with therapy. So if people have, for example, a personality disorder, so called. Quite often that can be a major strength and we know, again, that if you look at something like Borderline Personality Disorder, Emotionally Unstable Personality Disorder, alongside anxiety, people do very well in the treatment of anxiety. Similarly, and there's something else going on at the moment around things like autistic spectrum disorders. We know that having an Autistic Spectrum Disorder, interferes with treatmentmwith CBT somewhat. But there's a problem here because what happens is that there's a lot of people with anxiety problems who have ASD, who have Autistic Spectrum Disorders, and then what happens is they refer to services who say, oh, you've got autism, so we can't treat you. But then nobody can treat you. Now, what's the evidence? Well, the evidence is really clear. The evidence is that people with an ASD will do very well in conventional CBT. They'll do a little better, probably, if you adapt it. But you don't withhold it because they've got this. You don't withhold treatment of OCD because people have Emotionally Unstable Personality Disorder or whatever because they'll do fine. But you'll then have the additional things of the problems they've got with the ASD. So, there's a joke, isn't there, about a man who has got a problem with his hands and he goes to the surgeon and the surgeon says, you do this operation, you'll be fine. He says, will I be able to play the piano after the surgery and the surgeon says yes, of course. He said that's very good because I can't play the piano now. And you know, if somebody comes and has a couple of problems that might impact each other there's a reasonable chance that after you've dealt with your OCD or trauma or whatever it is that the other problem will need some further attention. But that's not a reason not to treat the initial problem in that way. Recently, we published a review of treatment of PTSD under conditions of continued threat. And it turns out that you should treat people under conditions of continued threat. So you shouldn't be refusing people the help that they so patently need because they have more than one problem. Rachel: and this is, yeah, it's a salutatory message and a hopeful one, isn't it? Because I'm sure the busy clinicians listening to this podcast, you know will have experienced that heart sink moment. It's a terrible word, isn't it? That heart sink moment, but it's very expressive when you get a referral and you think, Oh, this complexity, the longevity of this problem, I'm not going to get anywhere. And actually, it's that moment to go actually what does the evidence say? And am I going to withhold an effective treatment from people because they're, they seem to be more in distress but actually I'm going to give them the treatment that works really well. And actually you're selling it really well, Paul, because it sounds like these are not only the nicest patients, but the most diligent patients we'll work with. Paul: So, Yeah, let me take it back to ancient history as well, because when I was a boy, I don't remember when that was, but when I was a boy, there was no cognitive behavioural therapy, it was behavioural therapy and then cognitive therapy developing, and then we started to look at a whole range of problems like health anxiety, for example, or rumination and so on. And at that particular point, there were these patients who were just regarded as completely untreatable. People with severe OCD, people with health anxiety and so on. And that was wonderful because there was no expectation, you'd go and do therapy with people that nobody had ever been able to help and if you did anything at all, if you made any improvement at all, people thought you were a genius. Which obviously I'm not, but, if they didn’t get better, it was fine. So it was kind of like, so well, here's somebody who could be helped and we need to muck in and work with them to try to support them in making changes, getting better quality of life and so on. And I think if we could continue that attitude, you know, you see somebody coming through and you think, well, this is good. This is not going to be easy. Good. Let's get on with it. Rachel: In that vein. you've talked about, we've talked about complexity of longevity, we've talked about this kind of personality issues. What about other problems like psychosis, for example, where it might be, you know, someone might present, for example, with really, and these might be old fashioned terms now, Paul, around ego-dystonic and ego-syntonic but thoughts that of hurting other people, that they really feel very, are very aversive and difficult, but also maybe some other thoughts in other spheres that are, have a different kind of flavour, but presenting within the same individual. How do we work with unpick, unpack that? Paul: Formulate. I mean, in a sense, yeah, there's some very interesting work going on with people like Tony Morrison, and so on in psychosis but I think it's, I think the setting is somewhat different. I mean, there's somebody not a million miles away from me at the moment who's doing work on social identity theory in that, which I think spreads outside psychosis and so on. One of the things I'm arguing at the moment is that we need to move away from a purely disorder based approach and I think that some of the things we see are final common pathways that are kind of convergence of different effects, and that's one of the ways to think about hoarding. You know, so hoarding is not, I think, a single thing that's in somebody's head, it's like multiple ways. You can hoard because you're afraid that if you throw things away, you'll harm people because it'll contaminate them so that'd be OCD, or because you think that you might need those things in the future and so on. So, so there's multiple different ways you can end up with a house full of stuff. By the same token, people end up homeless for lots of different reasons. People end up in substance misuse for a lot of different reasons. And the idea of convergent processes, so a range of different things can lead to, for example, unusual experiences, psychosis, and so on. And so I think if we start to loosen off a little bit and be, and yes, be prepared to say, well, look, if it's honest to God OCD, then these processes are always going to be there. And that treatment is always going to work, but actually life's a bit more messy. And sometimes people are going to end up with these kind of repetitive thoughts or these beliefs, for a whole range of different reasons. And you have to work with the individual reasons. The other example of that is attempted suicide. Attempted suicide is a convergent process. There's no one reason, there's no one psychological profile that results in it. And I think if we start to hybridise the, if you like, the disorder specific model with a more trans diagnostic understanding and the idea that the outcomes that we see might be a bit more complicated and we might need to understand those complications, particularly in people with longer term problems with major interference in their life and so on. Rachel: So formulate, formulate, formulate. Paul: who would have thought, hey? Rachel: We've already alluded to some of the strange things we might end up doing as therapists, working with OCD and they can challenge us actually ourselves, our own assumptions and thoughts, you know, and those of people around us. My husband wasn't delighted at the idea I was taking our largest meat knife to work to have someone hold it against my throat. But there are other things we do, other things we may have as human beings doing this work. There are times when we have to challenge our own assumptions or fears and that can be demanding. How important is that, do you think, in CBT for OCD? And how do we both challenge those and look after ourselves in this work? Paul: I think this is true across the entire fields, not just OCD, you know, that we have to do extraordinary things sometimes, for example, let's take putting your hand down lavatory, you know, it's not how I generally do it. If I go to the lavatory later, I'm not going to put my hand down it and then eat my lunch without washing my hands or whatever. So that's not the norm. However, I would do that. And it's really important that if you work with OCD and somebody's contaminated, you're prepared to do something like that to demonstrate it. Now, you have, you kind of need to, I can't think of a better way of putting it than, say, losing your behavioural experiment virginity across the piece, you've got, and that's where training needs to come in, you need to get off your seat, go to the lavatory or if you work with PTSD, take the patient back to the site after appropriate preparation to where the trauma happened, so that they can process it differently, and so on. I see that as no different. These extraordinary things that we have to do to actually help people is no different from the extraordinary actions of a surgeon who has to cut into somebody's skin, you know, in through to the organs and do all kinds of stuff and so on. And you're not just going to be able to do that by saying, well, all you need to do is take a scalpel and make an incision. In the same way, you know, saying to people, Oh, you just have to put your hand down the lavvy, that's not going to work. So you have to become familiar with it. And it has to be the thing I talked, I've talked about a bit earlier there, about helping people discover how the world really works. And how the world really works is that it is possible when I put my hand down the lavatory and then eat a sandwich straight afterwards or whatever, that I might get a few days’ worth of diarrhoea. Actually, in 47 years, that's not actually happened to the end, but it will one day probably. Rachel: And you have had your hand down a toilet a lot! Paul: A lot of different toilets. And so, okay, and then the patient might say, well, why would you do that? And the answer, the short answer is to help you. And the question I put to the patient is, look, you get a choice between putting your hand down the toilet and you might possibly have a bout of diarrhoea that will last two weeks. Really bad diarrhoea for two weeks. Okay, that's one thing, but the other thing is that if you don't do it, you might, I mean you wouldn't put it this way, but if you don't do it, then you might suffer from, you will definitely suffer from OCD for the remainder of your life. So choice, two weeks diarrhoea, a lifetime of OCD, it's actually not that difficult in the end. The same goes for the extraordinary things we do. You know, in general, I don't do dangerous stuff, you know, if I'm not going to inject myself with live HIV because somebody's worried about HIV. I know that the toilet I put my hand down is cleaner than the keyboard that's sitting in front of me. There's more germs on that keyboard. I can tell you and your keyboard and all the rest of it than the toilet, but it kind of isn't the point. The point is about what the person's problem is and they need to be able to get it in perspective. And that perspective is you get your life back if you take some of those risks. Rachel: And throughout talking today and knowing you, Paul, you always speak so warmly and compassionately, but also so admiringly of the patients that you have treated over the years. I wonder what you've learned from the patients you've worked with or how, if in any way this work has made a personal difference in life, your life, or the focus of your work. Paul: that's a tough call. I've learned everything from my patients. I mean, as a clinician and as a researcher, then I've learned everything. I mean I've followed the patients. I've also followed, you know, the other giants mentioned Joe Wolpe, Tim Beck and there's Jack Rachman and that Clark chap and so on. So even that Handley woman, I've forgotten her first name, but anyway. The patients in the end that you, the test of your ideas, is with your patients. So, so at a professional level, I owe everything to my patients, and I can tell you where particular ideas came from, particular experiences and lightbulb moments that when I put together these things. Personally, I've just had a wonderful career. I don't think I've necessarily changed a great deal in terms of my personal life because of my work patients, other than it's made me happy to do the job and they even pay me for it, which is at times a little surprising. So I've benefited because it's an ever changing landscape. You never get bored and yeah, I've been very lucky because I can balance doing research and seeing patients. So I never stopped. For 47 years, I have been working with patients. I don't intend to stop any time at all soon or even ever, because I guess I'm a vampire, that I'm feeding off the energy of the people I work with and, and so on. But I also give something back. I hope that's my intention anyway. Rachel: A 100% and what's keeping you interested now? What are the pieces of research that you're excited about? What are the horizons? What are the areas you wanted to push in to? Paul: Well, OCD is still not a solved problem overall, and you know, Rachel: You've had 47 years, Paul, what have you been doing? Paul: I know, its lazy isn’t it? I just go into conferences and find bars and things like that. I'm coming to the conclusion from the data we're getting is that we need to go beyond responsibility, that's partly because of work that's going on at the moment where we're picking up that GAD and responsibility are more linked than we previously thought. So my eyes are turning towards issues of kind of interpersonal issues and whether they might be focusing on part of this. The clue might be in the reassurance, but reassurance is transdiagnostic and so on. Hoarding is completely, has completely kind of taken over in a sense as my second string. So, so I kind of feel like health anxiety, I'm still interested, but hoardings moved into second place where health anxiety was. And hoarding, it just seems to me, is so poorly understood, this idea of convergence at different reasons that people have for hoarding and makes it quite different I think from OCD in that way. I think we're making a really good headway on hoarding and that's taking us to the interpersonal domain as well. So one of the things that we picked up, one of the things that is different about hoarding as opposed to OCD where we've done the comparison is so we found, this is Victoria Edwards and Jess Barton and myself and other people like James Dennis coming forward. What we found was that the people with OCD and hoarding have less people in the social network than the people in the community. So far, so no different, but the people who hoard do not feel supported by those people, whereas people with OCD feel supported. And there's the difference. And so we've kind of progressed that now, in terms of, because people don't feel supported, it could be because they're not being supported. Or because they're being supported but they don't feel it. And so what we've been doing recently is looking at people who support people with OCD and people who support hoarders to find out what they think they're doing. And what we found was that people are supporting people with hoarding, are different from people who are supporting OCD folk. They're not different in terms of how much of a burden they find it. But they basically they kind of, they don't feel they're as effective in what they do, and they don't necessarily feel they're trying as hard as they could. That's different to what's happening in OCD. So something quite complicated going on there and I'm very struck, I've been working with self help groups, for hoarding support groups often run by fire and rescue who do a great job. And what's really clear is how much people with hoarding value the support groups, now people with OCD also value the support groups, but there's something slightly different going on there. And I think it's like they found people who aren't curling their lip in disgust at the state of their houses. And I think there's something about that and about, there's also something about the way society, things have changed for OCD. So 20 years ago people look at OCD and say, God, that's weird, these people are crazy and so on. I think that's changed that people do understand that people are almost happy to say they're a bit OCD and, and so on. So it's less stigmatised, whereas hoarding, we've got the thing that my friend Dave Westbrook called clutter porn, where you get these TV programs where you go, Oh, it's horrible. Look at that. Oh, there’s bottles of wee and stuff like that. And it's become stigmatised because the media, I think, has some responsibility in that respect and so I think it's important that we deal with it. I think it's pretty much not being treated nationally, and I think it's more common than OCD in the community. Rachel: it's sort of triggering that more disgusted and, and as you say, a stigmatised response rather than one of, it's very nice to go into a very clean environment that, that someone with OCD has sanitised for you. So next time you come on, we'll have to talk about hoarding. Paul: Jolly good. Rachel: Sounds like there's a whole podcast there. Also loads of really good work. And I know you've always been so good, Paul at encouraging people, young talent, people coming along, interested in doing this research and you do so much research with your trainees and with people in their early stages of careers. And it's really nice to hear about some of the folk coming forward with new areas. Paul: So young Handley, how is your research going on? Rachel: That's very kind of you, very kind of you, I think we might want to remove the young. And what about the dissemination of treatment, how’s that going? Paul: Oh, I'll leave that to that Clark chap…Clearly you know dissemination is the name of the game. We'll go back to this thing about whether we can disseminate very dilute versions of therapy or whether we should be trying to disseminate the full fat version of the therapy, not in terms of what you do, but in terms of the outcomes you get. And so I've got several projects already that we're trying to essentially build in things like blend, a blend of workbook and very focused therapist input. A lot of therapist time is spent on things like psychoeducation. You get psychoeducation as well from a computer program or an app or even from a good self-help workbook, which you can then just recycle endlessly, and so on. So those bits I think can be taken out and then they can be checked by a therapist. And so I think we can do more effective therapy, build up those understanding relationships, but remove some of the stuff from the therapy room, but not from the patient that just is a waste of time for the therapist, but not for the patient. Rachel: Yeah. So it's kind of self-study supported what we've now come to call high intensity therapy, it still remains that kind of that therapeutic process with the therapist but supported with materials. Paul: Yes, that's right. but also then if you go across the world, I mean, so we, we have the, the OCTC, the Oxford Cognitive Therapy Centre which I work with here. We're also then training people, for example, in Kurdistan, in terms of training. And then clearly, you have a completely different context and then there's the adaptation that's required and so the dissemination then is different and you're not going to do, it's not going to be in the context of NHS Talking Therapies, it's going to be in the context of a difficult, a very difficult and unstable political and healthcare system and so on. So, we need to find ways of doing that, of reinforcing that and that's just one example worldwide we've got the horrible situation in Gaza and the massive suffering that's taking place there. And, you know, the mental health needs of those people of refugees across the entirety of Europe and so on. So we can't use the same model. The Talking Therapies model will not work for that. And we need to be developing, you know, better models for translating dissemination. So the problem of dissemination is not particularly a UK problem. I think it's more an international problem. If we can work out strategies in the UK, which will then be open to adaptation maybe we'll get somewhere. You working at PTSD, you know how this works. How you, how you actually can't do you the standard stuff, but you're going to have to work through NGOs and so on. So, so we should be focusing on that global effort. And I think there's quite a lot of that going on, which is good. Rachel: Yeah. And if people want to learn more about your work or access training or develop their practice, or any advice you've got around people maybe mainly working in the UK in different settings, Paul: Go to the BABCP conference that's always good. It's good for a start. There's a couple of books. There's a ridiculously expensive book that Victoria Breen, Fiona Challacombe and myself wrote on CBT for OCD. Rachel: worth every penny of course. Paul: Get it from the library. I'm embarrassed at how expensive it is. Conflict of interest statement. I'll probably get tuppence if you buy it and there's also the self-help book, Break Free from OCD, which again, I only get a penny when we sell that, but that, those are accessible. There's our own website and of course, everybody should look at the OXCADAT website, but the BABCP is the best resources, and we're currently working on trying to make more resources available. I'm engaging with the BABCP to try and do that because we need to just get it out there. I mean, one of the things that drives me nuts is the way, more nuts than I already am, is when people sell things, that whenever I produce a questionnaire for clinical use. We do not sell it. You know, we don't copyright it and say you've got to pay two quid every time you use it. We give it away, basically. And we should be doing more of that. And we should be encouraging our colleagues to do more of that. We should give everything away and make it free for use. But at the same time, we also need to make sure that some of the junk that's out there then doesn't come in there. Because there are people selling junk in the name of CBT. And there's a, you get a Groupon voucher which allows you to train in CBT in two days and it would cost you five quid. Yeah, that's great. Rachel: Oh, all that time I've wasted Paul. Paul: The Accreditation people should get onto that and make sure that accreditation happens for that Rachel: Yeah. So, In CBT, we like to summarise and think about what we're taking away from each session. So in, in time honoured fashion, what key message would you like to leave folk with regarding this work? Paul: Your primary focus should be on the service user, the person who comes to you for help, and in terms of understanding and empowering them so that they can actually live a better life, they can have a better quality of life. And your job is to make that happen, not just to focus on the pathology, but also to focus on other areas of the person's life, help them reclaim things which have lost, and to aspire to longer term goals which are going to make a real difference to them and the people around them. Rachel: That's a lovely message to end on. And one that I think is a real antidote to what people often imagine CBT is, it's something very technical and, technique focused, and disorder focused. And actually, what you've just said is so much about the human being at the heart of the suffering. So thank you so much for all your time today. Thank you being on podcast. And thank you also, Paul, genuinely for all the research that you've spearheaded, all the work you've done over the years which really helps all of us engage and get satisfaction from engaging with this really important population of people who are suffering so much and can really genuinely be helped with these tools and techniques and this kind of wider focus on them as human beings and what they want to achieve in life. Paul: Thank you. Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team at [email protected]. That's [email protected]. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that new episodes are automatically delivered to your library and do please share the podcast with your therapist friends and colleagues.    

In this episode, Rachel talks with Professor Myra Hunter about the role of CBT in addressing some of the troublesome symptoms of menopause and the evidence base supporting its use. The conversation emphasises the need to engage women and acknowledge their unique experiences of the menopause, as well as the importance of an evidence-based, biopsychosocial understanding of these experiences. It highlights the opportunity for women to revisit positively their sense of self and identity during this stage of life. 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 X or email us at [email protected]. Useful Links: A full list of Myra’s publications can be found here: https://www.researchgate.net/profile/Myra-Hunter Hickey, M., Hunter, M.S., Santoro, N. & Ussher, J. (2022) Normalising menopause, British Medical Journal. BMJ 2022;377:e069369 Brown, L, Hunter, M.S., Chen, R., Crandall, C.J., Gordon, J.L, Mishra, G., Rother, V., Joffe, H., & Hickey, M. (2024), Promoting good mental health over the menopause transition, The Lancet, 403: 969-83 DOI: 10.1016/S0140-6736(23)02801-5 “The slow Moon Climbs: the Science, History, and Meaning of Menopause” by Susan Mattern, Princeton University Press, 2019 Hunter MS and Smith M. Managing hot flushes and night sweats: a cognitive behavioural self-help guide to the menopause. Routledge (2014). 2nd edition (2020) https://www.routledge.com/Managing-Hot-Flushes-and-Night-Sweats-A-Cognitive-Behavioural-Self-help-Guide-to-the-Menopause/Hunter-Smith/p/book/9780367853037   Hunter MS, Smith M. Living Well through the Menopause. Overcoming Series, Robinson UK (2021). https://www.littlebrown.co.uk/titles/myra-hunter/living-well-through-the-menopause/9781472148384/ 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 episode 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 so pleased to welcome Professor Myra Hunter to the podcast to talk about CBT and the menopause. Our agenda today is what is menopause and why is CBT relevant? The evidence base for CBT for menopause symptoms, adaptions to CBT in this area, common challenges and solutions, and what we can learn more generally from this work. But first, to introduce Professor Hunter. Professor Hunter is Emeritus Professor of Clinical Health Psychology with King's College London. She's published over 200 journal articles and eight books and her research on menopause has established her as an international expert in the field. She was expert psychology advisor for the NICE guidelines on menopause in 2015. She's developed and trialled cognitive behavioural interventions for hot flushes and night sweats and conducted research aimed at improving the experience of menopause for working women. Welcome Myra. Myra: Hi Rachel, hello to everyone and thank you for inviting me today to speak about CBT for menopause. Rachel: We'd love to hear a little bit about your journey into this work Myra and what you got you interested personally and professionally in working with women in the perimenopause. Myra: Interesting question, so I qualified as a clinical psychologist way back in 1977 and after that I went to work at the Institute of Psychiatry doing studies on pain, managing pain, headache pain at that time. So I've always been interested in the relationship between emotional problems and, physical health problems and emotional problems. And after that I went to work at King's College Hospital, basically as a clinical health psychologist working within the general hospital and taking referrals from psychological medicine departments. And, it happened that, I got quite a lot of referrals from the women's health, obstetrics and gynaecology, and at that time there was one of the first menopause clinics developed, and that, this was really unusual to have a menopause clinic in a hospital, I think there were only about two, two or three, during that period. And linking with your question, I was referred to women who often were depressed, anxious, going through the menopause. And I'd be asked this question by the gynaecologist, Is this woman depressed because of her hormones, or is it her? Something like that. And so, looking into this, and it was really fascinating, as a topic in general, I think, you know, especially for a psychologist to look at, because it's something that happens to everyone, every woman, more or less and it can be appraised in so many different ways. It can be a problem or not a problem. So the sociocultural aspects. So the psychosocial aspects are very important. And so I looked into this and then decided as I wanted to do a PhD at the time too, to do my PhD on that, which was looking at what symptoms are actually menopausal and what aren’t. And I got hooked to be honest thereafter. looking at really the psychosocial aspects of menopause and looking quite early on, really, at trying to develop. Looking at the factors that made the experience of menopause more problematic for women and then trying to find ways to help women to negotiate menopause transition, in the particular symptoms. So that, that's taken many, many years. And, and here we are. Rachel: So it sounds like the work really came to you and, and drew you in as you say, and part of that was the fact that this here's something that happens to all women who live long enough and it's a, a really, significant issue for a lot of women. But at that time, it was a relatively taboo subject I would imagine in terms of general conversation, but it's changed a lot, hasn't it? It has become quite a hot topic in the media in recent years Myra: Very, very much. I was thinking back to I was quite young, obviously, when I started to study this, and I'd go to parties, and people would say, Oh, what do you do? what's your PhD on? And I would hesitate, actually, to say menopause, because it wasn't, it was quite unusual to talk about it, indeed. And I think there's a dramatic change, actually, just in the last few years, really, in terms of awareness, talking about menopause. A lot of interest and in many ways it's a really good thing that people, women are becoming more aware of it. but it's a complex issue. Rachel: yeah, it's complex, isn't it? And despite the fact that we are talking about it more and maybe in part because of how much is said about it, people are still unaware or a bit confused about what menopause is and how it might affect women. Are you able to define menopause for us and the common symptoms that are associated with menopause? Myra: And just to say, I will do that, but just to say, I think half the confusion is there's more talking about it, but there's the focus on actual research has got drowned out by people's stories. So it's that balance I think that that that's often is tricky. So as an academic, I'm keen to really focus on the evidence that we have. So, the menopause literally means the last menstrual period, which happens I'm told now in the UK the ages of 52, 53. There is different stages, if we define this sort of biomedically, in terms of premenopause, and then there's perimenopause, when menstrual periods become irregular in lots of different ways they can become more frequent, or gaps between them and that's sometimes when the main symptoms of the menopause happen, which are hot flushes, night sweats. This can last, again, all aspects of the menopause are very variable between women, so it's really hard to, to actually generalise. So there's a big range of how long that lasts, the perimenopausal period. But then that leads to the last menstrual period. In the 12 months after the last menstrual period, it's said that a woman is postmenopausal. Now most of the more dramatic hormone changes, and this is really a drop in oestrogen levels and there are changes in progesterone too. Hormones fluctuate quite a lot during the perimenopause before they decrease. And obviously the menopause is triggered by the ovaries stopping producing eggs or there being no eggs left gradually, and the body tries to, goes into kind of overdrive to produce the eggs, and it's the rate of change of oestrogen during the perimenopause and early postmenopause that's associated with the hot flushes and night sweats. I mean, it's a big topic here, but those are the main symptoms. However, other symptoms are associated with it sleep problems, some joint pains, some, vaginal dryness can happen. That's a little bit later, usually, loss of libido, but a lot of this, the other symptoms that are associated with menopause also have other causes too and can interact with lifestyle, and I think that's when we talk about it, I always want to not just focus on physical symptoms but view the menopause in its broader biopsychosocial context. And I think as, you know, CBT therapists, that's something that is always helpful, isn't it, in an assessment situation. But the menopause, there's different kinds of menopause. Some people have early menopause, about 1 percent of women have it before the age of 40, which has other implications, doesn't it? And then you can have menopause because ovaries, by surgery, ovaries are removed or you have one exacerbated by chemotherapy after breast cancer. So again, the basic message is here, such variation, take time to ask the woman what she's experiencing and then help her to make sense of it in terms of where she's at. And you have to be a kind of detective to look at time frames to understand. Rachel: And it was interesting what you were saying, Myra, about often what we hear in the media are stories about individuals and you like to be very much research led. Now, I'm 47. I understand this is average age of onset of the menopause. Given what I read and hear about menopause and some of these stories in the media, sometimes I wonder, should I pack up, go home, hide under a very light, ideally cotton duvet for the next four to seven years and try not to panic. What do you have to say about these kind of negative stories that are out there? Myra: I love that you're actually thinking about it now. It's a really good thing. And I think there's a lot we can do to help women to prepare for the menopause. So I think it is worth thinking about it beforehand. I mean, actually, there's an early study, looking at preparing women who are 45 from GP practices in groups, looking at what they might expect, so it's basically looking at expectations and what lifestyle factors, and there are many that you can do to help yourself. So we would talk about what menopause is, but also very much look at these negative social stereotypes of menopausal women and ask the woman herself, ask yourself what you think about menopause, honestly, and verbalise it because often when you verbalise it, it does seem, hey, that can't be true, because in history and quite deep in our culture, our fears about aging, gendered ageism, would I become unattractive, unlovable, all these things, useless, lots of negatives we have, which haven't come just from us, they come from social perceptions of older women. And I think we really need to voice them and then criticise them, challenge them. And I think when you are talking about the myths, and I think a big concern for many of us is that while attention is drawn to the menopause, often it's drawn to the menopause because people have had a bad time and they're talking about that and that's quite valid and we want to hear about this. Some people do have quite a hard time and, but I think if, if all you're hearing is that it can feed into these negative expectations and worries and anxieties and attributing anything that happens in midlife to the menopause. I mean midlife is stressful, it’s not all menopause, of course, for men and women, midlife is stressful. We accumulate roles and responsibilities, and I think especially now, life's quite tough for a lot of women, I think, with financial pressures. If they've got children, and elderly parents and just managing themselves and life in general is really hard. So I think stress is a big thing that feeds into one's experience. It's understanding that. I think with everything I'm going to say really, I think a key thing is to have that bigger picture assessment and understanding the person, where she is in her life and to talk about stress in an interactive way. I think this is an important message. Rachel: It sounds like it is a potentially quite reductionist approach to assume that everything that's going on for a woman in that stage of her life, might be linked to the menopause but also that there is an interaction between these things that the menopause may have an interaction with other biopsychosocial factors in their lives to create some difficulty. Myra: Yeah. Rachel: And so we're talking about CBT and the menopause. we usually think about CBT in relation to psychological disorders, don't we, often we're thinking about specific disorder, specific models for CBT, but you've defined menopause as a normal part of the woman's reproductive journey. In what way is CBT relevant then to the menopause and what is it that women might need CBT for around this time in their lives? Myra: Sure. I mean, and I think it's relevant in a public health kind of way, but it's also helpful for those who are, might come to see a therapist and I think there's, there's two levels and just to link a little bit back to the previous question about approaching menopause and expectations. So, I think CBT could have a general role in terms of looking at beliefs and understandings and challenging some of those that aren't helpful, bringing in evidence. So I would say to you, approaching the menopause keep an open mind. There are many positives about menopause too, no periods, no need for contraception. And this is a quick aside, I'm sorry, but I need to say, there's that lovely book by Susan Matten called The Slow Moon Rises. And she talks, she's done extensive historical research and anthropological research and really supports the view of menopause being actually an adaptive part of the process for the species that we have women who don't carry on having children so that they can actually look after their own children. We have grandparents who can help with the next generation and it's those factors. So it actually is useful rather than one of these very negative phenomenon. So, why is CBT helpful for menopause? Well, I think extending that really, the research we've done does show that having negative beliefs about it actually impact on a woman's experience of it in an existential way and affecting mood, but also affecting their perception and the thoughts they have in relation to the physical symptoms, the hot flushes and night sweats. So, the particular focus of the CBT that we've, trialled that's novel is developing the CBT for the vasomotor symptoms or hot flushes and night sweats, how the women manage those. So, so that's a relevant part of CBT. However, as we know, given that midlife stresses happen around the time, a little bit before usually, but around that time depression, anxiety are quite common anyway. And so you'd be likely to be seeing people with those problems. So, I think a challenge is, and perhaps we'll be talking about that more in a moment, will be to, if a woman comes and she's perimenopausal and she's presenting with anxiety and depression, how do you manage that situation? Rachel: Hmm. Absolutely. And and are there some groups of women that are more vulnerable or at risk to developing depression, anxiety around this period of time than others? Myra: Sure. Yeah. I mean, we just had some papers come out in the Lancet and one of them is on mental health and menopause. And I think, and the headline for that is there's no need again for women approaching the menopause to necessarily expect to have mental health problems during the menopause. That's a big one. So if we think about risk factors, there's the usual risk factors, developing at childhood, adversity, lack of social support, the usual risk factors. But in relation to menopause, there are two specific menopause related ones- they are, hot flushes and night sweats having long duration with sleep problems. Sleep problems and depressed mood during the menopause are bidirectional in their core, they influence each other. And I think, again, talking about interactions is so much easier than getting caught up in mind body problems. Other risk factors are having an early menopause can be a risk factor. Having an induced menopause where the hormone levels drop very abruptly can put women at risk of depressed mood, depression, but also life stresses. I mean, there's an interesting study carried out in, 2016 by Gordon and colleagues where they looked at women with hormone fluctuations, taking lots of measures and they found that that was associated with depression, but only in people, women who had preceding recent stressful life events. That's another example of those interactions. So, most people have hormone fluctuations, but they don't all have depression. It's about nine to ten percent of women have an increase in depressive symptoms during the menopause. But a lot of the symptoms associated with it like brain fog and other things are relatively time limited to that perimenopausal period. So I would also always look for positives. You know that the woman shouldn't, that mood, if there is low mood during that time, that it tends to improve afterwards. Rachel: That is encouraging. So this is a, this is a time limited phenomenon. So if you do happen to be in that sort of 9-10%, it's not a life sentence. It's something that actually hopefully passes with time. Myra: And of course, this is why the therapy would help to abate that, wouldn't it? So the treatment for the vasomotor symptoms, the hot flashes, night sweats, it very much includes lifestyle advice, stress management, touches on anxiety and depression, because all these, and sleep problems, because they all mix, they're all together. Often when someone comes to seek help, they're feeling overwhelmed, so we, it's very much treating the hot flushes in the broader context and looking at the lifestyle and looking at what's stressful. And I think stress is a huge factor. Rachel: and we'll talk a little bit more about the therapy in a moment. But can you tell us a bit about the evidence base and the clinical recommendations for CBT with respect to the menopause? Myra: Sure. Well, the recommendation, it's all quite recent that CBT has been on the map at all for menopause. A lot of it's from the work that we've been doing and acknowledging my team over the years, here. So, the first NICE guidance in the UK happened in 2015. And that NICE guidance recommended CBT for low moods and anxiety associated with the menopause basically on the basis of some of our studies, but looking at having depression, anxiety, secondary outcome measures. But it didn’t say that there was enough evidence at that stage that hot flushes and night sweats should be recommended. Since then, the North American Menopausal Society has recommended CBT for vasomotor symptoms on the basis of our research. And currently, there's in process an update of the NICE guidance that's specifically looking at whether they should recommend CBT for vasomotor symptoms or not, and it's going to report finally. There was a consultation that, that felt that it was likely to be approved, but we'll know soon. So, but there's a lot of evidence, lots of the review articles, lots of the position statements of what menopause organisations recommend. And the CBT for vasomotor symptoms. It's also recommended for sleep problems, there have been studies done over the menopause period for sleep problems. So, yeah, you know, it's now acceptable. Rachel: So there's a wide and emerging and developing evidence base there, that's pointing in that direction. And given that it's in the NICE guidance for certain aspects and more talked about, it's really helpful for therapists out there to understand what it is they might want to offer in terms of CBT. Now you've developed and trialled CBT for hot flushes and night sweats, its a big area. And I know there's a huge amount in that treatment, Myra. It's really unfair to ask you to summarise that. But could you describe a bit about the approach? Myra: So, I'll describe the approach, but also I think some awareness of menopause, even if you're not going to use the CBT is really helpful. So I think we need to sort of try and cover a bit about if you're doing the CBT specifically for the vasomotor symptoms, but also if someone comes with low mood or anxiety, just if menopause comes into the room, into the therapy room. So the CBT we've developed, as I said, targets, well it's psychoeducation, we're using a behavioural, a biopsychosocial model, introduces CBT, focuses on stress, wellbeing and then on hot flushes. And then sleep and night sweats and then, maintaining changes. So, it's eight hours, either six sessions of an hour and a half, or four two-hour group sessions is what we've developed. And the groups can be face to face, with six to 12 women, but also with COVID we started to develop an online, you use that online and you can quite easily do that. And quite a few IAPT services are actually doing this already The key aspects of the CBT, I mean, the stress and lifestyle are really, really important because they exacerbate the symptoms. But for the hot flushes and night sweats, the research we've done shows that particular sorts of beliefs and thoughts, automatic thoughts are associated with problematic symptoms and these we've developed questionnaires to measure; The Hot Flush Belief Scale and Hot Flush Behaviour Scale that looks at these. So the first the beliefs that are common that we target are first of all what we call sort of beliefs in social situations -the idea that everyone's looking at me, they'll think I'm stupid, they’ll know how old I am or give away personal information about myself. So that embarrassment factor is really important and that's most women voice that if they're having problematic symptoms, particularly in the work situation, they're more difficult to deal with. And so they're using, often use a sort of cognitive style of mind reading. So, we would look at the evidence for those thoughts, and actually it's quite rare that you find out what people are thinking. So we did, Melanie Smith, who's working with me, co-authored the books with me, led on this study of people, men and women age 25 to 45 in work situations across different organisations. And we asked, give them a scenario such that you're in an open plan office, a colleague, a woman has a red face or is sweating. What would you do? What would you think? And we didn't mention menopause, hot flashes or anything. And it was quite interesting that they didn't, certainly not everyone mentioned they thought it was menopause. And often they'd say, or maybe she's run upstairs or gone to the gym or had a cold or something like that. So they had other explanations and they thought about it for just a few seconds. And they didn't think anything bad about her. And if anything, they were quite empathic saying, is she okay? So, we fed that back to the groups and they found that quite useful. So we would do experiments like that. Rachel: It sounds Myra that it, it reminds me a lot of the kind of what we might do with social anxiety, similar types of experiments and cognitive distortions that might be around within that context. Myra: That's right. And I think one difference is also where these come from. And to ask the way, well where do these come from? And, you know, it could be from. their mothers, or, but often it is, it comes from those general negative stereotypes about older women, and so that you can challenge those and especially in groups you quickly get to that point where you're talking about, well, why should they think that and if they think that, you know, tough, I'm not going to take any notice. So, it’s looking at the sources of that, and actually verbalising them does make them sound ridiculous. And the evidence that what would a friend say to you, these sorts of approaches and how unhelpful they are to you, what nurtures you, what makes you feel better, not these don't serve you at all to bring on and give yourself these negatives. So that's quite important. And the second, the second strand of the thoughts is perceived control. Feeling out of control that something awful is going to happen or I'm going to make a fool of myself, or I'm overwhelmed, these will go on forever, that kind of catastrophic type thought. And again, we would do behavioural experiments and look at the validity of the expectation, the anticipation and that's paired with a focus on the behaviours, which often is avoidance and again, a bit like anxiety, isn't it? That someone would have those thoughts and quickly dash away from the meeting or something like that. So, we would encourage people to stay in the situation. And another behaviour actually is that it's diaphragmatic breathing exercise, so they would do the breathing exercise, stay in the situation and work out what's a helpful thought, spend time in the therapy work, finding more helpful, self-serving, less critical thoughts, more compassionate thoughts, and then bring them in quite calmly. Just letting the hot flush flow over them, not fighting it. And when we did interviews with women who'd had the CBT, they said that control was really important but that came partly from starting off by accepting the situation and then managing it and then they felt more in control of it. The third type of thought relates to night sweats and sleep. And many of us will be aware of the negative thoughts that cause arousal when you're trying to go to sleep, such as if I don't get sleep, I'll feel terrible the next day, those sorts of thoughts. Well, it links with those, and we do proper CBT for sleep, but with the night sweats, often the thought is, if I have a night sweat I'll never get back to sleep, or if I have night sweats I'll feel terrible the next day, so it's adding that into the sleep therapy really. And for the sleep, we would, for the night sweats, we'd use similar approaches to the hot flushes, and they are really only hot flushes at night but have more impact because they're actually waking you up, but to help to develop automatic responses there so someone wouldn't be thinking about what to do or getting worried about it at night but just automatically accepting it, breathing and some people use sort of cooling imagery and lots of different things to go with it. Rachel: so, you've got your sort of automatic contingency plan. You don't have to use a lot of cognitive effort to put those things into action. Myra: So I've done the three main cognitions, and the behaviours were avoidance, not going on public transport, people would do things like, I remember a receptionist I was seeing who would hide her face with her hair like that when she was having hot flush, but actually, you know it's counterproductive because people, she look at her because she was doing that rather than the trying to hide the hot flush. We find again and again that this lot of problem solving comes in and I think this is where the groups are helpful that you can come up with things to say, can you actually talk about it and role playing. If you have a hot flush in the situation, what do you do? You know, we're saying stay with it and everything, but sometimes if it requires an interpersonal response, what would you like to say? How would you like to deal with it? And often by the end, people would say I'm having a hot flush and practice saying it without feeling, without qualifying, without apologising, just being normal about it. We very much encourage talking to family and friends outside the situation to normalize it for them. The other behaviour was a group, a bit like safety behaviours actually, it was carrying fans, water sprays, lots of different things like that, which weren't associated with problematic or less problematic symptoms, they were kind of in the middle. So we would think, we didn't actually encourage them necessarily, but if people, individuals found them helpful we would support that. So they're the particular types of thoughts and behaviours, but these will be practised across the therapy with homework, feedback, and it's all manualised, so with the manual that we'll talk about at the end, there are PowerPoint presentations, homework sheets, et cetera, et cetera that the therapist can use too to take the women through these. Rachel: So as we might expect, I guess what you're describing are some of the key standard elements of CBT. We're thinking about working with cognitive distortions and cognitive restructuring. We're thinking about behavioural interventions, thinking about avoidance, reversing avoidance, dropping safety behaviours, testing things out. We're thinking about normalising problems, talking to others, things like problem solving. But really importantly, I think what your work sort of guides us towards are these really specific cognitive themes that come up time and time again, or particular behaviours or avoidant situations that, that are very common in these scenarios. Myra: I think that's true. And I think, I think the other thing that's really important is to get to that stage. And I think we sort of talked about it a little bit. It's about engaging people to even talk about menopause with people because it can be quite polarised and everyone's coming into the room with a different view of it. So really to make sure to kind of pre-empt problems really, this is what we've learned to do. So, to start off by acknowledging that women have very different experiences and listening to their story. I'm sure you all do that anyway, but in these cases, particularly ask them what their view about it is and what's what they think is most is the main cause of their problems. And obviously what sort of treatment that they would like. It’s got to be an informed choice. And I acknowledge an understandable scepticism that lots of people might have to use a talking therapy for physical symptoms, so acknowledge that and say, we're not saying it's all in your mind. To say things before they have a chance to say them, really. We're not saying it's all in your mind. It is real. They are biological facts; we've got a model of what causes hot flushes and hormone changes and how thoughts affect bodily reactions and vice versa. All those sorts of things. And then, to use the biopsychosocial understanding about don't just start with the vasomotor symptoms, I would start with the menopause, because then you get the, the more, what I call existential, but the, the sort of appraisal of menopause is really important into as well as the biological changes, so, to understand that. And then talk about interactions, and I think, and that there's an evidence base for it, I mean, I think there's those reasons, but if people are sceptical, and some people came into our trials being, still being sceptical, but were willing to have a go and give it a try, And that's fine, so we would approach it like that. So I think if you get stuck, or if there's a problem, it's often around that. And people feeling that that it's all in your mind. And I think, I, I understand that, because I think for many, many years, centuries, women's health has been put down, so it's all in your mind or not taken seriously, and we haven't had enough research on women's health. So, you know, I do, I do understand that. But, it doesn't need to be. Rachel: Or worse to his hysteria or neuroticism, Myra: Exactly, exactly. So I think you have to be careful, I have to be very careful about, and if you talk about stress, you can get, you know, oh, you're saying it's all in my mind. No, we're not. And I think that now, with the awareness, obviously, we are still having quite extreme polarised voices over these issues, but at least they are being talked about, and there are, I think we will get a more, come towards a more balanced view. Rachel: So it sounds also like therapists may need to also do a little bit of self-reflection on their own attitudes towards these things. We recently did a podcast on aging and talked about how we have these negative attitudes often towards aging and these kind of hopeless attitudes towards what those stages in life might look like. It sounds like that might be helpful for clinicians as well when they're approaching women going through the menopause and presenting with some of these issues to reflect on what their own attitudes are towards that. Myra: Absolutely, I think that's a really, really good point. Because I think often we've heard, because we've done lots of research in the workplace, and talking to men and we've often heard people say, Oh, I've had this, therefore I understand. Or, my wife's had this, so I do understand. But we mustn't generalise from our own experiences either, but reflect on them, and then think about, well, what do I think about people in general and ask, I mean, asking the woman and taking that seriously and listening is, is the first, I mean, that gets you quite a long way to really understanding. I think what's also very therapeutic is to explain the evidence, really the evidence doesn't suggest that you're automatically going to be going to this decline and decay model. And some people talk about it as a disease. Well, I don't think that's helpful. It doesn't sort of fit with how I understand definitions of a disease, but people will have different experiences and I think our lifestyle stresses interact very much with these more difficult experiences. But I also think that for some women, taking hormone replacement therapy is quite empowering because they choose to take it. It's all about informed choice. And I think sometimes it is difficult if you've got lots of different, very stressful lifestyle and menopausal symptoms to know where to begin. And I think sometimes offering both can be helpful. Or sometimes trying one and then the other, it's not, it’s not either or. But I think, it's good that women now have more choice. They've got the choice of a medical and they've got the, the HRT as a, as a choice too which is very effective for vasomotor symptoms. Rachel: So there are some important themes there about empowering women, giving them choice and also maybe getting other narratives out there that maybe challenged some of these pervasive negative narratives about the menopause. And you spoke earlier about The Slow Moon Rising book and how actually this, this period of life could be adaptive and maybe open lots of opportunities for women who maybe have spent most of their life looking after others to this point and attending to the, the particular demands of their reproductive journey. Actually there may be opportunities in this stage. Myra: I'm really pleased you mentioned that, because it's something I wanted to talk about, is the results of qualitative studies with women which tend to over time, I did one a long time ago, but more recent studies, come up with the same themes which echo in part what you're saying. And I think this is really important that it's a journey. And at that other level, women often will find some things a bit tricky with it, symptoms that aren't welcomed. And also face facts often, and we don't welcome being older, just to face that. It doesn't mean you're diseased but it's something to adapt to but also some positives as you go through, and, and in many ways you stay the same. In this qualitative study I did, one of the themes was, I'm still holding onto myself sort of thing. I'm still the same person had to say that because there all the discourses were suggesting she would change dramatically. But there was another theme in mind when we were talking about staving off the unknown, sort of fears about the unknown. I think this is what, we don't have to put ourselves through that. We can actually, reassure ourselves and not to have the view that it was all going to be perfect, but these qualitative studies suggest that over time it is a journey and that women come through and often really re reform their sense of self and their identity and become a bit more assertive and, enjoy not, as you say, not having been tied to those roles of being reproductive. It’s not voiced like that, but it seems to fit with it, and I remember one group I did, these were women who had been depressed through the menopause, and as they came through it was amazing. They tended to reconnect with things that they sort of semi creative things, or things that had been slightly thwarted when they were younger that they wanted to do, particularly in a sort of more artistic way, or dancing, those sorts of things to sort of bring themselves forward and reconnect with the things that they, they perhaps wanted to do. So, it's also, when we can do this, make it a time for reflection, in a good way, look at your lifestyles. I think the lifestyle advice should be framed positively. This is a time that you can take time, but I think the emphasis is to encourage women to give themselves a bit more time. We would say, give yourself half an hour a day. That's heaven to many people, isn't it, these days? But if you're in a group or if you've got a therapist telling you can do this, you can, and make small changes to your lifestyle that serve you, that you need time to, it's like adolescence, you kind of need a bit of time to help yourself through it, and that's not pathologizing it, it's a compassionate way to help yourself through that life transition. Rachel: I can really see how the group dynamic could be helpful in that as well. And hearing other people's perspectives on that, because it is something we often struggle with as women, isn't it? Taking time for ourselves, not feeling selfish or self-absorbed for doing so. Myra: So important. That's so, so important. Often the simplest things have maximum, have a lot of impact. And I think, I think in order to get the most out of the CBT as well, that's why we start off with that stress and wellbeing sessions so that you prioritise yourself, and, especially to counter, particularly now, the stress on women, midlife women, and younger women as well, we can talk about social media and these things, but if you put everything together, it is quite a, quite everyone feels too busy, don't they? So, but there are simple ways, simple things you can do. Rachel: So maybe it's an opportunity to gather yourself and be yourself, but more yourself, even into these years, investing in the things that are really consistent with your values and who you are. Myra: And giving up things that don't serve you, that you've, it just habits. I think to look at lifestyle like that. Rachel: One of the things we're really eager to talk about on Practice Matters is looking after ourselves as therapists. Many CBT therapists are women, it's probably a female dominated, field. profession still and other like other professionals, they may find navigating menopause symptoms a challenge in the workplace. So, the idea of dissolving into a puddle of sweat in front of a socially anxious client might be a useful decatastrophising experiment for that client. But, undeniably emotionally challenging for potentially for the therapist. And it is an undeniably emotionally challenging profession at times. And that's when you're feeling your best. How would you advise female therapists working through the menopause who are, who are finding aspects of that challenging? Myra: Well two things come to mind. First of all, one is what we've been talking about is look, is prioritising your own self-care and really doing that and telling people around you that's what you're doing and not feeling bad about it, that it's warranted. And I think the other thing that can be helpful is to, is to link with other women that you know, your peers who are likely to be going through the same sort of thing and meeting and talking with them about that. I think you end up as somebody in these situations as being an advocate in the end too, quite quickly as to promoting an empowerment perspective on menopause. So, you can do it on your own, but I think it's really helpful to have a couple of other women that are maybe colleagues or friends that you can just set up a  group with that either support network or something and there's lots of possibilities there, it's so helpful. But I think, not trying to be perfect as well and it, it is a real test of ourselves, isn't it? It's easy to say about what I've been saying about using a CBT for vasomotor symptoms. But I think, to be able to say I'm having a hot flush, it's a test and that's what we should be trying to do. I mean something comes to mind, I was on the train the other day and there were lots of young people, maybe students or something, talking boys and girls. And, and I was listening to the conversation and the woman, the girl was talking about periods quite relaxed and the man, and the boys were asking her, oh really, oh is that, and she was saying, I feel, I crave a lot of sweet things, and they were saying, oh really, and they were actually having a conversation about periods, and I thought that was amazing. And so, I think. Yeah, it's taking the embarrassment out of it, isn't it? I suppose the test is, imagine you've got a cold and you're seeing a client. You probably excuse yourself because you don't want to give them the cold or something or deal with it, and I think it's trying out every situation is different, isn't it? It's a bit like using humour. Women together will use humour, but you don't want to use humour with your boss if you don’t want them to make a joke about you. So it's all situation specific, but I think if you've got a little group to brainstorm those things and to check it out, it becomes, it lightens the load hugely. Rachel: We've got a lot to learn, I think, from the younger generation and their openness around these things. But of course, they're able to be open because of many brave women, who have, have been advocates like you've, you've spoken about, and you've been open and, and put these things into the public domain and at a time when it hasn't been so acceptable. We've also got a lot to learn. I think often as therapists from our clients is one of the joys of what we do, isn't it? We we're learning about life just as, as we're kind of going along having those windows into other people's lives. What if anything, have you learned from the woman you've worked with or has this made a personal difference in your life doing this work? Myra: Oh, wow. Well, I think I was going through my menopause when, when I was doing the pilot studies for the CBT. So, that helped me, actually, to use those methods on myself. Rachel: So it was real lived experienced? Myra: In terms of what I've learned from clients, I mean, one person stands out to me that she came, and she was treated with CBT to manage her symptoms, and then she was discharged, and we had a couple of follow ups, and she was fine and everyone was happy about that. Then she came back and the symptoms had all come back, and she said she was bereaved. And I thought, you know, wow. You kind of know that stress makes them worse, but I think it made me think that it was just a really good example of that interaction between lifestyle and what's happening in your life. I think the simple question of what's happening in your life and looking at the time frame of when they started, together with the client, and we do that, don't we, with other problems. And the other thing was, it was more about the women who were in this group, who were reconnecting with things that were important to them was that kind of drive to do something extra with your life and the creative aspects. And I suppose not that that influenced me, but it was sort of an example. But myself, I've got a painting behind me, so I'm here at my desk and behind me I paint. So, I do all paintings and, and it's wonderful. It really does give you something that, I couldn't do this when I was working or when I was younger. So I think it is an opportunity. This is more about age, but responsibilities. I've also got grandchildren, which is another thing that you don't expect. So life brings other things if you have the, if you're well and look after yourself and are fortunate not to have health problems that stop you being able to function, I have to say, that, I mean, I think it's easy to say nothing's in our control, is it, at all, so we can't, we just get grateful for what, what happens day to day, I think, because we, things can happen and we can't control everything. Rachel: So I'm reassured. I don't have to go and dive under that duvet just because I'm 47 and entering this period in my life. And If people want to learn more about this work, Myra, you've given us a brilliant insight into it and I know it's, it's asking the impossible to summarise a kind of career's worth of work in a short time, but where can they access training? Do you have any recommendations for books, papers, workshops? Myra: So the self-help book is, with Routledge, called Managing Hot Flushes and Night Sweats. And that's by myself and Melanie Smith. And that includes what we gave to the women, basically, within the four-week treatment so people can use that. You could use it, they could use it, and then see you as a therapist weekly to, to encourage that. I think that that's, other people have done that, or they can have a WhatsApp group with other women to support each other throughout that. And then we've got another, Robinson published book, you know, in the Overcoming series called Living Well Through Menopause, it's more general for women going through it. And then, I think importantly, we've got the manual for health professionals which is really like learning to drive, and with all the details you might need with examples. And it's got the handouts, the PowerPoint presentations are available. For one's own use, it's not to be commercialised in other apps or anything like that. But, that's, if you wanted to run the groups and you're experienced in CBT, then that might be enough. But Melanie and Janet Balabanovich, who have worked with me, work, do a training, bigger training sessions with the British Menopause Society, and they are now running twice a year. They tend to be oversubscribed, but they are for health professionals. I think lots of GPs and nurses go for that training. So, but we are with colleagues at UCL and, with Rachel, you've expressed interest to help us a little bit with this. We're thinking of running perhaps a day course so that people who are CBT therapists and psychologists might be able to come and actually live through this, practice some of these skills in a day session. So that's something that we look forward to trying to establish perhaps later in the year. Rachel: That's fantastic. And we can put links to all of those resources on our show page so that people can access those after this. That that's great to know. It sounds like dissemination is a, is a big area for development now. And, and of course, as people become more educated as to CBT being useful in this period, they're going to ask for it more, which is a good thing, but we need to make sure that it's available when they do. Myra: Well it's great that you're, that you're promoting and developing this with the BABCP for people. Rachel: So in true CBT fashion, we like to summarize and think about what we're taking away from each session so what key message would you like to leave folk with regarding working with CBT and the menopause? Myra: I think to emphasise listening to her story, a biopsychosocial perspective, variety of experience of menopause, one size doesn't fit all and focusing on interactions. So I think all that work in informing the women about menopause, that work at the very beginning is key in my view. And then once you come to looking at some area that you want to work with, it becomes easier after that. But if you try and just home in straight away for I'll give you CBT for vasomotor symptoms without doing that, I think it's less likely to be successful. Rachel: So keeping an open mind, staying curious, asking questions and understanding the bigger picture. Myra: And providing the basic knowledge, it doesn't need to take too long about duration, about typical symptoms and what can interact with other things. And also the positives, that balanced view, I think is key as well as some positives. Rachel: Fantastic. And what I'm writing down to take away is that I'm allowed half an hour a day to myself. Myra: Good. Rachel: I'll tell my three children that later on. So Myra, thank you so much for being with us on the podcast today. I'm sure that everyone listening will have learned heaps and have so many more questions. We could, we could talk and talk and talk. Maybe I'll come back another time and we'll talk some more, but thank you so much for sharing your wisdom with us and for all the work you're doing to promote this and maybe even explode some of those myths and unhelpful attitudes, unhelpful narratives, as well as understanding the challenges that women do face in this time. Thank you so much for that. And to our listeners, thank you as always for the work that you do. And until next time, look after yourself and look after each other. Myra: Thank you. Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team at [email protected]. That's [email protected]. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that new episodes are automatically delivered to your library and do please share the podcast with your therapist friends and colleagues.

Let’s Talk about CBT has a new sister podcast: Let's Talk about CBT: Practice Matters with a brand-new host Dr Rachel Handley, CBT therapist and Consultant Clinical Psychologist. Each episode Rachel will be talking to an expert in CBT who will share their knowledge, experience, research and professional and personal insights to help you enhance your practice and help your patients more effectively.  Whether you are a novice or a seasoned clinician we hope you will find something to stimulate thought and encourage you in your work.  This episode Rachel is talking to Prof. Ken Laidlaw, a leading expert in aging about Cognitive Behavioural Therapy for older adults. He debunks myths and misconceptions about CBT with this population, highlights the evidence base for its effectiveness and discusses interventions, adaptions and challenges. Ken shares his personal journey into clinical psychology and his passion for working with older people. He emphasizes the importance of defining older people in the context of mental health and challenges ageist stereotypes 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 X or email us at [email protected]. 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 Useful Links: Ken Laidlaw (2015), CBT for Older People, SAGE Future Learn online course on CBT with Older People https://www.futurelearn.com/courses/cbt-older-people NHS talking therapies positive practice guide: Older People https://babcp.com/Therapists/Older-Adults-Positive-Practice-Guide A Clinician’s Guide to: CBT with older people https://issuu.com/thecbtresource/docs/laidlaw___chellingsworth_cbt_with_older_people_iap British Society of Gerontology https://www.britishgerontology.org Professor Ken Laidlaw publications: https://www.researchgate.net/profile/Ken-Laidlaw   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 am delighted to welcome Professor Ken Laidlaw to the podcast to talk about CBT with older people. On our agenda today is the evidence base for CBT with older people, including myths and misperceptions, adaptions to CBT with this population, common challenges and solutions, and what we can learn more generally from work with older people. But first, to introduce Ken, Professor Ken Laidlaw is a clinical psychologist with world leading expertise in the psychology of aging, CBT for older people and attitudes to aging. Ken has published and developed a multitude of research papers, treatment manuals, books and guidelines, including leading on the NHS Talking Therapies Positive Practice with Older People Guidelines recently updated and hosted on the BABCP website. Ken retired from his role as Professor of Clinical Psychology and program director of the clinical psychology doctoral training program at Exeter University in 2022 because of caring responsibilities. Thankfully, as things have improved, he's returned to part time clinical practice working with NHS Scotland, and he remains Emeritus Professor in psychology at Exeter. Over and above all those wonderful qualifications. I'm particularly thrilled to welcome you Ken as a friend, mentor, and former colleague. Through working with you closely in clinical training, I learned that your values align really closely with those of this podcast. You're a committed educator who invests enthusiastically in the development of psychological professionals, you're committed to excellence in research and research led practice. And despite working in the most demanding of leadership roles, you've always maintained your clinical practice within the NHS and your passion for working with older people. Ken, you're also a humble person and you won't like all those nonetheless factual accolades. But I suspect you might like to tell us a little bit about your journey into clinical psychology before you had all these professional achievements under your belt and how this has shaped your practice and approach to your work. Ken: Well, thank you first Rachel for such a privilege and such an honour to be invited to speak to you on this and especially given we have such a good friendship and I've been very privileged to have your friendship and your professional collaboration. There's lots of things at Exeter recently in recent years that I couldn't have achieved if we hadn't worked together. And so thank you first for doing this. And you're right. I do kind of think it's important to try to be humble and have humility by what we do, and I recognize that in you as well. So we've got shared values on similar ethos and similar approaches to working hard and trying to do the best we can. I got into clinical psychology training through an interesting, odd route, I suppose. So I left school at 16 and, I didn't really know what I wanted to do. I stayed on, did a few O levels, O grades in Scotland at the time. And then, as was traditional in my family, went to work for the National Coal Board and I did an apprenticeship. It was a four-year apprenticeship. And it was really there that education started to click for me. I started to really enjoy education partly it was to do with, I was going out with this girl at the time who later became my wife, and she was studying at university and just to keep her company, I would just study with her. And then I got the bug for education. And when I was at day release college, everything just started to click into place for me. Clearly, I was a late developer. And because I was working for British Coal and the National Coal Board, there was a strike in 1984, I was involved in the strike, and it was round about that time I decided I needed to think of what I was going to do for the rest of my life, because I wasn't going to be able to work in this place for the rest of my life, and didn't want to be working in that place for the rest of my life, but, I then got interested in in perhaps taking my college education further and, and perhaps going to university. And I was the first person in my family to go to university and I went later in life. I was about 26 when I went to university and so I took this vocational course. It was a nursing degree at Edinburgh University. And when I was there, we had to do clinical work alongside our training. And that was great. And I was doing psychology as an outside option from a degree. And I started when I was doing my clinical work, I started meeting these clinical psychologists. And I thought, that's the job I'd really like to do. And I was very fortunate, there was a, there was a couple of clinical psychologists, there was Ian Robertson, Nigel North, and Bob Lewin, at the Astley Ainslie Hospital. And they were really kind to me, and they helped me, and supported me, and eventually, weirdly, I got on clinical psychology training. That, that's, that's how I got to be a clinical psychologist. I had to give up my nursing degree, switch over to psychology. I was advised against doing that. I did it nonetheless, and I did my psychology degree, got on clinical training, and A whole new world opened up for me. It was fantastic. And at the time, I was really fortunate. When I trained at Edinburgh, there was a woman called Ivy Marie Blackburn. And it was Ivy Marie Blackburn who brought CBT to the UK. It was Ivy Marie Blackburn who, as one of the pioneers of CBT, really lit a fire for me around CBT. So before, when I first set out to do clinical psychology training, I wanted to do it because I wanted to be a neuropsychologist. And I was particularly interested in stroke, so always interested in older people, but I was interested in stroke. But then I met Ivy and I just got inspired by Ivy, and I just got captured by her evident passion for CBT, and just the ideas, and it was like, this was just like, amazing new world of possibilities has opened up for me, that the way we think about something affects our behaviour and affects how we feel, and because our psychological and physical state are not disconnected if you change one thing you change everything and let's start with thoughts. I mean it was like "this is amazing”. So that was really when I got really interested in CBT but I couldn't have, I couldn't have predicted, even when I started being interested in clinical training, that I'd be interested in CBT Rachel: And you said that you were interested in working with stroke initially, you always had an interest in working with older people and CBT with older people. What was it that, that got you interested personally, professionally in that population in particular? Ken: For someone who works with older people, I find that a really interesting question. And I've spoken to other older adult psychologists, and a lot of older adult psychologists, they'll tell you that they didn't necessarily plan or intend to train with older people, but in their background they've always had maybe contact with older people. So when I was growing up, I had a lot of contact with my grandmother and my grandfather and my grandmother on my father's side and my grandfather on my mother's side. And I had a lot of contact, particularly with my grandfather, and I used to love listening to their stories, and I was just really interested in people's lives. When people ask me what I do, if I ever say I'm a clinical psychologist, I'll also say “that's a professional nosy parker, by the way, that's, that's what my job is”. I've just been interested in people's lives and I've had an abiding interest in that, and I think there's, I think there's something really important about the fact that we value learning from experience. And so that's one of the things. So, I think from an early age, I was always interested in older people, enjoyed older people's company. but the direct answer to your question is, when I was training as a clinical psychologist, I did an older adult placement with somebody called Hugh Toner in the NHS in Fife. And Hugh was just phenomenally enthusiastic about working with older people. He was very charismatic and he just loved working with older people. And, cause at that point I was thinking, you know, I want to be a neuropsychologist, but no, I want to be a CBT therapist. And then doing training work, working with older people really cemented the idea that whatever I do, I wanted to do both work with older people and further training and then further work in CBT. So that was what it was. But it was Hugh, when I was doing my clinical placement, that really kind of made me enthusiastic about working with older people and opened my eyes to the huge potential and opportunities there were, and that there was so much that needed to be done to improve the well-being of older people, and I could make a contribution. Rachel: I love what you said about, being a professional nosy Parker. I love, as you know, Ken, I love reading. I love novels and I think people are the best novel you'll ever read. And if through, you know, being part of someone's story, there can be a sort of development of wisdom and well-being, both for the therapist and the, and, and the patient often that's a really special thing, isn't it? and a really joyous, joyous day at work. Ken: Yeah, no, no, absolutely. And that's the thing, isn't it? I mean, that's what, that's what is amazing about our job is that no two individuals are the same. No people think about the same situation in the same way. So every day with every person we're working with. We're challenged to really listen, to really try to seek to understand and to try to work together to help that person become empowered to overcome the difficulties or challenges facing them. And so every day is like a totally different event, which is brilliant. I mean, what a phenomenal privilege it is to be a professional psychologist. Rachel: And as a good researcher, you like to define your terms, don't you? So, so shall we define some of our terms here when we're talking about working with older people? What, what do we mean by older people in the context of mental health? Ken: Well, gosh, that's a really good. That's a really good question. And I often get asked what is an older person or when does a person become older? Actually, the first thing we've got to, the first thing we should state is that older people are people. And I often say this when I'm doing training is I often say when you're working with older people, please emphasize the people part rather than the older, right? That's, that's really important because there are as many experiences of aging as there are older people themselves. So, and I guess we've all met people who they're in their 80s and 90s and they seem decades younger and we've met people in their 60s and 70s and they seem decades older. So, it's really hard to be precise when we say older people. I mean, we've got the old benchmark standards of pensionable age, which is now in the mid-60s and you know, when I first started working with older people many years ago, I did start working with people and the people I would see would be in their 60s. I would never see clients now in their 60s unless they were dealing with issues that were to do with the challenges of aging. So I think, I think we shouldn't be so hung up on chronological age. We should ask the question, who or what is an older person? And, you know, there's many different answers. So, you've got chronological age, but you've got also biological age, you've got social age, you've got subjective perception of age. If we're classifying populations, then we often think of people in their 60s starting to become involved in later stages of life. But then again, when we've got the change in demographics, people living longer and then buying, by the way, in the main living healthier than previous generations. So life expectancy is now much higher than it used to be. And that when you're 65 you can expect to have at least 18 to 19 years extra life if you're a man and about 22 to 23 extra years of life if you're a woman. So, I don't know when you, when do you, when do you become an older person? I guess partly it's a state of mind, partly there's a social norm, partly there's a sense of your own perspective and we should remember that aging is a process, not a state So by varying degrees, we might start to notice that we've become older, we might start to notice that we've lived longer than we are likely to live and we might notice that there are some changes in our physical appearance or our psychological expectations that remind us we're getting older, and it's those factors if we're, if we're therapists working with older people, those are the factors we need to take heed of. What is a person's subjective age? What are the things people might have noticed have changed, they've gotten older? What may be some of the limitations they may perceive to be present if they've gotten older. Those are the more important factors. Knowing that somebody's 85, if you get a referral and the referral says go and please see this 85 year old woman who is depressed, then if that image conjures up for you, someone who is old, has lots of loss, and is unlikely to change, then rather than think, oh we can't work with people that old, maybe we need to think, what is it about my attitudes or beliefs about older people that might need to change so that I can go into any situation or any session with any client, regardless of their age and try and help them to achieve the change that may be possible because change is always possible at any age, we never stop developing. We never stop changing. And that's an amazing thing. Sorry, Rachel, that's a really long answer. Rachel: It's fascinating, Ken, and in colloquial terms, I guess we might say Really, you're as old or as young as you feel? Ken: Yeah, yeah. I mean, I think a lot of these sayings have a lot of truth in them, don't they? You know, some of them are false, but this one does. and if, and if you feel older than your years, then that's something we as therapists want to explore. Rachel: Well certainly approaching the end of my 40s Ken, I certainly think 50 is definitely the new 21. but that, that might be, that might belie some of my personal attitudes towards, towards aging and we will talk more about those. So we do hear a lot about aging population. Are you noticing that the needs of older people are becoming a more pressing issue or presenting challenges for mental health services? Ken: Yes. I think it's a very welcome thing that we're starting to recognise that. older people are making up larger proportions of society, relatively speaking, and therefore we can't ignore the well-being of people regardless of their age. aging of the population is a social good. It's a consequence of better health care, better facilities, but with lots of challenges to how resources are used to support the wellbeing of populations, it, it's nonetheless still a challenging area. Rachel: That's a really nice counter narrative to the often very negative narrative we hear about this. And those narratives exist not only in the sort of general population, but also within the CBT community. And there, there are some perceptions and myths perhaps about CBT for older adults that you've worked really hard to dispel over the years. So I've got a bunch of statements I'd like to put to you and maybe you can tell us whether these are true or false and why they're important. So here we go, true or false, poor mental health is an inevitable outcome of older age. Ken: Well, that's, that's false. Um, there's lots of different pieces of evidence that would contradict that. Anyone that's interested in this should look up gerontological research. So gerontology is the science of aging. And there's some phenomenal research that's been done. Most of it is done with older people living in communities. Most of it is, a lot of it is longitudinal type research rather than cross-sectional one-off surveys. And there's stuff done by people like Laura Carstensen who in, in the States at Stanford University has followed up older people for many years and has demonstrated that as we get older, we get better emotion regulation and we experience better emotional stability than comparable working age adult groups. There's this interesting work that's been done recently by a guy called Blanchflower, which he's looked at a lot of government statistics on happiness data and he's produced this, this idea about happiness being on a U shaped curve. So as we're younger, our happiness levels might be high, but as we go through midlife, they decline and they decline to the lowest point in midlife, anywhere between 47 to 55 years that is becomes the lowest point and then it increases again up to about 75, 79, 79, 80. If we didn't have this data, maybe we might fear growing old but mental health problems are not a consequence of ageing. They may be a consequence of something else, but if we attribute them to ageing, then, we’re missing the point and there's, there's not the evidence there that suggests that. Rachel: So as a 47 year old, I'll hang on till 55 and things will get better. Ken: Things will always get better. But seriously though, seriously, it's really interesting to look at different stages of life. And all, all stages of life have their challenge. There's no doubt about it. There's not a stage of life that's ever free from challenge. And aging can be a challenging experience. It can bring lots of challenges with it. But is it any more challenging than any other stage of life? Who knows? If old age was really such a negative experience, you wouldn't find survey after survey where older people report higher levels of life satisfaction comparable to working age adults. Rachel: Fantastic. So, true or false. Older people do not want access to psychological therapy. Ken: True and false, but mainly false. Actually it's complex. It's a complex idea. We can't say a population, a whole population are not interested in psychological therapies. And then the first thing, remember, when we think about older people, we're thinking about a very heterogeneous group of, a heterogeneous section of the population, which is currently would capture people aged anywhere from the mid-60s to right up to 100 or 105. So there's, there's lots of different generations. You can't say on mass that that group as a whole have turned their face against psychological therapies, it depends how it's presented. I think we are all members of a society that is somewhat ageist. We have negative images and stereotypes of older people projected at us all the time. We often internalize these negative stereotypes. We can often think that old age and older people are going to be set in their ways, when actually in fact they're not. So research suggests when the questions are about do people want access to psychological therapies and people are given a good description of what that constitutes, older people will prefer that over physical treatment options. And it's just common sense. If people have got lots of medication, the last thing they want is just another pill. I'm not against antidepressants. I think they have their place and it's phenomenal. We have good physical treatment alternatives for depression but, it's not true to say older people don't want psychological therapies, but we might need to do more outreach. We might need to do more about educating people what psychological therapies might mean. And there might be some older people who might reject the offer because, either because they think they are too old and can't change, which is false, and we should be making it more accessible for people, or because they have some other obstacle in their head about psychological therapies.  So you might come across somebody who says, I'm too old for that and you think, oh, well, that seems to be true or, but the real, the answer is really false because we just need to tell older people, this is what we're offering you. Does that sound like a common sense, practical solution to your current difficulty? Rachel: So, for older people, like all people, we, what we want is for them to be able to make decisions based on informed choice. Ken: Yes, absolutely. It's about giving people proper choice. And if we don't give them information about what their choice is, we're not really giving them a choice. Rachel: And on that, true or false, CBT is less effective with older people. Ken: Well, I'm really glad to say that is false. As I said earlier on, when I first, when I was a trainee clinical psychologist, I was told you couldn't do CBT with older people. And then, I shocked people when I qualified, and I did a post qualification course in CBT back in the 1990s. And, and I told people I'm wanting to do CBT with older people. I was being told, well, I was wasting my time, older people wouldn't want to have access to psychological therapies, and it's not going to really be effective anyway. It's only for people who are psychologically minded and all of those sort of things. So I set out to try and prove that wrong. I did a randomized control trial years ago, showed that CBT worked, and it was CBT on its own without CBT and medication. So it worked for a group of older people. recent evidence, much more powerful evidence comes from NHS Talking Therapies. NHS Talking Therapies for years has opened its door to older people, and okay, the numbers of older people going through NHS Talking Therapy services are much lower than we would ideally like but nonetheless, older people are getting into NHS Talking Therapies, and we have data. And the data there, and this is, this is standard clinical practice, so these are not research trials. Shows that older people tend to do better than working age adults in NHS Talking Therapies. And not only that, they tend also to have much less dropout. And there was a recent paper that looked at NHS Talking Therapies in eight services in London. And not only did the older people do better than the working age adults, After treatment in NHS Talking Therapies, they need less sessions. So you've got all that data. We've got lots of data from randomized control trials. We've got lots of data from systematic reviews and meta-analyses. So the evidence is, older people get as much benefit from CBT as working age adults and possibly even that older people make better candidates, Rachel: and so how about this one then Ken, most older people have cognitive deficits that mean that they cannot access CBT, true or false? Ken: Oh well, that's false, and that's very ageist, isn't it? I mean, so it's fair to say with the increasing numbers of people who are living longer, we are seeing increasing numbers of older people with cognitive impairment. That doesn't mean to say that the prevalence or the rate of dementia or cognitive impairment in older people has increased. It seems like it hasn't increased. There might even be some evidence it might be slightly decreasing but hasn't increased. So while the relative numbers have gone up, the proportions of older people with cognitive impairment haven't gone up. So dementia or cognitive impairment is not an outcome of old age. That means if we live long enough we'll all develop a form of dementia. and there are many different types of dementias. So we really talk about the dementias rather than we about a dementia. So there are many different types of dementias. Not all older people have cognitive impairment. As we get older, sure, there are changes to the things that we tend to remember and how we remember. It’s not an inevitable thing that people have to look forward to, if it was, then we'd be much more of a pickle than we actually are. Rachel: and this, this idea of cognitive impairment leads nicely to our final true or false question, which is older people need to be treated for psychological problems in specialist services? Ken: Well, it's a really interesting one. If you ask older people themselves, older people don't really want a specialised older people services because they feel like it's some sort of ghetto. And it's interesting, older people are the, are more likely to reject association within the, with the in group. Older people don't see themselves as old. Right? So you as a young therapist may actually be working with a person you consider to be an older person, but you have to watch because that person may not actually consider themselves old, and they may actually view people 10, 20 years older than them as being old. Years and years ago when I was developing the attitudes to aging, I had the great fortune of going and doing some focus groups with older people, and I asked what was a really daft question which is at what age does one, does one become old and I was asking these people and there was a collection of people in their 80s and 90s and the consensus seemed to be 10 years older than people were. So, you know, it's a really interesting. Your question is really interesting question, really. And I guess we just have to kind of just remember that older people don't necessarily have to be treated in specialist services. All they need is to meet people who may be willing to go and find out specialist knowledge if need but they don't have to be treated as specialist services. That would suggest if that was the case, that would suggest all the people who have gone through and have been helped by NHS Talking Therapies would never have been eligible to apply for that. So it's, so in some ways it's an attractive idea. You have specialists like me who've devoted their career to becoming expert in ageing and stuff like that. But actually it's, it's better that we increase access and we still have some access to specialist knowledge or training when and where we need it. Rachel: You did great on that true and false round. So I think what we can take away from that is that CBT is appropriate and effective for older people. That said, can you tell us from all the vast experience you have in this area, some of the key challenges you find people face with this work, as therapists, with all your years of clinical work, supervision and research in the area, what, where do Where do people or therapists get stuck? Ken: Gosh, that's a really good question. And I felt de skilled many times in my career working with older people. Um, often it's been when I've been faced with older people with chronic conditions where it seems like, what do we as psychologists or psychological therapists have to offer? And I guess that's some of the challenges is we need to kind of, if we're working with older people, we need to be aware that there are lots of comorbid conditions. But I guess to face the challenges, we just need to stay centred around the fundamental principles of CBT. And one of the fundamental principles is it's not the situation that causes distress for individuals, but it's the sense they make of it. And regardless of what situation we might face when we're working with older people, we can't lose sight of that. So you might meet somebody who's got macular degeneration, they've got physical problems to do with their eyesight. You might meet people who've had a stroke. You might meet people who've got a long-term condition that's deteriorating, like Parkinson's disease or even dementia. The key thing is isn't that the person has this experience, or this situation, or this challenge. The key thing is, what sense are people making of it? And how is the way they are thinking about it, how is the way they are approaching it, behaviourally, emotionally, how is that helping them or not helping them? So the challenge is, of working with older people is, you never know what you're going to face. There's lots of physical conditions out there still to learn about. But the key thing is we can meet any challenge by staying true to the principles of CBT. So we take any situation that we're working with our clients together on, and we try and learn as much as we can about them as individuals, how they've overcome difficulties in the past, because that may give us insights into how they overcome this kind of difficulty. Rachel: So you've spoken about staying true to those principles of CBT and evidence based practice and, and that kind of real curiosity about how people see their worlds. But are there ways in which we might need to, or benefit from adapting CBT or aspects we want to think about differently when we're specifically, when we're working with older people?  Ken: So again, this is a question that's taxed me my entire professional life. So, on one level, I've always been really keen to remind people that CBT, that's manualized and standard, has been shown to be efficacious, has been shown to work with older people in clinical trials. Right? So non modified, non-adapted CBT works really well with older people. We can see that from the evidence from the randomized control trials, the systematic reviews, the meta-analysis. We can see it in IAPT services, right? So in that way, I'm really keen that we don't drift away from the core principles. But nonetheless, if you are working with older people, and especially if you're working with people who are more older. So we often, so I think of, and I think I do think about older people, and I'm rapidly becoming one of those, one of the member of that population myself, we think of young old people, people in their, say, early 60s to late 70s, they would be young old and people who in the 80s and above, they're old old, maybe people 90s and above the oldest old, but we think of young old people and old old people, and perhaps the young old people really don't look very different from working age adults- unless they are facing an age related challenge. They may be having a stroke or they've got some long term condition that's more commonly associated with aging. But the old old or the oldest old, they may be facing more challenges associated with aging. And therefore, for us as therapists, it's probably helpful for us to be equipped with knowledge about normal aging. So we can challenge any ideas. People may compellingly present a picture of their problems as being entirely to do with the challenges of aging. But if we understand normal aging, perhaps we can challenge that and perhaps we can see actually there’s some cognitive distortions that we can help people to challenge and maybe we can do some psychoeducation, but also maybe we can understand how it is that people are making sense of things in that way that is disempowering them in making change. So you'd want to know about normal aging. You probably as a therapist working with older people need to start to equip yourself by knowing a bit more about some of the challenges of aging, learn more about different conditions, learn more about strokes and dementia and Parkinson's disease and all these other physical conditions. It's probably useful for you to also reflect and think about what some of the challenges might be for you working with clients that are older than you. Sometimes it's, you know, three, four, five decades sometimes when I've been, I do a lot of training on CBT with older people. Often I get asked by younger therapists about the age gap and about how older people might not take them seriously because they're much younger. And I guess the thing is, rather than see that as a problem, we see that actually as an opportunity because CBT is collaborative. So, how better to be collaborative than to say, okay, you know, as a, as a CBT therapist, I understand about how to do psychological therapies and understand about conditions like depression and anxiety. But if you're older than me, you've lived five or six decades more than I have. You're likely to have experienced some challenges along the way that I haven't yet experienced. So you may have life skills that you can bring in to the work we do together. And that way it becomes truly collaborative, very respectful and an opportunity to see age difference, not as bad but as an opportunity. Rachel: You've spoken in your work or you've looked in your work at a concept, which describes a Selective Optimization With Compensation. Is that something that, that you use to adapt CBT, in, in this work? Ken: I think Selective Optimization with Compensation is a proactive loss based approach that people use to minimize potential losses that may be associated with aging and, and to maximize the opportunity to. continue to engage in valued roles and goals. It’s, it's one of those theories from gerontology which is enormously helpful. It's very pragmatic. It is, at its simplest, Selective Optimization with Compensation is a bit like a problem-solving approach. So by saying, if, if you meet a situation or a circumstance that is potentially changing your life and could potentially stop you doing the things that you value most in life. Perhaps if you use Selective Optimization, Compensation, you might be able to maintain involvement in that. Rachel: Can you give us an example from maybe a patient you've worked with? Ken: Best example is working with people who have had strokes. You know, they might have been very active before they've had a stroke. They might have been interested in dancing and then they have a stroke and they can't dance. But if they use Selection, Optimization and Compensation, maybe they can select certain types of dances that they can still dance in. They can perhaps optimize. practice at certain dances so they can feel they're sufficiently skilled to go back and do the dancing. And compensation is, you know, we adjust to our physical level, our tolerance level, our fatigue level, and that allows us to continue to dance. We may not be able to do everything we used to be able to do before, but it's better doing something than doing nothing. It can be really, really simple though. It can be something like somebody who's got Parkinson's disease who's a keen photographer and many years ago, I had, I had someone who was, and it, when they were diagnosed with Parkinson's, they panicked and they gave away all their camera equipment because they thought, I won't be able to take photographs anymore because of the shakes, and I better do it now, get the pain over with now, rip the band aid off now, but actually, if they used the simplest form of selection, optimization and compensation, if they had just used like a tripod, that's a compensatory strategy, and maybe they could have selected, well I won't be able to go trampling along the hills to the highest peaks like I used to before, but I can still go out in nature and take photographs, and maybe I need to balance a tripod on somewhere. And maybe I can practice other styles of photography and different things and so it's a really simple idea. And it comes from Paul Balthus and Margaret Balthus, and it comes from the Berlin longitudinal study of aging, and it's just from the observation that some people as they grew older, met associated with aging. Some of those successfully managed that some of those didn't. The people who successfully managed were people who use Selection, Optimization and Composition and going along with that is there's work by this psychologist called Heckhausen and who talked about a motivational theory of lifespan development and talks about the fact that as we go through life, we have a series of engagement and disengagement. We might have goals that we set out to achieve and we engage in those, but at some point, we might have to disengage. So, when I retired, and it was difficult circumstances, you know, Rachel, because you were one of those people that I turned to for support and you were incredible. Thank you for that, but what I had to do was I had the process of, I'd engaged, here was something I'd engaged in all my professional life. And then I had to think about, could I engage in it in the same way I could before? No, I couldn't. So could I, did I decide just to disengage, walk away, or could I engage in a modified way? So my roles changed, my engagement changed, I disengaged in certain things, but engaged in other things. And so, aging is a process. But interestingly, aging is a very dynamic process, and we can think about how we age, and we can think about what's of importance or value to us, and what's important and of value to us is our emotional lives. Rachel: It's a really powerful approach to, in some ways, very simple adaptions that maintain what people really, really value. That, that word value seems really important. There that people can continue to do and invest in the things they value in life, even when there are significant challenges around them. So kind of pulling that together, you know, we've talked about fidelity to CBT. We've talked about some adaptions, and I know there are many more you talk about in your, in your work. if you were teaching this, Ken, you have a lovely PowerPoint and you're very good at PowerPoint and you would have boxes and arrows and diagrams that would make it all very clear. And we love boxes and arrows in CBT right?  But if we're, if we're to tie our hands behind our back and not have boxes and arrows, because this is an audio podcast, I'm going to give you a bit of, a bit of a special podcast challenge to give a brief explanation then of those key augmentations or adaptions for formulating with older people and ideally in, you know, sort of Radio four style without repetition, hesitation or deviation or boxes or arrows or other visual aids. How would you summarize that kind of older people formulation that that underpins the work you might do? Ken: Well, yikes, that's a tough challenge. Um, the first thing I'd say is, what makes us interesting is we’re talking about formulating with older people, which is a different matter when you're talking about formulating for, say, a treatment condition. So, formulating for one of the anxiety disorders, for instance. So, if you're talking about formulating with older people, many years ago, myself Professor Larry Thompson and Professor Dolores Gallagher Thompson from Stanford University, my long term mentors and we did a paper years and years ago which was it was a special issue of the BABCP journal on formulation and we took a slightly different approach. I don't think we successfully really explained what we were doing. And subsequently, years later, I've been trying to do that. What we, what we weren't trying to do was formulate older people or working with older people, but we were trying to say. Okay. If you're working with older people, an older, say the one, say the person you're working with has an anxiety disorder, use that standard formulation for that condition with older people, but bring in contextualizing factors, because it's understanding the person in their context. So the context may include things like cohort values. The fact that people are born in a certain generation, they may have values and beliefs that influence how they respond to things like seeking help for psychological therapies, seeking help through psychological therapies, or may influence the way they think about certain psychological conditions. So you take that into account. You also take into account that actually there may be a number of comorbidity issues you're dealing with. So you bring that into your contextualizing framework and you also bring in any other beliefs, stereotypes that older people might have about aging and what their expectations for change may be. And if you were formulating, that's how you do it. You contextualize the individual in their situation. And if you want a formulation for older people, that's it. It's a contextualizing framework. Use the standard formulation for the condition but contextualize the factors. And think very carefully about what is the context that this person finds themselves in? And that may be the final missing piece from your formulation. Rachel: Brilliantly done and not a box or an arrow in sight, although I could sort of see them appearing in my head because I'm so conditioned to, to CBT processes Ken: good. If you've got the boxes, if you wouldn't mind, if you wouldn't mind sketch that out for me and I'll use it in my next presentation, that sounds great. Thanks, Rachel, that would be good. Rachel: one of the things we're really eager to talk about here at Practice Matters is looking after ourselves as therapists. And one thing is for sure, we and our loved ones are all getting older. By, by the day, and we're not immune to the challenges that people we work with face. We may have parents or grandparents who are aging and, and facing age related challenges, like some of those you've talked about, or we may be caring for older relatives, facing ill health, physical vulnerability, premature retirement, you've talked about retiring in difficult circumstances yourself; redundancy, other major life transitions. We may be dealing with grief or loss or loneliness. Yes. What advice can you offer to therapists in this area when they're working with these kind of themes and issues that come up with their older clients? Ken: Sometimes the issues are really close to home, uncomfortably close to home. And. what we should do if we're practicing clinicians and say something catastrophic has happened or is happening to you, one of your loved ones, or you're becoming a carer for your parents. I think we just need to be mindful that we have got the supports in place to help us continue to practice sufficiently for our practice, not to be too unduly influenced by what's happening at home. but to remember that, there is help out there and not to be too proud that actuallyjust because you might have expertise in aging doesn't mean to say you know everything. Seek the supports that are available, keep the supports that are available, use that, be grateful for those supports and helps that are available because it's about trying to keep everything on an even keel and sometimes it's really difficult and sometimes we might need to think about whether or not we need a short period away to just have that space for ourselves to, if it's about loss, do the grieving, if it's about making changes or dealing with circumstances, we maybe need some time away. We're not, because we're psychological therapists, we're not, we're not superhuman. We are just humans. And therefore, we've got a finite set of resources. We've all got a different set of tolerances. And we need to work especially hard in these times to look after ourselves. Rachel: And there's tremendous personal and professional wisdom in what you're saying, Ken. And I guess on the flip side, we often draw some of our inspiration and hope from our clients, don't we? And we, we started by saying, you know, this profession is wonderful because you get to be a professional nosy Parker and, we get this, these windows into different lives and, and often we actually learn as much, if not more from our patients, it's the great therapeutic secret, isn't it, about life. Then they learn from us. And I'm just wondering what, what you've learned from the older people you've worked with and, and, and maybe how this has made a difference in your life. Ken: One thing I've learned from working with older people, because people would often say to me, Oh God, is it not really depressing working with older people because it's all about loss. And gosh, if it was all about loss, it would be, but it's not all about loss. The one thing I've learned from working with older people is hope. Over the years I've met a number of people who have faced their worst fears. Not because they wanted to, their worst fears were the thing that they hoped they would not face in their life, and then suddenly they're confronted with it. And the thing I've learned from these people is, no one feels prepared, because you can't be. But people survive it. People come through it. And people are changed by it. So there's hope. Even in the worst circumstances, there's hope. And if I talk just a wee bit personally, because I don't really do that very often, but personally, in my own experience, when I had a really difficult personal circumstance to deal with at the time, there was lots of different thoughts I had. And one of the thoughts was about the hope. I could think back to people that had overcome their worst fears. And at that point, I thought I was about to face one of my worst fears. And although I wasn't prepared and I wasn't sure that I would do as well as some of my clients that have faced that, I had hoped that I might get through it and interestingly, the people that I have spoken to have faced the worst fears often consider themselves not to have done particularly well. It's only when they're sitting talking to professional psychologists who points out how they have coped. Rachel: And I certainly saw Ken, through your time that you've spoken about how you put what you valued at the centre of what you did, which is what you've talked about in the work as well, you know, and the value of those most important relationships and things in your life, and how that brought you through with such strength, coming back to the present and even the future, what can you tell our listeners about other exciting horizons in, in work with older people, in your research, in the field, in the world. What are the next big challenges do you think Ken: Well, some of the big challenges, I think, is we are going to have larger numbers of people diagnosed with dementias. And there's some really interesting, exciting work that's been done that shows you can have psychological therapies that improve the psychological well-being of people living with dementia. And that is a really positive and exciting thing. I mean, to think back 30 years ago when it, when it was thought it wasn't possible to do CBT with older people, the idea that we could do CBT with people with, living with dementia is just an exciting thing. exceptional stage and for the, for the generations of psychologists and CBT therapists that are interested in doing that, there's so much positive that can be done. There's also the stuff that we really need to do that's not quite expanded fully and that's about working with the oldest old. In my clinical experience it's fantastic opportunity to work with people and, and to learn so much about the possibilities for change and that emotional and psychological development continues throughout our lives. To see that first hand is fantastic. So working with oldest old, working with people who are living with dementia, but also having a much more culturally informed CBT, working with older people and particularly older people from different ethnic groups and working with people from the LGBTQI plus community with older people. Do you know, if we get to the point where CBT therapists aren't even really even thinking about, should we do any adaptions for older people? They're just thinking, well, older people are people, and you don't even think about the person's age. That'd be fab. Rachel: and it's impossible to listen to you and not feel excited and to not to want to jump into this kind of work. If people want to learn more about working with older people, where can they access training? We can put links to your positive practice guide that you led on. We can put links to your books and, and papers as well. Are there other things you would recommend for people. Ken: those are the places I'd recommend. I mean there's some, there's some really inspirational people that have become older people champions within NHS Talking Therapies. Go and speak to these people and, looking out for any webinars that come around from NHS England, all those opportunities, but join in special interest groups like the, the BPS have a special faculty that works with older people, that's a good resource to find like-minded individuals, but just even, even kind of being aware that there are different professiona groups that have conferences. I know money is really tight, but some of these international conferences come to the UK, it's, it's one of the places I got started to learn about normal aging is going along to the British Society of Gerontology or other organizations like that and going to their meetings. They have lots of different local meetings or national meetings. People are really in a, people can be really supportive and there's just opportunities to learn, I'd do that. Um, there's things like FutureLearn has an online course on CBT with older people, I'd recommend that as a good starting point. Rachel: and thankfully you're still training around the country and with people all over the place are still benefiting from your workshops and, and input Ken. Rachel: So in time honoured CBT fashion, we should summarize what we've talked about, and there is so much to what we've said, I think, you know, some really key messages in there. What, what key message would you like to leave folk with regarding working with CBT in older people? Ken: I would say that working with older people is, can be inspirational. It can be challenging, no doubt about it, because we might be faced with things that we as psychological therapists are not used to, a number of physical conditions and so on. There might be complicating life factors, there might be age challenges, but older people contrary to popular belief, are actually really open about new ideas, they're not necessarily set in their ways and I think emotionally they respond to the ideas in CBT because it's about achieving a better balance in life, and by the time people have got to a certain age, they tend to have learned a few things about life. So, yeah, I'd say, it can be a really engaging, inspiring but challenging experience, and, and we shouldn't shy away from those. We should seek them out. Rachel: So not only in CBT for older people effective, but it sounds like it's a lot of fun too. Ken: Oh, it's been, it's been a phenomenal abiding joy in my life, really. Rachel: Ken, thank you so much for being with us on the podcast today. I'm sure that people listening to this will have learned loads and been really inspired in their practice. And not just with older adults, because lots of the challenges we've spoken about actually go across generations, cross age groups don't, don't they? And there's so much that we can learn from this work in all our practice. So thank you so much for sharing your wisdom with us. And to our listeners, thank you as always for the work you do. And until next time, look after yourselves and look after each other. Ken: Thanks, Rachel Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you Please email the Let's Talk About CBT team at [email protected]. That's [email protected]. 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