Prof Heather O’Mahen and Dr Sarah Healy on CBT for anxiety and depression in the perinatal period

In this episode of Let’s Talk About CBT- Practice Matters, host Rachel Handley is joined by two leading experts in perinatal mental health- Professor Heather O’Mahen and Dr Sarah Healy. Together, they explore the unique challenges, adaptations, and opportunities that come with providing effective CBT for individuals during the perinatal period. Heather and Sarah draw on their clinical experience, policy work, and research to discuss why perinatal-specific approaches are needed, the prevalence and impact of perinatal mental health difficulties, and how therapists can adapt CBT to meet the needs of diverse parents and families. The conversation also covers access to care, the role of identity and stigma, supporting culturally diverse and neurodiverse parents, and therapist wellbeing when working in this emotionally heightened period. Whether you're working in NHS Talking Therapies, secondary or specialist care, private practice, or simply want to deepen your understanding of this vital area, this episode offers compassionate insights and practical strategies for helping parents during this transformative time. Resources & Further Learning: ·        Find out more about the Pearl Institute here ·        Access the Perinatal Positive Practice Guide here ·        Take part in the Jame Lind Alliance perinatal mental health survey here ·        Listen to the our previous episode on OCD in the perinatal period with Dr Fiona Challacombe Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [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, we have the pleasure of being joined by not one but two experts in perinatal mental health, Professor Heather O’Mahen and Sarah Healy. Professor O’Mahen is Professor of Perinatal and Clinical Psychology at the University of Exeter and world leading expert in treatments for depression and anxiety in the perinatal period. Her work focuses not only on improving treatments, but also on improving treatment access, for example, through digital delivery. Heather is also currently National Clinical Advisor to NHS England's Perinatal Mental Health Policy Team. And Dr. Healy is a leading perinatal clinical psychologist with over 20 years’ experience in the field. She co-led with Heather the development of the Talking Therapies perinatal competency framework and contributes regularly to the development of perinatal mental health policy. They've also founded together the Pearl Institute, which provides evidence-based training for clinicians working in the perinatal period. You're both so welcome. Thank you so much for making time in your busy schedules to come on the podcast. I think the fact that from the first planning to recording this podcast has taken us about 10 months is probably a good indicator of just how busy you are doing this brilliant work. Heather: Thanks for having us, Rachel. Rachel: Now, I know you're both hugely committed to working in perinatal mental health, and I'm wondering how you came to work in the field and what's kept you fascinated by it personally and professionally? Heather? Heather: Well, I came to it accidentally. I applied to do a post-doc at the University of Michigan when I was living in the States and it was in primary care. But they had rejigged things and then said, we have this other one in perinatal mental health, would you be interested? I had a long-standing interest in women's mental health so that sounded really great to me and I said, yeah, I'm definitely interested. Then I started doing therapy with women, parents from the perinatal period, and also doing research in the area, and I just couldn't stop. It's such an incredible, transformative period in people's lives. It's such a meaningful time to get to work with folks. There's so much that's going on, but there's so many opportunities to walk alongside people during this period of change. And then of course I had my own children and that fed it further. And so here I am. Yeah, yeah, yeah. Then you learn like, wow, it really, really, really, really is important. Rachel: You learn what it's really about. Fantastic. And how about you, Sarah? Sarah:  Yeah, I guess I came a bit of a roundabout way into perinatal. My early kind of career was more on the research side of things, but I started with a master's in the psychology of early development. I was really interested in that early mother-infant relationship. So I did my PhD in that area and I kind of been moving towards clinical psychology. Thought I would end up in CAMHS because I really liked working with children and that kind of parenting piece and then have the great fortune of having an assistant psychologist post in a mother and baby unit. And I just really found the work fascinating and as Heather kind of said, such a transformative time to be working with. So that kind of started me on my perinatal path. And since then, I've really just found the work so rewarding. And similarly having my own, my son, obviously now eight, he just turned eight. The perinatal period is a little bit a while ago, but I think I learned a lot from the work that really helped me as a parent and then being a parent really, I guess, added to my knowledge and passion for the area. Such an exciting, interesting area to work in and you get such variability in the type of difficulties people are having and the outcomes are so rewarding. I get emails from clients I saw years ago, of pictures of their children that are now eight, nine, ten, and you feel you've been really part of that process. Rachel: Wow. So it sounds like you both really have a deep commitment to women's mental health, to parents, to babies, to seeing kids develop and thrive. And that you've really enjoyed working in this joyous, but also incredibly vulnerable and challenging period with people where you can really make a difference. Now, certainly my experience, I've got three kids and experienced postnatal depression after two of them and I remember look back at it being such a precious, incredible time, really special time in my life despite that, but also all these challenges that are piling in. And yeah, at eight, the challenges continue don't they Sarah, but there's a little bit more sleep maybe. Sarah: The sleep is nice. Rachel: But it sounds like you also both had an excitement about bringing together research and practice around multiple areas like physical and mental health and adult and child developmental psychology in ways that can make a big difference and you both obviously live and breathe this work at home as well. But people who haven't worked extensively in the area might ask if we need a special approach to perinatal mental health, you know, can't we just apply what we already know about the evidence-based practice and approaches to depression and anxiety, for example, for the adult population and adapt those where we need them in line with our individual formulations. Heather: I think that's a really good point. And the evidence would suggest that we can adapt many of the interventions that we do have, but that it's really important to understand what's going on for perinatal parents during this period of their life and to be able to, in those formulations and in those adaptations, make sure that you're addressing the key issues that are important for them. I think this has been for some and maybe historically challenging to get their heads around maybe a little bit. Back in the day, back before there was this lovely investment in England in perinatal mental health care, it was certainly the case that I would talk to some clinicians or service leads and they go, ah, but we don't really see that many perinatal parents in our service. I don't think there's actually really much of a need- and nothing could be further from the truth. The need is just as great, if not greater and we know that we see an increased incidence around issues like say OCD during this time and also that there are real problems around birth trauma and issues around loss as well. So it is that parents do experience problems during this time. They do want support, but they want the support that's really family focused, that really understands that the baby is so integral in their lives at that point, and that can address it. And we can do that, but we need to get it right. And if we don't, we don't see the parents, just like the service leads said, we won't see them if we don't get them what they need and want. And I think we can compare this to other significant problems that people might be having and very intensive or transformative parts of their lives, like veterans, for example, or people with long-term medical conditions. And we definitely see the priority there that we need to adapt for those problems as well. So likewise let's do right by perinatal parents. Sarah: I think just to add to that Heather, I completely agree with all those points there, but also thinking about looking at services that are doing it well. And when you have services that really are adapting their interventions to be specific to clients in the perinatal period that are doing lots of outreach, that are liaising with other perinatal colleagues, other health professionals, they are getting the clients. They are seeing a lot more perinatal clients and they are getting the positive outcomes. And similarly, most of my clinical work now is in private practice and people are sometimes coming having had not so great experiences of much more generic interventions where they didn't feel people really understood what they were going through, weren't taking into consideration, say, preparing for birth or timings of interventions, didn't really understand the demands of having a small baby or some of the physical issues that might come up at that time. And so we're looking for something that really could take that consideration in time. And often that's the feedback I get as a clinician. It felt like you really understood my journey. You knew what was coming up for me or what may be challenging or difficult. You're really able to help me prepare or link in with other services. So I think the feedback both from clients and you know from services that are doing a really good job about being responsive to perinatal clients, and not just the birthing person, but to the wider family. The feedback is always really positive. Rachel: So we need this specific approach because there's something different about the context we need to take into account. There are specific issues that people are dealing with. And I'm really struck by what you say that if we get it right, people come. If we're not getting it right, we're not going to see these folk and you can draw that faulty conclusion that that's because we don't need it. But that probably applies across the board to lots of different diversity issues and specific issues at different times that people experience in life. And you mentioned, Heather, that there is an increased prevalence of some problems around this time. How significant a problem are the psychological disorders in the perinatal period? Heather: So overall, the problems in the perinatal period, and we've just got new data out on this. So the Mental Health Intelligence Network has worked with NHS England to produce new prevalence with regional data as well on perinatal mental health. So, we know that mental health problems are about 25.8 %, just about, have perinatal mental health problems. Outside of the perinatal mental health period, you're probably talking about a similar slightly lesser prevalence rate across all of the problems. But some of those differences that you're going to find are, say for example, in OCD where we do see a higher prevalence rate. And I think what's also really interesting is that if you ask women who have had OCD at any point in their life, when did it start? A significant number up to about 50 % of them will say during the perinatal period. And also we have sadly high rates of birth trauma and PTSD associated with difficult childbirth experiences. Rachel: And if listeners haven't heard it already, we did a great podcast with Fiona Challacombe who talked a lot about OCD in the perinatal period, which was really so informative and so helpful. So we can see that there are these particular issues which may be raised in this period, but you're all saying that there's also the case that there may be, it may be the genesis of some problems that continue for people much longer than that. And then we may see them later in their life, but this is the period where it perhaps if we got in there and nip things in the bud, we might be able to make a really significant difference over time. And thinking about trauma, which you've spoken about, I provide supervision to folk in Talking Therapies and other secondary mental health settings, delivering trauma focused cognitive therapy for PTSD. And I've noticed that there has been a huge number of cases of perinatal loss coming through. I know this is an area that often culturally wasn't spoken about in the past. What does the data tell us about the prevalence of perinatal loss and outcomes for women and their wider family? Sarah: Yeah, it's interesting. We've been doing a lot of training to kind of increase awareness of the impact of perinatal loss and the prevalence of perinatal loss. I know that it's unfortunately a very common phenomenon, one in five pregnancies will end in miscarriage. We also have to think about the prevalence of ectopic pregnancies, around one in 90 pregnancies, tradition of pregnancies, stillbirth, neonatal deaths, a lot of areas in which one can experience a perinatal loss and that we do know that that can have a significant impact on people's mental health and that's reflected in the research with higher rates of PTSD so the prevalence of the research in this area is growing, but there is some evidence that the incidence of PTSD is higher than what you would expect following say childbirth in the general population. So anywhere between 7 and 20 percent. And also we see higher incidences of anxiety and depression following perinatal loss. We really need to be able to think about how we're offering evidence-based treatments. It's lovely to hear that that's coming up in some of the trauma-focused CBT work because I think one of the things that when we're doing training, we have to talk about is, we need to make sure we're treating the right difficulty or problem. And sometimes when people come with a lot of distress, which is so understandable, following a perinatal loss. They can get immediately signposted to bereavement counselling and that type of support, which may be absolutely appropriate, but we don't want to miss the PTSD, OCD, anxiety or depression that we might need to be supporting with someone with following perinatal loss. So lovely to hear that that's being kind of brought up in your supervision and people are being supported with that. And I think it's one of those areas that actually you do need a little bit of perinatal specific kind of training or information that you really need to inform yourself, kind of what that might have been like for somebody, understanding the physical implications of some of those losses for someone that had to birth a baby or maybe may have been producing milk after birth and have the kind of physical recovery and all of those areas that could have been quite traumatic and might be part of what they're struggling with in the present or they may be struggling in a subsequent pregnancy or contemplating future pregnancies. So thinking about actually having a good grounding and understanding about the different implications of all these different types of losses and ongoing investigations that they might have to be kind of considering or thinking about implications for future pregnancies. So it's a really big area that it's lovely to see getting more attention. So I think this is an area that wasn't really thought about much historically. And anyone who's experienced any of these losses really knows from a very personal place, the kind of impact of it. And we really want to help people be able to kind of process and accept and understand that it's normal to be grieving in this period, but we need to also be addressing any mental health difficulties that might be there. Rachel: Yeah. So it's really good we're seeing these come through and hopefully rewarding for both of you as well, having led on the good practice guidelines, you know, to see people and services following that and picking up on these cases early on and intervening. And I guess that leads us to think about, you know, the access issue that people have. What are the challenges people face in accessing good support in this period of their lives? What makes getting support difficult if indeed it is so. Heather: So I think we have to recognize from the perspective of people who are seeking support, it can be challenging just in general. But I think during this period of life, when there's so much that's going on, so you start off in pregnancy and you've got a lot of appointments that you have to go to, a lot of people are still in work, or they have other children. And so they're juggling all of that and appointments. There can be stigma. We would like to think that we've gotten far with stigma. But there is still quite a lot of stigma that people feel and that can vary across different kind of cultural or economic backgrounds as well and people's willingness to talk about those problems. And sadly, although it is rarely, very rarely the case, but sadly, a lot of women will say that they fear that if they say anything about their mental health problems, that their child will be removed from their custody. And a mental health problem alone should never be the reason to remove a child from somebody's care. So all of these things can be barriers and then there's trying to get into the treatment. If you tell a healthcare professional that you have a problem, you hope that they hear you and that they recognize those problems and that they appropriately refer you on and you get a smooth transition into service. But we know that can sometimes have difficulties and challenges as well. It can be challenging in part because it is normal, say, for example, in pregnancy to have a slight increase in anxiety. And from a healthcare practitioner perspective, and we've seen this data in large scale epidemiological studies that we've analysed, from a healthcare practitioner's perspective, that could be, oh well, it's normal to be anxious during this time period. But it's not normal to have problems that are causing you a lot of distress, most of the days that are impairing on your functioning that are kind of taking over your life. And so it's really healthcare practitioners understanding the difference between what's a little increase in anxiety and what's not a normal experience for somebody and where they do need a bit of extra support and then getting onto that support. Rachel: And I'm hearing that there are these practical barriers, and it does feel like sometimes you're taking on another full-time job, doesn't it? When you get all these appointments through the door when you're pregnant and there can be our own psychological barriers to worrying about how that's going to be perceived. And we're changing our sense of identity of someone who's very career focused, potentially having this other pool in demand in our time and other focus on our energy. And there are also structural barriers you were saying around healthcare professionals recognizing what's going on. I remember myself being given a poorly photocopied depression self-report measure with some of the items cut off the bottom. And as a psychologist, of course, I was slightly horrified that they were going to be adding up these scores incorrectly and not knowing what they meant on the standardized test. I also remember feeling huge performance anxiety as a new mum, you know, every weigh in or extra hour of sleep or developmental milestone was a measure or felt like a measure of my success or failure as a human being, or as a mum and a real need to appear to be, and also to be on top of it all. So, you know, it sounds like there is still a stigma that people experience of feeling like they don't want to admit to their mental health symptoms. Sarah: And I think Rachel, thank you for sharing your experience. I'm really sorry you kind of have that experience of someone actually not really talking to you about it, giving you a fuzzy measure to fill out that wasn't even probably an appropriate one if things were chopped off a bit. But I think unfortunately this is the experience that people sometimes have in the perinatal period. And it's definitely when I've heard clinically upsetting amount of times really is you know it takes so much to go and say I'm struggling; I'm finding this very difficult. Everyone keeps saying I should be excited about the pregnancy, or I should be enjoying my baby and I'm really not. And so to then come and ask for help and have that dismissed or not taken seriously or just offer, quite a few people I've heard just offered medication and they don't for various reasons don't want to or they do but it's not helping and not talked, they're not being talked to about what their options are in terms of talking therapy or support and making those referrals as easy as possible, not giving someone another piece of paper to go away and then they've got to kind of contact someone and fill something out and then they say we're not the appropriate service and you get bounced to someone else and unfortunately, you know, I've heard a lot of times where people are having to go multiple times to say I'm really scared about birth and they're not getting referred till they're 30 weeks pregnant and that you're limited in terms of what you can do clinically where somebody's been saying that right from the get-go at their booking appointment. So I think, you know, really healthcare practitioners need to be picking up on this as early as possible and if someone's asking for help, making sure that they get it. Rachel:  And I guess if there were some barriers or issues for me as a white middle-class educated psychologist in this country, that might be even more significant or there may be challenges for people in other social and cultural groups. What do we know about that, about barriers for other folks? Heather:  Yep, you've nailed it, Rachel. It's not an easy system to navigate with all the privileges. If you don't have a sense that this system is going to work for you, if you have a sense that maybe the system could be even discriminating against you, and certain groups have those experiences. So it's very difficult to trust a system that may be the very system that's hurt you and to get into treatment that way, or also to trust that this is the right place for you and this is what you would want. And even if you do trust the system, you've got to keep persisting often. And there's sometimes, I think, a sense that certain groups of individuals can have that we deserve this, we should keep going at it. But that's really hard work if that's not the mind frame that you're coming in at it with. What we do see, and we saw an evaluation that we did in the ESME 2 study, is that very frequently it was grandmothers who came in and they said, it's unacceptable that my child, my daughter, who's now a mother, is suffering like this. And they were the ones who persisted in the system. But if you don't have that support, how are you going to get in? And I think that's something that as clinicians, we can increase our awareness of that and think about how we can do outreach. We can't just sit back and let people come to us. We have to reach out to them as well. Rachel: And what are the outcomes for people from ethnically and culturally diverse backgrounds like at the moment? What do we see in terms of their journey through this period? Heather: Right, so the good news is if they do make it into services, the evidence that's coming out, particularly evidence around the new perinatally adapted services, is that it's good, it's positive. We also know from the Rushney 2 trial, which is an amazing large-scale study with South Asian women that adapt the interventions to what people need for their cultural needs as well, they will show up and they will do brilliantly. So the good news is, to repeat this theme again, if we provide the right kind of adapted interventions, they're acceptable and people have good outcomes. But if we don't, it's a real barrier and they don't get the same access to treatment. So we see that time and again, both for ethnically diverse groups and that's particularly acute for women from Black and Afro-Caribbean cultures, but also for South Asian cultures. So they don't tend to get access into it. And we also see this for people from lower economic situations, particularly the lowest economic strata. And often those are the individuals, they have so many stressors that they're dealing with, economic stressors as well and they may not have the transportation and the resources and the childcare to get into interventions. And they are more at risk for mental health problems. So we should be seeing more of them, not less. Rachel: And you mentioned earlier that one of the factors in stigma can be people are worried about their kids being taken away from them. They can be worried about how they're being judged. Is that a factor that's heightened for people from culturally diverse backgrounds as well? Sarah: Absolutely. I think, you know, people may have had experiences that have been quite negative with other health care professionals or other bodies like police or social care at different times and feel that they are more likely to be judged when they present with mental health difficulties and have more of, you know, you kind of were talking about Rachel, you're kind of, I'm a psychologist and admitting I was kind of struggling was tricky or difficult or felt challenging, you know, if you're carrying this weight of, I should be coping okay, people are going to judge me based on kind of my ethnic background, my socioeconomic status, they may be much less likely to disclose that they're having those difficulties and they have, you know, negative experiences where people are judging them. And definitely that's something we've heard kind of clinically where people are from in maternity when they're giving birth or the care they might receive at different times. There's a sense that I'm being judged, so not wanting to kind of come forward and ask for help because of that fear. Rachel:  And do some of the same or different factors show up for same sex couples? Sarah:  Absolutely, and I think this is an area that I've kind of really been looking into a lot more and we've been thinking a lot more about. I think even to the point that somebody presents to a talking therapy service and comes in and initially they're asked, what about dad? And there's an assumption made about the sexuality of their partner or that they have a partner. And I think male same-sex couples, there's very few services that actually they can access which is discriminatory really, you know, I think they can access talking therapy services but may meet a whole load of discriminatory attitudes or just even comments that they're not thinking about somebody's, you know, family background. So I think we always encourage people to talk about birthing person and partner, but also not making an assumption that there is a partner, you know of people having babies on their own and often by choice. So there's kind of a growing number of solo parents that are choosing to do this on their own and may feel an extra burden of asking for help because they've had a lot of effort into having this baby. So admitting that they're struggling or need some extra support might feel have an additional layer of shame attached to it that we need be sensitive to and talk sensitively about. So, you know, when we're meeting someone for the first time, not making assumptions about if they have a partner, who their partner is. Rachel: So we spoke a little bit about outcomes for people from ethnically diverse backgrounds that they can be good once they get into the system. Generally speaking, is CBT effective for depression and anxiety in this period? Is it as effective as it is in other periods of people's lives? Is it equally effective for everyone? Heather: So the evidence base in this area for CBT is for CBT that's been adapted. We haven't done studies that have looked at not adapted CBT. So we know that if you adapt CBT, you adapt it well, you're still doing good quality CBT, then we've just done a recent meta-analysis on this, it's just as effective as outside the perinatal period. So that's great. There's good hope for folks. Now that was for depression. We have less evidence base for anxiety, but some of the emerging studies suggest that there's promise there. But there's a significant research gap there and we really need to do that work. Rachel: So if we can get people in, if we can reach them where they're at, and if we can adapt the therapy, there's good hope there that we can be useful and helpful to people. And let's think about those adaptions then, and there's augmentations that we might need to do. What perinatal specific input is important to include? And I know you've talked about a few of these aspects, but putting it together, what do we need to really make sure as part of that package? Sarah: I think we really need to understand the perinatal journey. I think, you know, knowing what the different appointments someone might have, what the different kind of physical health implications might be to pregnancy, what timing points you need to think about. So, you know, for example, if someone refers in hopefully, you know, 14 weeks, write down the date that they're due so you can be planning and thinking about that as you move closer to that time and you're starting to think about birth and preparing them for what they might need to think about around that. So understanding different birth options and choices and where they might be seeing healthcare professionals that you might need to be thinking about managing, if they get really anxious before medical appointments, which ones do you need to know about? So really thinking about the journey and the postnatal journey thinking about, you know, people often forget things like when babies start to wean at that kind of six-month point, that might be a real increase in anxiety for some people. Say you're working with someone with contamination OCD, kind of starting to their baby is going to be something you're really going to need to think about. So knowing when that happens is really important. When people are going back to work, for example, after maternity leave and having to leave their baby in nursery, which I'm sure for all of us is so challenging and difficult. And for someone that might be really anxious or feeling really low or they're not doing good enough, leaving the baby in someone else's care might be really anxiety provoking. So really understanding and be able to think with our clients about that journey. The other area I think is really important to think about is family picture. Thinking about the baby, the implications of the baby, involving the baby in treatment, seeing the baby wherever we can working with baby in the room and also partners. I'm trying to think of cases where I don't bring the partner in the room because most of the time, at least for one session, I'm going to involve the partner or sometimes as you said, it's grandma, the client's mum or sister, whether you're working with depression or anxiety or OCD, I think I find it hard to think about doing OCD work without bringing in somebody else there to really help kind of think about extending the work outside of your therapy practice. So really thinking about the perinatal period is not just the person, you know, that might be birthing the baby, but the wider system and involving them where we can. The other one is about risk, know, really understanding the nature of perinatal risk. What are the real red flags you need to watch out for or think about and understanding certain presentations like if somebody has a history of postpartum psychosis themselves or their female family members or Bipolar I, you know, they should be even if they are well, they should be under the care of specialist services so that we can really plan and think about reducing risk of relapse and things like that. So really understanding the awareness of risk, thinking about liaising with other professionals. So you need to know who's in the system and understand the perinatal system. So knowing that people are going to come across midwives, health visitors, obstetricians, their GP, children's centres, knowing what's available in your area, you know, if you're doing, and that might be as simple as, you know, you're doing behavioural activation in the postnatal period, knowing what baby groups are available, and depending on the client, my personal favourite was baby cinema. Cause I could just sit there and relax. I'd like, so knowing, you know, kind of these sort of things are not, someone might not feel comfortable going into a baby group right away. That might not be a good first step, but you might be able to convince them to do baby cinema or, you know, what are these first steps? But you kind of need to know the system around. Rachel: What I needed my healthcare professional to know is exactly which groups were on at exactly the time my children weren't napping, which is probably an insight to the rigidity of my parenting style more than an issue with the system. Sarah: It reminds me of another really good point there Rachel, in that the napping is like we need to be flexible with our timings of appointments because you know babies needs change and somebody might want to bring the baby to sessions but they might also want to do them when baby's sleeping so being able to be flexible in that way so you know your appointment time might change as baby grows or pregnancy to postnatally and it's definitely the case you know in my work sometimes in pregnancy I might be seeing someone outside of working hours and then that really change postnatally and I might be seeing them first thing in morning when the baby's having the morning nap. Rachel: Which is the joy of parenting, isn't it? Just when you think you've got it nailed, it all changes. Sarah: Absolutely, that need to be flexible and understand all those different stages, know, what we would expect and even in things like baby movements in pregnancy, it's often a real trigger for anxiety, is my baby moving enough? So having a good understanding of what we would expect at different stages so that if someone is really anxious, we're really coming from an informed position to help them think about, say reducing checking or things like that but also being able to liaise with midwifery to get a good sense of what's going on for this individual client there on their journey. Heather:  Sarah, I think all of that is just really gold. And I think as you were talking through it, I think it paints a beautiful picture of how integrated the baby is to every single experience for the parent and how much you need to take account of that. And I suppose this is a BABCP podcast. And so there might be Talking Therapies folks who are listening and so there's so much I think in Talking Therapies, which is very adult focused that you can do while still thinking about the baby. And I think one of the key things is for all people working in this period is really understanding as well the impact of mental health problems in the parent on the baby. So this can be a tricky, a little bit of a minefield for some folks. There's this idea that if you are a parent and you have a mental health problem, then boy, your kiddo is terribly at risk. They're going to end up with all sorts of problems and that's the way that it is. The good news from the longitudinal data is that although there is an increased risk of that, it is just that it's a risk. It's definitely not a given. There are lots of parents who have mental health problems during the perinatal period whose children end up being just fine. And so, it's not written in stone and there are actually lots of things that you can do and taking care of yourself as a parent is an important first step and an important lesson for the child as well. It's good for kiddos to see that their parents can take care of themselves and to model that throughout their entire lifespan. That helps to build healthy children as well. Rachel: That’s such a hopeful message, as well as kind of feeling and experiencing the misery of depression or anxiety in that period, then to feel miserable that you're also damaging your child's prospects, can only just deepen that experience, can't it? Heather: Yeah, yeah. And I think from a clinician's perspective as well, they can watch the client who might be with a baby and working really hard and doing a very good job with that baby. But they might also report that they don't feel so close. They don't feel that rush of love. They don't feel that bond. And those are two different kinds of things. So addressing both things for the parent and helping them with the compassion towards themselves as a parent as they build that bond. It's a process often building that bond and it's hard to do when things are really rubbish. But at the same time, they might be parenting really well. Sarah: Absolutely. you know, Heather, as you were talking, I was also thinking, you know, we're talking about adaptations to CBT and things, bringing in that perinatal expertise, understanding the journey. But also, we're not talking about avoiding doing evidence-based work. You know, the adaptations is bringing in that knowledge, bringing in that experience, bringing in those other professionals and the wider family and the baby. But unfortunately, you know, Heather and I bang on about this, because every time we do training, somebody will bring up that their supervisor, either current or historical, said they can't do exposure-based work in pregnancy. This is just not true. So, you know, it's really shocking to me to hear that we are discriminating against pregnant women who aren't getting the treatment they should be getting in terms of EMDR, trauma-focused CBT, exposure-based work around panic or OCD and thinking, oh we'll deal with that when the baby comes. And so somebody is sitting through pregnancy with all these kind of symptoms and distress when they're coming to serve as wanting help. And then we're not kind of helping them before baby arrives, because that's not going to get easier. So I think we really also want to encourage people to use what they have and to use that evidence base to offer good treatment to clients in the perinatal period. Rachel: I think it's so helpful for clinicians to hear that really clear message that this is not contraindicated in pregnancy and beyond because people are worried about doing harm, aren't they? And they really want to do their best by their patients. But as you say, withholding the very thing that's going to help them is not doing your best by people, but it's understandable that people have those fears and absence of that knowledge. So grounding this little practically, if a person presents for support with, for example, depression or panic disorder or PTSD, aside from the psychoeducation around the perinatal period that you might want to be aware of and include and thinking about the wider system in your formulation and drawing on social support. Are the interventions we do essentially the same evidence-based approaches as one might usually take to depression or panic or PTSD, or is there something fundamentally different we're doing? Heather: So the good news is no, you're not. If you're doing CBT, are you going to continue to do say cognitive restructuring and behavioural experiments for depression? Are you going to apply behavioural activation for depression? Yes. You're still going to do the same principles. If you're doing PTSD treatment, are you still going to do imagery work? Are you still going to do, you know, narrative work? Yes, you are still going to do those things. But it's about taking all of the information that you have about the perineal period and thinking about how, what you are applying that to and how you are applying that. So for example, if you're trying to do some behavioural work for depression, what is it like trying to do that when you have a baby. What's going on? What are the things that have gotten this person separated from meaningful activities that bring them joy and valued based work into their lives? And so very frequently it means that you have to rejig kind of the what they got more broadly from what they were doing before they had this baby into these activities with this baby who doesn't give any clear reinforcement signals back. So that's the challenge. And it can be a bit tricky. Or if you're doing PTSD work and you're trying to do some exposure work, it's understanding, for example, that maybe if somebody's had a traumatic childbirth, and they have extremely vivid images of perhaps either the thought that their child was going to die and or that they might be dying, how important it is to do that imagery based work and how important it could be to involve healthcare workers alongside to help to support that work and to help to support maybe even getting back into a maternity based setting and to be visiting that place. It’s about really understanding the beliefs that were going on for them. For example, that nobody's helping me during this period. Nobody is caring about me. Nobody's going to help me. And how deeply that can touch on some really embedded kind of beliefs about themselves. So it's still doing the work that we know what we need to do, but it's really zeroing in on what is going to be the most harmful thing right now and going after that. If you're trying to, for example, go for a traumatic childbirth experience, it's also understanding that they may have had experiences, medical health experiences during that time that are medications that are contributing to loss of memory. And how is that going to impact on the ability to process that trauma? Sarah: Yeah, I would really echo what you've said there, Heather, you know, that sense of it's not you're still doing the work. You're still doing a lot of the same things you would do. So with OCD, for example, you're still doing experiments. You're, you know, getting out there. You know, you might be, you know, either I have people like put me on their phone and we're going for a walk or going out. You know, you can be really creative about how you get out there and active with clients even in a remote setting. But I think there's also the timing and planning issue, know, thinking about when they're referred, thinking about birth and some of these things that might be coming up and kind of having that knowledge. So I think you know what we're talking about a lot is really having a good deep grounding or understanding in the perinatal period. And if you don't know, ask your client, you know, what's coming up for you, learning from them about, you know, what they might be anxious or worried about and making sure we're asking the right questions. You know, in assessment, are we asking, you know, how many times, you how many pregnancies have you had, not just how many children do you have? So we get a sense, is there some loss in the background that might have led up to this? How was your journey to getting pregnant? You know, has somebody been through a lot of fertility treatments? And I think that infertility and fertility journey is one that often isn't really thought about and has big implications for when it's meant to well-being. So knowing to ask these questions and knowing when to normalize and kind of really go, oh man, it is so tough, you the lack of sleep and when it's like, actually this feels like you're really struggling, we really need to think about kind of intervening here. So you know, being able to make those judgment calls on what's kind of typical and you know, really understandable in those early days and what's a sign that someone is really, really struggling. And that kind of expertise or knowledge is really important and helpful to kind of hold in mind. I could keep going, Rachel, because there's lots of other bits, you know? I haven't even mentioned NICU, you know, people that have babies that have had experience in neonatal intensive care and, you know, where parents are told to like intensively monitor their babies breathing and symptoms. And then how do you let go of that as your baby grows a bit? So, you know, we need to understand what that might have been like for someone having to make continuous decisions about their baby's medical care. You know, what having to make choices, avenues to pursue or not pursue and having to ongoing kind of health implications or not knowing what their child's development is going to look like. You know, so all these different areas that yes, you might be doing the same thing in terms of the kind of good grounded CBT or EMDR or whatever your approach is. But you're still going to do that, but you need that knowledge and expertise around what someone's been through so that you can ask the right questions. People know, and it's okay to not know and say, I'm not really familiar with that fertility treatment, can you tell me a little bit about it? What did that involve? How was it for you? You know to really be making sure you have a good picture of what's actually going on for someone. Heather: One last thing that I wanted to say is although almost everything that we're doing is the same kind of the same principles, approaches in CBT, I think one thing that we can slightly adapt a bit is around how we're dealing with challenges around getting support. There are a few times in life where you need as much support from a broader network. This is definitely one of them. And for a lot of people, that's really difficult. There's so much that's going on and then there's this big ask that you need to go out and get more support from people. And that is really, really difficult. So kind of the approaches that people have used in the past that just got them by just barely, it's not cutting it anymore. So things like communication strategies are really important here. Now in CBT, we have some nice assertiveness skills, but there's a lot of shoulds in the perinatal period already. There's so many shoulds. Do we really want to add like, you should communicate like this? So I think there's adaptations around thinking about what kind of communication is going to work for you in different kinds of situations. And it's okay if it works for you and it's working for the other person as well that's fine. So I think there's a bit more about really understanding and mapping people's social support networks, helping them to develop that support, helping them to get the support that they need and to communicate that support. And then I also think there's a bit around folks' social anxiety rearing its head a bit, and we don't talk that much about that during the perinatal period. But it's huge, I think all of us who work in the perinatal period see that all of a sudden, you're supposed to be talking to all these healthcare providers, you're supposed to go to baby groups, what? And then you're going to end up at the school gates down the road as well. And so for somebody with social anxiety, that is massive. And as CBT therapists, we have a lot of skills that we can apply to that. So I think it's keeping that in mind as well and thinking that might be a barrier for lot of things that parents need to get to and how can we creatively think about how to address those things during this period. So it's an opportunity to redress social anxiety, things that people might have let quiet their lives and are rearing their head again. Rachel: I love that positive reframe Heather as an opportunity to address these issues. And I guess what I'm hearing is that in an ideal world, we are really well informed as therapists. We understand this perinatal period. We understand all those issues from the normal journeys that people might go through, normal in inverted commas to, because everyone's journey is different, right? But there may have had issues around neonatal care to those people that might have differing issues around their context and the support that they have, or they don't have, I love this idea of this fearsome grandmother who might be advocating on your behalf, but not everyone has one of those, right? But also, that core skill in CBT of remaining curious and collaborative with our clients is really important and can get us a long way. We probably need to know a bit more than just what we can ask because sometimes we don't know the questions to ask if we don't know a bit about the context. And so that training and understanding is really important, but not to be paralyzed when we don't know either to be remain curious and remain in a place where we can sit with our clients and understand their context from their perspective and what they've been through. Heather: That's such an important point, Rachel, because I think that brings up a point about our own experiences or our own knowledge. And so some of us may choose to become parents and those of us who choose to become parents who are lucky enough to become parents, that's great. But then we bring all of our own experiences to that. And so it's about understanding that that's your own experience but also allowing for curiosity and flexibility around what this person's experiences are and not interacting too much of that. Rachel: And you've mentioned that various points when we've been talking different adaptions that might be necessary to allow people to access care. And I know that you're both very much interested and focused on improving that access in this period. What seems to work to help improve access to perinatal treatment? Heather: Flexibility. Trickier, I think for some services given some structures of services than others. But to the extent that you can have flexibility, I think that's so important. And so that can be flexibility, as Sarah was saying earlier, around different appointment times and understanding that, or around cancellation and DNA strategies as well. But it's also flexibility around where and how you are conducting these appointments. So it might be that at some point somebody prefers to meet in person and it's where they might prefer to meet in person, maybe in clinic, maybe they prefer to meet in the neighbourhood centre, in the children's centre. At other points it might be better for them to meet online, and they might prefer that. Some people might prefer always to meet one way versus the other, but to just be flexible to that approach is so important. Sarah: The other thing I kind of always, when I'm first meeting with someone, is encourage people to, it's okay if you need to feed, you need to take a break, you need to put the baby down or play with baby for a minute. So you might need to even have a little bit of a longer or sometimes shorter appointment time to allow for some of that flexibility. But giving that message from the get-go you know, whatever you need to do if someone wants to be in a session or wants a privacy to do that or wants to do it just after or before the session. So checking in with them about what's going to be helpful for you, what's going to make this easier for you. I think this is really key. Heather:  And on that note, if you're going to see somebody in person, you need like a nice, baby-friendly, safe for a little crawling about six-month-old baby to be in the office with you or wherever you are seeing them. Sarah: That made me think of a couple other practical ones is like, you know, in services, making sure there's somewhere to park a buggy that someone's not trying to get a buggy up loads of stairs and things like that. There's a changing table. You don't have a changing table in your, in the toilets, you know, have that you can pull out. So if people need to change babies, you can do that. And the other that all of us will, you know, resonate with who have had small babies is reminders of appointments because, you don't know what day of week it is sometimes. So, you know, I think often when people have not shown up, it's not the same necessarily as when you might be working with clients in different periods of their life that, you know, often a client would go, my God, I'm so sorry. I totally forgot I've run our appointment today. But, you know, I send texts like two or three days before the appointment so people really can have that very fresh in their mind that appointment is coming because it's hard to hold information in and you have so many appointments for babies or pregnancy. Rachel:  And if you haven't slept in five days, it all feels like one long day, doesn't it? Right? It's still Monday. Monday has gone on forever. I love these very practical ideas for services. It makes me wonder what other barrier services face in implementing these kind of adaptions. I can imagine even just being flexible over parent schedules and perinatal appointments can be a challenge for some services when they're used to kind of organizing around that hour a week at a set time sort of model. And I know from working in other areas, even to get a double session sometimes to go out and do a bit of exposure work when you're not thinking about all these added factors can be a challenge for services. What works and what services, what have services been able to put in place that makes that possible? Heather: So some services I know have put into place if they've got, say perinatal champions, they've got specific caseloads for those folks, and there's maybe just a little bit more space around it. So it allows them a little bit more space to do some more outreach to folks, maybe to juggle clients a little bit more flexibly from week to week. So that can just make a huge difference. Now, obviously, it's an ask. And you've got to provide a little bit of protection around that space in order to do it. Another thing I think that's just really practical that works really well when services do this is when they base their clinicians part of the time in another service. It might be in maternity. We’ve got one service in Somerset, for example. I'll give them a bit of a shout out that they have somebody in the neonate unit. And it works beautifully for that because they get to know people in the neonate unit and they can continue to see them after they've been discharged which is really nice. Or sometimes in children's centres as well where there might be a creche that's available. If there is, that's really beautiful, but otherwise there's nice child-friendly spaces. And they can maybe see them right when they're coming in for an appointment. So those things work really well. Sarah: I think to add to that, it's really nice for clients that they can come and see you in settings they might be already going into. It's also really good for clinicians because you're working alongside other professionals. So you develop those links very naturally. They know about you. You get a better understanding of what's available and what different services you might want to link your client into. And if you have a medical question and you're based in antenatal and you get to know the midwives, you can kind of go, can I just pick your brain? My clients really worried about this around birth. Is that something that's very likely? Is there anything, you know, you can tell me or help me in terms of supporting my client around this? So you're also developing those links in a really nice way. The other thing I was thinking about that works really well is, you know, and some services are doing amazing jobs of this is doing groups or services that are embedded within the community, so that are led by community groups that are already existing and particularly helpful for harder to reach groups or groups that may be really underrepresented. So working with community leaders, community organizations, religious groups, and in perinatal specialist teams, a lot of times as well, there's now peer support roles that also can be really helpful for increasing engagement and helping people come into the service. Rachel: So there's a lot that can be done and it sounds like a lot of this could be quite time consuming, quite intensive work, could be quite demanding of the clinicians in the system. And clearly there is a moral and ethical imperative to do this work, but you know, channelling for the moment, the mentality of a sort of hard nose number cruncher in the NHS (if these exist) in our leadership. Is there evidence that it's worth making these adaptions from the point of view of helping people access care and outcomes? Heather: Yeah, so let's talk about outcomes and measurable outcomes. Some of it is access, but some of it also, if we're going to talk about NHS Talking Therapies, you're also looking at the number of people who are adherent with treatment or drop out of treatment. So this is a great way to improve those numbers. And sometimes you don't have to apply the whole package to everybody. Some people need just a bit, some people need more, and it can make a real difference to those kind of numbers as well. I think as Sarah was really nicely pointing out too, if you're working really closely in some of these settings, let's face folks with healthcare providers, you can see that there's efficiencies in that as well. Maybe somebody has of fear of childbirth and you want to work on the birth plan with them and you want a psychologically informed birth plan. What we hear about, lots of people might work with clinicians around that, but is it implemented then in maternity? Well, if you're working, if you're able to work closely with somebody, a healthcare professional around that, then they're more likely to implement those and that person is more likely to have a positive birth experience. That's a positive outcome clinically. So from services, it makes a real difference to a lot of the markers that they are interested in. Then there's the broader kind of why are we doing this work and what are the drivers? And so, part of that is helping people to get well and the belief around that is if parents are well, there's a better chance that their children are going to do well. So we are making an impact not just for one person, but for two. So it's the broader social gains that we have there as well. Rachel: And not even two, from what you've said in terms of the family system. And not one person at one time point, but that person may be at multiple time points at the things that won't, they won't need to present for help with later on in their journey. Heather: Yeah, Rachel, I think that's such an important point because there's nothing more heartbreaking to see a parent who finally gets into treatment kind of with their second child or their third child and they talk about the heartbreaking experience that they had with their first or their second child and how that's impacted them with subsequent children later on or a parent who is later down the journey with that child and real challenges have emerged in that relationship. And that's just, it's a tragedy. It doesn't have to happen that way. Sarah: And I also think your point, Rachel, about the wider system. Any of us who have had someone close to us that struggled in the perinatal period, there is a real obvious ripple effect to that. Their partner seeing their partner in such distress or having such a difficult time is going to have an impact on them and their mental well-being. The grandparent’s kind of seeing their child really struggling in this way we're helping a lot of a wider system if we're helping somebody who's struggling in that perinatal time point. Rachel: So not just the moral and ethical case for this work, but also it helps and it's effective and it helps so many people through intervening at these time points. Thinking about other adaptions, are there specific adaptions you might make for neurodiverse parents? Heather: I’m so glad that you bring this up, Rachel. So I have the great pleasure of getting to work with Verity Westgate, who is currently doing, she has lived experience of autism in the perinatal period and is doing her PhD on this right now. So what she's been finding in her research has been really great, I think. So first off, I think it's understanding, for example, autism and the experiences that an autistic parent might have. So considering that they might have sensitivity to sensations and what that might be like physically when they're pregnant, a baby moving all the time, the discomfort in your body, what if you're very sensitive? It's going to really heighten that. During childbirth, all of those noises and sounds and the pain, what would that be like? Likewise, once baby is born and now you're talking about routines and you're talking about crying and you're talking about possibly breastfeeding and all of these things are full or just having a baby on you. All of those things are full of sensations. It's thinking about with parents very practically about what they might do to manage some of those sensations so it's not tipping them over the edge. But it's also about a recognition that inevitably there will be a lot of sensations and smells and noises, et cetera, and they might need time to go and decompress and let some of that go. And it's really understanding the thresholds of where autistic parents, for example, might be versus non-autistic parents. What she has found a lot of autistic folks have said has been really helpful is a very practical and applied approach in perinatal teams where they've got an occupational therapy, for example, fantastic, it's been really positive. But I think within NHS Talking Therapies as well, there's a lot of practical work that we do. And so nice to know that, if we're thinking like, oh, to what extent does CBT apply to people with autism? Well, behavioural approaches work really well. It's really effective, you can get your head around it, particularly in the sleep deprived period, it can be really nice. So thinking about some of those adaptations. Also just thinking about routines, like autistic parents can be such great parents because they are good at routines, but baby schedules change all the time. There's a lot of flexibility that's also needed in those routines. So it's maybe not so much about getting into routines but thinking about how to flex around those routines. And then there might be a bit of communication work as well, thinking about the specific communication needs of those individuals and how they might want to adapt it during this period. Likewise, if you have somebody with ADHD, you know, routines and schedules, that might be a different kind of challenge and reminders and just thinking about what kind of cues you can use during this period with the baby when, woo, paying attention in the best of times is difficult, much less when you have a baby or if you're a hyperactive person and you're supposed to sit on the sofa with your baby and feed your baby a lot, like that is very difficult. So thinking about some of those things. Rachel: Well, as you're talking, I'm thinking of just what a challenge many of the things you're mentioning were like without that added challenge of neurodiversity or the issues that can bring with it. You know, the idea of finding decompression time when I couldn't go to the toilet for months on end on my own, you know, it sounds like there might be a lot of problem solving to be done around these issues or, know, the kind of issues around feeling like, you know, you just got a routine set down, it's working for you and then everything changes. All these things can be challenging for anyone, but if those are particularly challenging for you as an individual, then it must be so great to have support from someone who can work through that with you. Sarah: Yeah, and I think Verity's work is so interesting and really bringing a lot to our understanding of working with neurodiverse parents. And I guess holding in mind that that's not a homogenous group, that, you know, different people are going to have different things that help them or that they struggle with. you know, in the therapy context, you know, asking them what helps them to, you know, manage sensory stimulation or helps them with attention or what kind of things do they need to build some flexibility that might be helpful for them or where can they plan a little routine that might make things a little bit easier, both in a therapy context, like what do you need to do in sessions to help that person engage and help that person get the most they can out of therapy and in the parenting context and those two often align. Heather: And I think that that's so true and also want to highlight that actually a lot of people come into the perinatal period didn't know necessarily that they were autistic or had ADHD. And we know that getting that diagnosis, there's a huge wait list around that. It could be if you're in the NHS, could take quite a while for that. Rachel: It's not going to be nine months. Heather: It's not going to nine months. Yeah. So I think there's a both end. It's really important for clinicians, and it's great that this is rolling out more and more across the NHS and for a broader range of clinicians. It's really important to know about autism and about ADHD. so you have some of that knowledge so you can talk to parents who this might be a very different and new experience for them and think about what they might need in that context as well. Rachel:  I feel another podcast coming on now and we will be doing that down the line. So you guys are obviously world experts in this stuff. You're used to doing it. A lot of this is going to be second nature to you, but in your years of teaching, supervising and applying this therapy, where do you find most therapists get stuck? What are the most frequently asked questions or the tricky issues that come up for you? Sarah: I think the most common thing is what we were talking about earlier, and I laugh because it does come up so much, but exposure-based work. People are nervous of doing OCD experiments in pregnancy. For example, what if they do have a miscarriage? Say the client's like, I wear this colour, I'm going to have a miscarriage. Or if I don't do my rituals in this way, then I'm putting my baby at risk. And so the clinicians are, what if they did have a miscarriage or what if that does happen? So their own fears are kind of maybe getting in the way of them doing that work. So really being able to talk through that in supervision and think about what you're trying to do and really remember that you're trying to help this person reduce their distress. And so increasing some anxiety in the short term is going to really help them in the long term, being able to cope with that baby when they arrive. So I think that sense of a therapist anxiety about doing the exposure-based work. I think, Heather and I, that's kind of the thing we probably talk about the most in a lot of the training, how to do that, what the evidence and research say, and kind of how to work through your own possible anxiety around doing that work. The other, the two other areas that I kind of come up with a lot, one is around loss, you mentioned, and some of the overwhelming emotion that people might be really understandably experiencing in that time and as therapists how we can be with that and sit with that and be that space where someone can talk to about how they're feeling around that. So I think managing big emotions not just around actually as I say it out loud and that comes up in lots of different contexts but being able to help people think about what's going on for them emotionally and make sense of that. And again, this might've been something they may be always struggled with, but they never were in a situation that was bringing up so much emotion for them. They're really struggling to contain or manage that. So that whole kind of area around managing emotions. And then the other one is around couples and the couple relationship that comes up a lot, I think. Either there, you might be working with someone individually and kind of, you know, according to what you're doing, you're like, why is this not working? They, you know, we're really. They're engaged at the work, they're doing the treatment, they're doing homework in between, but every week they're coming back and talking about their relationship. I think we underestimate how much support people might need in the couple dynamic in the perinatal period. And we know that that's a really challenging time for couples and relationships. And so sometimes the support that might be most useful might be couples work. I know a lot of talking therapy services, offer behavioural couples therapy. And, you know, I've often been doing training and I kind of said, no, just like put up your hands if you offer BCT in your service. And like most people put up their hands and then I say, well, now put up your hands if you think about using that with perinatal clients. And like, for some reason, like lots of people don't think about doing it. And I find it a really meaningful time to work with couples. They're really committed to it doing things different, changing the way they're communicating. But also, there's a huge amount of need to be talking a lot more, to be checking things out with each other, to be deciding on parenting and that kind of thing. So what kind of parents they want to be. So addressing those kind of couple relationships and dynamics is so important in the perinatal period. Rachel: When you were talking, Sarah, about sitting with those big emotions and managing what comes up for the therapist there, facing those huge issues of loss, for example, it really sort of makes me think about the emotional burden that we often hold as therapists willingly because we love doing this work and it's part of why we do the work. And I'm wondering how we look after ourselves as therapists when we're doing this work? Sarah: I'm so glad you asked that Rachel. I think this comes up so much and I think any training that I do, I embed this throughout because any time you're working in the perinatal period the personal and professional often overlap here and it's really important to think about it. I have to call it being perinatal in the perinatal period, doing perinatal work while you yourself are somewhere on your journey which might be you've decided not to have children. It might be you're thinking you might want to have them in the future. It might be, as you said, you've kind of experienced your own losses or you're pregnant yourself and how you kind of bring that into your work. Even I remember being pregnant and I was working in a community, a perinatal team, and even disclosing that you're pregnant, you know, when it becomes very obvious, of course, at a certain point. So, you know, with some clients, it was a real issue that I really needed to think about because they were really struggling or ambivalent in their own pregnancy. So a lot of times where you're actually having to disclose personal information in a way that is not necessarily typical of what we would have to do with other kind of with other clients or other client groups. So I think good supervision, first of all, is so important and having services that really understand and can think with clinicians about how you manage some of this and how you kind of, you might disclose things, know, thinking a little bit about those trickier conversations, but also thinking about timings of when you do certain client work. I think sometimes when I'm working with a client that may be there is a lot of emotion around baby loss. I might give myself a break after that session. take a little walk, get a breather, you know, be able to be present then for clients I'm seeing later in the day. The other thing is there may be times where you might need to think about changing your caseload. You know, I think even thinking about if you're working in a talking therapy service and you're you've had a miscarriage, it might be thinking with your supervisor about actually for a little bit of time, think these kind of cases are going to be too tricky for me and how you kind of can manage that. And some services will be able to do that. And other times, you know, the service demands might be different. But thinking about a lot of those issues and having space. And for me, I think also having really good colleagues. One of the things I love about perinatal work is the perinatal community, you know, and I've got some good friends working in this field as well. So being able to reach out to someone and go, oh man, this case is really tricky for me. I really just talk it through with someone else. Rachel:  Yeah. And it sounds like you're challenging some of those beliefs we have often therapists, we should be on top of everything, or we should be able to handle every case or every issue that comes and actually that part of being good professionals is recognizing when this isn't the time for me or when I need a bit of extra support with this. One thing that's come through really strongly from both of you today is how important that message is that exposure therapy can and should be done during this period. I love the fact, Sarah, you went to the lengths of getting pregnant yourself to expose a client to other pregnant women. It just shows your commitment to the work. We also learn a lot from our clients, don't we? And I'm wondering what you've learned from the people you've worked with and how maybe doing this work has made a personal difference in your lives or the future focus of your work, you where it's taken you. Sarah: That's such a good question, Rachel. it's one I often, I often get asked, you know, did I change as a clinician when I had a baby? And like, is it, did being coming a parent make me a different, better, improved my clinical practice? And I say, it's the other way around. Actually, I got so much from the clinical work and from the wonderful clients I've worked with over the years that has made me a better parent and that helped me through that kind of perinatal period. And I think in a couple of ways, one in terms of tolerating uncertainty, you know, and that real awareness that we cannot predict a lot of what happens when you become pregnant, from when you become pregnant to what pregnancy symptoms you have, what your birth looks like, how feeding goes, you know, what those early few months are like, whether your baby sleeps well or doesn't sleep well. There's so much uncertainty. So I think I feel like because I've been working in perinatal, I went into becoming a parent with a little of expert knowledge and this is going to be a bit of a roller coaster, and I need to kind of flow with it. So that bit and then the other bit that I always kind of talk about what I've really has made a real personal difference to me is I remember saying to my husband just before we had our baby, nothing I say in the first six weeks counts. It's not an indication of how we're going to be as parents. I am going to sound crazy, I'm sure at times, or be short tempered or whatnot. I really feel like I should have said the first year, I'm really understanding that the perinatal period is a period of transformation and transition in relationships. I guess that might be your relationship with your partner, but even the wider system, your parents, your siblings, your friends. And kind of that awareness of actually, it'll always surprise you in some way, certain relationships that are either much stronger after having a baby or that can be really tricky or problematic and that you didn't quite expect it to unfold in that way. And I think those are the issues that my clients often bring. So I kind of stepped into it, I think, with an awareness. It still surprised me every now and then, obviously. Rachel: Anything you wanted to add Heather that you've learned from your patients in this work? Heather: Yeah, you know, I guess at any clinician working at any point, hopefully we're always learning from our clients, aren't we? So I feel like I've learned so much and it's been a bit of a gift because I would say all in all, almost all the parents that I work with, I'm so in admiration of them. They're trying so hard and being a parent is so meaningful, even when it's such a struggle for them. And inevitably, a lot of them think that they're just rubbish. I'm thinking, but you're doing such an incredible job. And so as a therapist, it's kind of a gift to say, right. Actually, we will have times as parents where we will just think this is not. It's all pear-shaped, it's not going the way that we want it to go. And actually, we're doing just fine. And I wish that every parent could have a therapist kind of perspective on things and to get to see that a bit and to help to grow that compassion within ourselves. Yeah, so thank you to all the clients that I've worked with. Rachel: That enable us to be good enough parents. Heather: Yeah, yeah, exactly, exactly. And you don't want to be perfect because that sets your kid up for failure doesn't it? Like they need to see that there's struggles and that there's ruptures and opportunities for repair. All of that. It's really excellent modelling. Rachel: I love that my kids are getting such a good model of an imperfect parent that that's really helping them. I also love this idea of space to explore and discover who you are as a parent, Sarah, that you said, know, this idea of the first six weeks or the first year being the safe space. We have a similar thing in our marriage. We had some very good advice from older married friends at one point that arguments in the car and the kitchen don't count. And I feel like it's a perinatal extension of that. There can be freedom and space to discover and learn and grow. And as Heather says, to be imperfect so that our kids can discover how to navigate the ups and downs of life through that as well. Rachel:  So I know you're both really committed to your leading roles and promoting implementation of all of what we've talked about in services. Heather, what do you think are the key points around implementation that really need to be taken into account when we're thinking about this work in our services and our service systems? Heather: So we've been talking about how if you have great CBT skills, for example, that that's really important, but it's about combining those skills effectively and integrating your knowledge and skills within perinatal and working with the wider system with those existing CBT skills. So it's both, right? It's having great competencies in CBT and great perinatal competencies. So I think one thing that Sarah and I are very committed to is helping to support work both within the Pearl Institute and within the NHS and within private practice around ensuring that those competencies come together so we can provide the best care for people and for their border families. Rachel: So big question, what's happening for you guys? What are the big, exciting areas and how can people get involved in this work? Heather: So I think it's a really exciting time around perinatal mental health. It continues to be an exciting time. I think there's actually not just clinically there's been growth around providing perineal adapted provision, but also research has been growing alongside that as well. So first off, how can people get involved in research? There's a very concrete way they can be involved. There happens to be right now a James Lind Alliance perinatal mental health research prioritization exercise that is going on. That's a very long term that means people can have their say around what they think are the research priorities. So we are going to be launching a survey around this that will go out and anybody can respond to this. We'll also, we'll have a website on this, but it'll be on my webpage as well. So if people are interested to have their say, they can have a say. Rachel: And we can link to that on the show notes so people can click on that after listening to this podcast. Heather: Yeah, that would be fantastic. But there is just, there's a lot of work that's going on right now. Sarah and I are involved, I'm leading a trial, a multi-set trial for an intervention for antenatal anxiety. And we are following up one year postnatally as well. So we'll be looking at parent-infant outcomes also on that. And that one is...People are seen in NHS talking therapy. So we're recruiting them in scanning clinics when they're 12 weeks pregnant. And then they go on to NHS Talking Therapies and Sarah is our excellent clinical supervisor on that. I'm also involved in some research around early pregnancy loss with Camilla Rosen. There's just about to be a perinatally adapted DBT group trial that's getting started that I'm also involved in around that which is really fantastic. And then there's lots of work as well going on around understanding kind of the broader perspective of perinatal and who is getting treatment, who isn't getting treatment. So really looking at linked data that's in regular care and understanding that. So we're doing that here in England and we're also doing some of that work with Dharmintra Pasupathy at the University of Sydney. So lots of different things, lots of opportunities. It great also to start doing some more work around sleep in this period because at what other time are you more sleep deprived and the impact that that has on mental health as well. Sarah:  Yeah, and I think so many, as Heather said, so many exciting things going on and we're kind of thinking about expanding the offer of kind of perinatal care. So thinking about how are we including partners more in the care and doing that couples piece of work but also thinking about working with perinatal law. So, you know, Heather and I both been involved in an expert reference group around adapting the prolonged grief treatment for working with perinatal loss with Kathy Scherr and colleagues in the States, which is really wonderful to see that kind of being applied in a perinatal setting. So really giving people some options of how to support clients who might be really struggling with perinatal loss. And I think, Heather and I are both really excited about the training piece, you know, that making sure that people are being trained in evidence-based treatments in the perinatal period. That was one of the things I guess we would have what I like to call our geeky chats, Heather. Heather would tell me about this neat research that she was doing, and I'd go, oh, that really applies to this client I'm working with. I might be able to kind of, I can really see how that would work here, or I might share that piece of research with them or I'd be talking about a client that I was kind of stuck with or something that, you know, it was coming up a lot and she'd be like, oh, I wonder, you know, that might really apply to this research. So we basically, that was the seeds of how we started the Pearl Institute of Perinatal Psychology and that we kind of thought, well, let's bring our geeky chats to a wider platform and bring in experts in the field. So I think we both get asked to do a lot of training. So we thought this would be a good opportunity to make sure we're offering people treatment that's really about how to adapt a lot of these questions have been talking about, how to adapt treatment in the perinatal period. So we've had kind of Fiona doing OCD and stuff around your childbirth. So I think I'm really excited about where that's going and what we kind of what experts were bringing in to do that. Rachel: Oh, there's so much going on, isn't there? It sounds like such an exciting field to be part of. And we will put all those links to the Pearl Institute, et cetera, on the show page for people, the show notes for people to follow up after they've listened to this. I feel quite privileged to be in part of maybe, maybe part of one of your geeky chats. I'm not sure whether this goes far enough to be defined as one of those, but it's been really interesting talking to you both today. In CBT, as you know, we like to summarize and think about what we're taking away from each session so in time-honoured fashion, what key messages would you like to leave or message would you like to leave folk with regarding this work in the perinatal period? Sarah: I think for me, it's remembering the honour we have of supporting clients in this hugely transitional period. It's such a big life transition and we have this very unique opportunity to be part of that, to be part of people's story and part of what helps make this an easier time for people and really supporting them with that distress. So I think for me, it's that, I guess, gratefulness I have to for allowing me to be part of their journey.  I think, you know, in terms of my personal kind of piece, that would be what I would take. And in terms of clinically kind of taking away as like, man, involve the wider system. So involve partner, involve baby, you know, really bring people in and do the evidence-based work. Don't avoid doing treatment in pregnancy. People really deserve to get that support. Rachel: Fantastic. Anything to add Heather? Heather: I guess I would just say that although on the one hand we've talked about the struggles and barriers that might be in place to delivering care, to also highlight that the perinatal period is often a period where people are looking for opportunities for improvement. They're motivated to change behaviours or beliefs. So there's a real open-door opportunity that we have here if we work past some of those other barriers. This can be such a rewarding point in which to work with people and as we've been highlighting throughout, it has ripple effects. If there's an opportunity to bring in more individuals and to really be very profoundly impacted. Rachel:  Thank you, Sarah. Thank you, Heather, for all your time and giving us the benefit of your knowledge and experience in this area. And I hope folk have really picked up some ideas about how they can enhance their practice, maybe new knowledge areas that they can push into to inform themselves, to really help us help folk in this vulnerable, but really exciting and formative period in people's lives. And thank you all for listening. Until the next time. Look after yourselves 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 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 with Professor Barney Dunn, clinical psychologist and researcher at the University of Exeter, about his work on Augmented Depression Therapy (ADepT) a novel approach to treating depression that targets anhedonia (difficulty experiencing pleasure) and aims to boost wellbeing. Barney shares personal and professional insights into why and how traditional CBT might be augmented to actively help people rediscover joy and meaning in life. He explains how ADepT, based on systematic research, integrates cognitive behavioural principles with techniques from ACT, mindfulness, strengths-based CBT and more, all aimed at helping clients live well alongside depression rather than simply reduce symptoms. Whether you’re a therapist working with depression or simply curious about new directions in CBT, this episode offers a thought-provoking and inspiring conversation about what it really means to get better- and stay better. Resources & Further Learning: Find more information about Barney and his publications here Find out more about ADepT here Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [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, we're joined by Barney Dunn, a highly renowned research and clinical psychologist specialising in therapies to improve wellbeing and functioning in depression and related mental health conditions. Professor Dunn is based at the University of Exeter, and he has a finger in many interesting pies, but today he's here to talk particularly about his work developing and implementing treatment for depression with a particular focus on symptoms of anhedonia. Thanks so much for joining us, Barney. Barney: Thank you very much for having me, delighted to be here. Rachel: And just as a starter, we want to think about how you got into this area of research. And as I said, you're interested in lots of different things, but you've devoted a lot of your time and effort to thinking about anhedonia. There's so much to fascinate in clinical psychology. I wonder what got you interested in the field of depression and specifically this anhedonia area personally and professionally? Barney: Professionally, when I was doing clinical training and learning to cut my teeth with a lot of depression cases, hitting a point where I felt like I'd done quite a lot of work reducing the negative and reducing symptoms, but the job was only half done. And clients were saying things like, at the end of therapy, well, I'm not depressed anymore, but I'm still not quite sure what life's for and I'm not enjoying stuff. And I felt...Well, maybe I'm not doing CBT correctly, or maybe there's a bit of a trick missing about how we can do that stuff better. So that was the kind of professional route into it. The personal route into it was a bit more growing up with my dad. So I lost my mum when I was little and was very well supported by my family but seeing my dad in my eyes never quite get back to life, never rediscovering joy and connection and meaning and grinding through and turning the wheels, but not getting pleasure back and thinking there's a missed opportunity there. Even after the difficult, there's possibility for the good. And so that's the kind of personal motivation is thinking of clients like my dad, how could I help them get back to life when they've been through some difficulty and rediscover wellbeing and joy? Rachel So that really meaningful connection for you from your own lived experience with being alongside someone who never got that meaning back. Those are big questions. And I hear what you say, you working in depression, you get good results with your clients in terms of their symptoms improving, but you talked about a job half well done or half done. Currently, how well are these symptoms targeted in mainstream treatments? I mean, it's a brave man who takes on, you know, Beckian cognitive therapy and thinks, right, we need to do better. Barney: Well, I mean, we should follow the data. So if you do Beckian cognitive therapy and indeed any other evidence-based treatment for depression under ideal circumstances, really good therapists who are really well supervised, you basically get about 60 % of clients who will meet diagnostic remission at the end, half of whom will relapse within the next two years. So that's ultimately a 30 % proper response rate. And that means we leave a lot of people with a lot of distress afterwards, you know, 70 % of the people that are coming through our doors. If you look at NHS Talking Therapies reliable recovery rates for depression lag a bit behind anxiety recovery rates, and they're a bit below 40%. So more than 60 % of the folks coming through NHS Talking Therapies with depression will be depressed again within a couple of years. So there's definitely still a problem to solve and it feels like a really interesting and clinically important question to work on but one to be humble about because lots of really great minds and really hardworking people have thrown themselves at it, and what we've done is proliferated a lot of equally partially effective treatments but we haven't made any stepwise gains since Beck who did make that massive stepwise improvement in the late 70s. Rachel: Yeah. So it's great that there's evidence-based treatments are out there, but there's still a lot of people that find that there's something lacking at the end of therapy or even don't improve. So if we treat the sort of negative feelings, so there's negative symptoms of depression. Doesn't that automatically also address some of this anhedonia or positive valence system? And if not, why not? Barney:  So I think that's the assumption we all came from to start with, which is there's a continuum of affects, which you go from being really negative, you get to this middle point where you've been meh, and then you move to this position where you're feeling really positive. So if you bring down the negative, the positive will inevitably increase. But then there's been some interesting other ways of thinking about that and recognising that they're at least partially dissociable systems, which means positive affect can move when negative affect doesn't move and vice versa. And again, just to come back to my dad as a case example, when my dad was dying of cancer, there was a lot of distress and difficulty and pain. And there wasn't a way to make that go away. He was dying of cancer, but that didn't mean there weren't things we could do to find wellbeing within the midst of that. One of my favourite memories with my dad in the last few months was he wanted to drive his car again, but he was on too much morphine to drive safely. So we put him on the sit on mower and drove around the garden, kind of destroying my mum's prized flower beds and my stepmother's prized flower beds. And that's one of my favourite memories, like chuckling with my dad on morphine, driving badly around the garden, amongst a whole lot of negative affect. So I think it's quite useful to realise even in the midst of depression, you can find joy and pleasure. There's also an increasing basic science argument here, which is the systems of the mind and brain that regulate negative emotions and avoidance of threat are partially dissociable from the systems of mind and brain that regulate positive emotions and approach towards things. So you can move one without moving the other. And my view is you need to do both in therapy. Bring down the negative, push up the positive. Rachel: Does everyone experience, I mean, you've just spoken about an example of your dad experiencing lots of negative emotion, but still having that positive emotion. Does anhedonia develop for some people and not others in the context of depression? Barney: I think it's like most ways of thinking about depression, things fall on a continuum. Estimates of how many clients have clinically significant anhedonia ranges from 30 % of them having really severe and profound anhedonia to 70 % having significant anhedonia. It's one of the, along with elevated negative affect, it's one of the two cardinal symptoms you need to get a diagnosis of depression. So it's pretty prevalent, but it isn't there for everyone. And it isn't there for the people that have it all of the time. Its just sometimes people need to develop the skillset when anhedonia is with me, how can I step away from it and get back to wellbeing and joy? Rachel: And is there a differential pathway? I mean, will it be some people who are more likely to develop anhedonia than others or circumstances that are likely to lead to that? Or as you say, is it just likely to be there or not at different times than that pathway? Barney: Well, so my view again is like most symptoms, there are many ways into it and many ways out of it. So it's dangerous to put hard and fast generalisations onto it. But I would say there definitely is a kind of genetic, biological basis for your reward system to be more or less reactive for better or for worse. So some people are just born with a capacity that reward washes over them and they really enjoy it. Others have to work a bit harder. I'm increasingly struck that in people's developmental histories, an absence of early positive experiences then makes it hard to understand and be able to lean into positive emotions. I love the move towards trauma-informed practice, but I think we also need to have just as much focus on clients who've missed the positive and how we can grow that system later from scratch when it wasn't developed during childhood. There is also a pathway from chronic exposure and stress and trauma that alters the reward system. So I'd say there are those three groups of biological predisposition to anhedonia, people through complex trauma have kind of what we'd call neuroendocrine scarring, the kind of hormonal and biological systems that regulate, change the positive affect system, and then people who just weren't exposed to reward and didn't learn how to play with it when they growing up. Rachel: And this for many people is kind of quite a new language and a new way of thinking. Lots of people listening to this podcast will have started their training in CBT, either as CBT therapists or within other professional trainings with the Beckian model of depression and learning their skills. And if we say the words, core beliefs or dysfunctional assumptions, they'll already be mapping out in their minds a longitudinal maintenance formulation. What would a formulation of depression look like taking into account these systems of positive effect and reward processing these kinds of perspectives? And before you start Barney, I need to make you aware of our Practice Matters podcast challenge. So we like a good formulation, but there can be no boxes or arrows or other visual aids because we're an audio podcast. So just a brief explanation about how the problem develops and is maintained without repetition, hesitation, deviation, power point, whiteboards or flip charts. Barney: I like the challenge, Rachel, and you also know me, I'll ignore the rules as we go along slightly. So I'm to give you a narrow formulation of what might get in the way of a client enjoying potentially rewarding experiences. In the therapy ADepT. we've developed, we think about psychological mechanisms of mind that when people are exposed to potential opportunities, get in the way of that leading to sustained and ongoing positive emotions. The first thing is behaviour avoidance, people don't put themselves in situations that are potentially rewarding. The second thing is behavioural shaping. So they're not choosing activities and refining activities in the best way they have to land. So if I'm going to a party, arriving with friends and making sure the music I like is playing. The third one is intentional. When they're in a potentially rewarding situation, they're noticing the bits they don't like rather than the bits they do like. So maybe I'm out for a beautiful meal but don't like peas, so I focus excessively on the peas on my plate, not the beautiful prawns I really like. Rachel: My kids need this. I'm just saying. Barney: The fourth one's kind of cognitive. So what we're realising is a lot of clients who are depressed have a set of appraisals when positive emotions start to switch on that dampen them or crush them. It's because they're a bit alien and scary and weird and uncomfortable. And the appraisals are things like, this is too good to last, I don't deserve this, people will think I'm too big to my boots. So what those kind of appraisals do is they instantly extinguish the positive emotion. And it's a bit like a candle snuffer in a church. The flame is instantly squashed. And what you're left with is the smouldering flame that isn't very pleasant afterwards. There's also a nature of how experientially engaged in the positive activity people are. Are they being very heady and evaluative? A bit like Barney going to a party and wall flowering at the edge and not really being part of it, watching it, versus Barney going to a party and really connecting to the sensory experience. So in ADepT, what we're doing is we're spotting all of those patterns that get in the way of positive affect, triggering and sustaining, and we're getting clients to take a step in the opposite direction. So when they want to avoid, we get them to approach. When they're focusing on the negative, we give them skills to focus on the positive. When we're having dampening appraisals, we give them skills to come up with realistic positive appraisals that can help them engage. When they're being very stuck in the head, how can we get them back into the mindful everyday moment and so on. Rachel: So that was a brilliant summary, Barney. And I know you've talked about high ADepT. You like to keep things short and punchy. So you're obviously well practiced at that. But you've said that there's key factors of behavioural avoidance, behavioural shaping, attentional processes and cognitive processes that are maintaining the model. And you've talked already a little bit about how your treatment focuses on that. Can you tell us a little bit about ADepT? What ADepT stands for and what that means. Barney: Well, so ADepT stands for Augmented Depression Therapy, which was basically an attempt to get better at treating anhedonia in depression. And the broad formulation model in ADepT goes something like this. We think people get depressed for good reason, usually because life isn't going in the way that they'd want it to. So what we're trying to do is help clients clarify what's important to them and makes them tick. So that's values work. Then we try and behaviourally activate them towards getting more of that stuff in their lives. And we fully expect that when that happens, depression is going to try and trip them up as they go. Life will throw them challenges and depression finds ways to make those small hills turn into mountains. How can we take a step away where clients have resilience to challenges in life? Life also simultaneously throws us opportunities and depression is really good at snuffing those out, how can we help clients instead lean into those opportunities? So we're trying to create a virtuous circle where clients clarify and move towards what's important to them and act opposite to their depression so that they get the full potential out of these life situations they're engaging in. And I guess the flip from CBT is actually producing depression isn't the goal here. By the time most people are coming to see us, certainly for high intensity CBT, they're usually on their third or fourth or fifth or sixth episode, if you look at the epidemiology of depression, we know it is a kindling condition that people are likely to have an ongoing vulnerability for. And in some ways it's an unrealistically optimistic model to say, I can cure you, I can get rid of this thing. In ADepT, we're instead saying, how can we support you to live well alongside your depression so that you can have wellbeing? And by wellbeing, we mean getting meaning, getting pleasure, getting social connection. And we frame depression as a barrier to achieving those goals. And we say to people, there'll be times in life when you are in a depressed episode, how can we help you get as much wellbeing at those times as you can? There'll also be times when you're not in a depressed episode, how can we really help you lean into wellbeing at those times? So it's ultimately learning to live well alongside depression, befriending the naughty black dog that's tripping you up and trying to turn it into a bit more of friendly house pet that you trust in your living room. Rachel:  And I was struck by what you said at the top of the podcast around, you know, patients getting to the end of treatment for depression and maybe feeling less low, but saying, actually, this hasn't addressed this huge important aspect to me of where's the meaning in my life and where's the positivity at the front end of treatment when you're engaging them in this idea of, of not maybe targeting the depression or, or the goal not being to be depression free but rather one of wellbeing. How do folk engage with that? Barney: I mean, this was one of the really interesting empirical questions when we talk, because I guess the standard view was you can do this well-being work at the end once you've got people better. And surely it will be profoundly invalidating to say to people right at the start of the work, let's really think about what will make you tick and make you want to get out of bed. And what we've found is the opposite. If you clarify what's important to people and help them move towards it, it often helps give them the motivation to keep pushing through when their depression is saying, all I want to do is lie in bed, stay on the sofa and withdraw. Having that, this is what my mind is telling me now, but what's important to me at a higher order level is I want to be a good father or maybe I want to be a marathon runner or maybe I want to do a good job at work. That can give me enough distal motivation to keep me pushing through the avoidance. Rachel: It sounds like as in standard cognitive therapy with depression, would expect trip ups, we would expect ups and downs and we might often formulate those in therapy as an opportunity to test things out. It sounds like those are not only formulated as an opportunity to test things out or put strategies into practice, but actually almost quite essential to the ADepT process that people are experiencing those trip ups to be able to kind of implement what they're learning. Barney:  Yeah, one of the things I found in my early CBT practice was I was thinking, well, these people are struggling to get back to reward. So thinking all I've got to do is give them a massive hit of reward. So they used to like parties, let's throw the best party ever so they can get back there. And people were trying it, and they were finding it really quite aversive and saying, I don't like that anymore. And then I was at a kind of talk by Paul Salkovskis, he was being really entertainingly provocative about how badly we've done in the depression field. They say you depression folk just need to learn from the anxiety folk about how to improve CBT outcomes. So I thought okay, I'm going to do a thought experiment of taking it literally. What happens if we re-conceptualise anhedonia as an anxiety disorder where the phobic stimulus is a fear of the good. What would I do there? Well, I'll do a graded exposure hierarchy where I'd gradually get people back towards rewarding activity in small steps. I'd fully anticipate it's going to be difficult as they re-engage with this stuff. They need to stay in it long enough for the difficulty to pass so that something new can come out at the end. And I'm going to keep really vigilant for safety behaviours that get in the way. So all of those psychological mechanisms I talked about earlier that get in the way of pleasure experience, you can conceptualize them as safety behaviours. We're trying to encourage clients to drop them, take a step in the opposite direction, sit with the initial discomfort of feeling positive. It feels unsafe, it feels weird, it can feel a bit disgusting for some clients who haven't had it for a while. Trust if you stay there long enough, the light starts to come in and feel a bit different. So that's the flip from how I used to do classic CBT behavioural activation. And we're really explicit in that early behavioural activation. What we're trying to understand here is how your depression trips you up. We're not expecting you to enjoy this stuff initially. What we want to understand is how's that depression coming in and snuffing that candle out so it gets blown out instantly. And we just welcome that as an opportunity. Great. We're now understanding how your depression trips you up as there's the chance to do something different with it. Rachel: So the major thrust of the therapy in all of this is that this thrust towards wellbeing and value and along the way there's going to be ups and downs. But actually those are to be expected and utilised in terms of developing those skills. Barney: And there will definitely be downs, but there are always ups, even with the most depressed clients. Because where, I'm sure we've all had this, where your depressed client comes in through and say, how's your week been? And they go, nothing's happened. And then you look at their mood diary, and there is always some variability in it. Now as a CBT therapist, I'm really well trained to say great, there's that really difficult, challenging point where they had an argument or they wanted to self-harm or their mood really dropped. And my attention would naturally be drawn there to go, let's understand and formulate and give them a way to step out of it. But what's it like if you do the thought experiment of let's look at those moments where it wasn't that, where it was slightly less low or maybe even good, what was happening there? Can you put an equal amount of your attention or focus on that? So clients learn from the good. And certainly, my experience when working with classic CBT is when negative affect is flooding the room and stuff is feeling really difficult, that's when our minds are really not open to cognitive change. It's like new ideas bounce off people, they're resistant. I found it much easier to actually do the cognitive work with people after a positive exception. So you're looking for those moments where it's been a bit different. You're reactivating them in the room so that positive emotion is switched on a little bit. And we know the evolutionary function of positive emotion is it makes us a bit more creative. It makes us a bit more open to social connection, and it makes us a bit more open to activation. So that's the time when it's easier to do the cognitive work after a positive exception, not in the midst of a negative pattern. So we're doing the cognitive change work in a different place. Rachel:  And being creative, social and activated sounds like a good place to be. And you've said that ADepT integrates interventions from CBT, ACT, positive CBT, strengths-based CBT, wellbeing therapy, goal setting and planning approaches, behavioural activation, MBCT, future directed therapy, the cognitive behavioural analysis system of psychotherapy and dialectical behavioural therapy, and that it integrates ideas from positive psychology literature. That's a huge and diverse range of approaches. What unifies the approach and makes it not just a sort of bunch of eclectic techniques, because I know that's not the way you work Barney. Barney: So I sometimes see two traditions of CBT. There's the very, I'd call the UK tradition is a very manualised one where we need to do it in exactly the way trials have shown it works that of following this particular treatment and anything off that is unhelpful therapeutic drift. But actually we need to remember the Beckian origins. Tim Beck was the ultimate theoretical magpie. And the few times I was lucky enough to meet him, he was really clear. It's good CBT if the intervention elements you are choosing match your cognitive case conceptualisation. So in ADepT terms, I'm thinking, what is the valued activity someone's working towards? What's the depressive mechanism of mind that's getting in the way of them dealing with the challenge or taking the opportunity? And therefore, what is the intervention element I want to bring in now that will help them step away from that So if a client is riddled with self-criticism and I want to move them towards self-compassion, I think about how can I weave in some ideas about compassion focused therapy, but in ADepT language where we're doing it with solution focused stuff. If a client's very behaviour avoidant, I'd go back to behavioural activation routes and I would think, okay, what are the ways to activate clients here, break things down into small steps, think about SMART goals and whatever, but I'm doing it in solution focused language. So what orients ADepT as a cohesive therapy is activating people towards values, spotting mechanisms of mind that trip people up and choosing an intervention element that has an evidence base to work on that mechanism. Rachel: And those mechanisms have been identified through basic science and cognitive science and theories and testing. Barney: Yeah, and actually, this is me putting a bit of provocative challenge back to the conventional CBT depression crowd. If you actually look at how highly established has been the mechanism for negative Beckian cognitive therapy, it's a little bit mixed. In my world, if something's really going to be a mechanism you should target in therapy, you need to have quite a high evidential bar that you should be working with it. It should be associated with the phenomena of interest and the mechanism should correlate with anhedonia prospectively and longitudinally. When you manipulate it in the lab, so you turn a mechanism on or off, anhedonia should come up or it should come down. When you do a treatment trial, the extent to which you change that mechanism should mediate the extent to which your symptoms improve- and there are very few mechanisms in any aspect of depression research other than what can work on rumination that they've taken all of those evidential steps to show it shouldn't really be a target. So we've been running for 15 years a basic science program that's applying that towards our candidate mechanisms of mind that get in the way of pleasure experience, so dampening appraisals, altered and reduced to positive attentional biases and so on. And when we are convinced something's a mechanism, then we start targeting it in the treatment. That's the kind of basic science roots to it. Very much influenced by David Clark's copy book about how he developed PTSD and social phobia treatments. He wrote a beautiful paper at John Teasdale's Festschrift about how did I actually develop these therapies? And we took that approach to how we've tried to target the positive affect system in ADepT Rachel: So systematic research. It sounds like both you and Paul Salkovskis like to be productively provocative. So you've given us a really good sense of the overall focus of therapy. How might that translate into what a therapist might actually do in therapy? And I hear what you're saying about you're not necessarily taking a manualised approach in a kind of paint by numbers manner, but what would a good course of therapy typically look like if you can say such a thing? Barney: Well, so just to be clear, I think where manualised treatments work really well is where you have a very clean and clear phenotype, so a particular clinical presentation walks through your door and you can be fairly certain mechanism X, Y and Z will be there and they need intervention elements, P, Q and R as a result. And that's why I think anxiety for CBT works so well. It's a more homogeneous presentation. If someone comes in with social phobia, you are pretty likely to see these things there. Depression is by definition, much more heterogeneous. It can be any combination of 10 symptoms and there are many different forms of presentation. So if you try and do the same things with everyone, it's going to be trying to squeeze a round peg into a square hole. So ADepT is all about training therapists to be good at that pattern matching. Rachel: I remember you saying, Barney, to me once when we were talking about exactly this, I was used to working very closely with anxiety disorders and we were talking about treating depression. there's something, something just feels more difficult about it. And I think you described it as the difference between a sniper approach and guerrilla warfare. And that really stuck with me and really helped me in terms of those formulations. Barney: Yeah, have to, you have to, you know, when you're doing guerrilla warfare, you have to take the opportunity and pop out and do what you can at the right time. So when a mechanism raises its head, that's when you work on it. You can't say in session four, I will always work on dampening appraisals and that will be relevant. You need to look for the opportunity when dampening appraisals are around and then choose to work on them. So with that in mind, how did we design ADepT? So it's a therapy of three parts. The first eight sessions we described was a bit like doing an A level in wellbeing. It's where we introduce the model and the tools of therapy. We start by giving a rationale about why it might be useful to grow a positive muscle and reconnect to wellbeing and learn to live well alongside depression. Then we do mood diary, like you would in the conventional CBT, but very much more interested in where are the moments of light. Where are the things that slightly lift mood? And we do a lot of solution focused inquiry. And we're just curious about what was it about that, that slightly reduced the darkness or maybe even turned the light on. And then we use that to populate what we call the values dartboard. So we split the world up into roughly four areas, work, hobbies, relationships and self-care. And we're trying to get to what makes clients want to get out of bed in each of those areas and how much of that stuff are they getting? And how can we help them get more of that stuff so that life is, work's going a bit better, relationship's going a bit better, hobbies are going a bit better, and they're looking after themselves as they go. And critically, that clients are getting a balance right between those two areas. So know, maybe Barney's values dart board is a bit too work occupied and I need to shrink that so I have time to go skiing with my kids. So that's kind of sessions two and three is clarifying values. And then we start activating people towards goals consistent with those values. And we say, this is where we really expect depression is going to come in and trip you up. And then we introduce them to a simple mapping tool, bit like Chris Padesky's hot cross bun, but with a few tweaks to understand how depression sometimes trips them up, but also just as well how things sometimes go well and they do something different. The tweaks we're bringing into that hot cross bun are we're taking a utility-based approach. So what is most likely to get you what you want here? So we start with going, what was the activity and the goal? And what were the consequences? Did you get what you wanted? And then we're thinking about patterns of thinking, attending, physiological regulation and behaviour to see, does it help clients achieve that goal? We're also building in a strong emphasis on self-care. So what are you doing first to create the opportunity for this to go as well as it could? And also, we have an environment element. How was the broader world helping or hindering you there? So what we can do is we can map out a depressed me. This is how depression tripped me up. And then we can start to move towards a new me. If I was trying to achieve this goal, what would be most likely to get me those consequences? We use that as a vehicle for loads of behavioural experiments. Like, okay, so maybe you could try a different thought on for size. I don't know if it's accurate or not. Let's see if it's useful. Maybe you could work on a different behaviour. And so I think most CBT therapists are very familiar with negative virtuous circles. We're trying to build here positive virtuous circles. Maybe the idea is if you think in this way, it makes it easier to behave in this way, which is more likely to get you your desired consequences. So where have got to so far? We've introduced the model, we've clarified values, we've introduced a mapping tool to formulate how depression trips them up. And then what we're also introducing is very systematic techniques to just consolidate positive experiences. We do regular positive journaling at the end of the day. What’s an opportunity taken? What's a challenge met? What did I do that helped? And we also get people to engage in what we call everyday simple pleasures but being experientially engaged and when they do it. So most clients like me, I've already spent £2.50 on a coffee this morning. I barely tasted it because I was prepping for this podcast with Rachel. And what would it be like if I stopped and fully engaged with the sensory experience around it? Rachel: I'm now feeling responsible for having destroyed your coffee. Barney, I'll buy you another one next time we see each other. Barney: Or another way to think about it is you've given me this great opportunity that's really values consistent and aligns with my personal meaning system to talk about work I really love. So thank you, Rachel. So we've introduced these techniques in the first third. Second third is putting them into practice to get clients to, okay, so if work was going to look 20 % better in the next few months, what do we need to change? Hobbies, relationships, and so on. And then critically, the last third is about how do we then turn this into a habit for life? What I found with classic depression relapse prevention plans is you build them and then clients put them in a file drawer and forget about them because you've got them better. And then six months later they go, what was it I did in that CBT stuff? It helped and they've forgotten. Whereas instead we're saying these are habits for life that if you keep going will sustain your wellbeing and make you less vulnerable to relapse. So using the language of Jon Kabat-Zinn, he talks about mindfulness is like weaving your parachute every day so that when you need it, you can jump out of a plane. But we're not just saying that in terms of, should you have a big mood challenge, you know how to manage it. We're also saying these are the skills you need to live well every day. So it an ongoing habit. And then because a lot of clients told us that the end of therapy feels like a cliff edge. And this is another thing, when you actually think about therapy from the outside, how many other close, caring, supportive relationships would have such a cliff edge ending as we do in classic CBT? Clients said it felt like it was great. I've got on with someone and then I never saw them again. That was so weird. So we offer booster sessions over a year, five flexible sessions that people can use as they see fit to continue with the progress they want. The structure of therapy is very similar to a CBT session except it's geared to overcome the client and the therapist biases to attend to the negative. So the first question is tell us about something that's gone okay this week, maybe an opportunity that you've taken or a challenge that you've met. So clients know I'm going to have to think of something to talk about. And the review at the end is, you know, what are the two or three things that you found useful in today's session and how are you going to put them into practice? So what we're trying to do is recalibrate the balance of sessions to notice strengths and better things. Rachel: Amazing. Can I ask about each of those stages a little bit more? So the values work at the start. Sometimes when I speak to clients about values, they look very blank. What's meaningful and valuable for you in life? And I can imagine if you've got a long history of depression, even harder potentially to engage with that. Are there tools you use to help people identify and connect with what's meaningful and valuable to them? Barney: Well, so I'm a big ACT fan and here's my critique of act. It sometimes feels like a very intellectual exercise, and it seems to lead people towards kind of, you know, apple pie and motherhood as well. This is what I'm supposed to say I like. From ADepT, we're much more trying to go from small positive exceptions that are happening in everyday life to start to explore what was it about that that floated your boat. So let's say a client comes in and goes, it's been a really tough week, but I did at least manage to get my dog out for a walk on the beach. Okay, so. And then we almost do the opposite of the downward arrow that would get you to a negative core belief. We do, this is borrowing language from positive CBT, we do the upward arrow, which is, okay, so you were out with your dog on the beach. What was it about that that floated your boat? Well, I suppose I'd like to be now in nature bit. Okay. So you being out in nature a bit. What is it about being out in nature that matters to you? And you're trying to get to the highest level of abstraction you can and go well, I'm wondering here if we've started to form a hypothesis that one thing that floats your boat is pets, if that's true, how about we test that out as a behavioural experiment? What happens if we get you to do a bit more of that? If that also lifts your mood in the same direction, that's starting to tell us what's important to you. So I sometimes use the language if it's like, maybe you're the kind of kid who's never had the chance to work out what your style is in the clothes you're in. So I'm going to take you to a clothes shop, I'm going to get you to try on loads of different clothes and you're going to walk around with them for a couple of weeks and see which ones feel like you. So we're getting there through behavioural experience, we're not getting there through intellectual abstraction. Rachel:  So it's from data and experience rather than just this actually quite terrifying blank canvas for some people when they're just asked to say, and maybe there's that pressure to say what you think you should say about meaning and values in your life rather than to really explore it as you say from experience upwards. Barney: Yeah, so one of the ADepT principles we give for therapists is just go from the informal to the formal. So I think in CBT we quite often explain the rationale and then we get people to think how does it fit them. In ADepT we're allowing conversation organically to explore areas. When we've switched something on and we've experienced it, we brought it back into mind, then we introduce the formal framework afterwards and that changes it a bit. Just a clinical example about how difficult and challenging that is, we've done a lot of co-design work around ADepT and one of the service users that has helped us do the work is called Katie, she's happy for me to use her name. She talks about at 30 after a reasonably long history of inpatient and outpatient mental health going, she didn't know at 30 who she was as an adult. One example she goes is, am I the kind of girl that wears make-up or not?   I said, I don't know, should we try it out? Her therapist, Megan, tried it out with her and it was doing behavioural experiments. Let's put some make-up on, see where that goes with you. What's it like? So you can try this stuff on for size in small steps, not suddenly flooding people to expect to know exactly what floats their boat. You can, almost the end goal of therapy is, I've got them much clearer map after 20 sessions of what's really important to me. So now I know how to live my life. Rachel: It sounds like a really lovely approach, especially for those people who miss that sort of developmental window where they are culturally supported to try things on for size and see where they fit. Actually, often people with these early traumas or long-term experiences of depression just haven't had that opportunity, have they? Barney: Yeah, absolutely. But I'm also struck by when you live with depression for the long term, the fear of falling back into the abyss actually paralyses you. So you feel like you're walking through life on a tightrope. And if I take a step the wrong way either side, I'm going to crash down into the ravine and break my legs. And what that does is it makes you see the world as one ginormous series of threats that's going to reactivate my triggers. And in a sense, what we're trying to do is just to get people to rediscover that curiosity and playfulness. We're trying to get them to reframe us. Think of life as walking through a forest. There are loads of paths you can go down. Some of them will be cul-de-sacs or get you somewhere dull or somewhere painful, but lots of them are really interesting and fun. And if you get to one that doesn't work, you can always just turn around and come back. So we're trying to move people from an all or nothing, and unless I get it right, it's going to be awful to I can play with this. I can experiment with it. And that's a big part of the therapist style in ADepT is be open, be curious, be interested, see potential, even amongst the difficult and the dark. Well, I'm sorry to hear you've had a really difficult week, but what can we learn from that about how your depression's tripping you up? How can we give you new skills here? Rachel: So it sounds like that black and white thinking can be applied to the positive equally as to the negative. Barney: Yeah, well, and we definitely see that unless it's a perfect 10, it's not worth having. So that means people are constantly monitoring is my half term trip with the kids a perfect 10 or is it like most half term trips with the kids where it rains a bit and they're sometimes a bit bratty, but we still have some genuinely fun moments. If your depressed mind says, well, there were those difficult moments, so it's all useless, that snuffs the candle out instantly. Rachel: So that's really helpful in understanding that values piece is a process of discovery and creativity. You talked about the mapping tool at your next stage. I'm thinking about bridges for people who are working in other ways. It sounds a bit like behavioural activation, work in standard ways of treatment, thinking about traps and tracks. Is there a similarity? Is there a parallel there?   Barney: There's definitely some traps and tracks, but it's actually closest to Chris Padesky's Strength Based CBT, one of my favourite papers in CBT. So read how she talks about, you can use a hot cross bun to formulate challenges and difficulties and what trips people up, or you can use it to lean into what allows them to run with good stuff. And you can do that both around the good and the bad. So you can formulate this really difficult thing coming up. Maybe it was, I had a really difficult encounter with my boss at work. I could formulate all the ways my depression tripped me up, or I could formulate all the ways I was able to be resilient, so I still managed to get through that meeting and achieve my objectives. So you're putting, you're using your simple CBT, hot cross bun, to formulate in a strength-based solution-focused way, what can I do here to get closest to what's important to me. Rachel: Then you move on to the systematic techniques to kind of build on that, enhance that, it into day-to-day life towards wellbeing. These sound like techniques that we could all benefit from using, is that right? Barney: Yeah, mean, absolutely. So when we're training therapists to do ADepT first, it's really natural as a therapist to have a whole set of reservations about doing this positive stuff. My clients are going to find it so invalidating, it's going to be a bit yucky, they're going to throw up all over my shoes and it's going to be awful. I couldn't do that. My job is to talk about the difficult. So how we get therapists to learn ADepT is try this stuff on for size with yourself and see how it lands and try it on even at times you're struggling a bit or there's a bit of darkness. And a lot of my therapy team would say a lot of us are now thinking about what's important to us in life and how are our patterns of mind tripping us up and how can we go in an opposite direction. For me, it's an interesting empirical question of if you're starting to move towards wanting to build wellbeing and a values consistent life and acting opposite to mechanisms of mind that do it, have we really invented a depression treatment or have we invented a fairly trans diagnostic life coaching approach? That it doesn't matter if you're depressed or anxious or you've got an eating disorder or whatever, we've all got patterns of mind that trip us up. We all could benefit from moving towards stuff that's more important and values consistent for us. Rachel: and drinking a coffee mindfully. Barney: Well, so that is another interesting aside. So the classic rationale for mindfulness-based cognitive therapy. So I've ended up running a mindfulness service despite my kids accurately describing me as the world's least mindful man. What I was struck by in the rationale for mindfulness is it's all about when negative reactivity gets switched on, how can you cultivate a non-judgmental, non-reactive observing mode of mind to stop you going back down the negative rabbit hole. But I was struck by the bits of mindfulness that engaged with me more, is it became a tool to let in a bit of light. So rather than just drinking the coffee without thinking about it, realising there's quite a lot of sensory experience in this. How does it smell? How does it taste? How does it touch? And so on. And realising that slightly enriched the experience. And also realising that capacity to observe my patterns of mind. Oh, there's me judging this isn't the perfect 10. This isn't as good as the flat white as I had last week. So therefore it's useless. Oh, there's that old familiar thought. I can just step away from that and come back into the sensory moment. So I'm increasingly interested in maybe one of the active ingredients of mindfulness is how do we build the positive? indeed we've started to show that that is important for mindfulness- based cognitive therapy, having relapse prevention effects. The extent to which you switch back on that capacity to experience the positive stops you getting depressed again in the future. Rachel: I was reminded as you were talking there about clients throwing up on therapist shoes, all this kind of positive wall of positivity hits them and they're kind of engaging in this different style of therapy where there's therapist cognitions that people have. It reminds me of a myth that certainly used to come up a lot talking to people about CBT, maybe therapists transitioning from other approaches and modalities. You know, they would think, isn't it just all about kind of positive thinking and replacing your negative thoughts with nice positive ones and just decide to think that the world is a nicer place. Does that come up when people are learning about this positive affect focus or the idea that you're not really getting to the root of the problem? It's all quite surface oriented, chopping the heads off dandelions or just convincing yourself that they really look rather nice on your lawn. Barney: Yeah, I mean, it definitely comes up. I'm someone with what I'd call well-managed depression. So I've probably had 15 or 20 episodes in my life. I do very well on a maintenance dose of Citalopram as an antidepressant. And I've thought really hard about lifestyle factors that help me stay well. And I've learned that the things that help me stay well and manage the depression are not feeding the beast, feeding the other side of stuff. So my world is simultaneously nearly always a mixture of the bad, the meh and the good and it's useful for me to have the attentional choice about where I direct my attention. Sometimes I need to attend to them now, like this morning I had to put some washing on, do the washing up and blah-de-blah-de-blah, you need to have that capacity. Sometimes it's really useful to be able to look at stuff that you're stuck with, it's really difficult, isn't going well and that's the evolutionary function of depression, is things aren't going as we wish, retreat to your cave, lick your wounds and change tack. But we also need the capacity to lean into the good and go, there's an opportunity here. Oh, look there's a new field I could forage, there's a new source of food. And what we need is a balance in our minds to at the right time, switch on the right mindset. Depression's trained us to be really good at leaning in to the stuck and the difficult. And we've basically got an impoverished positive muscle to lean into the opportunities. And so it's just getting clients to go, there's a choice here about where you direct your attention and you don't just want to follow a habitual pattern. You want to be able to make a wise choice at that stage. And it's definitely not easy to do that. When you are flooded with a lot of negative affect and all you want to do is retreat to your cave, shut your curtains, stay in bed, ruminate on things, realising actually what I need here is to get out and do something that normally would nourish me. It's really hard. That's not the easy choice, but it is the wise choice. So I'd say it's not just about thinking positively. It's saying you've got a choice with this complex world. It's a mix of the bad, the good, and the meh, where do I need to direct my attention now? Rachel: And it sounds like your personal experience gives you lot of credibility and authenticity when you're approaching these issues, both as sort of academic problems, but in real life, in real people's lives and experience. And you're not alone, I think. You can't be alone because depression is so prevalent and just human experiences that we always have ups and downs in life, whether we kind of experienced depression recurrently or not. On the face of it, focusing on positive affect might seem like a preferable approach for therapists managing their own stress and life challenges and ups and downs and maybe depression. How does this work apply to therapists themselves and how might they be challenged? And is there a risk they become avoidant of their own negative affect or are there assumptions they need to challenge? How do people look after themselves? Barney: Well, before I answer that, I'm going to say that the pitfall with ADepT is people think it's just about pivoting to only talking about the positive. If you just do that and you neglect the negative, it is going to be invalidating. You need that equal focus. So let's for example, hypothetically example, could be a client that's come in, she's self-harmed four times this week because of ongoing conflict with her boyfriend, but she did manage to get the dog out for a walk on the beach. If I just say, hey, I don't want to hear about the self-harm, I don't want to hear about the argument, I just want to tell me about that walk with the dog on the beach. What's the point there? You need to honour and validate the difficult enough to go, so what I'm struck by is it would have been so easy to carry on with that cycle, but somehow you've exited that cycle of self-harm and arguing to be able to do something different. So could we think from that really difficult, challenging moment. What did you do there that stopped the descent or allowed you to turn the corner? So it's not that we're not talking about the difficult, we're talking about the difficult in a different way, which is what were the strengths and resilience you brought to it that stopped that getting stuck in that? And then despite all of that difficulty, you've still managed to do some good stuff. And what was the strength and resilience you brought that allowed you to engage with that positive thing, to show that real grit and resilience that allowed you to get back into life. And if you talk about it in those ways, then when you turn to look at the good stuff, you're not giving clients the message, hey, life's all great, you just need to smell the roses. You're going, you can find good stuff, but sometimes it's really hard work and well done you for managing to lean into and engage it. And was it nevertheless worth having? I guess I'll go back to the example of my dad dying of cancer. Am I glad we hooved around in the garden, driving the mower and ruining the plants? Yeah, was one of my favourite ever memories of my dad. In amongst a lot of difficulty, I'm glad we created that opportunity. And that's the kind of language we're using with depressed clients as well. So what's it like as a therapist to learn ADepT? Superficially it feels like, that'll be really easy to learn. I can do that already. And therapists are then really surprised at how well trained they've been to attend to the negative and how all of their automatic behaviours are. Great, I caught that negative automatic thought that switched on negative affect. So learning to pivot away from that is surprisingly challenging. It's a bit anxiety provoking, like trying on a new behaviour in public and worrying you're going to be judged negatively, learning not to do that. There's also a sense of people realise it's really hard work to validate the difficult and keep pivoting towards the light anyway. It's hard work for the client, it's hard work for you and it's tiring. So those are the challenges of working this way. But the opportunities are, therapists starts saying, do you know what, to be really honest, I'm not sure I've looked forward to my depressed clients coming to see me each week for the last 10 years, but I'm starting to a little bit because I know as well as working in that really difficult stuff, they're going to tell me about, I've got back to tango or I managed to go on a date night with my husband or whatever. So it brings a different feel into the room that the therapist enjoys a bit more. And similarly, clients start to say that. I mean, how many clients go, okay, I've got to gird my loins and go into therapy and talk about all the really difficult stuff. It's going to be really painful, but I'm not sure I really like my therapist, or they like me. This is a process we need to go through, like going for a root canal at the dentist. Maybe therapy doesn't need to be like that. Maybe you can also go, yeah, this is fun. I can go in, I can celebrate some of the good bits. I can belly laugh. It's okay to experience the good even amongst the dark. That doesn't mean the dark isn't there. And what we've generally found is quite a lot of therapists start adapting themselves and they use it to, they find it as quite a useful kind of life coaching approach really. Rachel: In a small way, when I've been doing this or aspects of these techniques with clients, I can really identify with that. Those moments where you're enhancing the positive and seeing that positive affect spread across someone's face and maybe seeing them smile for the first time in therapy. It's, it is incredibly rewarding for as a therapist just to experience that affect in the room, even when it's a core part of our work to sit with the difficult and the negative as well. So you've talked a little bit about some of the challenges people experience. Where are the places people get stuck with this work? What are your most frequently asked questions in supervision or the trickiest issues that come up for therapists working in this way, do you think? Barney: So I think one of the things is it's deceptively simple to say just reorient your attention as a therapist to notice the positives and they have all the same mechanisms of mind clients do around that. So their attentional bias is much more towards the negative and the minute the positive starts to switch on, therapists then have a whole set of appraisals like, I shouldn't be talking about this. They're going to find me invalidating and so on. So it's teaching therapists to learn a new habit, which is why we just like in mindfulness would encourage people to learn it from the inside out first. Experience this, learn that it works and it's okay. Usually I say to people, because a lot of people I train are 30 to 50, so they might have kids, I go if you can get this past your teenage kids, you can get it past anyone. Getting them to experiment with these kind of ways of questioning with their teenagers and go, oh my God, even they swallowed it. So maybe I can do it with a client. Rachel: That's a tough audience. Barney: Yeah, well, exactly. If you can do it with your average teenager, can do it with anyone. The second thing that people find difficult is this is, to come back to that military metaphor, it's not following a manual. It's like being a sniper in the jungle. So how do I know what technique to pull out at what time? The challenge we're having training therapists to do is to be really good at pattern spotting. What's the psychological mechanism we're working on now? So when its around the difficult, yeah, we call them the three horsemen of depression, usually avoidance, rumination and self-criticism. So when clients are avoiding, what are the two or three evidence-based techniques I can experiment with using with them when they're ruminating? What are the two or three evidence-based techniques I've used with them? Yeah. When they're being self-critical and so on. Then get training clients to have that pattern matching approach where they're going, this is the mechanism at play, so this is the intervention element I need to pull out, is a bit different than saying in session four, bring out a negative automatic thought record. Rachel: Okay. So Barney, let's talk about effectiveness and efficacy. We started out by saying, you know, we've got good evidence-based treatments for depression, but you know, at best, perhaps they're kind of helping a third of people into recovery in the longer term. Is ADepT effective and is it equally effective for everyone? Barney: Okay, so I'm going to take a step back. The first evidence people need to know about is anhedonia- clinically important. So when you speak to clients, they say it's more important to their recovery than symptom relief. And when you look at the prognostic importance of anhedonia does it predict outcome? It predicts a whole loads of outcomes. So anhedonic teenagers are more likely to get depressed. Anhedonic depressed clients are less likely to seek help and benefit from help. Clients who are left with residual anhedonia are more likely to relapse or have a chronic partial recovery. So it's definitely prevalent and it's definitely prognostically important. The next bit of the evidence people need to know about is, cause a lot of, you know, very legitimate critique is Barney maybe you're just not very good at CBT or BA, when I do CBT and BA I get positive affect back up to better. We don't need to reinvent the wheel here; you just need to be better at CBT. So the way we looked at that is we've gone back to some of the best trials in the depression field, so led out of the Beck Institute and others, and we've looked at how well they normalise negative affect versus positive affect. And the story goes something like this; people are further away from general population averages around the positive and the negative, therapy and drugs repair positive less than negative. So at the end of otherwise successful therapies where negative affects go back to general population typical levels, positive affect is still robustly well below general population averages. And that is the same in CBT. The next critique I've tended to get is, well, but BA, it's a reward focused treatment. Surely BA is better than that, than CBT. And so we did a secondary analysis of a very big trial called COBRA, which was a head-to-head of BA and CBT in NHS talking therapy settings. And it's the same story. BA also isn't very good at repairing anhedonia. I think because it behaviourally activates people, but it doesn't teach people how to overcome the psychological mechanisms that get in the way of enjoying that activation. It's like taking the horse to water but not teaching it how to drink. So the last important piece is if you target the positive affect system, will that genuinely lead to long-term wellness? So we've done a secondary analysis of another big trial called Prevent which is Mindfulness-Based Cognitive Therapy for people with three or more episodes of depression, does it help people stay well? Where they also included a positive affect measure and somewhat surprisingly, what we found was having low levels of positive affect predicted relapse over and above all of the other residual symptoms of depression that people had. So reduced positivity was a stronger predictor than residual symptoms. And the extent to which mindfulness-based cognitive therapy switched back on positive emotion accounted for the clients who stayed well over the longer term. So I'm now really confident in saying there's a very strong evidence base that positive affect is prognostically important. Current treatments don't fix it perfectly. If they could, you would help people stay well for the medium to long term. Then it becomes a more open empirical question of, so are this new wave of therapies like ADepT any better than CBT and BA at achieving that goal? And let's just be really honest here. This is a really tricky problem. Beck was an absolute genius. No one's been able to do much better since. So just need to come at this problem with humility. Even small gains in this area are probably worth having, but they're not easy to get. And where we've got to with ADepT is the strongest evidence for it so far is we did a pilot trial head to head of high intensity CBT delivered under ideal circumstances to ADepT where we randomized 80 patients with depression with anhedonic features to either of the arms. So it's a pilot trial in that it wasn't powered to definitively test is ADepT better than CBT. To do that, you need a big trial with about 500 people because the gains you're looking for are relatively modest. But from that pilot trial, what we can conclude is we're pretty certain ADepT is no worse than CBT. So it's got less than a 5 % chance of clients doing worse in ADepT relative to CBT. And it's a bit of a 50-50 coin toss of do you do the same with ADepT and CBT or do you do better in ADepT than CBT? So we would say that is promising evidence that it's already a viable therapy. We're pretty sure it's no worse and it has a good chance of being better, but we now need a bigger trial to test that out definitively and that's what we're moving on to next. The other source of evidence in that trial is also the health economics of it. So if you want to implement something in the real world, you have to be able to show it adds value for an affordable amount of cash. And it looks like ADepT has the potential to what's called health economically dominate CBT. So it costs the same to deliver, but because of this wellbeing focus, returns more quality of life, so you get more bang for your buck. The other really interesting thing in the trial, and again, we're underpowered to answer it definitively, is what were the long-term outcomes? So I'm just going to give you the numbers and you can say whether they seem convincing or not. In the ADepT arm, we got 80 % of people into diagnostic remission post-treatment. And in the CBT arm, we got about 56 % of people into diagnostic remission. Of those 80 % who hit diagnostic remission after acute treatment, only 25 % of them relapsed over the next year, whereas 50% of the folks in CBT relapsed over the next year. So basically, ADepT s getting more people better and keeping them better for the longer term in this pilot trial, which suggests it might have potential to be a more effective treatment. But now all we need to do is take it into a big trial and critically not just do it in my little ivory tower bubble of the clinical setting I work in, which has got great therapists who are really well trained and supervised to see can we pull this off in the real world. So I'd say it's encouraging, but not yet nailed on. It's not worse, it might be better. It's also worth thinking or acknowledging that ADepT is only one of a number of emerging positive affect therapies that are coming out. There's excellent work being done from Michelle Craske around positive affect therapy in California. There's excellent work from Charlie Taylor developing a protocol called amplification of positivity for social anxiety clients. There's brilliant work by Nicole Geschwind taking Fredericke Bannink’s positive CBT and evaluating it. So I would say if you put those therapies together, is there now a credible evidence base that they're doing better than classic CBT and BA at repairing positivity? I'd say just about yes. Are we yet at the point of saying any one of those emerging therapies is definitely the one you put your money on and remortgage your house on? I'd say no, it's an open empirical question. Rachel: Impressive early data, certainly. And I wonder if the numbers are too small, the studies are too small at the moment to say anything about diversity within that. Are there people you think, or even have a hunch that this might be more effective, helpful for than others? Barney: Well, let's come back to the question of size. If you look at most of the sample sizes in most of the trials of CBT for most disorders that we would say these are really good evidence. They've typically had less than 100 people in and they've usually compared them to a waitlist or treatment as usual condition which is a really easy bar to beat. Doing something is usually better than doing nothing. So we're quite happy to say the evidence base for anxiety disorders or eating disorders or whatever is really robust and strong on trials that size. Depression's kind of a thornier problem because we've got pretty good treatments and you're trying to say, can we do better than them? So to run those trials, you genuinely need about 500 people because if CBT is, 50 % optimized, moving up to 60 % optimized is worth having, but you need a large trial. And there's just not been enough funding around to do large trials of those kinds. So I would say it is early data, but it isn't early data. We're just setting ourselves a more robust evidence-based bar around this depression stuff. But now to actually answer your question, can we say anything yet about who might particularly benefit from ADepT or not. You're right, the numbers are too small to do that in a statistical sense. So these are my clinical hunches around it. It works best for people who've tried quite a few therapies. They feel like I've done the talking about the difficult and the distress to death. I want something different. And so we're increasingly now trying it as a what we call a non-responders approach. I've tried low intensity NHS Talking Therapies, I've tried high intensity Talking Therapies. I'm still not better. What do I do next? I'm looking for something different and I'm ready to move to this position of going, I'm not sure I'm ever going to be able to eliminate my depression, but maybe I can tame the beast a bit and live well alongside it. Those are the folks that anecdotally do better with it. I'd also say if clients aren't saying experiencing pleasure and joy is a challenge for me and something I want more of, well, why would you give them a therapy like ADepT? If a client is saying what's really bothering me is I've got loads of intrusive negative memories coming in, they're not PTSD but they're making me very depressed, I'd probably think, well, you know maybe EMDR. If a client was saying, I've got loads of negative beliefs about self-world and future, and I really want to bring down my negative affect, I'd say classic CBT. But if a client's really anhedonic and they're saying, this is something I'd really like to work with, and I just never had any traction with it, that's where I'd be thinking, ADepT worth a crack. Rachel:  So Barney, you've worked with people with anhedonia in the context of depression and other problems for a long time now. And it's always such a privilege, isn't it, to work with the folk we work with. And we often learn more from them than we do or possibly than they do from us. And you've also worked with people at every stage of the development, implementation, testing of your work and thinking about developments in the future. What have you learned from people you've worked with? Barney: Lots in short. The two service users that have most helped me with the co-design of ADepT are Nigel and Katie. So Nigel helped me in the initial development of ADepT and Katie's helped me with more recent iterations for more complex depression. What Nigel encouraged me to do was to be really bullish about going for well-being and positive affect, not just trying to reduce anhedonia but getting people back to meaning, connection and pleasure and encouraging me to go further about doing it earlier with clients and that they wouldn't find it invalidating, they'd find it helpful. It had come from his own experience of being a participant in an MBCT trial where what really helped him work through his depression was reconnecting to the light. And Nigel also brought a whole range of broader experiences in life. We know wisdom as a professional in another field and lived experience to help us think about how to do the values work and do the coaching piece really well of ADepT. Then Katie basically reached out to me a couple of years later and said, I've heard about this ADepT work. I think you should be doing it with more complex cases because I spent a lot of years going through a lot of treatments that have helped me to some extent managed symptoms, but I'm still left with a sense of I'm not sure who I want to be or what matters to me in life. So she's encouraged us to set up this line of work for what we're calling complex depression. These are folks with a complex early trauma background that's leading to difficulties with regulating emotions and relationships alongside depression and anxiety as adults. You might recognise that as a description of personality difficulties or disorders. We're choosing to call it complex depression because we think that has less problems as a term. So we're just completing a case series with 30 people to see can you do this well-being recovery-oriented way of working with these more complex presentations and the headline is it looks like you can. The changes that Katie encouraged us to bring into that protocol were first of all that the values work is really hard if you've never had a chance to work out who you are and who you want to be because life's been very coloured by mental health from a young age. So go slower and leave more space for exploration around values. Also the need to bring in some additional work on giving people emotional interpersonal regulation skills, which is how we've brought ADepT into adept dialectical behaviour therapy elements in a solution focused fashion. And she was also saying, how can you manage the reality of quite often chronic fluctuating risk with these clients, which might be around suicidal urges or self-harm urges and not to allow the wellbeing and recovery oriented focus of ADepT to be too hijacked by that. Because the way you really keep people safe is you give them a life they want to lead. So even when they have strong urges to want to harm themselves, there's a reason to keep living for. So we've been working quite hard about safety plans in a more solution focused language than classic risk commentary. Katie has also very bravely, she came to us and helped us design the protocol but then she stepped out of being someone with a designer and actually received the therapy from one of our team and that's given her an additional set of insights coming back to support us later. Both Katie and Nigel also do a lot of co-teaching and co-training with me and it really helps to get rid of the them and us between clients and therapists to be teaching alongside as equals. And I asked them before this interview, what are the things you would want me to say about Adept from what you said? I think the main thing that came out was, it really helps to let go of symptom relief as your primary aim, learning to live well alongside depression and get back to wellbeing is the thing that they found most important on their recovery journeys. Rachel: Fantastic. We're hearing a bit about where you're moving things forward in terms of these complex presentations and new areas of development. What are the next horizons in this field of anhedonia? What are the next big challenges? What are the problems to solve? The knots to untie. Barney: Well, alas, it's a slow and steady process. So the next thing we need to do is a really big trial of ADepT compared to CBT to see is it really clinically effective and cost effective when done in real world pragmatic settings. What I've seen a lot of therapy developers do is they rush straight to that big trial after a promising pilot before they've fully ironed out the implementation pipeline. And for me the devil's in the detail and this is where I think David Clark and Anke Ehlers and others have been absolute geniuses in the field. They've really recognised you get you probably get 5 % difference from one protocol to the next, but you probably get 15 % difference of whatever protocol you're doing, training people and supervising people to do it well and creating a system of care in which they can deliver it well. So we've been spending a lot of time learning how to supervise and train folks in ADepT before we do a big trial so that we know it has the best chance of working. But also if we show it works, we'll be convinced it is implementable in an NHS Talking Therapy setting. The other bits of work we've been doing around the edges is in the pilot trial we found there were a few rough edges that we were less sure how to work with, reflecting the heterogeneity of depression. So I've talked about one of those already, folks with more complex trauma backgrounds, what you need to do differently for those. Another group we're interested in is neurodiversity, because generally those folks do less well in classic CBT approaches. So we're doing a case series and have adapted ADepT for folks with neurodiversity so that we can then weave that into the universal protocol about think about this if you're working with someone with ADHD or varying degrees of autism. The other piece that we're doing is trying ADepT for minoritized groups because a very legitimate criticism is of the therapy at the moment is to paraphrase, is it a bit too white Waitrose? And will the same techniques and approaches work with people with significant more kind of life grip in their oyster and or people who've come from different cultural backgrounds? So we're deliberately trying out the protocol with those folks to work out what are the tailoring and adaptations we need to do. We're putting all of that learning into the treatment manual that we're currently writing because we want it to be a book that recognises that working with depression is, it's come back to that military metaphor, it's a bit more like guerrilla warfare, you need a variety of different skills in your armoury to bring out at different times, rather than rushing straight to a big trial, where we don't think we've quite optimised the protocol before it. Because to be blunt, what happens after you've done a big trial is therapy treatments then get locked down. It becomes a bit like a stone tablet brought down from Mount Ararat and it becomes harder to innovate and change. So we want to make sure the protocol has got as far as it can before we invest all of that time and effort and taxpayer money into doing it. Rachel: So before we have that stone tablet and people have the ultimate authority on how to implement this work, how can they learn more? How can they start to implement this in the therapy? How can they get training? Barney: Well, there's two ways that these kind of techniques and ideas could be integrated into CBT practice. And the honest answer is I'm open to either of them. You could think of ADepT as a standalone therapy that you wish to be trained in. And we do various one-day workshops and there's lots of papers I can get you to read that we can link to after this podcast. But the other way you can think about it is that many of these ideas can be weaved in in a way that has fidelity to classic Beckian CBT into the work that folks were already doing in their high intensity therapy practice. And I give a lot of workshops saying here are some ADepT informed ideas that you could weave into a standard CBT treatment in a way that's entirely consistent with a Beckian way of working. And that's how I do encourage people to learn more at the procedural level. But what I would say is remember, another one of my heroes is James Bennett- Levy. I love all his work about how to train and get people to do therapy through the declarative procedural reflective model. The best way is try this stuff out on yourself. And it doesn't need to be super formal and perfect. Just play with solution-focused questioning, positive journaling, just see how it goes. See if you can find any benefit in yourself. So you also, if you can get it past your teenage kids, if you can do that, you're ready to explore with it in your own therapy practice. Rachel: Fantastic. So in CBT, we like to summarize, as you know, and think about what we're taking away from each session. I think it's almost hard to do better than Katie and Nigel's pithy statements about learning to live well with depression and enhancing well-being. But what key message would you like to leave folk with regarding this work with depression and anhedonia? Barney: For a CBT audience, think about positive affects as though it's an anxiety disorder. People are afraid of feeling positive. So the way that you can help folks work with it is a graded exposure hierarchy back towards what they love and matters to them, encouraging them to let go of safety behaviours as they go and build alternative strategies. Rachel: Thank you so much Barney for your time and all the wisdom that you shared with us today. Really look forward to seeing you again soon and people will take so much away from this. Thank you so much. Barney: It's been a privilege. Thanks for having me, 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 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 the second part of this episode with Professor Steve Hollon, we go beyond theory into the heart of applying cognitive therapy for depression in real-world settings. Steve shares what therapy really looks like across the spectrum from relatively straightforward to deeply complex clients and how therapists can stay grounded and effective, even when things feel messy. Resources and links Cognitive Therapy of Depression (Second Edition) Find out more about Steve and his research here OXCADAT: A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/ Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [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 Handley:  Welcome to Let's talk about CBT- Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Welcome back to part two of our conversation with Professor Steve Holland, international expert in cognitive therapy of depression. In our last episode, Steve gave us some fascinating insights into the development of the cognitive model and how we can understand the development and maintenance of depression. In this episode, Steve talks in detail and with lots of examples about how to apply the therapy to really help people with all sorts of complexity in their lives without fear of getting it wrong. So let's dive straight in. Rachel Handley: And so, if you had to put in a sentence the main task of therapy, and I know asking any researcher to put anything into one sentence is a challenge, right? But what would you say is the purpose of therapy that we need to keep foremost in our minds to guide therapy? Steven Hollon: I'll say two things if I can Rachel Handley: I'll allow you two. Steven Hollon: Then I'll say two things. The first component is, when in doubt, do. If you're depressed, don't wait to feel like doing something. You're not going to feel like doing anything. Do the stuff you would do if you weren't depressed. And then the desire will come back, but don't wait to feel like it. And the second thing is don't believe everything you think. And the most powerful way to disconfirm an existing belief is to test it in a situation that your therapist can't control. Therapists get paid to tell people they're okay, or in some cases, dynamic, tell people they're not okay and if you've got kids to put through college, that's a nice, long term life lifestyle. But, what I'll do with the client when we start out and I learned to do this with Tim Beck and Maria Kovacs and others is in the very first session say, look, we can do this a couple of ways. There's some things I'd like to teach you how to do. And I can either do them for you or I can teach you how to do them. My goal is to make myself obsolete. Is that okay with you? And usually then people say, yeah, I’d prefer that. Usually, occasionally they won't, but usually they'll say that. And I’d say, now, if we were going to help you learn how to do these things, how can we do that? Say, well, can I work on this stuff between sessions? That's a great idea! So let people reinvent the therapy each time coming through. Then you'll end the session and have something for them to do between this and the next session. And by the way, every major study that has shown an efficacy for cognitive therapy has always seen people who are clinically depressed at least twice a week in the beginning. If I have to wait seven days to meet somebody, to work with somebody who's deeply depressed, they're going to forget who I am. I mean, their hippocampus is turned over. It's a, you have to reintroduce yourself. I get a little momentum going over that first session. Give me two or three days later I can keep the momentum going like Sisyphus pushing the rock up the hill. I don't know what things are like in the UK, but I would always want the depressed client to have twice weekly sessions in the beginning. It doesn’t have to be an office, one could be over the internet and then I'll space it out later on. Maybe we get a couple of weeks in, then we'll drop back to every other week. Rachel Handley: And certainly that kind of frequency of therapy is one where we have fallen into habits of, the routine is once a week for an hour on the same day and not one that a one that services often struggle with implementing logistically in terms of this, but certainly, looking at the evidence and the good clinical practice, it seems to be a point that bears reiterating. Steven Hollon: Its for the benefit of the convenience of the therapist, not for improving clients. Rachel Handley: So in terms of therapy, then it's don't think about it, do it. And don't believe everything you think. Steven Hollon: Well, yeah, in terms of the behavioural components, don't wait to feel like it. Do it. But when you do, do a test that tests your beliefs when you do it. With the sculptor, if you don't think anybody's going to hire you, then put applications in. Let's see if you're right. You might be, in which case work on a career change, but don’t your problem is right now not that you're incompetent. You might be. Well, we don't know that yet. What we do know is you're not sending out your portfolio and until you send your portfolio out, we don't know how competent you are. So let's find out. Rachel Handley: So let's test the strategy. So keeping in mind that you've said in the manual, which is a brilliant revision, the second edition of Cognitive Therapy for Depression, that therapy is not just a set of strategies or techniques, however, it's helpful to know what a typical course of therapy might look like. Can you tell us what an episode of therapy might look like for someone coming in for cognitive therapy for depression Steven Hollon: I mean, yeah, that’s a great question. I think it depends very much on what the client walks in the door with, like the sculptor, nothing much going else going on for him, except he had lost his job, probably no misfortune of his own, but he was going about getting the next job the wrong way. I mean, he was working, but something he didn't consider work and it was just a relatively simple matter of pitting his Theory A, which is I'm incompetent versus Theory B, which is he's going about it the wrong way, which is take a big task, break it into small steps, take it one step at a time, rather than getting overwhelmed with the magnitude of the task. Easy for him. Another client that I talk about is a woman that came into one of our trials that Rob DeRubeis and I were doing, and she ended up drawing me as a therapist. She knew some of the graduate students already. She'd done her training at Vanderbilt several years earlier. And when she got back to town at this point, on the way to getting divorced, real things have blown up for her in her personal life. She's absolutely devastated. Gets back into town, talks to some of her graduate student colleagues, hears about this study, decides I'm going to be in that, goes on clinicaltrials.gov, looks up what the inclusion-exclusion criteria were, sees that we were referring out people with borderline because they could get DBT in Nashville, they're going to do better with that than with what we had to offer. She borrows a copy of DSM, looks up what criteria are for borderline, knows what to deny when she comes in for interview, gets screened into the trial, gets me as a therapist, to her misfortune. In the first session, I start the thing about saying what I prefer to do is teach you how to do this as opposed to simply do it for you. And she said no, you don't understand. I am flawed. I am deeply flawed. Something happened to me as a teenager. I don't want to talk about it. I don't think we need to, but it changed me forever. I tear up anybody I get close to. I would like to have relationships with people that I care about. But anybody I get romantically involved with, I just tear them to shreds. I become this dragon lady, tiger lady. And she said, no, don't worry about that cause I'm 29. I turn 30 in six months and I don't plan to live past 30. And the third thing she said was now I'm an incorrigible liar and you can't believe a word I say, will be a problem for therapy? And of course it won't be, and it won't be a problem for therapy because no matter what story she makes up, it's going to have coherence. Evolution constrains that if she comes and tells a story about something that got her angry, then she's going to have cognitions that are consistent with somebody did something they shouldn't. The physiology is going to be aroused, and the behaviour is going to be want to attack, which is what she did in context of her relationships. So you can work with all that stuff. I never worked with somebody quite like her before, we were 3 years and in the beginning, because she was able to coerce me into it, we were meeting daily and we're meeting pretty much daily for the 1st year. And then we drop back to a couple of times a week in the 2nd year and then spaced out beyond that time. She made a marvellous return recovery, but it was slogging and I didn’t know what we were doing half the time, so we're making it up as we go along, more complicated minds are going to take longer. Now, I know from some of the training with IAPT folks, they don't necessarily get longer. However, those folks are going to show up in the service again, as Marsha Linehan would say, you can either pay us now for DBT which is going to be a couple of years, or you can have them showing up in your emergency room, bleeding on the floor, you know, how you want to set up your systems? And what I'll encourage the folks in IAPT to do is, if you get what, 10, 12, session, however many sessions you get, go as far as you can go, but for goodness sake, lay out a cognitive conceptual diagram. So they have a roadmap. The next time they show up with a therapist, they can say, can we start here? I've covered all of this stuff. I'd like to pick up with you and, you know a new therapist, but we don't have to go through all the same ground, do we? I can show you this. I know how to do that. Rachel Handley: And what would that cognitive conceptualist diagram look like? Steven Hollon: Oh, yeah. For the sculptor, there wouldn't be much there. Just his dad used to favour his younger brother when he was younger, so he came to believe he was incompetent. And he did have a lot of other problems going on, just when he got in a tough situation, he would give up too soon. So instead of giving up, let's break it into smaller steps, make it easier to do. It's like walking up a hill. You're more likely to get up a hill if you have steps than if you have to go straight up the icy stream. For the architect, gee, this terrible, awful thing, which no great mystery was involved a gang rape when she was about 15 and her father totally blew her off. She'd already lost her mother about six months earlier. She developed the belief that nobody could ever possibly love her or meet her halfway. So in a relationship, she developed a host of compensatory strategies, what people treating anxiety disorders would call safety behaviours. And her compensatory strategies, when she got close to somebody, she wouldn't ask for what she wanted because she would assume they would turn her down. She couldn't be very direct with somebody she was starting to get close to. And she would be provocative without meaning to be because if they didn't give her what she wanted, she would then act out. And, yeah, she stayed basically 15. And those strategies were the things that were screwing up a relationship one after the other, but she thought they were protecting her from being rejected. And they weren't, they were just the thing that was causing the rejection and until she started to test some of that out we- it was Anke who had to walk me through, it was my first time walking through the reliving of the traumatic experience and Anka had to give me some guidelines on how to do that. We did. It took me about an extra month to get around to doing it, three months to talk her into it, a month to talk me into doing it. My graduate students shamed me into doing it because of course they all learned how to do that in the sexual assault centres before they ever get their degrees. At any rate, it was revelatory. She not only had this notion that she was damaged property, that no decent male would ever want to have a relationship with the thing that happened to her. She also had this notion that, which she didn't have a clue about, which was that it was so scary to think that something so awful could have happened to somebody that didn't deserve it. She wanted to wrap herself up in this really tough, film noir model role. And that was the image of herself she presented the world. What she had to do is drop that stuff and get somebody she was really getting close to, have some night where she would let down the guard, tell them everything that happened to her and see what happened. She wasn't going to do that with the current boyfriend, but she would do that with me as a therapist. She would do that with an old girlfriend that she hadn't seen for years. She invited her up to have a long weekend in Nashville, pleasant, etc. And then she told the girlfriend about what had happened to her. The girlfriend commiserated for about 30 minutes and said, you want to get something to eat? The girlfriend didn't care. Took her a while longer. We had a couple of additional pieces of information she wanted collected by people other than me. And, so we ran some surveys and the like, tape recorded. And then it turns out most people, most eligible males wouldn't be the least bit concerned. One or two would, but she blew them off anyway. She's not ready to talk with the current boyfriend but has a revelatory experience, conversation with him. He commiserates for about 20 minutes. Males aren't as good at that as female friends and said, you wanna get something to eat? He didn't care. What he didn't like was when she picked on him when she was mercurial in the relationship. When if she wanted something instead of asking where he could either decide whether he would give it to her or not, she would try to manipulate him that he didn't appreciate. So when she got past that, she was able to start dropping the compensatory strategies which she thought was protective from being rejected, that's why she was getting rejected, but it took us a while to get there. Now, maybe, having had more experience with that, of the 10 patients I worked with in the Penn-Vandy trial, five of them had histories of sexual abuse, which I do think is a diathesis. And, for four of the five, we got through stuff a lot faster than we did, but she was the first person I worked with. And I was learning how to do this for the first time. Rachel Handley: Wow. And it sounds like there's a huge range in what you say from your sculptor example to this lady who had three years Steven Hollon: That's right. And again, I think we probably could have knocked it out in a year or less with this lady, maybe even less. But the sculptor didn't need the cognitive conceptualisation diagram, wouldn't bother doing it with them. This lady until we got that on paper, that was the, we had a couple of sheets of paper. We always had on the desk every time we had a session, and we'd be talking about what could you do with this new boyfriend? What would you try? Is that risky? What's on the line? How would you like to behave? What would you like to be able to do? And if you were, the new you, and then she would go from that. Rachel Handley: So it sounds like in both cases, at both ends of the extreme, if you like, if we wanted to conceptualise it as a continuum, you're working with cognitions, that your sculptor had thoughts about his part in that he was flawed that it was a problem with him rather than a problem with strategy. But you are getting him in a very behavioural practical way to break down those strategies to test them out to do something different. With this lady there was a lot more involved in understanding why her compensatory strategies might have evolved why her beliefs what and what are maybe we might talk about core beliefs or what are quite fundamental beliefs about herself that there's a lot more working out to do in that, and a more prolonged period of understanding those strategies and testing those out Steven Hollon: Yeah. That's a great summary, next time we revise the manual, if I can, I'd like to borrow your summary. Yeah. The sculptor didn't need the heavy artillery. The architect did. And she wasn't going to take the leap in a relationship that she was with somebody who's interested in easily because it scared the daylights out of her. She was so sure that it was going to blow up on her. She wasn't willing to take that chance. So having the stuff in front of her, gave her a little extra. Rachel Handley: And this really illustrates to me something I've often noticed working with depression. I work a lot with anxiety, with trauma and social anxiety and these kinds of presentations. And often that feels like you're engaged in a kind of sniper fire. You've got a very clear set of cognitions that you go out and you test out, about blushing or about beliefs about the over generalised sense of danger in the world, you know what you're dealing with, you know what the trauma is, you know what the social anxiety is, what the panic cognition is. In contrast, sometimes working with depression feels more like guerrilla warfare. You don't know what's going to pop up when the patient comes in, what situation they're going to bring. The manual talks about being patient led in content, but therapist led in structure and that can lead to some therapist anxiety is like anything can come up any situation, shifting targets, thoughts. You've described a very beautifully illustrated, a kind of very complex piece of work that went on for a long period of time with someone who said they might, I might not even tell you the truth when I'm here, you've got some work to do to understand how things are for them. So what holds this all together when you're engaged in this guerrilla warfare and you don't know what's going to come up and you're preparing for a session? What holds it together? Steven Hollon: Well, yeah, a couple things. Number one is, I always think the patient brings the content, we bring the process. So whatever content they walk in the door with, we're going to put that into our process. And they're not that, this is where we come back to the principles, they're only a couple things we want a client to learn and if they're depressed, it's don't wait to feel like it 'cause your dopamine is not working quite yet, but then the cognitive component of that is don't believe everything you think. Let's see what you believe and let's see how accurate that is. And the most powerful way to find out if what you believe is really true is to set it up in the real world and see what happens. The architect was not going to believe, that, somebody she was interested in wasn't going to reject her until she heard a fact she was interested in. I could say anything I wanted to, the old girlfriend could say that, but you know, we got to it. Or have paid for doing that. So basic principle here is that there's certain things I want a client to do, which is, if it's depressed, don't wait. And by the way, the, sculptor was a lot easier to deal with because, for him to change his behaviour was no risk. It just meant mobilising his energy for the architect to change her behaviour. She was going to blow up a relationship or whatever else was going to happen.  For her it would make the world worse. If she was wrong, she, I mean, the world could get worse if it turned out the way she thought it was for the sculptor or wouldn't get worse, where we get better if it didn't turn out the way so easier to get somebody who's simply depressed to run a test to get somebody who's dealing with anxiety, or if it's depression superimposed on an access two disorder, which is depression. what was going on with in this case? It wasn't even access to disorder. she would make our turn for borderline, but she really, it was complex PTSD. her prior experience was such that awful things happen to people. They're in risky situations. So she was sure. So I'm not going to take this kind of risk unless you have a lot of reason to think maybe she can pull it off. We did a lot of, a lot of role playing with her that we didn't need to do with the architect and we've been role play anytime. She's going to have a conversation with the ex-husband with the new boyfriend with, my work, et cetera. We bro play. We bro play three different ways. What would be a passive way of doing it, which you usually don't ask, would be an aggressive way, which would be to demand, would be an assertive way, which is, I really like this from you. And if you do, I will do that for you, et cetera. you trade favours and we would do it all three ways. And, years later. As you have much improved and years later, ABC team wanted a symposium where people would identify toughest clients had worked with and I asked her because she was staying in touch as to what you'd be willing to do the videotapes did share as long as the camera shot over the back of her head. And we did. And one of the questions ABCG asked structured questions was, was there anything in therapy that you really didn't like? Said, oh, the role play, I hated the, I hated every minute of the role play. And a couple questions later were, what do you think was the most valuable part of therapy? Said the role playing. Rachel Handley: So, So it's just like what therapists in training say. Steven Hollon: exactly. Yeah, exactly. It's, it's,you put yourself on the line, then you take on risks and it's scary. But if you're gonna take a risk and do it with the therapist that you're paying or that's getting paid and not with the boyfriend, you don't want to lose. So there, there's sometimes when it's safer to take a risk than others, Rachel Handley: So it sounds like the unifying principle is don't believe what you think, or don't just believe what you think, and the unifing process is let's test it out. Steven Hollon: Let's test it out. let's find out what's really true. Rachel Handley: So whatever comes, that's the framework we're putting it into. Steven Hollon: And people, human beings are amazing that they can deal with virtually anything if they know what it is. It's the fantasy. It's the monster in the closet. That's really scary. It's most monsters and closets aren't as scary as the thing that you think is beyond the door. Rachel Handley: And sometimes if I'm frank, the lives that I hear about in the clinical room or in supervision across services here in the UK, do seem to support a pretty negative worldview? So we've got patients are unemployed in situations of domestic abuse of one or more frequently more long term health conditions, few social supports, custody battles, housing problems, live in high crime areas, are battling addiction. It can feel a fair way removed from a depressed sort of white collar, middle class professional or artist. Often or often students presented in kind of depression textbooks, not that depression is any less real in those cases for those individuals, but what about the patient who barely makes it out of bed in the morning and can't begin to think about how they find social and financial resources, never mind the motivation or the energy to engage in behavioural activation? Does the model really apply in the real world? That's my question. Steven Hollon: Sure. Because people are dealing with real world issues all the time, whatever their current status is, and people tend to the magnitude of the problem tends to be greater in people that have more. I mean, they see it as greater than somebody else that doesn't have as much to go with, but you're dealing with the same stuff and there's virtually nobody in a high crime area, who's not everybody in a high crime area is invariably depressed. Some things are worse than others. Nobody would sign their, 12 year old up for the concentration camp experience as summer camp, but, even people that deal with absolutely awful situations as bad as the situation is, if you keep your wits about you, you can reduce the impact on you, and it might be the best you can do, but at least get the best and move towards that. The sculptor, by the way, never got a job back in academia. When he was trying to do is interacting in the world. And in Minnesota at the time, Minnesota. Terribly cold winters. It was wintertime and he's at a donut shop. The way you get through cold winters is with fats, sugars, and caffeine. And he's reading the newspaper, finished the sports section, and some guy a couple stools over said, can I see your sports section? He handed it to him. The guy struck up a conversation. And he said, I've seen you from time to time. Who are you and what do you do? And the sculptor said, well, I'm so and so. But at this point, he was, he was done with therapy. He said, but I'm actually a sculptor by training. The guy said, sculptor? He said, yeah. Said, you ever thought about working for Tonka Toys? And the sculptor said no. He said, Tonka Toys is one of the world's largest toy manufacturers. They're out in Minnetonka, west of Minnesota, west of Minneapolis. He said, we hire sculptors. What we do is get them to turn the product design people's ideas into little scale models of the toys. Then we let the kids play with them to see what toys kids like. He went out there, he applied and got a job. He would not have gone back to academia. You don't know what you can do in the world until you start interacting in the world. And without relationships, there's always, they're always big brothers, big sisters. They're always people in the world that would benefit from having somebody a little older, who's going to take an interest in them. If there's nothing else, I'm going to go down to the animal shelter. I'm going to help feed and play with the pets. I'm going to do something that moves me in the direction that I want my life. If I ain't got it in my life right at the moment. And some problems you may or may not be able to solve. I mean, the death of a child, what could possibly be worse and the most depressogenic thing that we know about. But there are things you can do. One of the things we've learned, you throw yourself into the grief. You sit, you go through the photo albums, you have your little shrine in the home, you visit the grave sites, you might start coaching kids sports teams, et cetera. You don't cut yourself off and there's strategies that just work better than others. Rachel Handley: Reminds me, hearing you speak about this of some of the work that Ed Watkins has done in rumination and how he talks about how there are problems you can't work out in your head that need to be worked out in the real world. And going back to where we started with this kind of evolutionary principle that we're shut down, that we're intensely focused internally, the memories are primed, the short term memories there, that we're not distracted that we're trying to sort things on our head that actually need to be sorted out in the real world. Steven Hollon: It's absolutely brilliant. And he's really, he and Susan Nolen-Hoeksema might have really explored the role of rumination more thoroughly and better than anybody else. He's got some really lovely kind of approaches to dealing with that. Keep in mind when I talk about evolutionary perspective, most folks in the field, most depression experts would not agree with that. So that, and goodness knows, if you look at, my track record, I've been wrong more often than I've been right. I wouldn't bet money against Ed in the notion that rumination is the primary problem. It's not what I would bet money on myself, but, see where we go. I do think what we're doing is helping people structure the rumination. That's the adaptation of the brain involved to do when things make you really sad, then I want to facilitate the process and not leave you stuck. And I think what we do with cognitive therapy is teach people how to ruminate more efficiently. The three things I want a client to be doing when they have an automatic negative thought, the beginning of a rumination is say, what's my evidence for that belief? Any other alternative explanation for that? And even if it were true, if I don't know yet, what are the real implications? So, suppose you lose your job, first thought is, my God, must be because I'm incompetent. Well, any other things went wrong? Well, they've been downsizing. So maybe, a number of us lost our jobs. Maybe I was just the first out, et cetera. There's an alternative explanation, which is more consistent with the data. And as tough as it's going to be without my job, do I have unemployment benefits and how long do I have them for? What are the kind of jobs I want to pursue next? Is this a time when I want to take a chance in my life and try something I haven't tried before? They're the things you can do to get yourself mobilised which are not consistent with shutting down and doing nothing. And that's what we want to have clients move towards. Rachel Handley: Also thinking about complexities in who we treat, you've spoken a bit about a patient who met criteria for borderline personality disorder or EUPD. What about patients with personality disorders or longstanding chronic impairment? The manual talks a bit about a three-legged stool. Is this where this principle comes in? Steven Hollon: The biggest change in cognitive therapy since Beck first laid it out, the 1970s version that I trained in, has been dealing with more complicated clients. And the architect, the lady, we described it as a good example of that. She had a lot of other stuff going on. And the biggest problem was that she, and this is almost always the case with Axis I people with depression, superimposing Axis II disorders is that she had compensatory strategies that function like safety behaviours for her. She thought they protected her from loss from risk, etc. They didn't, but she couldn't know that until she dropped them, and she wouldn't know the role they played until she took the chance, takes a deep breath. With the sculptor, all he had to do was break stuff down into smaller steps. He's taken a risk to do that with just a matter of getting out in the garage and putting his portfolio together. With the architect, she had to take chances in interpersonal situations that she thought she had something to lose. So laying out a roadmap for her about where did this come from? When did you first start believing this about yourself? What other evidence do you have? Let's talk about the times when you have had relationships blow up on you. What are the things that you've engaged in usually out of a sense of desperation, have they served you well? Have they really served you better than just levelling with your ex-husband or with your new boyfriend, et cetera about what happened to you at age 15 and see if they have any problem with that. So for Axis II personalities, it's a matter of taking chances or giving up something that you really like. When Trump first got elected back in, what 2016, on that election we had our grad class on cognitive therapy the next night and everybody came absolutely dejected. So we talk about how would you deal with somebody with narcissism. And, say, look, if I were this guy's therapist, which of course I'm not, we'd walk out of the White House, we'd go out on the mall, I'd look, first to the left, see the Washington's Monument? You want one of those? How did Washington get that? Well, the father of our country, he gave up power voluntarily. He didn't try to, well, I don't know, at that point he was going to mobilise a mob. Then we look down the other direction, Lincoln Memorial, and say, how did Lincoln become the most beloved of our presidents? Well, he bound up the wounds. He didn't come down hard on the people that lost the war. He reintegrated them into the thing. So you look to helping out the people that are looking to you for help. You could do that as president. You'd be beloved, but you know, you do what you will. Who knew he was also a psychopath? But what do you know? Rachel Handley: We can only hope, Steve, that you get to him before the next inauguration speech, which is upcoming as we record. Steven Hollon: We can only hope, but I'm more likely to hit one of the concentration camps. Rachel Handley: And the three-legged stool, there's something about how you use the relationship in therapy as well which that sounds all very psychodynamic. Steven Hollon: And that's the biggest change in cognitive therapy. Tim and colleagues came up with that in the early 90s. In the 70s, most everybody we treated was depressed, but that's all they were, because in those days we were screening out folks with more severe disorders, and most folks were getting, 60, 70 percent were getting better within a couple of months. By the 90s, most people in the clinic were people that didn't get better fast, and they were simply the more complicated. They were the architects, not the sculptors. And, they had to come up with something different. And what Tim did say, look primarily in cognitive therapy, what we learned to do way back when was to focus on current life situation to get people to test the beliefs that lead to the behaviours that keeping them stuck in those situations. Now we got people that have essentially compensatory strategies. And those are the things that are actually getting them in trouble. You want to help them lay out where those strategies are coming from, what they think they're protecting them from, and then encourage them to test those. And he went to a three-legged stool. The first leg is what we always had done, which is focus on the current life situations and the beliefs, behaviours, etc. Second leg is the childhood antecedents. With somebody like the sculptor, I wouldn't bother talking about the past, once he's no longer depressed, rather than just talk about movies sometimes I go back to how'd you first get this way, just to tie a ribbon around the therapy, it might be a session or two at most. But the architect would spend a lot of time going back over the end of scenes where this happened, was in her mind, the rape was not that traumatic, the fact that her father couldn’t have cared less and blew her off, that convinced her that she was without value, what have you. We kind of laid that out and would then go down to what are the core beliefs that you learned. The core belief for her, it was I'm unlovable. For her, it's I'm unlovable, for the sculptor it was I’m incompetent. What are the underlying assumptions? Underlying assumptions don't reveal yourself in a relationship and you won't get hurt. If you want something, don't ask for it directly because they're not going to meet you halfway. Manipulate. And those become the compensatory strategies. And it was the compensatory strategies which kept getting her in trouble. Now, the third link is the therapeutic relationship. With the sculptor, I mean, it was like he was going to see his accountant or his mechanic. We came in, we talked, we did the stuff, and he left. With the architect, three o'clock in the morning the first week she's in therapy and I'm getting calls. Nobody's on the end of the line. You got a pretty good idea who that is. She's already manipulated me to have everyday sessions, done all kinds of things that I typically wouldn't do. It's quite clear that she's structuring the therapy in a way that's going to suit her convenience, the chance she wants to take, etc. So we lay out that third line, which is the therapeutic relationship. And anytime we put something on the agenda, how does that relate to what you learnt back when she was a teenager with her dad, and how we're working on that in here, anything about the way we worked on that, that rubbed you the wrong way? Anything reminded you about how pissed off you were at your dad or your ex-boyfriend, your ex, et cetera, et cetera. We touch all three legs of the stool. And then we'd use the interactions in the therapy session as, how would you say, they were stalking horse, and she could practice doing stuff with me before she was ready to do it with the people she really cared about out there. And there were times, there was one time she came in, called, we were starting to space out the therapies, only doing a couple times a week now. And there was a Monday afternoon, we were going to meet on Monday. I'm a big fan of a football team- we have a different kind of football over here. They're going to be on Monday night football, unusual because there's a very bad team, I really want to get home to watch the thing at eight. She calls late afternoon, can I have a session? Something happened. Okay, you have a session, but I want to make sure I'm home by eight. Is that okay? She shows up half an hour late with a hot cup of coffee. And I'll look at her and say, that’s I’ve got this depressed, maybe borderline, possibly suicidal client. I said, that really annoys me. That really pissed me off. And she gets really upset. So, we spend about the first 15 minutes going over how upset she is, pissed off. How could I do that to her? And we end up having this nice discussion where, look, I will meet you halfway. I'll treat you like a real human being if you do the same for me. But, I'll cut deals with you, but I expect you to honour your deals with me. And that she, later on, would say that was a really major breakthrough. We used that as a model for how she can deal with people that she really cared more about. And if you're going to manipulate people, be ready to own up to it. And, and if they call you on it, that’s good. But, so we put all three of those together. We did that three-legged stool model that shows up in the manual. First time I'd ever done that, but we had that on the desk. And everything we did, we go each step, each, leg in there. So you're dealing with this bossy person at work, how's it relate back to what happened with your dad? And how's it relate to how you and I are working together? We touch at each leg of the stool. And it didn't always have to, but it helped him enough of the time that for somebody who's dealing with depression superimposed on Axis II disorder, where they're used to either manipulating or avoiding or doing stuff with other people, where what they do is screw up their lives continually because of the way they treat other people it helps them understand that. And we're working on that in the therapy session itself. Rachel Handley: Yeah. So we often reflect in this podcast that being a therapist is an incredible privilege, the best, most rewarding job. But let's face it, it can be a tough one as well. Our own lives aren't always free of complications and challenges that make it harder when we're maybe we're working with depressed clients. What you've just described is some pretty complex interpersonal dynamics, the kind of having to make a decision to share your own anger, your own response to that hot cup of coffee that arrived in your therapy room. How might we be challenged by this work and how do therapists look after themselves and maintain that therapeutic stance? Steven Hollon: Yeah, that's a great question. I had 3 episodes of major depression in my early 20s; last year in college, the year between when I was working as a therapist at a communal health centre and my first year in graduate school, and nothing since I hit Philadelphia. Whatever I've been learning to do with my clients ha been working like a charm for me. And that's not usually the way the life course goes. There's something derailed the typical progression in my life. And I think it's what I learned to teach other clients to do. The second thing I learned in the whole process is that. is if you think something might be, you don't want to do things that are rude or harsh to somebody else unless you've already built a good relation, in which case you can ask for a minute and go and do that, but if you have an impulse to do something for God's sake, do it. The biggest errors we make as therapists is not acting. And its because depressed clients are not acting. They know what they want to do. In most of our trials, the toughest people to treat are people with chronic depression. And it's not usually the case that they don't have a notion as to what they could do in their life that might make it better, but they're not willing to take those chances. And, what I've learned in my professional career, my therapeutic stuff is, if you think something might be worth trying, for God's sake, try it. Ask permission first if needs be, to clean up the mess afterwards, but I think the mistakes I've made have been more likely errors of omission than errors of commission, and you've got a client you're working with, they've gotten to know you a little bit, they'll usually cut you a little slack. Rachel Handley: So don't get stuck in behavioural inactivation. Steven Hollon: Don't get stuck, don't get stuck in behaviour and not acting. Rachel Handley: I guess it's also really important to us as therapists to know that what we're doing has a high chance of, or a good chance at least, of success. what is the,effectiveness, efficacy of cognitive therapy for depression now, and is it effective for everyone? Steven Hollon:  No it's clearly not. A short term with a relatively uncomplicated person, relatively uncomplicated depressions, not chronic depression 10 to 20 sessions is going to be enough and in the last third of it you're going to be talking about other stuff. So for the sculptor, we had more sessions than we needed. For the architect, we needed more sessions than we had, although things continued on. I think it depends on how many episodes, how long the person's been depressed and other kinds of complications. If I get somebody who's depressed and has panic attacks, I'll ask if we go after the panic attack first, because that's a session or two. If I get somebody now, who's depressed on top of PTSD, I think we have to go after  PTSD first. We do the reliving quick because that I mean, you can get rid of the PTSD symptoms rapidly with the reliving, then you got all the trauma, the meaning there to deal with, but that's going to be part of it as well. And that usually moves faster than the depression per se. Social anxiety takes longer. And that's the anxiety that sort of reminds me more of depression than anything else. And it's not always the self that’s the problem its usually other people, you never know when they're going to turn on you, but usually there's a history of having been bullied something else. So there's often a self-involvement there as well. And I've not done much work with people with serious mental illnesses, at least not much successful work, but you guys have in England and you're good at it. And I remember we had a marvellous therapist out of the Maudsley that came over and did a weekend long workshop for us over here. She would describe a client and then ask people in the room what they would do. And I would usually be quick to volunteer. And I'd say something and it would be like, no that’s too soon, build a relationship first too soon. So, the one thing I learned out of that is don't rush. Got a depressed client- rush. He who hesitates is not serving his client or her client well. With somebody who's got a propensity to decompensate, take your time, let them get to know you, get to trust you, and then put stuff in. But you guys are much better at that than we are we're in the States, we're trained that you can't reason with somebody who's psychotic. And in England, you guys do it and it works. Rachel Handley: So it sounds like really important factors in the effectiveness of this therapy are going to be things like chronicity, severity, comorbidity and type of comorbidity, very importantly, whether it's severe mental illness or different problems that you can deal with. Steven Hollon: Can I comment on that? I think that's great. But I would start with that tucked in the back of the mind. I would probe to find out. I wouldn’t assume just based on, I would take my Sally's. It's like you're sending out a group to see where the gunfire occurs in the war zone. You never know for sure. And don't assume that something's going to be tough until you find out that it's tough. Rachel Handley: So someone walks into my office with unipolar depression, maybe it's the second episode in adulthood. Is there such a thing as an answer when they ask me? What are the chances of me getting better, Doc, when you've done cognitive therapy with me? Steven Hollon: Yeah, they're pretty good. And the question is, I mean, there are other kinds of therapies that work as well and great if this kind of thing works for you. By the way, it won't work if you don't take it, don't use it. It's like medications. You can't just hold the pill in your hand and expect it to do anything for you. But if you work on the therapy, try this stuff out, take a few chances, risk, et cetera, then we'll find out the odds are about 6 to 7 out of 10 that it's going to work for you, in a relatively short period of time. And by the way, if it works for you the odds are it's going to cut your risk by at least half for having future episodes. So not a bad bargain to get into, can't guarantee and I never want to make a promise, I can't guarantee. But we do know how to find out and it's to do the stuff and see what happens. Rachel Handley: So perhaps a bit controversially, we could say, well, we've reached the limits of cognitive therapy. It's going 50 years on, maybe there's a 6 or 7 out of 10 odds chance you get better, maybe less, maybe more depending on your presentation. Have we maxed out on recovery and remission now? Is cognitive therapy standing still or can it still improve? Steven Hollon: Yeah, it's a great question, but I think it's evolving. I think we've learned how to do things starting with the focus on the Axis II disorders that we didn't know how to do back when I first went through training and my hunch is most people that know how to do cognitive therapy haven't learned yet how to do that stuff. I think I'm a better cognitive therapist today than I was back in the 70s and I think I'm better cognitive therapist today than I was when I started working with tough clients like the architect. So, I think thats the trajectory for any given therapist as well. And I think I'm learning things. I've been watching the tapes that David and Anke put on the OXCADAT training tapes for social anxiety and PTSD and I’m a bit further along with PTSD, social anxiety, still a bit of a mystery. I don't quite understand anxiety, but I mean, amazing training tapes. So, I don't think we've got close to maxing out at all. Rachel Handley: And you've spoken a little bit already about the Philadelphia effect when you started doing this work, it helped you in terms of, as you reflect back, you haven't had further episodes of depression, you've been able to implement some of the tools and strategies. What have you learned most, do you think, from the people you've worked with? Is there any lesson or individual that stands out as someone you really impacted in your life? Steven Hollon: Oh, I mean, Tim Beck was just an absolute marvel. When Tim turned 100, Judy Beck and Rob DeRubeis set up a birthday thing for him, and about a dozen people came in by Zoom and we were going to share some kind of anecdote. We all basically told the same story. Tim identified something in us when we were generally early in training, graduate student, resident, et cetera, that he then nurtured over the course of our careers. And, just remarkable that, this is a guy who was an outcast in his own field, totally dismissed, totally ostracised, but he stuck to the data, and he built something really very positive out of that. He also, enlarged, expanded, what he was doing, went beyond the narrow structures in a way that is marvellous. I mean, other folks as well. I've learned so much from people like Anke Ehlers and David Clark and others and the marvellous folks down at the Maudsley; Sheena Liness and Suzanne Byrne and others, I come to, England from time to do training workshops, and I've learned more than you guys learned from me when I come. Rachel Handley: And what about from your patients? Steven Hollon: So much. I mean, you learn different things from different patients. Nobody ever worked me at and down the other more than the architect and I ended up being more of a friend than a former client, but just remarkable. And, most of the time I was flying by the seat of my pants. You trust your gut and you do what you do. And if something screws up, then you work your way through that. It's like any other kind of relationship you don’t know coming in with the other person's going to like it, you work your way through, you get feedback and you go from there. Rachel Handley: It's something really freeing. Yeah, there's something really freeing about that message around not getting stuck, not getting paralyzed in our work. Steven Hollon: Yep you learn more from tough patients. And, when I come over from time to time and get a chance to do the workshops, often we'll spend the second day, just going over, bring your toughest cases, the people you have the most difficulty with and we’ll role play around that. And sometimes we invent stuff on the fly, we come up with things we hadn’t anticipated. One of the things about cognitive therapy is Tim would always say we'll steal from anybody. And if it's a good idea, he'd incorporate it. And we keep the spirit there. If it's a good idea, then you bring it in. Rachel Handley: So it's important to pursue what works? Steven Hollon: Yeah, and it's important not to worry about whether or not it's going to work enough before you pursue it. Roll the dice, see what happens, and correct your errors. Rachel Handley: Test it out. So if people want to learn more about your work, Steve, where can they access training? You've spoken about coming to the UK and doing training here. I'm sure you're doing lots in the States. Where would you direct people if they wanted to dig deeper into this? Steven Hollon: Yeah. Well, again, you guys got, these recordings. I don't know if, Sheena and Suzanne, I usually, each year I've been coming to the Institute, the Maudsley, like I don't know if they tape those things. There are other folks I come over that I do trainings for that tape. I think in May, I'm scheduled to do three; one at the Maudsley, the other two- is there an Oxfordshire one and the 3rd place and I don't know, if they're taping those things, often they do and those may will be available. It's funny I do more training in the UK than I do in the States and because again, we're so when it comes to depression, we're so cognitive behavioural as opposed to cognitive and for anything else. Again, the basic principles you get from the marvellous training tapes that David and Anke put up on the OXCADAT site. And, I'll be teaching a course this semester, graduate course on cognitive therapy and the depression stuff I'll handle. We'll have examples and tape some things, but for the last third of the course, we'll go to the OXCADAT and watch tapes together and talk about what they have. So that again, the marvellous source of training, Rachel Handley: Fantastic. And of course, as we've spoken about a lot, there's this new manual, that, that is last published last year and really worth a look. Look, I still have my old version, my first edition, which was, and I know we're not supposed to have superstitious beliefs as cognitive therapists, but it was signed by Beck. So I'm never going to be able to relinquish that because that will clearly make me a bad therapist if I dropped the book, Steven Hollon: if you didn't have time, there's the revision. I'll be absolutely amazed but do your best. Rachel Handley: that might be beyond even my superstitious reach. So 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? Steven Hollon: I would say always the cognition is primary. What somebody believes is what you really want to know. But different kinds of disorders are going to play in different kinds of ways. If it's depression, usually people aren't moving, going to be better for them if they do it. Do you want them testing stuff out? So you really try, usually trying to activate them. And that usually is going to mean taking stuff they're trying to do that isn't working well or not even trying and break in small steps of behavioural components. Very useful there. But always it's the test in the real world that matters the most. But what you want to test is the belief that they have and other things, and again, so often you get other things in the midst of the depression, the anxiety, the phobias, the trauma histories, et cetera. Yeah. find out what they've come to believe, and then, see what, see what evidence they would find compelling to help them change their belief. It doesn't matter what you find compelling. It matters what they would find compelling, then help them move on that to run those tests. Always in the session, there's going to be somebody in the session that knows the most powerful test to run of a belief, and that's going to be the client himself or herself. It's the last thing they want to do, and find out what's the last thing they want to do, particularly if there's any anxiety involved, and encourage them to do that. And when they do, then they find out whether they needed to be afraid. Rachel Handley: And I'm taking away from this as a therapist, not just that message for work with my clients, get them to test it out, But to test stuff out myself, not get stuck in that paralysis. And we can all make mistakes, but they can be fixed. they're all grist of the mill Steven Hollon: When you say this is a really tough client, that's the beginning of the conversation, not the end. And then you say, did the stuff we know how to do, is that likely to work? Let's try some of that stuff, but if not, what do I have to invent? We've got to come up and then involve the client in coming up with that. The architect was remarkable in the way she helped modify and redesign the therapy with me. Rachel Handley: And the rewards are great if we can help people live more fulfilling, happier lives. Steven Hollon: Yep. That beats parking cars. Rachel Handley: Thank you so much, Steve. It's been so interesting talking to you. As I predicted, we could have gone on a lot longer, so many questions, but this has been really helpful. Thank you very much for your time early out there, in the States. So thank you for joining us. Steven Hollon: Been a great delight and thanks so much. Much appreciated. Rachel Handley: Well, if you've made it to the end of this podcast, perhaps like me, you'll want to go back and listen again. There is so much in what Steve had to say. We have more coming up soon on our series on depression, so watch this space and until then, look after yourselves 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 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 the first instalment of this special two part episode, Rachel Handley talks to Professor Steve Hollon, international expert on the prevention and treatment of depression and co-author of the second edition of Cognitive Therapy of Depression about how we understand and treat depression. Steve shares what first drew him to the field, his early encounters with Aaron T. Beck and the rise of cognitive therapy, and how insights from evolutionary biology, psychology and neurobiology can enrich our understanding of depression. Next time: In Part 2, Professor Hollon discusses how CBT can be applied to a wide range of presentations, from more straightforward to highly complex and even tries his hand at devising a brief intervention for the President of the United States. Don’t miss it! Resources and links Cognitive Therapy of Depression (Second Edition) Find out more about Steve and his research here OXCADAT: A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/ Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [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 Handley:  Welcome to Let's talk about CBT- Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. My guest today is Professor Steve Hollon, who had so much fascinating information, theoretical and clinical insights and stories to share that we just had to produce a special two part episode. In this first part, Professor Hollon shares the reasons for his fascination with depression, the story of Beck's development of the cognitive therapy for depression model and insights from psychology, neurobiology and evolutionary biology that can help us understand the development and maintenance of depression. Professor Hollon is an international expert on the prevention and treatment of depression and co-author of the long awaited second edition of Cognitive Therapy of Depression, the definitive and groundbreaking psychotherapy manual, first published by Aaron T Beck and colleagues in 1979. Professor Hollon is professor of Psychology at Vanderbilt University in the US but is no stranger to us in the UK and supporting the dissemination of evidence-based therapies here as he regularly provides training to services in the UK and teaches on the Talking Therapies Program at the IOPPN annually. So welcome to the podcast, Professor Hollon. Steven Hollon: Thank you very much. And Steve, please. Rachel Handley: So Steve, you've been working in this field for quite some time now, you might not want to tell us how long, but can you recall for us who or what got you invested in the field of depression personally and professionally? Steven Hollon: Yeah, I can't tell you exactly why I got interested in depression, but that goes way, way back. We have some family history that I got my own personal history of episodes of depression, but to make a long story short, I was in graduate school in Florida State which was good, strong program, but I was reading Aaron Beck and Marty Seligman and Jerry Claremont, the fellow that generated IPT and I was showing up, in those days we had libraries, we had stacks. And I was looking at some of the same journals that my then graduate student colleague Judy Garber, now 50 years now we've been together looking at the same kind of things and we just decided that we weren't getting the kinds of training that we absolutely wanted, as good as the program was in Tallahassee, we want to work with some of the leaders in the field. So she wrote to Marty and cut a deal with him to run his research labs while he was off on sabbatical at the institute in London. And I was finishing up my dissertation collection data and I followed her up about six months later, with the notion that I would work for Beck. Of course, Tim Beck didn't know me from Adam and couldn’t get in to see him. And his cognitive therapy approach hadn't taken off yet, but we ended up seeing that his group was going to be presenting at a conference, Society for Psychotherapy Research in Boston. So we drove up the coast and went to the meeting there and I spent the next three days getting to know the other people in this research group and, talking with Maria Kovacs, really first rate psychologists who ended up becoming a leading figure in developmental psychopathology, Hungarian and wanted to go back to Hungary for an extended visit that summer and Tim was reluctant. They had a research grant going on. She was interviewing people that survived suicide attempts. I'm just hanging out on the fringe of the group, and I said, well, I'm a psychologist, I'll stand in for it. So I stood it on a volunteer basis and spent the next three weeks trying to make myself indispensable. We ended up negotiating my first year in Philadelphia as my clinical internship. Second year, with Tim's blessing, I went over to the psychiatry residency program, continued working with him, and then ended up going off to Minnesota for a job I was thoroughly unprepared for. Nonetheless, things went well, I got an offer and went out there. Judy graciously finished up her doctoral training at Minnesota and eight years later, we were left eight years and 16 winters later, we left for Nashville Vanderbilt and where we’ve both been on faculty for close to 50 years. Rachel Handley: Wow, that's quite a trajectory. I'm old enough to remember what it's like to go down into a basement of a library and roll the stacks along and actually have to find a physical journal paper, not just type it in on the internet. Right. But from there to working at the heart of the revolution, really, of cognitive therapy with Beck and his team must have been quite something. Steven Hollon: It was something, but it was not a thing yet. Tim Beck, Philadelphia Penn was heavily psychodynamic, he was heavily ostracized. He'd been dropped by the Philadelphia Psychoanalytic Society. Every year they'd have the various psychiatry faculty meet with the residents, and when he met with the residents, virtually nobody showed up. It became a thing with the publication of the first outcome trial, the Rush et al study that suggested that cognitive therapy not only held its own with medications, it was actually better than turns out. It only looked better than because we did a terrible job with the medication comparison, but everything since that's done a good job with cognitive therapy, done a good job with medication treatment suggested they're about comparably effective and cognitive therapy has an enduring effect that cuts subsequent risk by about half something medications can't do. Rachel Handley: And as you hinted there, that was the journey for Tim Beck as well. He came from this psychodynamic background training team, anyone with a passing interest in cognitive therapy now knows about or has started by training in the principles and practice of cognitive therapy for depression. But can you tell us a little bit about his story and the development of the approach? Steven Hollon: Yeah, he was, although he was marvellous fellow, a marvellous human being, but originally wanted to be a pathologist because you could get definitive answers, but he ended up getting diverted into psychiatry. And in those days, the late 40s, early 50s, everybody was trained dynamically. He was trained by some of the best. And of course, the dynamic explanation for depression was it was anger turned inward. These were unconscious motivations laid down in early infancy, to be angry with your parents about something, some kind lack of sexual gratification and the notion was you had to, the patient himself or herself couldn't be aware of what their true motives were because there were defence mechanisms that got in the way. So you had to sneak up on them. You had to rely on free association. People would take the couch and just say, first thing that popped into their head, or you would interpret dream content, and you might spend two or three years exploring the underlying motivations without ever approaching them directly. The therapist might go, certainly better part of a session without saying anything. So it was a very long term, expensive therapy form of therapy. Tim was interested with his interest being a pathologist was interested in doing some research as well. And he was struck by the fact that the things his clients to him and their free associates in their dreams, which is like what they told him when they were walking into the office. I'm an addict. I'm unlovable. I'm a loser. I never do anything right. As, and they weren't screens for underlying, sexual and aggressive drives, They were just what they believed. He did some research where he investigated dream content, investigated free associations, and as hard as he looked, he could not find evidence of anger turned inward. It just wasn't there. He did an experimental study with colleagues across the street in psychology at Penn where they manipulated outcomes on a performance task. And it turns out if you want to get somebody who's not depressed really activated and motivated to try harder the next time, give them a failure experience. Rig it so they don't win. If you want to get somebody who's depressed activated the next time, give them a success experience, contrary to what they expect that then gets them mobilized. And on the basis of that, he started, I think, in ‘63. he was writing those things up in the late 50s, but a ‘63 article in what was then the Archives of General Psychiatry, laid out the basic notions of the theory. And in ‘64, he came back and described some of the things he was doing therapeutically, which were really almost common commonsensical, if you take your client's beliefs at face value, you have them exactly the accuracy of their beliefs, and it got him dropped by the Philadelphia Psychoanalytic Society, ostracized by his colleagues, but the last laugh, he wrote his ‘67 book on depressions now considered a modern classic an things took off from there. Rachel Handley: Well, that's the kind of failure we can all live with, right? Steven Hollon: Exactly. The one thing Tim would always say is it much like, working with people who are depressed is you always want to turn adversity to advantage. Something goes wrong, find out a way to get something out of that. Rachel Handley: That's what he did. And it sounds like, very much took that, that, that pathology approach. He was dissecting the presentation, what was in front of him and understanding it rather than the bringing theory a priori to the presentation. Steven Hollon: Yeah, absolutely. He was always driven by data, which is again given a psychiatric background, you wouldn't necessarily have expected that, but he did and he was. He also spent at least a year at Oxford in the early 80s. Michael Gelder picked up on this growing phenomenon fairly early on and invited Tim over for a year sabbatical and he did, and that's where he had contact with people like David Clark and Paul Salkovskis. And, just, in some respects, England moves a little closer to Beckian Cognitive Therapy than we do in the States. We have a lot of folks that came to cognitive behavioural approaches from a more behavioural background, and they still have a little trouble thinking about the meaning behind the belief, for them, but a cognition is just another behaviour. You reinforce that in you replace negative thoughts with positive ones, as opposed to getting people to examine the accuracy of their beliefs. So there's a bit of a contrast. And I would think nowadays, David Clark, Paul Salkovskis and Anke Ehlers are closer to Beck in spirit than the states and depression. But, most of the rest of the folks over here, particularly anxiety, stress, et cetera, are more nearly behavioural with cognitive over than are you guys are in England. Rachel Handley: So there's that difference of emphasis and approach, but depression is a worldwide problem where we're used to thinking about and hearing about the statistics and figures like one in five, often quoted in terms of what lifetime prevalence is a big burden on the health of the world population. But it's been suggested that even those high figures might be an underestimate. How significant, Steve, is depression as a problem? Steven Hollon: Yeah, I do a undergraduate class. I'll go and do another meeting later on this afternoon where the whole focus of the class is everything we were wrong about a decade ago, and one of the things we were most wrong about is, we've always thought of depression as the single most problem with psychiatric disorders, and it is, but it turns out it's about 4 to 5 times more prevalent than we realised. And our estimates were based on good retrospective epidemiological surveys, the kind of thing we did in the States with the National Comorbidity Study. Ron Kessler, superb epidemiologist, did that but the methodology is to interview a large number of people over the course of a year, and they range in age from their late teens up to the 80s. And when you do that, about once a year, you'll start getting calls from journalists that say, I noticed that people in their 80s have fewer episodes than people in their 20s. Is there an epidemic? No, there's no epidemic. Just people in their 20s remember an episode of their 20s. People in their 80s don't. So it's a memory problem. If you look at the birth cohort studies that follow people from birth on, like the marvellous Dunedin sample that Terrie Moffit and Avshalom Caspi have inherited and followed, where the sample is now in the mid-forties, you get estimates of depression which are at least 3 to 5 times higher than what we get from the retrospective surveys. And the biggest proportion of extra cases that we hadn't realised are single episode patients. We've always assumed that depression was quite common, about, as you say, about one person in five but highly recurrent. Turns out it's much more common than that. The Dunedin sample, over half of those folks have now had at least one episode of depression, but the bulk of them don't go on to have a second. And what it turns out is that, what it looks like is what an evolutionary biologist would call a species typical behaviour. Any one of us could get depressed if something bad enough happens. Now, there's a subset of folks that go on to have multiple episodes. We don't have a good explanation as for why that is. Scott Monroe and Kate Harkness did a terrific pair of articles, 2019, in Psych Review, and then 2022, I think, in Annual Review where they suggested a dual pathway model that some folks hit adolescence at elevated risk which sounded very compelling. I thought they're really onto something. I remember writing very positively about that. But when you check in the distribution of episodes, in the Dunedin sample it's purely linear. Most folks that have an episode only have one, the next largest group of people have two, next larger group of three, et cetera. But there's no bimodality and that were something like intelligence where there are a large number of factors, no one of which counts for much of the variance. You got a nice normal distribution with a small number of people, genetic anomalies, birth, trauma, et cetera, at the low end, get a little bump. We don't get anything like that. Or if you think of gender or height is normally distributed within women, normally distributed in men, but the two together make a bimodal distribution. If there were really some kind of diathesis that accounted for a large number of cases of recurrent depression, you would expect bimodality, and we just don't see that in the data. Rachel Handley: And so when we look at current reports of increasing incidents of depression since COVID, for example, would your perspective be that's more likely to be measurement area error? Or is that just something so bad has happened that we can get depressed from that. Steven Hollon: yeah, I mean, things happen. We had increases during the depression and increases in suicide, usually suicides, a hard index, and more people jumped out of windows in the 1930s than before or after. I do think when bad things happen, more people are going to get depressed, so it wouldn't surprise me if we have an excess, I would be surprised if they go on to become recurrent. Rachel Handley: Okay. So it doesn't necessarily mean in the longer term, we're going to see an increase in of people presenting for therapy, but we don't know. Steven Hollon: We don't know. I'll be curious. My wife's a developmental psychopathologist. And what she would say is that the thing you don't want to do to 12, 13-year-olds is not let them be in classrooms with other 12 and 13 year olds and make them go through social media, feel criticised, et cetera, that's a recipe for generating angst in young adolescents. Rachel Handley: Absolutely. And given this huge prevalence that you're talking about of single episode depression and then these other presentations where people have recurrent depression, when you see a presentation like that, so pervasive across the species, it might lead you to speculate about is something adaptive about this? And when we look at anxiety, for example, it can seem obvious that being alert to threat would have some adaptive functions, perhaps even things like anger, the function around seeking justice or restoring kind of normal social norms. What might be the value of a depressed mood? Steven Hollon: We thank God for first responders, they keep the rest of us alive. But in our ancestral past, if you didn't walk up to the edge of a cliff, you're more likely to live and have offspring than if you did. So anxiety does serve a function. We've never had a problem with that. Pain serves a function, and pain keeps you from doing additional damage to injured tissues. We've never thought about depression as having a functional advantage. Paul Andrews, the evolutionary biologist at McMaster in Canada, has I think really come close to nailing this. The number of good evolutionary biological theories of depression, any one or all of them might be true to greater or lesser extent. The thing I like particularly about, Andrews and Andy Thompson, his colleague, in a paper they published back in 2009 in Psych Review. When I first read it, I thought, hey, these guys, lovely, but they have no idea what they're talking about, they just got it wrong. And over the last decade of arguing with the two of them, I'm now convinced they were more right than I was. The thing I like about that, what they say is that depression evolved because it gets us thinking very hard and long about social, complex social problems. And in our ancestral past, the one thing young primates couldn't afford to do was be thrown out of the troop. If you were, you're going to get picked off by predators. And if you're a young adolescent female, who's probably already been impregnated, it's going to be a double whammy evolutionarily because you and the offspring are going to be lost to posterity. Now the problem with, you can avoid falling off a cliff if you don't walk near the cliff. but if you've offended the elders in the troop, you got to sort out how you're going to deal with that. Now we know, and by the way, let me just say there's a major difference between unipolar depression and depression as it occurs as part of a disorder, the depressions are virtually identical. However, unipolar depression is not only our single most prevalent single psychiatric disorder, and a lot more prevalent than we used to recognise, but it is so high prevalence, modest heritability. It's heritability is about 0. 3 to 0.4, which makes it less heritable than political preference and huge gender distribution from early adolescence on, women about twice as likely to get depressed as men. I suspect it's because they tend to get involved with men, but what do I know? The bipolar disorder, you don't necessarily have to have a depression to get diagnosed with bipolar disorder, although most folks will have depressive episodes as well, but the defining feature is one or more episodes of hypomania or mania. And of course, mania, hypomania are the mirror opposites of clinical depression, virtually all the same symptoms are involved, they just go the opposite direction. But it's highly heritable. 0. 7 to 0. 8. along with the schizophrenias, it's the next most heritable disorders to autism. The gender distribution, there's no split, every bit as common in women as in men. And even though the depressions are virtually identical, you just don't see the swing to hypomania/mania. Now, there's some reason to think that we are sometimes diagnosing people that truly belong in the bipolar spectrum as unipolar if they hadn't had a major manic episode, the individuals who tend to be hypomanic don't regard that as abnormal. I mean, I wouldn't have realised- I've mentioned earlier, I have my own personal history of depression, three bona fide episodes. I always thought of myself as somebody that had a history of unipolar depression. I'm out to dinner one time with colleagues in Amsterdam and they'd invited in Jules Angst, the great Swiss psychiatrist of marvellous longitudinal studies. And I didn't know the guy before, but they were kind enough to invite me to join and we're talking over dinner and I just gotten in that morning and, he mentioned in polite conversation was I concerned about jet lag? I said, well, I don't get jet lag. I just, I get a little speedy. But the rate of speech picks up a little bit, and he asked me a few other questions. He said, you've had depression? I said, yes. He said, well, are you unipolar? I said, yes. He said, no, you're bipolar. You're in the spectrum. Rachel Handley: Wow. It's not necessarily what you expect when you accept a dinner invite. Steven Hollon: Yeah, well, you do when you meet with a Swiss psychiatrist who devote their career to longitudinal research, open for anything. But it's probably true. And I wouldn't want to lose that. I mean, some people take drugs so they can get the sense of great energy, a little bit of grandiosity. And except for occasionally making an inappropriate comment, it's never gotten my way. And I suspect, half of my publications come from getting a buzz on something and 3 days later coming up for air. So we know that Bipolar II is one of the hardest diagnoses to get right. And it turns out if you, as we often do with clinic interviews, you ask the individual himself or herself, they don't see it, to them it’s just normal coincidence. If you ask their significant others, the people that live with them, coworkers, they all recognise it. So it's not hard to diagnose if you ask the people that live with the person, but it's hard to ask the person himself or herself. At any rate, psychotic depression is a problem, but we also are learning now, and a lot of that's coming out of research, people doing at the Social Genetics Institute at the Institute of Psychiatry, one of the things we're learning with these large GWAS studies is that the serious mental illnesses, the schizophrenias and the psychotic affective disorders, particularly, psychotic mania are more closely related genetically than bipolar disorder is to unipolar, or at least as closely as bipolar disorder is to unipolar disorder, and non-psychotic unipolar disorder is at least as closely related to the anxiety disorders. So, the evolutionary biologists are calling for reorganising our nosologic system, so that we're separating out the serious mental illnesses, all of which are highly heritable, low in prevalence, and show no gender disparity, and almost always need to be treated with medications or somatic treatments from the non-psychotic disorders; anxiety, stress, depression, unipolar depression which are modestly heritable, usually have a big gender disparity an, tend to respond at least respond to neuropsychological intervention often with an enduring effect. Rachel Handley: And it sounds like you were saying this might have a difference for how we view the adaptive properties of these different types of presentations. So you were talking about unipolar depression, and I'm on tenterhooks to hear what is it? So, so I've offended the elders, and I've got to solve a social problem. How do I get there? Steven Hollon: Of the several various good evolutionary biological theories of depression, something like conservation withdrawal, which is when things go wrong, you don't want to expend a lot of energy. So you hunker down. it's probably the case because that's older. You find that in organisms that don't have cortexes. So, molluscs show a conservation withdrawal when the environment is not supportive, and it looks for all the world like a depression. One of the things Paul Andrews and colleagues would point out is we have at least three symptoms that revolve around negative affect stress and they are, sickness, starvation and then clinical depression. And in sickness, quotes, depression, energy gets routed away from the cortex, it gets routed away from growth, reproduction. It gets routed away from hedonic pursuits like sex and food and towards the immune system. If you've got an infection, what you got to do is survive the infection so a lot of the energy goes there. If you're starving the energy gets routed to the maintenance of our organs, the brain, the heart, the liver, et cetera, the extremities waste away. If you're thinking about anything, it's only food and if your behaviour changes at all, it's only spend more time foraging, looking for food, it turns down the nucleus accumbens. So again, you lose interest in sex, you don't want to go out on dates, you lose interest in other kinds of things. In clinical depression, the energy goes to the cortex. And it doesn't go to the immune system, it doesn't go to maintenance of vital organs, and it goes to the cortex. And when it goes to the cortex, it does a couple of things. The Raphe nucleus deep in the brain stem is where all of the neurons in the brain that use serotonin as a neurotransmitter have the cell bodies. It's very ancient, probably came in with the mitochondria- God knows how long ago when we had separate organism organallia, and it was probably mitochondria, probably separate or just the blast pharmacist in all organisms. Now they're what convert sugars into energy, that's how we get energy to do things. But serotonin was very closely associated with that. And it looks like serotonin's primary role in the brain, in the body and in the brain, is not so much to be the target for antidepressant medications, which it is. It was to shift energy back and forth between positive hedonic pursuits and negative pursuits, avoiding danger. And any organism has to do two things over the course of the day, it has to get lunch without becoming something else's lunch and our positive affective responses push the former; sex, food, et cetera, things good for the individual, good for the species. And our negative hedonic pursuits push the latter. Jeffrey Gray, who started Oxford and was for years the head of psychology down at the Institute of Psychiatry, really lay out the neurobiology that, probably two decades ago now. And, with dopamine seems to be the primary neurotransmitter driving it. Dopamine is not the “I like it” neurotransmitter, it’s the “I want it” neurotransmitter. And when you pursue things, the dopamine neurons are lighting up. Norepinephrine is the primary neurotransmitter involved in regulating negative affect. If you're going to have a panic attack, it's when the locus coeruleus fires, which is where all the norepinephrine neurons in the brain have their cell bodies. At any rate, when the raphe nucleus fires, it projects to the amygdala, which gets you paying great attention to whatever it is that's distressing to you at the moment. It projects to the hippocampus which activates short term memory, which is energetically expensive, it burns up a lot of energy to think hard about something. It projects to the prefrontal cortex, which makes you resistant to distraction. It projects to the nucleus accumbens, which turns down hedonic pursuits, sex, food, et cetera, and it projects to the hypothalamus, it cuts down activities like growth and reproduction. Basically, when the Raphe Nucleus fires, it makes the brain ruminate. And then it asks itself the question, why in God's name would evolution set something up which makes you ruminate about things? Rachel Handley: Because we hear rumination in therapy and we think that's a bad thing. We don't want to be there. Steven Hollon: We all got it wrong. I spent the last 40 years trying to help patients not ruminate and an evolutionary biologist like Paul Andrews comes up and says no, that's what depression was designed to do. And it's a basic principle of evolutionary biology that any intervention which facilitates a function that an adaptation evolved to serve is preferred over one that doesn't. And it works in the following way, what I think we do with cognitive therapy is we structure people's rumination, so they don't get stuck and any client I've ever worked with gets stuck blaming themselves for their misfortunes. Now, sometimes they've engaged in behaviours which can be trip into the misfortune, sometimes they haven’t, it’s just the piano fell out of the second floor and hit them on the head. But, mostly everybody I've ever worked with is convinced when they come in that either they're unlovable if they're interested in affiliative concerns, or they're incompetent if they're pursuing achievement kinds of concerns or both. And when I first read the dual pathway model by Monroe and Harkness. I thought that seems weird that that's the diathesis. And we have good data that people go into, for example, college with the propensity to blame themselves when things happen or more likely get depressed during their college years. However, with the absence of bimodality, you got to think maybe that's one of the things that gets triggered when you get depressed and not necessarily something that predates the depression. That's one of those mysteries we still have to sort out. But I'm with all of this is Andrews and Thompson's approach, accounts for what goes on in the brain and where the energy goes in a way that no other existing, evolutionary theory does. And on, on that basis, I got to think there, there are too many little factoids that it accounts for it. You just couldn't account for any other way. Rachel Handley: So let me check. I've understood what you've said. So it. We started thinking about what might be adaptive about low mood and that might lead to this kind of prevalence of depression. And you said that the changes that go on in the brain are really well positioning us to focus our attention very closely on the problems, the threats that we're dealing with in the here and now and to resist distraction, to be absolutely able and ready to, in effect not eaten-we want to solve the problem, the threat that's out there, that we're dealing with and you still. Steven Hollon: Exactly, although the threat here isn't getting eaten, it's being ostracised. Rachel Handley: So it's a social problem. It's there. I've offended my elders. I've offended those around me. I don't want to get, become an outcast from the social group. So low mood is really setting us up well to problem solve our social problems, but it gets stuck. It gets hijacked when you think I'm unlovable or unworthy. Steven Hollon: Thats that's what I think. Now, again, I'm still arguing with Paul Andrews about this, but my hunch is in two to three years he will have convinced me. He would say, if you make people sad, just an experimental task, like having them do expressive writing risk happen, they'll start switching into this type two thinking. And there's nothing exotic about the type two thinking. Daniel Kahneman talks about thinking fast versus thinking slow. If you don't want to step on a poisonous snake in the woods (unless you're in Ireland and we don't have to worry about it) there's something squiggling on the ground, you put your foot back before even aware of what you think the dangerous, that's thinking fast, heavily heuristic driven. And there it's having a fire alarm that rings when there's no fire. It's okay to have some false alarms. You don't want to miss a true fire. Depression seems to activate when you get sad, it activates type two thinking, which is slower, requires short term memory.You have to store the stuff in memory, sort out. Could it be this? Could it be that? What can I do about it? And it's energetically expensive. So you don't want to spend your time doing other things that are going to distract you. You don't want to be pursuing other kind of hedonic values. Get your complex social problem solved and then you go on with your life. And if you track the longitudinal work, what Andrews would say is that the first thing that's going to happen when you get sad, it's going to take you into what he calls root causal analysis. What went wrong? What went wrong? What went wrong? Which then feeds relatively logically on to problem solving. What can I do about it? And if you track people across time, across the course of an episode, they go from sadness to root cause analysis, heavy focus on where have I screwed up or what screwed up to the problem solving? What can I do about it? And the problem solving is negatively correlated with subsequent depression. The problem solving brings it down. It looks like evolution built a mechanism which helps you identify and resolve a complex social problem which would have led to ostracism from the truth. The fact that depression, highest incidents, highest levels of onsets of more than half the folks ever get depressed, unipolar depression kicks off in early adolescence and twice as common in women as in men. Rachel Handley: And some folk get stuck there. So it doesn't solve their problem. They get stuck there. Steven Hollon: Some folks, I mean, I'm so used to working only with the people that get stuck, that, I've been really been looking for what the diatheses are. And that doesn't mean there aren't diatheses, certainly, some people have more genetic predispositions than others. Some people have childhood trauma, et cetera, a number of things we know increase the odds for getting depressed down the line but how much of that played into our evolutionary past, ancestral past, who knows. Rachel Handley: So, you've said a lot about where depression may come from, what role it might play in us as a species. We've talked about a bit about vulnerability, what we know about that, you said bad things happen, people get depressed, gender can play a role, and there may be other factors that we as yet don't know that play a role. Once depression is set in motion (we love a great formulation on this podcast) we love to know what keeps it going, what maintains depression. But we don't have boxes or arrows, we love those in CBT, but on the podcast, we have to do this without any boxes or arrows or diagrams. That’s your challenge. Steven Hollon: Yeah, I mean, that's why God made napkins. You got to drop your calls in the office. The, the, how Rachel Handley: I'm getting it. I'm getting a good picture of your dinner parties, drawing diagrams on napkins. Steven Hollon: Well, I show up at family gatherings with slides, really annoys them. But, gee, I think it works almost in the following way, almost nobody in a first episode comes in for treatment unless it's become chronic. So we don't see the bulk of the people that get depressed. And by the way, I don't know what they're doing in ICD now, but in the States, we have an ongoing debate about what do you do with grief reaction. Somebody loses a spouse, losing a child is most depressogenic, it could happen to anybody. And we know what grief is like, Freud in his classic article back in what, ‘17 we published in ’21, to differentiate between mourning and melancholia. He said in mourning, your life is diminished and in melancholia, you see yourself as diminished. And, increasingly, we're not sure that there's a difference between the two, that a loss that you would get in mourning triggers the same underlying mechanisms. But you're still going to have to think your way through that. I remember watching a family member, lose a husband young, with a couple of young kids and watching the grief reaction set in. She had to do a lot of sorting things out. Had to decide how is she going to provide for her children, how is she going to cover their college expenses? Because they were, going to be going from early teen on. She had to navigate once again, the dating role. All kinds of things, problems she didn't have three months earlier. And she had to think about things. So if Andrews and Thompson are right, evolution built a mechanism which almost always is going to help a depression resolve, almost always going to lead you to have to think your way out of whatever the situation is that you're in, that you probably weren't in before something bad happened to you. Now, that's not to say necessarily that they're right, but there's a grief reaction neurobiologically it’s a depression, so why would you separate out. For some reason, the field has always assumed that if you know what the reason is that somebody is depressed, then it's not a depression. And that's just silly. And, what's the saying? If it looks like a duck, if it walks like a duck, if it quacks like a duck, it's a duck. So, once you start bringing that in, then any one of us could have the propensity to get depressed if something bad enough happens. Mercifully, most of us don't have that many bad things happen, but if they do we're going to have multiple episodes. Now, it could well be that people learn the wrong things in the midst of a depressive episode. And I think that's where the treatments come in. Again, I've never worked with anybody that didn't have a propensity to do what, Paul Salkovskis would say, their theory A is something wrong with me. And an alternative theory B is usually, well, maybe you're using the wrong strategies. So what we try to do in cognitive therapy is to pit one against the other. We'll start with what their theory is walking in the door, I'm unlovable. I'm inadequate, whatever that may be. Get them to do self-monitoring, where they monitor their experience over a couple of days or weeks, getting them to start paying careful attention to what's going through their head when the affect is triggered. And by the way, it’s the lovely book that you held up, thank you, in the very beginning, is Cognitive Therapy for Depression, but you treat the person, patient that walks through the door. And, when we do one of our trials with people who meet criterion for major depression, two thirds of them meet criterion for other things, anxiety disorders, stress disorders, about a third of them would meet criterion for substance use disorders, so whatever you're going to do, you have to be a generalist, you have to meet where they are. And one of the other things that comes out of evolutionary biology, they would say that Jerome Wakefield, the, social worker who has been a major critic of existing diagnostic categories, Wakefield would say for something to be a disease must meet two criteria. It has to represent a dysfunction in an evolved adaptation, something has to have broken down and it has to cause functional impairment. And an example he would give of the latter is a very small percentage of people are born with the hearts on the right side of their body. But they don't do anything to them. They go to their lives, same kind of life expectancy, et cetera. So there is a breakdown of the mechanisms wherever the in utero, the various organs are shown where to go and where to develop. For them it develops on the wrong side but doesn't affect their lives at all. So it, meets the first criteria and it's a breakdown and evolved adaptation, but it doesn't cause dysfunction. On the other hand, something like a brief reaction, may not be a breakdown and evolved adaptation be exactly what the brain evolved to do, which is to think long and hard about a problem. If you've got a problem, you have to deal with that you didn't have to deal with before. The reason I go there is the other thing that for years as a psychologist, I'd say, well my colleagues up in psychiatry want to talk about diseases and most folks get depressed, they don't have a disease. What they have is a disorder. From an evolutionary biological perspective, it's also not a disorder. It's very orderly. And anytime, there, what a evolution biologist would say is that, our adaptations evolved to generate a whole body response given the different threats that we're exposed to. If there is something dangerous rustling in the bushes, you want to experience anxiety. You want your physiology to get turned up, sympathetic nervous system to fire up so you can run away fast, and your behavioural impulse is going to be to flee. The cognitions are, I'm in danger. I'm in danger. I'm in danger. All orderly. It's not disorder. It's orderly and it's an orderly adaptation. If you are challenged, particularly interspecies challenged, the affect's probably going to be anger. They shouldn't do this, et cetera, et cetera. The physiology again is going to get elevated. You've got sympathetic arousal so you can fight, if that's your natural inclination, the behavioural impulse is going to be to attack and the cognition is going to be they have no right doing that to me. How dare they. It's orderly. In depression, the affect is sadness, physiology gets turned down, it's more parasympathetic than sympathetic. You get this whole dropping feeling in the pit of your stomach, and the behavioural impulse is to do nothing except sit and think. And the cognition is going to be, what did I do wrong? What did I do wrong? What did I do wrong? Or at least what went wrong? Again, orderly. And the thing that evolutionary biology is going on is all of our negative affects are unpleasant to experience, but they all organise a whole body response that in our evolutionary past was probably the optimal response for whatever it was, wherever the different threat was that we had to deal with at the moment. Now, individuals differ in the way they interpret different situations, which means they're going to generate different whole-body responses, often to the same situation. My wife, absolutely lovely, but East Coast ethnic and her whole family has to and does spend a lot of time worrying about things, which is good because I never do it. It balances off the relationship nicely. But if we get bad news, she'll go oh, that's awful. And I’ll go, that's inconvenient. Just different. Her autonomic nervous system gets triggered faster than mine does, which is beneficial in some respects. And, God knows, I certainly have done stupid things like said, gunfire, let's go see what it is. It just, some folks can live longer given that kind of thing. But if different individuals interpret the same situation differently, then we're going to trigger different whole-body responses. But it's our evolutionary process that gave us the different whole-body responses and virtually nobody can't feel anxiety, anger, grief, depression, et cetera, they just sometimes do it in response to different kinds of things. One of the first things I'll try to do with any client in the first session is go to that marvellous circle diagram, that Chris Padesky and Kathleen Mooney came up with. They call it the five-factor model, which has five factors. It's the original ABC model, antecedent, events, beliefs, and that the consequences of the behaviour are affected. They expanded it they put the environment out and then they have a circle which is the organism, it’s classic without really realising its the classic SOR behavioural, learning model. And you've got the environment, things happen. And then within the organism, you're going to feel, you're going to have physiological reaction, have behavioural impulses, and you're going to have cognitions. And what I would say as a cognitive theorist is the cognition drives the others at what's determined, what you're going to get and what cognition you have may be determined by your prior life experience, maybe somewhat by temperament, et cetera, but it all was laid down by evolution. They're adaptive processes that left to run their course in the millennials before we had therapists or medications, we had nothing else. And one thing we know about depression is they almost always go away, we have spontaneous remission, even if you don't get treated depression is going to resolve. I don't know what they're doing in England now but I know in the States, 90 percent of the people who are clinically depressed get medicated and they get medicated by the primary care physician, and primary care physicians are marvellous. They have to worry about 80 different things, 40 of which will kill you. Depression isn’t one of them, but if you mentioned being depressed or anxious they’ll put you on an SSRI because they're relatively safe. The problem with the antidepressant medications is they anesthetise the distress so the facilitate the function that depression or anxiety or anger revolved to facilitate. Rachel Handley: So just stepping back slightly, we started with a thinking about a maintenance model of depression. And it sounds like what you were saying is loss can happen to all of us. Sadness happens to all of us, but if someone has a particular set of beliefs, thoughts, ways of interpreting the world habitually, like that's awful rather than that's inconvenient, or that's personally this sense that there's something wrong with me, what's happened means there's something wrong with me. This will trigger this kind of evolutionary, instilled physiological whole-body response. It leads to kind of natural behavioural responses, of withdrawal and down regulating our kind of impulses for behaviour Steven Hollon: Well, it does all that until you sort it out. And once you decide what you're going to do, then it, and again, it's, it, follows a sequence, which ends up generating an action plan, which then if you carry out, it resolves the depression. Rachel Handley: So, if all works well, it resolves, and we move on. But we know that when we do see people for psychological therapy, when we are treating them that actually we tend to see them when they're stuck, when they're in that kind of disordered place that you've spoken about when its functionally not helpful for them anymore. Steven Hollon: We tend to see them when they're stuck. And the stuck is almost always is something deeply wrong with me. And, again, back to Paul Salkovskis and that brilliant observation about Theory A, Theory B, which I never had heard about until I started working with folks in IoP, they taught it to me. Theory A is almost always defective in some way, usually unlovable or incompetent, depending on what you most want in your life or both. And Theory B is almost, well, maybe you're going about it the wrong way. And to give an example. I had a client I worked for way, way back when in Minnesota. I talk about him in the, in the revision of the manual. He was a sculptor by training, he was teaching at a small community arts college. Their entire art department, I think three people, got retrenched during the first Gulf crisis. And now three years later, he's working as a handyman on a condominium complex. Hates it. Hates it. Hates it. Think what he has is a reality-based depression. How could he not be depressed? A sculptor by training, he's doing a blue collar job. He's getting paid more than he was as a low grade academic but as far as he's concerned, that's a terrible, awful thing that's happened to him. The one thing he hasn't done in three years is apply for another job in academia. And you ask him, how come? He said, well, I start to think about it and then I get overwhelmed. So, he'll start to take the steps, what he has to do if he wants that kind of job, is to apply. They're not going to come find him at his home, but he has to apply. So, what we did is laid out the notion, his notion is he's not doing that because he is inadequate, he's incompetent. And the alternative, coming off of Paul Salkovskis is just you choosing the wrong strategies, which is, when you go out in the garage and try to do everything all at once in one evening, you get overwhelmed, and you don't start. So, how about we take the large task and break down it into steps for me, which he did. He knew I didn't know. He broke it into a half dozen steps each night to go out and do one. And if you don't finish first time to come back and finish the next night. Within three weeks, he had a portfolio together. That's how sculptors get their jobs. And he was mailing it out to places. So, I mean, it's not rocket science. It's just taking a big task, break it down into smaller steps. That's the behavioural component, but in the process, we would differ from a more pure behavioural therapist is we don't only do that, we get him testing his beliefs. His belief was it's my confidence; it’s gotten in the way, the alternative hypothesis is you’re choosing the wrong strategies. Not repeating his theory A, something deeply wrong with me, is theory B which is I'm going about it all wrong so let me try something different. And it worked out better for him. Rachel Handley: So the principle underpinning the theory is that the cognitions, the thoughts, the referential beliefs are the main obstacle to him being able to effectively problem solve, break that down. Steven Hollon: That's right. Yep. The main obstacle, I think, and that's why Tim Beck called it cognitive therapy and not cognitive behaviour therapy, as far as he was concerned, that was the primary mechanism that was going on there. And I think, somebody like David Clark would talk about panic disorder, the main issue is you have these catastrophic cognitions. You interpret benign physical sensations or psychological sensations catastrophically. And that's the real issue. There are things you can do about that behaviour that help move the process along. I think Anke with stress disorders would talk about the failure to recognise that that was then, this ain't then, this is different-and getting past that focus that, that belief right at the moment is the kind of thing. So always we would see the cognition at the core but often use behavioural strategies to go after the accuracy of those beliefs. David and Anke don't bother with thought records at all. And they get people moving very rapidly into behavioural experiments, going into stores on the, on you guys have what high streets or something where you have shopping districts, with a rouge on their face or obvious stains in their underarms, that kind of thing. Or I'll go have people going back to the park where the rape occurred that to regain their lives. We'll make a lot more use of thought records with somebody who's clinically depressed because so much, well, I think so much of what revolves in the depression is the self-referential, the blaming of the self. And for that, you want to get people out testing things, testing their beliefs, et cetera, in real world experiences. But a lot of that stuff, you got to go back and trace down what it meant to them that it did work. Rachel Handley: So you have to take some time identifying, seeing the patterns, the habits, the… Steven Hollon: I could be wrong. Somebody's come, come along from Oxford that's going to blow that out of the water and show you, you can do all this stuff, wrap it up in two, in 20 minutes. But, so far I've done this for 50 years, I'm probably not going to be the one to do that. Rachel Handley: But it sounds like an important part about the point about the terminology. So it's not that cognitive therapy isn't incorporating behavioural techniques at all. It's just that where behavioural techniques are incorporated as they frequently are, it's in service of changing the cognitions Steven Hollon: Yeah to test the accuracy of the cognition. And this goes way back to Tim Beck, and he picked up on this back in the early sixties. Even if the primary problem is, what you believe the best way to test it out in the real world is to put it against an alternative and let the data decide. Rachel Handley: So this seems like a good point to take a break to allow you to ruminate, hopefully in a healthy way, on part one. Those of you with extra stamina may wish to dive straight into part two where we get to work discussing the application of cognitive therapy of depression to the problems people present with, both more straightforward and much more complex. And Steve even has a go at planning a brief hypothetical invention for the president of the United States. Thanks so much for listening, and as always, till next time, look after yourselves 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 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, Rachel Handley talks to two expert guests – Professor Kim Wright from the University of Exeter and Associate Professor Tom Richardson from the University of Southampton – about bipolar disorder and the role of CBT in supporting people with this diagnosis. Tom and Kim share their extensive clinical and research experience, alongside insights from Tom’s own lived experience of bipolar disorder. They discuss common myths, the importance of timely and accurate diagnosis, and how CBT can support people with bipolar in a meaningful and collaborative way. They explore what CBT for bipolar looks like in practice, including work on relapse prevention, mood stabilisation, routine regulation and addressing beliefs about mania. The conversation also covers important systemic issues such as gaps in service provision, barriers to access and the need for more widespread training and implementation. This episode is released to mark World Bipolar Day and aims to raise awareness and improve understanding of this often misunderstood condition. Resources & Further Learning: ·        Richardson, T. (Eds). Psychological Therapies for Bipolar Disorder: Evidence-Based and Emerging Techniques. Spinger-Nature, 2024. ·        Bipolar UK Commission ·        Find out more about Kim Wright’s research and publications ·        Find out more about Tom Richardson’s research and publications Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [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 delighted to be joined by not one, but two expert guests, my wonderful friend Kim Wright, Professor of Clinical Psychology at the University of Exeter, and the equally wonderful Tom Richardson, Associate Professor of Clinical Psychology and CBT at the University of Southampton. Both of our illustrious guests specialise in researching, treating, teaching, and training others in psychosocial interventions for bipolar disorder. Welcome guys. Tom: Thanks for having us. Rachel: I know you've both been working in this field of bipolar for many years. Kim, when I first met you, you were doing a PhD in bipolar, even before embarking on your doctorate in clinical psychology. And Tom, I know you have personal as well as professional reasons to be so committed, and passionate about the area. Can you tell us a little bit about your pathways into this work? Kim: Yeah. Hello Rachel. It's really good to be here. So, I, started out quite a long time ago, when it was possible to finish your psychology degree and go straight into a research associate job and I was very fortunate to be able to do that and work with Dominic Lamb on his trial of CBT for people with bipolar, for relapse prevention. And that is at the, or was at, Kings College London and it was one of the early CBT trials in the area and it was really exciting to be involved in it and as part of that, again, this is a bygone era, it was possible to do a part-time PhD that was heavily subsidised for members of staff of the institution. So I did my PhD part-time with Dominic alongside my role, and that gave me the opportunity to meet hundreds of people with bipolar disorder and hear about their experiences. And then, after I finished, I did clinical psychology training and then worked in a community mental health team for a bit. And then I had a really wonderful opportunity to join the clinical research group at the University of Exter where I am now. And back then it was led by Willem Kuyken and Ed Watkins, who work in the area of depression. And they liked the idea of broadening out the team to include a focus on bipolar. So that was a great opportunity for me to return back to research in the area of bipolar and also to work in the research clinic that we set up in the university not long after. Rachel: What a brilliant opportunity to work with such amazing people, but also to be in there from the ground up, working on that first CBT trial in the area. Really exciting. How about you, Tom? Tom: Yeah. Well, as you said, my research interests really has come a lot from my own experiences because I have Bipolar disorder type I. I haven't always been completely open about that. It's taken a few years of qualified life for me to feel comfortable with that, but yeah, I ended up having a manic episode just after my A levels, just before I started my degree, my undergraduate degree. I ended up in a hospital with a manic episode, so that got me interested in it. And then, when I was doing my undergraduate degree, actually I started doing a little bit, I started doing some stuff for kind of student journals and my thesis was actually about hypomania and how it relates to impulsivity and risk taking in the general population. So I actually became hypomanic about my dissertation, about hypomania. So, and then I was working as a research assistant on sort of computer-based CBT at the University of Bath with children. But I did a little bit of stuff, a few bits of research and kind of papers around bipolar disorder, around like letters to the editor and reviews and that kind of thing. And then when I started my doctorate here in 2010, and that's when I started to get my kind of first real clinical experience, my first placement, I worked with a couple of people with bipolar disorder. And then, I was working in the NHS in Portsmouth community mental health teams for eight years. And that was a whole range of problems, but I did a lot of bipolar work there. I set up and ran a bipolar group, which was, which I really love doing. So it's gone from there. And then I joined the university in 2021, and this is a big part of my research here is about psychological therapies for bipolar. So influenced by my own experiences a lot of the time, as well as my service users. Rachel: And I know that's naturally and rightly a very personal choice to share that information about your own mental health, but incredibly helpful, I think, for other mental health professionals as well as I'm sure your research to de-stigmatise that area and to be able to think about it from the inside out. Tom: Thank you. Rachel: We've recorded a number of podcasts recently on unipolar depression, and in fact, we've got a whole series of podcasts on depression coming out. This will probably be the first one because we've got World Bipolar Day coming up, but those conversations really underlined to me how common unipolar depression is. And our listeners will be not only aware of that, the massive numbers of people suffering from depression, but also probably seeing them in their practice’s day in, day out. But bipolar is perhaps a little less well recognised and understood. So, can we start with some of the basics? How might we recognise bipolar disorder or bipolar spectrum disorders outside of sort of dramatic portrayals, like the likes of Claire Danes on Homeland? Kim: Yeah, so you're absolutely right. Bipolar is quite a lot less common than unipolar depression. I would say if you're seeing someone with recurrent depression and they report periods of consistently elated or irritable mood that go on for, say around four days or so, as well as some heightened energy and activation that's pretty persistent over that period, you could ask them a bit more about that time. A key thing is often sleep, people often talk about dramatically reduced need for sleep, but still feeling rested. They might also talk about that their mind's racing, that they're talking a lot more than normal and importantly, if they're around other people, noticing that they're different at those times and there isn't another obvious explanation like stimulating drugs or an overactive thyroid, for example. And I think it can be a tricky one because I think a lot of clinicians are quite reluctant to pursue diagnosis for the, supposedly the milder, subtypes of bipolar. But there is this concern in the prescribing community about the potential for SSRI drugs, antidepressants, to increase vulnerability to mania. So it can be important for people to know if they do have that tendency to periods of hypomania, in terms of treatment choice, in medication. Rachel: Why? Why do you think clinicians are reluctant to pursue those diagnosis? What do you think is driving that? Kim: I think it's partly to do with maybe concerns about people getting a stigmatising diagnosis, concerns about people being, particularly young people, being prescribed what are often seen as quite heavy medications with a considerable side effect profile. And also, the difficulty that there can be if people have quite a rapid cycling, mild or subtype of bipolar with distinguishing that from other potential explanations. So that can make people, some clinicians, maybe more reluctant to diagnose. Tom: I think it's also worth saying that it also just gets missed a lot of the time. I was part of the Bipolar UK Commission, so we wrote some reports as part of that and that one of the key, really shocking findings was it was nine and a half years average to diagnosis. And nine and a half years after you'd been in touch with a mental health professional. Most people are originally diagnosed with unipolar depression, they're diagnosed with a depressive episode, but the hypomanic/manic side often gets missed because you're not likely to go and get help for that unless it's really severe. And then you might end up in hospital or contact with criminal justice or something horrible like that. But actually, a lot of the time people won't go and get help. So it does get missed for a long time because these episodes of hypomania/mania, they go on for a long time, they go on for weeks. That's an important distinction, we're not talking about daily ups and downs here. These go on for a long time, but they still don't go on as long as depression, people are depressed for months, people are hypomanic for a few weeks. So it's very easy to get missed even if you're under a mental health team. Rachel: And Tom, Kim mentioned stigma and that being a barrier sometimes from a professional's point of view to diagnosing these problems. Do people suffering from these issues want diagnosis? What do you think about the whole issue of stigma for people who are presenting in services? Tom: And I know there, there might be some therapists and clinical psychologists who, maybe don't agree perhaps with the term, but actually the research we did with Bipolar UK I think it was 85%, 87% that they found the diagnosis helpful. So we need to listen to that and we need to respect that. Yes, some people did say it increased feelings of stigma, but that was a real minority. And actually, other people were saying positive things like it got me the help I needed, it got me the medication, and it gave me an understanding from my experiences. Maybe there's a small risk of stigma, but I think it's improving. I think the awareness about bipolar disorder in the general public is better than it was a few years ago. And actually what the Bipolar UK Commission found people saying it, it helped make sense of my experiences, I think that's counteracting shame and internal stigma about this because the consequences of bipolar, how people act when they're manic in particular, spending money and changes in sexual behaviour, there's a lot of shame and stigma that can come with that internally, people being very hard on themself and that fuelling depression. So actually people having an understanding and knowing that, and if they're not alone with this and this is part of a condition, can be really helpful. Rachel: I think at risk of finding very circular, diagnoses in general are helpful if they're helpful. So if they help people understand and also help them access appropriate help and treatment for the issues they're facing, which we will come on to, won't we? Is there anything that’s helpful for people to know about distinctions between subtypes of bipolar disorder or a spectrum of bipolar disorders? Tom: Yeah, so there's the two main types are Bipolar I and Bipolar II disorder. Now this wasn't always made as a distinction and a lot of people who are listening to this with bipolar might not be aware if they are Bipolar I or Bipolar II, a letter from a doctor might just say Bipolar Affective Disorder. They might not be clear. The main difference is mania versus hypomania. So Bipolar I, which is probably a little bit less common than Bipolar II. It's the more severe mania, full mania where these changes in energy and impulsivity really do get quite extreme and it causes all sorts of problems, people might end up in hospital. So Bipolar I is the more severe mania. Usually with depression, not always, there are some people who just get manic, but most of the time it's depression as well. Bipolar II tends to be sort of more severe depression and then hypomania, which is less severe than full mania, won't cause as many problems, you're not likely to go into hospital with hypomania, but it still causes problems. I think that's important to say, I think hypomania can be dismissed as, oh, it doesn't cause any problems, but it does, and you don't meet the criteria for a hypomanic episode. So that's the main distinction, is mania versus hypomania. Sometimes people may get a diagnosis of cyclothymia, which is where people have these sort of milder hypomanic episodes and depression episodes that don't quite tick those boxes. So I'd consider them people who are high risk for bipolar disorder. Rachel: Okay. That's really helpful. I wonder if there are any other, or any myths about bipolar and how it presents or is often understood that you'd like to bust that might be barriers to clinicians understanding or engaging well with people in this area. Kim: I think a big one for me is the portrayal of the high periods as being times of extreme happiness or extreme positive feelings. Whilst they can be for many people, one of the kind of key symptoms of mania can be irritability rather than a kind of happy, high mood. And that can mean that it can be missed because it's the person isn't saying, wow, I feel really joyful and elated. It's more like this huge level of frustration often that things aren't happening quick enough, that people are getting in the way, the world isn't letting things evolve and goals to be met as quickly as the person might like. And also, even if people do start out feeling quite high and elated for some people, that it can become quite unpleasant. People talk about feeling I'm overactivated. I'm not even sure I really want to be, but there's nothing I can do to put the brakes on. Yeah, so that's one myth I would want to bust. Another one would be that some, and this is really important, that there can be a portrayal in the media that someone with bipolar is always up or down, when in fact lots of people with bipolar have very long periods of being feeling pretty stable, being well, and only occasional episodes. Rachel: Yeah. I'm reminded of a recurrent dream. You know, we all have these recurrent anxiety dreams from time to time. One of mine is being in a car and not being able to put the brakes on. When you were talking about that feeling of just speeding up and not being able to stop, that's what that reminded me of and that horrible feeling of being out of control. Kim: Yeah. Tom: I agree with Kim. It's not all pleasant when people are manic people, it can feel very unpleasant, it can feel very distressing, out of control. I think a big one for me is, as I suggested a little bit earlier, a big misunderstanding is that this is daily ups and downs, which might be seen more with something more emotional sort of dysregulation. And when people are manic, they can have this dysregulation where the moods are quite up and down. But these episodes we're talking about are like weeks at a time. We're not talking about it changes one day to the next. We're talking about your hypomanic for a few weeks, and like Kim said, then you can be stable for a long time and then you might have an episode of depression that goes on for kind of a couple of months. So that's a really important distinction. Rachel: Brilliant. Thank you so much for, enlightening us in those areas. What's the place then for psychological treatment with bipolar disorder? I guess we hear a lot about the biological vulnerabilities to bipolar disorder, or there's a sense that this is something that's genetic or biologically driven and I'm sure we'll talk more about that. Is it a presentation that really requires primarily or exclusively a pharmacological intervention, or does that differ depending on what stage you're at in terms or phase you're at in terms of the symptoms or you're experiencing. Kim: So you're right, pharmacological treatment has historically been the main treatment offered to people with bipolar and in the NICE guidelines there are certainly plenty of recommendations about pharmacological treatment and there are differences depending on the phase of bipolar, but psychological therapies are also recommended and those include CBT. And they're recommended really for two main aspects; so one is for relapse prevention and the other is for acute bipolar depression, at least within the NICE guidelines. I think it's really important to say that unlike maybe with some other conditions, we don't have much in the way of trials of psychological therapy without medication compared to medication. Instead, it's usually psychological therapy in addition to medication or usual care compared to usual care. So the evidence base for psychological therapy as an alternative to medication is not well developed. However, what I would say is, I would hate to see a situation where somebody who can't take medication for bipolar, or chooses not to, is denied psychological therapy because there are just really good reasons to expect it will be potentially really helpful for people. So I would want to see that being an offer to people, who can't or don't want to take medication. Tom: I think a lot of people might underestimate just how effective psychological therapies can be for bipolar. The biggest meta-analysis that's been done, it showed that CBT, group-based psychoeducation, which is often very sort of CBT informed and family interventions, family therapy, nearly halve the risk of relapse, Rachel: Wow. Tom: Which is really impressive. My take on the kind of literature so far is that if you add in medications like lithium, it halves your risk of relapse and then you add therapy on top, it halves the risk again. Which is pretty huge really. It really is. And I think that there, there's sometimes an issue about, maybe there's a little bit of, it's not as clear how much it reduces acute manic symptoms, but I think the evidence suggests maybe it does. And the same with acute depression symptoms. I mean, it is hard to do therapy with someone if they are really acutely manic and really acutely unwell. But actually, the evidence does say, well, it still might reduce kind of manic symptoms. So yeah, there's sometimes an issue about when you do it and what the motivation is cause it's really good for relapse prevention work. Sometimes I personally think that actually working with someone when they're quite stable is a good time to work with them. But there's, you've got to be careful of motivation because if someone's completely stable in mood, why would they want to engage in therapy? Trying to work with someone on a relapse prevention focus can be really useful time. And often people come to therapy after an acute manic episode, for example, and they're trying to pick up the pieces, they've been in hospital for a couple of weeks and they're trying to make sense of what happened and recover and move forward to their life, and that can be a really important time for therapy as well. Rachel: So it sounds like there's really good evidence about this additive effect, about this relapse prevention, perhaps better times when you can do this, where maybe some of the good times to do it where people are less motivated, but perhaps could be really helpful. Do you think there's ever a time ahead where we might have a trial where it's psychological therapy versus medication? Or is that, would that be unethical given the… Tom: I mean, we were talking about this Kim, weren't we? And we were talking about whether you could look back at the trials that had been done because maybe some people weren't on medication. I mean, I think it's been done with psychosis, hasn't it? I think Anthony Morrison did a trial for people who declined to take medication. I think, that would be an ethical way to do it, is you, the people who do decide that they don't want kind of medication, But I, yeah, I suspect it'd be quite hard to find people who weren't taking medication cause that usually is the treatment, the first treatment, and that's not what NICE guidelines say. NICE guidelines say that medication should be given an important weight as well. But yeah. Rachel: Interesting, and perhaps maybe there is that group that you said, Kim, who people who don't want to take medication, that might be where some of this evidence comes from. Kim: And certainly people do ask me that sometimes, is there, are there studies of psychological therapies for people who choose not to or can't tolerate medication? So I think that there is demand out there to know the answer to that question. Rachel: And it's clear that psychological therapy, therefore, is very helpful, can be very helpful. How easy is it for people to get access to the evidence-based treatments that there are currently, and are there any particular barriers that people face? Tom: So NICE guidelines are pretty clear that it should be offered in secondary and primary care but unfortunately the access isn't as good as it should be. So Bipolar UK Commission, again, we found, so 69% have been referred for therapy on the NHS and that might sound okay, but I suspect a hundred percent of them would've been offered medication on the NHS. Only one in five had been offered a group-based psychoeducation intervention, which are very evidence-based and very kind of cost-effective to run and very helpful for the individuals. What's more shocking is that 29% had never been offered therapy on the NHS, and about a quarter had been told they'd have to pay for it privately. Rachel: Wow. Tom: About a quarter had been specifically been told you can't get therapy on the NHS and up to half of people have had to pay for their own therapy at some point. So it, it definitely could be better. Now, I think with the positive side is that health education in England has put a lot of money into training for bipolar, and that's part of my role here is working on the CBT diploma. The Department of Health has been pushing training for CBT for personality presentation, CBT for psychosis, CBT, for bipolar. So, we are getting more and more people trained in this, which is great, so I do hope it will improve, but it is hard and myself and Kim have been looking at for NHS Talking Therapies, formally IAPT, we've just had a paper accepted about what the rules, what the guidelines are, what the kind of policies are about working with people with bipolar within these services because traditionally, officially you don't work with bipolar per se, but you can work with anxiety disorders, for example, or PTSD trauma work within these services. And one paper we did, we found that 33. 0% of people attending one IAPT service potentially had bipolar disorder that was undiagnosed. So there's a huge kind of iceberg of people who aren't diagnosed. So there isn't as good access as there should be. I mean, there is a lot of really great work going on there, there are more people being trained in CBT, which is great, but access to it is difficult. And I think it does vary. That's another thing unfortunately, that we showed with the Bipolar Commission is that there are, it's a bit of a postcode lottery. There are some services, there are a few specialist bipolar services, but then there are other services where you get you are in a mental health team with a lot of other people, and I think the reason people with bipolar can get missed and not get off with therapy is that because they can stay stable for a long period of time. That's one of the key findings we found in the Bipolar Commission is episodic care, which is, as well as just not being the clinically right thing to do. It's also a false economy where don't give people a lot of input and then they relapse and they're in hospital for two weeks and then it's, well, you're okay now, so we'll discharge you. Rachel: And from various insights into Talking Therapy services, I imagine that those sort of time pressures can operate in different ways on the problems that you've raised. So even a good thorough diagnostic assessment and with a good history taking, sometimes it doesn't feel like there's time for that when you've only got so many sessions and asking these questions. But then there's also the rush to get people out the other end, isn't there? Kim: And I think there's three pieces to think about in terms of this, the access question. One is, do we have the evidence-based protocols? Which for bipolar we do. Do we have the workforce? And as Tom said, there've been quite a lot of stride in that direction. But the third piece is the one we've been alluding to and just mentioned around NHS Talking Therapies is, do we have the place, the services in which these therapies would be delivered And at the moment, NHS Talking Therapies aren't really set up to deliver therapies for people with bipolar, and secondary care would be the place. But the barrier to getting or the threshold to entering secondary care where you can access these therapies is very high in a lot of areas. And so we're left with a gap and an absence of psychological therapies really often in that gap. And so I think that third piece for me is the piece that really needs attention. It's all very well to have the protocols and the workforce, but you need a place where the patients can come into contact with those two things easily. Rachel: Do you have a sense of, and this is a big question to ask you, Kim, but do you or Tom, do you have a sense of where that place might be or what might work better? Kim: I mean, I think there are different ways to address this. There are different models that could be used, but I suppose there's something about seeing psychological therapies as an important treatment that shouldn't be behind too many barriers. I think that's one of the things NHS Talking Therapies have done really well. They've put psychological therapies at the front and they're relatively easy for people to access, even if there can be a wait and we don't really have that situation for people with bipolar, although different parts of the country are trying different models of addressing this. For example, having teams that sit in between primary and secondary care or more reach down from secondary care or more reach up from primary care. Tom: I think there's often a little bit of a change in mindset that is needed within services. Because, I mean, firstly, I think I'll just say that CBT for bipolar disorder is easily 10 to 15 years behind where CBT for psychosis is. And I think as a result, I've had people kind of saying, oh, I'm used to referring for CBT for psychosis, but I haven't really thought about it for bipolar disorder, which is slightly infuriating, but I do think it, people aren't aware of the psychological mechanisms, a lot of mental health professionals don't know about CBT, and so people aren't referred. And so it it's that combined with people are relatively stable for a long period of time, so maybe they're not ringing up and asking for lots of help so they can just get left to their own devices. So there is something about a change in mindset needed that, a lot of men's health professionals and service users really just think like, all I can do is take medication. And we really need to think about, well, there's more than that. Medication's really important, but there's a lot more to living well with bipolar than that. And yeah, these two kind of misconceptions that me and Kim have been talking about, which seem to be polar opposite, but people seem to buy into them. On the one hand, as I kind of said before, you are stable, you don't need therapy. But then also people can have this mindset that, well, someone's unwell now so they can't engage in therapy. You have it both ways where I've heard it. Yeah, you can't, you are too stable or you're too unwell, I've heard both. I have Rachel: And when you say 10 to 15 years behind CBT for psychosis, Tom, is that in terms of evidence-based research or is that in terms of knowledge gaps and implementation? Tom: Everything. I think, to be honest, I think, I mean certainly for the kind of the evidence base, like if you think about how many different models we have for psychosis and really big trials, we're just not, we're just not there with bipolar disorder. There's not as many trials, there's not as many people researching it as there are in psychological therapies for psychosis. In terms of actual kind of implementation in the real world, again, I think it's just CBT for psychosis is very well established, we have EIP services in the UK, early intervention in psychosis. So, it's just much more embedded into the culture of psychosis work that CBT is referred for. And I just don't see that being as embedded for bipolar-yet. We're working on it. This is part of it, right? Rachel: Well, and it makes your work all the more important. So Tom, you said a little bit about your experience, your journey into bipolar. I wonder, if there is a typical, how does bipolar disorder develop for people and typically who suffers from bipolar disorder? Tom: Yeah. So bipolar affects everyone. I mean, there are some research about differences in terms of different countries and that maybe more kind of western societies like here and the USA might have a slightly higher prevalence than some other countries, but it does affect everyone. Prevalence, gender differences, there's not that much way in the gender differences or ethnicity, but we know that, for example, and this makes my blood boil, analysis of South London, showed that black service users were less likely to be offered CBT. We know it seems to be a little bit more prevalent in younger people, and it does tend to peak in kind of late adolescents, early, early twenties. How it develops, so in terms of risk factors, and again, there is a role of genetics, I think, and there's various research about how it might run in families to an extent. There's not like a bipolar gene, but there might be this risk and there might be something to do with the brain and the limbic system, how it processes emotions. But there's other risk factors as well, substance use is, there's one paper recently that found very heavy cannabis use in adolescence increases risk. But there's a lot of big role of trauma. We know that parental loss is quite common, parental loss in childhood, bullying and all sorts of childhood abuse. But emotional abuse in particular, emotional abuse is four times more likely in people with bipolar disorder. So I think it's a combination of risk factors. They're never just one thing. There's often a combination of kind of, yeah, I always think of it like the nature and the nurture, stress, vulnerability, people might be vulnerable because of family history, a difficult childhood, et cetera. And then stresses, so life events are often a real trigger. There's evidence that stressful life events, negative life events can lead to depression. But also, a uniquely rubbish thing about being bipolar is positive, good life events can also make you manic, good things happening, getting a promotion, et cetera. Rachel: That is highly disheartening, I would imagine, to realise that positive things can affect you negatively. Tom: Yeah, it is. I mean, for me personally, there have been times where I'm going, oh, I wish I didn't keep getting good news about papers published and stuff because it fuels the mania. Yeah. Rachel: You need to underachieve. Tom: Wow. Well that relates to another thing about high standards and perfectionism, which is some of the stuff I've been researching about bipolar, because when you say you need to underachieve, there's part of me, core beliefs that goes, oh, I don't like that. Rachel: Yeah. I know- and you won't be the only academic who feels that way. I am sure. I know that you've mentioned, previously Kim, other sort of biological systems that might be coming into play. I'm really interested in what Tom was saying about the limbic system. Is there more to say about those pieces interacting in the onset and development of Bipolar I. Kim: Yeah, so I think a couple of these sort of biobehavioural models that have been looked at in the literature over the last few decades, have been particularly helpful for me to have in mind as a CBT therapist. So one of those is about circadian rhythm dysregulation, and this idea that in people who have a tendency towards bipolar episodes, the circadian system is somehow oversensitive or prone to dysregulation, which means that the system that's regulating the secretion of various hormones on a 24 hour cycle, might get thrown out. And when it gets thrown out, it can lead to an escalation into an episode. And the sort of things that might throw that out would be big changes to your routine, like taking a long-haul flight, for example. And there's quite a lot of circumstantial evidence that this circadian system is implicated in bipolar risk, at least for some people. And it chimes really well with research around sleep disruption as being a kind of a risk factor for relapse into a manic episode in particular. And also what lots of people say, I mean, when I talk to people about early warning signs of mania, sleep is there so often, sleep disruption and disturbance, not just as a sign but also as a kind of cause. So people will say, this happened, it disrupted my sleep and then that was it. So, the circadian system then that's, it's so useful to know about as a therapist, because you can think about then, what people can do to keep a stable, rhythm routine going. And that's a component of a number of the psychosocial therapies for bipolar work on routine stabilisation. And then the other big biobehavioural theory that's around in the literature is around dysregulation of the system that organises our pursuit of rewards. So the approach system and the idea that this system might be, almost have a bit of a sticky switch in bipolar. So in all of us, when we see something or we know about something we need to work towards, strive towards in the environment, our approach motivation would go up and then it would return back to where it was once we've finished that piece of goal striving. Theres an idea with bipolar, that maybe firstly the system's more sensitive. So it might go up easier and higher and then it might get a bit stuck, people might find they've achieved the goal but they still feel that heightened approach motivation, which then forms a bit of a platform for further goal striving because people might feel they want to do something with that energy and that motivation. And that's really helpful to be aware of as a therapist. I never think this is definitely going to apply to everyone, but it's something, it gives you some pointers of what to look out for. And some people I've worked with have just found it really helpful to think about it. Oh, it's not necessarily everything positive that might trigger off some of these feelings, it's particularly when I'm striving towards something, and I feel that energy and that kick. And then they might think about, well, I still want to do that in my life. How can I do that in a way that isn't going to end up in a hypomanic place. Rachel: It really makes me think about what you were saying, Tom, about this sort of interaction between these vulnerabilities and environment. And I'm thinking about you in a higher ed education institute where, it's institutionalised the sticky switch towards drive, isn't it? The more papers you publish, the more papers you need to publish, it must be hard for folk, as you describe, maybe with perfectionistic standards, maybe with kind of this reward striving and these underlying vulnerabilities, and then in an environment which really rewards that further. Tom: Yeah. And I, I think some research I'm doing here, we're trying to, I'm trying to look at how high standards and perfectionism kind of interacts with these positive life events. because it makes sense to me that if you have very high standards and drive when something, as always described to my client when something bad happens, it's, oh, I'm going to criticise myself and go into a depression cycle when I don't meet my own high standards. But when you do meet them, you don't put your feet up and rest. You go, right, I'm on a roll. What's next? So yeah, that is, I mean, I love academia. I'm definitely in the right place with my fellow psychology nerds. But it is hard at times because a lot of bipolar folk, and I'm one of them, can really hang a lot of self-esteem to goals, very goal focused. And when people are manic, it becomes really goal focused behaviour and wanting to achieve. So people with bipolar have very high sort of dysfunctional attitudes, beliefs about achievement, needing to be outstanding, perfectionist, et cetera. So a really important part for me, therapy over the years has been to try and, well, for me, like a lot of it is focusing on values and what matters to me and why I do this rather than just these kind of goals because it is you can't win in academia, can you? Because there's always another paper to write. There's always someone who's got a bigger H index than you. And so part of me is trying to just a little healthy dose of who cares. But also, just the work-life balance is really important for everyone and certainly that's the case with me. And living well with this is just really being able to just go, I've done a good enough job, I've done enough for today, I'm going to go home. That's really important because that, that drive to wanting to do more is very powerful in bipolar. Yeah, trying to be a little bit more sensible and boring is a good thing. Rachel: Well, well certainly in researching this podcast, I can see there's nothing boring or minimal about your research output and publications. Tom: I mean, boring in a, I mean this in a, I use the term strategic boredom with my patients. I mean, hopefully my work isn't boring- I find it exciting. But I mean, sometimes there's that urge to, to work more, to do a big idea, to go out and socialise that drives mania. And actually, strategic boredom is, I need to go home and just binge watch some Netflix. It really is, can be as simple as that. So that work-life balance is really key, but it's very hard, a lot of the time for people with bipolar because there's this real pull to achieve, I need to do more. What's next? Rachel: Okay. So to tap into your, both of your high achieving schema here, we've got challenge. You may or may not be aware of our Practice Matters podcast challenge, but as you'll know, we all love a good formulation of CBT and usually it has boxes and arrows, but this is an audio podcast. So here's the challenge. Can you give us a brief explanation about high bipolar disorder develops and is maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids? You can go individually, or you can help each other out, or you can fight it out up to you. Kim: So I'd say, you could take a diathesis-stress model, where people may have a preexisting vulnerability, and that can be in the form of a tendency to the high and low mood states, potentially with a genetic component, family history that's more or less maybe important for different people as well as that alongside them might, there may be, as Tom's alluded to, particular beliefs that interact with that tendency or ramp it up, whether those are about achievement or are about mood itself and the implications of the mood itself and what you have to do with it to, to manage it or get the most out of it. And then when the early signs of a mood swing emerged, either because of a trigger or just out of the blue, how we meet that swing can affect how it develops. People might have thoughts like, this is my chance to show everyone what I can do when they experience some increase in activation and mood. And then that can lead to goals striving behaviours that can drive mood up further, potentially via sleep restriction or just more excitement or use of stimulating substances. And then on the other side, daily signs of depression might be interpreted as, oh, I'm getting low, I can't inflict myself on the world. I have to retreat, withdraw. And then as we know, in terms of the behavioural theory of depression, that can make the depression worse, and then either the high or the low episode as we've already talked about can create further problems for the person, further stress, which then can feed into future triggers, but also can reinforce some of the beliefs people might have. Like mood is dangerous and uncontrollable. Or if I don't try a hundred percent on everything, then hings are going to catastrophically fail. So there can be that sort of cycle in that respect. Tom: Just to add to what Kim was saying there about how it can escalate from a trauma informed perspective, thinking about how trauma and these high standards interact. Let's imagine a diagram, longitudinal formulation, if your listeners can sketch it out in their heads. Early experiences, was a very high achiever at school, competitive athlete, and was very criticised when I didn't get top marks by my parents, I was someone who came from a background where there was a lot of pressure, they then developed beliefs that I need to be outstanding, I need to work really hard, I need to impress others. And then when they're starting to become manic, they're feeling very overwhelmed at work, they're feeling that they can't cope. They start to get these ideas and confidence, and then the way they make sense of it, the appraisals is, I can finally reach my potential. I can work really hard. I can get promoted. People will respect me. I can use this energy; I can use this confidence and mania. And then they go with it and they do all the things Kim was talking about that bring your kind of mood up, working more, sleeping less, taking drugs, et cetera, that maybe brings mood up more. So yeah, how people think about these when they're starting to become unwell really is important in whether it becomes a full-on relapse. Rachel: So there's these background vulnerability factors, which include all the biological, and pieces that we've spoken about already. But there's also these beliefs which may have been formed and influenced by this early experience of having achievement rewarded and beliefs that have been developed around that about the need to strive and achieve. Mood changes or starts to change, there's interpretations of that which then lead to these behaviours depending on which, direction your mood might be changing in, maybe withdrawal, maybe striving further. And that leads into, again, of other stressors, other challenges and can strengthen some of these earlier beliefs we have about mood, which kind of see us cycling around the bipolar cycle. Tom: And if people feel like they were very creative in a past manic episode, and we have to respect that actually, people think that they're very, you know, I'm really creative, et cetera and I get great ideas when I'm manic. There might be a bit of truth to that. There might be a bit of truth, certainly in early stage in hypomania, so we do need to listen to that. But the problem is, it can spiral out of control and what starts is maybe a sensible idea becomes very grandiose, very overly confident. Rachel: I think you passed the challenge. I'm not sure whether you cheated slightly Tom in asking people to imagine arrows. I think I think we may have strayed from the rules, but I'll give it to you because it was such a clear explanation. So given this understanding of the maintenance of bipolar disorder, what are the key elements of standard CBT interventions for bipolar? And I know there are many, and we'll talk about sort of the family of interventions as we, we move on, but what are the key elements that we might see in CBT for bipolar disorder and how they link to this development and maintenance of the problem? Kim: I suppose if you're thinking about relapse prevention work, then you're probably thinking about psychoeducation, about bipolar sort of looking at people's information needs in relation to bipolar, and around medication treatment. How the person, what their relationship is with medication, are they able to get the information, advice and support they need around that and with their prescriber? And then you're thinking about somebody's pattern of activities and their routine because you're thinking about this stabilisation idea with rhythms and routines and exploring that together. And if you are a kind of traditionally trained CBT therapist, then you've already got the skills for that in terms of activity monitoring and scheduling. So there'd be an element of that. You often would do a life chart with people to look at the patterns of relapse and what likely triggers might be, and also protective factors. And then there'd be a piece around looking at early warning signs of those episodes and how you might cope with those, what's worked, what hasn't worked, what you'd put in place and making a relapse prevention plan and thinking about how you would store it, revisit it, who you would share it with. And then I guess another particularly cognitive piece in it might be around, not only the cognitions that come up when somebody's starting to get unwell and how you might work with those, but also there could be longstanding kind of cognitive patterns that increase vulnerability, as Tom's alluded to, if people have certain beliefs about, ongoing beliefs about, achievement, for example, or about what mood means and how dangerous it is. If those beliefs are there on an ongoing basis that might make people maybe more vulnerable to relapse. You'd look at factors in the person's life that could, that they could work on that would make them less likely to get unwell. That's in the kind of classic relapse prevention package, and I suppose for acute depression, you'd be very much doing in traditional CBT what's done for unipolar depression. So Beckian CBT for unipolar depression, but with some extra components, thinking about psychoeducation, about bipolar relationship to medication, bearing in mind this circadian rhythm potential idea. And then at the end of the, at the end of the course of therapy, thinking about doing some work around manic relapse as well as depressive relapse. Tom: And for the manic side there really is some quite simple behavioural stuff that can be done. So your listeners will probably know, as Kim said, about behavioural activation for depression increasing activity, but really some fairly simple stuff around decreasing stimulation and activity if people are starting to become manic is really important. This is what I was saying about the term strategic boredom, we're actually trying to just watch a work life balance, reduce excessive socialising and all of that, and working on that sleep pattern. Some quite simple stuff can really have a really big impact. Rachel: So it sounds on the surface of it, as you describe it, it's almost a bit like the kind of the standard protocols for depression. You might start working very much in the here and now, and then working backwards while solving those problems. Working backwards maybe to doing some more work on the longitudinal part of your formulation around these vulnerabilities and then thinking about relapse planning. But I guess from what you've already said that people present at very different times and stages, for therapy in this area. Is there a typical good course of therapy and if so, what does that look like? Kim: So I'm a big fan of thinking about starting where the person's at. I think if you have somebody who's well and seeking advice and support around relapse prevention, if you start off with a depression protocol, it's probably not going to feel particularly relevant. So you're thinking, what does a person need and then sequencing the bits depending on what's most important. So if I'm working with someone who relapses very frequently, even if they're well when we start, we probably need to front load thinking about responding to a relapse, because it may well happen in the next couple of months. Whereas if you're working with someone who very rarely relapses, we can probably do that later on if the person wants to focus on that. So there's that sort of element of planning and moving things around to suit the individual. Rachel: And Tom, I’m aware you were talking earlier about how sometimes the time to have therapy is when things are stable. That said, as a therapist I often find it's almost harder to work with people when they're well, because you don't have a kind of active symptom to get your teeth into for, that's a terrible expression I've just used, but I think you probably know what I mean, really seeing things in the here and now that you can be intervening with. Does that complicate delivering therapy? Tom: Yeah, I think that can be the case sometimes. There's a certain amount of distress you need to have the motivation to engage in therapy because therapy's hard work. I think it doesn't come up too much because a lot of the time people will be stable, but they might be recovering from an episode, they're worried about a future episode. And some of the works Kim's done is even when people are stable in moods, they might have be a bit depressed or a bit emotionally up and down. So there's still stuff to work with. Anxiety, for example, a lot of people with bipolar have problems with kind of various anxiety problems as well. For me, a good course of therapy is about doing this relapse prevention work, the psychoeducation, what I'd say the more here and now, kind of surface level, like what you're getting right now, your thoughts and your emotions right now. And, for me, a good course of therapy goes a little bit deeper and that's what I'm really interested in and that's where it can be useful, even when people are stable in mood, if we're going at that core belief rules for living level, those high standards, those dysfunctional attitudes, beliefs about achievement and trauma often as well, like early trauma, I think that's a really good course of therapy if it goes a little bit deeper. Rachel: So we've talked a bit about a standard CBT package if you like, and there's lots in there, which I think if people haven't been working with bipolar disorder, you can immediately see the transferable skills and knowledge that people have. But I know you've both been involved in developing and applying different approaches to treating bipolar disorder, including using dialectical behavioural therapy and behavioural activation approaches. And Tom, you're the editor of a very recently published Handbook of Psychological Therapies for Bipolar Disorder, which seems like a really comprehensive and brilliant resource. Can you tell us a little bit more about the diversity of treatments, and when and why we might look to different psychological approaches. Tom: Yeah, the book's out and it's a handbook, so it's trying to cover kind of everything and its 29 chapters I think. So it is pretty comprehensive. Rachel: My favourite chapter, by the way, or the favourite chapter title I've seen is one that you've written, Gently Bursting Bubbles and Raining on Parades: a chapter on problematic positive beliefs. Tom: Yeah. And according to my US colleagues, that's the most British chapter title they've ever had, apparently. But I really wanted to delve into that going deeper in the book. And it's called evidence-based and emerging because I've got chapters on the very strong evidence-base, like CBT and group psychoeducation but I wanted to give a platform to these kind of emerging therapies. Kim wrote a chapter about sort of behavioural, dialectical behavioural. We had a chapter about mindfulness, acceptance commitment therapy. But then there are also chapters on working with specific issues. So yeah, there's that book about positive beliefs about mania and challenging overly optimistic cognitions because that's a weird thing to do, because we're all used to challenging negative cognitions. But what about when someone's overly optimistic and you have to gently burst their bubble. It's a difficult thing to do as a therapist. So working with issues, so we did a working with anxiety, working with trauma and working in particular groups as well. So we had a chapter about how you might work with people who have a learning disability and bipolar disorder as well. So I wanted it to be comprehensive, for my sins. But it really to show that the relapse prevention work is key and it's really important, but there's a lot of work where you can go deeper and there's a lot of other work outside of relapse prevention work that is often needed if we're really going to give a comprehensive treatment to someone with bipolar. Kim: I think that's a really important message that just because somebody has a bipolar diagnosis, not to assume that what they're going to want to work on is something directly about the bipolar symptomatology. Some people may want to work on other aspects of life and living alongside bipolar. Some people might want to work on an anxiety disorder or PTSD or relationship issues and when it comes to the balance of new versus existing treatments, I think there's still quite a bit of work to be done, as we said, to get access to existing evidence-based psychosocial treatments, and potentially some tweaks to those and improvements to make them more effective or to make sure they're delivered better. And then the investment in new treatments might be around where we feel there are gaps or there seem to be gaps that aren't being addressed by the new treatments. So I think we need to be thinking about both. Rachel: What's your experience been like, Kim, of integrating some of those, for example, the DBT ideas or thinking about behavioural activation rather than a kind of full CBT type package? Kim: So the work I've been doing has been for people with ongoing mood instability or residual symptoms in between episodes, and it came out of a feeling that, certainly as a clinician, using kind of standard CBT packages with people where their mood is up and down an awful lot, felt a little bit clunky, because it felt like there were chunks of work we had to do and if somebody came in a different mood state, it was maybe it was the way I was applying it, but it was like, oh no, we're going to have to put that on pause while we do this. And I guess I wanted something that was more like a set of principles that you could use whatever mood state somebody was in when they came to the session. And the work I'm doing at the moment is about integrating sort of behavioural activation with some emotion regulation concepts and techniques, primarily from dialectical behaviour therapy. So it's behavioural activation, but with more focus than usual on the person's relationship to affect and how they might think about their feelings or emotions or affect and how they might respond to it. Because finding, and there is evidence about this in literature, just in terms of people's relationship to their affect, people who've had like lots of extreme mood states can sometimes feel quite burned by that and quite scared of their increases in changes in mood and energy and maybe need to befriend it again and work out which of the feelings states I can trust in terms of my feelings and what I might need to take action with so that maybe people are not always catastrophising or avoiding changes in affect. And that, that has been really interesting work to do but what I found, as I've talked to clinicians about is people are doing this already. So I feel like what I'm doing is simply formal formalising what a lot of clinicians around the country and around the world are doing anyway in terms of integrating emotion regulation techniques into their cognitive or behavioural practice. Rachel: And it sounds like importantly, really articulating those principles that you're coming back to. I know you work closely at Exeter with Barney Dunn, who's recently recorded a podcast with us thinking about ADEPT and working with positive affect and think targeting anhedonia. You know very much I'm hearing this theme come back through with all this depression work of coming back to principles and sessions because what can pop up in any session, even with unipolar depression can be so variable, can't it? Kim: Yeah absolutely. I think when people have got major sources of instability in their lives, whether that's life events or relapsing, unpredictable physical health considerations or whether that's mood state being very back and forth. I sometimes, when I'm doing training with therapists, use the metaphor of a tent in the wind. You're trying to peg a tent out before it gets really windy, you don't want to spend ages on one peg. You want to get a couple of key pegs in so when the wind hits, you've got something to fall back on that's keeping things in place. So usually if I've got somebody whose mood is really up and down, usually what we'll try to do at the beginning is get a few key things in place so then we've got something to refer back to when they come back in and they're feeling differently than how they did before, or they're experiencing a real exacerbation of how they're feeling. And a practical example of that would be relapse prevention early warning sign work, when you do that in therapy it can take sessions and sessions. I think it can be really helpful to do a quick version of that right at the beginning so that when somebody comes in and their mood's suddenly going up, you can refer back to that and it took you 15 minutes in the session and you can go over it in much more detail later on in the therapy, but at least you've got that peg in there to help you keep things in place. Rachel: That's such a helpful metaphor. And I think we're used to talking about therapists having tools in their tool belt. I love the idea of them having tent pegs that they can be working with their clients. So it sounds like there's a variety of approaches to treating bipolar disorder that, that, broadly fall under the CBT umbrella, like CBT/DBT/ACT, other related therapies but there are other therapies like family focused therapy, which we know are applied, and Tom you've talked about group approaches with different, maybe different modalities, but maybe some of those modalities, but applied in a different way. What do we know about the effectiveness and efficacy of these treatments? Tom: I think I briefly mentioned earlier, so the biggest meta-analysis that's been done to date shows that CBT group, psychoeducation, family focused therapy reduce the risk of relapse by about half nearly. And also they do appear to reduce kind of acute symptoms as well. Individual studies have also shown benefits, like it reduces how long the episodes go on for, it reduces the risk of hospitalisation, but I think the evidence is really strongest for that relapse prevention focus certainly. Rachel: And what does a good outcome for bipolar therapy look like? Tom: Well, it's based on goals. I think definitely, it’s based on what the patient goals was. As Kim said, sometimes people might not be particularly bothered in, you know, they might not want to work too much on relapse prevention, there might be other focus about their relationships or their anxieties, for example. I think for me personally, a revised relapse prevention plan is always a good outcome because people will usually have one, but a more CBT kind of informed one is good. But then I think something that goes deeper than, like I said before, that relapse prevention, something if people are able to reevaluate some of their high standards and soften those up a little bit, that's a really good outcome for me I think as a therapist, Rachel: So I guess all good CBT we're thinking about the individual's goals. Tom: We are, we're thinking about the individuals’ goals, we're thinking about the here and now, but we're thinking back to a bit of a deeper core belief level as well. You want to see some of those rules for living and core beliefs sort of soften up at the end of therapy, Rachel: Yeah, because this isn't a kind of one-off event that people are going to be experiencing. It's something that they need to be thinking about through their lifetime. Tom: Yeah, there's the having a really good relapse prevention plan and knowing what to do if you're starting to become unwell. But the deeper stuff as well, that reduces your future vulnerability. Rachel: And let's say you are sitting in front of a client with bipolar disorder for the first time. What can you reasonably say to that person about their outcomes? Because it’s one thing, thinking about the kind of these big trials, what do you say to someone presenting for treatment? Because the individual can benefit differently, can't they, depending on their own circumstances. What do we say to clients when they're presenting for therapy in terms of hope for outcomes? Kim: So I would be honest that we can't predict for a given individual exactly how the therapy will affect them or work for them. Generally, these therapies are found to be helpful. It depends on what the target is obviously, but for example, in reducing risk of relapse, I might have drawn a diagram of the person's mood switches, and it might be that, it nips the tops off or the bottoms off the highs and lows rather than you end up with a completely flat line. And I'll be curious about what the person's own aims would be around that and what would be tolerable for them. Because I think there can sometimes be a perception that people without bipolar have very stable mood and that's normal to have very flat, stable mood and that isn't the case. So just being interested in where people think is realistic to end up and where they would like to end up. But always keeping that space open for the possibility that the episodes may recur, symptoms might recur- but does that mean that you can't live well and live a valued life alongside that. Tom: Yeah, sometimes people will ask the question of can it be cured? And I think having just an open, honest conversation from a very recovery focused approach, is useful to say that it reduces the risk of relapse if you're depressed, it will hopefully help you get out that sooner. We're not saying it's going to stop it completely, just to sort of have these kind of smart goals and realistic expectations, but I think people take that on board if you say this can help,. It's like medication, it's not going to get rid of it, but it can help you live better with it. Rachel: And I've heard what you said about one of the myths about bipolar being that the manic or hypomanic episodes not necessarily being experienced as entirely positive and they can actually be quite negative for people, but for some folk, is there a sense that there might be losses involved in this if I'm going to nip the top off my curve? Tom: Yeah. It is hard. And again, that chapter you referenced, it's about there are positive beliefs about bipolar. I mean, not all, I say a minority of people, but there is evidence that some people with bipolar, they don't want to stop mania, in particular, or they don't want complete control over their moods. And that's often because they feel like they're more productive or they're more creative, for example. I remember once I was running a relapse prevention group that people had signed up for and 10 people who wants to stop getting depressed, all of them put up their hands. Who wants to stop getting manic? Like one person put up their hand? And this was a relapse prevention group. So this is part of the work. It is. And as we were talking about in that formulation diagram challenge, those beliefs that this is a positive thing and I can use this, that is often part of the process, and it spirals out of control. So sometimes having to work with these beliefs, which are often underlying by those kind of perfectionism and high standards is really important because there's no point doing relapse prevention work if the person isn't entirely convinced they need to stop getting manic. Rachel: And talking about efficacy and effectiveness. Do we know much about different groups engaging with this treatment? Are there diversity issues around who benefits? Who doesn't? Tom: I think we know in the UK certainly from one study that black service users were less likely to be offered CBT as I think I mentioned earlier, which, obviously it makes my blood boil. It isn't right. I don't think we really know about in terms of who kind of benefits the most really. I mean there was this one study that showed that the people who had positive beliefs about mania didn't benefit quite so much, as you'd probably expect. I don't think we know that. I think this is, this is one of the things that we're probably a little bit behind on is tailoring it a little bit more and seeing who benefits the most. I don't think we're there yet, to be honest. Rachel: So an area for more work and more research. And in your, you've both got extensive experience of developing interventions, teaching, supervising, applying the therapy. Where do therapists get stuck? What are the questions that they ask most frequently or the tricky issues that people come up with? Kim: So I think we've already mentioned about, that the issue of people may be having mixed feelings about letting go of high mood, and I think therapists do worry that it will come across like they're telling people not to be happy. So I think there's a couple of answers to this. I mean, firstly, not all positive mood is created equal, so I think it can be helpful to look at what different types of positive mood there are, and to work with people to discriminate between a kind of, okay, safe, high mood and one that is more indicative of the beginning of a relapse. And often people will say that the kind of more like contented happy feelings are not involved so much in a relapse, but the more energised, activated feelings are. But even within those, you wouldn't, I wouldn't want people to never, to be scared, to ever feel excited or energised. So what makes the difference? Because if we know what is particularly associated with those feelings heralding an episode, it means we can relax about the other times when we might feel excited and energised if it's unlikely they're going to lead to an episode. I guess the other thing is, it's not actually really the mood that tends to cause the problem. It's usually what people do when they're manic. That's the thing that people tend to say, they feel a lot of guilt or shame about that tends to cause lots of stresses in life, like overspending and so on. So for me, the target to address around a manic episode isn't really the high mood, it's the behaviour. And what I tend to work with people on is increasing a sense of control over the behaviour so that if there's a high, they do experience a high, it's not as damaging as it might be. Sometimes that does mean downregulating, the high mood because it helps the person to think straight about the next best thing to do. If you're really in the grip of a feeling, it can be difficult to make a wise behavioural choice. So sometimes there is that downregulation, but not always necessarily. And I think that can be quite, in terms of training therapists, can be a helpful message. No, don't worry, your main job isn't to make people less happy. It's to help people feel more in control. Rachel: That's really helpful because I imagine, as we've said earlier, that's quite, almost inhibiting for therapists thinking, my whole life I've been trying to make people feel better. I don’t want to take this away from them. So to focus, as you say, on the behaviour and the control rather than on taking someone's positive affect away from them. Tom: I think when I'm training therapists, one thing that people struggle with is to formulate the mania. They can bind into this idea that a lot of mental health professionals and people with bipolar do; that mania comes out of nowhere and it's very biological and there's kind of nothing you can do about it. When actually it can escalate quickly, but it often builds up for sort of several weeks and there will be early warning signs. So I always say to people, formulating the mania is key, and once you've got that, the rest will follow. I've said before about this issue of working with people when they're stable, when there are people, when the people, when they are unwell, it can be done. It just needs to be done in a particular way. Rachel: I know we spoke about high folk are often presenting for treatment, maybe not for the bipolar disorder, but sometimes for other comorbid issues that they're experiencing, so for example, presenting in services for treatment of an anxiety disorder or PTSD. And I think therapists can sometimes be nervous about treating those other presentations in that context if indeed they know about it. What do we know about the efficacy of standard evidence-based treatments for other presentations if they're the person's primary concern in the context of the bipolar disorder? Tom: Yeah, well, unfortunately there's not a whole lot of evidence. That's why kind of my book was, that came within the emerging part rather than the evidence-base. So we know, for example, about half a people who have anxiety with bipolar, would meet the criteria for an anxiety disorder at some point in their life as well. And there's quite high levels of kind of drug and alcohol abuse as well. There is evidence that CBT can reduce anxiety within bipolar disorder, but not a whole lot of research, PTSD as well. There's disproportionately high levels of traumatic events and PTSD and bipolar. And there’s a little bit of evidence, there's a couple of small RCTs about trauma focused CBT and about EMDR and how that can be used with bipolar. But, really not a whole lot to go off at the moment. But we know that in NHS Talking Therapies, that's usually what's worked with is the kind of anxiety or the PTSD, rather than the kind of bipolar per se. Rachel: So it sounds there's, as you say, it's emerging evidence, we don't know, but equally, it doesn't sound like there's a good rationale to withhold that treatment for folk. Importantly, we don't know that it doesn't work either. Tom: Yeah, there's, what is it? The absence of evidence or evidence of absence? I can't remember what the term is, but yeah, the stuff with trauma work and anxiety, for example, is pretty promising. Some people did prolonged exposure with bipolar and they found that it was fairly effective, nobody became unwell. There weren't any people who became manic as a result, for example. No, it's not a reason not to withhold it at all. It just needs to be done with kind of a few slight tweaks really, and just being cautious and for trauma work the stabilisation- I know there's disagreement about how much is needed, but for bipolar, even if it's just doing a simple relapse prevention work before you do trauma work can be really important as a bit of a safety net for you and your patient. Rachel: So we always like to take a moment in the podcast to think about self-care and self-reflection as working in mental health is so rewarding. I know we all love it, but it can also be very challenging on both a personal and professional level. If you really care about the people you're treating as hopefully most of us do, and bring not just your mind, but also your empathy, your whole self to the work- perhaps even more if you have lived experience of the challenges your clients are facing, as you've spoken about, Tom. How do you think therapists or as therapists, we might be challenged by working with bipolar disorder? What things might we have to examine, put under the microscope around our own assumptions, behaviours, how do we look after ourselves? Kim: I think one thing for me that I notice is, is that sense of, we usually work with people who don't like their condition. They don't like being really anxious. They don't like being really depressed and they want to change it. And this isn't, as we said, always the case for high moods. I think it's really important as a therapist to make sure that your agenda isn't at odds with that of your patients, not going in thinking, right, what they need to do is they need to work really hard on never becoming even slightly high ever again, when actually that's not the person's agenda at all. I mean, obviously sometimes we have to do, I have different, agendas for safety, but generally speaking, we want those to line up. Rachel: So it sounds in this work, it can really help actually think about when we're taking a stance towards therapy, that is what I'm doing to someone else rather than working with them and that kind of professional mindset is I know best for you, which I guess we don't want to have in place for any of the work we do, but it sounds like it really throws that into focus. Kim: Yes, exactly. It would be the case with anybody but, I think it's particularly at the forefront when you have somebody who may think, actually, I enjoy being high and it's not something I want to change. Tom: I think when someone is fully manic, like you'd see in Bipolar I, it can escalate quite quickly and it's very chaotic and scary and feels very out of control for the service user. And it's also the case for the therapist. It can be a scary time when people relapse like that. And it can be really emotional and sometimes clients can feel very anxious about the future. You will be as a therapist as well. So I think a lot of that when people are manic, it is difficult. And I think, just trying to remind yourself as your therapist, your own high standards, having smart goals, it's not a sign of therapy gone wrong or a failure from you or the patient's part if they do unwrap- that is the nature of the condition. And what we're hoping to do is that this is going to happen less often and you're going to be able to pick up the pieces quicker. Rachel: I suppose it's important. We can really believe that and model that in our own work. Kim: I agree so much with that, Tom. I think I've seen therapists feel like, oh, somebody's having a relapse or their mood's dipped, or it's gone up- I failed as a therapist. When actually this is, you are walking alongside them as they experience this. And it's an opportunity for you to learn more, for them to have an experience of the therapy during one of those phases and maybe learn how to relate to that episode and respond to it differently. It's a potentially a really helpful opportunity, even though you and the patient wouldn't have wanted that relapse to happen. So you know for therapists really not to catastrophise. Rachel: So in fact, it's not the work gone wrong. It is the work. Kim: It is the work, yeah. Tom: Yeah. Rachel: So one of the really great privileges of being a therapist is we get this window into the lives of others and, we get to benefit also from seeing their resilience and creativity and face of life's challenges. I wonder what you've learned from the people you've worked with and how this work may have made a difference, a personal difference even in your life, or the focus of your work. Tom: I mean, I'm always in awe of the bipolar community and their wisdom. I think the bipolar community is a, it is that it is a community, and you get lots of people supporting each other, which is a lovely thing. And when I ran groups in the NHS, I think, what was great is that we had the content, but we also learned from each other. And I learned from my service users and all sorts of wisdom, the kind of early warning signs you just wouldn't really be aware of. And the coping strategies, the people that have already be developed, people are amazingly resilient. And I think that term strategic boredom came from someone who sort of said, I need to be boring in order to stay well, which has stuck with me. I think another thing I've just learned is just not to underestimate how powerful, quite a simple intervention as a CBT therapist can be, work with people who have never had therapy despite living with bipolar for years or decades, and just a few sessions doing a relapse prevention work plan can be so helpful for them. So not to underestimate the power of something simple like that. Rachel: It may be a very simplistic parallel to draw and hopefully you'll correct me if so, but I'm struck when you're talking about that community and also earlier about, the perhaps the sense of ambivalence people might have around some of the work in terms of their goals. It reminded me a little bit of sort of the Alcoholics Anonymous movement, the idea that you're supported by people around you who will spot signs for relapse, who maybe have developed other strategies themselves to work with that. and benefit from that kind of wisdom when it's easy to see how the problem doesn't always feel like a problem. Tom: Yeah, I think peer support is really important and that's something that Bipolar UK is trying to roll out more is more peer support. Kim: Yeah, I think as therapists, we are, we're meant to be doing therapeutic interventions, but we don't have the monopoly on therapeutic interventions. So I really agree with Tom about the huge benefits that people can get from groups, communities around bipolar, but also I've done some work on lifestyle factors and bipolar and psychosis and hearing about the effects of nature exposure on people's wellbeing. There were so many therapeutic mechanisms in what people talked about with regard to time spent in nature. And it just helped remind me that formal psychological therapies are one small part of somebody's therapeutic journey and most of the therapeutic contacts actually really happen outside of the therapy room and we can help facilitate that and be open to that as therapists. Rachel: And as we've hinted at throughout this podcast, you're both really engaged in research and on the cutting edge of what's happening with bipolar disorder. What do you think are the really important questions that need answering or the next big challenges in the field? Kim: For me, it's that the main thing really in the UK is access  to evidence-based psychological therapies. I mean, that's around the world. In the UK we've got the benefit of a centralised, pretty centralised system. We've got quite a relatively high number of therapists trained in at least some of the approaches we need- but there are barriers around cost and resourcing that, so we might need to look at how we deliver the therapies to manage those issues, but also as I've said about the way that services are organised so that people don't find themselves in a different place in the system to where the therapy is available. I think that sort of systems-based research and development is really needed. Tom: Like I said, I think we're quite behind where CBT psychosis is. So I'd like to see us play catch up a little bit. I'm interested in the, this going deeper. There is a bit of evidence that dysfunctional attitudes can improve, following CBT and bipolar, but I think we need more research on that. Same with kind of trauma work and these high standards as goal focused behaviour. And yeah, there really hasn't been much about these positive beliefs and how that can impact treatment so I think we need to dig into that and try and work on some of these positive beliefs about mania as well. One thing that's really exciting is, I think the reason CBT for psychosis is there's better access and there's more research is because we have these early intervention in psychosis. It's not a guideline; it's a target to offer CBT and that's one thing the Bipolar UK report has called for is more of these targets and more bipolar specific care. One really important thing is, could we use this as early intervention? And there's a big trial up in Manchester led by Sophie Parker that myself and Kim are on the steering group for, which is essentially trying to do what those big trials for early intervention in psychosis did decades ago, years ago, for bipolar disorder. Can it actually prevent, can it actually improve outcomes for people who are at risk of bipolar disorder? And, that would be, yeah, that really would be a game changer if this shows some positive outcomes. So that's a definitely one to watch. Rachel: And we see again and again, don't we in mental health that you can have the best treatments in the world. And it sounds like there's still plenty to be developed around that, but actually if they're not implemented, and if there isn't the policy and the infrastructure around that to make sure that people access it, it’s not doing its job. And I know that whole, environment is maybe getting more complicated to access to, to influence. Maybe not with, we're recording this just a couple of weeks after the announcement about NHS England being folded up. So it'd be really interesting to, to see in this space what happens around those policy decisions and that implementation. But really great to know that there's folk like yourselves with such a deep and wide-ranging knowledge that hopefully will be influencing the next stages in that. If people want to learn more about your work, where can they access training or how can they get involved? Tom: So I am chairing special interest group for bipolar disorder. So if you log onto your system, if you want to sign up to that, you'd be very welcome. It's been recently restarted, having been dormant for a few years. My book's called The Handbook of Psychological Therapies for Bipolar Disorder and, Yeah, I'm on kind of social medias @drtomrichardson. I'll often share about my work there. Kim: And Tom and I are on the Psychological Interventions Task Force for the International Society for Bipolar Disorders. And we have in the task force, we have a working group at the moment who are putting together a web resource on evidence-based therapies for bipolar, trying to make it a one stop shop for clinicians internationally in terms of what should we be delivering, how should we deliver it, and links to useful resources. And we're hoping to launch that later this year. Rachel: That's fantastic. That's so useful for therapists to have a place that they can go to, that they can trust also. So that, that sounds brilliant. And the book Tom looks like an incredible achievement. I'm sure. people want to get their hands on that after listening to this, if their appetite has been wetted or I'm working in this area, or indeed, if they're already deeply burrowed in there. So in CBT, we like to summarise and think about what we're taking away from each session. So in time honoured fashion, what key messages or message would you like folk to leave with from this podcast regarding the work? Kim: So I suppose mine would be if you're a fully trained CBT therapist, you've got 95% of what you need to work with people with bipolar. And the additional 5% is important, but it's not complicated. Tom: I think A: it is possible to formulate mania and B: CBT techniques can reduce the risk of relapse, both for depression and mania. Rachel: So there's hope. Nice to leave on a message of hope. Fantastic. Thank you both so much. It's been brilliant talking to you. I think we could have done a series of podcasts on this. So thank you so much for your time and all your wisdom and all that you've shared with folk at home. Tom: You're welcome. Thanks for having us. Kim: 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 [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, 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. 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, 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. 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