Let's Talk about CBT- Research Matters (Steph Curnow for BABCP)

In this episode of Let’s Talk about CBT – Research Matters, host Steph Curnow speaks with Dr. Nick Grey, a consultant clinical psychologist with extensive experience in anxiety disorders and PTSD. Together, they discuss the paper “Ten Misconceptions about Trauma-Focused CBT for PTSD,” co-authored by Nick and published in the Cognitive Behaviour Therapist.

The paper addresses common myths and challenges in trauma-focused CBT, offering insights for both therapists and researchers in the field.

Key misconceptions discussed include:

• Misconception 1: “Trauma-focused treatments are not suitable for complex or multiple trauma.”
• Misconception 2: “Stabilisation is always needed before memory work.”
• Misconception 10: “Cognitive Therapy for PTSD is rigid and inflexible.”

If you enjoyed this episode, please rate, review, and subscribe wherever you get your podcasts. Follow us on Twitter at @BABCPpodcasts or on Instagram . Share your feedback or episode suggestions by emailing podcasts@babcp.com.

Useful links:

The paper discussed is:

Murray, H., Grey, N., Warnock-Parkes, E., Kerr, A., Wild, J., Clark, D. M., & Ehlers, A. (2022). Ten misconceptions about trauma-focused CBT for PTSD. The Cognitive Behaviour Therapist, 15, e33. doi:10.1017/S1754470X22000307

The full version of the article can be found freely available here: https://bit.ly/47KIwPL

Transcript:

Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT.

Today I am talking to Dr Nick Grey. Nick is a consultant clinical psychologist and has worked in the field of anxiety disorders and PTSD for many years. He is also one of the authors of the paper we are going to be talking about today which is titled “Ten misconceptions about trauma-focused CBT for PTSD” and is published in the Cognitive Behaviour Therapist.

So Nick, welcome to the podcast.

Nick: Thank you, Steph. It's nice to be here.

Steph: It's great to have you. So before we get talking about the paper, I was wondering if you would just mind telling everyone a bit about who you are and the areas in which you work.

Nick: Yeah, sure. So, I'm a clinical psychologist by professional background and a sort of a CBT therapist by sort of flavour of psychological therapy. And I work down in Sussex now, based in Brighton working across Sussex partnership and for many years I worked up in London at the Centre for Anxiety Disorders and Trauma and continue to work together with David Clark, Anke Ehlers and other members of the Wellcome Trust anxiety disorders team who are based in Oxford. And, and that's where a lot of the work that we're going to be talking about has originated in both London and Oxford and in particular the paper is pulled together by the Oxford team.

What I should also say and just wanted to say up front is that the paper is lead authored by Hannah Murray, who sadly passed away after a long illness in December 2023 and her input, not just to this paper, but to us as a group has been unbelievably crucial and, both us as a team, but I know that the wider, sort of CBT community will really miss her. Miss her contribution.

Steph: Absolutely. And thank you for mentioning Hannah. She was a great friend to the journals as well. She spent so much time contributing to both of our journals, mentoring people, reviewing for us. Yeah, we really miss her.

So I really wanted to talk to you about this paper today, because not only is it one of our most widely read papers, which is brilliant, but the format of this paper was so popular, it's actually sparked a whole new series of papers for us. We're doing a whole new set of “10 Misconceptions” papers now that we're currently commissioning. I just wanted to ask how did this come about? What was the idea for this?

Nick: The idea came around because we found ourselves, doing a lot of training, a lot of supervision over a number of years, particularly for the treatment that we provide Cognitive Therapy for PTSD, which is one of the types of trauma focused kind of CBT. And we found ourselves saying many of the same things again and again, really sensible questions that people would raise in training workshops, really sensible questions people would raise in supervision, and we thought it would be helpful for us and therefore for all the people that we are also sort of like supervising and training to have us almost perhaps a single resource. So like an FAQs, around some of the things in this line of work.

Steph: Before we get into talking about the misconceptions themselves, you've worked in PTSD and trauma for a long time now. If you don't mind me asking, when you started out were there any myths or misconceptions that you held about working with clients with PTSD?

Nick: Yes, all of the ones that are in the paper at some stage or other, I think this is a normal process that actually we hold all of these to one degree or other, until perhaps we've had the chance to test them out or we've had the chance to learn more.

One of the key things for me, I think one of the key things that we're always trying to get across in the work that we do is there's a difference between having a history of traumatic events and having experienced traumatic events, and then the types of presenting problems that people may have, which will include, may include PTSD, but may not only be PTSD. And this really came through to me, the sort of where I started in, in sort of psychology and mental health in the NHS was a long time ago, working as a research assistant, actually at the Spinal Injury Centre at Stoke Mandeville Hospital and part of the project that I was working on, led and supervised by Paul Kennedy, a clinical psychologist, was around how do people cope following spinal cord injury. And my job involved speaking to lots and lots of people who had experienced a spinal cord injury and how they were coping and, how, what helped them, what was difficult and those kind of things. And one of the things that I was really struck by was just how varied their current presenting difficulties or lack of difficulties were, given many of the similarities in the experiences that they'd had which had resulted in life changing injuries for all of them, essentially. And a small proportion of those people who had a spinal cord injury also were having repeated unwanted memories, nightmares, waking in the night on the wards, reliving the experiences that had led to their injury. But it was only a kind of a proportion. And then there was differences in how they coped with, with those experiences as well.

So one of the things that I really took from that is that firstly that not everybody who experiences a traumatic event is going to be negatively affected in the long term, that the types of impact and effects that people may have following a traumatic event may be very varied or be very personal to them and even for those people who are having like unwanted memories or nightmares, for many people those also reduce naturally over time. And then what we're working with, certainly thinking about cognitive therapy for PTSD, thinking about trauma focused therapies as a whole, we're working with people who have become stuck in that process of natural recovery.

So, I think one of the first misconceptions for me in this area was that everybody who goes through a trauma is going to be affected and they're going to be negatively affected and they're going to have PTSD. And I think some of that, that sort of misconception that I certainly, I think, held before getting more experience, is still to some degree commonly held in health systems. I wouldn't say necessarily by CBT therapists or people working in mental health, but as a whole, if you've had a trauma, it's definitely going to affect you and you're definitely going to need a trauma focused therapy. And I think this is one of the things that certainly exercises me in the present day as well, when people talk about things like treating complex trauma. And this ties in a little bit with the first misconception in the paper about multiple traumatic events or prolonged traumatic events and the complexity of kind of memory presentations and for me complex trauma is a description of the history, is a description of what the person has experienced and it's not a description of the presenting difficulties that they may have if they do in fact have significant difficulties.

So we're never, and I don't think it is just semantics, I think it's important about how we conceptualise reactions to traumatic events, how we conceptualise PTSD, and therefore, really importantly how we provide treatment, is that we need to make sure that actually when we talk about treating complex trauma, it makes no sense. We're not treating the history per se. Of course, the history is massively important in the formulation, in understanding what's going on, in the possibility of there being PTSD. But what we're talking about in this paper, what we're talking about with cognitive therapy for PTSD is helping people, that subset of people who have experienced traumatic events who do meet criteria for PTSD or complex PTSD. And crucially it's those people who have re-experiencing symptoms where they have unwanted memories or bad dreams, where when they have those experiences, it feels to some degree like those events are happening again in the present. Rather than being simply memories from the past, and it's definitely taken me time to, to really get my head around that, that it's just a small subsection of people that kind of we're working with, and, and actually that treating multiple traumas, actually what we're treating is the re-experiencing symptoms, perhaps, to people who may have had a whole range of traumatic events, but maybe they may only be re-experiencing one or two, and then there's a question about well, why those one or two- usually links but a long answer meandering answer, but just to say that, I think my main misconception very early on in my career was that everyone after trauma gets PTSD. Yeah. And if there's multiple traumas, we're treating complex trauma, we're treating multiple trauma. Whereas actually what we need to think about carefully is to listen to people about what are the difficulties that they have and how are those influenced by their histories, but also how do we help them now? What's got them stuck now?

Steph: I think that's really, really helpful. Yeah. So shall we get into the paper itself? As we discussed before we started recording, if we went through all ten misconceptions, we might be here for quite some time and end up with a very long record. But there were a couple that we wanted to pick out and highlight that we thought might be really helpful for people to hear. So, do you want to kick off with the ones that you've picked and why?

Nick: Yeah, so, so the ones, I started getting into it a little bit there and got a little bit more to say about it, which was about, the first one is around multiple traumatic experiences and how we work with those. The other ones I want to bring to the fore are also around the second misconception around stabilisation and that we always have to have lots of sort of stabilisation before being trauma focused. And then the very last sort of misconception, which was, that, you know, that this treatment, Cognitive Therapy for PTSD is rigid and inflexible and protocolised. So those were the three and I know there's something that probably we'll get into discussion about a couple of the others around talking about certain events and stuff. But, if we come back to the first one, which is the thing around multiple kind of traumatic events.

Steph: Yeah, and I'll just say for the listener as well that the way that we phrased it in the paper is “trauma focused treatments are not suitable for complex or multiple trauma”.

Nick: Yes, thank you and I should have had right in front of me to just remind myself of exactly the wording. Again, the first point is that. because the person has had a history, which has unfortunately included multiple traumatic experiences, that in itself doesn't tell us anything about their presenting difficulties. We need to listen carefully to what their presenting difficulties actually are, whether those would meet criteria for PTSD or complex PTSD, or whether those would be better conceptualised as some kind of other kind of presenting problem. Then within the realm of multiple traumatic experiences, if there are a number of events being re-experienced, actually there's a question of, well, where do we start?

Yeah, it's not a case of well we know it's not suitable for complex kind of traumatic histories. What we're looking for is what are the kind of the key moments, the key events, the key memories, nightmares re-experienced, kind of flashbacks. And that's our guide. That's where we I think would want to start typically. I think one of the questions or issues here is that sometimes people think what if there's lots and lots of traumatic events, I can't possibly talk about them all. And that's true. I think that's right. Nor would we want to try. And even when we're talking about a single event, we can't ever talk about every single detail of it in as much emotional detail as possible. We're always getting a story. We're always getting the person's recollection. We're always getting what their experience is of these flashbacks or nightmares. And so what we're looking for, I think, if people have had multiple traumatic experiences, is to think about, well, look, given the range of kind of memories or the range of difficulties, what might make the biggest difference to how they're living their life? What is it that they want to be different about their life? How is it that what's getting in the way of that? And if it's these memories that are getting in the way, which of the memories is causing the greatest difficulty? And what we can do is focus on that memory or those memories around that particular period of time. And what we're trying to do particularly in this treatment is not to try and grind through talking about every memory, but we're trying to identify what some of the key meanings are, the key meanings associated with an individual memory, but key meanings which then generalise across experiences. Typically, the same kinds of meanings that may be across a whole range of experiences. Meanings such as people can't be trusted, I'm weak, I'm to blame, things that kind of commonly come up in this work. And what we're trying to do is work on a particular event or memory and then think about how we can generalise the learning for people. And I don't think that, because people have had multiple traumatic experiences and maybe reliving multiple traumatic experiences, that should mean that they shouldn’t receive the kind of treatments which are known to be most effective for those types of kind of presentations.

What is the case and what I do want to recognise is that those people who have had multiple traumatic experiences are also likely to have additional difficulties. Yeah, this is captured within ICD-11 within the complex PTSD label, which in addition to the core symptoms of PTSD, which is the re-experiencing, the avoidance and hyper arousal. The three additional areas of difficulty that are needed, which are around difficulties in emotion regulation, including dissociation, interpersonal difficulties and also difficulties related to kind of sense of self-worth, seeing oneself as worthless. And of course, those additional difficulties, the emotion regulation, interpersonal difficulties and the self-worth are much more likely to be present if people have had multiple traumatic experiences. Yeah, they can be present after single events as well, but they're more likely present after multiple traumatic experiences, particularly if those experiences occurred in childhood at developmentally important stages of the person's life. And so, what we will need to do is to think about what additional interventions or how do we flex the interventions that we have within cognitive therapy for PTSD to address those meanings.

Fortunately, and this will come to the misconception number 10 about how protocolised things are or how rigid or otherwise things are. One of the great things for me about this kind of treatment is that actually we do personalise it. We are driven by the formulation. We do try and make it individual so that actually we can draw on our range of CBT tools and ideas in order to address the particular difficulties and the particular meanings that people have.

Steph: Great. Should we move on to the second misconception then, which is “stabilisation is always needed before memory work”.

Nick: Yeah. So, stabilisation, there's a question here. What do we even mean by the term? Yeah. So there's a, from the early nineties, there was a kind of fabulous book, “Trauma and Recovery” by Judith, Herman where she suggested a sort of a phased model for treating people following kind of traumatic experiences and people with PTSD, which included sort of a stabilisation phase, a phase where people are helped to be made safe, a trauma processing phase, a sort of telling the story phase and a kind of a reconnection kind of phase. That framework, which actually my reading of things and what we say in the paper from Judith Herman's work was never meant to be too strict and linear, over time got a bit kind of like reified as you've got to have stabilisation, then you have trauma focus, then you have reconnection in that kind of way and I think that's a misreading of both her work and also a kind of an unhelpfully rigid ki way of approaching treatment. But there is something really important about this idea of stabilisation and ensuring safety. Yeah, what we do need to do is ensure that people are safe and safe in a couple of ways or the best we can do.  If somebody is living at home, when they go home, they're living with a perpetrator and they're likely to be assaulted again. Yeah, they don't need a trauma focused therapy, they need help being made safe. And we as CBT therapists may be able to help that, but lots of other people, lots of other agencies are massively important in that. And we need to raise the appropriate concerns around that. So of course we need to help people get that physical safety. It may be from a perpetrator. Ideally, if it would be in my mind, more tricky to be offering this work to somebody who is street homeless, there wants to be a sort of some sense of safety in terms of almost like some roof over one's head, access to nutrition, food, drink, those kind of things, the basic needs being met.

In addition, there's another element of stabilisation which is often wrapped up in the same thing, which is like psychological stabilisation. Yeah, and so that psychological stabilisation often refers to things like having better control over one's emotions. It might also include thinking about managing risk and of course, this is absolutely crucial for all of our work. So the things around almost basic needs and basic safety stabilisation. Of course, we're always thinking about that. We're also thinking about the psychological stabilisation around risk, risk to oneself. And that's got to be a crucial part of all our work in that way. Stabilisation work is just part of what we do as therapists. Yeah. It's not anything that's special to PTSD. The additional bit that sometimes come in when treating PTSD is that that kind of stabilisation means, Oh, we've got to treat everybody. So I offer or treat people with a whole range of tools. You've got to offer them a whole bunch of tools before we go anywhere near the memory, and that might be breathing retraining. It might be grounding strategies; it might be having a whole range of different tools to manage emotions.

Now, none of those things are unhelpful. However, applying them in a kind of a rigid one size fits all way, the same thing has to be offered to everybody and commonly, for understandable kind of service sort of demand reasons, often in a kind of a group format, although there are some advantages to group formats around normalisation, overcoming sense of shame. I think often groups are offered, because it's seen as a kind of a, well, we'll pack as many people as we can into a stabilisation group. Then they've all got the basics and then some of them might graduate on to the trauma focused work. And there are many pathways like that, and I can understand that, but the evidence does not stack up. Yeah, the evidence does not stack up particularly around the idea of stabilisation groups where people have to go through a whole set of particular procedures and kind of treatments includes useful things like psychoeducation, like information about PTSD. Actually, making people go through a whole set of, kind of like set stabilisation procedures before getting trauma focused therapy isn't borne out by the research and isn't very personalised or individualised. What I think we're moving towards, and I think is much more in keeping with Judith Herman's actual original writing, which was where there was much more flexibility between moving between the phases rather than these being rigid linear things, is multi component interventions, where actually, of course, we need to be offering things that can help people with their emotions. Of course, we need to be helping people with their immediate safety, with managing their risk to themselves. But we don't need to offer the same things to everybody. There are different components that we can draw on for different people. And what we absolutely need to do is to personalise this rather than, everybody gets the sort of a stabilisation group. So what we're trying to get over in the paper is not to say, Oh, stabilisation is not helpful. We all do stabilisation. Again, depends on the meaning. We all do stabilisation with every single person we see for therapy. Yeah. Not just people with PTSD. And there may be some specific things that will help in stabilisation for people with PTSD, if they're very dissociative, thinking about grounding strategies. That makes sense. Yeah. But let's be individually tailored. This is one of the things that I'll find myself ranting about. So I apologise.  

Steph: No, not at all. And that's the one thing I was thinking as you were explaining that is, it goes right back to the very basics of therapy, doesn't it? Which is you treat the individual and I think that's a general misconception that CBT on the whole has in general, isn't it? That it's very formulaic and it's not tailored to the individual when actually that's really just not the case.

Nick: I think, well, I think that's true. But I also think, it gets us into the 10th misconception, but, I think probably there are some cultural differences in how CBT is implemented and certainly in how it's written about and therefore from my perspective some CBT therapists and researchers and clinicians haven't done themselves any favours because they write about it; it's like you do this, you do this, you do 10 minutes of this and 20 minutes of that and then 30 minutes of this, then 10 minutes that and then you do the set the homework in the last 10 minutes. And it's like, well, yes, but, but actually what's missing from that is, is actually the individual formulation. And there is a difference between, kind of like the formulation driven kind of CBT versus a kind of like a, a rigid, almost like, I couldn't see almost like how you do it, but formulation lacking kind of CBT. Certainly, that's how it's sometimes written about. And by formulation, if we're saying a formulation driven, it's not that kind of, we're trying to make something up, for each person completely differently each time. If we're working, let's say, with someone with PTSD, within cognitive therapy for PTSD, we have a roadmap. We have the Ehlers and Clark model. And the kind of this very simple thing I try and keep in my head, and I try and encourage my supervisees to keep in their heads, is look, key thing in this PTSD model is we're trying to reduce the sense of threat. We do that by giving a sense of safety through how we are with them through the therapeutic relationship, absolutely crucial. And also, we think about the things that keep that sense of threat stuck, which are about memories, meanings and then the behaviour. Yeah. And if we're working, if we know we've got information in each of those areas and we can work in each of those areas, then actually that is a model.

So if you want to say that's rigid, okay, so be it. But what I'm saying is how we implement that model, how we implement those underlying principles will vary from person to person. And that's where the flexibility is. And that's where the creativity is. And that's where the challenges in this treatment and this kind of work.

Steph: Okay, great. Thank you. I just wanted to touch on two more misconceptions before we wrap up really. And they, to me, they seem interlinked, but you might be able to tease apart the important differences in them, which are “talking about trauma memories is re traumatising” and “that some traumas shouldn't be relived”.

Nick: Yeah, these are related. And again, like many of the things that we've talked about, it depends what we're talking about. What do we mean by re traumatising? Yeah. The area of trauma and PTSD is people use terms in so many kind of different ways, and particularly in recent years where trauma almost as a model for human experience has become much more commonly spoken about in public, not just in health care systems, but just in society as a whole, and people use terms like “flashback” and “trauma” quite loosely and people use terms like complex trauma, like I was saying earlier, loosely and stabilisation and retraumatising. So partly my reaction to a lot of these is, well, okay, so what do you mean? Let me understand, let me understand what the concerns are here, what you mean about this. And clinicians are commonly using kind of retraumatisation in the way that deliberately thinking about past memories is going to make things worse. It's going to make the symptoms worse, and that worsening is going to be long lasting as well. Yeah, and that is definitely worth us considering. We need to understand that. We need to think about that. Not least from, the sort of in this field in history, the role of, let's say, individual emotionally focused debriefing and the big debates around that, which we won't get into right now, but we know that things that we can do might make things worse. We absolutely need to consider that.

So it's a really sensible question to have. What the evidence tends to suggest is that most people actually don't have a significant symptom exacerbation, an increase in the symptoms when talking about the memories. And even if they do, that that symptom exacerbation is typically temporary and short lived. The large audit that we did in CADAT, it was like over sort of 300 people, there was reliable sort of deterioration. There was a sort of symptom exacerbation, I think in 14 people out of 300 and over 330. Yeah, so it does happen. We need to be mindful of it. We need to think, well, who are the people it might be more likely for, but it's very small numbers. And what we're looking to do, of course, with the memory focus work is to help people get better control over the symptoms over the unwanted memories.

And that's what the evidence kind of suggests. However, what we need to think about is what does the person that we're working with, what their history? What's their experience of previous treatment? What's their experience of engaging with or not engaging with the traumatic memories? And what can we learn about that so that we can personalise things for them as well? And what we're not asking people to do, and I think this is one of the points I made much earlier is, is we're not asking them to tell us every single last detail of every single experience. That's not what's happening. It's not what could happen even. What we're trying to do is approach the memory, approach the emotion in order to identify key meanings. I mean, for me, one of the key principles of CBT is follow the emotion. Yeah. One of the reasons we follow the emotion is because that's where the key meanings are. PTSD actually kind of hands it to us on a plate for us as therapists because we know there's lots of emotion with the memories and these are the things that people are typically avoiding. So, we're going to want to go towards it in order to identify the key meanings. We're not, certainly even cognitive therapy for PTSD, we're not going over and over again the kind of traumatic experiences, we're trying to identify the key moments, and the key meanings associated with those so that we can work with them with people.

The other thing here is that people with PTSD are experiencing, re-experiencing these awful memories. But it feels like they're happening in the here and now, in any case. So we're not typically asking them to do things, i.e. approach the memory, which is outside of their experience. What we're trying to get them to do is that when those memories come up, and of course we may try and deliberately approach it together with them, when those memories come up is to have almost like a different relationship with them, to try and use our understanding of the emotions and the meanings with those kinds of memories to try and help unstick things. So, if we simply just avoid the memories and avoid talking about the memories, we know that's actually one of the maintaining factors for PTSD. So, we're very unlikely to lead to the types of improvement that we're really trying to look for. So, it depends on what we mean by re traumatising. Absolutely. We want to be attentive to where how things could deteriorate. We do want to think about the personal circumstances of the individual that we're working with. But actually, we're only typically asking people to work with what's already coming up for them in any case.

What ties in with that, then, is also this idea that, well, you're saying some traumas shouldn't be relived. And, again, I think what people are getting at, my understanding is, is that, is about that there'll be some things which will be too distressing for people. And most of these misconceptions are really well rooted in therapists desire to provide empathic, compassionate treatments and not to make things worse or not to put people to have unnecessary distress. Absolutely. I'm in complete agreement there. And that can have, of course, the unintended consequence that actually, for all problems that are characterised by avoidance, which PTSD, anxiety problems, maybe other problems as well, is that if those problems are characterised by avoidance, in all of those kinds of treatments, we need to move towards the thing that the person is avoiding. Yeah, because avoidance is one of the maintaining factors. So, a compassionate urge, the compassionate route here is not to avoid the memory. The compassionate route here is not to kind of like, allow, to encourage avoidance. The compassionate route is to encourage approach and engagement and hold the safety and to be there for the person and to explore the meanings and to try and change those meanings.

So that compassionate urge to reduce distress, absolutely, but actually one of the things we know across avoidance related problems is that actually we're going to need to help people approach- and that will include almost like no matter what the memories are, no matter what the event is. Sexual trauma is the one that comes up most commonly here and actually the work around particularly Cognitive Processing Therapy and Prolonged Exposure which are two of the kind of evidence-based trauma focused CBT's, they began with working with women who'd been raped and PTSD in those circumstances. The thing that I think, again, and there's always a grain of truth in all the misconceptions, is, but what about those people who are really, really ashamed about what they're talking about? Absolutely. And that's such a good thing to be considering, and such an important thing to be considering. That doesn't mean we avoid it, but it does mean that we think about how do we work with shame? How do we work with the beliefs associated with shame? Like, I'm inadequate, I'm weak, I'm a bad person. Yeah. And what we might need to do, and I think we make reference to this in the paper, is that when there's a lot of shame, we may need to have a certain amount of work around normalising and discussion and cognitive work around that before we do some of the memory focus work so that we've got some work that we've done to draw on in terms of thinking about the person's immediate shameful reactions, not least when shame is activated in clinical sessions, is how are we as the therapist reacting and there's a lot of learning that can happen and a lot of kind of sort of change of beliefs by how we as a therapist are showing that actually we still think they're acceptable and we still want to work with them and we still think that they're a good, valued kind of person, despite things that they've disclosed. Which they may not have disclosed to anybody else. So, it's not that we avoid the things that are loaded with shame, but we do need to think about, ah, we need to spot shame, we need to normalise, we need to work with that and actually, we need to think about how in the relationship, that's a really kind of crucial opportunity for people to have new experiences of being heard and of, not being heard perhaps in their perception, not being dismissed or thought badly of.

Steph: I wonder if part of the misconception around that as well, or how that misconception came to be, might be avoidance on the therapist part too, thinking, not just, is this going to be really upsetting or distressing for my client, but actually, is this going to be really upsetting and distressing for me? How do I handle this?

Nick: I think you're absolutely right, Steph. And, all of these things that we've flagged as misconceptions, they're all about therapist beliefs. They're all about therapist beliefs and they're all about what, what do we know? What have we learned? How do we, how do we change beliefs? And it's partly about giving some information. It's partly about thinking about the evidence. It's partly about then putting it to the test. It's testing it out. And one of the key things that is in this work as well is how does this impact us as therapists? So that kind of like the sort of the emotional things almost like follow the emotion find the meanings. This is true for us as therapists as well. If we're finding that we're feeling anxious in a session or we're feeling angry in a session, let's reflect and let's use our own supervision as well to think about actually what's happening there.

And one of the things that's really crucial in this area, not just in supervision, but definitely in supervision is how we're looking after ourselves and more importantly, how we're looking after one another. Yeah, what are the systems that we set up within supervision, within services, within how we have informal contact, particularly now that we're working often remotely. How are we supporting one another with the challenges of this work? And look, I don't, I don't want to make a sort of big claim. Oh, it's only PTSD work that can affect us as therapists. All therapeutic work can affect us as therapists, maybe some additional elements within PTSD, which may be around a matching of life experience or the traumatic experiences that we as therapists may have had. It may be about sometimes the sort of the high levels of emotion that kind of difficult to deal with as well. So it may be that some of those things are brought more to the fore in PTSD work, but I think they're there in all of the work that we do.

Steph: Yeah, I completely agree. I think this sort of leads me nicely into the next point I was going to make, which is one of the things that I really like about this paper is that right from the very beginning, it sets out its position, which is that it's not to blame or shame clinicians for having these misconceptions. Misconceptions exist for a reason. Normally, like you said, there's sometimes a grain of truth in some of what the misconceptions are and how they've come to be.  So, and I guess what the hope for the paper was, was that you just want clinicians to read this, take this forward and apply it to their practice and really learn from it. Like you say, it's almost like an FAQs of things that you want people to know to be able to use.

Nick: Absolutely, I think that's right. And I mean, any paper leaves a million questions hanging. Yeah, so there's loads of questions that we wouldn't ever expect a written paper to lead to belief change. Yeah, look, we're CBT therapists. We know that that in itself is not going to lead to belief change. One of the things that we know is much more likely to lead to belief change is experiential. Yeah, it's experiential activity. It's trying it out. It's actually trying some of these things and seeing what do we learn from experience as well as what my supervisor tells me or what these people have written in a paper somewhere. I wouldn't want anyone just to go. “Ah, yeah I've read that therefore, that's therefore I should be thinking that this is fine.” It's look, it's test it out. Let's try out. Let's think about how we can actually try and learn. How do we learn? How do we change our beliefs as therapists? How do we help our kind of clients change their beliefs as well? And in some ways misconceptions was a kind of like a, I don't know, it's a bit of a negative way of pitching it really, you know but we couldn't think of a kind of a more sort of like positive spin on, here's 10 good things to think about cognitive therapy for CBT. Yes, you can use it for multiple trauma. Yes, you don't always need to do stabilisation. We could have pitched the whole paper in that way. But actually, what we were hearing in supervision, what we're hearing in training are the, the yes, buts, the kind of like the, the way in which we've framed it here. So this is why we've framed it in this way, rather than a kind of a more positive facing way. It's because this is how we're hearing the questions. This is how we're hearing the questions from therapists.

Steph: Yeah, that's great. I was just going to ask if you had any reflections on the peer review process because this is quite a new paper and obviously it's very different to the way in which a very traditional research paper would have been presented when it went into review. Did you find reviewer comments helpful in that? Can you remember if you had any kind of things where you were like, oh, we should really change this, or if were you quite happy with it?

Nick: I may be misremembering. Yeah. But look, reviewer comments are always helpful. Genuinely. Yeah and for those people listening who haven't reviewed, please do. And if you do review, thank you very much. It, it always improves papers and the more attention given to the review process by reviewers, usually the more improvement there is in the papers. I think. And I can't remember if we changed it, or it was due to kind of reviewer comment. It was originally called 10 Myths Around Cognitive Therapy for PTSD. Yeah, and I think the reviewer comment was like, Oh myths is a bit pejorative. Yeah, these exist for a reason. It's not, it's not like quite like a, a unicorn. These are more grounded. And so that's why it's misconceptions. Yeah which again is our word. And maybe that's not a word that everybody likes either. But there were other things which helped us also helped us tease out the review process about which of these things apply to all trauma focused CBTs and which of these might be more particular or specific to cognitive therapy for PTSD. Look, cognitive therapy for PTSD is where our experience lies. But actually, it was highlighted that some of these are true across kind of trauma focused CBTs. And, and this isn't a normal, a sort of a research paper. That, that's for sure. And I think one of the benefits of the Cognitive Behaviour Therapist is that there are more kind of clinical guidance papers and practice papers, which is what BABCP members want, what CBT therapists want and, in some ways, it was interesting when I was re reading this paper, prior to this conversation, was that in Behavioural and Cognitive Psychotherapy, like the sister journal, there's a section now which is Empirically Guided Clinical Interventions, yeah?

And, and that's a section which is a bit like this really, but it was a section which, which never used to exist. Yeah, and then actually I submitted a paper with colleagues back in around 2000 and in conversations with Paul Salkovskis, who was still the editor back then, extraordinary behaviour. But, actually he could see that it wasn't and it wasn't a research paper. It was a kind of a clinical paper, like a how we do things paper, but drawing on evidence and pulling things together. And it was off the back of that submission, plus other submissions, I don't want to make too big a claim, that actually he then developed the Empirically Guided Clinical Intervention section and that paper that I authored with Kerry Young and Emily Holmes on hotspots was the first one of those types of paper. And actually, probably that's, that's where over the years where my interests and, and efforts have gone in is, is around these kind of like guidance papers, practice papers. And so, while this is a kind of a slightly different paper in the way it's structured, 10 misconceptions and stuff. The principles underlying it there were, were the same as pretty much the first paper I ever submitted to BABCP journals, which was back in 2000. Which is look we want practice-oriented things which are grounded in evidence, which are drawing on models and thinking about how do we flexibly implement things? So, this for me this paper actually is probably a full loop to, it's not a loop, but it's it made me think back around. Actually. That’s for me been really helpful when I've read those papers from other authors as well.

Steph: Hmm. And this paper type is definitely the clinical guidance papers. They're definitely the paper type that are most read, and I think most widely shared. Because again, we want to disseminate knowledge, don't we? And we want to share information. It helps us be better clinicians. It helps us work for our clients better.

Nick: Exactly. And look, the aim of all research and the more clear-cut empirical research papers, certainly for us as CBT therapists, for the journals, for the, of the BABCP, the aim of all of these including this paper, is that we’re helping people. We're helping people get better treatment. We're helping become better therapists ourselves or supervisors or whatever. And the aim of all of this work is to try and actually make sure that our treatments are safe, they're effective, that they're well implemented and that people are given the best opportunity they can of making improvements.

Steph: Oh, that's great. Thank you so much, Nick. Just before I let you go, is there anything else that you're working on that you want to talk about? Anything we can look out for?

Nick: I think, I mean, as a group, the group of us who wrote this paper about misconceptions, where it came out of, I was saying it was about supervision, but that was actually partly around some top up training for NHS Talking Therapies, which is ongoing, and has been really, really rewarding and I think there's going to be probably more guidance that comes out of that, including for supervising trauma focused treatments and cognitive therapy for PTSD in particular. So hopefully there'll be a f supervision paper in due course. In terms of new research, the thing that I mentioned a little bit earlier in the conversation was, around, thinking about treating complex PTSD and we're looking at that together with a really great team from Berkshire, led by Deborah Lee, looking at the role of compassionate resilience as well and compassion focused elements being provided either earlier in treatment or not provided earlier in treatment to see what, what impact that might have on treatment outcome.

Steph: Brilliant. Well, Nick, thank you so much. This has been such a great chat. Really thank you so much for coming on and talking to us.

Nick: Well, thank you for inviting me.

Steph:Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts.

If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at podcasts@babcp.com. And why not check out our sister podcast. Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT.

 Thanks for tuning in, and I'll see you next time on Research Matters. Bye.

In this episode, Steph interviews Liz Marks about the upcoming special issue on climate change in the Cognitive Behaviour Therapist.

They discuss the origins of the special issue and chat a bit about the Climate Change Special Interest Group (SIG) within the BABCP. Liz also gives an overview of all papers in the special issue, covering topics such as eco distress, transdiagnostic approaches, compassion-focused therapy, acceptance and commitment therapy, environmental identity, active hope, and climate cafes.

Useful links:

tCBT Special Issue - CBT in a Time of Climate and Biodiversity Crises

Liz is part of the Bath Centre for Mindfulness and Community mission and an affiliate of CAST- The Centre for Climate and Social Transformations

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 podcasts@babcp.com.

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

Transcript:

Hello. I welcome to let's talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT.

Today, I'm talking to Dr Liz Marks. Liz is a Guest Editor for our upcoming special issue “CBT in a time of climate and biodiversity crises”, which will be published later this summer in the Cognitive Behaviour Therapist.

Steph: Hi, Liz, welcome to the podcast.

Liz: Hi Steph. Thank you so much for having me on your podcast today.

Steph: You're welcome. So, before we get into the episode, would you tell us a bit about who you are and the work that you do?

Liz: Yeah, sure. So, I'm a senior lecturer at the University of Bath and I'm also a clinical psychologist, so I teach clinical psychology, but I also do a lot of research into relevant aspects of psychology and particularly CBT. So I'm also an accredited CBT therapist, I'm an MBCT trained mindfulness teacher and my work sort of covers all of those different aspects, both clinically and in terms of research.

Steph: So we're talking today, not just about one paper, but we're actually talking about several papers, which make the upcoming special issue in the Cognitive Behaviour Therapist. So this is a special issue on climate change, which you guest edit alongside Mandy Cole. Can you tell me a little bit about how the idea for the special issue came around?

Liz: Yeah, it's, it's really, interesting journey. I guess it sort of started in 2022, at the London conference. I don't know if you were there or your listeners were there, it was in the middle of that blistering heat wave. I had put in a symposium about climate change with Mark Williams at Cardiff and some others. And Mandy, who I didn't know at this point, had put in a request to run an interactive table. BABCP suggested we link up and have a round table, which is what we did. And that's where I met Mandy and also Claire Willsher who had been looking for some guidance from the organization around activism so Mandy and Claire were engaged in a consultation, with the BABCP members at the conference about what they wanted in relation to climate change and so that was all going on. And one of the things that happened was, Richard, Thwaites, who's the editor in chief at tCBT, spoke to Mandy there and asked if she might be interested in guest editing a special issue on climate change and me and Mandy, who had, who'd been talking at the conference, talked about that, and she asked me to join her, and that's kind of where it started.

Steph: Brilliant. Thank you. And did you want to talk a little bit about the climate change SIG? How many members do you have? What kind of goes on in the climate change SIG?

Liz: Yeah, okay. So the, the, climate change SIG was another outcome from this conference in 2022. And Mandy put in an application for the SIG at that point. It hadn't been successful previously, but it was accepted then. And, we were a temporary committee until 2023 when we had our first AGM and that was a conference in Cardiff. And now we've got over a hundred people.

Steph: Oh, wow.

Liz: and we, yeah, it's great. It's really exciting. It's building. And, so they, the SIG supported this special issue and we also are running various events. So we are running an event on eco therapy and CBT in September, we're supporting that and we're also going to be supporting the running of some climate cafes, which I can talk about a bit later as well.

One of the other really important things that came out of the conference and that goes beyond the SIG, in fact, is the climate statement that the BABCP have made about the organization's aspirations and guidance around climate change as a whole. I think it's really important to mention this. I'm not sure if your listeners will all be aware, but they made it really clear there that BABCP recognizes we're in a climate and ecological emergency and that we all need to take action on climate change, regardless of what our roles are. And recognizing that CBT has the tools to alleviate suffering, but that we also need to develop new ways of working. So I think that's really important and also is well aligned to what we're doing with the special issue.

And one last thing that SIG has done that's really interesting that your listeners might be interested in is that people in the Climate SIG have been interviewing the leaders of the organization about what they think is important about climate change. So President Saiqa Naz, President Elect Stirling Moorey, and the CEO, Tommy McIllravey, and they all talk about feeling passionately about climate change as individuals, as well as for the organization. So there's a real energy around this at the moment.

Steph: Okay. Brilliant. Thank you. So, if we get into talking about the special issue, then it's full title is CBT In A Time Of Climate And Biodiversity Crises. So it has eight papers in the issue, and it also starts with a really lovely introduction from yourself and Mandy, which really sets the context of the issue and how all the papers fit within it. Do you want to start talking a bit about some of the papers and why they're significant.

Liz: If I could just start by setting all of the papers in a particular context, which is the recognition that we are living at a time where we're facing significant threats and losses from climate change and the biodiversity crisis. And we wanted these papers to drive forward our understanding, offering original and pioneering ideas about what CBT can do in this context. And I think we, we talk about the distress that people might experience when aware or experiencing the impacts of climate change and related issues, which I will probably refer to as eco distress as we go through. but I, I think it's really important that this isn't some sort of diagnosis. It's referring to the experience of challenging thoughts and feelings in response to what is really happening, so just as we might have an emotional response when we are living with a chronic or terminal illness, and reality cognitions about that, we see that we're living with a, in a planet, who is also facing a chronic health condition, a sort of planetary health crisis and it's really important I think that we recognize that the thoughts and feelings that people have aren't pathological. They're actually showing a real awareness of what we're all facing.

Steph: The first paper that we were going to talk about was the paper with Mark Freeston and Claire Willsher. And this is quite an unusual paper in that it doesn't read as a research paper, but it is Claire's experiences as a climate change activist, and then Mark’s responses to her with the kind of academic evidence backing up her kind of personal insights. Do you want to talk a bit more about that and start us off?

Liz: Yeah, this is a really unique paper. And I think it's really helpful to set the scene as well because it ties our understanding of people's emotional responses to climate change. And so something I think that we can all relate to as kind of a citizen of the world of somebody who is aware about what's going on. But Claire brings to it the perspective of somebody both with the lived experience and with a psychological understanding as a CBT therapist, so she's able to reflect on her thoughts and feelings about climate change and how that shaped her decisions to engage with activism as well. She's very brave and open about her personal journey with difficult eco emotions and I think what, what Mark does really well is to show how and why these experiences might arise by linking them to different aspects of the evidence base and it's, it's really clearly shows how therapists are not going to be immune to climate change or the emotions that they elicit. And I think something that's maybe really relevant to a lot of CBT practitioners and more broadly to therapists around the world is, many of us go into this because we're tuned into suffering. And we, we wish to alleviate that suffering in some way we wish to show compassion and care for others. And something that climate change does is it, it threatens people's health and wellbeing, particularly people who are more vulnerable. So it may well be that people who are working in this area could even be particularly tuned into the painful emotions that elicits for themselves as well as others. And I think what this paper really beautifully shows is how important it is to make sure that therapists have the support that they need, and that the tools they could use for that around self-reflection, self-practice, supervision, personal and community support are all going to help them navigate their own eco emotions.

Steph: Brilliant. Thank you. So that's actually quite a hard paper to follow then, because as you say, it brings out a lot and will probably bring up quite a lot of personal feelings for CBT therapists too. So do you want to talk about some of the other papers in the issue now and kind of what comes up after this one?

Liz: Yeah, absolutely. And I guess just to speak to that point, Steph, I think what this paper really shows and maybe one of the key take home points from the whole special issue is that if therapists are going to be working with people who are reporting painful ecological emotions, then they are going to need to understand what their own response to the climate crisis is. If you're going to have the capacity to validate and, work with a patient on something really difficult, if that elicits something in you and you're not familiar with it, that's going to be really difficult for you. So there's this sense in which it's really important for all of us to know and understand how we're feeling.

Steph: Yeah, what a great point, thank you.

Liz: yeah, so the papers do cover a wide range of things. I think to, to start from sort of looking at this transdiagnostic perspective. So, moving away from this idea that maybe we need a, a new model or a new way of diagnosing eco distress, which I don't think is appropriate is that actually we can use existing ways of understanding distress, in different contexts and trans diagnostic processes are one of those. And Mark Freeston, has, has, with other colleagues, written a paper that looks at uncertainty intolerance and its relationship to eco distress, using empirical work and a statistical approach called network analysis- which I won't go into, but if you're interested, it is well explained in the paper. One of the things that's really interesting here is that although uncertainty can often be associated with more distress in certain conditions like anxiety problems, in terms of people who are experiencing eco distress, uncertainty actually seems to be associated with less distress. Which makes sense in a way, because if you're able to think, oh, maybe climate change isn't happening, maybe the worst outcomes are really uncertain, then you're going to feel less scared and less distressed. And I think that finding, which is different from what one might expect in other aspects of clinical research, emphasizes why it's important to do empirical work in this area and not just assume that things will translate directly. And the other thing that Mark's paper does is it replicates a lot of work that's been done elsewhere, that eco distress is quite strongly correlated with pro environmental behaviour. That is the behaviour that we all need to be adopting in order to see the social transitions that we need to see to reduce carbon emissions, so that really highlights why eco distress is perhaps motivating and important, and so we don't really…what we need to think about is not necessarily about getting rid of it, but rather navigating it, learning to relate to it differently.

Steph: Okay. So thank you for summing up Mark's papers so succinctly. How did these findings relate to any of the other papers that are in the special issue?

Liz: I think this idea around eco distress being not pathological, being understandable and potentially really important in terms of motivating pro environmental behaviour is really drawn out in a couple of papers that talk about third wave approaches and how we might adapt those, for working with eco emotions.

So Mark Williams and colleagues talk about compassion focused therapy and they focus interestingly on a group of people that maybe we don't normally think about as, as needing support, which is climate scientists. But just as healthcare workers were at the sharp end of working with the COVID pandemic, climate scientists are now on the front line of the climate crisis. They are the ones that are reading probably the scariest scientific findings and recent reports have shown that this is having an effect on, on their health and wellbeing. So CFT here is offered as a framework to help understand how this group of people might be feeling and how they can relate more kindly to their experiences, without, without necessarily saying that they shouldn't be feeling that way. And another, model that's quite useful about thinking about how we relate to emotions and distress is of course ACT, Acceptance And Commitment Therapy, and Mark and Victoria Samuels then explore adapting ACT for eco distress, and how it could be used to increase flexibility, openness, and a more aware relationship with experience and also how that pertains to the values that people hold. And I think understanding values and meaning is so essential to understanding eco distress, because often people will feel distressed because they recognize that the things that they hold dear the things that they really value, like, fairness in society or protecting the natural world, are really threatened by climate change and its drivers. And, and I suppose building on that is a paper by Ines Zevallos Labarthe and myself, where we explore this idea of moral injury or moral distress. I don't know how familiar your listeners will be with that. It may have, they may have come across it in work with veterans or again, healthcare workers, but it's where we either witness or even perpetrate something that violates our core values, our core moral codes and the findings from this paper suggests that, at least some aspects, and for some people, a lot of the experience of eco distress is driven by this sense of relational betrayal and moral distress because governments and those in power are failing to act in line with science. And that is causing them distress and anguish. And again, that perhaps is particularly interesting because it has ramifications for what we do as CBT therapists in the room and how we understand the distress, but actually beyond that. So, you know, some might argue that by not acting in line with the science, governments and people in power are failing to protect human rights. You know, the right to safe life, and an argument that was actually mentioned in a recent legal case is the right not to be subjected to cruel, inhuman, or degrading treatment that causes anguish, and one could potentially argue that moral injury is a form of anguish. So these are some of these new ideas that I think need drawing out and further investigation, but it's sort of pointing the way towards why this area of research is so important beyond CBT as well.

Steph: one thing struck me when you were talking about one of the papers there about the climate scientists was not just that they must be reading really the scariest facts and figures and having the knowledge about what is going to happen to the world, but also the backlash that they must face against that as well and so many people telling them that they're wrong or that they don't believe them. That must be really difficult.

Liz: Yeah, I think that must be very difficult and I think there is a real challenge in this area about how we communicate and what we communicate to people, you know, as I said, right at the start, becoming aware of this stuff can be really scary and it can feel extremely overwhelming. So to expect people to turn towards and absorb all of the information that's being given to them may be a really big ask. As the science seems to suggest that people who are more aware and have greater proximity to climate change, both cognitively and experientially tend to report higher levels of distress. And that's why it's so important to, you know, outside of the therapy room. Think, okay, well, this is going to be happening more and more, how can we support this? This distress. So people feel able to turn towards this and make the changes that we need to see. It's, it's a really, really, really important issue.

Steph: And were there any kind of surprise findings or insights that emerged from contributions to this issue that you maybe hadn't expected?

Liz: Yeah, I think there are, there are three other papers that offer some really interesting new perspectives that I think some listeners may not have come across. And these are ideas around environmental identity, a type of eco therapy known as active hope and climate cafes. I'll just talk about them each briefly cause, cause they're related, but they're a bit different.

So Thomas Doherty and colleagues describe a case study where they talk about environmental identity which means how people see themselves in relation to the world. It's akin to this idea of nature connectedness, and how much part of nature you feel, how important the natural world has been in your upbringing, in your daily life. It isn't relevant for everyone. I think that's important, but for some people, it's actually a really big driver of their distress and also perhaps their motivation and inspiration to be involved or get active or be an activist. And he explains ways in which you can bring environmental identity into the awareness of someone and use it as part of formulation and use it to support your therapy in really helpful ways, that can actually mitigate the distress by again aligning values and action. So that was really interesting. And then Rosie Jones and Chris Johnston describe a methodology that that already exists called active hope, and it involves cognitive work, but also, systems thinking ecology, wisdom traditions, and things that may seem really far out there for CBT therapists, but what they do beautifully is they align the processes and proposed mechanisms of active hope with CBT. And you can see there are really strong resonances between the two. And by doing this, they show kind of skills and ideas for bringing nature into therapy in a way that's consistent with CBT and also offer new ways of working with eco distress, some of which may actually feel like they could fit in quite well with your standard process. And both of these, I think point to why CBT perhaps needs to start to learn a bit more about the profound relationship between human and planetary health.

And then the last, the last paper is one that I wrote with, Luis Calabria. And this is about, again, taking these ideas outside of the therapy room and into the community. So if this distress is going to be something that isn't necessarily clinical, but it's widespread because it's something we're all facing, we need to find ways of helping people to navigate their emotions, perhaps in new and more accessible ways. And climate cafes are a space that are held in a non-clinical setting, lightly facilitated where people come and just talk about how they feel about climate change. So it's not an action space, it's a feeling space and this research was qualitative and looked at people's experiences. And what it showed is that just by sharing how you feel with a group of people who, perhaps feel similarly, could really normalize the distress and, and build a sense of community. So moving away from a lot of the isolation that people often feel when they're worried about climate change. But it also seemed to help people build a sense of compassion for themselves and for others. And even for others who maybe don't believe in climate change or have a different point of view and that really alleviated some of the most distressing aspects of what they were experiencing. But none of these things will cure eco distress because that's really not what we can do. The only thing that cures eco distress is going to be if we stop climate change, which means we stop burning fossil fuels and that we protect the natural world. That's, that's the cure for eco distress, but we can find ways to live well with it and we can find a way to be resilient in the face of these challenges and we can find a way to actually use it to motivate us to move towards the kind of changes we probably all want to see regardless of who we are.

Steph: great. Thank you. Well, in the special issue, there are so many great papers that have come out of that, and they cover such a wide range of topics and let you say some surprising ones, some maybe slightly left field ones and some kind of really empirical evidence as well. So it's a great issue and I really, really recommend that people go and read everything in the special issue, not just the ones that they might pique their interest because there are some really, really good bits of information in there. so I was just going to ask you, what was it like being the guest editor of a special issue? How did you and Mandy commission the papers you wanted to include? How did you find the experience?

Liz: it was really fun and, and exciting and hard work, but good hard work.so Mandy and I met quite a few times over a few months to identify people working in the area, who might have, have, some, some work or some ideas that they would like to publish with us. and we, planned a sort of two-phase approach. And one was to invite people that we had identified as doing really relevant work. and then to put out a call for papers. but we had an overwhelmingly positive response from everyone that we invited. So, we ended up with these eight papers, without needing to go to a call for papers. So that's what we have in the special issue now and with incredible support from you in particular, Steph, helping us navigate the whole thing and, and also from Richard, which really allowed us to kind of do everything smoothly. So if anyone's got an idea or is thinking about it, I'd really recommend it. Cause, it was a really interesting, and exciting thing to do.

Steph: Great. It's great to hear that you really enjoyed it cause we love doing special issues at tCBT cause they're just a really great way to get really good ideas together in a really nice, coherent way. And I'm glad that this issue really came together really well.

Liz: I think it works for these kind of areas which are new and emerging, and you can sort of start to pull things together and start to kind of get a bit of a map of the landscape and all of the places in the landscape that definitely need more research, which is most of this landscape, I would say.

Steph: And this leads quite nicely into my next question then, which I think we've touched on already. What's the impact that you hope that the special issue will have on the world of CBT? What do you think CBT therapists can learn from this?

Liz: Yeah, I mean, I'll go back to my first point, which is, I really hope that what people will take away from this is that the reality upon which the distress about climate change and ecological degradation is happening is terrifying. People are suffering. There, there is, there's already been a great amount of loss. Vulnerable and more marginalized people are suffering the worst impacts already. And this is going to get worse. These are the predictions and that that's scary. And so feeling scared, feeling anxious, feeling grief about what has been lost, feeling angry about inaction, even feeling guilty or ashamed yourself. I mean, living in the Western world, it's, it's quite difficult not to have a carbon footprint, all of these are really understandable and rational feelings, and I, I really hope that that is what people will, will take away. And I think it may be going, you know, beyond, or outside of climate change is maybe this speaks to a wider issue in CBT, where perhaps it's thinking about moving a little bit away from a medical model of distress that has its place. It's really useful and it's very familiar. So it's not about getting rid of that, but it's about perhaps bringing in a new perspective as well. And we see that in transdiagnostic approaches, versus disorder specific models. And that it's possible to understand and respond to distress without medicalizing it and that's important when we're thinking about, like I said, maybe there are plenty of ordinary people who won't meet any kind of clinical criteria, but who are distressed and might benefit from new ways of thinking about this. So it brings up some interesting ideas about what the role of a scientist practitioner is and what CBT is for and what it can look like.

And that isn't about reinventing the wheel, we've got incredible models and skills and techniques, but it's about maybe using them in slightly different ways. I guess, I hope that the data driven technical papers will appeal to those who are interested in the technical aspects of CBT that's there for, for them, shows it's grounded in a scientific basis and I hope for practitioners, it'll help them see why it's relevant, what they might need to take care of themselves, maybe to think about asking about it when they meet a client who's in distress, particularly younger people, it seems to be more relevant to them. And yeah, so to start to integrate some of those ideas in, in formulation assessment and practice. And then maybe it's relevant outside of the world of CBT, outside of the world of therapists, to people who are involved in working in climate change, charities, scientists, the wider world thinking about maybe we need a bit more emotional literacy to support our resilience in the face of climate change, to think about how we communicate what's going on and how we support the, the people that, that are distressed about it and that it's not just a negative thing, that eco distress may well be a guiding light that can help us move towards living in a way that supports our values and supports a kind of just and sustainable world.

 Steph: what do you see as the next steps or future directions for research in this area?

Liz: I think it's wide open and I think that's really exciting. I think we need an army of people to start working on this. So we've got lots of theoretical papers suggesting the types of mechanisms and processes that, that might be helpful and that needs testing. We've got ideas about interventions that might help. And that needs testing too. I think we need more clarity around what eco distress is, when eco emotions turn into something that's more debilitating and why I think we need to consider what a good outcome might be for someone who's eco distressed. If it's not about getting rid of all of the emotions or even the distress itself. And I think thinking about the importance of the relationship with the natural world, there's loads to do.

Steph: Yeah, that's like a whole other special issue, isn't it, on future research and things we can do.

Liz: Yeah. Yeah, maybe, maybe.

Steph: Well, maybe we'll be back here in a few years’ time building on what you've done before and what's come next. That would be really exciting if we could get together again to talk about different changes that have happened in CBT since this special issue.

Liz: Yeah. I'd love that.

Steph: Yeah.

Liz: that'd be great.

Steph: and so very finally, do you have any further work coming up that you'd like to talk about anything you want to plug while we're here?

Liz: I'm working with a colleague in the States at the moment, Susan Clayton, and we're developing a way of measuring moral injury in relation to climate change. So we're hoping to get that out in the next few months. I'm thinking about developing some work around enhancing resilience in young people with eco distress, particularly based on third wave CBT type approaches and I'm working on a grant at the moment with people at the University of Bath, looking at how young people, and their shared values are related to their wellbeing for environmental behaviour and ecological emotions. So those are things that are in the pipeline at the moment.

Steph: Great. And I'd also really recommend anyone who is interested in the climate change to come seek you out and have a chat to you at the conference as well which is coming up next week in Manchester.

Liz: yeah, absolutely. So we will have a climate change table and, Mandy and I will be there and lots of other members of the SIG will be on the table. And we've also got a symposium there on the Wednesday, so please come along. yeah, the more members, the merrier. We're very friendly.

Steph: Brilliant. So Liz, thank you so much for talking to me today. This has been brilliant.

Liz: Ah, thank you. It's been a real pleasure, Steph, and, and thank you very much for, supporting this, this special issue and bringing climate change into greater awareness of the BABCP and its membership.

Steph: No problem.

Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts.

If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at podcasts@babcp.com. And why not check out our sister podcast, Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT. Thanks for tuning again, and I'll see you next time on research matters. Bye.

In this episode of Research Matters, host Steph Curnow talks to Dr. Alex Lau-Zhu, lead author of the paper “Flashforward Mental Imagery in Adolescents: Exploring Developmental Differences and Associations with Mental Health,” published in Behavioural and Cognitive Psychotherapy.

Alex discusses his research into flashforward mental imagery—vivid mental pictures of future events that can be intrusive and emotionally powerful. We explore how these flashforwards relate to anxiety in adolescents, why mental imagery isn’t always a focus in CBT, and how young people may benefit from imagery-based interventions.

Guest Bio:

Dr. Alex Lau-Zhu is an MRC Clinician Scientist Fellow at the University of Oxford's Department of Experimental Psychology and a clinical psychologist supporting young people affected by trauma. His full list of publications and research areas can be found here: https://www.psy.ox.ac.uk/people/alex-lau-zhu

Links & Resources:

Read the paper: “Flashforward Mental Imagery in Adolescents: Exploring Developmental Differences and Associations with Mental Health” - https://bit.ly/3Eysxd0

Explore more from Behavioural and Cognitive Psychotherapy –https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy

Find our sister podcasts and all our other episodes in our podcast hub here: https://babcp.com/Podcasts

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Music is Autmn Coffee by Bosnow from Uppbeat

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License code: 3F32NRBYH67P5MIF

Transcript:

Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT.

Today, I'm talking to Dr. Alex Lau-Zhu, Alex is lead author on the paper “Flash Forward Mental Imagery in Adolescence: Exploring Developmental Differences and Associations with Mental Health” which has been published in Behavioural and Cognitive Psychotherapy. I really enjoyed this chat with Alex. We talked all about his paper, and we also talked about maybe why mental imagery isn't explored so much with adolescents, or even in CBT in general. It's a really interesting listen, so I hope you all enjoy.

Hi Alex. Welcome to the podcast.

Alex: Hi Steph, thank you for having me.

Steph: You’re welcome. So, before we get into talking about your paper, would you mind introducing yourself to the listeners and telling us a little bit about who you are and the areas you work in?

Alex: Yeah, of course. I'm currently an MRC clinician scientist fellow at the Department of Experimental Psychology at the University of Oxford, and I also work as a clinical psychologist in our local county in Oxfordshire, supporting young people who are affected by trauma.

Steph: Thank you. So we're talking today about the paper that was published in the last issue of Behavioural and Cognitive Psychotherapy, which is about flash forward mental imagery in adolescents. So could you tell us a bit about how this paper came about? Was there any particular motivation for the research?

Alex: Yeah so I work with a lot of young people in my clinical work and often find that they sometimes struggle with expressing themselves, sometimes around identifying what goes on in their minds in particular, which is really a key part of doing CBT, for example. And speaking to other clinicians, also working with young people, it seems like actually sometimes they do find thinking on mental images perhaps a bit easier to thinking about, for example, using visual mediums or drawings to express how they feel and what they think, but sometimes it goes to be around talking about mental images that they experience inside their mind, just describing what is it that they see, what is it that they hear, as a way to then better understand some of those thinking processes or what we might call as distortions in CBT.

And that led me to think kind of more broadly around how much do we know about these sorts of processes in young people. And actually, we know incredibly little. There's some really I think exciting work that has happened in the last 20 or 30 years in working with adults and doing CBT with adults around thinking about mental images, not just verbal thinking. But that knowledge somehow hasn't really trickled down to working with young people as much. So I'm really curious more generally in, in understanding mental imagery in young people and whether that can help us improve our treatments.

Steph: And would you mind just explaining what flash forwards are for anyone who might not be aware of the term?

Alex: Yeah, I think it's probably a term that if once I explain what it means, then you might realise it's something that you're familiar with, you just perhaps haven't used this term to describe that before. So, the simplest way to think about it is the opposite of what a flashback would be. So a flashback is, you know, often a mental picture, often very visual, of the past, of a stressful, traumatic past event that just popped back into mind. So we think of flashforward as the almost the opposite of that. So again, mental images that just pop back. They're depicting something stressful and threatening, but they are about the future rather than about the past. And so perhaps another term that have been used in the literature or in clinical practice is intrusive images that are specific around the future.

So one example would be, let's say, perhaps, last night before coming to the podcast, I had a flash forward of being on this podcast and perhaps, I don't know, my, my voice breaking, the technology not working, you know, something happens and maybe it's going live and I could kind of see your face or the laptop running out of battery. That's what I can see in my mind. And naturally that if someone has a very sticky image like that, then it's going to be very anxiety provoking. But if we take that to clinical case, let's say with young people that I work with, they might have flash forwards of having to do a school presentation later in the week and feeling like people are not really paying attention because they find that presentation boring, maybe laughing at them for not really knowing perfectly what they're talking about. So that's perhaps that, that brings about in terms of social anxiety, for example, and we can think about different types of flash forwards of different content for a range of anxiety presentations.

Steph: Yeah, it's interesting you saying that mental imagery hasn't been explored in adolescents so much because you would imagine the kind of flash forwards being quite prominent in clients with OCD, for example, you would imagine that they would often quite have flash forwards about what might happen if I don't do this or if I don't do that. So it's interesting that in adolescents has not been explored so much.

Alex: Yeah, and I don't really know why exactly that's been the case. I think there's something about imagery work that, that, well, you know, by now we know that imagery can be really emotionally powerful, in our therapies. I’ve been reading actually some very old work by Aaron Beck, who was still developing CBT in the early 70s. And actually, I didn't know, maybe other people do know, but he had a psychoanalytic sort of background right before breaking into CBT. But a lot of his clinical work in the early stages of CBT used loads of imagery. So, asking his patients about imagery, finding ways to interrupt those images and manipulate those images, changing the ending of a lot of images, like the way you would do that in imagery rescripting, for example, for those who are familiar with that technique. He was doing a lot of that sort of, not typical kind of CBT techniques and somehow then that got lost as CBT became more developed and disseminated and other researchers, you know, expanded on that thinking. I don't really know why. I wonder whether there's something about imagery that, that it kind of feels like it has too many links to psychoanalytic thinking, thinking about dreams and fantasies and CBT was perhaps trying to move away from that, but I think Beck always said that cognition is not just verbal thinking, it can also be imagery. Somehow the verbal thinking took over as CBT expanded, and actually, it would be great to be able to talk to Beck about what he was thinking.

But I think for young people in particular, imagery is helpful and powerful for all ages, I believe. But for young people, I think, particularly relevant because I think it could be really creative work, it could be really imaginative, it could be really playful and fun, and young people often like therapists that has that kind of greater sense of agency on what they can bring to therapy.

Steph: So I imagine imagery work as well must be really subjective too, and so that must be really helpful for adolescents to be able to sort of think, oh my therapist isn't just going to tell me what to do, they're going to ask me, you know, how to describe something, and if I can't, imagery might be a really helpful way to kind of get this out and to explain myself.

Alex: Yeah, exactly. I mean, how you might want to change the content of an image, you know, from a more negative to more positive ending, for example, that the young person can become the director of their own film and I think at an age where agency is quite important, to me, it feels like imagery techniques really lend themselves to that developmental sensibility.

Steph: Yeah, absolutely. Okay, so we'll get into talking about the paper a little bit then. You very helpfully laid out some very clear hypotheses in your paper, which were very helpful to talk about what you were going to be investigating. Would you mind just going through those and explaining what they were?

Alex: Yes. So we were interested in exploring flash forwards, this sort of different mental imagery about the future and whether that relates to anxiety in young people based on some work that has been done in adults showing that there is a link, but no, let's just do the kind of first step, because there's been so little done in the area. So, is there a relationship between flash forwards and anxiety in young people? But we're also, we're very clear on asking that question with a group of young people to perhaps it's more reflective of what we might see, in terms of presentations in everyday CAHMS and often some of the complexities that comes with working in CAHMS are often linked to things like neurodiversity, like diagnosis of autism, or a background of some people might call it like developmental trauma or an early history of maltreatment, such as abuse and neglect. Those are the sort of developmental differences that often make treatment a little bit trickier, makes engagement a little bit trickier. So we wanted our sample to kind of reflect that actually in terms of generalisability, and there is some interesting work in terms of memory. So understanding emotional memories in autistic kids and autistic adolescents, as well as those young people with trauma backgrounds that actually made that thought, Oh, maybe they might have a greater propensity to also experiencing flash forwards.

So let me break it down. In the context of autism, one of the challenges I often describe relates to executive functions. So, the harder that one is going to struggle with inhibiting information, perhaps that means that flash forwards are going to be more likely to keep popping up. Right? And in the context of trauma, there’s some suggestion that people across all ages with a trauma background might develop a tendency to cope by avoiding negative thoughts and negative feelings. But actually, we know that can be quite counterproductive. We know that the more you try to suppress something, the more it's going to bounce back. So if we apply that to flash forwards, if young people with trauma background have that tendency to try to avoid and suppress those flash forwards, perhaps that means they're going to bound back even more. So, in summary, we're thinking about two groups of young people where flash forwards might be more prevalent, but perhaps through different mechanisms.

Steph: So you were actually looking at quite a range of adolescents then, in this study. Would you mind telling me a bit about how you recruited them? Was it actually quite difficult to get people to take part in this study?

Alex: Well, the study actually happened in the middle of COVID. So it was planned before, then COVID happened, and our initial plan was actually a more kind of extensive interview based in person approach, but with COVID, you know, doing research and taking part in research was challenging for everyone which is why we then swiftly adapted to a more kind of simpler survey approach. But I think we still were able to capture some important findings.

Steph: That's probably answered my next question then, which was going to be, were there any challenges in conducting this study, especially as you had such a diverse group of adolescents? COVID would be one of the major challenges, I would imagine.

Alex: Yeah, I mean, as I mentioned before, we're really keen on, on thinking our diverse sample with a diverse background in terms of those developmental differences that meant that we had to engage with a range of services and develop partnerships, for example, with CAHMS services but also with social care, particularly for the young people that had that trauma background that I mentioned, schools, and also using online platforms. But we managed in the end.

Steph: Yeah, I've talked to Sandra Krause, who was on the podcast a while ago, and she highlighted the peril sometimes of trying to do online surveys, particularly through social media and how sometimes recruiting through Twitter doesn't always work.

Alex: No, and actually there are increasingly more problems around imposter participants, sort of fake participants, and that's the real issue but thankfully that was not an issue for my research at the time. The imposters were not as developed and included at the time. And I think it was a time where there was a lot of awareness around the importance of mental health around that time, actually. So, in some way, that also helped with the study.

Steph: Yeah, brilliant. So can you talk a little bit about what you did then? And then what did you find? And was there anything you found that was surprising?

Alex: Yeah. So, as I mentioned, we use a survey approach. So, a combination of asking questions to the young people directly. So these were adolescents age 10 to 16, but also asking questions to one of the carers or parents. Everything was done online because of the context. So they had the flexibility to, to complete those measures at their own time. And what we found mainly, well, first of all was that- so do you remember I mentioned those hypotheses that perhaps some young people will have an increased propensity, for example, to experience flash forwards. We actually did not find that was the case. So autistic young people or young people with the trauma background or typically developing ones, they all seem to have comparable levels of flash forwards. It was the flash where they describe were equally emotional, equally frequent, equally vivid. But what we did find was that across the whole sample, as the intensity of those flashboards increased, so the more emotionally intense they were, the more anxiety problems young people exhibited. Actually, both in terms of their own self report but also based on the description from the caregiver parent, which provides with converging evidence that there is a link between those two measures. And that fits with, of course, what we know so far from the adult literature, right? That flash forwards are particularly important for anxiety. And in some ways sounds quite intuitive, right? Like if you're going to be having mental images of threatening events, you know, things that are really important to you, but that you perhaps think in some way will go really wrong, and you have that frequently all the time. In the same way that a flashback makes you relive a past event, a flashforward can help you pre live a future event. And then over time that unsurprisingly can lead to more anxiety problems, right? Your body's much more gear and more on edge. You're worrying more. Perhaps you might start avoiding such a situation. So, as a result, you might start acting like that future threatening event. It's really real and it's going to happen because it keeps popping up in your head.

Steph: So it's very much like doing a safety behaviour when you have social anxiety, isn't it? Where you might start to avoid certain situations because you've already thought that this is what's going to happen.

Alex: Yeah. Yeah. So our sample was quite a broad sample, right? We didn't just have a sample from CAMHS. So it's very different from doing research that just focuses on young people with a diagnosis of anxiety disorder, for example. So we don't fully understand how do these flash forwards then lead to an anxiety disorder. We know that they lead to symptoms. But perhaps there might be other processes that are needed, to then turn symptoms into a disorder. So, of the sample that I presented, we didn't have diagnostic information. We only had symptom measures, so we can't really tell who would have better diagnosis, but, I imagine quite a few probably from those that came from a CAMHS setting, but we don't have that information.

Steph: And did you find any kind of similar themes that came up in the kind of imagery that people were describing and in their flash forwards?

Alex  Yeah, that was another interesting finding. It seems like a lot of the adolescents were thinking about events related to career, about education, about future professions, and that perhaps matches with being in secondary school. And I think a lot of the learning around what, why are you going to choose this special subject in GCSE? Why are you going to choose these A levels? So, I think, in that sense, it makes sense with the developmental preoccupation.

Steph: Yeah. And I think for young people as well, at the moment, the future feels very uncertain for them, doesn't it? You know, they're constantly being told that there's no hope, you know, the planet is burning, there's going to be no jobs. So it would make sense maybe that actually. There probably is quite a preoccupation about what my future is going to look like in terms of job and career and profession.

Alex: And the data was during Covid so I imagine that preoccupation was even more pronounced during that time. So, it'd be interesting to see whether doing that study now perhaps outside of Covid would be different. But as you mentioned there are all these big world scale problems and maybe some of those would feature in terms of content now.

Steph: So given these findings then, what do you think are the implications for clinical practice and future research? I always ask people, what impact do you think this paper will have on the world of CBT?

Alex: Yeah. I mean, I think it's very early stage. I think just developing that curiosity for asking about mental images and clinical practice. I think we don't ask enough, even when we work with adults, you know, often images for a lot of people, it's like mainly restricted to, I think, PTSD, maybe sometimes people think about it in social anxiety, but often it's not really used that much. And so I think just that curiosity on thinking about cognition and thought, not just as the sentences that we write down in words, but also in images. And I wonder whether the more we ask young people what they see in their mind that they might be able to more readily express and access those cognitions more, more so than verbal methods that we rely on. And I would say that there's so much more research we need to do in terms of how best we measure these things in young people, how do we adapt interventions in young people. But given that we know a lot of really good, imagery-based techniques could be used in adults, there's no reason to believe that they wouldn't be useful for young people. So I think if someone has gone on some training, for example, using some imagery techniques for adults, whatever condition that is, there's no reason to think that’s not going to be applicable to young people. And in fact, I would say, potentially even more applicable for young people.

And I think the findings about autism is quite important. So, in my experience, talking to other clinicians that have worked with autistic individuals, there’s a bit of a myth, I think, that at least for some autistic people, they can't really use mental imagery which I always found that kind of quite interesting, because in my experience working with autistic individuals, I can't think of one where imagery wasn't useful, and obviously that is just my anecdotal experience and that's something that my, in my research, I'm trying to explore a little bit more. And I suppose there is probably some that are amazing imagery and some that really struggle and therefore, I think just because someone has a diagnosis, I think we should not rule out the use of these techniques that might be particularly useful, particularly for those are really good at it.

Steph: Yeah, and maybe that goes back to what we touched on before as well, and maybe it's about having the really good therapist that will try that with them and try and bring that out and work with them to draw that out rather than just assume because they have a diagnosis that maybe that won't be applicable to them.

Alex: Yeah, exactly. And we know from lots of research now that people often don't spontaneously talk about imagery, but you actually really have to ask. There's lots of reasons why imagine I guess, I guess, as humans in our day to day life we don't really talk about our images, but we talk about our thoughts. And so that's kind of like the default and clinically in clinical conditions, some images might be linked to shame for example, and you might not want to share them unless the clinician normalises the experience. So, you asked me about the impact in the CBT world, I think just to begin to have that curiosity and asking about images routinely, we're doing our initial assessment, for example, we're just beginning our CBT work.

Steph: And I think that's really great advice for clinicians as well, it's about having the openness and that curiosity. I think it's something we should all try and bring to our work, isn't it?

Alex: Yep, I mean, I imagine that for some clinicians, they might be like, Oh, but what if they say they have images? What do I do with them? And obviously my paper doesn't talk about necessarily interventions, but there is. a really kind of rich set of techniques out there. Most of the writing is in adults, and I think that your journal actually has published quite a lot of work in mental imagery. Mostly in adults, I would say. I've seen recently papers on pain and other anxiety conditions and depression. And actually all of those techniques could be used for either dampening negative imagery or promoting positive imagery in young people.

Steph: So just going back to the paper then for a minute, is there anything you would have done differently if you could do this all over again?

Alex: Good question. I think it was a first step and our approach was very much let's ask the first question with the methods that we have available. But actually, I would say I would be rethinking the way we measure flash forwards in young people. We have relied so far on measures that have been proposed and used with adults, but actually we don't fully understand is the language used in those measures appropriate for young people? Is it really capturing the way they experience mental imagery and flash forwards in particular? Are there aspects of flash forwards that are not being captured that are unique to the adolescent period, for example. And actually, I'm doing some research now trying to develop a new measure that's more youth friendly in terms of language, but also more, can develop in consultation and collaboration with young people with lived experience of flashforwards and anxiety. Because otherwise I think we might be underestimating the impact if we're only measuring it based on an understanding of how things work in adults. And I think as most people who have some sort of psychology background would know that a correlation is not the same as a cause. I would have liked to, to do that study with longer follow ups, for example, so that we can understand what flash forwards at a given time really help us predict anxiety later. So, moving a little bit closer to think about causal links.

Steph: Brilliant. And as the journals managing editor, I'm always curious about this, how did you find the peer review process for this?

Alex: I think that as a whole with peer review processes, you know, you see the comments at the beginning and you're like “urgh I don't like this”. And then you cool down and it's often a really helpful conversation. It was definitely helpful. I'm trying to remember what are the specific points that, that really helped shaped the final writing. I think, it really made me think about, that we should be better at distinguishing intrusive images and flash forwards when they are quotation mark “normal”, you know, normal part of human experience. You know, we'll have images about things that we worry that just will pop up all the time, some people that work in cognitive psychology, in fact, have suggested that's just how, that's our default way of existing. We just have things popping up. We have images popping up that say something really important to us, right? That's how our minds work. Can we really differentiate those sort of images from the ones that we need to really pay attention to that are toxic and sticky? The ones that are then cause mental health problems. And do we have good measures that really distinguish those two? So, I think that's something that, that needs to be thought about a bit more. and that's why developing better measures, it's really important.

Steph: Yeah. Oh, brilliant. Thank you. And I'm really glad that they were helpful as well. I always think it's helpful to hear from other people's experiences about peer review process because it can be really daunting.

Alex: Yeah. I mean, I think of it as like, you know, whenever you might be giving a talk and then you have such a diverse range of people with different backgrounds in the audience and sometimes you kind of get bit of an odd question and a side question you've never thought of. I like to think of it's a bit like that in the sense that the review process will always be different depending on like, I think, who you get,

Steph: Absolutely.

Alex: And ultimately we need to be engaging in this sort of conversation with, like, all different types of research and different types of background. So I just see that as kind of part of that process if that makes sense?

Steph: Yeah, brilliant. And finally, I was just going to ask, what's next for you? Can you tell us what you're working on now? And is there anything we should be looking out for you from you in the future?

Alex: Yeah, so I've alluded to some of the things I've been thinking about already. So I think broadly describing two different streams. So the first stream is around continue to improve our understanding of flash forwards and mental images more generally and to do that, we are exploring using more rigorous design. So, as I mentioned, using longitudinal approaches. But also experimental approaches, studying this process is not just in kind of a laboratory type setting, but also naturalistically and understanding a little bit more, you know, why is it having mental images like flash forwards can then lead to anxiety problems in young people.

And the second stream is more around, thinking about how we can then change and modify these processes if they are relevant. So thinking are there interventions that not only be effective, but actually also appealing for young people that they actually want to use and do, and ideally also interventions that could be easily accessible, given the scale of, mental difficulties and the problem with access that are well known now.

Steph: Okay. Well, that sounds brilliant. Alex, thank you so much for coming on the podcast and talking to us about your paper. It's been really interesting to listen to you.

Alex: Thank you so much, Steph, for having me.

Let’s Talk about CBT - Research Matters is a brand-new podcast from the BABCP, hosted by Steph Curnow, Managing Editor for the BABCP Journals Behavioural and Cognitive Psychotherapy and The Cognitive Behaviour Therapist.

In this episode, Steph talks with Sandra Krause a senior PhD student at Concordia University. Sandra is lead author on the paper “‘Things that shouldn’t be’: a qualitative investigation of violation-related appraisals in individuals with OCD and/or trauma histories” with her co-author Adam Radomsky published earlier this year in Behavioural and Cognitive Psychotherapy. Sandra explains what is known about the cognitive model for mental contamination and how her research builds on this to explore what her participants with lived experience of OCD or trauma define as violations and the implications of this for clinical practice.

You can find Sandra’s full paper here: https://bit.ly/3YLyoUn

If you enjoyed this episode, please rate, review, and subscribe to the podcast on your preferred platform. Follow us on Twitter @BABCPpodcasts for updates and join the conversation. Have feedback or suggestions for future episodes? We'd love to hear from you! Email us at podcasts@babcp.com.

Useful links:

You can follow Sandre and Adam Radomsky on Twitter for more updates about their work or follow their lab at the links below:

@SandraKrause4

@AdamRadomsky

Lab website: https://www.radomskylab.ca/

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

Transcript:

Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT.

Today I am speaking with Sandra Krause. Sandra is the lead author on the paper ‘Things that shouldn’t be’: a qualitative investigation of violation-related appraisals in individuals with OCD and/or trauma histories published in Behavioural and Cognitive Psychotherapy.

Steph: Sandra, welcome to the podcast.

Sandra: Thank you. Thanks for having me.

Steph: No problem. So before we begin, would you like to introduce yourself and talk a little bit about the research that you do?

Sandra: Sure, my name is Sandra Krause, and I'm a senior PhD student at Concordia University, which is in Montreal in Canada. And all of my research that I've done as part of grad school has been in the anxiety and obsessive-compulsive disorders lab. So that's been under the supervision of Professor Adam Radomsky and really, yeah, we've been interested in trying to understand different cognitive mechanisms that are at play. I'm trying to kind of better understand different aspects of anxiety disorders, OCD. My particular interest is in kind of the crossover with trauma, ultimately, really, just so that we can improve treatments and better help people who are suffering from those kinds of issues, so that's kind of the broad strokes of what we do, and clinically kind of work to apply the knowledge that we learned from the research to evidence based approaches to working with individuals who are struggling with those concerns.

Steph: Okay. Brilliant. Thank you. So we'll start talking about the paper that you've just had published in BCP. So can you tell me a little bit about what the aims of the study were, and were there any particular motivations behind the research?

Sandra: yeah, so when I started grad school, my research interest was on trying to kind of understand, we know a lot about within OCD contamination related symptomatology, but there's kind of a sub section of those types of symptoms that we know less about, and it's called mental contamination. And so this is, we often see people wash excessively, feel dirty in response to kind of intrusive moral thoughts rather than in response to any kind of contact with physical germs or dirt. So, maybe having an intrusive thought about something like incest or paedophilia, or intrusive memories of past assaults, things like this that have happened to them and that that's the driver of kind of the contamination symptoms that they experience. And so coming into my PhD, I was really curious, there's a cognitive model of mental contamination that was proposed initially when sort of the symptom domain was newer, but there's a lot of aspects of the model that aren't super fleshed out. So, for example, a big part of the model is the fact that these feelings, this is feeling of dirtiness and the washing that comes up, comes up because of a perceived violation, but there's not a super clear definition of what is a violation? What constitutes a violation? What kinds of events are violating for people and why? And then also, as the name suggests, the cognitive model kind of proposes that it's the way that people appraise or think about those violations that lead to the symptoms of mental contamination, but there's not a ton of work yet too that's been done at, zeroing in on specific types of thoughts that are linked to mental contamination feelings after experiencing a violation, and kind of differentiating between the types of thoughts that lead to mental contamination versus other kinds of negative emotions that might come up after a violating experience. So things like shame or anger or sadness that you might expect someone to experience as well. And so that's kind of where my study came in was that I wanted to really start from the ground up and speak to people who have lived experience with either OCD or trauma histories and hear from them, how they define the construct of violations so that we could get a clear definition for the model.

And then also walking through past instances of violation that they've experienced to understand different types of thoughts that they have, different appraisals that they make, and how those appraisals are linked to different kinds of negative emotions. So, again, kind of differentiating between those that were associated with those feelings of dirtiness, disgust, contamination, and the ones that are related to other kinds of negative emotional experiences like anxiety, fear, anger, shame, Et cetera. So that was really the aim of aim of the study.

Steph: brilliant. Thanks so much. So, if we get into the paper then, I think that leads quite nicely onto your participants. I see from the paper that you interviewed 20 participants. Who were they and how did you recruit them?

Sandra: Yeah, so, the inclusion criteria for the study. So in order to be able to participate, we were interested in interviewing people who either met criteria for OCD or who met criteria for, we call Criterion A and the DSM for PTSD. And so this is people who have experienced a serious trauma, so either actual or threatened death or serious injury or sexual violence that they experienced themselves or witnessed firsthand. And so, in order to get participants, we have a clinical registry as part of the lab. So there was at the time of my study, there was also a randomized control trial happening in the lab for treatment for OCD. So, we advertised through that study to see if anyone was interested in participating in the study as well. And then we also advertised on Twitter and online. And so really we were just looking for people who had these experiences or kind of experienced these types of symptoms who are adults, so over 18, and who spoke English. So it was pretty broad inclusion criteria. And yeah, anyone who was interested reached out and then I had a phone screener with them and just went over those kind of symptom, sections of the Mini-International Neuropsychiatric Interview and confirm that they were eligible. And then we conducted the interview over Zoom with them. But yeah, these were just kind of people in the community. Some were seeking therapy, and some were just kind of interested in contributing to research.

Steph: And did you get many, people come forward from Twitter? I'm always intrigued when I see studies on Twitter and how much uptake they really have.

Sandra: Yeah, there was a bit of, interest. I would say that there was a lot more screening that was required of the broad social media ads that there was, again, we were just sort of in the ads were just describing the symptoms pretty generally. Yeah, so people can interpret that in different ways so that we didn't actually end up with a ton of participants from the Twitter ads. But actually ran into another sort of new research hiccup that we hadn't anticipated was bots that there was, we got one day like 300 emails from different Gmail addresses, that were sort of automated, I guess. The bots that had reached out about the study. So just, I guess, a caveat for anyone doing social media recruitment for research that to be careful about.

Steph: I hadn't even considered that. But yeah, I can imagine 300 emails is annoying.

Sandra: yeah, I mean, luckily for us, there was a screening call, so I was able to weed out all of those people through that, but, yeah, for people I know who have been doing just online questionnaire studies via social media that people kind of just go on, I guess there's automated ways of, getting whatever compensation at the end. So they go in and submit a bunch of responses and it's hard to screen out.

Steph: So going back to the interviews then, when you completed all the interviews, am I right in thinking that you did some analysis on the transcripts and then some apparent themes emerged from these interviews?

Sandra: Yeah. So the, again, because it was like a pretty exploratory study and we were going in pretty open ended because again, we didn't have like really specific hypotheses of what we were expecting to find because we didn't really know a lot about this area from previous research. So, yeah, I conducted the interviews, with pretty like broad questions just to get a sense of people's experience more or less and then, went in and used a grounded theory approach to the qualitative analysis. So, as the interviews were being conducted, I was also coding them and kind of adjusting the interview protocol based on what we were finding. And certain themes came out which was always nice when you see some consistency across participants. But yeah, we found kind of similar themes across participants in terms of, first of all, how they define violation, or what constitutes a violation. Most interestingly for me, we found similar themes in terms of, the types of thoughts people had about the violation so the way that they appraise the violation, and then also in terms of, the functions of the behaviours that they engaged in, in response to the violating thoughts or, experiences. So, yeah, so I guess, do you want me to get into the specifics of those?

Steph: Yes, I was going to ask you if you had any good examples that we can kind of really listen to and kind of picture, that would be great.

Sandra: Yeah, yeah. So, in terms of the definition, what I found really interesting was that across participants, every single person that we interviewed, alluded to the fact that in order for something to be a violation, it needed to contradict a previously held belief. So it wasn't sort of whether how bad something was that happened to you, how serious it was, how life threatening, how, how much it infringed on your body or your space, but it was really whether it violated or contradicted sort of the way that you saw yourself or the world previously to that experience. So, yeah, a lot of people kind of talked about, they thought they were a smart person, but then they experienced the situation and made them feel dumb or they thought other people were trustworthy and then they were betrayed and it kind of eroded the trust that they had in people or interestingly, on the opposite side of things, there was one participant who talked about how he had been assaulted and mugged at one point, but that he actually didn't see that as a violation because in his mind, that's something that could happen to people. So, it sort of reinforced a previously held belief he had about what was possible in the world. So I thought that was sort of interesting that it's, it's really this, this contradiction of your beliefs or your sort of expectations that makes an event feel violating or perceived as a violation. And then in terms of the appraisals, so there were kind of common themes in terms of appraisals of other people. So the way that people thought about others after experiencing a violation, the way that they thought about themselves and then the way that they thought about the future were sort of the 3 bigger picture themes that that came out of the appraisals. And so what we found was that when people talked about feeling dirty or disgusted or contaminated that that came up most often when people sort of in terms of the appraisals of the self, thought that they were responsible in some way for the violation, or thought that it was some indication of their self-worth. So, I'm worthless because of having experienced that, or I'm worth less than I was before. Or I don't bring anything to the table now that this is something that I've experienced, or, yeah had thoughts about and then the last one that was linked to the mental contamination feelings was this appraisal of permanence. So, this idea that I'm tainted forever now, because of this experience or because of this thought that I can't get rid of it. This has changed me now permanently because of that.

And then for the behaviours, what I found most interesting was that it didn't really matter what the actual behaviour was. People talked about all kinds of very, very specific behaviours that they engaged in. Some of them were similar across participants, but there was a lot of sort of unique from person to person behaviours or urges that they had. But what I found interesting about it was that the function of the behaviours were a lot more similar across people, even if the behaviour itself wasn't. So, whether it was, cleaning or washing or thought replacement or avoidance or self-harm that, even if the behaviour on surface level look different from person to person, for most people, all of these things either serve to kind of avoid or distract away from thoughts about the violation. To sort of punish the self or, or kind of, inflict some kind of yeah, self-punishment because of the violation that they felt that they deserved. Or to regain a sense of control. So to feel this thought that I can't control or this experience that happened to me in the past that I have no longer have control over. This is something in the here and now that I can do to try to regain a sense of control over that event, even if it doesn't actually impact it. So, whether that's washing or showering or arranging things, again, self-harm came up with a couple of participants. That all of these things in the here and now made it feel like, okay, I might not have control over the original thing that happened, but I can regulate that anxiety and sort of get a sense of control in the here and now, by doing these different behaviours.

So, those were kind of, yeah, I guess the spark notes of the different themes that came up. But, yeah, the take home, I guess, was that there were different appraisals, that seemed to be linked to different emotions and that we were able to zero in on specific ones that were linked to mental contamination for the participants.

Steph: and apologies if this is a stupid question,

Sandra: No such thing as stupid questions.

Steph: As you were saying some of that, I was just thinking, when we talk about trauma and we talk about PTSD, it's not necessarily the event itself, but it's the meaning that we make of it. And is that kind of linked into the appraisal? So it's not necessarily that, what has happened to them, but their behaviour is kind of the meaning that they've made then of that violation.

Sandra: Yeah, no, absolutely. That's 100 percent kind of in line with what we found. And within trauma, that's the case. And also within OCD, right, that it's not about the intrusive thoughts themselves. Actually, we know that most people in the world, almost everyone experiences intrusive thoughts, but it's more about the meaning that's attached to having those thoughts that leads to the urge to engage in different behaviours for both PTSD and for OCD. So whether that's avoidance or whether that's certain compulsions that people engage in and so this kind of reinforce what we know about these things and what we know about cognitive models of, the fact that meaning and appraisals tend to drive a lot of emotional and behavioural outcomes for people and gave us a lot more sort of specific details to work with when it comes to this symptom domain specifically which hasn't gotten as much attention when it comes to past research.

Steph: So given these findings, then what do you think are the implications for clinical practice or even future research?

Sandra: Yeah, it's kind of a, I think, an important building block. Like you said, there was only 20 participants, and it was done qualitatively which I think has a lot of strengths. We heard from people directly who, are living with these experiences and were able to kind of use that to construct the analysis that we use for the study. Taking what we found from the study and replicating it in bigger samples and experimentally to be able to see causally when we make people think about things in particular ways do we then see a causal impact on the feelings of mental contamination? I think it's an important next step.

But. I think that what we found is super practical and clinically useful in a lot of ways, because we know that actually people who experience higher levels of mental contamination when they start treatment. So, I think the research has been done in OCD, but theoretically, I think there's no reason why it wouldn't apply to trauma as well, but that individuals who start treatment with higher levels of mental contamination actually do worse after treatment that they don't improve quite as much. And a lot of what's been proposed, for the explanation as to why is that a lot of the first line treatments for OCD are pretty behaviourally focused. So exposure and response prevention where it's exposing people to their fears and then, preventing them from engaging in the compulsive behaviour so the washing or the cleaning that they might engage in, and actually, what seems to kind of have come out in a really rich way from this study and from previous work that's been done in this area is that mental contamination might be a much more kind of cognitive process than physical contact contamination concerns and so for treatments to incorporate more sort of targeted cognitive intervention. So targeting the specific types of thoughts people are having in the specific meaning that people have ascribed to these violating experiences that are driving the washing and the feelings of dirtiness, might actually prove to be a lot more effective for people. And so we've kind of known that for a long time, theoretically, but the study, I think, gives us concrete intervention targets of specific types of appraisals that you can target in cognitive therapy. So you could engage in psychoeducation, just about these models, but also designing behavioural experiments to be able to test out, these different appraisals and meanings that people are ascribing to see when it holds up, if there's room for flexibility, maybe there's certain context where those things are true, but maybe it's not true across the board and all types of context.

I think that the themes that came out here could be really useful clinically to target as yeah, cognitive intervention targets, either as an adjunct to ERP or in, in place of more sort of behaviourally focused treatment. And then I think the last thing that I see as being a particularly clinically useful piece from the study is, again, because of the history of where mental contamination, the theory and concept of it sort of evolved from, we tend to think of the, the feelings as being associated mostly with just like washing and cleaning behaviour. But actually, what the study showed is that people engage in all kinds of different types of behaviour and that we should really be focusing more on understanding what the function of the behaviour is that people are engaging in, and maybe assessing for sort of a broader range of different types of, urges or behaviours that people are engaging in beyond just kind of washing and cleaning, because it seems even for the feelings of dirtiness and disgusting contamination that people engaged in really idiosyncratic, unique behaviours from 1 person to another. And so kind of not pigeonholing your assessment into just those types of things, but taking a broader sort of lens when it comes to assessing those types of aspect of the model, I guess.

Steph: Yeah, and speaking of kind of like not pigeonholing people, did you find when you were looking at the type, because you said there's quite a range of different types of behaviours that all the participants engaged in were there particular behaviours that seemed, were there any that were surprising to you?

For example, did you expect the participants who, we're experiencing OCD to have more washing, for example, or were you, were you quite surprised at just like the range of behaviours that everyone had?

Sandra: Yeah, I was actually, and it's a good question. I think, Yeah, it's interesting because I mean, I can get into it more, where we talk about some of the limitations, but a lot of the people in the study had both OCD and trauma histories, and there is a smaller subset that had just OCD, and a smaller subset that had just experienced trauma in the past.

But based on just looking at the transcripts and analysing the behaviours and the patterns, you wouldn't really have been able to tell the difference so much between the sort of sub samples within the sample, which I thought was really fascinating because yeah, I think there's sort of this instinct to think that maybe that the OCD group would engage in more of the ritualistic washing and maybe the trauma group would be, I don't know, maybe more fearful or avoidant, more sort of like, anxious, fear based types of emotional experiences and behaviours, but there really was kind of across the board a pretty wide range. I think the part that maybe I wasn't expecting, in terms of the behavioural side of things was that, self-punishment or self-destructive kind of urges is not necessarily something I think I anticipated beforehand, that even for some people, like the washing itself, like they would wash with really hot water, for example, as a way to, you know, they experience some kind of intrusive thoughts that they experienced as violating, they perceive themselves as being a horrible person, disgusting person, forever tainted by those thoughts. And then, would wash themselves with like really hot water to sort of punish themselves for it. And so that wasn't one that I was necessarily going and expecting to find, but again, it makes sense based on what we know about cognitive models and the way that our appraisals drive our behaviours and our emotions. I think it was interesting how trans well, I mean, there was only 2 kind of diagnostic groups of focus in the study, but it really was. It felt like a homogenous sort of, experience, I guess, based on the transcripts and the analysis that I ran, both in terms of, the emotions and also in terms of the behavioural sort of outcomes that people expressed.

Steph: it sounds like it must have been really fascinating.

Sandra: Yeah, it was. And I think just I think qualitative research sometimes gets a bad rap, that like hardcore evidence-based researchers, really value, quantitative experimental work. And I think that there's obviously huge strengths to doing that kind of research, but just the richness of being able to hear firsthand from these people and use their language as the data. Often as researchers, we can get sort of siloed and have blinders on sometimes when we have a concept and we think we understand the concept fully and it sort of reifies a bit where we develop a concept and then we test that concept and prove that that concept kind of continues to exist. And I think, mental contamination is a good example of this, where it developed out of the contamination literature. So we define it kind of more narrowly in terms of the contamination feelings and urges to wash is sort of the behavioural part of the definition, but then when you go in and you hear from people who are living it that it actually kind of expands our viewpoint, I think, quite a bit by being able to see stuff that maybe, we don't necessarily come to instinctively as researchers with all of our theory and kind of knowledge of the field that is super useful and practical in a lot of ways, but I think can sometimes blind us to stuff that maybe is outside of what we've already know of an area. So, yeah, it was super rich and interesting to be able to talk to people 1st hand and see how the interviews evolved over time, too, because I think that's another awesome part about qualitative research is that it's meant to kind of evolve as you're working through stuff with people. So, as things came up in early interviews around, maybe these broader behavioural outcomes or specific types of thoughts that people had that I wasn't anticipating, I was able to kind of probe more for those things with later interviews and see that it actually was quite common and that a lot of people sort of experience those things as well. So, yeah, it was a really fascinating experience for me. And I think it's rich the data that comes out of it and the quotes from the participants that you can see in the paper.

Steph: Absolutely. So if you were going to start this all over again, was there anything that you would have done differently if you could do it again?

Sandra: Yeah, so it's a good question. I think, like I said, the nice part about qualitative research is that you can sort of course correct a bit as you're going. So, the interview became more open ended as I went on with later participants, which I think if I could do it over, I would start with a little bit more open-ended prompts rather than, really specific, more closed ended questions guided by the theory and research that we already have. I think if our theories are accurate then those things will come to light, even if you don't probe for them specifically. And that's what we found kind of later on with the interviews is that it allowed for a little bit broader information to come out and also to sort of demonstrate that our cognitive model holds up, even when we're not asking people specifically about what emotions were caused by that thought, or more sort of, I guess, closed ended or directive questioning. So, I think that's 1 thing. I think also, just in terms of the diagnostic profiles initially, I was sort of anticipating having 10 people with OCD and 10 people with trauma histories and actually getting out there, I think there's a lot more overlap between these groups, they're not so cleanly divided. And I mean, that lines up with epidemiological research that we have that shows that there's a lot of comorbidity between these things and that there's a big sub sample of people with OCD where the ideology is trauma or these violating experiences in the past.

And then I think, yeah, I think sort of along those lines, just looking at it as more of a transdiagnostic construct and not really zeroing in specifically on certain diagnostic categories, because even with the participants in the sample. So, as part of the study, I conducted the whole MINI, so it's a semi structured diagnostic interview for everybody. And so, in order to participate, they needed to meet criteria for either OCD or Criterion A for PTSD, but a lot of them, I'd say most of them also had comorbid other disorders. So things like social anxiety or depression or eating disorders. So I guess, maybe rather than trying to be more specific diagnostically in the future, based on what came out of this, I think it would actually be useful to just ignore the diagnostic categories and see whether this model holds up trans diagnostically as a more universal experience that people have. So, I guess, yeah, if I were to do it over again, those would be the main, the main things.

Steph: Cool. Thank you. And this might not be relevant, but I always like to ask authors, as a journals Managing Editor, it's always interesting to me, how did you find the peer review process? Were reviewer comments helpful? Did you find, was there anything that you disagreed with or that you found difficult about the process?

Sandra: So I think, I think qualitative research, especially like clinically focused qualitative research can be sort of hard to find a home for in terms of a journal just because I think a lot of hardcore clinical journals tend to prefer like quantitative research and then more qualitatively focused research journals, have sort of a rigor and standard in terms of the methodology that a lot of applied research doesn't kind of, I guess, meet the bar for. So I think in that sense, just finding the right place for it was an interesting experience. And also just the length of qualitative papers is quite long because of the quotes, rather than having a nice table that synthesizes all of your means and standard deviations. The data itself are these paragraphs of text from people. So I think that was a bit of a challenge initially, but, once we submitted it to Behavioural And Cognitive Psychotherapy, I actually found the review process was super helpful. And it was nice because the reviewers comments that we got, there were 2 reviewers and 1 was able to provide more comments about kind of the theoretical, practical, clinical, aspect of it. And the other, appeared to have a lot of experience with qualitative methodology. So, in terms of, adding reporting details about the analysis process was useful. I think for us, we're not a qualitative research lab. We've done some qualitative studies, but it's not sort of our area of expertise. And so there was a lot of really constructive feedback within that about, what to include what's maybe not necessary to include, from the methodological sort of standpoint. So I actually found it, I think it ended up with a much more sound balanced final product, which isn't always the case with peer review.

I think sometimes it can be a little nitpicky and not the most constructive, but in this case, I actually found that the combination of the reviewers feedback was super helpful and constructive and I learned a lot from it.

Steph: That’s really good to hear and it's so nice, for people to have good experiences as well. Cause like you say, some peer review can be very nitpicky and lke you say, if it took you a while to find the right place for your research, then I'm really glad that the peer review process was just as smooth as it was then. I think that's really great.

So just before I let you go what's coming up next for you? What else are you working on? Are you going to try and continue with the research that you've done here or anything you want to plug that's coming up?

Sandra: Yeah, so actually we used the interviews in the study that we just talked about as sort of a basis to develop a quantitative measure of appraisal. So, as I kind of alluded to earlier this interview data, I think, is super rich and points to a lot of really interesting directions. And I think that the next step is to kind of validate it more quantitatively and experimentally. So, we took the themes of the different appraisals that came out and tried to create a new measure of just kind of a broad range of different types of violation appraisals. And so that's where we just submitted that for publication. So, yeah, we validated this new measure and hopefully developed a clinically and research useful scale that people can use moving forward to look at quantitatively how different maybe themes of violation appraisals lead to different kinds of outcomes for people. So that's kind of, more imminently in the pipeline and then, Yeah, I think down the road, I'm looking to sort of use that experimentally and see if we can try to manipulate different types of appraisals and look at their impact on mental contamination and see, maybe clinically within sort of clinical populations on the flip side is whether we can sort of reduce those types of appraisals or get a little more flexible with those types of appraisals and see whether that can maybe help people who are, who are experiencing these kinds of symptoms. But yeah, overall, just I'm excited about more research in this area. I think it's a really interesting subset of clinical populations, this intersection between trauma and OCD. And I think it's getting more attention in the research world and in terms of sort of like clinical implications that stem from that. And I guess I'm just excited to be a part of whatever comes up in that domain down the line.

Steph: Yeah. Brilliant. Well, this has been really, really interesting. Thank you so much for coming on and talking to us.

Sandra: Thanks for taking the time to ask me interesting questions.

Steph: Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts.

If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at podcasts@babcp.com. And why not check out our sister podcast. Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT.

 Thanks for tuning in, and I'll see you next time on Research Matters. Bye.

In this episode, host Steph Curnow interviews Vickie Presley, the lead author of a paper titled "Crossing the Reflective Bridge: How Therapists Synthesize Personal and Professional Development through Self-Practice/Self-Reflection (SP/SR) during CBT Training", published in The Cognitive Behaviour Therapist. Vickie shares her insights from the research, discussing the importance of reflective practice in CBT training and how it shapes therapists’ professional growth and personal awareness.

If you enjoyed this episode, please rate, review, and subscribe wherever you get your podcasts. Follow us on Twitter at @BABCPpodcasts or on Instagram . Share your feedback or episode suggestions by emailing podcasts@babcp.com.

Useful links:

The full version of the article being discussed can be found freely available here

The SP/SR book that Vickie mentions is “Experiencing CBT from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists (Self-Practice/Self-Reflection Guides for Psychotherapists)” by James Bennett-Levy, Richard Thwaites, Beverly Haarhoff, and Helen Perry. Foreword by Christine A. Padesky

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

Transcript:

Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT.

Today, I'm talking to Vickie Presley. Vickie is course director for CBT training at Coventry university. She's also the lead author of the paper “Crossing the reflective bridge’: how therapists synthesise personal and professional development from self-practice/self-reflection during CBT training” which she co-wrote with Gwion Jones and is published in the Cognitive Behaviour Therapist.

Hi, Vickie. Welcome to the podcast.

Vickie: Hi Steph, thanks for having me.

Steph: Thank you. It's lovely to have you here. I was wondering if you would mind telling everyone a bit about who you are and the areas where you work.

Vickie: Yeah, of course. So my name is Vickie, Vickie Presley. I'm currently the lead for psychological therapies training at Coventry University and the course director for our CBT training programme. And I guess outside of my university role, I'm also a CBT therapist and supervisor in private practice. I guess for the purposes of today as well, it'd be important to say I am also Vickie. I am a lady heading quickly towards my 45th birthday. I am a mum. I'm a wife to a long-suffering husband. I'm a sister. I'm an auntie. I'm a great auntie, Lots of things outside of that sort of professional context. And I guess also I'm a nervous wreck today, if I'm honest. I guess just thinking about conveying things around this research, but it just seems important to say that given we're going to talk about sort of how therapists might synthesise their personal and professional development, there's bits about me that might come through today that are about my personal self, not just my professional self.

Steph: Great. Thank you. And that's great that you've sort of brought in some of the personal as well. That's really nice. And I'm always nervous when we start doing podcasts as well. So it's fine. And I've been doing this for a while now.

Vickie: Oh, that's good to know. Thanks, Steph.

Steph: The paper we're going to be talking about today is about self-practice, self-reflection in CBT training but before we get into talking a bit about the paper, would you be able to tell me a bit about how this research came about? What inspired it?

Vickie: Yeah, of course. I mean, I suppose the answer to that question is, one that takes me back, sort of, 15 years or so to my own CBT training. So, I trained at Coventry. Coventry's got quite a long-standing ethos of reflective practice as part of the training course. And for me, I think that allowed me to really think about the role of myself in my therapeutic interactions with clients. And I started to notice as part of my training that I was getting in the way sometimes. So sometimes my own stuff was getting in the way of my work with clients. There's this example that I always give where, I was working with a lady who was very, very depressed, and as part of that presentation she was very perfectionist and held herself to really high standards, which, is something that I have to manage myself. So, there's kind of this schema match, I guess, if you like, that we noticed, and we did some work around that. And technically it was really good. Technically we did this continuum exercise. It worked really well, it was really helpful for her in the session. But right in the last minute, I suggested to her that she took the worksheet home, and she rewrote it because mine was too messy.

And I suppose the whole irony of that, that one statement, which, I mean, I suppose we look back at that and sort of laugh at the irony, but it really had the potential to undo a lot of good work in the session. And that was about my own stuff. So, I really do think that's the point where it started for me, and I started looking at some of the research that was around about therapist perfectionism in particular. I suppose as my career has gone on and I've supervised trainees and qualified staff and obviously I've worked at the university for many years now, we notice the same patterns that therapist’s own stuff will get in the way a lot of the time. So some of my previous papers have focused on areas like therapist perfectionism, like things like experiential avoidance and one of the things we always suggest at the back end of those papers is that therapists get involved in SP/SR so they can get to know themselves a bit better. And I guess that brings us to this paper where we wanted to know whether that was working as part of our own program. And if it is, how trainees experience that, how do they get to know themselves as part of SP/SR and as part of the training process? And how do they make sense of that in a professional context? What meanings and what the experience of synthesising those two parts of themselves is like. So that's how we got here and that's what this paper aims to elucidate in some way.

Steph: And I think that's really important, isn't it? Because when you're really busy training and you're taking in all this new information and then you're putting it into practice, it must be really difficult actually to take that time to think about yourself and to really self-reflect and think about how that might be impacting you.

Vickie: I think it's really difficult and I think, in some ways, it seems more difficult in the CBT model, I think, because lots of the things that we have to teach are quite technical and there's lots of demands on trainees to show technical flair and that they understand quite complex models and ways of working. But that can become, this whole reflection stuff can become sidelined and feel like it's less important. I think my view is that the technical stuff, the technicalities of CBT take place within a relational context, and they take place within the dynamic between two people and if the therapist isn't holding what's their own stuff in that dynamic, that can become problematic.

Steph: Could I ask you to just explain a bit about what is self-practice/self-reflection for anyone who might not be, familiar with the term?

Vickie: Yeah, of course. So, I mean, I suppose the simplest terms, self-practice/self-reflection is about practicing CBT techniques on oneself, so using, the interventions of CBT on oneself and then having time to reflect on what that experience is like. I guess there's a myriad of ways that people can get involved in self-practice/self-reflection but on our training course specifically, we use the text “Experiencing CBT from the inside out”. So that's a well-established text. It's an evidence-based text, and we provide one of our trainees with a shiny workbook at the beginning of the year, and that's what we use to scaffold the process of SP/SR. So, we find that's a really nice text that helps the trainees work through some of the stuff that SP/SR incorporates, but also helps our staff who are facilitating that process to keep some framework around the process.

So for our trainees, we give them that book and actually SP/SR is a mandatory part of our training program, so all of our trainees will be given the book and have space to work through that, but they'll also meet 12 times across the training year with their group facilitator to have space to reflect with peers and to reflect with the group facilitator about the process of taking part in SP/SR.I suppose for us it's an integrated part of our training programme and we find that this huge benefits from for including that as part of the training program. So yeah, so each of our trainees would be working through the process and have a formal space to reflect on how that's going across the year. And then they're also asked to submit an assessed summary of their learning from SP/SR and how they're making sense of that in terms of their clinical practice. And I guess that last bit is the key point. That we don't want people just to do SP/SR. We don't want them just to experience what it's like to do CBT interventions. We want to give them space to make sense of that in a professional context so, bridging that professional arena and what those insights mean for their clinical practice and how it can help with their skills developmentment.

Steph: Yeah. And that's a really nice segue into my next question, actually because we're going to dive into the paper now on what you did and it's that reflective piece of work was kind of the basis for how you recruited your participants really, wasn't it? Am I right in thinking that you were analysing that part of their reflective work.

Vickie: Yeah, so each of our trainees will just as part of the training program, submit a 1000 word reflective piece in which we ask them to say a bit about their personal learning. So what they've learned about themselves as part of the SP/SR process. Also, then to bridge that to their clinical practice and what does that mean for their clinical practice and how they sort of synthesise what they've learned about themselves and how that's helped their professional development. That's what we use for the basis of this piece of work. I guess we've noticed across years that even though it's a brief summary, a thousand words isn't a lot. It's so rich with the sort of data for this piece of research. I guess because instead of interviewing people really have chance to sit down and think about what they want to convey about their learning. It's a deeply personal piece of work. So yeah, so our trainee needs to submit that 1000 word summary of their learning. And we analysed that using thematic analysis, really just to try and, highlight what it is that people are learning about the self and how they make sense of that in a professional context.

Steph: Yeah. And so several themes then came out of that analysis that you and your colleague did. We were saying just before we started recording, I actually felt very seen during some of that as well. There's definitely schemas that I've had during my counselling training. Were there any that surprised you when you looked at them?

Vickie: You know what, that’s such good question.  Probably not, and I think that was a really important part of how we approached the analysis. So I'm a CBT therapist, and I'm involved with the facilitation of those SP/SR groups. And we were really aware that might sort of skew how I came at the data. So it wasn't just me that analysed the data, a colleague analysed the data with me, my colleague Gwion. Gwion’s not a CBT therapist, Gwion's a psychoanalyst, so we came to the analysis from a completely different psychotherapeutic model, which we thought was really important for us to have a more sort of nuanced relationship with the data. Gwion also doesn't facilitate the SP/SR groups so it's interesting that you asked that because I probably wasn't particularly surprised, but I think that's because of how I'm positioned in terms of the data and the way it was collected and the training process as a whole but maybe if you were interviewing Gwion he may give a different answer to that. I suppose the only thing that might have surprised me was how strong the themes were, so most of the participants engaged with most of the themes. There was such similarity and it's interesting how you're saying Steph that you felt seen and that's coming from a different model again and somebody who's not involved in our training course having sort of similar things and that's quite heartening really. There's a sort of shared humanity perspective on this that these are things that we lots of us struggle with.

Steph: Yeah. And the first theme was really about the identification of self schemas, wasn't it? And that sub theme about not feeling good enough. And that's definitely something that I think comes up in any kind of therapy training a lot I think.

Vickie: Yeah, I mean, probably any kind of training, really, if we strip it back. Training is difficult, isn't it, right? There's often a transition from what you know to what you don't know, and I think that's really quite hard. And for us, we know that people are transitioning into this profession from lots of different varied sort of professional backgrounds, but also personal backgrounds as well. Our cohorts are hugely professionally and personally diverse, which is wonderful. But I think that sort of sense of being de skilled at the same time as having your practice evaluated from every conceivable angle is quite exposing. And I think that sense is not good enough really came through in their reflections and their ways of coping with it, which is often about getting into compensatory strategies like perfectionism. Yeah, so a really strong theme around the not good enough stuff, which I think we need to pay a bit more attention to because that's a difficult place to be for anybody.

Steph: And I think one of the quotes from one of the participants that came out in that was about, really worrying about not being liked then and the kind of interpersonal relationships. And I was wondering, do you think that was being liked by their client or not being liked by their colleagues on their cohort from being able to express what they were saying?

Vickie: Do you know what? I think it might have been multifaceted. I suppose this is one of the downsides is the data in some respects is very rich, but it is two dimensional. And we didn't follow up with any interviews or any focus groups or have any opportunity to ask questions like that, which are really important. I suppose what we did find as we move into the other themes is people did identify that there was sort of historical longitudinal backdrop to a lot of the things that were happening professionally. I think maybe the quote you're talking about is, that’s sort of not good enough thing, even coming into the SP/SR process and being worried about whether they're doing it right, whether they're reflecting right, whether they're feeding back right in the sessions, all of that stuff can be really difficult.

Steph: yeah, definitely. I just, I think what I was saying, I felt seen, that was something I really felt when I was doing my training as well. There was often a question of am I doing this right? And often there is no right, is there?

Vickie: No, often that there isn't and you know, one of the things I always say to my trainees is that sense of imposter syndrome It never really goes away or you know, I have that now talking to you about this paper and Yeah, the need to get it right and to have approval and be likable all of those things. There's such a commonality there with lots of us experience.

Steph: And like you said in theme two as well, that was round about the increased awareness of the personal context. And as you were saying, it was helpful for the trainees then to maybe be able to put that into some sort of context for them and maybe why they were feeling some of things that they were.

Vickie: Yeah, absolutely. We have this really strong theme of identification of self-schemas which is around the not good enough stuff, but also around sort of having difficulty sitting with difficult internal experiences and difficult emotions. And what we found is people sort of extended those reflections to start thinking about where does this come from in terms of my personal context? And there was, you know, so much data, which was deeply personal, I guess, with people linking those things back to relationships within their family, the meaning they've given to some of the expectations within their own culture. For some people it was about sort of their socioeconomic status and some of the meanings that they'd given to that. For some people it was this sort of process of making sense of what they'd learned about themselves in the backdrop of their own faith and spirituality. There was lots of things around personal context which, it was so important and I know when I was writing this paper just feeling like I'd got all of this data and really needed to be quite delicate with how it was conveyed in the paper.

I know when I wrote the first drafts, that results section was pages and pages long because there were so many things that I wanted to give credit to or, to be seen and to be valued by other people, but you know, you can't do that, you have to sort of get less attached to your data in some respects. Yeah, I thought that part was really quite powerful, how people had sort of made sense of themselves in that sort of longitudinal framework.

Steph: Yeah. And what about the other themes that you found? Is there anything else that you wanted to highlight from those?

Vickie: Yeah, I mean, I suppose one of the important things was this idea of, okay, this is what I've learned about myself and who I am. And then the trainees sort of conceptualising how that then came into their clinical work. And I guess this is about sort of this bridging process, which is reflected in other research papers, that there needs to be this process where people, they learn about themselves, but then they think about what actually means for their practice. And lots of the trainees noticing that their own need to be good enough, their own need to not make mistakes, or to be liked, or to not experience discomfort was actually getting in the way of them doing CBT with a lot of their clients or getting in the way of a therapeutic alliance. So that kind of became a central theme, I guess, that holds the other ones together. But then what we found is a lot of the trainees had then been brave enough to sort of step out of the reflective space and do things more experientially to try and find out what happens when they don't adhere to some of those schemas and the rules that come out of those and when they try to change things in their personal and professional sort of arenas.

That was quite powerful. I guess part of their reflective summaries was thinking about how they'd been brave enough to make changes and then how they just sort of reach professional benefit from that. Which I guess matched a lot of the stuff we already know about SP/SR, certainly in terms of helping people to work more effectively within the therapeutic alliance. But I think a major thing that came out of this study in particular, was people's ability to just work more authentically with difficult emotions. And to see that as a really key part of cognitive behavioural therapy that we talk a lot about cognitions and behaviours right? But there needs to be a real sort of processing of emotion when we're trying to change those things with people and I think that lived experience was really important for the participants, for the trainees, but that lived experience of how difficult that is was really important to helping develop their professional practice.

Steph: So sometimes think as well when working with my own clients, you know, bringing about change sometimes brings about almost like a grief process because they've been holding onto whatever they've been holding onto for such a long time. And that can really bring up some really quite strong feelings and even if they want to let it go and they don't want to be like that anymore, it can be quite surprising what comes up, isn't it?

Vickie: Yeah definitely. And you know that's a difficult part of therapy and that's a difficult part of SP/SR. You know,  a lot of the trainees that took part in this study said they flew through all the sort of reflective self-formulation stuff, but then got really sort of halted by the more experiential things. So when it gets to letting go of safety behaviours that give us comfort or letting go of, things that we do to try and soothe our emotions in the short term, letting go of those things and making changes is really hard.

Steph: So is there anything else on the themes that came up that we haven't discussed yet that you want to kind of bring up a talk about?

Vickie: I think we had these five themes and we weren't sort of intending to provide any sort of conceptual framework, but those themes just beautifully linked together to show this journey of finding out who I am, finding out where that comes from, understanding how that comes into my work, being brave enough to change it, and then knowing that I've taken personal and professional benefit from that, that, I guess that sums up what we found.

Steph: Yeah, brilliant. So given these findings then, what do you think are the implications for clinical practice or even for some future research? So I always ask the question, what impact do you think this paper will have on the world of CBT?

Vickie: Well, gosh, I mean, I'd love it to have some impact. I suppose the first thing it brings me to because we run a CPT training program. It's just really encouraging training courses to bring SP/SR into their teaching and learning strategy. I think a lot of courses do more of this now, which is brilliant, I don't think it's necessarily alien in the way it might have been going back a decade or so. But I think that's the key implication, that if we don't allow space for trainees to get to know who they are, get to know who they are as a therapist, they may well go out into the world and continue to practice in ways which isn't optimum for clients doing well in treatment. I guess it brings a circle to what I was saying at the beginning, that we can get so focused on the technical flair of CBT that we forget those unique interpersonal dynamics which is the context where it all takes place. So I think hat's one of the key implications is how do we bring SP/SR into CBT training programs in a way that is safe, that is ethical, that is well resourced, which looks after trainees as part of that process and allows them to gain some of these insights that are really important to their professional practice.

Steph: And what you were saying there was something my course tutor always spoke to me about, which was always, you know, you shouldn't be asking clients to do something that you won't be prepared to do yourself as well. And you know, if you're asking them to really look and analyse something, then you should be able to do that for yourself and have that your own self-reflection and your own reflective space too.

Vickie: Absolutely. And I think a sort of strong, sense that we got. It was really interesting because Gwion and I had seen this data before because we'd marked it as part of an assessment. When we came back to it to analyse it, you relate to what people are saying in a much, just in a different way. And I'm not sure I can even articulate what that was about, but you come to the data in a different way. There was just this really strong sense of trainees saying that they could practice with more authenticity and more emotional connection and that just seems so important when you're working with people and asking them to do really difficult things as part of CBT sometimes.

Steph: Yeah, definitely it is really important, isn't it? So is there anything that you would have done differently if you could do this all over again?

Vickie: I mean, I suppose we've noted some limitations. I mean, I've already mentioned that we didn't go back and sort of talk to the trainees about what we found or sound out this sort of conceptual framework that we put together. And maybe that would have been a great addition to the studies to go back and perhaps do some focus groups or some interviews with the trainees.

I suppose the other thing really to say is SP/SR doesn't really take place in a silo as part of our training program. The trainees are doing other things outside of that textbook and outside of the 12 sessions that they do, they're doing things like process reports. So they're having to analyse their interpersonal transactions with clients and having to reflect on what they're bringing to that process. So there may even have been things that we could have brought in from those parts of the training program or that we should do in future research about those parts of the training program and how that helps with this whole sort of self-practice, self-reflection concept.

Steph: Yeah. And I always like to ask people this question as a managing editor, just to kind of gauge how people feel about it. But how did you find the peer review process? If you can remember, did you find reviewer comments helpful? Was there anything that was surprising for you?

Vickie: This paper in particular was just met with such warmth and that was, I suppose, equally surprising and very lovely that the reviewers were very just bought into the whole concept, very positive about it, as well as offering really helpful suggestions just to improve the paper. So for this paper in particular, I've just found the whole review process really supportive. But my impression is for the journal that was the real ethos of that of reviewers providing supportive and helpful feedback, and that was certainly my experience, Steph. So whoever the reviewers were, thank you very much.

Steph: That's good. And like you say, with the journal ethos, it is something that we really try and do is to make sure that when we have reviews, they're good, constructive reviewing, something I'm really trying to move us away from is from anyone feeling that when they go into peer review, they're going to be really judged and they're going to have a professor in an ivory tower come and critique their paper and pull it apart because that's not really what peer review should be about. So yeah, I'm pleased it was good.

Vickie: Yeah, it was really good but equally, I've also had a review processes where it has felt, you know, that you come out barely with your self-esteem intact. But do you know what, it's the fine line, isn't it? Because I want journals to produce really good research that's of benefit to the community, but you know, certainly there are ways of doing that's really supportive. And that's my sense of this journal, which is great.

Steph: Yeah, definitely. And you know, the paper was really excellent. It was covering an area that sounds like it's really needed and your passion and warmth as well came across in that. So I'm not surprised it was well received because it was really good.

Vickie: You know, it’s interesting that you say that because, obviously out of utter anxiety about being helpful as part of this process, I've read the paper this morning and had a completely different relation to it, reading it, than I did when I was writing it. And I was kind of reflecting that when you're writing a paper, you get hung up on not making mistakes, getting it right, getting it technically accurate, meeting the approval of the reviewers. You get so enmeshed with that whole process that I don't think when I wrote it, I'd emotionally connected to what I was writing. And when I read it this morning, I was really moved by some of the trainees’ reflections and how authentic and deeply personal a lot of those disclosures were to help us sort of bring this out into the research arena.

So massive thank you to the trainees that took part in that as well. It just made me think about this whole parallel processes of getting so bogged down with getting things right that we forget to emotionally connect and I guess that's really the essence of what this paper is talking about, is trainees can get so bogged down with their own stuff, some of the really nice interpersonal stuff can fall by the wayside.

Steph: Yeah. And that comes quite nicely full circle to where we started at the beginning, wasn't it? Talking about your feelings of perfectionism and CBT training and trying to get it right.

Vickie: Absolutely, I am a recovering perfectionist Steph, it's always a work in progress.

Steph: So finally, before I let you go, I just wanted to ask what's next for you. Is there anything you're working on now? Any papers we can look forward to from you in the future.

Vickie: At the moment I am very busy with lots of things course related. I am working on a little project with the BABCP, which is about just producing some helpful sort of best practice type guidance for courses for integrating equality, diversity and inclusion into training programs. I don't profess to be an expert in that area, but I think things like self-practice/self-reflection are so key. So there's a nice link there that hopefully we can pull into that work, which is about people getting to know themselves as therapists and getting to know where their stuff comes from in a cultural context as well, and how that sort of plays out when they're working with people that are different to themselves. So that's one of the things that I'm working on at the moment. If I'm very honest, I do have a raft of interviews that are awaiting analysis, they’ve been sitting there for some time, Steph, which I'm hoping we'll be able to come back to once we've got a bit more time and that's, exploring trainees experiences of working with distress as part of the training process. Because we know that trainees find it really difficult sometimes to work with difficult emotions. So, don’t hold me to that anytime soon Steph, but that is in the pipeline.

Steph: We'll look out for it when it comes. Oh, Vickie, thank you so much. This has been really great.

Vickie: No problem at all, thanks for having me Steph.

Steph: Thank you.

Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts.

If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at podcasts@babcp.com. And why not check out our sister podcast. Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT.

 Thanks for tuning in, and I'll see you next time on Research Matters. Bye.

Let’s Talk about CBT - Research Matters is a brand-new podcast from the BABCP, hosted by Steph Curnow, Managing Editor for the BABCP Journals Behavioural and Cognitive Psychotherapy and The Cognitive Behaviour Therapist.

In this episode, Steph talks to Dr Jake Camp a clinical psychologist and DBT therapist about their paper “Gender- and sexuality-minoritised adolescents in DBT: a reflexive thematic analysis of minority-specific treatment targets and experience” published in the Cognitive Behaviour Therapist.

This study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Jake talks about what this study found and highlights some really helpful recommendations for clinicians working with young LGBTQ+ people.

You can find Jake's ful paper here: https://bit.ly/45GhM1C

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 podcasts@babcp.com.

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

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Transcript:

Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT?

In this episode, I talked to Dr Jake Camp. Jake is a clinical psychologist and lead author of the paper “Gender and sexuality minoritised, adolescents in DBT, a reflexive thematic analysis of minority specific treatment targets and experience” which was published in the Cognitive Behaviour Therapist.

Steph: Hi, Jake, welcome to the podcast.

Jake: Hello, nice to be here.

Steph: Thank you so much for joining us. So just to start off the podcast, are you okay to tell me a bit about yourself and the service that you work for?

Jake: Yes, absolutely. So, so my name is Jake Camp. the pronouns I use are he/they. I'm a clinical psychologist, and DBT therapist. So my main area of work is at a national, DBT service for adolescents that's based at the renowned Maudsley Hospital. I also work academically, mostly with the department of psychology and the LGBTQ+ mental health research group. So that is at King's College, London. and I mostly work with young people who have experienced a ton of trauma, sadly, and have had a lot of difficulties that have led to, finding it very hard to sort of survive and thrive in the world. Often, young people end up being quite highly suicidal, sadly and my area of research that I'm particularly keen with, and of course what we're hopefully talking a bit about today, is mainly around how therapies work for minoritised groups and particularly LGBTQ+ groups as my sort of main area of research. So, it's great to have a chat about that.

Steph: So yeah, that leads us really nicely into talking about the paper because we are talking about one of the minority groups that you have been researching. So do you want to tell us a bit about who they are and what the paper is that we're talking about today?

Jake: Yeah. So, the paper that we are focusing on today is, one where I really wanted to spend some time privileging and I suppose, increasing the sort of voices of LGBTQ plus young people in DBT. For those who are not familiar with that acronym, although hopefully most people are, of course, that is usually people who identify with a minoritised or minority sexual identity, so that's like lesbian, gay, queer, etc and or a sort of minoritised or diverse gender identity, so that might be trans, non-binary, or so forth. So the paper really was to try and, you know, sort of give a platform to LGBTQ+ young people about their experiences of Dialectical Behaviour Therapy or DBT, because what we know from the literature is that, generally LGBTQ plus people experience quite a lot of barriers to accessing services.

There's also some evidence of poorer experiences of services and even some of the poorer outcomes, particularly in the sort of adult literature. So we know that there's a bit of a problem with how we meet the needs of LGBTQ plus group generally across our services, and we know that LGBTQ plus groups usually are significantly more likely to experience mental health difficulties and particularly engage in self-harm and suicidal behaviours, sadly, which we think is associated with, societal oppression, what we call minority stress. So those are stressors unique to their sort of minority characteristics or identity. So, we think it's super important, you know, to sort of do more work in this area. And of course, sadly, there's not actually that much, particularly in DBT about this, but, I would say there's also not much robust work, across that sort of fields as well. So, so this is the paper.

Steph: And I think one thing that really struck me when I was reading the paper, I've read a couple of iterations of it from when it was submitted to the published version, it's really about how much the lived experience of the young people you were researching in this was very important to, to the topic and to you. And so what motivated you really to look at this research area in particular and, and focus on this.

Jake: Yeah. Yeah, good question. I think, it really stems, obviously, from early on, and I touch on this a little in the paper, I identify as LGBTQ+ so generally just describe myself as a queer/nonbinary psychologist and I think, you know, growing up in a societal context where we had the sort of echoes of what I now know was sort of Thatcherism, Section 28, which precluded, the sort of conversations around what was termed homosexuality in schools, which ultimately meant that, you know, things like bullying with content around this, things like talking about modelling good experience of this, showing you that you could be a queer young person and be okay and thrive, were just completely absent from my childhood, mixed in with, I think, you know, we certainly were coming out of the AIDS epidemic when I was growing up and a number of other social, cultural things, I think just meant that, you know, growing up as a queer kid really wasn't comfortable and from a very early age, starting to feel different from people and starting to feel that societal oppression was very heavy.

Mixed in with, a number of other sort of areas of difficulty and trauma in my sort of familial environment. I think I was I've always been very keen to try and use my privilege to help people, help my kin almost, help people, help those queer kids, you know, to sort of grow up and thrive, because I really didn't feel like I had that.

And so that sort of informed how I've ended up going down the route of LGBTQ mental health as my sort of main area of research. And, I think, of course, part of that is they're my tools, they're my tools for activism in some ways, is that, the area that I can use and the privilege I have is that I can focus my research energy into this and hopefully try and make the system better.

So, they're the sort of overarching aims. The reason I ended up in this sort of project area specifically is firstly, because, I work in DBT and very passionate and keen about supporting people who have quite complex trauma that other sort of traditional services don't always quite meet their needs, you know, so the sort of the running theme for it, and I think DBT does that really nicely and when I started working in the National DBT Clinic, I was very surprised to quickly see that in this group of very highly suicidal young people, that about 60 to 70 percent of them were LGBTQ+ which of course is an outrageous over representation, compared to what should be if there was no health inequality there. And that sparked my interest because I thought, I need to work out what's going on here. And I need to try and make sure we're meeting their needs and make sure that other services are meeting their needs too, because I think what that potentially speaks to is that their needs are not being met sufficiently earlier in the treatment pathway before they end up needing DBT.

And of course, DBT, you know, is really made for people where they're highly suicidal, high severity of difficulty usually been going on a long time. So this paper sort of squarely came out of that. I thought, where do I start? Well, I want to start, you know, with the young people and their voices, and I want to know what's working for them, what isn't working for them, and actually what is important about their experience as a minoritised individual that we need to be thinking about in therapies, in particular, of course, DBT. So that was the sort of inspiration for it, and it's part of a wider program of work, of course, to try and complement some of those questions that I had. But here it was squarely about, what do the young people think? what would they advise us to do, which I think is super important.

Steph: Yeah, absolutely. And that really comes across in the paper, I think. Like I say, it's really nice when you can read papers that you know have been written with real thought and real compassion as well, that definitely comes across in the paper. Before we getting into talk about the paper itself, would you mind explaining a little bit about DBT for maybe listeners who don't know what it is, or maybe don't know that much about it?

Jake: Yeah, of course, yeah. So DBT stands for Dialectical Behaviour Therapy. so, we usually describe it as a sort of third wave CBT approach. for those who are not familiar with that terminology, third wave, I usually think of as meaning standard sort of second wave CBT, which is the usual CBT you see out there for, you know, specific disorders, often like panic, social phobia or so forth plus some other elements of something, mostly mindfulness, of course, and that's usually the biggest, sort of inclusion of other principles or techniques in third wave CBT and models, but also usually a lot of other stuff to borrowed from other areas of work or, or schools of thought as well.

So DBT is a very good example of that, it builds in mindfulness, it builds in a number of other principles to try and support its target population. DBT mainly aims to work with people where emotion dysregulation or difficulties managing emotions is sort of the key underlying difficulty to, so, you know, generally we think it works quite well as a nice transdiagnostic intervention because that's the key treatment target rather than key symptoms necessarily, albeit, of course, Borderline Personality Disorder was the original symptom structure or sort of ideology that they were sort of made to target. Most of the people that I work with tend to have emotion dysregulation and engage in self-harm and suicidal behaviours or other behaviours that are judged, by society as being dangerous and maladaptive. We work with people in quite an intensive way in DBT so, it isn't just individual sessions.

If you're getting full comprehensive DBT, which is the most widely evidenced version, you usually should be getting weekly individual therapy sessions to build motivation, support with your problem solving and a number of other things, weekly skills groups, try and teach you skills to sort of manage life and emotions. You should get your therapist phone number where there's a between session phone coaching. So it's like a tips hotline. So you get to call your therapist and navigate your life. I know, right. And it's pretty good. I feel like, you know, I need a therapist hotline sometimes just to, um, and there should be a therapist consult which is a sort of weekly meeting where it's almost like therapy for the therapist. Therapists support each other to stay in frame, to do a good job for their clients and not to burn out. Because of course, the risk is working with high complexity and suicide, which is very scary of course, is that there's risk of therapist burnout.

So DBT delivers it through those modes and it has all these principles such as problem solving, validation, zen and mindfulness, skills, which is probably the biggest, known part of DBT is the skills aspect, behaviourism, cognitive restructuring, a number of principles that we pull on to help our clients, you know, sort of build that life worth living. So pretty complex model. But, you know, it's a pretty good model for working with people where they wouldn't naturally fit maybe that sort of lower severity frame if that makes sense, usually where emotional dysregulation is particularly tricky.

Steph: And how long would you expect a young person to be in your service then? Cause it sounds it's much more intensive than like you say, like a traditional second wave CBT.

Jake: Yeah, good, good question. It's interesting actually. Um, and this, so we have debated lots since DBT has been integrated into the NICE guidelines, for young people. So for adult DBT most of the time, it's about a year and DBT is meant to not be the end goal. So DBT is like the first stage, which sometimes people call stabilization. And then the next stages are meant to be going on to do things like trauma reprocessing, working through other difficulties, building your life, making everyday decisions so they get a year usually. In our, adolescent program, our treatment length has differed over time based on a number of different factors.

Currently, we are a seven-month program with opportunity to extend to nine. The actual evidence base for DBT for adolescents though, usually positions itself as three to six months. And the NICE guidelines only quotes the three months, which is interesting because they miss all of the other lovely RCTs and pieces of evidence out there, like uncontrolled studies or controlled studies that actually usually mostly use the six month model. And that's, I think, because DBT for adolescents was always positioned a little bit more as early intervention. So get in there before the difficulties really emerge. Whereas, often what we see in our clinic is people have had these difficulties for a pretty long time. And they're usually in that sort of slightly artificial threshold, between adolescence and adulthood, you know, so in that sort of 16, 17, 18 range as well. So usually a lot of difficulties

Steph: Yeah, well, that was a really good explainer. Thank you. Okay, so shall we get into the paper itself then? So, am I right in thinking that your participants for this study were already in your service receiving DBT, and they were recruited because they identified as Gender and sexuality minority.

Jake: yes, that's correct. So, I think part of the inclusion criteria that I had was to make sure that they had finished at least the first six months of our skills group. And that's because by that point, you've covered pretty much every piece of skills content. So, my rationale behind that was thinking, you know, I want you to have enough experience of the program to be able to talk about it. But otherwise it was just that they were in the program, that they identified as LGBTQ+ or gender and sexuality minoritised. And yeah, and that they were willing, of course, because that's, that's very important.

Steph: first rule of participation is are you willing?

Jake: Absolutely,

Steph: Okay. So you conducted some interviews with the ones that were willing to participate. What kind of things were you asking them and what did you find?

Jake: Yep. So, I, I sat down with, 14, young people who were in our program. they were really wonderful interviews, actually. Like, I felt very privileged. privileged to have the young people share their wisdom and their experience with me. I came out of nearly every interview thinking, wow, like, you know, this is such a wonderful thing to be able to do.

And what was really lovely is that they were saying similar to me at the end. There was like, no one's ever asked this, like no one's ever sat down and sort of spoke to me about this stuff. So they were really grateful as well. So I felt very reinforced in behavioural terminology, for doing this project and I'm very motivated, to do more, with it.

So, so yeah, so I was asking them questions about how they found DBT. So as a person who identifies as LGBTQ plus, how did you find it, and where were, where were our blind spots or where we needed to, make things better and where were areas that we did well. I also asked them, what experiences related to their LGBTQ plus identity were important for us as therapists to know and to potentially work on or integrate into the therapy somehow and this was to try and get an idea of potential minority specific treatment targets or, areas of conversation. I hesitate with targets because, of course, it suggests a certain amount of potential. possible pathology, which, you know, I really want to stay away from, of course, but areas that, as a therapist, I need to be clued into and I need to be potentially supporting my client with if I can.

So that's why I asked them. What we found was, well they shared so much wisdom as well. The analysis was really tricky because of course what you have to do in qualitative analysis is where you distill meaning into these themes and, I battled lots with losing lovely nuanced bits of information in the sort of collective overarching theme and, my supervisors and my co-authors were very wonderful at supporting me with thinking about how to still do it justice and of course you can't include everything.

But anyway, the sort of main areas were; there were sort of themes that were about potential targets in DBT. So these were, one area that was particularly spoken about was, difficulties with identity. So what a lot of the young people spoke about was being quite confused about gender and sexual identity Understandably, of course, for their developmental stage, but also, more so possibly because of the difficulties that they had had, and actually struggling with building up self-acceptance. It was interesting because the young people said, gender actually was a lot harder. Of course, given the socio-political context around that right now, compared to sexual orientation, which they felt was, somewhat easier in comparison, albeit still tricky. And what a lot of them said to me was like, this was an area that needed a lot more space if we could have done in DBT. The other area around targets that was mentioned was, like, the impact of others, so a big area that was spoken about was what we call, like, cis heterosexism, which is, like, a sort of umbrella term that describes societal oppression related to gender and sexual orientation or minority status.

And they said that this was from the spectrum of overt versions, so that might be, like, explicit homophobia, transphobia, biphobia, and all the way through to those more subtle, insidious versions which we sometimes call more microaggressions, where maybe a therapist didn't mean to, make an aggression and at the same time did sort of thing.

So they said these were important for therapists to know and help me to cope with and played a big role in why I found things difficult. The flip side to the impact of others was a lot of young people said one of the biggest protective things for them was community connectedness. So finding a way to connect with people either who were accepting, or were similar to them so that they could see similarity and they could find connection with others. So they felt like DBT nurtured that quite well, especially in the skills group aspects, because we of course bring young people together, even though they would love to not most of the time- but most of the time by the end of the group, they actually tend to really get a lot out of it and get a lot out of being around other people who share some degree of similar experience as well.

So, so yeah, and, and the ultimate thing we're pointing out that like identity and the impact of other stuff was to say, this is the areas where DBT therapists particularly here, but therapists generally probably need to be a bit aware of what that might look like for young people and to try and help them navigate some of those key dilemmas, because of course, you know, these young people in particular were saying, these are things we're going through, these are things that would probably be helpful to support with more, if you can. And of course, I'll speak a little bit to that a bit in the future, because it can be a tricky dilemma with fitting everything into your therapy, especially when you've already got a lot of higher order targets that, you know, you need to focus on first.

The second area of findings were about, well, how did they find it, what worked and what didn't and this was split into two main themes. So the first was difficulties or wherever it worked about negotiating, focusing on LGBTQ plus stuff or associated dilemmas in DBT. And the other one was about creating safety.

So the first one, the negotiating focus, what young people said was, what was a bit tricky in DBTs, because it has a really high threshold for including difficulties in the therapy, because of course we work with highly suicidal clients, our first and foremost priority is keeping our clients alive. So life threatening behaviours are always going to be priority, first and foremost. And then even then, when you get past that and you get more towards the other things that are causing them problems, it often has a really high threshold for being included in DBT because of course the sort of principle is like, is it severe enough that you need DBT rather than an alternative sort of intervention? And that can be tricky because the young people are saying I wanted to focus on it, it was there. But I couldn't get to it because there was so much other stuff in the way. even though their wisdom was actually if you could have helped me a little bit with some of that stuff more, it might have made the other problems better.

So some of our recommendations are very much around how therapists find some of these what we call controlling variables or like key, almost like hot links in the chain that lead up to these difficulties or, or difficult behaviours, which might be to do with minority stress, right? Might be that it's often their own thoughts around, you know, their gender or their sexual orientation or, or people's behaviour towards them that lead to say self-harm or alcohol use or so forth. That actually, if you can find those and work with those, that's a way around the trickiness with getting it on our, our treatment hierarchy or what we're going to work on. so yeah, so that was one difficulty. The other thing that they said is they actually thought that a lot of the DBT stuff was really generalisable. They were like, it's great, you know, the skills themselves are not like pigeonholed into this idea that they wouldn't work for queer people or LGBTQ young people. But what they said is that sometimes, Well, a lot of the time, therapists didn't help them generalise it in that way, so they, they, a lot of the young people said to me in the interviews, like, Now you're talking about it, I know I could use X skill for, you know, when people are transphobic towards me, or when people do, do X behaviour, but no one ever told me, so I never sort of made that link. And, there’s a really big, you know, the whole function of phone coaching, for example, but also just, generally an emphasis on generalisation in DBT and making sure we're helping people generalise and not assuming that they naturally would generalise the skills to all relevant contexts.

So, that was another really important point that was pulled out that therapist generalise and help your clients like scaffold their ability to generalise where you can. Another area was they were saying you know, actually, sometimes the skills needed a little bit of extra something to help with LGBTQ specific areas. So, you know, if I'm navigating trying to come out or, I'm navigating trying to challenge someone on, say, transphobia or something, it's probably going to have to have an extra couple of steps or layers in it that are going to be really important for that skill to be applicable. So one of the biggest examples of that was the consideration around safety and how you build safety into skills practice.

Because of course, yes, it might be great for me to say, yeah, sure. Be assertive, go assert your needs. But if you've got a risk of say, being harmed physically or killed at worst, like you, You probably want to weigh that up, before you do that. And that's super important to do.

So some of the stuff just needs a little bit of like extra thought or augmentation in order to make sure people are safe. So that was the main stuff. Final bit, which was creating safety, super important. A lot of the young people said it was a lovely safe space. So that very much warmed my heart to know that they found it, DBT, a relatively safe space, and the way they described that, as I said, it felt very open, non-judgmental, very accepting, which is the spirit of, there's a lot of Zen philosophy that's built within DBT, and of course, therefore, the spirit of stuff is genuinely and radically accepting people for who they are and that sort of wonderful, innate wisdom that they have, so that came through which was nice and that's extra needed. So again, another tip for therapists is you know, as Queer people we experience a lot of messages about change in our lives. So we're told from a very early age that there's something not quite right with us or unacceptable, and that therefore we need to change ourselves, you know, in very subtle and explicit ways as well as people explicitly saying you should be straight or you should be cisgender or, or so forth in, in much less nice ways than I just said it. So therefore, it's really important for people working with LGBTQ people to lean much more on their acceptance and validation side of skills, because you really want to, you need to sort of outdo the balance of all the change based messages that we have in society, in order to make us feel a bit more safe.

So this came through a little bit in that feedback. Other stuff with creating safety was just things like making sure confidentiality is clear, like who, where are you going to record this information about my sexual orientation and gender, and where is it going to end up? making sure that you display safety signals, so some of those are like environmental safety signals, like pride symbols, diverse examples in content, some of it might be policy based safety signals to make sure there's like, like policies in place for those where that becomes, visible to, or is necessary. Making sure that you model diversity within your team, of course, ideally, and disclose if you feel comfortable doing so, although actually, we, we think that that's super important. If you're asking your young person to disclose, it's possibly quite important that you're willing to do, you know, what you're asking of, although I know that that doesn't fit for, for all models. yeah. And just sort of making sure that we're cautious around sort of inclusive language, like on forms in person as well. So get rid of that other section, you know, in, in your social demographic forms, because it's very othering. It's really problematic. It should be preferred to self-describe with the option to self-describe or ideally you just have all of the categories, making sure you do ask about sexual orientation, gender identity in forms and in therapy, because of course context, identity, it's all very important to the work and the lens of which we see the world. And if I go somewhere and on the form I see they're asking me about gender and sexual orientation, usually it's a good sign, like, hmm, they're being thoughtful about me and, people like me. Even better if it doesn't just say male, female, other, Because I'm like, uh, you know, I don't quite fit any of that, which, makes me immediately feel slightly not welcome there. So, hence the, you know, subtle and subtle things like that, that are quite small changes, can make a big difference, and the young people really commented on, they loved pronouns being announced and disclosed by clinicians and put in emails, they loved the sociodemographic form, being very inclusive, they loved rainbow lanyards, you know, all of those things that just help people feel a bit more safe in the environment.

Steph: Was it important to the young people that their therapist, wasn't just a straight cisgender person or did that not matter to them so much as long as they were accepting of who they were?

Jake: Yeah, this is a good question because, of course you see in ethnicity and race minoritised groups that, that, that ethnicity or race based matching actually has a really positive effect. in other research around LGBTQ+ stuff, the sort of idea currently suggests that actually you don't need to match based on gender or sexual orientation, as long as you are overtly and relatively overtly, accepting. albeit, there may be benefits, of course, for people feeling a bit safer, maybe, if they see someone who's overtly queer or quirky or, you know, something that just communicates that they're likely, thoughtful and accepting in this area.

The young people I interviewed didn't massively comment on this because what they spoke more about was it was just super important that their therapist was really overtly accepting. Because they did say that, One of the biggest barriers to safety was thoughts about and expectations that they generally would just be rejected or judged negatively as a queer person by their therapist or their team once they did know.

And of course, nearly all of them said, but when I did come out, it was received so well that, it was great. but that worry was there and, you know, and I can testify to that as a queer person, that worry is always there for me. There's like a sort of standard, cognitive, automated process that's in any new interaction with a person is immediately like, they are more likely to reject than not, you know, sort of thing, which of course, thankfully, many behavioural experiments and exposure to us later, mostly doesn't come true nowadays. But yeah, so that was very present for the young people.

Steph: And one thing that we touched on right at the beginning when we started talking about the paper was, being able to listen to the young people and, you felt very privileged to hear their thoughts and their experiences. And, one thing that really came across to me was you put little excerpts of the transcripts in throughout the paper to, highlight certain points, for example, when they've been feeling not accepted with regards to their identity and things like that, just a comment really that I wanted to make was how articulate a lot of them came across and actually, it must have been really lovely to hear some, I mean, heartbreaking sometimes, but also really lovely. I work with a lot of adult clients, and some of them can't so articulately explain, I feel othered because this happened to me or my therapist misgendered me or assumed I was straight. And that made me feel like this because, and that really came across, I think, in just the small excerpts of just how articulately could be and, really in tune, I think, with their feelings and their experiences.

Jake: Yeah, no, they did, you know, an absolutely wonderful job. And some of them did comment on, they felt like they had, really learned a way to describe their experience a lot through the work in DBT, because of course, a lot of our mindfulness practice is about how to observe and describe experience. It was very hard, at a similar point to like, you know, all the information fitting into themes, to cut the quotes, because some of the quotes were so beautiful in how they described, you know, of course that's a judgement, but like, how they described their experience, I just wanted to keep them all.

It went through a really, like, challenging process to cut them down to what was necessary, of course, for the reader, to see what was the sort of best quote to, to articulate that particular theme. But they did an absolutely wonderful job. I sometimes, and this is, of course, an assumption, not based in empirical evidence, but, you know, my assumption is that the generation, Gen Z, as they're often called now, that sort of generation that I was interviewing tend to be a lot more, well versed in areas of sort of equality, diversity, and inclusion in such a lovely way, that I think they're a lot more thoughtful about it, because I, for example, I never come across the word, like, heterosexism or internalized homophobia or any of that stuff until I started research. But yet, some of them were saying to me, without me even mentioning those terms, like yeah, that's heterosexist, or like, you know, that's so, you know, it's interesting, they've definitely picked up a lot more on some of that language.

Steph: So I think you've probably answered a lot of this, but what do you think the implications of your study are for the world of CBT? What impact do you want it to have made?

Jake: I've obviously been peppering some of the recommendations throughout, so, not to overly duplicate those, but certainly to say that, like, Yeah, absolutely. I, I think there is a bit of a problem with how we meet the needs of LGBTQ+ people in services, or at least how safe it feels to just access services.

So, from that standpoint and the fact that there's huge health inequalities, I think generally we should come from the default position as therapists as we probably need to do better for this group and we're still probably not fully meeting their needs I mean we may be but I would say it's better to come from that default point and therefore I suppose this paper is to like invite us to take a non-defensive fallible stance which is very much part of DBT sort of agreements and spirits is like, it's okay to be fallible. We're human, of course, we're going to make mistakes and, we need to learn from them and, still find our blind spots and so forth. So I think I would love it if, therapists would go away and, and reflect on, similar to anti racist principles, right, reflect on their blind spots, their privilege, think about, where they need to learn stuff, where they don't, educate themselves, and of course, yes, sure, you're, like I said in the paper, your clients are well placed to educate you, of course. And at the same time over relying on minoritised individuals to educate you about their oppression and minoritization is very exhausting, it's very burdensome. So unless you've got a lovely, willing, queer person in front of you who wants to give you, the lowdown of that is to try not to over rely on that, and it's to try to rely on finding your own sources, of information and checking those things out. So I think that's really important. I think therapists, I would say, to ensure that they use much more of those acceptance validation principles where possible, as I explained earlier, to try and undo those sorts of heavy change based narratives and ideas that, that sort of exist in society.

Accept that identity and especially these areas of identity are very fluid at times for some people, not for all, but not to invalidate that, therefore, you know, say someone. I don't know, identifies as bi now, maybe heterosexual or gay later, you know, vice versa, or any other iteration of that, that that means that any of those were not, valid or that at times that it's really, being okay with, with that change and that fluidity, still asking about it, still checking out, of course, being accepting of people because that's sort of the biggest problem is that it comes from lack of acceptance or sort of judgments of LGBTQ+ people. Trying to include context and minority stress in formulations and in interventions I think is a really important one as well because of course often our difficulties don't arise, in isolation of context and experience and, I think it's really important that we consider how, you know, say being LGBTQ+ how that's in some ways interacted with, the events or situations or experiences that have led up to the difficulties that I'm experiencing.

So just being mindful of that and, trying to, as I mentioned earlier, consider safety with clients. So, you know, whenever you're trying to do work around this stuff or generally, just making sure that there's not really rational, justifiable, safety concerns that, may come up and try not to invalidate that.

So I think that's some of the general stuff. I think that's definitely important stuff. Like I mentioned around creating safety. So get those safety signals out there. Like, you know, you want as much of that as possible. the overt stuff, model and disclosure, pride symbols, even just asking about it, like what I mentioned on forms or in assessments or so forth, you know, our safety signals asking is important because, of course, otherwise people just assume often, cisgender and heterosexuality. I think that that's fine if you're cishet, but that is not fine, you know, if you're LGBTQ+ of course, ask in a way that feels developmentally appropriate and, you know, feels, appropriately tentative that sort of communicates very clearly. You do not need to tell me if you'd rather not. But actually I'd love to know a bit about you, who you are, your context, you know, that's gender, sexual orientation, culture, race, religion, tell, give it all to me and know that there's some sort of explicit or implicit invite that if that stuff feels important, that's very welcome in this space.

Being overtly, nonjudgmental and part of the ways to of course, position yourself like that. Knowing that social connection and connectedness is really important for this population. So that might be a good area to focus, say your behavioural activation or, whatever other work that you're, you're doing with someone and make efforts to try and get pronouns, correct, and disclose them.

And if you get them wrong, non-defensive, fallible stance, and try your best in future. Of course. The thing is, is pronouns of course are, about gender and they are starting to become a bit more of a universal signal for I'm on board with and supportive of LGBTQ+ culture, that is a very easy augmentation to make in regards to disclosing your own in emails or at the start of meetings, and asking people for what they prefer to be used. And of course, if you're not used to using They/Them pronouns, or something similar, it's okay, practice. Like, language shifts and changes all the time. I tend to just prefer, from a sensitivity point of view, to remain relatively gender neutral about everything I'm talking about, until I know otherwise just because then there's less risk, of causing harm. So yeah, so, important. And obviously if people do want to bring this stuff to therapy, it's about trying to make sure that you show them what's possible and what isn't. And part of the principles that I often think about with this is like, what is your remit to treat.? And what are they, what do you have permission to be working with or treating in therapy? And actually, if your client isn't giving you permission to go near that stuff, that's okay, don't go. Like, you can invite it, you can ask for it, but you don't need to go there. Just because, say, you see them and you judge that maybe they are LGBTQ+ or assume that, you know, it doesn't have to be bigger than they want to make it, type thing. So being led by your client, of course. but inviting space because you are the person in power. So, you've got the sort of, you know, the more powerful privileged position in the therapy room. And therefore, you need to lead in some ways and show, you know, equalize the playing field a bit by showing that there's space for this stuff. But if you can and, and the person wants it and thinks it's important, absolutely collaboratively negotiate, build it into the therapy, whether that's just formulation, whether that's in some of the work you do, whether that's just in some side talk about people's lives and what goes on. It's just, acknowledging that for some it's important, for some it's not, and that's okay too of course.

And final tip I suppose is just say that of course none of this is in isolation of intersectionality with other areas of minoritised characteristics and therefore some of the beauty of that is really being able to have really lovely rich conversations about other areas of difference or identity and how these things intersect and, you know, how, how that person sort of makes sense of their world through that lens.

Steph: That's all really, really wise and insightful. So thank you so much for all of the thoughts and for sharing. Two last questions I have before I let you go and get back with your day. the first was, if you had to do this study all again, is there anything you'd change or anything you'd do differently?

Jake: Hmm, good question. I mean, what I would love to do is, this was very specific of course to the program I work in, which is a national program, so to some degree has a slightly more wide-reaching population, than maybe a local clinic but I would love for something that's a little more widespread in regard to DBT programs, etc. So, that would definitely be one thing. I think the other thing that probably needs to be done, and it has a little bit, there's some studies out there, is that I think gender and sexual orientation here made sense to keep together as an ideology, because the way the young people spoke about it made a, you know, they didn't speak about those two things in isolation really much. So they felt very intertwined in regards to experience and difficulty, and yet there's going to be very specific potential, needs and adaptations for sexual minorities that may be the same or different from gender minorities. So, you know, I would also have loved to have gone out there and got a nice group of gender minority young people who have been in DBT, get their views, and then same sexual minority.

And yeah, thankfully in my program I've researched the sort of next steps, some co production work to try and build a bit of an augmented, or sort of optimised, part of the treatment or component of the treatment, that can be easily built into the model and, I'm really hoping to get a bit more opportunity to sit down with lots of wonderful, young people who, you know, willing to give their time to sort of help build this and for us to use as therapists.

So, that's, that, that's what I'd love to do too, but that's what I'm planning to do next as well.

Steph: So that leads into my very final question then for you, which was, what can we expect from you next? I know that you've had a couple of papers in both of the journals, which are in progress so what can we expect to see from you?

Jake: Yeah so this was sort of the foundational program of research really to sort of build on so that includes, this paper, which was the centre of the voices of young people, one of the papers that's coming out soon is, disaggregating outcome data from DBT for different gender and sexual orientation based groups to check quality of outcomes that should be out there soon.

And a number of other projects that are side projects in other areas of equality and diversity. So, you know, we've just published one which is around people from race and ethnicity minoritised groups speaking about ethnicity, race and culture in DBT and how, to try and, support the work in building on anti-racist principles in DBT, and also stuff around autistic young people in DBT.

So there's a paper recently published on disaggregated outcomes, and then we've got another qualitative piece of work ongoing, which is trying to get the experience of autism, autistic young people in DBT to try and optimize that. So I think there's really nice learning from across those groups that can be pulled together.

So it's why I like to not keep it specific to LGBTQ groups. So that, that are the ongoing bits. The next step of the program of research is there's a small side project to think about implementing adapted DBT skills training for trans or gender diverse people that's outside of the NHS because of course, you know, the NHS is riddled with sadly systemic transphobia and so forth that means that it's not the most accessible system, to say the least for this population. So trying to get DBT into more safer community based organizations. So that's a lovely side project that's going on. And then I'm hoping to do some co production and piloting work for sort of augmented slightly adapted version of, of DBT principles and skills. We can easily pull into DBT and other models as well, hopefully, for specific dilemmas that have been brought up by the young people in this paper. So that's the next stage and hopefully will be out soon.

Steph: I’m really looking forward to seeing this research coming out Hopefully you can come on again and talk about some further research when it's published and the results from that. So, Jake, thank you so much.

Jake: Thank you.

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