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Let's Talk about CBT- Research Matters

Steph Curnow for BABCP
Let's Talk about CBT- Research Matters
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  • How to treat someone suffering with PTSD following rape in adulthood with Dr Kerry Young
    In this episode, Steph Curnow is joined by consultant clinical psychologist Dr Kerry Young to discuss the paper "How to Treat Someone Suffering with PTSD Following Rape in Adulthood", published in The Cognitive Behaviour Therapist. Kerry shares the motivation behind the paper and reflects on over two decades of clinical experience in trauma services. Listeners will gain insight into: Why evidence-based trauma-focused therapy for PTSD following rape is so effective Common myths that prevent therapists from engaging in this work Practical guidance for assessment and treatment using CT-PTSD The importance of addressing dissociation, self-blame, and shame Strategies therapists can use to protect their own wellbeing while doing this work The powerful impact this intervention can have on clients’ lives This episode also highlights the invaluable video resources linked to the paper, which show exactly how to put the guidance into practice. Kerry offers encouragement to therapists: if you know how to do CT-PTSD, you already have the skills to help survivors of rape and it’s some of the most rewarding work you can do Explore more from the Cognitive Behaviour Therapist Find our sister podcasts and all our other episodes in our podcast hub here: Have feedback? Email us at [email protected] Follow us on Instagram & Bluesky: @BABCPpodcasts If you found this episode helpful, please rate, review and subscribe so more people can discover these important conversations. 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 Dr Kerry Young. Kerry is one of several authors on the paper How to Treat Someone Suffering with PTSD Following Rape in Adulthood published in the Cognitive Behaviour Therapist. Hi Kerry, welcome to the podcast. So, it's so nice of you to come on and talk to us today about this paper. I think most people will probably know who you are already, but for any listeners that don't, would you mind just introducing yourself and telling everyone a bit about you and the areas that you work in? Kerry: Yes, hi. So I'm Kerry Young. I'm a consultant clinical psychologist and I've worked in specialist trauma services. I worked it out just now for 28 years. I'm a bit tired. And at the moment I run a PTSD service for refugees and asylum seekers in West London near Paddington station. Steph: So, the paper we are talking about today is How to Treat Someone Suffering with PTSD Following Rape in Adulthood. That's the title of the paper and it does exactly what it says on the tin. So, I really wanted to get you onto the podcast to talk about it because it's such a comprehensive and helpful paper. Would you mind just talking a little bit about where the motivation to write this paper came from? How did it come about? Kerry:  Yeah, so as I said, I've been working in trauma services since the late 1990s. And I think when you start out working in specialist trauma services, you really appreciate how treatable PTSD is. So we would be expecting, if we treat PTSD for someone really not to have any symptoms anymore. So it really is a wonderful thing to treat. And over the years, I've done more and more supervising in other services. And in fact, I've been part of the NHS England funded top up for NHS Talking Therapies to work with PTSD. And what I think all of our supervisors noticed doing this is that people are a bit sheepish about treating PTSD following sexual violence. There's lots of myths and there's lots of things that get in the way, but for good reasons, I think. But we were, all of us, I think, feeling really worried, not just in NHS Talking Therapies, but in other people we supervise that, you know, if someone has PTSD to rape or sexual violence, their chances of getting someone to treat it in an evidence-based way were quite variable, I think. And I just found that really upsetting really, because you'll hear all of these stories about people being raped, you know, maybe in their teens, in their twenties, and it changing the whole course of their life. And them going through the rest of their life really feeling to blame for what happened or feeling really bad about themselves. And this sort of one moment really kind of can change the course of someone's life and that's very particularly the case if they have PTSD. And so what I was noticing is that people are flashing back to being raped day in, day out, dreaming about it when they're asleep. And it’s reinforcing this, they're feeling really bad about themselves, feeling really responsible for what happened and then, making choices about their life on the basis of that. And I just sort of thought, I think we all thought, oh my God, you know, if we could just 10 sessions and the person will stop re-experiencing it, they'll be able to make choices about themselves and their lives that aren't based on re-experiencing rape. And we just thought, how can we get people to do this evidence-based therapy? And it's not just me that's written the paper, you'll see there's an enormous number of people who've written it. So don't think for a minute it was just me, but we thought, well, look, I think the problem is that people really just don't know quite how to do it. They don't know how to ask these questions about body parts and stuff. And there's lots of myths about what you should and shouldn't do. So we thought, look, we'll just tell them. We'll just tell them how to do it and show them how to do it. And so what's brilliant about this paper is this film showing you how to do it. And then hopefully people will just have a go. So that was what was behind it. Steph: Yeah, yeah. And that really nicely segues into my next question then, which was to say, in the beginning of the paper, you do talk about, about therapist fears and maybe some myths around working with sexual violence. I think it'd be really helpful if you could just take us through some of these and actually what might be barriers for therapists working with these clients. As you just said, you know, there are so many that are shy about working with this. Kerry: Yeah, and I just want to make it clear that we're all a bit shy of working with sexual violence. When they invent the thing that means we don't have to talk about it with people, I'll be the first to sign up but there isn't anything else that works as well as trauma-focused therapy. Please don't, I don't want people to think I'm thinking they shouldn't, you know, not want to talk about this stuff because I think it's very natural. There's lots of myths, I think. People often think that someone has to be stable to be able to do this work. They need to be in stable housing. They need to not be waiting for a court case. It all needs to be well in their life. And actually, so often that's the reason why people don't do the therapy. And actually, that is not the case at all. And there's very good evidence in fact, there was a great systematic review that came out last year by someone called Vanessa Yim that really looked into that and found out that actually even when you're in a war zone or even when you're still in a domestically violent relationship, you can still benefit from trauma-focused therapy. So the stability thing is a myth. Now obviously some people might not want to do it when they're unstable, but we shouldn't make that choice for them. In other myths, the things like you can't sort of on a similar vein, you can't treat people who've been raped and have PTSD if they're substance misusing. Again, that's one of those really kind of widely put about beliefs. And actually, again, the evidence not only doesn't back it up, but backs up the opposite, that people can benefit from trauma focused therapy while they're still actively substance misusing. And if you treat the PTSD, the substance misuse comes down alongside it. those sorts of things. So people don't have to be stable. They don't have to not be drinking or taking drugs. And then I suppose the main thing that people worry about is, because the therapy involves talking about the rape in some detail, people think it will be too shame inducing for the client. And on the surface, that makes perfect sense. You think, yeah, no, fair enough. But if you just think about it a little bit more, what the problem with rape is nobody can really tell anybody about the details of it. Not even your best friend, I don't think would you would say this happened and then this and then this. And so people tend to feel ashamed when they've been raped and they never really get the chance to tell anyone exactly what happened. And then, so if you actually, you're with a therapist and you tell a therapist exactly what happened and the therapist goes, oh no, I'm so sorry, poor you, that's just dreadful, what a horrible man. I'm so sorry that happened to you. And the therapist remains compassionate and caring and doesn't blame them and doesn't run out of the room horrified, the client learns that actually the person isn't judging them, and it actually reduces their shame. So the act of telling something that you're ashamed of tends to actually reduce the shame because someone reacts nicely to it. And indeed there's research that backs that up that actually talking about sexual violence reduces the shame associated with it, doesn't increase it. So I think that's the big one. And I suppose related to that, people often think as well that talking about sexual violence will be too much for the client and that they'll just drop out of therapy or something. And again, that's just not backed up by the research. The dropout rate for PTSD to rape is incredibly low. It's no higher than any other PTSD treatment. And in fact, all of the early PTSD research that was done in the 80s was done in America and almost all of it was on rape and sexual violence. So, we've known for 40 odd years that actually trauma focused therapy really works with that client group. Steph: Yeah. And I remember when we had Nick Grey on the podcast quite a while ago now, and we're talking about PTSD more generally and misconceptions around it. We were talking about then, is it that we're worried about the client and the client can't handle it? Or is it maybe the therapist is actually shying away from it and the therapist is actually thinking, can I handle this? Can I manage it? Kerry:  Yeah, well, yeah, no, you're right. I should have said that really. And I think that's really understandable. It's not something we do in everyday life. And I think it's a particular skill in working with PTSD to, you know, I often say to trainees when they're working with me, if you get an overwhelming urge not to ask about something in trauma work, that's your cue that you should. And it's a really paradoxical thing to do to get someone to talk about something that's really upsetting. And it is upsetting, it is upsetting listening to somebody talk about being raped, because, particularly with reliving, you kind of have to picture it yourself in your head, you're sort of there nearly, it's uniquely upsetting. There's no doubt about it. And I suppose it's only, it's only really worth doing to you yourself, I think, if you know it's going to help. Yeah? And so whenever I sit with someone and they're talking about sexual violence, which is basically every day in my job, I take a breath and I say to myself, I'm going to help you. Yeah? I'm going to make you stop having to think about this. And I say it to myself in my head and I'm confident that I can make it stop for people. So it's sort of easy for me to put myself through it because I know I can help. And I think if you don't know you can help, you're not quite sure what to do, you are exposing yourself to some horrible stuff without really quite being sure why. And so again, I wanted the paper to be a bit of a rallying cry to say it is worth listening to this stuff. You will help people. And the research on vicarious traumatization and burnout around PTSD therapy is that if you know that you can help and you know that you're being affected, you're much, much less likely to be traumatized by what you hear. Yeah, so I mean, I think there are some things that you can do to help you cope. And think we're going to come on to them in a bit. Steph: Yes, yeah, we'll definitely come on to that in a later question. It must be really difficult for a client coming to seek treatment following a rape. I think that must be a really brave and difficult thing to do. Would you be able to talk us through some of the things that therapists maybe should be taking into consideration when assessing clients in this context? And also, how do they know it's PTSD? Kerry: I mean, it's quite hard to know if it's PTSD and lots of things look a bit like PTSD as well. I think the first thing that that's useful to know is that the rate of PTSD after one rate is 50%. Okay. So it's incredibly likely. It's the most likely thing that someone's going to suffer from after a rape. And of course, once it's more than one rape, you get this load effect. So the more times you have been raped, the more likely you are to get PTSD. So it is quite likely. So I would definitely have PTSD glasses on when assessing a survivor of rape. But yes, someone has come to you. If they have PTSD, the key thing about PTSD is that the person can't bear to think about the rape. One third of the symptoms of PTSD are avoidance. And so the person is really, really not going to want to talk to you about it. So they've done the most incredibly brave thing to come to talk to you because they sort of know you're going to ask them about it, and they can't stand it. So, you know, really making sure that you're, I'm sure most therapists would anyway, really encouraging the enormous effort that someone's gone to, I think, pitching up for therapy for PTSD following rape is a bit like sort of, I don't know, pitching up to a doctor and saying, go on chop off my arm or saw it off really slowly. It's going to feel that painful, you know, in anticipation. Obviously it's not in reality. So it's an incredibly brave thing to do. So really, really encouraging people. And then coming in very quickly with something encouraging about how treatable it is. So if someone has PTSD to one off rate, I would be expecting them to get all better, to stop re-experiencing it in 10, 12 weeks. So it's not something that has to be with you for the rest of your life. I mean, you're not going to be unaffected by it, but you shouldn't have PTSD to it with a good bit of evidence-based treatment. So coming with a very kind of positive now then, this is worth talking about. And then how do you know it's PTSD? I mean, I think the real key to knowing if something's PTSD is thinking what exactly it looks like. So with PTSD, I sort of think about it like imagining that your brain has made a multi-sensory video of the rape. So it's got a picture track and a soundtrack, but there'll also be a body sensation track, smell, taste. So you've got this multi-sensory video and then it's as if that's shoved away somewhere in your brain. And then to have PTSD, you're going to have to have actual bits of that video pinging into your head when you absolutely don't want them to. So it might just be a frozen image of it, or it might be a clip of film with sound in it, or it might just be the taste of something or the smell of something that that belongs to that recording. But the key is it does belong to that video. So I often talk about it a bit like as if, old video tape and there's some sort of pixie sitting in your head, chopping up bits of it and throwing them into your mind. It has to be part of the original recording. And then because this multi-sensory video is so frightening and so shame-inducing and so disgusting, you will do anything at all to get it out of your head again. So it's like its burning oil, like someone has just poured burning oil into your mind. Oh so frightened, so ashamed. So you just immediately try and do something to push it out. And those are the avoidance symptoms of PTSD. And if you know that talking to someone will make this stuff come into your head, you're going to avoid talking to them. If you know that walking down a certain street will make it ping into your head, you won't go there. And if you know that seeing a man will make it come into your head, you're going to avoid men and you're going to avoid anything that makes this stuff come into your head. But I think it is quite difficult to really pin down PTSD. And of course, the person who has PTSD is not going to want to talk about it. So it's quite hard to really get that. There's a very good film hyperlinked into the paper telling you how to assess PTSD that really goes through it in about an hour of very sort of fine detail. But yeah. It's really sort of thinking about, it part of this film? And really encouraging the person that you can do something very early on, I think. Steph: Yeah, and it's one of the really lovely things about this paper as well. And we very much want people to encourage people to go and read the paper really thoroughly as well, because each bits that we're talking about will have so much more detail in the paper. And one of the really lovely bits is that you have interspersed all the sections with videos too, so people can really see in really practical terms how this can work. Kerry: We thought that was really important. So we thought it's really important for people to see someone saying the words, you know, when he did that, what did that feel like? How did that, you know what did you think? What happened next? Then what? You know, just to show that you can do this and you can say these words out. Steph: So should we get into the guidance that you've laid out then for working with clients experiencing PTSD after rape? As we've already mentioned, this is kind of a how-to guide for working with this client group and there's so much information in there. Are there any particular parts of the guidance that you would particularly like to highlight or to point out? It's a very long paper, so it could be quite a long record if we went through it all. Kerry:  I'm sorry it's such a long paper people. What I suggest you do is actually ignore Steph and don't read the whole paper in one go. What I suggest you do is you decide hopefully at the end of listening to this to try treating someone in this evidence-based way and then just read the few bits that are relevant to the session you're going to do next and then read the next bit. Otherwise you forget it. Steph: Yeah, maybe that is a better way of doing it. Kerry: Yes, apologies for that. But at least because you can watch the films as well, to be fair, I think watching the films and reading the paper is the perfect combo. But you could always just watch the films. But I shouldn't say that in front of someone who works for journal. So I suppose the message is that you do not have to do anything different in terms of the bare bones of what you're going to do. You're going to do Cognitive therapy for PTSD, that's what we're going to take you through in the whole paper. You're going to do the same outline that you do for anybody in a car accident, in a disaster, mugging, whatever it is, you're going to do the same basic process of CT-PTSD. And the paper kind of runs through it in that order too. And there are just a few sort of little flexes that you need to think about or things that we're just going to say a bit more on. And so the first thing is that you're probably going to be dealing with dissociation. Now you might in other areas too, but we know that people are most likely to dissociate during a trauma if it's an inescapable trauma like a rape. And to be fair, I have never met someone with PTSD to a rape who didn't dissociate. It's an entirely adaptive thing to do when you're being raped. And in the paper, there's a load of stuff about how to explain it to a patient, including a film, how to manage it and so on. So number one is expect dissociation and we've got film and words on that. Number two, and I think this is really important, is you're going to have to give this person of all people a really good rationale for why you think reliving this event is a good idea. Yeah? And they need that because it's a very paradoxical thing to ask someone for details about rape. It's going to feel very uncomfortable for you and it's going to feel very uncomfortable for them unless you really, really know why. And so we can talk about evidence and so on, but in the end, I think you need a sort of user friendly explanation. the explanation that we give in the paper, I think is genius even though I made it up myself. Steph: I think that's fine. Own it. Own it. Kerry: Which is a lock and key metaphor. So we talk about the hotspots in trauma, the moments that we're going to update has been a bit like a lock and our updates are a key. And so if you wanted to design, if you were, what's his name? So what's it Timpson and you were making keys, you'd want to make, I can't remember his name, you'd want to. James Timpson, lovely guy, you'd want to make, if you wanted to make the best key to most likely slide into a lock, in order to make the best key, you'd take a mould or something with the lock, wouldn't you? I don't know how they do it. And so when we're really going into loads of detail with hot spots, know, what can you feel, what can you smell, what can you taste, we're doing that because we're trying to understand every single indentation in a lock. And we're not doing it for the hell of it. We're not doing it for any other reason than the better we understand the lock, the better we can design a key to update that moment and help someone stop re-experiencing the trauma. So a very good rationale is really important. And again, we show you how to explain that and how to do it. So expecting dissociation, a very good rationale. And then just, you're going to talk about rape, you're going to talk about people's body parts, how to do that. And there's a film in which we just get some outlines of people's bodies and look at which parts of their bodies involved in this incident. And then we agree what terms we're going to use, because you don't want to use a term that someone finds offensive. And then that's very straightforward explanation that's dealt with, two or three minutes. I think the other thing that is worth knowing again, you're just doing normal CT-PTSD. But you know, it's only really the kind of understanding the hotspots and updating them where you're going to have to go into loads of detail. With the reliving, you can do the best you can. You'll see in the paper that we don't go into loads of detail with that. We're only doing reliving so that the person can tell us what the hotspots are. And in fact, most people who are raped don't remember quite big parts of what happened anyway. So the reliving is not such a big deal and there probably will be lots of gaps in it. In terms of updating hotspots again, the usual way, but just being aware already that you're going to probably have some very somatic elements to it, pain or smells or tastes. And so again, we go through in the paper and in the films how to update somatic elements of hotspots, which you do with another sensation. And the same really, some of the things that happen in during a rape, words might not update them as well as maybe images. And so we go through some of the ways in which you might want to use imagery to update hotspots, escaping or having your say. And there's a film of us doing a joyous imagery update of a hotspot that involved Michelle Obama and me telling off this rapist, which was a nice way to end our day of filming. The last thing and the probably the most important thing. So doing normal CT-PTSD with just expecting dissociation, good rationales, bit sensory updating, bit of imagery updating maybe, how to agree the terms. But probably the most important thing is that every single person I've ever seen with PTSD following rape blames herself for it in some way. And the guilt will keep the PTSD going, the self-blame will keep the PTSD going. And so it's really, really, really important to get working on that and really not to accept someone blaming themselves for rape and to work really hard with every technique you can come up with to reduce that self-blame down as low as you can possibly get it. And I think in this regard, it's also worth just having a little chat with yourself as a therapist. think, you know, most therapists are lovely people, but we do come with our own stuff from our own background. And I think we do have to be super clear about the law and about what it says. And, you know, what it says very clearly is that there is no mitigation for rape. So even if you're really drunk or even if you're off your face on drugs or whatever, it is still a crime of equal level of severity. And that's really important because if we're aiming to help someone see that, we need to be very clear about it ourselves. And I always say to people when I'm teaching about this, and I think it leaves an appalling image in their mind, which they don't easily forget, is that I, a 56 year old woman have the right to be down the town centre of Oxford where I live at 11.30 on Saturday night with no clothes on, absolutely off my face on drink and drugs and not to be raped. And that if I am raped it is solely the responsibility of the person who chooses to rape me. It is against the law to have sex with someone if they cannot consent. So it's an image, it works better if you can see what I look like. But you know, I think it's a really important point. And that's not a radical feminist idea. That's the law. So I think we need to have that in our heads. Because we want to get people, we want to help people to get to something approaching that themselves, because nobody should be blaming themselves for a rape ever. Steph: No, absolutely. It reminds me of something my supervisor has always said when we work with survivors of sexual violence, which is put the guilt and shame back where it belongs because it's not with you. Kerry: Yeah, absolutely. There's one person who should be ashamed of himself in a rape scenario and that's someone who raped someone. And that self-blame and shame keeps PTSD going. It's not something we can leave. We need as therapists to try and reduce it with people somehow. Steph:  Mm, yeah, I think that's so, so important. I think we've touched on this a little bit already, but is there anything you would like therapists to know specifically before they start this work with clients? And also, it's kind of a twofold question really, but then how do they keep themselves safe too? Kerry: Well I suppose in terms of keeping yourself safe, I think it's very important that you know yourself as a therapist and a very high proportion of therapists are female and a very high proportion of women have got some sexual violence in their past, we know that. Now it depends what's happened and what therapy you've had or what you've managed to do with it, whether or not you think that if you have that in your past, you want to or can do the work. And there's no rules about that. But I do think it's really important that if you think that you can't because it's too upsetting for you, too close to the bone, that's fine. People should not be made to do this work by their managers. And there are, unfortunately, I write quite a lot of emails to managers saying, this is unreasonable. This is not trauma informed. You know, you have to be trauma informed with your staff and you should not be forcing them to see cases that are too triggering for them. There's a list of stuff I don't like to do, for example, I'm absolutely terrified of dogs and I don't want to do any traumas that involve dogs. I can't, because I just know it's going to make me too frightened. It's a minor example, but knowing yourself is important. So number one to looking after yourself is, you know, really knowing that it's a reasonable and sensible thing to do to opt out if it's too triggering for you. Number two, I would say is don't have an entire caseload of people who've been raped if you can help it. Now, obviously, if you work in somewhere where that's all you do, you've done that with your eyes open, but mix it up a bit. No matter how long in the tooth you are, no matter how good you are at it, it will grind away at you. So see some other kinds of trauma for a light relief or something. I think the key to keeping well is to know that it's worth it. Yes. So to know that you're going to be effective. And that's what the research tells us. So if you read the paper, watch the films, if you're still not sure attend some extra training on it. Get yourself feeling up to speed on it so that you know that it's worth putting yourself through this because it's going to work. And do what we do with our clients as well. If someone said something that you're finding particularly upsetting, say it out loud to somebody else in your team. So we have the system in our clinic, which we call the corridor march and blurt. And you know, I'm listening to terrible things all day, but it's just some things that get to me. And I never know which it's going to be, but I can feel it inside me when I'm listening to it. And that's my key really. And what I do is as soon as I finished with that patient, I walked down and I grab a qualified member of staff and I say, can I just tell you what they've told me? And I say it out loud and we've got that deal in our team that we all do it with each other. And you have to have that deal because we never really tell someone something upsetting deliberately. Yeah, we would kind of summarise it. No we need to say exactly what it was that was so upsetting, the exact words. And what we found almost without exception is if you say it out loud to somebody, it stops pinging around in your head. So yeah, I think that's it really. allowing yourself to opt out, the corridor march and blurt, spacing these kinds of cases out so it's not all day rape. More training, more supervision if you need it. And then I suppose the final thing that I want to say about that is it is worth it. Yeah, I mean, I do, you know, I'm a terribly soft-hearted person and I can't watch horror films and I can't watch violent films. I never have been able to. It's got nothing to do with trauma and I'm a very soft person. But I do do this work because it's really worth it. I can't tell you what a buzz is to know that you have stopped someone re-experiencing being raped day in, day out in 10 sessions, in 12. So to know that you've done that is the best reason to have got out of bed this year. I know it's frightening but it really does feel good when you've done it. So I really, really want to encourage people to try it. Steph: Yeah. And that reminded me what you said towards the beginning when you were saying you have to give a really good rationale for your clients. But imagine saying to someone in 10 to 12 sessions, we can fix this. That must be magical. Kerry: Yeah, it's wonderful. It's, can't tell you what a buzz it is. And in a world in which there are, let's face it, some bad guys at the moment, particularly going around making everybody's lives miserable. We can't do much about that, but we can as CBT therapists, stop someone doing this kind of Groundhog Day, jumping back in time, re-experiencing being raped, feeling just ashamed, feeling full of self-blame, we can make that stop really in not very much time. Everybody who knows how to do PTSD knows how to do this.   Steph: And I think we've very clearly answered this question already, which would have been what impact do you hope the paper will have on the world of CBT? So I might slightly rephrase it and say, what impact do you hope it will have? But also, have you seen any impact already? Kerry:  Well, I mean, the papers only just come out. We did make the films about a year ago and I have been giving them out to people I supervise and others. And people have come back saying, people write me emails quite a lot saying, I was going to have to do reliving to a rape and I watched your film and I thought, I can do this and I did it. And it was fine. And she said she was so relieved that we managed to do it. And now she's not blaming herself so much. So you get this really good feedback really quickly. What I wanted, and again, it's not just me, I did kick it off, but about 20 people wrote the paper bits and we sort of smudged it all together. Was that wanted someone, I wanted to be more confident that a woman or a man had been raped and turned up to a CBT therapist or psychologist somewhere, anywhere in the country, that their chances of getting effective evidence-based therapy was greater, so that they could stop re-experiencing rape all of the time. And alongside that, that they would get this evidence-based therapy so that they would get better. And really for me and my kind of sense of justice in the world, I don't want a single rape survivor blaming themselves at all. I just don't, it's wrong. And so I want to give people effective tools to help rape survivors stop blaming themselves because they are never responsible for being raped. And so within the paper, there is also a resource document that we put together of all of the sorts of reasons that people blame themselves and sort of arguments to go through to take them through that the therapist can use. And so every single sort of helpful thing is there in one document that you can look at with your patient. And in fact, there's also reference to a paper we did a few years ago on how to work with guilt in PTSD. And again, that has film showing you all the kind of responsibility too. So again, I think it's entirely possible if you know what you're doing to help people not blame themselves for rape. And for me, I just can't stand the idea of people blaming themselves for rape. And we've got the technology to make that stop or really reduce it. So that's what I wanted, I really hoped for. My colleagues, Sam Akbar and Millay Vann did a webinar for the BABCP on it two weeks ago, three weeks ago, and had 500 people came to that. And they're doing another one on the 20th of November for BABCP in the morning. I've offered to do one for NHS England as well, which would be free, I think. They haven't come back to me yet, but hopefully they'll say yes. Can't think why they wouldn't. When we looked at the films have been viewed 1200 times so far. So, they've only really been widely available for about a month, isn't it? So hopefully we're looking at thousands of people watching them, which should be brilliant. Steph: Yeah, we're doing what we can to spread this paper far and wide as well so that people really do read it because it is, it's just so helpful. yeah, we really do. And maybe a slightly more left field question then, but if you had to do this all again, is there anything you would change about the paper or anything you'd want to do differently? Kerry:  Hmm, make it a bit shorter. I don't know how to do that. There are a few films I wish we'd made actually, the more I thought about it. So I've probably made it longer unfortunately. I've made a few more films I think. No, I'm really very pleased with it. Steph: Well, that's great. That's what we want. I always like it when people say, actually, I'm really proud of this. It's really good. And I always like to ask our guests, as the journals managing editor, it's always interests me. If they have any reflections on the peer review process, if you can remember it, not everyone can. So was it helpful? How did the review was fine looking at this paper? Because it is slightly different to some of the papers that we get in. Kerry: Yeah. I was very interested to see what they made of it because, you know, it's not like quite a normal paper. There's no data. It's just, you know, this is what we think you should do in films as well. So my first sort of main thing was feeling very grateful to the poor people that had read this incredibly long paper and must have watched at least some of the films. And so I was really grateful. And I think it's very important because as I said, there's about 20 people who are authors on the paper but they're basically all my friends or colleagues. We've all worked together in the past and that's why we're authors. And so I was a little bit worried that we were a bit of an echo chamber and because we all think the same way. And so, you is there some massive thing we've missed out or is there some angle on it that we've just assumed,? So it's really helpful. And the reviews did point out some assumptions that we were making that we hadn't really thought about. And actually, you know, they just made so many detailed, helpful... There wasn't a single suggestion that I thought, that's ludicrous. I thought, gosh, that's a good point, let's put that in. So, it's so thoughtful, so much time was spent on it. It improved it. It did. Steph: Yeah. And I remember me and Richard looking at this paper when it came in and being like, who are we to ask to review it? They're all authors. Who's going to look at it? They're all on it Kerry: I don't know who you found because everybody that I would have thought of was an author on the paper. Steph: Yeah, a real diverse mix actually, so we were really grateful for that. Kerry: Yeah, well, we wanted, I didn't want it just to be clinical psychologist trauma specialists. I wanted a load of CBT therapists from NHS Talking Therapies there as well, and some survivors who are also therapists. So really wanting it as wide as possible. Steph: What would be the one thing, if you could narrow it down to one thing, that you would like clinicians to be able to take away from reading this paper? Kerry: That you have the skills to do this. If you know how to do CT-PTSD, you know how to do CT-PTSD with rape survivors. And please do it because I can't tell you how wonderful it feels to make someone stop re-experiencing rape. Honestly, if you do that once a year, it was worth you going to work for the whole year. Someone's life will change direction if they're no longer jumping back to being raped. How can you move forward if you're jumping back to being raped all the time? Day in, day out, even when you're asleep. So you can help someone change direction and sort put one of the terrible wrongs in the world slightly right. That was just wonderful. Steph: Yeah, and that's a message that's really reiterated throughout the paper as well. And it's such a hopeful one as well, because in what is such a dark, dark topic, something that just can be just really hopeful that you can change someone's life and it will be, it will, it will be life changing for them. Kerry: Yeah, and I know that sounds really like a megalomania thing to say, but someone's life does pivot around rape, particularly if have PTSD and goes down one direction. So you really can turn that the other way. Steph: This has been such a lovely chat, Kerry. Thank you so much. Just before I let you go, what's coming up next for you? Is there anything else you're working on that we can look out for or that we should be looking out for? Kerry: Yes, so despite promising everybody that I work with that we'd give it a rest, well that's not what's going to happen… Steph: I know there's at least two papers in our system from you at the moment. Kerry: We're on to something else now, which is I actually, so again, it's my experience of supervising around the country and in talking to all my colleagues, particularly the ones we've written the paper with, I think there is the same issue that's just slightly different with providing evidence-based trauma-focused therapy to adult survivors of childhood abuse. And I think that's people in NHS Talking Therapies particularly have been asked to do some of this work now. There was guidance last year that sort of said you can work with survivors of childhood abuse under certain conditions. And that's lovely, but you might say, how do we do it? Yeah. And if there's a lot of myths about rape, there's tenfold myths about childhood abuse. So we want to do exactly the same paper, hopefully not quite as long, on what to do with adult survivors of childhood sexual abuse in NHS Talking Therapies. And it will be do this, then this, consider this, films, films, films. And I'm thinking of calling it Don't silence the silenced. So I think that people who are adult survivors of childhood abuse go from service to service trying to find someone who will hear their story. And they were silenced as children and unfortunately, unknowingly, I think a lot of us silenced them as therapists. And again, I just don't want that to happen. I want us as therapists to help release people from jumping back in time to being scared little children all of the time. So that is the next project. And I have signed up already about 15 people to help me write it. Grudgingly they've signed up. Steph: Well, that sounds amazing. I'm really looking forward to that coming out. Well, as well as all the other papers you've got on the go as well. I know you've been very busy. So thank you so much, Kerry, for talking to me today. It's been really great to hear about the paper and we really encourage people to go read it, watch the videos and really put it into practice. Thank you. Kerry: Thank you. Steph: Thanks so much for listening. You'll find a link to the paper we discussed along with any other useful resources in the show notes, so please do go and check those out.  If you enjoyed this episode please take a moment to rate, review and subscribe. It really helps others to find us. And if you have any feedback then I would love to hear from you. You can reach me at [email protected] or follow us on Instagram and BlueSky @babcppodcasts. Our journals are there too, sharing all the latest research as soon as it is published.  And don't forget to check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Practice Matters. Whether you're new to CBT or just looking to enhance your practice, they're full of insightful discussions and some really helpful tips.  Thanks for tuning again, and I'll see you next time on research matters. Bye    
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  • Is it time for a more individual approach to adolescent eating disorder treatment – with Dr Daniel Wilson
    In this episode of Let’s Talk about CBT- Research Matters, Steph speaks with Dr Daniel Wilson, a clinical psychologist and researcher based in Brisbane, Australia. Dan is the lead author of the paper “CBT-E following discontinued FBT for adolescents with eating disorders: time for a more individual approach?” published in The Cognitive Behaviour Therapist. Steph and Dan explore key findings from the study, which compared the effectiveness of CBT-E (enhanced cognitive behavioural therapy) for young people who had previously discontinued FBT (family-based treatment) versus those who had not tried FBT at all. The research offers important insights into treatment options for adolescents with eating disorders and highlights the value of providing alternative pathways to recovery. Links & Resources: Read the paper: “CBT-E following discontinued FBT for adolescents with eating disorders: time for a more individual approach?” - https://bit.ly/3Eysxd0 Explore more from the Cognitive Behaviour Therapist Find our sister podcasts and all our other episodes in our podcast hub here: Have feedback? Email us at [email protected] Follow us on Instagram & Bluesky: @BABCPpodcasts 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. In this episode, I’m talking to Dr Daniel Wilson. Dan is lead author on the paper CBT-E following discontinued FBT for adolescents with eating disorders: time for a more individual approach? Which was published in the Cognitive Behaviour Therapist. Hi Dan. Welcome to the podcast. Dan: Thank you very much. Thanks for having me. Steph: It's really exciting to have you on. Actually, you are our first guest from Australia. So would you like to tell the listeners a little bit about yourself, maybe where you work and your research areas? Dan: Yep. Sure. So I'm a clinical psychologist. I'm from Brisbane, Australia, and my work here in Brisbane, I do a little bit of a mix. So I am working at Children's Health Queensland at a specialist eating disorders clinic for our child and youth mental health service and I work clinically there as part of the CBT-E team. I'm on a research fellowship for the last two years and we're researching eating disorders generally and what factors contribute to treatment outcomes amongst adolescent eating disorders. And also do a little bit of work in private practice as well. Steph: Okay, brilliant, thank you. So I was really keen to get you on the podcast. It was Eating Disorders Awareness Week here in the UK a couple of weeks ago. And, as we just talked about off air, we also recorded a Practice Matters podcast with Rebecca Murphy, which you said you listened to as well for Eating Disorders Week, talking all about it. So I thought this would intersect really nicely with that. We don't actually get many eating disorders papers into the journal as well, so I thought it'd be really nice to showcase this one and talk about what you do. So could you tell us a little bit about how this paper came about? Was there any particular motivation for the research? Dan: Yeah, so I guess in part, it was on behalf of our young people, on behalf of the treatments that we offer as well. I think unfortunately still with all the evidence we've got with treatment with eating disorders, sometimes they can get a bit of a bad rap. Not so much within our service, but they can be perceived as people that are hard to treat, or the treatments don't work, or people don't recover, despite there being like really good evidence for outcomes. And so what in particular we noticed as well was with family-based treatment, it's a treatment that a lot of people have heard of. It's probably the most well studied treatment for adolescent eating disorders and when it's not going well or it hasn't completely worked, then that kind of perception that, oh, they're not going to recover, can be even worse. And sometimes when family-based treatment doesn't go well, it can not look too good. There can be a lot of distress, there can be a lot of like argumentativeness so that the perception- this is very much anecdotally- is well, if they haven't been able to recover with full family support, what hope is there? And that they're not suitable for an individual treatment. But within our service, what we noticed was that when we'd had sort of some young people that hadn't done quite so well with FBT and we gave them a chance for CBT-E, a good proportion of them did really well and engaged really well on the treatment. So we thought that was really important to be able to demonstrate to give the families and to also clinicians hope that, even if their family-based treatment hasn't worked, then the young people can still achieve full recovery through a treatment like CBT-E. Steph: That's probably a really good point then to just talk about the two treatments a little bit. Would you be able to just sort of talk a little bit about the differences between the two for those who might not be so familiar, and actually maybe why family-based treatment might not work as well? I'm quite intrigued to some of the reasons why. Dan: Yeah, sure. I think that's, that's a really important distinction between the two treatments to make. And I think that's also a really great, to have two treatments that contrast quite differently. I think a lot of times in psychology there's a large overlap between the treatments and it's like one hasn't worked then the other one maybe is also quite similar. But with FBT and CBT-E, there's some really striking differences there, which I think might give some rationale for why if one doesn't work, the other one might work. So with FBT to start off with, the theory behind the two treatments are quite different. With FBT, they take the medical model, the disease model. So with that model, the eating disorder is conceptualised as an illness that the young person has, they don't have any control over, and the symptoms of the illness are the eating disorder behaviours, which might be the concerns overeating, the concerns over weight and shape and the desire to restrict. So according to that model, if you've got the disease, it's something that's external to you that you have no control over. It's a little bit like having covid or something, you don't choose to have a sniffly nose, you don't choose to have a cough, you don't choose to feel awful. It's an illness that you’ve contracted so you need some form of external medicine, external control to recover from the illness. So when you've got covid, you take whatever medicine's going to help you recover from that. According to the FBT model, it's the eating disorder that is causing these symptoms. It's not something that the young person's chosen to have, but they need some sort of external force to regain control. And according to FBT, the food is the medicine, and the family is that external support that's required to help the young person regain control from their illness and achieve recovery. So there's a lot of advantages to that model, in that because it's conceptualised an illness like no one's to blame. It's no one's fault. It's something that's happened. So the young person isn't to blame the families aren't to blame. And according to that model, you can garner the resource of the whole family to, to help the young person recover. So it's a good model and the evidence is that it works but it's also quite different to the CBT-E model where we take that psychological approach. So rather than it being an illness that you've got no control over, we think according to the CBT-E model, that there's reasons why this young person might be really concerned about their weight, concerned about their shape and want to engage in eating disorder behaviours. And it's not because they've got an illness or got something that's external to them. It's according to the CBT-E model we usually conceptualise it as being a maladaptive schema of achieving self-worth. So it's a way that the young person has learned to feel good about themselves. And if they can control their eating, if they can control their shape and weight, then they feel really good about themselves and they feel in control and they feel great and that's why they want to engage in the behaviours, and that's why they're so concerned. But there's also mechanisms that maintain it and can make it a problem. So according to that model, it's the road to recovery isn't through an external force being required. It's the road to recovery is understanding what the mechanisms are that the maintaining the eating disorder as a problem. Making the decision, okay, I want to explore other ways of achieving my self-worth. Other ways of feeling better about myself that don't rely on just controlling eating, weight and shape and then applying the strategies to be able to change them. Steph: Yeah. So it sounds like it gives them more autonomy. Dan: Yeah. Yeah definitely. And, yeah, in that early on in the stages of FBT, it's very much kind of parents are in control and that they need to be, because according to that model, the young person doesn't have any control. Whereas with CBT-E, it's all about autonomy from the very first session, it's like you are in control here, you are making the decisions through treatment and it's your decision to, to literally sit down in session one and talk about what's going on. And then if you want to hear more and make the decision to engage and it's your decision to go on from that. So, yeah, a lot of difference in the role of autonomy there. Steph: Yeah, and this might be a bit of a left field question then, but do you think maybe that's why FBT doesn't work sometimes because the control feels more with the parents and not actually with the young person themselves? Dan: Yeah. I think there's, there could be lots of reasons why FBT doesn't work. I think it's age appropriate for young people to want to be in control, that's a developmental milestone to try to feel in control and gain autonomy through that period. So I think that can lead to some clashes and can be really difficult for the young person to relinquish that control more generally to parents. But that said, through successful FBT, that's a part of the process as well is returning control back to the young person. Steph: So shall we get into the paper then? So this was a pilot study, so what were your initial hypotheses for the paper? What were you trying to set out to find? Dan: It was an effectiveness design, so we were, we didn't have any specific hypothesis per se, but we were wanted to compare the relative effectiveness of young people who had come with no FBT previously compared to people who'd had FBT that had been discontinued for some reason without achieving full recovery. So we really wanted to compare ok are these two groups similar or different in terms of their effectiveness and answering the question really, should we still be offering CBT-E to, to those who've not achieved recovery through FBT or is it, or are they going to not do well in that treatment either? Steph: So tell me a little bit about the participants then, who were recruited and was it easy to recruit participants for this? Dan: Well, yeah, it was based on everyone that've done CBT-E in our service. So we're a public mental health service, and the young people as part of our protocol, we offer FBT as usually the frontline treatments. So in terms of recruitment, we're the largest public service in Queensland and so we recruit from all around Brisbane and the local surrounding areas. So we do get a lot of, a large population, come through. So in terms of recruitment, that, yeah, wasn't too much of a problem and in terms of the protocol, I guess. Yeah, we offer FBT as frontline and so most of our young people typically go into FBT unless it's contraindicated or declined by the family for a range of different reasons. So we had a, if they're, if the family or the young people choose to not engage in FBT, then CBT-E is usually offered as a second line treatment. So we had, of our group, we had 69 young people and 42 of them engaged in CBT-E as their first treatment at our service. And then another 27, had tried FBT and that had been discontinued for one reason or another. And then they were offered a CBT-E suitability assessment. Steph: Okay. So then what kind of did you do with these participants and what did you find? Dan: So we implemented the manualised CBT-E according to Riccardo Dalle Grave and Simona Calugi’s manual from 2020. So we went standard CBT-E, by the book. Our team is lucky enough to have supervision with Riccardo who is on the paper, who wrote the manual. So we're lucky to have tips from him. And that kind of keeps us hopefully fairly adherent to the model throughout. So yeah, in terms of what we did, the treatment was the same for everyone in terms of manualised CBT-E, the real kind of variance was what had they done before? So, we implemented between 20 to 40 sessions of CBT-E according to whether the young person needed weight restoration or whether they needed to do the broad form or the focused form of CBT-E, which is dependent on if they've got external maintaining mechanisms that are being identified that maintain their eating disorder as well. It takes a little bit longer to target those mechanisms. So that was the intervention. and yeah, like I said, so the two groups contrasted in terms of one group went straight through and CBT-E was their first treatment. The second, the second group were people who had engaged in FBT previously. So again, they engaged in FBT at our clinic and we've got a really good FBT team as well that's really well trained. But if the young person hadn't had showed they were unable to progress, or they've being a little bit stuck, or the family had been unable to maintain the treatment or had chosen to disengage from FBT then they were offered the CBT-E assessment and then if they were suitable and the young person chose to engage and they received the CBT-E intervention. Steph: Okay. Brilliant. And were there any surprises that you found then? Was there anything unexpected that kind of came out of this? Dan: I don't think so. It reflected our initial thoughts. So the results that we found was that there was no difference between the groups on their measures of eating disorder psychopathology. So the measures we took, I should have mentioned that, sorry, was Steph: That's okay. Dan:  The Eating Disorders Examination, which is a measure of restraint and eating, weight, shape concerns. So a fairly standard eating disorder outcome measure. We also measured them on the Clinical Impairment Assessment which is a measure of not so much core eating disorder symptoms, but how much is it getting in the way of your life? How much is it impacting you doing the things that you want to do? And we also measured BMI Centiles as well. So the results, what we found was that, yeah, both groups did similar on measures of eating disorders psychopathology and clinical impairment, the intervention worked, the effect size was large. And there was no difference in the magnitude of effect between the groups on those measures. So it confirmed what we'd seen that we hadn't really noticed much of a difference on what the young person's background was, they were like more or less likely to do the same, than it wasn't a big factor. In terms of treatment completion there was no difference between the groups either. So they were, the young people were just as likely to get through to the end of treatment, regardless of whether they'd done FBT previously or not. We found a slight difference in BMI changes across treatment. And the group that had done FBT previously, they didn't change according to their BMI Centile across treatment, but the group who had no FBT did. So what we made of that, there's a lot of uncertainty around that measure because we didn't have like individual weight histories, we didn't have a lot of information that would know okay, did this young person, were they below their healthy weight range or what had happened to their weight across FBT? But the most likely explanation that we sort of think is that maybe those young people that had done FBT previously had achieved some level of weight regain or were maybe closer to their healthy weight range, through FBT. So they've had some benefit there, maybe whereas the group that had no treatment prior to that, maybe they needed to gain some weight to achieve their healthy weight range. That's a suspicion. We don't have enough data to, to be confident about that. But that's the yeah guesses we made. Steph: Yeah. So given these findings then, what do you think are the implications for clinical practice or any future research? I always like to ask people what impact do you think this paper will have on the world of CBT? Dan: I think it's got some important implications. I think, again, like circling back to our young people and our families, I think the biggest implication is hope for them. I think in our Australian context, definitely FBT is probably the more well known treatment, and around the world it's got a more robust evidence base. It's been studied more comprehensively than CBT-E. So a lot of young people, a lot of families have heard of FBT, and they're quite hopeful about achieving recovery through that treatment, as they should be. The flip side of that is when it hasn't worked, it can be disappointing, and I think some families and young people can lose a bit of hope with that. But the implications for this, I think is that they're just as likely to succeed with this treatment, despite whatever's happened with FBT previously. So I think, yeah, first and foremost, it's a hopeful story in terms of that there's a really good chance of achieving full recovery, which with eating disorders, they're horrible things. So, if we can give that hope to our young people and our families, that's super important. I think for clinicians it's also important to know that again, like even if FBT hasn't worked, and even if FBT is not looking good for want of a better word, and you're like the young person might not be engaged and might not look like they're ready to take charge of change themselves, CBT-E can still be a viable option. And again, anecdotally, and this is maybe leading to future research, but it's we don't appear to have like really good markers of okay, like who, who is going to do better or worse. So it's implications I think is, it's worthwhile, offering the young person CBT-E, to see if it's something that they want to or are ready to engage in cause yeah, in our experience, there's some people that were really struggling with FBT that did really well in CBT-E. So I think that, having that in the back of your mind to, to offer the treatment to the young person and the family is important as well. Steph: So it's that real thing about treating the individual, isn't it, and not expecting them to fit into the model. Dan: Yeah, exactly. And, yeah, and then I think that kind of like highlights future research is what we’d love to know is to be able to know who does better in what treatment so that we can get them straight into that to start off with and we, we don't have to do that dance. So yeah, ideally, that's like a little bit of the work that we're trying to do. It's a big question and I know that we're not the only ones to have thought of about asking that question, but if in part we can help figure that out, what are the factors that make people more or less suitable for FBT or CBT-E, then, we've got a better chance of being able to allocate them into a more successful treatment first time round so they recover quicker which is obviously what we want. Steph: Yeah. This probably just leads on to my next question nicely then is, is there anything you would've done differently if you were going to do the study all over again now? Anything you'd change? Dan: Yeah, I think so, well, yes is the answer to that. Lots. I think a lot of our limitations come at the setting that we are, it's not a research clinic, it's a real world clinic so we did have a lot of missing data, so I'd like to be able to tidy that up a little bit. We didn't collect data on who was offered CBT-E but then chose not to engage. So that would've been good to be able to understand a little bit more about the acceptability of the treatment. I was talking about weight trajectories before, so we didn't collect data on that, and we didn't have any data from what the young people were like prior to starting FBT. So it's hard to know the degree to which they improved prior to starting CBT-E. So all of those questions would be nice to have a little bit more data around. I think, other things that would've been nice to be able to collect data on is more qualitative. So like asking the young people about what their experiences were like, and particularly like what made them engage in CBT-E, why did they want to do it? Obviously we listen to the young people and they tell us, but it would be nice to document that and have that understanding about what are the reasons why people choose CBT-E, and why do they choose that, particularly if they maybe haven't had a great experience with FBT previously would be good for us in the field to know. Steph: Yeah. And I always like to ask this question mostly because I'm curious. As a journal's managing editor, it's always good for me to know. How did you find the peer review process going through with this paper? Dan: It was really good. It was prompt, and it was really clear that the reviewers had taken time to read the paper well and pick up nuances and just really well thought out revisions that they suggested that really improved the paper. And yeah, that they both read the paper really well, and then they really articulated their comments, well, which made it really easy to respond and overall the paper was improved. So yeah, it was a good experience. Steph: Good. So you weren't subject to the stereotypical reviewer two who's critical and difficult. Dan: No, no we avoided the Reviewer Two syndrome Steph: And just before I let you go and get back to your evening, because I appreciate that time difference between UK and Australia, this is eating into your evening now. What's up next for you? Is there anything that you're working on? Anything that we should be looking out for from you? Dan: Yeah so we've got a couple of things on the go. As a follow up to this paper, we've just written like a clinical companion piece about managing that transition for the CBT-E clinician, for people that are working with clients that have previously done FBT. So we think that's a really important transition to manage and there's some real unique difficulties or challenges amongst people with that FBT history, because of the differences that I described earlier between the models. So I think that's, yeah, that, that was written with the CBT-E team that I think we did a really good job in writing that. And, yeah, I'm hopeful that it is out there because I think that's, important for the CBT-E clinician to know and understand because there's some little traps there or some things that can be important for not just a clinician, but the families, the young person, everyone in the treating team to understand and make that transition a successful one. So I've got that. And, yeah, the research that we're doing at the clinic, like I mentioned, we're looking at trying to understand more about the young people that we see and the factors that contribute to treatment outcomes. And yeah, ideally would like to know what makes people do better in treatments, what makes people more suitable for one treatment compared to the other? So we know like how we can allocate people to have the greater chance of success and also for to know, okay, who might need extra support or who might need other services that we can offer them. Steph: Okay. Well that all sounds brilliant. Dan, thank you so much. This was really great to have you on. Dan: No worries. It's been nice to chat. Steph:  Thanks so much for listening. You'll find a link to the paper we discussed along with any other useful resources in the show notes, so please do go and check those out.  If you enjoyed this episode please take a moment to rate, review and subscribe. It really helps others to find us. And if you have any feedback then I would love to hear from you. You can reach me at [email protected] or follow us on Instagram and BlueSky @babcppodcasts. Our journals are there too, sharing all the latest research as soon as it is published.  And don't forget to check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Practice Matters. Whether you're new to CBT or just looking to enhance your practice, they're full of insightful discussions and some really helpful tips.  Thanks for tuning again, and I'll see you next time on research matters. Bye  
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  • Flashforward Mental Imagery in Adolescents with Dr. Alex Lau-Zhu
    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 Have feedback? Email us at [email protected] Follow us on Instagram & Bluesky: @BABCPpodcasts 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 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.      
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  • ‘Crossing the reflective bridge’: how therapists synthesise personal and professional development from self-practice/self-reflection during CBT training...with Vickie Presley
    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 [email protected]. 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 [email protected]. 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.      
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  • Ten misconceptions about trauma-focused CBT for PTSD with Dr Nick Grey
    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 [email protected]. 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 [email protected]. 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.      
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