Let's Talk about CBT- Research Matters

In this episode of Research Matters, Steph talks with Dr Rebecca Murphy about her forthcoming paper, Evolving perspectives on CBT-E for eating disorders: clarifying ten key points – misconceptions and communication gaps explored, published in The Cognitive Behaviour Therapist. Rebecca is a clinical psychologist and Research Director at the Centre for Research on Eating Disorders at Oxford, where she specialises in developing and disseminating evidence-based treatments for eating disorders, particularly CBT-E. Rebecca discusses why she and her colleagues wrote the paper and identifies that there are not just misconceptions around CBT-E but areas where more clarification could be helpful for clinicians. Steph and Rebecca explore three of the most common misunderstandings, including concerns about rigidity, questions about the applicability of CBT-E in real clinical settings and therapist worries about treating people with co-occurring conditions. Rebecca explains how flexibility within fidelity supports truly individualised care, why outcomes in routine settings can match research trials, and how clinicians can deliver CBT-E effectively even when presentations feel complex. Links and resources The paper discussed is: Murphy, R., Bailey-Straebler, S., Dalle Grave, R., Calugi, S., Osborne, E. L., & Cooper, Z. (2025). Evolving perspectives on CBT-E for eating disorders: clarifying ten key points – misconceptions and communication gaps explored. The Cognitive Behaviour Therapist, 18, e50. doi:10.1017/S1754470X25100299 The full version of the article can be found freely available here: https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/article/evolving-perspectives-on-cbte-for-eating-disorders-clarifying-ten-key-points-misconceptions-and-communication-gaps-explored/47CC468578C77CD65064DAFFE151A0B9 CBT E training and resources: https://www.cbte.co If you enjoy the episode, please rate, review and subscribe. You can contact the podcast at podcasts@babcp.com or follow @babcppodcasts on Instagram and Bluesky. 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

In this episode of Let's Talk about CBT- Research Matters, Steph speaks with clinical psychologist Katherine Wakelin about her recently published clinical guidance paper, Cognitive therapy for moral injury in post-traumatic stress disorder: integrating religious beliefs and practices, in The Cognitive Behaviour Therapist. Together, they explore how therapists can compassionately and effectively incorporate clients' religious beliefs into cognitive therapy when working with moral injury. Katherine shares the motivation behind writing this paper, guidance on involving spiritual leaders in treatment, and practical tips for therapists who may feel apprehensive about discussing religion in therapy. Read the full paper here Wakelin, K. E., & El-Leithy, S. (2025). Cognitive therapy for moral injury in post-traumatic stress disorder: integrating religious beliefs and practices. The Cognitive Behaviour Therapist, 18, e2. doi:10.1017/S1754470X24000436 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 podcasts@babcp.com 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. In this episode, I am joined by Katherine Wakelin. Katherine is lead author of the paper Cognitive therapy for moral injury in post-traumatic stress disorder: integrating religious beliefs and practices which was published in the cognitive behaviour therapist Hi, Katherine Welcome to the podcast. Katherine: Hello. Thank you for having me Steph. Steph: Thank you for coming. So just before we start, would you please tell the listeners a little bit about yourself and the areas that you work? Katherine: Sure. My is Katherine, Katherine Wakelin, I'm a clinical psychologist. I did my training at the University of Surrey and since then have always part of training and after training worked in a range of different specialist trauma services, so I guess certainly work in PTSD has been a specialist interest of mine for quite a few years now. I currently work in a community mental health team in Hampshire, and I guess my role within the team is in a specialist trauma place there as well. And by the time this airs I'll also be working at the University of Southampton as part of their doctorate programme as well. So that's a bit of my background and yeah what I'm currently doing. Steph: Great. And congratulations on your new role then. That's exciting. So I probably collared you about this paper this time last year, maybe we were at the conference, because it was in progress. And I really wanted to chat to you about it, because I thought it was a really interesting paper. And I was like, if it gets published, do you want to come on the pod? You very, very kindly agreed. So often on the podcast, we often talk to people about research papers, what they did, why they did it. This is slightly different because this is a clinical guidance paper where you're giving actually practical guidance for CBT therapists on how to work with this client group. So was there any particular motivation behind writing this paper, how did this come about? Katherine: Definitely. Well, I guess it probably brewed over a few years. I think the first case I worked with, which was a PTSD case using cognitive therapy for PTSD, where moral injury was a big component in it, was when I was working at the Traumatic Stress Service in South West London with my colleague Sharif, who co-authored the paper with me. And I guess that certainly was a really exciting piece of clinical work where I drew, with lot of Sharif's encouragement and support, but drew on the client's religious beliefs that were largely underpinning and driving the moral injury that initially we'd overlooked that aspect. And then I guess as time has gone on, worked with similar cases across different religions and different religious backgrounds, but really clearly seeing this theme, particularly when working with moral injury, actually the real value if religion is a key part of somebody's identity, then the real relevance to their PTSD and their distress and that ongoing maintenance, unless that's considered. So that's something that over time kept coming up and with Sharif's encouragement, he'd been saying all along, we should publish a paper on this. And I was like, yeah, yeah, sure. But then I guess when, over time when that kept coming up, we thought, okay, this is an idea actually that I think is a key part of the missing puzzle that perhaps didn't seem to be written about or widely talked about within the PTSD world or CBT world either. Steph: So I'm sure that many people will be familiar with the term moral injury, but just in case for anyone who isn't, would you mind just saying a little bit about what we mean by moral injury and how this might present when working with clients with PTSD? Katherine: Definitely. So I guess the paper or the definition our paper drew on throughout was Litz's definition of moral injury, which is sort of the leading in the field generally and how it's defined is the profound psychological distress that arises from very extreme events which violate somebody's very deeply held morals. This could involve somebody maybe perpetrating acts or failing to prevent acts or even bearing witness to acts that really violate their own moral code. So that could be for example somebody, it's really common in the veterans I've worked with, perhaps who've been part of events whether it be civilians are injured or killed or unintended consequences of actions, accidental car crashes or accidents where others are hurt or harmed or even where you've been a bystander of events and you've been unable to intervene and you've watched something very horrific play out. Or I guess even being subjugated to other people maybe betraying you or treating you in ways that severely violate your own moral code. So I guess that's the definition that's talked about in the paper, consistently refers to you throughout. But certainly Hannah Murray, has written a very fantastic paper on moral injury in cognitive therapy PTSD so I would certainly read that and our paper definitely leans on that a lot as a foundation and introduction to work in moral injury which was I think Hannah's paper was one of the first I think really clearly and explicitly laid out conditions of how you might be able to routinely be working with this for PTSD and then I guess mine and Sharif's paper expand on that and think particularly in the realm of working with clients with religious beliefs and that's a part of the identity. And actually the paper highlights the intro but Litz's actually original definition of moral injury, I guess defines it as profound as a whole list but profound psychological, biological but also like spiritual distress is named in that which I think the clues in the name, isn't it? If we're not considering someone's spiritual religious beliefs as part of working with this deeply, deeply held distress that is very relevant to somebody's moral code, then we're missing an obvious piece of the puzzle. Steph: So in the paper, you offer several practical ways of incorporating religious beliefs into therapy in the context of moral injury. Would you be able to just talk through a few of those? Katherine: Yeah, definitely. I guess the paper tries to of walk readers through how they might consider religion at various different aspects of somebody's treatment. In the beginning, certainly holding that in mind when you're formulating distress with clients. And I guess the formulation is always a work in progress. So certainly I've been, I've certainly missed that to start off with somebody in our initial formulation. And as our work's progressed actually we've come back to formulation, added that in actually that perhaps maybe a fear of a higher order judgment or condemnation based on acts they've perpetrated perhaps is actually really fuelling that current threat in their PTSD that might have been missing initially. And I guess it's been really I guess some of the guidance by Griffiths talks about listening out for the sacred but I guess the idea of clinicians more routinely listening out for sort of language that might imply religion or spiritual beliefs, people talking about maybe being deserving or mentioning prayer or religious communities at all. I guess really listening out for that in your sessions as natural points to then pick up on and just explore I guess, if religion is part of their identity. So listening out for religion, I think it's really important. But then certainly when you're getting into the work and when moral injury is a big theme of that, because that's not always necessarily obvious when you first begin. And I guess these are things that people may never have ever admitted or talked about before because the traumas and the shame and the guilt could be so profound. It might not be obvious you're going to be working with moral injury until you get into the work. I guess as you get into that that often feels an actual place also to just gently prompt and open up conversations around religion. I guess you can give really good psycho education around moral injury and Hannah certainly lays that out in her paper really nicely. But then sort of opening up and sort of thinking, I guess, very understandably when these types of events happen, people can be informed by their morals or things that govern their behaviours and actions and can hold a lot of shame. I guess I'm curious for you, whether or not religious or any beliefs around spirituality can impact on moral code. Is that relevant for you? Opening questions early on or when moral injury comes into light is helpful. So we can hold that in mind on our formulation. But I guess the big part of the paper then moves into thinking about how we can actually practically use religious beliefs and teachings or spiritual beliefs and teachings within the updating work of cognitive therapy for PTSD. So I guess a big part of it is I think often having these conversations with clients. I know I've certainly worked with clients where it's really obvious on the surface that they may be feel very responsible for maybe some horrific events that happened. But actually when you can't I guess keep downward arrowing perhaps beneath that, fears of what that means about themselves or being condemned, being maybe judged as evil, being punished by a higher order God. And I guess that then really driving the distress. So I think when you reach that bit and you're able to acknowledge those appraisals, I think a key part of then starting those updating conversations often is- certainly I name that I'm not a religious expert or not trying to be a religious expert. And I know that they'll know a lot more about their religion than I do. So I guess I'll often start quite general questions of asking, I wonder, is there any religious teachings or scriptures that they're aware of that could be quite important to us when we're kind of trying to update some of these appraisals? And clients can really surprise you sometimes and draw on things that you certainly would never have thought of. And then I guess when clients get stuck, that's a really natural point in which the paper then guides you through of how you might set up inviting a religious leader or surveying religious experts to bring in their perspective. If that's going to be, if these are really key cognitions that we're needing to think about, but in terms of the updating work. And then as we always do, then linking those updates really nicely back into the membrane. Steph: Yeah. And one thing that I really liked about this paper as well is that you had some really illustrative case examples of that as well, didn't you, and how incorporating those techniques, I guess, into the work has really helped them move forward. Katherine: Definitely. And yeah, so try to really bring it to life in the paper. We had Zara and Ali were some of the case examples we discussed throughout. And I tried to put within the paper real life quotes and answers that we gathered from imams and like religious Christian chaplains and ministers that we surveyed as well included as well so that's hopefully can be quite a useful resource for other therapists when they're working with similar clients or similar beliefs to get ideas from and have some confidence I guess to sort of implement similar ideas within their CBT work. Steph: So I guess the process of seeking advice from other religious experts for me was quite new, but obviously something really innovative that you've done in your therapy. Is there anything that people should be mindful of or consider if they're going to incorporate that into the work that they're doing? Katherine: Yeah, definitely. And I get these questions quite a bit because I think it does feel daunting, doesn't it? Inviting a religious leader into a therapy session, perhaps. But I guess I'll just reflect back. I think every time we do behavioural experiments, every time we take clients outside of the therapy room, every time we interview someone or survey someone, we're taking a relational risk, aren't we? We don't quite know what's going to happen. We can't predict the whole thing. So I guess there is an element of I guess being able to know that we won't know exactly what's going to happen but I guess what we can really do is really think about it carefully beforehand and put in as much support and preparation to try and make this as a most helpful experience as possible for the client and make it as therapeutic as possible. So I lay it out on the paper how I guess my experience of doing this, which so far has had a great success rate but obviously you can't sort of foresee everything. I guess the big things being starting this conversation collaborative with a client and really thinking through together. If you get into this point of actually acknowledging that you as a therapist aren't an expert in this particular religious area, certainly, but you can see how important it to the client and really validating that, how essential it obviously is to their belief system and their identity and actually the real, I guess, significance of that and importance of us weighing that into therapy. I guess usually I've had expensive clients being like, yes, yes, of course, and buying into that. I guess thinking, okay, if you don't know these answers to these big questions, because often clients in my experience have been grappling with questions around, could they be forgiven? Perhaps if they've maybe unintentionally or accidentally maybe ended somebody's life or resulted in very serious accident and thinking about who could we ask? And I guess how I usually set it up is sort of saying that, you know, in CBT, when we get to really important issues, there may well be things where we want to survey or ask xperts in the area so that we, both me and you can learn. And I think it's a really nice modelling as well of lowering the power dynamics as well, because you're really naming that you're the therapist, don't hold the answers, and you're going to be really guided by the client. So really making those conversations as collaborative as possible. And generally I've found clients to be really over actually that a sort of seemingly secular NHS clinician would be entrusted in their faith in this way. So then I guess lead you on to if they've brought into this, if you know if they're really nervous, I guess it's thinking about ways we can do it and to reduce maybe some of the some of the fears they may have and thinking what that pretensions may be. So for some people I've certainly found it to be helpful often, giving them a choice, but generally clients I've experienced prefer maybe for me to source a religious leader as opposed to themselves. So, it's someone who's not known, they're not in their community. I guess these communities often are quite small and quite tight knit and I guess fears around confidentiality can be quite real for our service users or whether it's a survey rather than actually face to face interview, again, that can reduce obviously, anonymity of the client even more so. I mean personally my preference is generally to try and interview somebody with the client there as well if possible because I think it really could bring it to life for the client. It can really I guess allow them to have natural follow-up discussions and questions you didn't even know that they had and arise from it and I guess if you get a really compassionate I'm thinking about some of the leaders I work with, like a really compassionate minister or imam who's able to kind their tone of voice and the way they speak can really, it's not just the words on the paper that they're saying, but also the way they're saying it and teaching the client can have a really emotional felt sense to those words as well that a survey might not. But you know, you'd be led by what the client is wanting. And then I guess in terms of then actually setting it up, I'd usually always give a session to really think through what questions we'd want to ask, linking them really to some of the key appraisals that we're wanting to update, all the key things that they're really stuck on. And I give examples of the types of questions some of my clients have asked in the paper. So whether it's around certain scenarios, whether it's feasible for God to forgive them or what they can do in terms of moving forward or making an amends can be really, I guess, key things to ask or particularly asking about what teachings we can draw on. And then I guess what I've also found is a big emphasis on once you've agreed some difficult questions, I guess the importance is you get in their consent, but I guess how much they'll be willing for you to share with a spiritual leader in advance. So, you know, normally you don't need to share their full name or anything like that, but maybe a bit of background about the sort of thing you're looking for help for. So maybe it might be saying that, you know, I'm in NHS therapist, I'm working with somebody, maybe who was a veteran holds a lot of shame and guilt around some of the lives that have been lost in combat and whether or not we're looking for a religious leader who might be able to help answer some of our questions about God's forgiveness and our war or injust actions. That sort of level of detail would be initial things I'd be thinking about. And I usually would always try and if you find somebody suitable, NHS Chaplaincy is a really good place to start if you're an NHS therapist. But as well, or if they don't have somebody who's suitable, whether they can recommend you somebody. I've used networks, I guess, within my workplace or colleagues who I know are particularly aligned with a certain religious. If they can recommend me a leader, I guess that's going to be particularly compassionate and understanding to mental health. I'm really sounding that out. I think then largely set up really nicely. I usually would meet with the religious leader with the clients agreement in advance of the session actually just to have a brief chat with them really check out that they do feel comfortable asking these types of questions or show them the questions. And I guess if I had any concerns at that point that would give me a chance as a therapist to step back or reconsider if we need to, if there's maybe someone who'd be more suitable. Steph: Yeah, that did answer one of my questions, which was like, I wonder if this has ever gone wrong. When you've been like, actually, maybe this person isn't suitable for this after all. Katherine: And I mean, yeah, exactly. So I think that's the real importance of trying, if possible, to have a conversation with them in advance. It gives you a bit of a as well as a therapist to give them, the religious leaders, bit of psycho-ed around a bit about what PTSD is, if they don't know already, which can be really helpful. But generally, I've found religious leaders to be so respectful and so compassionate, and I guess often a big part of their role within their communities is also a very pastoral role often and they've brought a whole level of , I guess, spiritual knowledge, but also a real warmth and like a real compassion that's hard to convey, I think. Yeah. Steph: Yeah, because it just took quite a special type of person to be a religious leader, doesn't it? So you would imagine that they would be bringing that really, compassion and that empathy with them to the work as well. Katherine: And you know, I think therapists often have lot of apprehensions about that, but I think just do your homework and do your thinking carefully beforehand. And certainly, I think if you're having a recommendation, so if it's through the NHS Chaplaincy Service, they'll have been screened, they'll have been vetted, they'll be trained to work within health settings. If not, if it's maybe a colleague or a friend of yours who has an understanding of mental health who's able to recommend somebody who knows somebody and going through that way I found I guess to be a really effective and helpful way. And I guess also I guess also needing to think in ahead in advance of like who I guess a client would deem an expert as well so I guess there's lots of different sects or denomination between various religions or I guess what if any qualifications a client would require to feel that they would have the knowledge I guess to be able to answer some of these questions are obviously helpful things to think through with a client in advance of then going on your search for somebody but yeah. Steph: Yeah, and I think your paper talks about that a bit doesn't about how you work really collaboratively with the client on that and asking them who they would feel would be most appropriate and how, how then you could find that person. Katherine: I guess I've certainly been quite surprised because I'd say almost most people I've worked with have often been a lot less picky or specific than I thought they would be. Maybe if they've particularly aligned within a specific denomination and I've thought, do we need to really match this? And then they've actually been a lot more open than I thought. So sometimes clients can surprise you. And I guess it's really understanding who and what they would deem as knowledgeable on this. Steph: And you say in the paper as well that CBT therapists often report some discomfort maybe in bringing religion into the therapeutic work. Is there anything that you'd like therapists to know or any practical tips about how they can manage this if they are feeling apprehensive? Katherine: Yeah, I think that's such a big question. I my big take home would be, be curious and actually, because we're curious about so many things, why are we often just not curious about religion? Actually, there's no difference there. I think, you know, your therapeutic training of empathy, validation, open questions, your Socratic questioning, being, listening. All of that are going to be your key soft skills that you're going to be needing here. And it's not about you as a clinician holding religious answers or expertise on spiritual guidance topics. Often when clients have sort of said, I guess maybe being a bit surprised that I've been interested or even being like, I guess, maybe are you religious too? But I guess how I always frame it is if it's important to you then it's important to me and in our work and when you're getting to this point in cognitive therapy PTSD and think moral injury is so explicitly tied to somebody's moral beliefs and if they're religious then religion is going to be a good part of that. It's quite a natural seamless flow I've found and so actually just being curious, holding those open questions and I guess naming that you don't, you may get it wrong as well. So, think that's a really nice way of balancing the power dynamics. You know, I'm really mindful. You know a lot more about Hinduism than I do. There may be things that I say, I get it wrong. You do call me out on that and name that because I certainly am willing to like learn alongside you and I can hear how important this is to you. So I guess I'm wondering how we can integrate into this work more. And I guess those kinds of conversations have really reducing the power dynamic. I think therapeutically that is also really valuable as well. And clients can teach you things. So I've learned so much through this work, things I never would have known, amazing updates that I never would have, we never would have generated ourselves or I never would have generated with my standard CT PTSD textbook in mind. And that's been so, I've seen such a quick and rapid clinical shift for clients because we got to something that I guess is so culturally meaningful and so in line with their religion and their identity. Steph: Yeah, well, that's amazing. And it sounds like that's just been such a helpful thing to give your clients as well. Like you say, just really meeting them where they're at in this process and asking them, working really collaboratively with them. Katherine: I think sometimes there can be like, maybe it's not a nervousness but I guess maybe a general sort of ambivalence perhaps around, I guess if a therapist sees themselves maybe thinks sort of, I'm not religious or I'm in a secular service so religion's not really, it's not relevant I guess to CBT, it's sometimes an attitude I've come across. I guess what I've really found is religion, particularly working in moral injury, can be your sort of supercharge, I think, and can actually be your sort of superpower in terms of updating and working with some really challenging and really complex and very tightly held morally injurious beliefs. And actually, I think being open to considering how you might be able to draw on it is only going to be in your advantage because there's so much in the religious literature that I think around moving forwards, making amends, forgiveness around building new life, how we keep moving forwards after these events that's going to be really helpful for clients when they're grappling with this. Steph: . So I guess we might have covered this a little bit already just with what we've been talking about. But what impact do you hope that this paper will have on the world of CBT then? Katherine: Well, I'm hoping it will be widely read. It's been in the top 10 actually downloaded, which has been excited recently. So we're hoping that means people are reading it. I guess for it to become more routine, for it not to have to be seen as a specialist or unusual adaptation. I think what I guess the angle of the paper was that there is lots of trials which have specifically adapted CBT for religious interventions and followed specific like protocols I guess for spiritually adapted CBT for behavioural activation for people who are Muslim or something like that like very specific and I guess as part of that you need specialist training, you need to access the specialist protocols and the average routine clinician couldn't deliver that intervention and I guess what the angle of this paper was that was meant because the hope was empowering any and all CBT therapists to read that and think, you know what, I could do that. But actually I don't need to have done a specialist course. I don't need to have to have a specialist protocol for doing this. Actually this involves like a good dose of curiosity, openness, a willingness to not have the answers and then be able to draw on the experts when needed is the I guess, real hope of the paper. So that hopefully it can become more of a routinely thought of idea. Steph: And have you had any feedback from the clients that you've worked with when you've incorporated this or any of the clinicians when you've been using this approach? Katherine: Yeah, definitely. Definitely been really, really striking, qualitatively and quantitatively from the feedback from clients where we've incorporated religion, certainly have found often to be cases that maybe have felt quite stuck. Maybe they've worked on these traumas before in previous therapy and it's never quite hit the nail on the head. And I guess it's that idea that we maybe hit the surface level initially of maybe it feeling around their fault or something and the whole sort of next layer of the onion around maybe feeling judgment had been missed. And I guess what I found clients fed back, I guess clients have often been quite overwhelmed or even quite emotional actually towards the end of therapy, feeling back that I never thought a white British therapist would be interested in this part of my identity. I guess feeding back often that maybe their friends or their families had been quite suspicious or maybe quite negative of them receiving secular help for their mental health. And they sort of ran out of options. So I ended up going to the NHS. But actually, then their friends and family turning around and being like, why are you going to the mosque now? What have you been doing with that therapist now? How is that NHS therapist now, I guess, seeing you, I guess, re-engaging with their community and their spiritual life again. So guess often that has been reported back and one client I guess put it really well I guess they sort of gave feedback at the end of their words were basically that I couldn't argue with you that you were using or we were using the whole logic and the whole framework that I've built my whole life around aka her religion and actually when we were bringing in passages from the scriptures that I guess her whole religious identity believed in, actually she'd already bought into it so actually it was quite easy win in terms of updating because these are things that already they've built their life around. I guess feedback I've often had for people is I maybe knew that God or Allah was forgiving, but I never knew if he'd forgive something as serious as this, perhaps maybe when someone's died as a result of their actions and never obviously felt brave enough or able to ask that question to their community or to religious leaders. So I sort of held this for many, many years and just the relief that they've felt like, yeah, like a boulder being lifted off the chest was one analogy of describing it was just phenomenal. Steph: Yeah, sounds like it just really set them free, just being able to do this work and like you say, having not having a boulder on your chest anymore, that must feel such a relief. Katherine: Definitely, one imam that I worked with, with one client, their language round, I guess it was around whether or Allah could forgive the unintended consequences of the events that have unfolded. And I guess the imam kept referring to Allah giving you a blank page. And that then came sort of a bit of the catchphrase in therapy of this time, now having a blank page and what they were going to do with their blank page now in terms of moving forward and building their lives again. I guess language, I guess it's just different ways of framing things, but I think it fits really naturally with CT-PTST and actually everything we're trying to do in terms of updating key appraisals and cognitons. But then also like fits really well with the reclaiming and rebuilding your life. Religious leaders have often clients I've worked with I guess around specific actions they can do in terms of moving forwards after life. Sometimes there's really specific examples that I would never be able to have generated myself, hold so much meaning for a client and to then be able to start moving on after the events. Steph: And just from a journal perspective, really, because I'm always curious to ask our guests this, but how did you find the peer review process? Can you remember now? Because it was quite a while ago. Because it's a clinical guidance paper. Did you find the reviewers quite helpful with you in that? Katherine: Yeah, we did. I had a really good experience. Obviously, I liaised with you quite a little bit when I was sort of working out if it was appropriate for the journal and had specific questions. And yeah, you were really, really fantastic and really responsive. So I felt quite confident submitting that it was felt relevant and appropriate for the journal and then had really fantastic feedback from the reviewers. Both actually were probably the most overwhelmingly positive reviewing experience I've had because reviewing can sometimes feel quite critical. I guess the big point that came out probably from the reviewing process which we tried to tweak the paper to still convey, I guess the key point is that, and hopefully this comes off, is we can all do this. And I guess also about it not being something that necessarily takes extra time, that actually I guess this is something that can routinely slip into our practice. And guess often when we are in time limited practices or companies or cultures or whatever, it can be tempting to cut out, I guess, cut out a lot of CBT, I guess, some of these behavioural experiments, things you do live together and things like surveying or interviewing people. But I guess certainly, I guess the message of the paper, hopefully, if it comes across is that actually by investing just a little bit of time in doing that, you will save yourself many, many, many sessions after that where you're still going round and round on the same cognition you haven't been able to update it. But actually, this builds the effectiveness and certainly what we found in our clinical work. And actually, if we can get to this as soon as possible, then actually you'll have a much, much greater likelihood of completing successful treatment outcomes in your time-limited number of sessions that you've got. Steph: And I'm really glad that you've got that good feedback then. And I think that definitely comes across in the paper now. And that's a really important message to have, I think, in there too. So finally, before I let you get back to your afternoon, what's next for you? Is there anything that you're working on now that you'd like to share with us that you'd like us to know about? Katherine: Yeah, I'm working with a couple of other colleagues, going through and Hibbah Hassan, and we're writing another paper at the moment, I guess, trying to , this paper will be specifically about cognitive therapy for PTSD in moral injury. I guess our next paper we're working on is more generally encouraging clinicians to think about how we can discuss religion in CBT when therapists have their concerns, so think about CBT more broadly. I guess thinking about apprehensions or concerns or questions they often have around how do I raise this as topic, what terms if I get it wrong, ones that highlights the differences between me and my client or actually I just don't have enough time to do this justice. All of those key concerns that we've found highlighted in literature and our own clinical practice is writing a practical paper I guess trying to sort of address each of the concerns and give clinicians, I guess, practical ways to try and think about overcoming them more generally in CBT. Steph: Brilliant, I can't wait to read that when it comes out. So Katherine, thank you so much, this has been such a nice talk. Thank you so much for coming on. Katherine: It's a real pleasure. Thank you for having me, Steph. 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 podcasts@babcp.com 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

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://doi.org/10.1017/S1754470X24000400 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 podcasts@babcp.com 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 podcasts@babcp.com 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

In this episode, host Steph Curnow interviews Vickie Presley, the lead author of a paper titled "Crossing the Reflective Bridge: How Therapists Synthesize Personal and Professional Development through Self-Practice/Self-Reflection (SP/SR) during CBT Training", published in The Cognitive Behaviour Therapist. Vickie shares her insights from the research, discussing the importance of reflective practice in CBT training and how it shapes therapists' professional growth and personal awareness. If you enjoyed this episode, please rate, review, and subscribe wherever you get your podcasts. Follow us on Twitter at @BABCPpodcasts or on Instagram . Share your feedback or episode suggestions by emailing podcasts@babcp.com. Useful links: The full version of the article being discussed can be found freely available here The SP/SR book that Vickie mentions is "Experiencing CBT from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists (Self-Practice/Self-Reflection Guides for Psychotherapists)" by James Bennett-Levy, Richard Thwaites, Beverly Haarhoff, and Helen Perry. Foreword by Christine A. Padesky Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF Transcript: Steph: Hello and welcome to Let's Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT. Today, I'm talking to Vickie Presley. Vickie is course director for CBT training at Coventry university. She's also the lead author of the paper "Crossing the reflective bridge': how therapists synthesise personal and professional development from self-practice/self-reflection during CBT training" which she co-wrote with Gwion Jones and is published in the Cognitive Behaviour Therapist. Hi, Vickie. Welcome to the podcast. Vickie: Hi Steph, thanks for having me. Steph: Thank you. It's lovely to have you here. I was wondering if you would mind telling everyone a bit about who you are and the areas where you work. Vickie: Yeah, of course. So my name is Vickie, Vickie Presley. I'm currently the lead for psychological therapies training at Coventry University and the course director for our CBT training programme. And I guess outside of my university role, I'm also a CBT therapist and supervisor in private practice. I guess for the purposes of today as well, it'd be important to say I am also Vickie. I am a lady heading quickly towards my 45th birthday. I am a mum. I'm a wife to a long-suffering husband. I'm a sister. I'm an auntie. I'm a great auntie, Lots of things outside of that sort of professional context. And I guess also I'm a nervous wreck today, if I'm honest. I guess just thinking about conveying things around this research, but it just seems important to say that given we're going to talk about sort of how therapists might synthesise their personal and professional development, there's bits about me that might come through today that are about my personal self, not just my professional self. Steph: Great. Thank you. And that's great that you've sort of brought in some of the personal as well. That's really nice. And I'm always nervous when we start doing podcasts as well. So it's fine. And I've been doing this for a while now. Vickie: Oh, that's good to know. Thanks, Steph. Steph: The paper we're going to be talking about today is about self-practice, self-reflection in CBT training but before we get into talking a bit about the paper, would you be able to tell me a bit about how this research came about? What inspired it? Vickie: Yeah, of course. I mean, I suppose the answer to that question is, one that takes me back, sort of, 15 years or so to my own CBT training. So, I trained at Coventry. Coventry's got quite a long-standing ethos of reflective practice as part of the training course. And for me, I think that allowed me to really think about the role of myself in my therapeutic interactions with clients. And I started to notice as part of my training that I was getting in the way sometimes. So sometimes my own stuff was getting in the way of my work with clients. There's this example that I always give where, I was working with a lady who was very, very depressed, and as part of that presentation she was very perfectionist and held herself to really high standards, which, is something that I have to manage myself. So, there's kind of this schema match, I guess, if you like, that we noticed, and we did some work around that. And technically it was really good. Technically we did this continuum exercise. It worked really well, it was really helpful for her in the session. But right in the last minute, I suggested to her that she took the worksheet home, and she rewrote it because mine was too messy. And I suppose the whole irony of that, that one statement, which, I mean, I suppose we look back at that and sort of laugh at the irony, but it really had the potential to undo a lot of good work in the session. And that was about my own stuff. So, I really do think that's the point where it started for me, and I started looking at some of the research that was around about therapist perfectionism in particular. I suppose as my career has gone on and I've supervised trainees and qualified staff and obviously I've worked at the university for many years now, we notice the same patterns that therapist's own stuff will get in the way a lot of the time. So some of my previous papers have focused on areas like therapist perfectionism, like things like experiential avoidance and one of the things we always suggest at the back end of those papers is that therapists get involved in SP/SR so they can get to know themselves a bit better. And I guess that brings us to this paper where we wanted to know whether that was working as part of our own program. And if it is, how trainees experience that, how do they get to know themselves as part of SP/SR and as part of the training process? And how do they make sense of that in a professional context? What meanings and what the experience of synthesising those two parts of themselves is like. So that's how we got here and that's what this paper aims to elucidate in some way. Steph: And I think that's really important, isn't it? Because when you're really busy training and you're taking in all this new information and then you're putting it into practice, it must be really difficult actually to take that time to think about yourself and to really self-reflect and think about how that might be impacting you. Vickie: I think it's really difficult and I think, in some ways, it seems more difficult in the CBT model, I think, because lots of the things that we have to teach are quite technical and there's lots of demands on trainees to show technical flair and that they understand quite complex models and ways of working. But that can become, this whole reflection stuff can become sidelined and feel like it's less important. I think my view is that the technical stuff, the technicalities of CBT take place within a relational context, and they take place within the dynamic between two people and if the therapist isn't holding what's their own stuff in that dynamic, that can become problematic. Steph: Could I ask you to just explain a bit about what is self-practice/self-reflection for anyone who might not be, familiar with the term? Vickie: Yeah, of course. So, I mean, I suppose the simplest terms, self-practice/self-reflection is about practicing CBT techniques on oneself, so using, the interventions of CBT on oneself and then having time to reflect on what that experience is like. I guess there's a myriad of ways that people can get involved in self-practice/self-reflection but on our training course specifically, we use the text "Experiencing CBT from the inside out". So that's a well-established text. It's an evidence-based text, and we provide one of our trainees with a shiny workbook at the beginning of the year, and that's what we use to scaffold the process of SP/SR. So, we find that's a really nice text that helps the trainees work through some of the stuff that SP/SR incorporates, but also helps our staff who are facilitating that process to keep some framework around the process. So for our trainees, we give them that book and actually SP/SR is a mandatory part of our training program, so all of our trainees will be given the book and have space to work through that, but they'll also meet 12 times across the training year with their group facilitator to have space to reflect with peers and to reflect with the group facilitator about the process of taking part in SP/SR.I suppose for us it's an integrated part of our training programme and we find that this huge benefits from for including that as part of the training program. So yeah, so each of our trainees would be working through the process and have a formal space to reflect on how that's going across the year. And then they're also asked to submit an assessed summary of their learning from SP/SR and how they're making sense of that in terms of their clinical practice. And I guess that last bit is the key point. That we don't want people just to do SP/SR. We don't want them just to experience what it's like to do CBT interventions. We want to give them space to make sense of that in a professional context so, bridging that professional arena and what those insights mean for their clinical practice and how it can help with their skills developmentment. Steph: Yeah. And that's a really nice segue into my next question, actually because we're going to dive into the paper now on what you did and it's that reflective piece of work was kind of the basis for how you recruited your participants really, wasn't it? Am I right in thinking that you were analysing that part of their reflective work. Vickie: Yeah, so each of our trainees will just as part of the training program, submit a 1000 word reflective piece in which we ask them to say a bit about their personal learning. So what they've learned about themselves as part of the SP/SR process. Also, then to bridge that to their clinical practice and what does that mean for their clinical practice and how they sort of synthesise what they've learned about themselves and how that's helped their professional development. That's what we use for the basis of this piece of work. I guess we've noticed across years that even though it's a brief summary, a thousand words isn't a lot. It's so rich with the sort of data for this piece of research. I guess because instead of interviewing people really have chance to sit down and think about what they want to convey about their learning. It's a deeply personal piece of work. So yeah, so our trainee needs to submit that 1000 word summary of their learning. And we analysed that using thematic analysis, really just to try and, highlight what it is that people are learning about the self and how they make sense of that in a professional context. Steph: Yeah. And so several themes then came out of that analysis that you and your colleague did. We were saying just before we started recording, I actually felt very seen during some of that as well. There's definitely schemas that I've had during my counselling training. Were there any that surprised you when you looked at them? Vickie: You know what, that's such good question. Probably not, and I think that was a really important part of how we approached the analysis. So I'm a CBT therapist, and I'm involved with the facilitation of those SP/SR groups. And we were really aware that might sort of skew how I came at the data. So it wasn't just me that analysed the data, a colleague analysed the data with me, my colleague Gwion. Gwion's not a CBT therapist, Gwion's a psychoanalyst, so we came to the analysis from a completely different psychotherapeutic model, which we thought was really important for us to have a more sort of nuanced relationship with the data. Gwion also doesn't facilitate the SP/SR groups so it's interesting that you asked that because I probably wasn't particularly surprised, but I think that's because of how I'm positioned in terms of the data and the way it was collected and the training process as a whole but maybe if you were interviewing Gwion he may give a different answer to that. I suppose the only thing that might have surprised me was how strong the themes were, so most of the participants engaged with most of the themes. There was such similarity and it's interesting how you're saying Steph that you felt seen and that's coming from a different model again and somebody who's not involved in our training course having sort of similar things and that's quite heartening really. There's a sort of shared humanity perspective on this that these are things that we lots of us struggle with. Steph: Yeah. And the first theme was really about the identification of self schemas, wasn't it? And that sub theme about not feeling good enough. And that's definitely something that I think comes up in any kind of therapy training a lot I think. Vickie: Yeah, I mean, probably any kind of training, really, if we strip it back. Training is difficult, isn't it, right? There's often a transition from what you know to what you don't know, and I think that's really quite hard. And for us, we know that people are transitioning into this profession from lots of different varied sort of professional backgrounds, but also personal backgrounds as well. Our cohorts are hugely professionally and personally diverse, which is wonderful. But I think that sort of sense of being de skilled at the same time as having your practice evaluated from every conceivable angle is quite exposing. And I think that sense is not good enough really came through in their reflections and their ways of coping with it, which is often about getting into compensatory strategies like perfectionism. Yeah, so a really strong theme around the not good enough stuff, which I think we need to pay a bit more attention to because that's a difficult place to be for anybody. Steph: And I think one of the quotes from one of the participants that came out in that was about, really worrying about not being liked then and the kind of interpersonal relationships. And I was wondering, do you think that was being liked by their client or not being liked by their colleagues on their cohort from being able to express what they were saying? Vickie: Do you know what? I think it might have been multifaceted. I suppose this is one of the downsides is the data in some respects is very rich, but it is two dimensional. And we didn't follow up with any interviews or any focus groups or have any opportunity to ask questions like that, which are really important. I suppose what we did find as we move into the other themes is people did identify that there was sort of historical longitudinal backdrop to a lot of the things that were happening professionally. I think maybe the quote you're talking about is, that's sort of not good enough thing, even coming into the SP/SR process and being worried about whether they're doing it right, whether they're reflecting right, whether they're feeding back right in the sessions, all of that stuff can be really difficult. Steph: yeah, definitely. I just, I think what I was saying, I felt seen, that was something I really felt when I was doing my training as well. There was often a question of am I doing this right? And often there is no right, is there? Vickie: No, often that there isn't and you know, one of the things I always say to my trainees is that sense of imposter syndrome It never really goes away or you know, I have that now talking to you about this paper and Yeah, the need to get it right and to have approval and be likable all of those things. There's such a commonality there with lots of us experience. Steph: And like you said in theme two as well, that was round about the increased awareness of the personal context. And as you were saying, it was helpful for the trainees then to maybe be able to put that into some sort of context for them and maybe why they were feeling some of things that they were. Vickie: Yeah, absolutely. We have this really strong theme of identification of self-schemas which is around the not good enough stuff, but also around sort of having difficulty sitting with difficult internal experiences and difficult emotions. And what we found is people sort of extended those reflections to start thinking about where does this come from in terms of my personal context? And there was, you know, so much data, which was deeply personal, I guess, with people linking those things back to relationships within their family, the meaning they've given to some of the expectations within their own culture. For some people it was about sort of their socioeconomic status and some of the meanings that they'd given to that. For some people it was this sort of process of making sense of what they'd learned about themselves in the backdrop of their own faith and spirituality. There was lots of things around personal context which, it was so important and I know when I was writing this paper just feeling like I'd got all of this data and really needed to be quite delicate with how it was conveyed in the paper. I know when I wrote the first drafts, that results section was pages and pages long because there were so many things that I wanted to give credit to or, to be seen and to be valued by other people, but you know, you can't do that, you have to sort of get less attached to your data in some respects. Yeah, I thought that part was really quite powerful, how people had sort of made sense of themselves in that sort of longitudinal framework. Steph: Yeah. And what about the other themes that you found? Is there anything else that you wanted to highlight from those? Vickie: Yeah, I mean, I suppose one of the important things was this idea of, okay, this is what I've learned about myself and who I am. And then the trainees sort of conceptualising how that then came into their clinical work. And I guess this is about sort of this bridging process, which is reflected in other research papers, that there needs to be this process where people, they learn about themselves, but then they think about what actually means for their practice. And lots of the trainees noticing that their own need to be good enough, their own need to not make mistakes, or to be liked, or to not experience discomfort was actually getting in the way of them doing CBT with a lot of their clients or getting in the way of a therapeutic alliance. So that kind of became a central theme, I guess, that holds the other ones together. But then what we found is a lot of the trainees had then been brave enough to sort of step out of the reflective space and do things more experientially to try and find out what happens when they don't adhere to some of those schemas and the rules that come out of those and when they try to change things in their personal and professional sort of arenas. That was quite powerful. I guess part of their reflective summaries was thinking about how they'd been brave enough to make changes and then how they just sort of reach professional benefit from that. Which I guess matched a lot of the stuff we already know about SP/SR, certainly in terms of helping people to work more effectively within the therapeutic alliance. But I think a major thing that came out of this study in particular, was people's ability to just work more authentically with difficult emotions. And to see that as a really key part of cognitive behavioural therapy that we talk a lot about cognitions and behaviours right? But there needs to be a real sort of processing of emotion when we're trying to change those things with people and I think that lived experience was really important for the participants, for the trainees, but that lived experience of how difficult that is was really important to helping develop their professional practice. Steph: So sometimes think as well when working with my own clients, you know, bringing about change sometimes brings about almost like a grief process because they've been holding onto whatever they've been holding onto for such a long time. And that can really bring up some really quite strong feelings and even if they want to let it go and they don't want to be like that anymore, it can be quite surprising what comes up, isn't it? Vickie: Yeah definitely. And you know that's a difficult part of therapy and that's a difficult part of SP/SR. You know, a lot of the trainees that took part in this study said they flew through all the sort of reflective self-formulation stuff, but then got really sort of halted by the more experiential things. So when it gets to letting go of safety behaviours that give us comfort or letting go of, things that we do to try and soothe our emotions in the short term, letting go of those things and making changes is really hard. Steph: So is there anything else on the themes that came up that we haven't discussed yet that you want to kind of bring up a talk about? Vickie: I think we had these five themes and we weren't sort of intending to provide any sort of conceptual framework, but those themes just beautifully linked together to show this journey of finding out who I am, finding out where that comes from, understanding how that comes into my work, being brave enough to change it, and then knowing that I've taken personal and professional benefit from that, that, I guess that sums up what we found. Steph: Yeah, brilliant. So given these findings then, what do you think are the implications for clinical practice or even for some future research? So I always ask the question, what impact do you think this paper will have on the world of CBT? Vickie: Well, gosh, I mean, I'd love it to have some impact. I suppose the first thing it brings me to because we run a CPT training program. It's just really encouraging training courses to bring SP/SR into their teaching and learning strategy. I think a lot of courses do more of this now, which is brilliant, I don't think it's necessarily alien in the way it might have been going back a decade or so. But I think that's the key implication, that if we don't allow space for trainees to get to know who they are, get to know who they are as a therapist, they may well go out into the world and continue to practice in ways which isn't optimum for clients doing well in treatment. I guess it brings a circle to what I was saying at the beginning, that we can get so focused on the technical flair of CBT that we forget those unique interpersonal dynamics which is the context where it all takes place. So I think hat's one of the key implications is how do we bring SP/SR into CBT training programs in a way that is safe, that is ethical, that is well resourced, which looks after trainees as part of that process and allows them to gain some of these insights that are really important to their professional practice. Steph: And what you were saying there was something my course tutor always spoke to me about, which was always, you know, you shouldn't be asking clients to do something that you won't be prepared to do yourself as well. And you know, if you're asking them to really look and analyse something, then you should be able to do that for yourself and have that your own self-reflection and your own reflective space too. Vickie: Absolutely. And I think a sort of strong, sense that we got. It was really interesting because Gwion and I had seen this data before because we'd marked it as part of an assessment. When we came back to it to analyse it, you relate to what people are saying in a much, just in a different way. And I'm not sure I can even articulate what that was about, but you come to the data in a different way. There was just this really strong sense of trainees saying that they could practice with more authenticity and more emotional connection and that just seems so important when you're working with people and asking them to do really difficult things as part of CBT sometimes. Steph: Yeah, definitely it is really important, isn't it? So is there anything that you would have done differently if you could do this all over again? Vickie: I mean, I suppose we've noted some limitations. I mean, I've already mentioned that we didn't go back and sort of talk to the trainees about what we found or sound out this sort of conceptual framework that we put together. And maybe that would have been a great addition to the studies to go back and perhaps do some focus groups or some interviews with the trainees. I suppose the other thing really to say is SP/SR doesn't really take place in a silo as part of our training program. The trainees are doing other things outside of that textbook and outside of the 12 sessions that they do, they're doing things like process reports. So they're having to analyse their interpersonal transactions with clients and having to reflect on what they're bringing to that process. So there may even have been things that we could have brought in from those parts of the training program or that we should do in future research about those parts of the training program and how that helps with this whole sort of self-practice, self-reflection concept. Steph: Yeah. And I always like to ask people this question as a managing editor, just to kind of gauge how people feel about it. But how did you find the peer review process? If you can remember, did you find reviewer comments helpful? Was there anything that was surprising for you? Vickie: This paper in particular was just met with such warmth and that was, I suppose, equally surprising and very lovely that the reviewers were very just bought into the whole concept, very positive about it, as well as offering really helpful suggestions just to improve the paper. So for this paper in particular, I've just found the whole review process really supportive. But my impression is for the journal that was the real ethos of that of reviewers providing supportive and helpful feedback, and that was certainly my experience, Steph. So whoever the reviewers were, thank you very much. Steph: That's good. And like you say, with the journal ethos, it is something that we really try and do is to make sure that when we have reviews, they're good, constructive reviewing, something I'm really trying to move us away from is from anyone feeling that when they go into peer review, they're going to be really judged and they're going to have a professor in an ivory tower come and critique their paper and pull it apart because that's not really what peer review should be about. So yeah, I'm pleased it was good. Vickie: Yeah, it was really good but equally, I've also had a review processes where it has felt, you know, that you come out barely with your self-esteem intact. But do you know what, it's the fine line, isn't it? Because I want journals to produce really good research that's of benefit to the community, but you know, certainly there are ways of doing that's really supportive. And that's my sense of this journal, which is great. Steph: Yeah, definitely. And you know, the paper was really excellent. It was covering an area that sounds like it's really needed and your passion and warmth as well came across in that. So I'm not surprised it was well received because it was really good. Vickie: You know, it's interesting that you say that because, obviously out of utter anxiety about being helpful as part of this process, I've read the paper this morning and had a completely different relation to it, reading it, than I did when I was writing it. And I was kind of reflecting that when you're writing a paper, you get hung up on not making mistakes, getting it right, getting it technically accurate, meeting the approval of the reviewers. You get so enmeshed with that whole process that I don't think when I wrote it, I'd emotionally connected to what I was writing. And when I read it this morning, I was really moved by some of the trainees' reflections and how authentic and deeply personal a lot of those disclosures were to help us sort of bring this out into the research arena. So massive thank you to the trainees that took part in that as well. It just made me think about this whole parallel processes of getting so bogged down with getting things right that we forget to emotionally connect and I guess that's really the essence of what this paper is talking about, is trainees can get so bogged down with their own stuff, some of the really nice interpersonal stuff can fall by the wayside. Steph: Yeah. And that comes quite nicely full circle to where we started at the beginning, wasn't it? Talking about your feelings of perfectionism and CBT training and trying to get it right. Vickie: Absolutely, I am a recovering perfectionist Steph, it's always a work in progress. Steph: So finally, before I let you go, I just wanted to ask what's next for you. Is there anything you're working on now? Any papers we can look forward to from you in the future. Vickie: At the moment I am very busy with lots of things course related. I am working on a little project with the BABCP, which is about just producing some helpful sort of best practice type guidance for courses for integrating equality, diversity and inclusion into training programs. I don't profess to be an expert in that area, but I think things like self-practice/self-reflection are so key. So there's a nice link there that hopefully we can pull into that work, which is about people getting to know themselves as therapists and getting to know where their stuff comes from in a cultural context as well, and how that sort of plays out when they're working with people that are different to themselves. So that's one of the things that I'm working on at the moment. If I'm very honest, I do have a raft of interviews that are awaiting analysis, they've been sitting there for some time, Steph, which I'm hoping we'll be able to come back to once we've got a bit more time and that's, exploring trainees experiences of working with distress as part of the training process. Because we know that trainees find it really difficult sometimes to work with difficult emotions. So, don't hold me to that anytime soon Steph, but that is in the pipeline. Steph: We'll look out for it when it comes. Oh, Vickie, thank you so much. This has been really great. Vickie: No problem at all, thanks for having me Steph. Steph: Thank you. Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts. If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at podcasts@babcp.com. And why not check out our sister podcast. Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT. Thanks for tuning in, and I'll see you next time on Research Matters. Bye.

Let's Talk about CBT - Research Matters is a brand-new podcast from the BABCP, hosted by Steph Curnow, Managing Editor for the BABCP Journals Behavioural and Cognitive Psychotherapy and The Cognitive Behaviour Therapist. In this episode, Steph talks with Sandra Krause a senior PhD student at Concordia University. Sandra is lead author on the paper "'Things that shouldn't be': a qualitative investigation of violation-related appraisals in individuals with OCD and/or trauma histories" with her co-author Adam Radomsky published earlier this year in Behavioural and Cognitive Psychotherapy. Sandra explains what is known about the cognitive model for mental contamination and how her research builds on this to explore what her participants with lived experience of OCD or trauma define as violations and the implications of this for clinical practice. You can find Sandra's full paper here: https://bit.ly/3YLyoUn If you enjoyed this episode, please rate, review, and subscribe to the podcast on your preferred platform. Follow us on Twitter @BABCPpodcasts for updates and join the conversation. Have feedback or suggestions for future episodes? We'd love to hear from you! Email us at podcasts@babcp.com. Useful links: You can follow Sandre and Adam Radomsky on Twitter for more updates about their work or follow their lab at the links below: @SandraKrause4 @AdamRadomsky Lab website: https://www.radomskylab.ca/ Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF Transcript: Steph: Hello and welcome to Let's Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT. Today I am speaking with Sandra Krause. Sandra is the lead author on the paper 'Things that shouldn't be': a qualitative investigation of violation-related appraisals in individuals with OCD and/or trauma histories published in Behavioural and Cognitive Psychotherapy. Steph: Sandra, welcome to the podcast. Sandra: Thank you. Thanks for having me. Steph: No problem. So before we begin, would you like to introduce yourself and talk a little bit about the research that you do? Sandra: Sure, my name is Sandra Krause, and I'm a senior PhD student at Concordia University, which is in Montreal in Canada. And all of my research that I've done as part of grad school has been in the anxiety and obsessive-compulsive disorders lab. So that's been under the supervision of Professor Adam Radomsky and really, yeah, we've been interested in trying to understand different cognitive mechanisms that are at play. I'm trying to kind of better understand different aspects of anxiety disorders, OCD. My particular interest is in kind of the crossover with trauma, ultimately, really, just so that we can improve treatments and better help people who are suffering from those kinds of issues, so that's kind of the broad strokes of what we do, and clinically kind of work to apply the knowledge that we learned from the research to evidence based approaches to working with individuals who are struggling with those concerns. Steph: Okay. Brilliant. Thank you. So we'll start talking about the paper that you've just had published in BCP. So can you tell me a little bit about what the aims of the study were, and were there any particular motivations behind the research? Sandra: yeah, so when I started grad school, my research interest was on trying to kind of understand, we know a lot about within OCD contamination related symptomatology, but there's kind of a sub section of those types of symptoms that we know less about, and it's called mental contamination. And so this is, we often see people wash excessively, feel dirty in response to kind of intrusive moral thoughts rather than in response to any kind of contact with physical germs or dirt. So, maybe having an intrusive thought about something like incest or paedophilia, or intrusive memories of past assaults, things like this that have happened to them and that that's the driver of kind of the contamination symptoms that they experience. And so coming into my PhD, I was really curious, there's a cognitive model of mental contamination that was proposed initially when sort of the symptom domain was newer, but there's a lot of aspects of the model that aren't super fleshed out. So, for example, a big part of the model is the fact that these feelings, this is feeling of dirtiness and the washing that comes up, comes up because of a perceived violation, but there's not a super clear definition of what is a violation? What constitutes a violation? What kinds of events are violating for people and why? And then also, as the name suggests, the cognitive model kind of proposes that it's the way that people appraise or think about those violations that lead to the symptoms of mental contamination, but there's not a ton of work yet too that's been done at, zeroing in on specific types of thoughts that are linked to mental contamination feelings after experiencing a violation, and kind of differentiating between the types of thoughts that lead to mental contamination versus other kinds of negative emotions that might come up after a violating experience. So things like shame or anger or sadness that you might expect someone to experience as well. And so that's kind of where my study came in was that I wanted to really start from the ground up and speak to people who have lived experience with either OCD or trauma histories and hear from them, how they define the construct of violations so that we could get a clear definition for the model. And then also walking through past instances of violation that they've experienced to understand different types of thoughts that they have, different appraisals that they make, and how those appraisals are linked to different kinds of negative emotions. So, again, kind of differentiating between those that were associated with those feelings of dirtiness, disgust, contamination, and the ones that are related to other kinds of negative emotional experiences like anxiety, fear, anger, shame, Et cetera. So that was really the aim of aim of the study. Steph: brilliant. Thanks so much. So, if we get into the paper then, I think that leads quite nicely onto your participants. I see from the paper that you interviewed 20 participants. Who were they and how did you recruit them? Sandra: Yeah, so, the inclusion criteria for the study. So in order to be able to participate, we were interested in interviewing people who either met criteria for OCD or who met criteria for, we call Criterion A and the DSM for PTSD. And so this is people who have experienced a serious trauma, so either actual or threatened death or serious injury or sexual violence that they experienced themselves or witnessed firsthand. And so, in order to get participants, we have a clinical registry as part of the lab. So there was at the time of my study, there was also a randomized control trial happening in the lab for treatment for OCD. So, we advertised through that study to see if anyone was interested in participating in the study as well. And then we also advertised on Twitter and online. And so really we were just looking for people who had these experiences or kind of experienced these types of symptoms who are adults, so over 18, and who spoke English. So it was pretty broad inclusion criteria. And yeah, anyone who was interested reached out and then I had a phone screener with them and just went over those kind of symptom, sections of the Mini-International Neuropsychiatric Interview and confirm that they were eligible. And then we conducted the interview over Zoom with them. But yeah, these were just kind of people in the community. Some were seeking therapy, and some were just kind of interested in contributing to research. Steph: And did you get many, people come forward from Twitter? I'm always intrigued when I see studies on Twitter and how much uptake they really have. Sandra: Yeah, there was a bit of, interest. I would say that there was a lot more screening that was required of the broad social media ads that there was, again, we were just sort of in the ads were just describing the symptoms pretty generally. Yeah, so people can interpret that in different ways so that we didn't actually end up with a ton of participants from the Twitter ads. But actually ran into another sort of new research hiccup that we hadn't anticipated was bots that there was, we got one day like 300 emails from different Gmail addresses, that were sort of automated, I guess. The bots that had reached out about the study. So just, I guess, a caveat for anyone doing social media recruitment for research that to be careful about. Steph: I hadn't even considered that. But yeah, I can imagine 300 emails is annoying. Sandra: yeah, I mean, luckily for us, there was a screening call, so I was able to weed out all of those people through that, but, yeah, for people I know who have been doing just online questionnaire studies via social media that people kind of just go on, I guess there's automated ways of, getting whatever compensation at the end. So they go in and submit a bunch of responses and it's hard to screen out. Steph: So going back to the interviews then, when you completed all the interviews, am I right in thinking that you did some analysis on the transcripts and then some apparent themes emerged from these interviews? Sandra: Yeah. So the, again, because it was like a pretty exploratory study and we were going in pretty open ended because again, we didn't have like really specific hypotheses of what we were expecting to find because we didn't really know a lot about this area from previous research. So, yeah, I conducted the interviews, with pretty like broad questions just to get a sense of people's experience more or less and then, went in and used a grounded theory approach to the qualitative analysis. So, as the interviews were being conducted, I was also coding them and kind of adjusting the interview protocol based on what we were finding. And certain themes came out which was always nice when you see some consistency across participants. But yeah, we found kind of similar themes across participants in terms of, first of all, how they define violation, or what constitutes a violation. Most interestingly for me, we found similar themes in terms of, the types of thoughts people had about the violation so the way that they appraise the violation, and then also in terms of, the functions of the behaviours that they engaged in, in response to the violating thoughts or, experiences. So, yeah, so I guess, do you want me to get into the specifics of those? Steph: Yes, I was going to ask you if you had any good examples that we can kind of really listen to and kind of picture, that would be great. Sandra: Yeah, yeah. So, in terms of the definition, what I found really interesting was that across participants, every single person that we interviewed, alluded to the fact that in order for something to be a violation, it needed to contradict a previously held belief. So it wasn't sort of whether how bad something was that happened to you, how serious it was, how life threatening, how, how much it infringed on your body or your space, but it was really whether it violated or contradicted sort of the way that you saw yourself or the world previously to that experience. So, yeah, a lot of people kind of talked about, they thought they were a smart person, but then they experienced the situation and made them feel dumb or they thought other people were trustworthy and then they were betrayed and it kind of eroded the trust that they had in people or interestingly, on the opposite side of things, there was one participant who talked about how he had been assaulted and mugged at one point, but that he actually didn't see that as a violation because in his mind, that's something that could happen to people. So, it sort of reinforced a previously held belief he had about what was possible in the world. So I thought that was sort of interesting that it's, it's really this, this contradiction of your beliefs or your sort of expectations that makes an event feel violating or perceived as a violation. And then in terms of the appraisals, so there were kind of common themes in terms of appraisals of other people. So the way that people thought about others after experiencing a violation, the way that they thought about themselves and then the way that they thought about the future were sort of the 3 bigger picture themes that that came out of the appraisals. And so what we found was that when people talked about feeling dirty or disgusted or contaminated that that came up most often when people sort of in terms of the appraisals of the self, thought that they were responsible in some way for the violation, or thought that it was some indication of their self-worth. So, I'm worthless because of having experienced that, or I'm worth less than I was before. Or I don't bring anything to the table now that this is something that I've experienced, or, yeah had thoughts about and then the last one that was linked to the mental contamination feelings was this appraisal of permanence. So, this idea that I'm tainted forever now, because of this experience or because of this thought that I can't get rid of it. This has changed me now permanently because of that. And then for the behaviours, what I found most interesting was that it didn't really matter what the actual behaviour was. People talked about all kinds of very, very specific behaviours that they engaged in. Some of them were similar across participants, but there was a lot of sort of unique from person to person behaviours or urges that they had. But what I found interesting about it was that the function of the behaviours were a lot more similar across people, even if the behaviour itself wasn't. So, whether it was, cleaning or washing or thought replacement or avoidance or self-harm that, even if the behaviour on surface level look different from person to person, for most people, all of these things either serve to kind of avoid or distract away from thoughts about the violation. To sort of punish the self or, or kind of, inflict some kind of yeah, self-punishment because of the violation that they felt that they deserved. Or to regain a sense of control. So to feel this thought that I can't control or this experience that happened to me in the past that I have no longer have control over. This is something in the here and now that I can do to try to regain a sense of control over that event, even if it doesn't actually impact it. So, whether that's washing or showering or arranging things, again, self-harm came up with a couple of participants. That all of these things in the here and now made it feel like, okay, I might not have control over the original thing that happened, but I can regulate that anxiety and sort of get a sense of control in the here and now, by doing these different behaviours. So, those were kind of, yeah, I guess the spark notes of the different themes that came up. But, yeah, the take home, I guess, was that there were different appraisals, that seemed to be linked to different emotions and that we were able to zero in on specific ones that were linked to mental contamination for the participants. Steph: and apologies if this is a stupid question, Sandra: No such thing as stupid questions. Steph: As you were saying some of that, I was just thinking, when we talk about trauma and we talk about PTSD, it's not necessarily the event itself, but it's the meaning that we make of it. And is that kind of linked into the appraisal? So it's not necessarily that, what has happened to them, but their behaviour is kind of the meaning that they've made then of that violation. Sandra: Yeah, no, absolutely. That's 100 percent kind of in line with what we found. And within trauma, that's the case. And also within OCD, right, that it's not about the intrusive thoughts themselves. Actually, we know that most people in the world, almost everyone experiences intrusive thoughts, but it's more about the meaning that's attached to having those thoughts that leads to the urge to engage in different behaviours for both PTSD and for OCD. So whether that's avoidance or whether that's certain compulsions that people engage in and so this kind of reinforce what we know about these things and what we know about cognitive models of, the fact that meaning and appraisals tend to drive a lot of emotional and behavioural outcomes for people and gave us a lot more sort of specific details to work with when it comes to this symptom domain specifically which hasn't gotten as much attention when it comes to past research. Steph: So given these findings, then what do you think are the implications for clinical practice or even future research? Sandra: Yeah, it's kind of a, I think, an important building block. Like you said, there was only 20 participants, and it was done qualitatively which I think has a lot of strengths. We heard from people directly who, are living with these experiences and were able to kind of use that to construct the analysis that we use for the study. Taking what we found from the study and replicating it in bigger samples and experimentally to be able to see causally when we make people think about things in particular ways do we then see a causal impact on the feelings of mental contamination? I think it's an important next step. But. I think that what we found is super practical and clinically useful in a lot of ways, because we know that actually people who experience higher levels of mental contamination when they start treatment. So, I think the research has been done in OCD, but theoretically, I think there's no reason why it wouldn't apply to trauma as well, but that individuals who start treatment with higher levels of mental contamination actually do worse after treatment that they don't improve quite as much. And a lot of what's been proposed, for the explanation as to why is that a lot of the first line treatments for OCD are pretty behaviourally focused. So exposure and response prevention where it's exposing people to their fears and then, preventing them from engaging in the compulsive behaviour so the washing or the cleaning that they might engage in, and actually, what seems to kind of have come out in a really rich way from this study and from previous work that's been done in this area is that mental contamination might be a much more kind of cognitive process than physical contact contamination concerns and so for treatments to incorporate more sort of targeted cognitive intervention. So targeting the specific types of thoughts people are having in the specific meaning that people have ascribed to these violating experiences that are driving the washing and the feelings of dirtiness, might actually prove to be a lot more effective for people. And so we've kind of known that for a long time, theoretically, but the study, I think, gives us concrete intervention targets of specific types of appraisals that you can target in cognitive therapy. So you could engage in psychoeducation, just about these models, but also designing behavioural experiments to be able to test out, these different appraisals and meanings that people are ascribing to see when it holds up, if there's room for flexibility, maybe there's certain context where those things are true, but maybe it's not true across the board and all types of context. I think that the themes that came out here could be really useful clinically to target as yeah, cognitive intervention targets, either as an adjunct to ERP or in, in place of more sort of behaviourally focused treatment. And then I think the last thing that I see as being a particularly clinically useful piece from the study is, again, because of the history of where mental contamination, the theory and concept of it sort of evolved from, we tend to think of the, the feelings as being associated mostly with just like washing and cleaning behaviour. But actually, what the study showed is that people engage in all kinds of different types of behaviour and that we should really be focusing more on understanding what the function of the behaviour is that people are engaging in, and maybe assessing for sort of a broader range of different types of, urges or behaviours that people are engaging in beyond just kind of washing and cleaning, because it seems even for the feelings of dirtiness and disgusting contamination that people engaged in really idiosyncratic, unique behaviours from 1 person to another. And so kind of not pigeonholing your assessment into just those types of things, but taking a broader sort of lens when it comes to assessing those types of aspect of the model, I guess. Steph: Yeah, and speaking of kind of like not pigeonholing people, did you find when you were looking at the type, because you said there's quite a range of different types of behaviours that all the participants engaged in were there particular behaviours that seemed, were there any that were surprising to you? For example, did you expect the participants who, we're experiencing OCD to have more washing, for example, or were you, were you quite surprised at just like the range of behaviours that everyone had? Sandra: Yeah, I was actually, and it's a good question. I think, Yeah, it's interesting because I mean, I can get into it more, where we talk about some of the limitations, but a lot of the people in the study had both OCD and trauma histories, and there is a smaller subset that had just OCD, and a smaller subset that had just experienced trauma in the past. But based on just looking at the transcripts and analysing the behaviours and the patterns, you wouldn't really have been able to tell the difference so much between the sort of sub samples within the sample, which I thought was really fascinating because yeah, I think there's sort of this instinct to think that maybe that the OCD group would engage in more of the ritualistic washing and maybe the trauma group would be, I don't know, maybe more fearful or avoidant, more sort of like, anxious, fear based types of emotional experiences and behaviours, but there really was kind of across the board a pretty wide range. I think the part that maybe I wasn't expecting, in terms of the behavioural side of things was that, self-punishment or self-destructive kind of urges is not necessarily something I think I anticipated beforehand, that even for some people, like the washing itself, like they would wash with really hot water, for example, as a way to, you know, they experience some kind of intrusive thoughts that they experienced as violating, they perceive themselves as being a horrible person, disgusting person, forever tainted by those thoughts. And then, would wash themselves with like really hot water to sort of punish themselves for it. And so that wasn't one that I was necessarily going and expecting to find, but again, it makes sense based on what we know about cognitive models and the way that our appraisals drive our behaviours and our emotions. I think it was interesting how trans well, I mean, there was only 2 kind of diagnostic groups of focus in the study, but it really was. It felt like a homogenous sort of, experience, I guess, based on the transcripts and the analysis that I ran, both in terms of, the emotions and also in terms of the behavioural sort of outcomes that people expressed. Steph: it sounds like it must have been really fascinating. Sandra: Yeah, it was. And I think just I think qualitative research sometimes gets a bad rap, that like hardcore evidence-based researchers, really value, quantitative experimental work. And I think that there's obviously huge strengths to doing that kind of research, but just the richness of being able to hear firsthand from these people and use their language as the data. Often as researchers, we can get sort of siloed and have blinders on sometimes when we have a concept and we think we understand the concept fully and it sort of reifies a bit where we develop a concept and then we test that concept and prove that that concept kind of continues to exist. And I think, mental contamination is a good example of this, where it developed out of the contamination literature. So we define it kind of more narrowly in terms of the contamination feelings and urges to wash is sort of the behavioural part of the definition, but then when you go in and you hear from people who are living it that it actually kind of expands our viewpoint, I think, quite a bit by being able to see stuff that maybe, we don't necessarily come to instinctively as researchers with all of our theory and kind of knowledge of the field that is super useful and practical in a lot of ways, but I think can sometimes blind us to stuff that maybe is outside of what we've already know of an area. So, yeah, it was super rich and interesting to be able to talk to people 1st hand and see how the interviews evolved over time, too, because I think that's another awesome part about qualitative research is that it's meant to kind of evolve as you're working through stuff with people. So, as things came up in early interviews around, maybe these broader behavioural outcomes or specific types of thoughts that people had that I wasn't anticipating, I was able to kind of probe more for those things with later interviews and see that it actually was quite common and that a lot of people sort of experience those things as well. So, yeah, it was a really fascinating experience for me. And I think it's rich the data that comes out of it and the quotes from the participants that you can see in the paper. Steph: Absolutely. So if you were going to start this all over again, was there anything that you would have done differently if you could do it again? Sandra: Yeah, so it's a good question. I think, like I said, the nice part about qualitative research is that you can sort of course correct a bit as you're going. So, the interview became more open ended as I went on with later participants, which I think if I could do it over, I would start with a little bit more open-ended prompts rather than, really specific, more closed ended questions guided by the theory and research that we already have. I think if our theories are accurate then those things will come to light, even if you don't probe for them specifically. And that's what we found kind of later on with the interviews is that it allowed for a little bit broader information to come out and also to sort of demonstrate that our cognitive model holds up, even when we're not asking people specifically about what emotions were caused by that thought, or more sort of, I guess, closed ended or directive questioning. So, I think that's 1 thing. I think also, just in terms of the diagnostic profiles initially, I was sort of anticipating having 10 people with OCD and 10 people with trauma histories and actually getting out there, I think there's a lot more overlap between these groups, they're not so cleanly divided. And I mean, that lines up with epidemiological research that we have that shows that there's a lot of comorbidity between these things and that there's a big sub sample of people with OCD where the ideology is trauma or these violating experiences in the past. And then I think, yeah, I think sort of along those lines, just looking at it as more of a transdiagnostic construct and not really zeroing in specifically on certain diagnostic categories, because even with the participants in the sample. So, as part of the study, I conducted the whole MINI, so it's a semi structured diagnostic interview for everybody. And so, in order to participate, they needed to meet criteria for either OCD or Criterion A for PTSD, but a lot of them, I'd say most of them also had comorbid other disorders. So things like social anxiety or depression or eating disorders. So I guess, maybe rather than trying to be more specific diagnostically in the future, based on what came out of this, I think it would actually be useful to just ignore the diagnostic categories and see whether this model holds up trans diagnostically as a more universal experience that people have. So, I guess, yeah, if I were to do it over again, those would be the main, the main things. Steph: Cool. Thank you. And this might not be relevant, but I always like to ask authors, as a journals Managing Editor, it's always interesting to me, how did you find the peer review process? Were reviewer comments helpful? Did you find, was there anything that you disagreed with or that you found difficult about the process? Sandra: So I think, I think qualitative research, especially like clinically focused qualitative research can be sort of hard to find a home for in terms of a journal just because I think a lot of hardcore clinical journals tend to prefer like quantitative research and then more qualitatively focused research journals, have sort of a rigor and standard in terms of the methodology that a lot of applied research doesn't kind of, I guess, meet the bar for. So I think in that sense, just finding the right place for it was an interesting experience. And also just the length of qualitative papers is quite long because of the quotes, rather than having a nice table that synthesizes all of your means and standard deviations. The data itself are these paragraphs of text from people. So I think that was a bit of a challenge initially, but, once we submitted it to Behavioural And Cognitive Psychotherapy, I actually found the review process was super helpful. And it was nice because the reviewers comments that we got, there were 2 reviewers and 1 was able to provide more comments about kind of the theoretical, practical, clinical, aspect of it. And the other, appeared to have a lot of experience with qualitative methodology. So, in terms of, adding reporting details about the analysis process was useful. I think for us, we're not a qualitative research lab. We've done some qualitative studies, but it's not sort of our area of expertise. And so there was a lot of really constructive feedback within that about, what to include what's maybe not necessary to include, from the methodological sort of standpoint. So I actually found it, I think it ended up with a much more sound balanced final product, which isn't always the case with peer review. I think sometimes it can be a little nitpicky and not the most constructive, but in this case, I actually found that the combination of the reviewers feedback was super helpful and constructive and I learned a lot from it. Steph: That's really good to hear and it's so nice, for people to have good experiences as well. Cause like you say, some peer review can be very nitpicky and lke you say, if it took you a while to find the right place for your research, then I'm really glad that the peer review process was just as smooth as it was then. I think that's really great. So just before I let you go what's coming up next for you? What else are you working on? Are you going to try and continue with the research that you've done here or anything you want to plug that's coming up? Sandra: Yeah, so actually we used the interviews in the study that we just talked about as sort of a basis to develop a quantitative measure of appraisal. So, as I kind of alluded to earlier this interview data, I think, is super rich and points to a lot of really interesting directions. And I think that the next step is to kind of validate it more quantitatively and experimentally. So, we took the themes of the different appraisals that came out and tried to create a new measure of just kind of a broad range of different types of violation appraisals. And so that's where we just submitted that for publication. So, yeah, we validated this new measure and hopefully developed a clinically and research useful scale that people can use moving forward to look at quantitatively how different maybe themes of violation appraisals lead to different kinds of outcomes for people. So that's kind of, more imminently in the pipeline and then, Yeah, I think down the road, I'm looking to sort of use that experimentally and see if we can try to manipulate different types of appraisals and look at their impact on mental contamination and see, maybe clinically within sort of clinical populations on the flip side is whether we can sort of reduce those types of appraisals or get a little more flexible with those types of appraisals and see whether that can maybe help people who are, who are experiencing these kinds of symptoms. But yeah, overall, just I'm excited about more research in this area. I think it's a really interesting subset of clinical populations, this intersection between trauma and OCD. And I think it's getting more attention in the research world and in terms of sort of like clinical implications that stem from that. And I guess I'm just excited to be a part of whatever comes up in that domain down the line. Steph: Yeah. Brilliant. Well, this has been really, really interesting. Thank you so much for coming on and talking to us. Sandra: Thanks for taking the time to ask me interesting questions. Steph: Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts. If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at podcasts@babcp.com. And why not check out our sister podcast. Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT. Thanks for tuning in, and I'll see you next time on Research Matters. Bye.

Let's Talk about CBT - Research Matters is a brand-new podcast from the BABCP, hosted by Steph Curnow, Managing Editor for the BABCP Journals Behavioural and Cognitive Psychotherapy and The Cognitive Behaviour Therapist. In this episode, Steph talks to Dr Jake Camp a clinical psychologist and DBT therapist about their paper "Gender- and sexuality-minoritised adolescents in DBT: a reflexive thematic analysis of minority-specific treatment targets and experience" published in the Cognitive Behaviour Therapist. This study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Jake talks about what this study found and highlights some really helpful recommendations for clinicians working with young LGBTQ+ people. You can find Jake's ful paper here: https://bit.ly/45GhM1C If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X or email us at podcasts@babcp.com. Credits: Music is Autmn Coffee by Bosnow from Uppbeat 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 talked to Dr Jake Camp. Jake is a clinical psychologist and lead author of the paper "Gender and sexuality minoritised, adolescents in DBT, a reflexive thematic analysis of minority specific treatment targets and experience" which was published in the Cognitive Behaviour Therapist. Steph: Hi, Jake, welcome to the podcast. Jake: Hello, nice to be here. Steph: Thank you so much for joining us. So just to start off the podcast, are you okay to tell me a bit about yourself and the service that you work for? Jake: Yes, absolutely. So, so my name is Jake Camp. the pronouns I use are he/they. I'm a clinical psychologist, and DBT therapist. So my main area of work is at a national, DBT service for adolescents that's based at the renowned Maudsley Hospital. I also work academically, mostly with the department of psychology and the LGBTQ+ mental health research group. So that is at King's College, London. and I mostly work with young people who have experienced a ton of trauma, sadly, and have had a lot of difficulties that have led to, finding it very hard to sort of survive and thrive in the world. Often, young people end up being quite highly suicidal, sadly and my area of research that I'm particularly keen with, and of course what we're hopefully talking a bit about today, is mainly around how therapies work for minoritised groups and particularly LGBTQ+ groups as my sort of main area of research. So, it's great to have a chat about that. Steph: So yeah, that leads us really nicely into talking about the paper because we are talking about one of the minority groups that you have been researching. So do you want to tell us a bit about who they are and what the paper is that we're talking about today? Jake: Yeah. So, the paper that we are focusing on today is, one where I really wanted to spend some time privileging and I suppose, increasing the sort of voices of LGBTQ plus young people in DBT. For those who are not familiar with that acronym, although hopefully most people are, of course, that is usually people who identify with a minoritised or minority sexual identity, so that's like lesbian, gay, queer, etc and or a sort of minoritised or diverse gender identity, so that might be trans, non-binary, or so forth. So the paper really was to try and, you know, sort of give a platform to LGBTQ+ young people about their experiences of Dialectical Behaviour Therapy or DBT, because what we know from the literature is that, generally LGBTQ plus people experience quite a lot of barriers to accessing services. There's also some evidence of poorer experiences of services and even some of the poorer outcomes, particularly in the sort of adult literature. So we know that there's a bit of a problem with how we meet the needs of LGBTQ plus group generally across our services, and we know that LGBTQ plus groups usually are significantly more likely to experience mental health difficulties and particularly engage in self-harm and suicidal behaviours, sadly, which we think is associated with, societal oppression, what we call minority stress. So those are stressors unique to their sort of minority characteristics or identity. So, we think it's super important, you know, to sort of do more work in this area. And of course, sadly, there's not actually that much, particularly in DBT about this, but, I would say there's also not much robust work, across that sort of fields as well. So, so this is the paper. Steph: And I think one thing that really struck me when I was reading the paper, I've read a couple of iterations of it from when it was submitted to the published version, it's really about how much the lived experience of the young people you were researching in this was very important to, to the topic and to you. And so what motivated you really to look at this research area in particular and, and focus on this. Jake: Yeah. Yeah, good question. I think, it really stems, obviously, from early on, and I touch on this a little in the paper, I identify as LGBTQ+ so generally just describe myself as a queer/nonbinary psychologist and I think, you know, growing up in a societal context where we had the sort of echoes of what I now know was sort of Thatcherism, Section 28, which precluded, the sort of conversations around what was termed homosexuality in schools, which ultimately meant that, you know, things like bullying with content around this, things like talking about modelling good experience of this, showing you that you could be a queer young person and be okay and thrive, were just completely absent from my childhood, mixed in with, I think, you know, we certainly were coming out of the AIDS epidemic when I was growing up and a number of other social, cultural things, I think just meant that, you know, growing up as a queer kid really wasn't comfortable and from a very early age, starting to feel different from people and starting to feel that societal oppression was very heavy. Mixed in with, a number of other sort of areas of difficulty and trauma in my sort of familial environment. I think I was I've always been very keen to try and use my privilege to help people, help my kin almost, help people, help those queer kids, you know, to sort of grow up and thrive, because I really didn't feel like I had that. And so that sort of informed how I've ended up going down the route of LGBTQ mental health as my sort of main area of research. And, I think, of course, part of that is they're my tools, they're my tools for activism in some ways, is that, the area that I can use and the privilege I have is that I can focus my research energy into this and hopefully try and make the system better. So, they're the sort of overarching aims. The reason I ended up in this sort of project area specifically is firstly, because, I work in DBT and very passionate and keen about supporting people who have quite complex trauma that other sort of traditional services don't always quite meet their needs, you know, so the sort of the running theme for it, and I think DBT does that really nicely and when I started working in the National DBT Clinic, I was very surprised to quickly see that in this group of very highly suicidal young people, that about 60 to 70 percent of them were LGBTQ+ which of course is an outrageous over representation, compared to what should be if there was no health inequality there. And that sparked my interest because I thought, I need to work out what's going on here. And I need to try and make sure we're meeting their needs and make sure that other services are meeting their needs too, because I think what that potentially speaks to is that their needs are not being met sufficiently earlier in the treatment pathway before they end up needing DBT. And of course, DBT, you know, is really made for people where they're highly suicidal, high severity of difficulty usually been going on a long time. So this paper sort of squarely came out of that. I thought, where do I start? Well, I want to start, you know, with the young people and their voices, and I want to know what's working for them, what isn't working for them, and actually what is important about their experience as a minoritised individual that we need to be thinking about in therapies, in particular, of course, DBT. So that was the sort of inspiration for it, and it's part of a wider program of work, of course, to try and complement some of those questions that I had. But here it was squarely about, what do the young people think? what would they advise us to do, which I think is super important. Steph: Yeah, absolutely. And that really comes across in the paper, I think. Like I say, it's really nice when you can read papers that you know have been written with real thought and real compassion as well, that definitely comes across in the paper. Before we getting into talk about the paper itself, would you mind explaining a little bit about DBT for maybe listeners who don't know what it is, or maybe don't know that much about it? Jake: Yeah, of course, yeah. So DBT stands for Dialectical Behaviour Therapy. so, we usually describe it as a sort of third wave CBT approach. for those who are not familiar with that terminology, third wave, I usually think of as meaning standard sort of second wave CBT, which is the usual CBT you see out there for, you know, specific disorders, often like panic, social phobia or so forth plus some other elements of something, mostly mindfulness, of course, and that's usually the biggest, sort of inclusion of other principles or techniques in third wave CBT and models, but also usually a lot of other stuff to borrowed from other areas of work or, or schools of thought as well. So DBT is a very good example of that, it builds in mindfulness, it builds in a number of other principles to try and support its target population. DBT mainly aims to work with people where emotion dysregulation or difficulties managing emotions is sort of the key underlying difficulty to, so, you know, generally we think it works quite well as a nice transdiagnostic intervention because that's the key treatment target rather than key symptoms necessarily, albeit, of course, Borderline Personality Disorder was the original symptom structure or sort of ideology that they were sort of made to target. Most of the people that I work with tend to have emotion dysregulation and engage in self-harm and suicidal behaviours or other behaviours that are judged, by society as being dangerous and maladaptive. We work with people in quite an intensive way in DBT so, it isn't just individual sessions. If you're getting full comprehensive DBT, which is the most widely evidenced version, you usually should be getting weekly individual therapy sessions to build motivation, support with your problem solving and a number of other things, weekly skills groups, try and teach you skills to sort of manage life and emotions. You should get your therapist phone number where there's a between session phone coaching. So it's like a tips hotline. So you get to call your therapist and navigate your life. I know, right. And it's pretty good. I feel like, you know, I need a therapist hotline sometimes just to, um, and there should be a therapist consult which is a sort of weekly meeting where it's almost like therapy for the therapist. Therapists support each other to stay in frame, to do a good job for their clients and not to burn out. Because of course, the risk is working with high complexity and suicide, which is very scary of course, is that there's risk of therapist burnout. So DBT delivers it through those modes and it has all these principles such as problem solving, validation, zen and mindfulness, skills, which is probably the biggest, known part of DBT is the skills aspect, behaviourism, cognitive restructuring, a number of principles that we pull on to help our clients, you know, sort of build that life worth living. So pretty complex model. But, you know, it's a pretty good model for working with people where they wouldn't naturally fit maybe that sort of lower severity frame if that makes sense, usually where emotional dysregulation is particularly tricky. Steph: And how long would you expect a young person to be in your service then? Cause it sounds it's much more intensive than like you say, like a traditional second wave CBT. Jake: Yeah, good, good question. It's interesting actually. Um, and this, so we have debated lots since DBT has been integrated into the NICE guidelines, for young people. So for adult DBT most of the time, it's about a year and DBT is meant to not be the end goal. So DBT is like the first stage, which sometimes people call stabilization. And then the next stages are meant to be going on to do things like trauma reprocessing, working through other difficulties, building your life, making everyday decisions so they get a year usually. In our, adolescent program, our treatment length has differed over time based on a number of different factors. Currently, we are a seven-month program with opportunity to extend to nine. The actual evidence base for DBT for adolescents though, usually positions itself as three to six months. And the NICE guidelines only quotes the three months, which is interesting because they miss all of the other lovely RCTs and pieces of evidence out there, like uncontrolled studies or controlled studies that actually usually mostly use the six month model. And that's, I think, because DBT for adolescents was always positioned a little bit more as early intervention. So get in there before the difficulties really emerge. Whereas, often what we see in our clinic is people have had these difficulties for a pretty long time. And they're usually in that sort of slightly artificial threshold, between adolescence and adulthood, you know, so in that sort of 16, 17, 18 range as well. So usually a lot of difficulties Steph: Yeah, well, that was a really good explainer. Thank you. Okay, so shall we get into the paper itself then? So, am I right in thinking that your participants for this study were already in your service receiving DBT, and they were recruited because they identified as Gender and sexuality minority. Jake: yes, that's correct. So, I think part of the inclusion criteria that I had was to make sure that they had finished at least the first six months of our skills group. And that's because by that point, you've covered pretty much every piece of skills content. So, my rationale behind that was thinking, you know, I want you to have enough experience of the program to be able to talk about it. But otherwise it was just that they were in the program, that they identified as LGBTQ+ or gender and sexuality minoritised. And yeah, and that they were willing, of course, because that's, that's very important. Steph: first rule of participation is are you willing? Jake: Absolutely, Steph: Okay. So you conducted some interviews with the ones that were willing to participate. What kind of things were you asking them and what did you find? Jake: Yep. So, I, I sat down with, 14, young people who were in our program. they were really wonderful interviews, actually. Like, I felt very privileged. privileged to have the young people share their wisdom and their experience with me. I came out of nearly every interview thinking, wow, like, you know, this is such a wonderful thing to be able to do. And what was really lovely is that they were saying similar to me at the end. There was like, no one's ever asked this, like no one's ever sat down and sort of spoke to me about this stuff. So they were really grateful as well. So I felt very reinforced in behavioural terminology, for doing this project and I'm very motivated, to do more, with it. So, so yeah, so I was asking them questions about how they found DBT. So as a person who identifies as LGBTQ plus, how did you find it, and where were, where were our blind spots or where we needed to, make things better and where were areas that we did well. I also asked them, what experiences related to their LGBTQ plus identity were important for us as therapists to know and to potentially work on or integrate into the therapy somehow and this was to try and get an idea of potential minority specific treatment targets or, areas of conversation. I hesitate with targets because, of course, it suggests a certain amount of potential. possible pathology, which, you know, I really want to stay away from, of course, but areas that, as a therapist, I need to be clued into and I need to be potentially supporting my client with if I can. So that's why I asked them. What we found was, well they shared so much wisdom as well. The analysis was really tricky because of course what you have to do in qualitative analysis is where you distill meaning into these themes and, I battled lots with losing lovely nuanced bits of information in the sort of collective overarching theme and, my supervisors and my co-authors were very wonderful at supporting me with thinking about how to still do it justice and of course you can't include everything. But anyway, the sort of main areas were; there were sort of themes that were about potential targets in DBT. So these were, one area that was particularly spoken about was, difficulties with identity. So what a lot of the young people spoke about was being quite confused about gender and sexual identity Understandably, of course, for their developmental stage, but also, more so possibly because of the difficulties that they had had, and actually struggling with building up self-acceptance. It was interesting because the young people said, gender actually was a lot harder. Of course, given the socio-political context around that right now, compared to sexual orientation, which they felt was, somewhat easier in comparison, albeit still tricky. And what a lot of them said to me was like, this was an area that needed a lot more space if we could have done in DBT. The other area around targets that was mentioned was, like, the impact of others, so a big area that was spoken about was what we call, like, cis heterosexism, which is, like, a sort of umbrella term that describes societal oppression related to gender and sexual orientation or minority status. And they said that this was from the spectrum of overt versions, so that might be, like, explicit homophobia, transphobia, biphobia, and all the way through to those more subtle, insidious versions which we sometimes call more microaggressions, where maybe a therapist didn't mean to, make an aggression and at the same time did sort of thing. So they said these were important for therapists to know and help me to cope with and played a big role in why I found things difficult. The flip side to the impact of others was a lot of young people said one of the biggest protective things for them was community connectedness. So finding a way to connect with people either who were accepting, or were similar to them so that they could see similarity and they could find connection with others. So they felt like DBT nurtured that quite well, especially in the skills group aspects, because we of course bring young people together, even though they would love to not most of the time- but most of the time by the end of the group, they actually tend to really get a lot out of it and get a lot out of being around other people who share some degree of similar experience as well. So, so yeah, and, and the ultimate thing we're pointing out that like identity and the impact of other stuff was to say, this is the areas where DBT therapists particularly here, but therapists generally probably need to be a bit aware of what that might look like for young people and to try and help them navigate some of those key dilemmas, because of course, you know, these young people in particular were saying, these are things we're going through, these are things that would probably be helpful to support with more, if you can. And of course, I'll speak a little bit to that a bit in the future, because it can be a tricky dilemma with fitting everything into your therapy, especially when you've already got a lot of higher order targets that, you know, you need to focus on first. The second area of findings were about, well, how did they find it, what worked and what didn't and this was split into two main themes. So the first was difficulties or wherever it worked about negotiating, focusing on LGBTQ plus stuff or associated dilemmas in DBT. And the other one was about creating safety. So the first one, the negotiating focus, what young people said was, what was a bit tricky in DBTs, because it has a really high threshold for including difficulties in the therapy, because of course we work with highly suicidal clients, our first and foremost priority is keeping our clients alive. So life threatening behaviours are always going to be priority, first and foremost. And then even then, when you get past that and you get more towards the other things that are causing them problems, it often has a really high threshold for being included in DBT because of course the sort of principle is like, is it severe enough that you need DBT rather than an alternative sort of intervention? And that can be tricky because the young people are saying I wanted to focus on it, it was there. But I couldn't get to it because there was so much other stuff in the way. even though their wisdom was actually if you could have helped me a little bit with some of that stuff more, it might have made the other problems better. So some of our recommendations are very much around how therapists find some of these what we call controlling variables or like key, almost like hot links in the chain that lead up to these difficulties or, or difficult behaviours, which might be to do with minority stress, right? Might be that it's often their own thoughts around, you know, their gender or their sexual orientation or, or people's behaviour towards them that lead to say self-harm or alcohol use or so forth. That actually, if you can find those and work with those, that's a way around the trickiness with getting it on our, our treatment hierarchy or what we're going to work on. so yeah, so that was one difficulty. The other thing that they said is they actually thought that a lot of the DBT stuff was really generalisable. They were like, it's great, you know, the skills themselves are not like pigeonholed into this idea that they wouldn't work for queer people or LGBTQ young people. But what they said is that sometimes, Well, a lot of the time, therapists didn't help them generalise it in that way, so they, they, a lot of the young people said to me in the interviews, like, Now you're talking about it, I know I could use X skill for, you know, when people are transphobic towards me, or when people do, do X behaviour, but no one ever told me, so I never sort of made that link. And, there's a really big, you know, the whole function of phone coaching, for example, but also just, generally an emphasis on generalisation in DBT and making sure we're helping people generalise and not assuming that they naturally would generalise the skills to all relevant contexts. So, that was another really important point that was pulled out that therapist generalise and help your clients like scaffold their ability to generalise where you can. Another area was they were saying you know, actually, sometimes the skills needed a little bit of extra something to help with LGBTQ specific areas. So, you know, if I'm navigating trying to come out or, I'm navigating trying to challenge someone on, say, transphobia or something, it's probably going to have to have an extra couple of steps or layers in it that are going to be really important for that skill to be applicable. So one of the biggest examples of that was the consideration around safety and how you build safety into skills practice. Because of course, yes, it might be great for me to say, yeah, sure. Be assertive, go assert your needs. But if you've got a risk of say, being harmed physically or killed at worst, like you, You probably want to weigh that up, before you do that. And that's super important to do. So some of the stuff just needs a little bit of like extra thought or augmentation in order to make sure people are safe. So that was the main stuff. Final bit, which was creating safety, super important. A lot of the young people said it was a lovely safe space. So that very much warmed my heart to know that they found it, DBT, a relatively safe space, and the way they described that, as I said, it felt very open, non-judgmental, very accepting, which is the spirit of, there's a lot of Zen philosophy that's built within DBT, and of course, therefore, the spirit of stuff is genuinely and radically accepting people for who they are and that sort of wonderful, innate wisdom that they have, so that came through which was nice and that's extra needed. So again, another tip for therapists is you know, as Queer people we experience a lot of messages about change in our lives. So we're told from a very early age that there's something not quite right with us or unacceptable, and that therefore we need to change ourselves, you know, in very subtle and explicit ways as well as people explicitly saying you should be straight or you should be cisgender or, or so forth in, in much less nice ways than I just said it. So therefore, it's really important for people working with LGBTQ people to lean much more on their acceptance and validation side of skills, because you really want to, you need to sort of outdo the balance of all the change based messages that we have in society, in order to make us feel a bit more safe. So this came through a little bit in that feedback. Other stuff with creating safety was just things like making sure confidentiality is clear, like who, where are you going to record this information about my sexual orientation and gender, and where is it going to end up? making sure that you display safety signals, so some of those are like environmental safety signals, like pride symbols, diverse examples in content, some of it might be policy based safety signals to make sure there's like, like policies in place for those where that becomes, visible to, or is necessary. Making sure that you model diversity within your team, of course, ideally, and disclose if you feel comfortable doing so, although actually, we, we think that that's super important. If you're asking your young person to disclose, it's possibly quite important that you're willing to do, you know, what you're asking of, although I know that that doesn't fit for, for all models. yeah. And just sort of making sure that we're cautious around sort of inclusive language, like on forms in person as well. So get rid of that other section, you know, in, in your social demographic forms, because it's very othering. It's really problematic. It should be preferred to self-describe with the option to self-describe or ideally you just have all of the categories, making sure you do ask about sexual orientation, gender identity in forms and in therapy, because of course context, identity, it's all very important to the work and the lens of which we see the world. And if I go somewhere and on the form I see they're asking me about gender and sexual orientation, usually it's a good sign, like, hmm, they're being thoughtful about me and, people like me. Even better if it doesn't just say male, female, other, Because I'm like, uh, you know, I don't quite fit any of that, which, makes me immediately feel slightly not welcome there. So, hence the, you know, subtle and subtle things like that, that are quite small changes, can make a big difference, and the young people really commented on, they loved pronouns being announced and disclosed by clinicians and put in emails, they loved the sociodemographic form, being very inclusive, they loved rainbow lanyards, you know, all of those things that just help people feel a bit more safe in the environment. Steph: Was it important to the young people that their therapist, wasn't just a straight cisgender person or did that not matter to them so much as long as they were accepting of who they were? Jake: Yeah, this is a good question because, of course you see in ethnicity and race minoritised groups that, that, that ethnicity or race based matching actually has a really positive effect. in other research around LGBTQ+ stuff, the sort of idea currently suggests that actually you don't need to match based on gender or sexual orientation, as long as you are overtly and relatively overtly, accepting. albeit, there may be benefits, of course, for people feeling a bit safer, maybe, if they see someone who's overtly queer or quirky or, you know, something that just communicates that they're likely, thoughtful and accepting in this area. The young people I interviewed didn't massively comment on this because what they spoke more about was it was just super important that their therapist was really overtly accepting. Because they did say that, One of the biggest barriers to safety was thoughts about and expectations that they generally would just be rejected or judged negatively as a queer person by their therapist or their team once they did know. And of course, nearly all of them said, but when I did come out, it was received so well that, it was great. but that worry was there and, you know, and I can testify to that as a queer person, that worry is always there for me. There's like a sort of standard, cognitive, automated process that's in any new interaction with a person is immediately like, they are more likely to reject than not, you know, sort of thing, which of course, thankfully, many behavioural experiments and exposure to us later, mostly doesn't come true nowadays. But yeah, so that was very present for the young people. Steph: And one thing that we touched on right at the beginning when we started talking about the paper was, being able to listen to the young people and, you felt very privileged to hear their thoughts and their experiences. And, one thing that really came across to me was you put little excerpts of the transcripts in throughout the paper to, highlight certain points, for example, when they've been feeling not accepted with regards to their identity and things like that, just a comment really that I wanted to make was how articulate a lot of them came across and actually, it must have been really lovely to hear some, I mean, heartbreaking sometimes, but also really lovely. I work with a lot of adult clients, and some of them can't so articulately explain, I feel othered because this happened to me or my therapist misgendered me or assumed I was straight. And that made me feel like this because, and that really came across, I think, in just the small excerpts of just how articulately could be and, really in tune, I think, with their feelings and their experiences. Jake: Yeah, no, they did, you know, an absolutely wonderful job. And some of them did comment on, they felt like they had, really learned a way to describe their experience a lot through the work in DBT, because of course, a lot of our mindfulness practice is about how to observe and describe experience. It was very hard, at a similar point to like, you know, all the information fitting into themes, to cut the quotes, because some of the quotes were so beautiful in how they described, you know, of course that's a judgement, but like, how they described their experience, I just wanted to keep them all. It went through a really, like, challenging process to cut them down to what was necessary, of course, for the reader, to see what was the sort of best quote to, to articulate that particular theme. But they did an absolutely wonderful job. I sometimes, and this is, of course, an assumption, not based in empirical evidence, but, you know, my assumption is that the generation, Gen Z, as they're often called now, that sort of generation that I was interviewing tend to be a lot more, well versed in areas of sort of equality, diversity, and inclusion in such a lovely way, that I think they're a lot more thoughtful about it, because I, for example, I never come across the word, like, heterosexism or internalized homophobia or any of that stuff until I started research. But yet, some of them were saying to me, without me even mentioning those terms, like yeah, that's heterosexist, or like, you know, that's so, you know, it's interesting, they've definitely picked up a lot more on some of that language. Steph: So I think you've probably answered a lot of this, but what do you think the implications of your study are for the world of CBT? What impact do you want it to have made? Jake: I've obviously been peppering some of the recommendations throughout, so, not to overly duplicate those, but certainly to say that, like, Yeah, absolutely. I, I think there is a bit of a problem with how we meet the needs of LGBTQ+ people in services, or at least how safe it feels to just access services. So, from that standpoint and the fact that there's huge health inequalities, I think generally we should come from the default position as therapists as we probably need to do better for this group and we're still probably not fully meeting their needs I mean we may be but I would say it's better to come from that default point and therefore I suppose this paper is to like invite us to take a non-defensive fallible stance which is very much part of DBT sort of agreements and spirits is like, it's okay to be fallible. We're human, of course, we're going to make mistakes and, we need to learn from them and, still find our blind spots and so forth. So I think I would love it if, therapists would go away and, and reflect on, similar to anti racist principles, right, reflect on their blind spots, their privilege, think about, where they need to learn stuff, where they don't, educate themselves, and of course, yes, sure, you're, like I said in the paper, your clients are well placed to educate you, of course. And at the same time over relying on minoritised individuals to educate you about their oppression and minoritization is very exhausting, it's very burdensome. So unless you've got a lovely, willing, queer person in front of you who wants to give you, the lowdown of that is to try not to over rely on that, and it's to try to rely on finding your own sources, of information and checking those things out. So I think that's really important. I think therapists, I would say, to ensure that they use much more of those acceptance validation principles where possible, as I explained earlier, to try and undo those sorts of heavy change based narratives and ideas that, that sort of exist in society. Accept that identity and especially these areas of identity are very fluid at times for some people, not for all, but not to invalidate that, therefore, you know, say someone. I don't know, identifies as bi now, maybe heterosexual or gay later, you know, vice versa, or any other iteration of that, that that means that any of those were not, valid or that at times that it's really, being okay with, with that change and that fluidity, still asking about it, still checking out, of course, being accepting of people because that's sort of the biggest problem is that it comes from lack of acceptance or sort of judgments of LGBTQ+ people. Trying to include context and minority stress in formulations and in interventions I think is a really important one as well because of course often our difficulties don't arise, in isolation of context and experience and, I think it's really important that we consider how, you know, say being LGBTQ+ how that's in some ways interacted with, the events or situations or experiences that have led up to the difficulties that I'm experiencing. So just being mindful of that and, trying to, as I mentioned earlier, consider safety with clients. So, you know, whenever you're trying to do work around this stuff or generally, just making sure that there's not really rational, justifiable, safety concerns that, may come up and try not to invalidate that. So I think that's some of the general stuff. I think that's definitely important stuff. Like I mentioned around creating safety. So get those safety signals out there. Like, you know, you want as much of that as possible. the overt stuff, model and disclosure, pride symbols, even just asking about it, like what I mentioned on forms or in assessments or so forth, you know, our safety signals asking is important because, of course, otherwise people just assume often, cisgender and heterosexuality. I think that that's fine if you're cishet, but that is not fine, you know, if you're LGBTQ+ of course, ask in a way that feels developmentally appropriate and, you know, feels, appropriately tentative that sort of communicates very clearly. You do not need to tell me if you'd rather not. But actually I'd love to know a bit about you, who you are, your context, you know, that's gender, sexual orientation, culture, race, religion, tell, give it all to me and know that there's some sort of explicit or implicit invite that if that stuff feels important, that's very welcome in this space. Being overtly, nonjudgmental and part of the ways to of course, position yourself like that. Knowing that social connection and connectedness is really important for this population. So that might be a good area to focus, say your behavioural activation or, whatever other work that you're, you're doing with someone and make efforts to try and get pronouns, correct, and disclose them. And if you get them wrong, non-defensive, fallible stance, and try your best in future. Of course. The thing is, is pronouns of course are, about gender and they are starting to become a bit more of a universal signal for I'm on board with and supportive of LGBTQ+ culture, that is a very easy augmentation to make in regards to disclosing your own in emails or at the start of meetings, and asking people for what they prefer to be used. And of course, if you're not used to using They/Them pronouns, or something similar, it's okay, practice. Like, language shifts and changes all the time. I tend to just prefer, from a sensitivity point of view, to remain relatively gender neutral about everything I'm talking about, until I know otherwise just because then there's less risk, of causing harm. So yeah, so, important. And obviously if people do want to bring this stuff to therapy, it's about trying to make sure that you show them what's possible and what isn't. And part of the principles that I often think about with this is like, what is your remit to treat.? And what are they, what do you have permission to be working with or treating in therapy? And actually, if your client isn't giving you permission to go near that stuff, that's okay, don't go. Like, you can invite it, you can ask for it, but you don't need to go there. Just because, say, you see them and you judge that maybe they are LGBTQ+ or assume that, you know, it doesn't have to be bigger than they want to make it, type thing. So being led by your client, of course. but inviting space because you are the person in power. So, you've got the sort of, you know, the more powerful privileged position in the therapy room. And therefore, you need to lead in some ways and show, you know, equalize the playing field a bit by showing that there's space for this stuff. But if you can and, and the person wants it and thinks it's important, absolutely collaboratively negotiate, build it into the therapy, whether that's just formulation, whether that's in some of the work you do, whether that's just in some side talk about people's lives and what goes on. It's just, acknowledging that for some it's important, for some it's not, and that's okay too of course. And final tip I suppose is just say that of course none of this is in isolation of intersectionality with other areas of minoritised characteristics and therefore some of the beauty of that is really being able to have really lovely rich conversations about other areas of difference or identity and how these things intersect and, you know, how, how that person sort of makes sense of their world through that lens. Steph: That's all really, really wise and insightful. So thank you so much for all of the thoughts and for sharing. Two last questions I have before I let you go and get back with your day. the first was, if you had to do this study all again, is there anything you'd change or anything you'd do differently? Jake: Hmm, good question. I mean, what I would love to do is, this was very specific of course to the program I work in, which is a national program, so to some degree has a slightly more wide-reaching population, than maybe a local clinic but I would love for something that's a little more widespread in regard to DBT programs, etc. So, that would definitely be one thing. I think the other thing that probably needs to be done, and it has a little bit, there's some studies out there, is that I think gender and sexual orientation here made sense to keep together as an ideology, because the way the young people spoke about it made a, you know, they didn't speak about those two things in isolation really much. So they felt very intertwined in regards to experience and difficulty, and yet there's going to be very specific potential, needs and adaptations for sexual minorities that may be the same or different from gender minorities. So, you know, I would also have loved to have gone out there and got a nice group of gender minority young people who have been in DBT, get their views, and then same sexual minority. And yeah, thankfully in my program I've researched the sort of next steps, some co production work to try and build a bit of an augmented, or sort of optimised, part of the treatment or component of the treatment, that can be easily built into the model and, I'm really hoping to get a bit more opportunity to sit down with lots of wonderful, young people who, you know, willing to give their time to sort of help build this and for us to use as therapists. So, that's, that, that's what I'd love to do too, but that's what I'm planning to do next as well. Steph: So that leads into my very final question then for you, which was, what can we expect from you next? I know that you've had a couple of papers in both of the journals, which are in progress so what can we expect to see from you? Jake: Yeah so this was sort of the foundational program of research really to sort of build on so that includes, this paper, which was the centre of the voices of young people, one of the papers that's coming out soon is, disaggregating outcome data from DBT for different gender and sexual orientation based groups to check quality of outcomes that should be out there soon. And a number of other projects that are side projects in other areas of equality and diversity. So, you know, we've just published one which is around people from race and ethnicity minoritised groups speaking about ethnicity, race and culture in DBT and how, to try and, support the work in building on anti-racist principles in DBT, and also stuff around autistic young people in DBT. So there's a paper recently published on disaggregated outcomes, and then we've got another qualitative piece of work ongoing, which is trying to get the experience of autism, autistic young people in DBT to try and optimize that. So I think there's really nice learning from across those groups that can be pulled together. So it's why I like to not keep it specific to LGBTQ groups. So that, that are the ongoing bits. The next step of the program of research is there's a small side project to think about implementing adapted DBT skills training for trans or gender diverse people that's outside of the NHS because of course, you know, the NHS is riddled with sadly systemic transphobia and so forth that means that it's not the most accessible system, to say the least for this population. So trying to get DBT into more safer community based organizations. So that's a lovely side project that's going on. And then I'm hoping to do some co production and piloting work for sort of augmented slightly adapted version of, of DBT principles and skills. We can easily pull into DBT and other models as well, hopefully, for specific dilemmas that have been brought up by the young people in this paper. So that's the next stage and hopefully will be out soon. Steph: I'm really looking forward to seeing this research coming out Hopefully you can come on again and talk about some further research when it's published and the results from that. So, Jake, thank you so much. Jake: Thank you. Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts. If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at podcasts@babcp.com. And why not check out our sister podcast. Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT. Thanks for tuning in, and I'll see you next time on Research Matters. Bye.