Metacognitive therapy (MCT) offers a distinctive approach to case conceptualization based on the self-regulatory executive function (S-REF) model and the cognitive attentional syndrome (CAS). This review examines how metacognitive formulation can organize clinical presentations involving overlapping diagnoses, shifting symptom content, and multiple competing explanations. The paper does not propose that clinical complexity creates a special difficulty for MCT or that diagnostic information is clinically irrelevant. Rather, it considers how diagnostically distinct problems may involve overlapping patterns of worry, rumination, threat monitoring, maladaptive coping, and metacognitive beliefs. The review clarifies the distinction between the cognitive-attentional components of CAS and the metacognitive beliefs that regulate them. It also examines potential departures from metacognitive formulation, including prolonged engagement with symptom content, the misclassification of coping strategies, the use of MCT techniques for unintended functions, and the equation of insight with therapeutic change. Clinical content, developmental history, interpersonal context, culture, and actual environmental threat remain relevant to assessment and treatment planning; the distinctive contribution of MCT concerns the mechanisms selected as direct therapeutic targets. The paper also compares MCT with Beckian cognitive behavioral therapy and the intolerance-of-uncertainty model to clarify areas of overlap and the specific theoretical and therapeutic commitments of metacognitive formulation. By articulating the assumptions, scope, and clinical implications of metacognitive case conceptualization, the paper aims to clarify how the S-REF model can contribute to the formulation of complex clinical material while remaining compatible with diagnostic assessment, contextual understanding, and collaborative treatment planning.
Self-talk can carry reports, predictions, global evaluations and rules for action, so distressing internal cognition is not therapeutically homogeneous. Cognitive Therapy (CT), rational emotive behaviour therapy (REBT) and Logic-Based Therapy (LBT) already provide sophisticated methods for examining evidence, inference, evaluation and pragmatic consequences. This critical integrative review develops the Socratic Three Filters (S3F) as a formulation-sensitive scaffold for organising, rather than replacing, these established operations. Truth concerns epistemic adequacy: what kind of claim is made and how strongly it is warranted. Goodness concerns evaluative-relational adequacy: whether a cognition evaluates self, others or circumstances specifically and proportionately rather than through global condemnation or rigid demands. Usefulness concerns pragmatic-functional adequacy: what continued attention, rehearsal, belief or action from the cognition accomplishes over time. The distinctive proposal is configurational: discordance among the three domains may clarify which aspect of a cognition warrants therapeutic attention and thereby orient selection of an established intervention. S3F is not an evidence-based treatment or established mechanism. Its incremental value over skilled cognitive-behavioural practice remains an empirical question requiring direct testing.
OCD is a chronic and debilitating condition. The number of individuals who partially respond, do not respond, or relapse with first-line treatments is substantial. Recent findings indicate that early maladaptive schemas and schema modes may contribute to the development and maintenance of OCD symptoms, highlighting the importance of schema-based interventions. This systematic review aimed to synthesise emerging evidence on Schema Therapy (ST) for OCD, with a particular focus on its potential to address limitations of first-line treatments and relevance within clinical and cultural contexts. The review aimed to determine its effectiveness in reducing OCD symptoms, identify commonly used techniques, and assess methodological rigour. Following PRISMA guidelines, a systematic search was performed in several databases of studies published from 2015 to 2025. Five studies (one randomised controlled trial and four quasi-experimental/pilot studies) met the inclusion criteria for qualitative synthesis. ST, administered as a standalone intervention or in conjunction with ERP, was associated with reductions in OCD symptoms as well as improvements in maladaptive schemas. However, the evidence is limited because of small sample sizes, insufficient reporting of techniques, lack of systematic evaluation of treatment fidelity, and short-term follow-up. Cultural factors were not systematically examined. Preliminary evidence suggests that ST may be a useful adjunctive or alternative intervention for OCD. It may offer clinically meaningful advantages by addressing underlying vulnerabilities and potential barriers to treatment engagement. However, methodological limitations, heterogeneity and lack of cultural considerations restrict definitive conclusions. Future research should prioritise large-scale trials, standardised protocols, and culturally informed adaptations.
Clinicians frequently encounter clients who remain psychologically stuck despite insight, skills training, and repeated efforts to change maladaptive thoughts. The present article proposes that such difficulties may reflect not the content of thought but the manner in which thought is engaged within ongoing experience. Drawing on a process-based framework, psychological experience is understood as continuously generated and reorganized through interactions among interpretive activity, experiential rendering, and homeostatic regulation. Within this framework, a distinction is introduced between relatively effortless, self-resolving thought and effortful, recursive thinking sustained through attention. Persistent distress is proposed to be associated with the latter mode, which contributes to experiential constriction characterized by repetitive interpretation, emotional intensification, attentional narrowing, and reduced behavioral flexibility. Therapeutic change is understood as involving increased flexibility in the relationship to thought and emotion rather than modification of cognitive content alone. The framework is discussed in relation to contemporary process-based and experiential approaches to psychotherapy, and implications for clinical practice are considered.
In psychotherapy, the clinical value of an intervention depends not only on whether it is theoretically indicated, but on whether the patient can make use of what it evokes. This question becomes decisive when therapists deepen emotional exploration, initiate exposure, interpret relational patterns, confront avoidance, or slow the work down. Apparent readiness can be misleading. Patients may present as articulate, motivated, and psychologically minded while losing reflective contact once treatment begins to place pressure on familiar ways of maintaining stability. This article introduces psychological holding capacity as a treatment-focused estimate of whether therapeutic challenge is currently usable. The concept refers to a provisional clinical judgment about the patient’s ability to continue thinking, feeling, and remaining in therapeutic contact when psychotherapy mobilizes affect, conflict, uncertainty, dependency, or change. Psychological holding capacity is distinguished from adjacent constructs by its specific focus on intervention usability: whether relevant psychological functions remain sufficiently available under the demands introduced by a particular therapeutic intervention. The article outlines observable clinical markers and proposes a calibration framework for intervention planning. Its central claim is that an intervention is not usable simply because it is technically correct. It becomes clinically usable when the patient can remain organized enough to process what it sets in motion.
Acceptance and Commitment Therapy (ACT) is a contextual intervention that targets psychological flexibility rather than symptom elimination. Its effectiveness for psychosis compared to active treatments is unclear. This study analysed the results of randomized controlled trials (RCTs) comparing ACT with active interventions for psychosis. Searches were conducted in PsycINFO, Scopus, and Web of Science up to February 2025 (PROSPERO ID: CRD420250653645blinded). Eligible studies compared ACT with active conditions and reported outcomes on social functioning, quality of life, rehospitalization rates, psychological flexibility, psychotic symptoms, and affective symptoms. Eleven RCTs (N = 606; 65.1
Contemporary psychotherapy approaches increasingly converge on shared explanatory principles and change processes, while retaining distinctive theoretical roots.This narrative review aims to identify the shared components and different features of Compassion-Focused Therapy (Gilbert, 2005), Acceptance and Commitment Therapy (Hayes et al., 2012) and Internal Family Systems Therapy (Schwartz 2013a). To do so, each model’s theoretical foundations, clinical principles, intervention targets and core procedures is presented and compared. The approaches all foreground mindfulness, acceptance, and compassionate self-relating as central pathways to change. They differ, however, in their conceptualization of psychopathology, the role of psychoeducation, the degree of therapist directiveness, and the clinical functions assigned to mindfulness-based practices. These findings suggest that clinicians aiming to cultivate mindfulness, compassion, and acceptance can select among multiple evidence‑based frameworks considering their therapeutic orientation and interpersonal style.
Health anxiety is often maintained by maladaptive cognitive and behavioral strategies, including catastrophic interpretations of bodily sensations and compulsive checking. Although existing interventions effectively reduce symptoms, less attention has been given to the experiential and integrative processes underlying these difficulties. This case study illustrates the application of experiential-unifying psychotherapy in a 22-year-old male presenting with severe health anxiety and compulsive blood pressure monitoring. The intervention aimed not only to reduce symptoms but also to facilitate emotional processing, symbolic expression, and relational integration through experiential techniques, including metaphor-based interventions, gradual body awareness, and a paradoxical behavioral strategy targeting compulsive checking. Over the course of therapy, the client demonstrated complete cessation of checking behaviors, reduced anxiety, increased emotional awareness, and improved functional and relational autonomy. These findings suggest that experiential-unifying psychotherapy may promote therapeutic change by addressing the fragmentation of experience and fostering psychological integration, highlighting the value of integrative interventions that engage cognitive, emotional, bodily, and relational dimensions in the treatment of complex anxiety presentations.
Mentalization-Based Therapy for adolescents (MBT-A) has been shown to be effective in reducing personality pathology following acute treatment, but less is known about the long-term effects of MBT-A and whether benefits are sustained. This study used a multi-informant, multi-domain approach to examine outcomes up to 2-years post-discharge for 118 young people completing MBT-A who attended an inpatient programme at a Centre for Child and Adolescent Psychiatry Triversum, The Netherlands. Outcome measures included personality pathology dimensions, health-related quality of life and general psychiatric symptoms. Findings revealed that improvements reported post-treatment were maintained up to 2-years post-discharge in many domains. Clinically meaningful changes in measures were also maintained, with benefits observed in areas including self-harm, affective instability, emotion dysregulation as well as quality of life and symptoms of depression and anxiety. These results suggest that MBT-A is effective in providing long-term gains for adolescents with personality pathology. Replication of this study in further clinical settings and with an appropriate control group is needed to further demonstrate the long-term effectiveness of MBT-A.
Symptom reduction remains a central endpoint in psychotherapy, yet it provides an incomplete account of therapeutic benefit, particularly with respect to durability, generalization, and relapse vulnerability. This paper advances a process-based theoretical framework specifying how therapeutic change becomes retained and functionally expressed beyond symptom relief through the development of psychological capacities. Psychological capacities are defined as relatively enduring and context-sensitive patterns of adaptive responding that emerge through repeated cycles of therapeutic learning and remain accessible across changing contexts (e.g., attentional regulation, psychological flexibility, values-based action). The framework distinguishes proximal mechanisms of change from longer-term capacity development, proposing that therapeutic processes contribute to durable recovery insofar as they strengthen capacities that support adaptive functioning under real-world conditions. By positioning psychological capacities as the retained level linking mechanisms of change to long-term adaptation, the model reframes outcome evaluation toward the stability and contextual expression of adaptive functioning rather than symptom change alone. The framework further generates testable predictions regarding long-term outcomes, assessment, intervention design, and relapse prevention.
The primary objective of this article is to present a conceptualization of grief complications and its therapeutic approach from an Emotion-Focused Therapy perspective. Prolonged Grief Disorder affects a significant amount of individuals who experience psychological, social, or physical difficulties. Although interventions based on cognitive-behavioural models have demonstrated efficacy, they are not effective for all bereaved individuals (Wittouck et al., 2011), highlighting the need for alternative therapeutic approaches. EFT offers a conceptualization of grief complications, grounded in the description of the emotional processes’ characteristic of prolonged grief, including problematic self-treatments, and core emotional pain. Its main therapeutic goal is to transform painful primary emotional experiences linked to the loss of the other and to the relationship with the other when they were alive —such as fear (e.g., not being able to function without the other)—through accessing adaptive primary emotions—mainly connection and the adaptive grieving of loss. The paper offers a description of emotion-focused therapeutic work with prolonged grief accounting for possible complications in experiencing adaptive emotions, the type of relationship with the deceased, and the nature of the grief complications, etc.
Schizoid personality disorder (SZPD) is a complex personality disorder with little, sometimes just anecdotal, evidence informing its treatment. The aim of this study was to document the availability and effectiveness of psychosocial treatments of SZPD. A systematic literature review identified 7794 publications, of which only nine met the study inclusion criteria. A paucity of high-quality treatment evaluation research for SZPD was found, with mostly non-empirical clinical descriptions and observations. Still, some promising treatments focusing on cognitive, behavioral, and psychoanalytic processes are described. There has been insufficient research to propose evidence-based treatment recommendations for people with SZPD. An interdisciplinary effort between clinicians and researchers is needed to develop, test and disseminate specific, adapted and accessible interventions.
In this article, I will trace my development as a psychotherapist from my childhood experiences to my present-day interest in single-session therapy. My main theoretical allegiance has always been to Rational Emotive Behaviour Therapy, a ‘second-wave’ approach to cognitive behavior therapy that is currently neglected by the CBT tradition as it continues to embrace ‘third-wave’ approaches. I will explain why I have remained ‘faithful’ to REBT for all these years, while always striving to bring my personal stamp to its practice and to everything I do in the world of psychotherapy.
This article describes a professional journey in the field of clinical suicidology that led to the creation and the development of an evidence-based, suicide-focused, clinical treatment called the “Collaborative Assessment and Management of Suicidality” (CAMS). Several professional challenges and successes are described along with personal experiences that have shaped this approach to working with suicidal risk. Some reflections and lessons-learned about effective psychotherapy are proffered based on over four decades of work as a clinician, researcher, teacher, and supervisor. It Is argued that evidence-based, patient-centered, psychotherapy that stresses empathy, collaboration, and honesty is an ethical and professional imperative for providing effective care and realizing optimal clinical outcomes.
Substance use disorder (SUD) is a profound clinical challenge for justice-involved individuals navigating community corrections, where severe environmental stressors frequently hinder psychotherapeutic recovery. While effective treatment relies heavily on foundational psychological pillars like self-control and self-efficacy, the intricate mechanism translating self-regulation into authentic recovery confidence remains complex. Consequently, this study investigated resilience and self-esteem as modifiable mechanisms connecting self-control to self-efficacy among high-acuity justice-involved clients. A cross-sectional survey was successfully administered to 312 adults undergoing SUD psychotherapy under community supervision. Participants exhibited severe clinical profiles, with 97.8
The field of psychotherapy advances through an integration of theory and research, combined with actual clinical practice. Each year, numerous journal articles are published that examine issues related to mental health care. The Journal of Contemporary Psychotherapy hosts the annual Psyche Awards in an attempt to identify, highlight and recommend the best articles published in the previous year. The contents of 177 academic journals were scanned for articles that focused on issues related to psychology, psychopathology or psychotherapy. The three-stage selection process identified 79 interesting papers that were then evaluated more closely using seven criteria. A final list of 35 recent articles were sorted into eight award categories with 4–5 nominated articles within each award category. Two additional awards were used to highlight older papers that have had lasting impact on the field and to show respect for several of the forgotten pioneers in the field of psychotherapy. A panel of panel of judges read and rated each article to identify the most valuable article within each category. The present article highlights the award process as well as the most valuable articles published during the previous year.
Objective Disclosure of a personality disorder (PD) diagnosis is a clinically sensitive moment that may influence patients’ engagement with treatment, identity, and therapeutic relationships. Despite its importance, little is known about how patients themselves experience and interpret this process within specialized psychotherapies. Methods The present study explored how patients in Transference-Focused Psychotherapy (TFP) experience and make sense of receiving a PD diagnosis. Using a qualitative design, we analyzed written accounts from 17 patients engaged in TFP. Data were examined using reflexive thematic analysis. Results Participants described diagnostic disclosure as a complex and emotionally charged experience that evoked a wide range of reactions, including fear, relief, curiosity, and validation. Most reported an ambivalent relationship to the diagnosis, with its meaning evolving over time through therapeutic work and reflection. Six themes captured how patients understood and integrated the diagnosis into their therapeutic experience. For many, the diagnosis initially disrupted self-narratives and was experienced as an external verdict; however, over time it often became a framework that helped organize distress, support self-understanding, and guide therapeutic change. The relational context of disclosure emerged as central: when communicated within a supportive therapeutic relationship, the diagnosis was more often experienced as meaningful and containing rather than stigmatizing. Conclusion These findings suggest that diagnostic disclosure in PD treatment functions not merely as the communication of clinical information but as a relational and meaning-making process embedded in psychotherapy. Understanding patient experiences may help clinicians approach diagnostic discussions in ways that support engagement, reflection, and therapeutic collaboration.
Insomnia following trauma exposure is strongly intertwined with posttraumatic stress disorder (PTSD) yet frequently persists despite successful trauma-focused treatment. This clinical review reframes trauma-related insomnia as a disorder of threat perception in which nocturnal wakefulness is maintained by conditioned fear of sleep-related cues, heightened monitoring, and impaired safety and extinction learning in the sleep context. Drawing on clinical research in PTSD, emotional learning and memory, and behavioral sleep medicine, the review describes how hyperarousal, fear of sleep-associated vulnerability, biased interoceptive appraisal, and safety behaviors perpetuate insomnia and nighttime distress. The review translates this framework into trauma-informed adaptations of cognitive behavioral therapy for insomnia (CBT-I), emphasizing (1) stimulus control as graded safety/extinction learning, (2) sleep schedule stabilization delivered with careful titration and collaboration, (3) reduction of monitoring behaviors that function as safety strategies, and (4) targeted integration of nightmare-focused interventions when indicated. Evidence from randomized trials and clinical studies suggests that treating insomnia—either prior to or alongside trauma-focused psychotherapy—improves sleep outcomes and may enhance PTSD symptom reduction, treatment engagement, and retention (Pigeon et al. in Psychother Psychosom 91(1): 50–62, 2022; Taylor et al. in J Trauma Stress, 36(4): 712–726, 2023). The review concludes with assessment considerations, differential diagnosis (including trauma-associated sleep disorder), and research directions for testing trauma-specific CBT-I adaptations.
Depression is a prevalent and complex condition that often requires approaches beyond single-model interventions. This study describes patterns of therapeutic change across five cases of Major Depressive Disorder treated with an integrative psychotherapy approach combining cognitive-behavioral, analytical, and existential principles. A retrospective clinical case series design was used, with data derived from psychotherapy records and analyzed through reflexive thematic analysis. Across cases, change followed a progressive and recursive pattern. Early stages involved improved cognitive regulation and behavioral engagement, followed by greater emotional responsiveness and reorganization of relational patterns. Symbolic processes, particularly through dreams and imagery, supported the integration of previously unarticulated experiences. In later stages, participants engaged in meaning reconstruction, reflecting increased autonomy and alignment with personal values. These findings suggest that psychotherapy may operate as a multi-level process and highlight the potential of integrative approaches in addressing the complexity of depression. This study shows that psychotherapy for depression may be more effective when organized progressively, beginning with cognitive and behavioral stabilization and moving toward deeper emotional and meaning-focused work. It highlights how integrating techniques across different levels of experience can support more sustained and meaningful change in clinical practice.
