Depersonalisation (DP) and derealisation (DR) experiences can cause clients and therapists a lot of confusion and anxiety. Therapist confusion has led to the under-recognition of DP and DR symptoms, under-confidence in working therapeutically with this client group and unequal client access to effective cognitive behavioural therapy (CBT) interventions. Client confusion has resulted in missed opportunities to engage in meaningful discussions with therapists about their DP and DR experiences and under-confidence that CBT can be of help. This article seeks to provide clarity for clinicians and clients around key misconceptions we have identified from the authors' clinical experience of using CBT to treat DP/DR, both when presenting as symptoms in the context of other diagnoses and when presenting as a primary depersonalisation derealisation disorder (DDD). In addressing symptom misconceptions, we want to increase clinicians' confidence when assessing DP and DR. We hope this will lead to productive discussions with clients and the inclusion of these symptoms in clinical formulations. We draw attention to client misconceptions in the hope that this facilitates better therapeutic dialogues about DP and DR and the potential benefit of CBT. Finally, we address therapist misconceptions about the use of CBT with this population in the hope that we can encourage more CBT therapists to work more proactively, confidently and effectively with DP and DR.Key learning aims To help therapists better recognise depersonalisation (DP) and derealisation (DR) symptoms when in the context of another disorder and when presenting as primary depersonalisation derealisation disorder (DDD). To recognise therapist misconceptions leading to under-confidence in working with clients whose presentation includes symptoms of DP/DR and/or diagnoses of DDD. To understand misconceptions clients might hold about their DP and DR experiences and how these may impact engagement with CBT. To help therapists engage with clients in helpful discussions about the effectiveness of CBT to help with DP and DR, both when experienced in the context of another disorder and when conceptualised as DDD.

Background: The high prevalence of childhood sexual abuse (CSA) in India is a cause for concern. Survivors of CSA often experience psychosocial difficulties in their adult lives. Whilst their difficulties are partly recognised in India, there is a need for further exploration on the availability and access to support.Objectives: We explored the views and experiences of adult survivors of CSA in India on different types of treatment and support.Method: We conducted semi-structured interviews with adults who were sexually abused before the age of 18. The data were analysed using reflexive thematic analysis, followed by narrative analysis of two transcripts.Results: We interviewed 10 adult survivors of CSA in India. All participants were female with formal education. We conceptualised their recovery beginning with initial introspection and reliance, for example, on artistic and animal-assisted avenues. This is followed by seeking informal support, and, for some, seeking more formal support. Some also sought help through public figures, social media and Government initiatives and/or from their faith communities. We have further presented two narrative summaries explaining the genre, tone and core narrative of participants' experiences.Conclusion: Our findings suggest that these adult female survivors of CSA in India predominantly relied on their own coping strategies in the absence of holistic support. This was pronounced due to the dearth of mental health and social care for those who have experienced CSA in India. Future research needs to focus on understanding the meaning and language of CSA to enable the development of culturally tailored interventions.

Developmental trauma (DT), defined as abuse or neglect before age 18, is linked with elevated risk and poorer outcomes in psychosis. This systematic review aimed to elucidate the relationship between DT and dissociation in psychosis and discern the potential mediating role of dissociation in the link between DT and psychotic manifestations. Our study protocol was pre-registered with PROSPERO (CRD42022330026). We adopted broad criteria, including a variety of methodologies exploring dissociation post-DT in individuals exhibiting psychosis or psychotic features. Risk of bias was assessed for all included studies. Our review incorporated 40 studies, totalling 6941 participants. A significant moderate association was observed between DT and dissociation (r = 0.33 (95 %CI: 0.28-0.38)), underscored by dose-response effects. Sexual and emotional abuse demonstrated the most robust associations with dissociation. Individuals with psychosis and DT reported elevated dissociation relative to their non-traumatized counterparts. Dissociation mediated the link between DT and positive psychotic symptoms, notably hallucinations, across clinical and general populations. Five studies pinpointed dissociation's mediating role in tying DT to paranoia and delusional ideation. The review delves into clinical considerations, emphasizing screening for psychotic and dissociative symptoms in DT survivors, and outlining dissociation management strategies. Future research, employing longitudinal, qualitative, and experimental approaches, remains paramount.

People who have experienced trauma, especially adult survivors of childhood sexual abuse (CSA) are at risk of experiencing subsequent emotional and mental health difficulties. South Asian countries have high prevalence rates of CSA and other forms of complex trauma. Despite the requirement for mental health support for trauma survivors in South Asia, their needs are poorly understood, and specific interventions are still in their infancy. We aimed to explore the views of mental health professionals and key stakeholders on the mental health and support needs of trauma survivors, especially CSA survivors in South Asia and the treatment and support available. We interviewed mental health professionals and key stakeholders from six countries in South Asia who had experience working with trauma survivors. Data were analysed using reflexive thematic analysis. We interviewed 17 professionals and key stakeholders working in Afghanistan (n = 1), Bangladesh (n = 2), India (n = 8), Nepal (n = 2), Pakistan (n = 2) and Sri Lanka (n = 2). Four main themes were developed: mental health symptoms as the tip of the iceberg; a pragmatic approach to treatment and services; systemic factors are roadblocks to trauma services; cultural beliefs and practices across communities. We found that the participants view survivors’ difficulties as a combination of mental health problems and relationship difficulties, often dominating the mass of trauma. Despite systemic barriers, they extended their services to the survivors to make them as applicable as possible to the clients’ needs. For this, they considered the clients’ context. Overall, these professionals in South Asia acknowledged that the treatment and support that should be provided to trauma survivors, specifically adult CSA survivors, have not yet been formally established in South Asian contexts. Future research is needed to inform guidance for specific communities in the South Asian context.

Background: How we adapt treatment algorithms to complex, clinically untested, difficult-to-engage patient groups without losing evidence base in everyday practice is a clinical challenge. Here we describe process and reasoning for fast, pragmatic, context-relevant and service-based adaptations of a group intervention for unaccompanied minor asylum seekers (UASC) arriving in Europe. We employed a distillation-matching model and deployment-focused process in a mixed-method, top-down (theory-driven) and bottom-up (participant-informed) approach. Prevalence of mental disorders amongst UASC is extremely high. They also represent a marginalised and hard-to-engage group with limited evidence for effective treatments.Method: Content and process adaptations followed four steps: (1) descriptive local group characterisation and theoretical formulation of problems; (2) initial adaptation of evidenced treatment, based on problem-to-component grid; (3) iterative adaptation using triangulated feedback; and (4) small-scale pilot evaluation.Results: Based on evidence and participant feedback, adaptations included minimising verbal demands, facilitating in-session inductive learning, fostering social connectedness via games, enhancing problem-solving skills, accounting for multi-traumatisation, uncertainty and deportation. Quantitative evaluation suggested improved feasibility, with increased attendance, low drop-out and symptom improvement on depression and trauma scores.Conclusions: By describing the principles under-pinning development of a group intervention for severely traumatised UASC, we contribute to the literature supporting dynamic adaptations of psychological interventions, without losing reference to evidence base. Complex and difficult-to-reach clinical groups are often those in most need of care, yet least researched and most affected by inequality of care. Pragmatic adaptations of proven programs are often necessary to increase feasibility.

AbstractSurvivors of childhood trauma are at increased risk of complex post-traumatic stress disorder (CPTSD). The Recovering from Child Abuse Programme (RCAP) is a cognitive behavioural therapy (CBT) group promoting adaptive coping strategies which may help overcome CPTSD symptoms in adult survivors of childhood trauma. We sought to explore patient experiences of factors influencing treatment acceptability and potential mechanisms of therapeutic change in a sample of participants in the RCAP programme. As the group was delivered during the COVID-19 pandemic, necessitating a transition to remote therapy, we further aimed to capture experiences of the transition to telehealth delivery of the programme. A naturalistic sample of 10 women with CPTSD attending a specialist out-patient psychological trauma service participated in the study. Therapy sessions were recorded, transcribed verbatim and group members completed written feedback forms following each session. Reflexive thematic analysis was used to analyse the written feedback and transcripts. The RCAP was acceptable to group members and several themes were identified related to the experience of change in the group. Key themes centred on group solidarity; safety in the psychotherapeutic process; schema changes related to the self, others and future catalysed by the shifting of self-blame; increased emotional regulation to feel safer in the present; and increased future optimism. Therapeutic progress continued following the transition to telehealth, although face-to-face delivery was generally preferred. The programme was acceptable and led to cognitive change, enabling increased emotional regulation in the present and improved self-concept, thereby addressing key symptoms of CPTSD.Key learning aims(1)To identify potential mechanisms of therapeutic change related to participation in the Recovery from Childhood Abuse group CBT intervention.(2)To understand factors influencing acceptability of the group intervention among women with CPTSD to childhood sexual abuse.

Abstract Assessment of cognitive behaviour therapy (CBT) competence is a critical component in ensuring optimal clinical care, supporting therapists’ skill acquisition, and facilitating continuing professional development. This article provides a framework to support trainers, assessors, supervisors and therapists when making decisions about selecting and implementing effective strategies for assessing CBT competence. The framework draws on the existing evidence base to address five central questions: Why assess CBT competence?; What is CBT competence?; When should CBT competence be assessed?; Who is best placed to assess CBT competence?; and How should CBT competence be assessed? Various methods of assessing CBT competence are explored and the potential benefits and challenges are outlined. Recommendations are made about which approach to use across different contexts and how to use these effectively to facilitate the acquisition, enhancement and evaluation of CBT knowledge and skills. Key learning aims After reading this article you will be able to: (1) Identify key issues about why, what, when, who and how to assess CBT competence and use this framework to guide decisions about the best strategy to use. (2) Be aware of the range of methods for assessing CBT competence and consider the main benefits and potential challenges of these. (3) Consider the most effective ways to implement CBT competence assessment strategies as a tool for evaluation and learning.

Based on research from previous pandemics, studies of critical care survivors, and emerging COVID-19 data, we estimate that up to 30% of survivors of severe COVID will develop PTSD. PTSD is frequently undetected across primary and secondary care settings and the psychological needs of survivors may be overshadowed by a focus on physical recovery. Delayed PTSD diagnosis is associated with poor outcomes. There is a clear case for survivors of severe COVID to be systematically screened for PTSD, and those that develop PTSD should receive timely access to evidence-based treatment for PTSD and other mental health problems by multidisciplinary teams.

Experiencing psychological trauma during childhood and/or adolescence is associated with an increased risk of psychosis in adulthood. However, we lack a clear knowledge of how developmental trauma induces vulnerability to psychotic symptoms. Understanding the psychological processes involved in this association is crucial to the development of preventive interventions and improved treatments. We sought to systematically review the literature and combine findings using meta‐analytic techniques to establish the potential roles of psychological processes in the associations between developmental trauma and specific psychotic experiences (i.e., hallucinations, delusions and paranoia). Twenty‐two studies met our inclusion criteria. We found mediating roles of dissociation, emotional dysregulation and post‐traumatic stress disorder (PTSD) symptoms (avoidance, numbing and hyperarousal) between developmental trauma and hallucinations. There was also evidence of a mediating role of negative schemata, i.e. mental constructs of meanings, between developmental trauma and delusions as well as paranoia. Many studies to date have been of poor quality, and the field is limited by mostly cross‐sectional research. Our findings suggest that there may be distinct psy­chological pathways from developmental trauma to psychotic phenomena in adulthood. Clinicians should carefully ask people with psychosis about their history of developmental trauma, and screen patients with such a history for dissociation, emotional dysregulation and PTSD symptoms. Well conducted research with prospective designs, including neurocognitive assessment, is required in order to fully understand the biopsychosocial mechanisms underlying the association between developmental trauma and psychosis.

Background: We need to better understand the cognitive factors associated with risk for bipolar disorders. Recent research suggests that increased susceptibility to mental imagery may be one such factor. However, since this research was primarily conducted with Western students and at a single time-point, it is not known whether the relationship between imagery susceptibility and bipolar symptoms exists across cultures or within the general community, or whether this relationship remains stable over time.Aim: This study evaluated whether Chinese adults identified as being at high (HR) versus low (LR) risk of developing bipolar disorders showed greater mental imagery susceptibility. We aimed to test whether such a relationship was stable over time by measuring imagery characteristics at baseline and at the 7-week follow-up.Method: This prospective study recruited a community sample of N=80 Chinese adults screened for the absence of neurotic and psychotic disorders. The sample was split into HR (n=18) and LR (n=62) groups at baseline based on a criterion cut-off score on a measure of hypomania, the Mood Disorder Questionnaire (MDQ). Participants completed measures of imagery susceptibility and its impact: the Spontaneous Use of Imagery Scale (SUIS) and the Impact of Future Events Scale (IFES), at baseline and 7 weeks later.Results: HR group reported greater tendency to use imagery in daily life (SUIS) and greater emotional impact of prospective imagery (IFES) than LR group at baseline. These results remained stable at follow-up.Conclusion: This study provides preliminary evidence for increased susceptibility to mental imagery in individuals at high risk of bipolar disorders recruited from a community sample of Chinese adults. This extends previous research in Western student samples suggesting that imagery (both levels of use and its emotional impact) may be a cognitive factor with cross-cultural relevance that is stable over time.

'Flash-forwards' - mental images of suicide - have been reported in selected Caucasian samples. Perceptions of defeat and entrapment are considered to be associated with suicidal ideation. We aimed to investigate (1) the presence of suicidal flash-forwards in people with recent suicidal ideation versus those without such ideation in an Asian sample, and (2) associations between suicidal flash-forwards, and perceptions of entrapment accounting for suicidal ideation. Eighty two suicidal and 80 non-suicidal participants from the Hong Kong Mental Morbidity Survey completed questionnaires including suicidal ideation, presence of suicidal flash-forward images, defeat and entrapment, at baseline and seven weeks later. Suicidal 'flash-forwards' were present only in suicidal cases. People with recent suicidal ideation and suicidal flash-forwards had more severe suicidal ideation than those without flash-forwards. Compared to those without suicidal ideation, people with recent suicidal ideation reported higher entrapment and defeat levels. Resolution of suicidal ideation over time was associated with fewer suicidal flash-forwards and reduced entrapment perceptions. At baseline and seven weeks, suicidal ideation was predicted by an interaction between suicidal flash-forwards presence and perceptions of entrapment. Mental imagery of suicide appears to be associated with suicidal ideation, and may represent a novel target in suicidal risk assessment and prevention.

Background.  The impact of cognitive behavioural therapy (CBT) interventions in routine clinical practice depends on those interventions being delivered competently. Since direct observation or independent assessment of therapists’ skills are typically limited in routine clinical practice, the assessment of competence, and thus of the need for further training and/or supervision to improve competence, rests mainly on the individual therapist's self-assessment. Aims.  To examine the accuracy of therapists’ self-assessment of their CBT competence in relation to supervisors’ assessments. Method.  Self-ratings on the Cognitive Therapy Scale (CTS; Young & Beck, 1980; 1988) from two groups of trainees on established cognitive therapy training courses ( n = 64) were compared to supervisors’ ratings of the same therapy sessions. Results.  There were moderate correlations between self- and supervisor assessments, and the previously reported over-estimation of CBT skills (Brosan, Reynolds, & Moore, 2008) was not replicated in the current sample. Instead, these groups showed under -estimation of their skills compared to supervisors’ ratings, with the less-competent trainees’ ratings not being significantly different from their supervisors’ and the more competent trainees’ ratings being significantly lower than those of their supervisors. Conclusions.  Several possible explanations of the results are discussed and recommendations for ensuring the integrity of CBT delivered in routine clinical practice are made.

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BACKGROUND:The impact of cognitive behavioural therapy (CBT) interventions in routine clinical practice depends on those interventions being delivered competently. Since direct observation or independent assessment of therapists' skills are typically limited in routine clinical practice, the assessment of competence, and thus of the need for further training and/or supervision to improve competence, rests mainly on the individual therapist's self-assessment.AIMS:To examine the accuracy of therapists' self-assessment of their CBT competence in relation to supervisors' assessments.METHOD:Self-ratings on the Cognitive Therapy Scale (CTS; Young & Beck, 1980; 1988) from two groups of trainees on established cognitive therapy training courses (n= 64) were compared to supervisors' ratings of the same therapy sessions.RESULTS:There were moderate correlations between self- and supervisor assessments, and the previously reported over-estimation of CBT skills (Brosan, Reynolds, & Moore, 2008) was not replicated in the current sample. Instead, these groups showed under-estimation of their skills compared to supervisors' ratings, with the less-competent trainees' ratings not being significantly different from their supervisors' and the more competent trainees' ratings being significantly lower than those of their supervisors.CONCLUSIONS:Several possible explanations of the results are discussed and recommendations for ensuring the integrity of CBT delivered in routine clinical practice are made.

Background: As part of the UK government's initiative to Increase Access to Psychological Therapies (see http://www.iapt.nhs.uk/for full details of the IAPT programme) there has been an expansion in the provision of post-graduate Diploma training in cognitive behaviour therapy (CBT). Previous evaluations of such training programmes have yielded mixed results but have been limited by small sample sizes and/or limited assessment measures.Aims: To evaluate the impact of a long-standing Diploma in CBT training programme on a variety of measures of CBT competence.Method: Trainees' levels of CBT skill are compared at the beginning and end of CBT training. The effect of therapist factors such as age, professional background and gender on the development of CBT competence is also examined.Results: Results show that trainees demonstrate higher levels of CBT skills after completing the training than they did before, with the majority achieving pre-determined criteria for competence. Trainees' gender was not related to their performance but trainees' age showed a negative association with CBT skill (older trainees performed worse). Trainees' professional background also had an impact on their level of CBT competence, with trainees who were clinical psychologists demonstrating the highest levels of competence across a range of measures.Conclusions: CBT Diploma training leads to increases in the level of trainees' CBT competence, with the majority achieving the levels demonstrated in research trials by the end of training. Thus, this training is likely to lead to improved outcomes for patients. Further research is needed to determine the most efficient ways of enhancing CBT skills. (C) 2010 Elsevier Ltd. All rights reserved.