Interest in understanding outcomes in Talking Therapies for culturally and ethnically diverse clients has been steadily growing. This service improvement project utilised a mixed-method design combining auditing recovery data and exploring staff views and needs to create recommendations for staff training on culturally responsive therapy in a Talking Therapies service. Audit findings showed that diverse clients had significantly lower recovery rates than White British clients, with ethnicity, treatment type, number of sessions, and baseline severity predicting outcomes. A staff survey on delivering culturally responsive therapy indicated high motivation but varied perceived knowledge, skill and opportunity. Identified needs included improving cultural knowledge, the ability to adapt therapy, and creating reflective spaces. Thus, recommendations included training on key concepts and ideas relating to working within diverse cultures, adapting protocols, and improving culture-focused supervision. A lay summary is presented in Appendix A of the Supplementary material.

Key learning aims

1. (1) To understand recovery rates in culturally and ethnically diverse clients in a Talking Therapies service, and the factors influencing these outcomes.

2. (2) To understand how staff perceive capability, opportunities, and motivation to deliver culturally responsive therapy.

3. (3) To identify practical recommendations for staff training to improve the delivery of culturally responsive therapy which may help improve the recovery rates for culturally and ethnically diverse clients.

NHS Talking Therapies for Anxiety and Depression (TTad) offers evidence-based psychological interventions for individuals with depression and anxiety disorders across England. Despite substantial progress in improving access to therapy, disparities remain, particularly for clients from diverse backgrounds. Given the increasing linguistic diversity across England and the reported preference among clients to engage in therapy in their first language, it is not yet known whether requiring or requesting an interpreter affects access to timely and appropriate therapy, or whether such needs contribute to disparities in treatment outcomes. This study, therefore, examined waiting times and outcomes for interpreter-mediated CBT within TTad. The sample consisted of 177,340 clients who accessed TTad services for the year 2022 to 2023 and received Step 3 CBT. Clients using an interpreter were significantly more likely to wait longer for treatment compared with those not using an interpreter. Treatment outcomes differed significantly; only 58.5% of clients using an interpreter showed reliable improvement, compared with 69.2% of those not using an interpreter. Similarly, reliable recovery was lower in the interpreter group (32.5%) versus the non-interpreter group (44.5%). Among those requiring an interpreter, the lowest reliable recovery was seen in clients using professional interpreters (28.8%). These findings highlight the need for targeted strategies to reduce delays and improve outcomes for interpreter-mediated therapy, ensuring more equitable access and effectiveness of psychological interventions within TTad. Further research is needed to explore the underlying factors contributing to these disparities and to identify best practices for delivering effective, culturally and linguistically appropriate therapy.

Key learning aims

1. (1) To examine whether a request or requirement for an interpreter is associated with increased or altered waiting times for Step 3 CBT within NHS Talking Therapies for anxiety and depression.

2. (2) To investigate differences in clinical outcomes, specifically reliable improvement and reliable recovery, for clients using interpreters compared with those who do not use interpreters.

3. (3) To compare outcomes across different interpreter arrangements, including professional interpreters, family/friend interpreters, others, and instances where interpreters did not attend, exploring any differences in outcomes.

Despite religion being an important part of some patients’ identity and value systems, therapists report finding it challenging to discuss religion in therapy. Avoiding religion for these patients can have detrimental effects on the therapeutic alliance, treatment outcomes, and parity of access for minoritised groups. Therefore, this clinical guidance paper aims to support therapists to bring religion into the therapy room by addressing six key concerns: (1) difficulties raising the topic, (2) ‘getting it wrong’ when discussing religion, (3) therapist and patient differences, (4) managing negative or ambivalent beliefs about religion, (5) perceptions of insufficient knowledge, and (6) a lack of time for meaningful discussions. These barriers are explored by drawing on empirical evidence, clinical experience, and illustrative case examples. The paper aims to provide suggestions and next steps for how therapists can reflect on and address these concerns, aiming to enhance confidence and competence in integrating religion into CBT.

Key learning aims

1. (1) To support therapists to overcome commonly held concerns around discussing religion in therapy.

2. (2) To provide practical guidance, tips, and suggestions for how therapists can discuss religion with patients.

3. (3) To help therapists to take responsibility for bringing religion into the therapy room where it is relevant.

NHS Talking Therapies for anxiety and depression (NHS TTad) were established in 2008 to increase and improve treatment for anxiety and depression, with the intention of reducing inequalities through being particularly responsive to individuals from marginalised groups. However, racially minoritised clients are under-represented within NHS TTad services, and are more likely to drop out of treatment. A service evaluation was carried out at a central London NHS TTad service to explore the experiences of clients from the ethnic group that was most likely to disengage. The aim was to find ways in which the service could be improved to enhance the experiences of this group and increase the rate of treatment completion. A service audit revealed that clients with a Black background, regardless of their specific ethnicity, had the highest drop-out rate and were significantly more likely to disengage than the White British group. The service evaluation involved interviewing six clients from this group who had recently dropped out of or declined treatment. Interviews were structured and analysed using narrative inquiry, and pattern coding was used to reduce large amounts of data into four main themes. Overall, participants found accessing support relatively easy but had limited knowledge on the service. A lack of choice and flexibility around appointments were highlighted as key factors in not completing therapy. Based on their experiences, participants recommended incorporating community and cultural learning into therapists’ training, and giving clients the option to request a therapist from a similar background. Recommendations are provided for service delivery.

Key learning aims

1. (1) To identify which clients, based on ethnicity, are most likely to decline or discontinue treatment within an NHS TTad service in Central London.

2. (2) To increase understanding of the treatment experiences of clients from the ethnic group with the highest drop-out rates.

3. (3) To provide recommendations offered by these clients for service providers, aimed at improving engagement and treatment completion.

Microaggressions have been a topic of significant debate in the psychological and social sciences. Despite an extensive body of empirical evidence, numerous misconceptions persist. This paper deconstructs common misconceptions surrounding microaggressions and addresses their origins, underlying biases, and empirical refutations. We explain the mechanisms that cause and maintain microaggressions through a CBT lens. We examine widely propagated misconceptions, including claims that microaggressions lack scientific validity, are too subjective to measure, and are not indicative of racism or other forms of prejudice. Drawing on the substantial literature base, including validated psychometric scales, experimental studies, and cross-cultural analyses, we demonstrate that microaggressions are not only real but also have significant psychological and social consequences. Empirical evidence links microaggressions to outcomes such as depression, anxiety, and lower self-esteem, reinforcing their relevance in clinical, educational, and workplace settings. CBT models provide a useful lens for understanding how individuals navigate the psychological complexities associated with microaggressive behaviours, helping explain why some people resist acknowledging microaggressions and their consequences. Lastly, we highlight the importance of education for reducing the prevalence of microaggressions and mitigating their harmful effects. Our goal is to provide clinicians with correct information so that they may skilfully and empathetically help clients experiencing microaggressions, and to no longer accept microaggressions as a harmless, misunderstood, or dismissed phenomenon. By debunking these misconceptions, this work contributes to a more scientifically grounded understanding of microaggressions, emphasizing the necessity of continued research and intervention efforts to address the impact of discrimination in society.

Key learning aims

1. (1) Build awareness around the various misconceptions associated with microaggressions.

2. (2) Knowledge of why these misconceptions exist, where they came from, and why they are important to consider and refute.

3. (3) Refuting misconceptions with scientific explanations and evidence.

4. (4) Understand how CBT clinicians can better prevent and respond to microaggressions.

The experience of human trafficking is associated with a high prevalence of mental health problems, particularly post-traumatic stress disorder (PTSD), anxiety, and depression, for which cognitive behavioural therapy (CBT) would be indicated as an evidence-based intervention. However, lack of knowledge about trafficking survivors’ psychosocial needs, and the complexity of their presentation and circumstances can deter clinicians and impact on survivors’ access to evidence-based care. This article aims to offer guidance for clinicians working therapeutically with adult survivors of human trafficking. It draws on existing CBT evidence-based interventions, and highlights survivors’ holistic needs. This article proposes the use of an existing three-phased approach to treatment and draws upon cognitive behavioural principles. The psychological impacts of exploitation, key assessment topics, and safeguarding concerns are discussed. Considerations for psychological formulation and intervention are described, with a focus on trauma reactions, including PTSD. The integration of a survivor’s social and cultural context into treatment is also explored. CBT interventions can be adapted and applied effectively to address the mental health needs of survivors of trafficking alongside other support to meet their holistic needs.

Cognitive behavioural therapy (CBT) is a frontline treatment for a range of mental health problems and is increasingly offered as the psychological therapy of choice across the globe. Access to or benefit from this psychological therapy relies on proficiency in the dominant language of the area. However, to meet our clients’ needs in an increasingly mobile, multicultural, and diverse society, it may require adaptation through the use of spoken language interpreters. The benefits of interpreter-mediated CBT for mental health problems remains uncertain. The objective of this review is to systematically identify, evaluate, and integrate the existing empirical literature on interpreter-mediated CBT for mental health problems. A comprehensive search was conducted in July 2024 across CINAHL, MEDLINE, PsycINFO and Scopus. Studies meeting the inclusion criteria resulted in a total of eleven articles being included in the review. The included research shows promise in terms of feasibility and efficacy, but not conclusively. The narrative review enabled the synthesis of recommendations, which have been conceptualised as being at individual, service, and organisational levels. There is limited research and a need for further studies into the influence of other factors such as therapist proficiency, interpreter proficiency, complexity/co-morbidity and service context. Further evaluation should consider controlled trials of interpreter-mediated CBT, while also establishing its efficacy more robustly in regular practice. It should also further explore the experiences and perspectives of the client, interpreter, and therapist regarding the suggested recommendations.

Key learning aims

1. (1) Gain an understanding of the existing evidence on the effectiveness of interpreter-mediated CBT for various mental health problems across diverse populations.

2. (2) Learn about key recommendations emerging from empirical research on the implementation of interpreter-mediated CBT.

3. (3) Acquire clear, practical guidance that can inform the work of interpreters, practitioners, services, and healthcare systems to improve the delivery of interpreter-mediated CBT.

The original declarative procedural reflective (DPR) model is a well-established model of therapist knowledge and skill development. To date, although it has been used to guide reflection and discussion around personal and practitioner selves, it has not emphasised the various intersecting identities of practitioners and how these interact within wider concepts such as power, society, service contexts and the patient and supervisory relationships. The learning, development and implementation of CBT skills does not occur in a vacuum or separate to the practitioner identities however relatively little has been written on this. This paper aims to expand the original DPR model to illustrate potential ways that social context, identity and power could be considered within CBT training, delivery and supervision. It delineates and explores the additional components of the model (i.e. practitioner identity(s), context/society and power) and then provides examples of how this framework could inform key CBT activities (including low-intensity CBT).

Cognitive therapy for post-traumatic stress disorder (PTSD) is recommended in a range of national and international guidelines. This clinical guidance paper specifically focuses on cognitive therapy for PTSD (CT-PTSD) where racism has been part of the index trauma event(s). It aims to support CBT therapists to maintain fidelity to the CT-PTSD model but also ensure that racism is integrated into the formulation and interventions in ways that are sensitive and validating. It explores barriers to this occurring ranging from societal factors (e.g. ongoing racism, discouragement from discussing racism), to therapist factors (e.g. lack of understanding of racism, lack of own understanding of racialised identity, anxiety, lack of knowledge, skills and confidence) and patient factors (e.g. shame, fear of therapist response). The paper aims to provide guidance on how these can be addressed alongside case illustrations and practical considerations for therapists and supervisors.

Existing research indicates that clients from diverse backgrounds often experience poorer access to and outcomes from psychological therapy in primary care mental health services in England. This issue is arguably compounded for clients with limited English proficiency or those who wish to access therapy in other languages. Guidance on interpreter-mediated therapy provides essential recommendations to ensure equitable access, effective communication, culturally sensitive care, and parity in outcomes. Despite these guidelines, they are not always consistently implemented in clinical practice. This study aims to explore and address staff experiences and perspectives on the barriers to interpreter-mediated therapy within Talking Therapies for anxiety and depression (TTad). An online survey was used to collect data on professionals’ experiences and perceptions of these barriers. A total of 133 staff working within TTad completed the survey. The data was analysed using reflexive thematic analysis (RTA), revealing four key themes: (1) individual level, (2) service level, (3) organisational level, and (4) overlapping barriers. The study highlights that while the barriers to effective interpreter-mediated therapy are distinct across individual, service, and organisational levels, they are also interdependent and often overlap. The findings suggest that addressing these barriers requires a comprehensive approach that considers the interconnected nature of these challenges. Improving training for both therapists and interpreters, enhancing administrative processes, ensuring sufficient funding, and promoting adherence to best practice guidelines are crucial. Future research and continued efforts to implement and monitor these changes are essential for improving access and outcomes for clients within TTad.

There has been limited consideration of the training and support needs of therapists from minoritised ethnic backgrounds. This study quantitatively evaluates a novel application of self-practice/self-reflection (SP/SR) to CBT therapists from minoritised ethnic backgrounds. The study aimed to explore the impact of the SP/SR programme on (1) therapists’ skills in working with ethnicity in their clinical practice; (2) their ethnic identity development; and (3) their perceived levels of personal and professional wellbeing, during the intervention and at follow-up. A multiple baseline single case experimental design was adopted. Measures were developed and adapted for this evaluation and weekly outcomes relating to therapist skill development, ethnic identity development, and personal and professional wellbeing were collected. The outcomes of six participants were analysed using visual and statistical analysis. The results indicated that the SP/SR programme significantly improved therapist skills in identifying and addressing similarities and differences in ethnicity within therapy during the intervention. Improvements were also seen across other skills, ethnic identity developmental and wellbeing outcomes between the baseline and SP/SR phases, with some participants showing significant improvements. Outcomes from the follow-up phase presented a more mixed picture. Therefore, the findings give some support for the SP/SR programme in developing therapist skills in working with ethnicity, as well as highlighting differential outcomes for participants related to their levels of experience and engagement. The findings may have possible implications for the personal and professional development of ethnically minoritised therapists, as well as future quantitative SP/SR research.

Key learning aims

1. (1) To provide an overview of self-practice/self-reflection (SP/SR) and its theoretical underpinnings.

2. (2) To summarise the current issues around the development of cultural competence, particularly for therapists from minoritised ethnic backgrounds.

3. (3) To introduce and describe a novel SP/SR programme for CBT therapists from minoritised ethnic backgrounds.

4. (4) To highlight the importance of considering ethnicity within clinical practice, both in terms of the provision of culturally competent therapy as well as to support the personal and professional development of therapists from minoritised ethnic backgrounds.

Moral injury is the profound psychological distress that can arise from exposure to extreme events that violate an individual’s moral or ethical code; for example, participating in, witnessing, or being subjected to behaviours that harm, betray or fail to help others. Given that the experience of moral transgression is inherent to moral injury-related post-traumatic stress disorder (PTSD), it is important to consider patients’ religious beliefs and formulate how these may interact with their distress. In this article we describe how to adapt cognitive therapy for PTSD (CT-PTSD) to treat patients presenting with moral injury-related PTSD, who identify as religious. Anonymised case examples are presented to illustrate how to adapt CT-PTSD to integrate patient’s religious beliefs and address moral conflicts and transgressions. Practical and reflective considerations are also discussed, including how a therapist’s personal beliefs may interact with how they position themselves in the work.

Key learning aims

1. (1) To understand the importance of patients’ religious beliefs in the context of moral injury-related distress.

2. (2) To understand how patients’ religious beliefs can be integrated into Ehlers and Clark’s (2000) model when working with moral injury-related PTSD.

3. (3) To offer practical adaptations for CT-PTSD to integrate patients’ religious beliefs and practices, including how to set up a consultation with a religious expert in therapy.

4. (4) To aid therapist reflection on how their personal beliefs interact with how they position themselves in therapeutic work with religious patients.

Culture plays a significant role in psychotherapy practice, with cultural adaptations being implemented more commonly as globalisation and cultural awareness increase. An abundance of systematic reviews, meta-analyses and randomised controlled trials exploring culturally adapted interventions have been published across the globe. In this paper, we present the historical background to cultural adaptation by summarising and evaluating previous frameworks, as well as reviewing current evidence for such adaptations and highlighting routes for further research. Around twenty cultural adaptation frameworks have been published, covering various population demographics and intervention types, providing general guidelines for the implementation of cultural adaptations to psychosocial interventions. Nearly all the frameworks used previous literature and research to develop models on culturally adapted interventions. Some even implemented stakeholder discussions, randomised control trials, and even pilot studies. A variety of cultural adaptation factors have been outlined and discussed; however, there is no agreement on which elements work and which do not. Existing evidence indicates that culturally adapted interventions are effective, regardless of intervention type or population. While cognitive behavioural therapy (CBT) was the most common intervention in trials, there are, at present, no high-quality comprehensive meta-analyses or systematic reviews on culturally adapted CBT which include all literature on this topic. This is needed in order to provide a holistic and detailed comprehension of where current understanding lies. We conclude our paper with recommendations for researchers, trainers and commissioners.

Cultural competency is a core clinical skill. Yet, psychological therapists may be inadequately trained to deal with the needs of service users from Black, Asian and Minority Ethnic (BAME) backgrounds. This can lead to dissatisfaction with mental health services, disengagement from therapy, and poorer treatment outcomes when compared to the White British population. The aim of this study was to explore whether practitioners working for Improving Access to Psychological Therapies (IAPT) services are culturally competent to deal with the needs of diverse communities. Semi-structured interviews were carried out with a range of practitioners, from early career psychological wellbeing practitioners (PWPs) to senior cognitive behavioural therapists (n=16). Reflexive thematic analysis (RTA) was used to analyse the data, guided by a six-phase process to produce a robust pattern-based analysis. Overall, three themes were generated: (1) encountering cultural dissonance within therapy; (2) challenges in making cultural adaptations to therapy; and (3) identifying cultural competency needs. Out of sixteen participants, only nine therapists received one-day formal training throughout their therapeutic career, whilst seven reported receiving no cultural competence training at all. Overall, it appears that there is an urgent need and desire for therapists to be offered cultural competency training so that they can better serve BAME communities. Clinical implications and future recommendations are made.

Individuals from Black, Asian and Minority Ethnic (BAME) groups experience profound disparities in accessing mental healthcare, show poorer treatment outcomes, and high attrition rates when compared to their White British counterparts. Despite the national rollout of Improving Access to Psychological Therapies (IAPT) services, research exploring service users’ recovery narrative has been scarce. The aim of this study was to explore whether evidence-based psychological interventions are suitable to the needs of BAME communities. Semi-structured interviews were conducted with nine BAME service users who received evidence-based psychological treatment(s) from IAPT services. Reflexive thematic analysis (RTA) was used to analyse the data which included a six-phase process to produce a robust pattern-based analysis. Overall, three themes were generated. The first theme highlighted the importance of recognising cultural dissonance within therapy, which considered patient therapeutic expectations, therapeutic guilt, and conflicting cultural identities. The second theme identified the need for therapists to develop cultural competency. This included the importance of building therapeutic trust and exploration of patient culture within therapy. The final theme considered the road to recovery and highlighted challenges with therapeutic engagement and evaluations of therapeutic effectiveness. Overall, BAME service users felt that therapy was not a cure, but found it helpful. Clinical implications and future recommendations are discussed.

Racism is a pervasive problem in Western society, leading to mental and physical unwellness in people from racialized groups. Psychology began as a racist discipline and still is. As such, most clinical training and curricula do not operate from an anti-racist framework. Although most therapists have seen clients with stress and trauma due to racialization, very few were taught how to assess or treat it. Furthermore, clinicians and researchers can cause harm when they rely on White-dominant cultural norms that do not serve people of colour well. This paper discusses how clinicians can recognize and embrace an anti-racism approach in practice, research, and life in general. Included is a discussion of recent research on racial microaggressions, the difference between being a racial justice ally and racial justice saviour, and new research on what racial allyship entails. Ultimately, the anti-racist clinician will achieve a level of competency that promotes safety and prevents harm coming to those they desire to help, and they will be an active force in bringing change to those systems that propagate emotional harm in the form of racism.

Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, culture can influence engagement and treatment efficacy of CBT. Several attempts have been made in Asian countries to develop a culturally adapted CBT for depression. However, research in the Indian context documenting the views on cultural influence of CBT is limited. The present study is an attempt to explore the views of patients and therapists in India by following an evidence-based approach that focuses on three areas for adaptation: (1) awareness of relevant cultural issues and preparation for therapy; (2) assessment and engagement; and (3) adjustments in therapy techniques. Semi-structured interviews with three consultant clinical psychologists/therapists, a focused group discussion with six clinical psychologists, and two patients undergoing CBT for depression were conducted. The data were analysed using a thematic framework analysis by identifying emerging themes and categories. The results highlight therapists’ experiences, problems faced, and recommendations in all three areas of adaptation. The findings highlight the need for adaptation with understanding and acknowledging the culture differences and clinical presentation. Culturally sensitive assessment and formulation with minor adaptation in clinical practice was recommended. Therapists emphasised the use of proverbs, local stories and simplified terminologies in therapy. The findings will aid in providing culturally sensitive treatment to patients with depression in India.

In the UK, over three-quarters of a million people cannot speak English well enough to access cognitive behavioural therapy (CBT) in English. If they are to receive an equitable service, they need to be able to access (spoken language) interpreter-mediated therapy. This means that CBT therapists may need support, through training and supervision, to feel confident and positive about incorporating an interpreter into the therapeutic relationship. The requirement for CBT therapists to be able to work effectively with an interpreter is currently acknowledged in the new BABCP minimum training standards and core curriculum, which are recommended for adoption (BABCP, 2021). Understandably, therapists can feel anxious about working with a third person in the room, but when these anxieties are honestly addressed and explored, creative solutions can be found. Therapy is usually conducted in a dyad. A triadic relationship requires attention to the systems at play inside and outside of the therapy room. With careful preparation and planning, interpreter-mediated therapy can be an effective and positive experience for the patient. After an introductory section, the paper is divided into six implementation sections: preparing for interpreter-mediated therapy; meta communication; boundaries; managing three-way relationships; working with interpreters remotely; and support needs of interpreters. Using a case example approach, interpreter-mediated therapeutic situations, which illustrate challenges and solutions, and examples of good practice, are explored. The paper offers practical guidance and illustrations which can form the basis of a training programme which teaches CBT therapists how to form a collaborative working relationship with an interpreter, how a therapist can stay active and maintain their clinical authority in a session in which they do not understand what is being said, and how CBT therapists can ensure that the therapy session remains safe and effective for all three of the participants in the interpreter-mediated encounter.

Online cognitive behaviour therapy (CBT), self-help and guided self-help (GSH) interventions have been found to be efficacious and cost-effective for treatment of anxiety and depression, but there are limited data from low- and middle-income countries on culturally adapted digital interventions for these common mental disorders. The aim of this study was to investigate the feasibility and acceptability of an online culturally adapted CBT-based guided self-help (CaCBT-GSH) for patients with anxiety and depression in Pakistan. This randomized controlled trial recruited 39 participants from primary care in Karachi, Pakistan and randomized them to two groups. The intervention group received seven modules of CaCBT-GSH plus treatment as usual (TAU) over 12 weeks. The control group was a waitlist control plus TAU. The primary outcomes were feasibility and acceptability. Clinical outcomes included results from the Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule 2 (WHODAS 2). Assessments were carried out at baseline and at 12 weeks. All 39 individuals who met eligibility criteria for the study agreed to participate. Adherence to the intervention was excellent, with 85% (17/20) completing more than five modules. Statistically significant improvements were found in all clinical outcomes in the intervention group. This was the first trial of an online CaCBT-GSH intervention, which was found to be feasible and acceptable to Pakistani patients with anxiety and depression. CaCBT-GSH may help improve symptoms, depression, anxiety and overall functioning in this population. The results provide rationale for a larger, confirmatory randomized controlled trial of digital CaCBT-GSH.