Judith Beck's first book, Basics and Beyond, was a godsend to me in my first post when I had little access to CBT supervision. She has the gift of explaining sometimes complex ideas with admirable simplicity and clarity. Finding myself in a similar position, seven years down the line, and, like most clinicians, with a caseload of increasingly complex cases, I was keen to read the sequel “. . . What to Do When the Basics Don't Work” and I was not disappointed.

The book is structured in a similar form to its predecessor, with chapters devoted to each of the essentials of cognitive therapy: formulation, the therapeutic relationship, structuring sessions, identifying cognitions etc. The challenges that may arise in each are then delineated and strategies presented as to how to address and resolve them. I particularly like the way that in each section she also addresses the criteria for how and when to depart from standard CT practice, e.g. varying the structure of sessions.

As one might expect, substantial emphasis is given to establishing a clear formulation of the problematic issue, including specifying the target cognition with precision. For example, Beck points out that those who see themselves as worthless may see themselves as unacceptable, as “nothing” or as actively evil or toxic and that these may require subtly different interventions.

The points are illustrated with case examples and transcripts of sessions, which provide very useful models of exactly how to address tricky issues such as people who keep talking and become controlling whenever a therapist becomes directive. She demonstrates how to uncover the underlying assumption, such as “if I let my therapist direct the session, it means she's strong and superior and I'm weak and inferior”, and suggests ways to respond. I thought her deft comment that allowing someone competent to advise is a sign of intelligence, analogous to companies’ Chief Executive Officers or government leaders seeking advice from aides with special expertise would be likely to be persuasive in such situations.

Unlike many American texts, her examples did not jar on British ears, or at least, with only one exception, not mine. Case examples are presented with information about both axis I and axis II diagnoses, but without information regarding how they are assessed, although she does include a copy of the Personality Belief Questionnaire (PBQ) in the appendix. This may reflect differences in the training of clinicians in North America as compared with the UK. My impression is that greater emphasis is placed on the assessment of both axis I and II problems from the outset on the other side of the pond. In my own experience, this is relatively neglected in the UK and it is rare for standardized measures that might identify axis II difficulties to form a routine part of assessment. Improving the identification of axis II problems at assessment – and therefore developing a more accurate formulation – should benefit both clients and clinicians. It is to be hoped that the 100-item PBQ will prove effective and user-friendly.

Having identified people who might meet criteria for a personality disorder, Beck then conceptualizes their difficulties in terms of overdeveloped and underdeveloped coping strategies, which helps both clients think about such problems as a question of balance, instead of focusing exclusively on “negative” or “pathological” strategies. This less stigmatizing approach is likely to facilitate the engagement of clients who are at increased risk of dropping out of treatment.

Beck also engages with the issue so often encountered with more complex cases where people report being able to muster challenges to their thoughts that they agree with “intellectually”, while still feeling guilty, shamed, humiliated etc. She presents a technique, the “rational-emotional role-play”, which involves encouraging people to respond “from the head” and “from the gut” and a transcript of its use, which is likely to be a helpful addition to the repertoire of strategies to address this problem. I also welcome the greater attention given to imagery, dreams and metaphors, the last two not traditionally considered cognitive therapy territory.

I especially like the way secondary gain is conceptualized in terms of therapy-interfering beliefs. Using that language places them firmly as cognitive phenomena that can be explored, tested and modified. “Secondary gain” suggests little possibility of change and tends not to be considered a hypothesis, but used to justify terminating or not offering therapy. Exploring other therapist contributions to problems in therapy receives a chapter in its own right, including a section on therapist self-care. The possibility of transferring clients to therapists better able to meet their needs is also discussed, an option rarely considered in most departments. The point that the need for supervision is the greater when working with challenging problems is made, but not stressed, nor discussed as part of the process of deciding whether one has the right set of skills to best help the client, an issue that seems the more important as we experiment with “low intensity/high intensity” stepped care models of service delivery in the UK.

As someone working with PTSD, one of the most challenging (but relatively infrequent) problems is working with highly dissociative clients. I was disappointed to find no mention of dissociation, but this is a minor cavil. As with the previous book, I like her focus on the first principles of CT which, given the level of co-morbidity seen in most services, I find ultimately more helpful than those presenting models for each condition, necessary as these are.

Given the proliferation of cognitive therapy courses, the relative lack of experienced supervisors, and the complexity of cases seen, more and more therapists are likely to feel the need for advice on what to do when the basics don't work. Fortunately, this timely arrival goes a long way to filling that gap.