Over the course of the last year, the Cognitive Behaviour Therapist has rapidly published a range of excellent and highly appreciated papers looking at a range of issues such as working with specific disorders during the pandemic such as obsessive compulsive disorder (OCD) (Jassi et al., Reference Jassi, Shahriyarmolki, Taylor, Peile, Challacombe, Clark and Veale2020), eating disorders (Murphy et al., Reference Murphy, Calugi, Cooper and Dalle Grave2020), social anxiety (Warnock-Parkes et al., Reference Warnock-Parkes, Wild, Thew, Kerr, Grey, Stott and Clark2020) and post-intensive care unit post-traumatic stress disorder (PTSD) (Murray et al., Reference Murray, Grey, Wild, Warnock-Parkes, Kerr, Clark and Ehlers2020). There were also papers on how to adapt training and supervision to be delivered remotely (Cromarty et al., Reference Cromarty, Gallagher and Watson2020) and how to conceptualise uncertainty within the context of the pandemic (Freeston et al., Reference Freeston, Tiplady, Mawn, Bottesi and Thwaites2020). These were often rapidly written by individuals struggling with the same pandemic stresses as everyone else. We appreciate their commitment to disseminating their knowledge and guidance in such a timely way to support frontline staff and whilst dealing with the impact on their own lives.

In this commentary we wanted to highlight aspects or implications of some of these papers which may need to be considered with reference to staff or patients from racialised groups (although we may use the term BAME or BME when referring to its usage in other literature). For many individuals from racialised groups, COVID-19 is having a disproportionate impact on top of the killings of George Floyd and Breonna Taylor, which had already provided a stark repeated reminder of the many systemic inequalities within our societies. It is therefore important to make space to consider both within our clinical work.

One of the earliest of the COVID-19 Special Issue papers was on the fascinating topic of death anxiety and how this might function in the context of a pandemic (Menzies and Menzies, Reference Menzies and Menzies2020). In the UK, Brexit had already been linked with a reported rise in the number of racist incidents (Komaromi, Reference Komaromi2016) and Menzies and Menzies point out that:

Over the course of the pandemic, there has been growing evidence that the impact of COVID-19 has more significantly impacted groups such as those already experiencing higher levels of social deprivation (Office for National Statistics, 2020a) and those from certain ethnicities (Office for National Statistics, 2020b). On average, Bangladeshi and Black African households have almost ten times less wealth than White British households (Khan, Reference Khan2020) and Bangladeshi communities currently have the lowest recovery rates in IAPT (NHS Digital, 2020).

One of the first Special Issue papers looking at potential services responses to support NHS staff throughout the pandemic pointed out that:

One of the most recent Special Issue papers has discussed working with moral injury in PTSD and in particular how this might be applied to health workers (Murray and Ehlers, Reference Murray and Ehlers2021). This useful paper provides a framework and helpful clinical guidance on how to address moral injury related PTSD. The paper clearly identifies potential issues within the NHS:

One interesting question not covered within the paper is how this might interact with discrimination within the NHS. This might be significantly amplified in groups where there is already recognised discrimination and a greater risk of disciplinary action for staff such as those from racialised groups (Kline, Reference Kline2014; NHS England, 2020). This is likely to be exacerbated by the more widespread current feeling of being ‘vulnerable to the risk of prosecution for unlawful killing’ when treating coronavirus patients ‘in circumstances beyond their control’ (Lowe, Reference Lowe2021). This is something that we may have to consider as therapists (and explicitly ask about) when working with individuals from these groups. Also, as therapists, supervisors and leaders, we need to consider how we contribute towards psychological safety within the services and organisations we work in to support individuals from racialised groups when issues such as experiences of racism or microaggressions are raised (Edmondson and Lei, Reference Edmondson and Lei2014).

Finally, services have started to consider the impact of COVID-19 on specific communities with description of good practice by commissioners and providers:

The pandemic is not yet over, and the impact will be felt for years to come within our societies and mental health services. As CBT therapists, part of our role is to ensure equal access and work towards equal clinical outcomes for all groups within society by working in partnership with our commissioners, employers and services (often needing to press them to engage against a backdrop of under-funding and other targets). Additionally, race is a protected characteristic of the 2010 Equality Act, and therefore services are legally obliged to ensure that they are meeting the needs of racialised groups. Anecdotal feedback provides ample evidence that there is much more to be done whether as simple as collecting data on patient ethnicity and their clinical outcomes in secondary care, the need to develop a centralised resource of translated materials, and ensuring that all IAPT services implement the IAPT BAME Positive Practice Guide (Beck and Naz, Reference Beck and Naz2019; Beck et al., Reference Beck, Naz, Brooks and Jankowska2019). The implementation of the IAPT BAME Positive Practice Guide will ensure that BAME communities receive appropriately early intervention for a common mental health problem rather than wait until their mental health deteriorates.

Following on from the Cognitive Behaviour Therapist Special Issue on Cultural Adaptations back in 2018 (see https://cup.org/2NlerRF), tCBT remains committed to publishing clinically focused articles that improve how we deliver CBT (and also train and supervise therapists) across all cultures and backgrounds but acknowledging the current starting position which is one of structural inequalities between groups.