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In this episode of Let’s Talk About CBT, Helen Macdonald speaks with James from the charity Gambling with Lives about the serious impact of gambling addiction, its links to mental health, and the role of CBT in recovery. What We Cover in This Episode: 🔹 How gambling has changed – From a backstreet niche to an industry making billions through addictive products. 🔹 Gambling addiction and mental health – How gambling harms go beyond financial loss and can lead to depression, anxiety, and even suicide. 🔹 The neuroscience of gambling – How gambling rewires the brain, making it difficult to stop. 🔹 Recognising the warning signs – What to look for in yourself or a loved one. 🔹 The role of CBT in recovery – How cognitive behavioural therapy is a key treatment approach in NHS gambling addiction services. 🔹 Breaking the stigma – Why gambling addiction is not just about personal responsibility and we need to talk about how it can harm people and the amount of gambling advertising that is out there. 🔹 Getting help – Resources for those affected, including training for healthcare professionals. Resources & Links: Find out more about Gambling with Lives: Visit Chapter One for training and resources: NHS gambling support services: If you or someone you know needs urgent help, reach out to Samaritans at 116 123 (UK) or visit Find our sister podcasts and all our other episodes in our podcast hub here: Have feedback? Email us at Follow us on Instagram & Bluesky: @BABCPpodcasts Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This episode was edited by Steph Curnow Transcript: Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't.  I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies   Welcome to today's episode. I'm really pleased to have James with me today. He's from an organisation called Gambling with Lives, and I will ask him first to introduce himself. Hello, James. James: Hi Helen, thank you for having me on. I'm James. I live in Stockport, originally from Norfolk, hence I haven't got a Northern accent, but I'm here today representing the charity Gambling with Lives. The charity was set up by bereaved families who'd lost loved ones to gambling related suicide and I now oversee our prevention work, which includes education, training, information, and resources. And a lot of that stems from my own lived experience of a 12-year gambling addiction, which started as a young person, and which I'm sure we'll touch on today. Helen: Thank you, James. And so I'm very aware that a charity that's been very much grounded in the experiences of bereaved families, there's going to be some difficult things to talk about here. And just to say for our listeners, there will be links to where to find help and support on the show page and as well as anything that we talk about during today's episode. So can I ask you just to tell us a little bit more about gambling? What is it? You know, how people might get themselves into trouble with it, maybe? James: Yeah, it's a big question. And the first answer that comes to my head is that gambling is not what it was. I think a lot of people have a perception of what gambling is, and that's a weekly bet at the horses or going to the bingo on a Thursday night, or the football pools. Gambling has absolutely transformed over the last 10, 20, 30 years. And it all really started from a point in 2005 when the Gambling Act was created by the Labour government at the time, which changed gambling from being this thing that was, you know, quite hidden, quite behind closed doors, wasn't promoted, was quite hard to go and do, wasn't that easy or available or accessible, and that Gambling Act changed that completely and allowed for relentless advertising, sponsorship, marketing, and allowed for bookmakers in the high street to have really addictive electronic machines in their premises. And they were things like the fixed odds betting terminals, which were roulette machines, which at the time were called the crack cocaine of gambling because they were that addictive. And that was not what gambling was. I remember when I was a child, in our town, I'm from a quite a sleepy, small town in Norfolk. And the bookies in our town used to be this like really dingy, horrible place to be honest behind in a back alley that I used to walk past it and think I'm never going in there, that is a place not for me. It's for old men, smoke coming out the doors, did not have any interest in that. But then when I was 16, which was a couple of years after this Gambling Act, it changed into a massive Ladbrokes in the middle of the high street, you could see through there, you could see the machines and you could see all the advertised on the outside of the windows. And that's what's happened to gambling. And the impact on society is huge. We now know that 2. 5 percent of the adult population are experiencing so called “problem gambling”. And just to note on that terminology, it's not a term that we like to use, but this is what the statistics say. And we don't like to use it because we don't like to put the problem with the person. There are many reasons why people experience gambling harms, which is what I'll come on to later. But that figure alone. So that's the very sharp end of gambling harms, but then you've got many more impacted by somebody else's gambling. You've got widespread harms happening to young people. So, a really important point here is that these harms aren't just financial. Again, I think there's a perception that gambling addiction is a financial problem, and the harm is felt through debt and long-term financial worries. Actually, this is a mental health condition. This is a diagnosable mental health condition. Gambling disorder is in the DSM manual since 2013, and it's a mental health harm first and foremost. And that then causes anxiety, depression, and suicidal thoughts as well, which again, we'll come on to based on the work we do at Gambling with Lives. Helen: Thank you, James. So, what I've just heard you describe there, that it's gone from being a bit of a backstreet, rather unattractive niche thing, to being sort of very attractive and perhaps more widely, I don't know, more people participate in it. And you mentioned gambling machines and I'm also aware that people can gamble on the internet as well. They don't have to go out to do it necessarily. And I'm also aware that you used words like addiction, which most people would associate with substances, perhaps alcohol or drugs or something. And I wonder if you could say a bit more about, perhaps the difference between what I might have thought of as a harmless flutter and something that's harmful. James: Yeah, another good question and potentially asking the wrong person because I, obviously I experienced a gambling addiction myself, but I'll try to answer based on my own experiences. And on your first point, actually, probably the thing I forgot to say, which is most important is that the biggest change for gambling is, as you say, the fact that all of these products that are now available on our phones, in our pocket. At the time when the legislation was written, there was concerns about super casinos in places like Blackpool and on the coastal towns of England. And actually what's happened is we all now have a super casino, but it's in our pocket and anyone can access it over the age of 18. There's very little safeguards and protections on there. And that's where the harm is felt most on online gambling. And that's sort of the answer to the second question as well is that gambling is not just one product, and some products are more harmful, risky and addictive than others. And that's not to say you cannot be harmed by, as an example, buying a lottery ticket. Because if you've only got 5 pounds to last you for food that week and you spend 5 pounds on a lottery ticket, you are experiencing gambling harms. But evidence shows and experiences from people who have been there and been harmed are that the quickest, more attractive, the things that are designed to be addictive products like online slot games, online casino games, online bingo as well. These are the things that are really causing the harm and causing addiction. And the difference is the indication someone is experiencing gambling harm is how often someone is spending on those products and how much money someone is spending on those products and how quick all of those things are, those products. That's why people can get harmed quite quickly. Back in the day, again, you used to have to go somewhere to place a bet on, and you maybe did that once, twice a week. Now, because of how quickly you can do that, that creation of addiction is so much quicker and instant, and it can happen really quickly. I can give you examples of times where I spent five, six, seven hours just in bed spinning online roulette tables on online casinos. And that time I, it didn't feel like five, six, seven hours. It felt like I was just trapped in this zone. And that's because it's deliberately designed that way. So what happens is, and this is very medical and I'm not a scientist or a medical person, but this is a physiological change in the brain. So when you play these really fast paced products, these intense products like slots, like casino games, your pathways in your brain are rewired and it becomes a dopamine driven urge to do this thing again and again. And what's really worrying and something for your listeners to look out for, is if this happens to a young person before the age of 25, where their brain isn't fully developed and if they experience a big win and they get an explosion of dopamine in the brain from that win, that can be a real big indicator that they're going to experience gambling harm and even gambling addiction. So I would say that and the other thing that I would just say to answer the question is, there is no national guidance on a safe level of gambling. So I'm hesitant to say what that is, but there are clearly signs, indications, symptoms that someone may be experiencing gambling harm, such as feeling the need to check devices a lot, not being motivated by relationships or by career, lying about how much time and money is being spent gambling, and then of course, feeling suicidal or feeling like the world would be better off without you. There are some, but there are an exhaustive list of, of indications someone might be experiencing harm. Helen: I mean, this sounds really worrying, James. You've said probably around two and a half percent of the population may be experiencing gambling harms, and that doesn't count the people around the person who may be affected by their changes in how they interact, as well as things like, I don't know, would have an impact on household finances, for example, or occupation, things like that. And yet what we see in the media seems to be more about how to place bets and how to gamble rather than what the potential risks might be. James: Yeah, there's very little public health messaging about the risks of gambling. From my own experiences, if I take you through the journey of my life, really, as a child, not at any point was I taught or warned about the risks of gambling. You know, I was warned about drugs, warned about wearing a seatbelt, warned about sexual predators, was never ever told that gambling came with a risk to my mental health. And then when I started to gamble at the ages of like 18 to 25, there was no preventative health messaging, through campaigns or through advertising that told you that this is a risk to your mental health that you're probably likely to lose your money but there is places to go for help and support. That didn't exist. All we got, my generation, were messages like, When the fun stops, stop. Which was a ludicrous message but was the main one for years and years which just, you know, really put the onus of responsibility on an individual to use addictive products responsibly, which of course is a contradiction in terms. And even now there has been some progress, but there isn't messaging out there on the whole that really says the things that I've just said. Not many people know that this is a thing that impacts the pathways in the brain. Not many people know that this is an industry that makes 14 billion pounds every year and it makes most of that money from the most addictive products and from the people that are experiencing harm. And most people don't know where to go for help, support or treatment. We do a lot of prevention work and every time we're in a room with young people or with professionals, we ask them at the start of the session, do you know where to go if you're worried about someone you know because of gambling harms? And it's between like 80 and 90 percent of respondents to that question is a no, and that is really worrying. So it's not just that people aren't being warned, people aren't being protected from this either. And so there is a hell of a lot to do to ensure people don't experience harm in the first place. But if they do, they are, they're cared for. Helen: Thank you, James. And I'll want to come back to talking more about that as well. I mean, I think, one of the things standing here as a cognitive behavioural psychotherapist, I was really curious about what you were saying about how addictive these products are, about the dopamine rush that people experience, and actually physiological changes in the pathways of the brain which we know happen if you do something repeatedly, and gambling is one of those situations. And I remember very early in my learning about gambling, from a cognitive and behavioural point of view, one of the things that we talk about is the power of rewards. And you mentioned a big win, which may happen sometimes, even though, as you pointed out, overall, people would tend to lose money almost certainly if they gamble regularly. But the idea is that if you get a reward in an unpredictable way, especially if it's a really good one, we're much more likely to carry on doing that behaviour. The technical term for that would be intermittent reinforcement and when I'm talking about how CBT works, gambling is an example that I use because of that every now and again, you'll win something but what it does is it tends to keep going. Is that a reasonable understanding of, you know, how it's so addictive- are the things that I'm missing? James: No, that's a much better explanation than I would give. I think it's true and the gamble industry knows that. It employs some of the best psychologists in the world to design these products because they know what makes brains tick and what makes people coming back to the products. And, you know, in my experiences, I used to know that on the whole, I would lose money. And I used to know that on the whole, it didn't matter how many times I tried to stop that I couldn't and yet I couldn't stop myself going back to using these products and I didn't understand why. And it's only coming into recovery and doing the work that I do now and being taught this and being told this and finding out myself what actually happened to my brain, that gave me agency to realise that I was being tricked, I was being conned by gambling companies. It's all an illusion, these products are designed to fool you, designed to think that you have an illusion of control. They're designed to make you think that you've got a chance of winning in the long run, but the truth is the algorithm is against you and the house always wins. And again, going back to messaging that people need to hear, I think to be more hopeful and positive. That kind of messaging can be absolutely crucial to unlocking something in people's brains and giving them that freedom and agency and license to not just rewire their brain for good reasons, but to rebuild their life. And I, you know, I have a little mantra now that because of this knowledge that I have and because I know how the products are designed and I know how the industry operates, and I know the psychological tricks they used on me, they truly do not deserve another penny of my money or another second of my time. And that is such a big motivating factor for my recovery, and it keeps me going and I'm adamant until the day I die, I will not give them any of those things. Helen: And I just want to check with you, when you're talking about these things, I'm thinking there might be listeners out there who perhaps every now and again enjoy a day out at the races with their friends, or perhaps when there's a big football match or something like that, that they want to put a bit of a bet on. Is that the same kind of risk for certain people or, you know, if somebody was vulnerable, would that lead to harm in the same way as the internet and the machines in the betting shop? James: Yeah, again, I think all forms of gambling do carry a risk and some are more risky than others, and we're much I am genuinely and our charity is to not anti-gambling, we don't want to stop people recreationally gambling or go into events like that where gambling may be involved. But I would urge caution in that so often people's experiences of gambling harm and gambling addiction do start with what is perceived to be the more harmless or innocent forms of gambling, such as a bet on sports or a night at the bingo. And that's what happened with me. My first ever bet was a five pound football bet on a football match in a bookmakers. And you know, that, that led to years of devastation. And what the industry does is it spends lots of money on getting to these audiences in these sorts of venues, in these sorts of environments and in these sorts of sports to, to lure young people especially into then the more addictive forms of gambling, because that's where the profit is. Yes, they do make profit from football betting and from horse racing, of course, but most of their money now, most of their profit comes from the quicker, more addictive products. And that's the business model, to get people through one avenue to the next. And of course, that's not to say that everybody that goes to the horse racing or put bets on the football will become addicted. But the truth is, again, is that the industry wants people to spend lots of money on their sites. That's their business model. And the longer you are on those sites, and the more money you are spending, of course, the more profit they are guaranteeing in the long run. So again, it's just being aware of how quickly this can happen and being aware of the ways the industry targets people. Helen: And I mean, you've said, you know, just how quickly this can have an impact on people, how much it can suck you in to spending a lot of time and all the money and so on. How would somebody get from being in that position, and this is probably quite difficult to speak about, but where people are actually dying by suicide in relation to having gambling difficulties, how does it get to that situation? James: Yeah. And I can answer from my own experiences partly, but I can also answer from the facts from the position of our beneficiaries, which are families who have lost loved ones to gambling related suicide. And I'll just start by saying that for those families, and I didn't meet the people that died, but I've met their families, and they all say the same thing, that these were just every day, normal, bright, happy, young people with their life ahead of them with no real vulnerabilities, no preexisting conditions, good upbringings, and gambling was the thing that changed them, that robbed them of their future. And I can really resonate with that.  When I first came across the charity and I listened to the mums talk about their sons that had died. I did honestly think that could have been my mum quite easily. And that is because I feel like I know what it was like to get to that point. And what it is, it's not about losing substantial amounts of money. And of course, when that does happen, it can feel absolutely catastrophic. But what it is that sense of never being free of this. And, you know, I used to think I would always be addicted to gambling. I genuinely remember thinking I would spend my life addicted to gambling. This was just the, who I was, just the way I was. And that was such a horrible mindset to be in because it made me very pessimistic, nihilistic, didn't really care about myself, didn't care about my well-being, didn't do anything for myself, didn't look after myself, and because I had no control over what I was doing, that feeling of not being in control of your actions, you sort of think, well if I'm not in control of myself, what is the point? Because agency and control and freedom is sort of all we have and they're the fundamentals of how we live so to be robbed of those things, I can see so easily why people get to that point and think I'll never be free of this and I have lost all control over my life and there is no hope. And there is now, thanks to the work of bereaved families, there is now national recognition that gambling can be the dominant factor in a suicide, without which the suicide would not have occurred. And, sadly, it's somewhere between 117 to 496 people every year in England alone take their life because of gambling. And, you know, we're there to support the families who come to us and thank God we are. But this is something that is happening far too often, and we're getting far too many families who need us. And again, where is the message that by engaging with these products, there can be a serious risk to your life. And it's, you know, it's not a drastic thing to say that gambling can kill. And the point of disclosure, the point of, sometimes what's referred to as rock bottom, but the point of when someone says, I can't do this anymore, I can't be like this anymore. That is where the suicide risk is greatest. And so, we as professionals, as people that come into contact with people experiencing harm, always have to be mindful of the suicide risk and do everything we can to use the right language to, to support someone as adequately as we can. Because a common feature and experience of those that are no longer with us was that they try to access services. They try to stop, they try to have the conversation with people, but there wasn't that understanding about how serious this is. I think going back to my first answer on today was people thought that this is just gambling. It's just betting. It's just, you know, he just can't stop a few bets at the weekend. This is not, this is a serious health issue that drives people to that, that moment. Helen: And that's absolutely shocking statistics there, James, talking about the sheer number of people that are being lost to suicide, related to gambling and you're spending time with the families of people who've already gone. You said that you haven't met those people. You've met the people who've been affected by their loss. And you described what I would think of symptoms that sound very much like depression. You know, that sense of hopelessness, I'm never going to get any control over my life. I've tried everything and I've run out of ideas and all of those things. If somebody came to me and described that and didn't say that they were betting, I would think this person was really quite depressed. And you also said you weren't looking after yourself and your relationships weren't going well. And again, those would be things where I would expect a healthcare professional to be concerned about someone's mental health and think about depression. Is there anything that people like me, healthcare professionals, should really take care to check to know whether there's a gambling element to how someone's feeling? James: Yeah, and it's interesting you mentioned depression because I think it's one of the most common harms felt from gambling. And I, again, from my own experiences, I used to think when I was addicted to gambling that I was just a depressed person who gambled. Having now been nearly seven years in recovery, I realise that I was a person who gambled and that caused depression and those feelings, because I wasn't like that before gambling and I haven't been like that after gambling. So it's something about gambling specifically, I think that makes people feel depressed. And similarly, with anxiety as well. And in terms of what healthcare professionals can do, a real basic ask from us would be just to ask the question, and that is something that's not traditionally happened, but this is a new and emerging field so there's no judgment at all on any healthcare professional. But begin to ask the question and you can ask it in an empathetic way. You can ask it in an unjudgmental way, and it could just be as simple as, are you worried about your gambling or someone, you know, if you're worried about an affected other, and that could unlock something. It might be the first time someone's been asked that question. And if the answer is yes, then it's really absolutely crucial to determine what type of gambling they are gambling on, because as we know, if it's a weekly bet at the football or if it's some of the less harmful products like buying a lottery ticket or taking part in the, you know, the village fate raffle, we can probably assume there is a less risk of addiction and all the harms that I've talked about. But if they say, I've just been using an online roulette machine for four hours. Okay, alarm bells would need to be start ringing because we know how powerful those products are and the impact that has on the brain. It would then be to determine how often they're gambling, how long they're spending when they gamble, and asking them about their support networks around them. And I kind of feel like here, I need to give a bit of a shameless plug to the work we do through Chapter One, is that there's no expectation for healthcare professionals that are listening to this to be experts in gambling because there hasn't been adequate information and training, but our program through chapter One is there for you. We are here to help. We are here to train you to be able to have these conversations, to have the information and the knowledge that you need. So if someone says, I can't stop gambling, it's not that you just know what to say next, but you know, why that person is experiencing that and what we can do to help them, stop and rebuild their life. Helen: And I probably want to ask you a bit more about that, James, if I can come back to that. I think it's really important for our listeners in general, particularly the ones who are healthcare professionals, but also everybody out there to understand more about that. And I wonder, on the way to that, whether we could talk a little bit. You said that one of the things that you've done is talk to people working in NHS gambling services, and particularly people who do CBT. Can you tell us a bit about what it's like to talk to people doing CBT when it comes to gambling and gambling harms? James: Sure. So, I didn't get any treatment or any support other than the self-exclusion tools that you can put on yourself and just support from my mum and from family and close friends. And that was because when I stopped gambling in 2018, I think there was just one specialist gambling addiction clinic in the country, possibly two. But not one that was local to me and not one that was accessible to me. I'm now pleased to say that there are 15 specialist clinics across the country that cover every single area of England. Same cannot be said for Scotland and Wales and Northern Ireland, unfortunately yet. But there is wider support out there, other than the NHS services. Having met with all but one of these NHS clinics now, they all take a nearly identical approach and that is CBT first and foremost for someone that's experiencing gambling harm. And I've spoke to the clinicians at these organisations extensively and we've worked with them to learn how best to tailor our materials and to work together. And honestly, I'm not just saying this, I leave those conversations feeling like these are truly people who understand what happened to me, what happened to my brain and have the answers to rewire it and to change the behaviour for the better. And I left feeling like I would send anybody I knew that's experiencing gambling harms into their service tomorrow, because they would be in the safest possible hands and that's kind of what we're doing with our work now is we want to be that support and treatment pathway into these services because we know how effective CBT is. We think, and I say that because I'm not actually sure on the best international evidence, but we think this is the best form of treatment for people experiencing gambling harms. And this is what these services offer. So our job is to get many more people into those services because currently only one in 200 people who may benefit from treatment for gambling harms are accessing it. So there is clearly a massive gap and a massive job to do to get more people into those services. Helen: Again, you're giving us some fairly shocking statistics there about the sheer number of people with the difficulties, the people who are losing their lives and the families affected by it, and the number of people who are accessing help. And I'm just thinking about the work that you do in Chapter 1. Did you say that training is one of the key things that you offer? James: Yeah, so Chapter One provides information and support for everyone affected by gambling, including training for professionals. So, it's designed to give information to everybody about the causes and effects of gambling harms and how to support someone if you're worried. But a big focus of the work has been helping professionals perform very brief interventions and also helping them understand where specialist support and treatment is. And we have a training program for frontline professionals, which has been rolled out across Greater Manchester, in Yorkshire, and in Nottingham to really good results. And we're about to have an e-learning platform as well, which professionals will be able to access towards the end of 2025. And we just hope that it makes it easier because we are totally aware of how time pressured people are, how stretched people are, the fact that, you know, health professionals have to be experts in lots and lots of different fields and we want to lighten the load on that and make it easier for people because we know this stuff, we know gambling, everything has been informed by lived experience and by gambling addiction clinicians and those messages, that information, those resources are all accessible, on the Chapter One website, which is chapter-one.org. And there's actually a dedicated professionals hub on the website as well, where it's got additional resources, stuff that you can print off and start using tomorrow to put up into the places where you work, takeaway resources, posters, flyers, and that will be a really good starting point. But I would highly recommend trying to book on to some training to learn more about what we do and how you can help. Helen: Sounds like a fantastic resource and we'll make sure we put that link on our show page so that everybody can follow that up and have a look. Thank you. So, I mean, it sounds like you've done a huge amount of excellent work, and you've also said there's probably a lot to do. How do you see the future? I mean, what do you want to see, you know, in, in the next few years? What would you want to see happen? James: Yeah, well, I kind of have a vision of how to prevent gambling harm and to save people dying because of gambling related suicide. And it's a number of things and you have to bear with me here, but I think it has to start with better legislation of gambling laws to make gambling much safer in the first place and better regulation of those laws by the regulator, so the industry is accountable and those laws are enforceable. But beyond that, look, I think every young person, in every school should have a curriculum mandated lesson on the risks of gambling. And that lesson has to talk about the risks to mental health and the addictive nature of gambling and the industry business model and the practices they use to draw us all in. I think that everybody in the public deserves public health information and messaging about why this happens to people and how best to support someone if you're worried. I think that every professional should have access to training. I think that every professional who works with children and young people should be empowered to have resources to deliver preventative education to the young people they work with. And I think there should be much, much better joined up services so there's no wrong door for people experiencing gambling harms. If someone comes to a service and says, I'm worried about gambling or I can't stop gambling. Everybody should know at the very least where to point that person in the right direction. It’s no good fobbing people off with generic mental health support advice. This is a unique and diagnosable mental health condition that deserves recognition for that reason alone. And everybody should know that there are now specialist NHS clinics that can provide support. So that's the vision. And I don't think we're a million miles away from that happening. The political context is that we're about to get a statutory levy on the gambling industry, which will be roughly 1 percent of their profits that will be given to independent prevention, research and treatment. So that is a really positive step, and it will ensure that there is more treatment, better access to treatment. The truth is again, on the prevention side of things, probably 30 million pounds of that will be spent on prevention activities. But if we think about how much money the gambling industry spends on advertising which is 1. 5 billion pounds every year. Well, we're using a 30-million-pound budget to try and compete with 1.5 billion pounds of advertising, telling everybody that gambling is safe, harmless fun. So there's, the balance is still not there. So I would advocate for more investment in prevention and all the things that I said to make sure people know about the risks and how to get help much earlier. Helen: Thank you. And I really would say hearing what you're saying about the extent of the difficulty, and that people are starting to talk about it more. you have the ear of the government, perhaps in a way that hasn't been the case in the past and things are perhaps moving in the right direction. And it really comes across how passionate you are about making a difference here. One of the things that I did wonder about, going back to one of the things that you said right at the beginning about this sort of dirty backstreet betting shop thing and, how the presentation of it all has changed and it's kind of shiny and attractive. I still wonder though if there's anybody listening out there who's thinking about, well, maybe this is something that is affecting me, but feeling embarrassed or ashamed or hasn't got a social support network that would hear them if they said I've got a difficulty. Have you got anything that you'd say to them? James: Yeah, I would say, try to self-reflect on gambling and your relationship with it. So ask yourself, what is gambling costing me, not just financially, but including the money, but time. What is potentially gambling benefiting me and literally write those things out. And I can almost guarantee that the list of things that will be costing you will be greater than the things that you are getting benefit from. I would encourage you to really question whether you can engage with sport without having to put a bet on. That was a huge point for me is that the idea of watching sport, especially football, without putting money on it used to be an awful feeling. I couldn't bear it. And so ask yourself that. Has that become such a part of your routine that you always put a bet on when you watch the football? Do you find yourself gambling when you intended not to, how many days do you honestly think you can go without gambling? Ask yourselves those questions as a starting point. And I'm not going to tell you the answers to those because I don't think it's our job to, to tell people that I think self-reflection is really important. And that's, you know, that's something that I did for my recovery was write down all the things that gambling had done to me. And every time that I felt, oh actually, maybe a bet on the football this weekend might be fine. Cause I'm over it now. I literally got that list out on paper and would go through it and go, oh yeah, I remember now this is what it costs me. This is what it did to me. And I'm not going to go into that. And the other thing that I'll say as well is it try and give yourself as much information about gambling as possible. So again, look at Chapter One, go on the website and look at the information on there about how gambling products are designed, what the industry business model does, the whole myth of safe and responsible gambling initiatives, that kind of information might make you see gambling in a different light. And I'll give you one personal anecdote actually recently that has helped me, is that I've started to look into and read about ultra processed food. And it's really opened my eyes about the tactics and the mechanics and the playbook of the junk food, fast food industry. And it's really put me off it. It's made me think, actually, I don't want to eat this stuff because I now know what's in it. I now know how the industry operates and lobbies similar to what happened with me with gambling. So I'm always a big advocate for information. Giving people information is absolutely key. So go find it. Helen: It sounds as if, there's anything from just asking yourself some questions and educating yourself, just checking who's benefiting here, all of those kind of questions, but also places that you could go to learn more and places you can find help. And it sounds for you as if that comes in the context of a more generally healthy lifestyle as well, that you live these days. James: Yeah, if you ask my wife, she may disagree, but I still eat unhealthy food. I still have a drink. I'm no angel, but I am now much more aware of how a whole range of industries actually, do everything they can to keep us as customers, especially the gambling industry, but, you know, I feel like we're all quite attached to our phones and to social media. And that's really difficult and it's deliberate. And that's the thing that really gets me is the deliberate nature of all this and going back to gambling, that is, you know, there is a deliberate side of this. It's to generate profit at the expense of widespread social harm. And that's the thing that, you know, you mentioned passion. That's the thing that gives me the passion to know that I can counter that information by going to tell people the truth and my personal experiences are what keeps me going, drives me on, but also knowing that I have the opportunity to tell people that and tell people the truth, yeah, is good for me and I'm hoping it will be good for many others. Helen: Thank you. So if you had one key message out of all of those things that we've been talking about today, where you want people out there to know, especially if they've got a worry about a loved one or a worry about themselves. What's the one key thing that you really want people to remember from our conversation today? James: The first thing that came to my mind, it's really difficult because there's lots of things I'd like to say, but I'll stick with the one. And the first thing that came to my mind is, please don't think this is all your own fault, and please don't think it's all the fault of the person that you care about or you love. And that's really difficult, especially for that latter category of people because you may be experiencing harms and none of this is definitely your fault because you've not even gambled, and you may be experiencing harms through a loved one. But there is a reason this happens. Nobody wants to be addicted to gambling. Nobody wants to experience gambling harms. And of course, yes, people do have agency, and people are responsible for their recovery and for seeking help and for staying recovered and abstinent. But from my perspective, I will never take responsibility for being given an addiction at 16 years old and never, ever take responsibility for throughout 12 years of addiction, never being asked by a gambling company if I was okay, or if I could afford to lose the money that I was losing. And so, to summarise, try to remove this blame that people feel because that is another reason why people get to that point of feeling that they've let everybody down and it's all their own fault. So challenging that narrative is absolutely fundamental for us and for me. Helen: Thank you, James. And I just want to check whether there's anything that you would want to ask me or anything else that you'd like to say before we finish today. James: I just like to say thank you for the opportunity to speak to anyone that's listening and thank you for dedicating time to this topic. I know it's not a topic that is always high up the agenda, until it needs to be. And that's the sad truth that gambling harms are often identified way too late, or at crisis point, or at death. And hopefully, by just spending a bit of time listening to this and looking up Chapter One, you may avoid those situations. So just to thank you for me. And if anyone wants any more information on these, anything from me, you can get in touch with me through, my email address, which is, Helen: Thank you so much, James. Thank you. James: Thanks. Helen: Thanks for listening to another episode and for being part of our Let's Talk About CBT community. There are useful links related to every podcast in the show notes. If you have any questions or suggestions of what you'd like to hear about in future Let's Talk About CBT podcasts, we'd love to hear from you. Please email the Let's Talk About CBT team at , that's . You can also follow us on X and Instagram at BABCP Podcasts. Please rate, review, and subscribe to the podcast by clicking subscribe wherever you get your podcasts, so that each new episode is automatically delivered to your library and do please share the podcast with your friends, colleagues, neighbours, and anyone else who might be interested. If you've enjoyed listening to this podcast, you might find our sister podcasts Let's talk about CBT- Practice Matters and Let's Talk about CBT- Research Matters well worth a listen.  

In this episode of Let’s Talk About CBT – Practice Matters, host Rachel Handley speaks with Andrew Beck, consultant clinical psychologist, CBT therapist, and author of Transcultural Cognitive Behavioural Therapy for Anxiety and Depression. Andrew is a leading expert in culturally adapted therapies and a former president of the BABCP. Together, they explore the importance of culture, language, ethnicity, and identity in therapy and how these factors influence mental health, therapy engagement and treatment outcomes. Andrew shares his personal and professional journey into transcultural CBT and he and Rachel discuss practical strategies for therapists to approach conversations about culture and difference in therapy, as well as the evidence supporting culturally adapted approaches. Andrew encourages therapists to engage with these topics, step outside their comfort zones, and take a flexible and collaborative approach to transcultural CBT. If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on Instagram, @babcppodcasts.bsky.social on BlueSky or email us at . Resources & Further Reading by Andrew Beck The Cognitive Behaviour Therapist Special Issue on IAPT Black Asian and Minority Ethnic Service User Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to Let's Talk About CBT- Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who share insights that will help you understand and apply CBT better to help your patients. Today I'm going to be talking to Andrew Beck, consultant clinical psychologist and CBT therapist. Andrew is a former president of the BABCP and author of the influential book, Transcultural Cognitive Behavioural Therapy for Anxiety and Depression. He's also a leading expert nationally and internationally on culturally adapted therapies. So we're so delighted to have you, Andrew. It's one of the great joys of hosting this podcast, having the opportunity to read and reread the work of world experts in different areas of CBT, like yourself, and to talk to them about their work and having dipped into your book a few years ago over the years, it's been wonderful to have an opportunity to read it from front to back as there’s such a rich, wide ranging and thought provoking and practical information in it. I'm also really curious, cause at first glance, not necessarily the obvious choice of a topic for a white British therapist to write. And I'm wondering how you got engaged in this work. What's motivated and informed your interest in it personally, professionally? Andrew: Yep, it's a really good question, Rachel. And first, thanks for letting me know that it was a helpful book to you and something that was readable. It's one of those really difficult things about putting a book out there that you never know how it's landed and how it's landing, really. Because people pick it up, but you seldom hear from people about what it was like as a resource. I mean, how I came to be interested in it was through a couple of strands, really. One was quite personal, going right back to, I suppose like my early political life. I was born at the end of the 1960s. By the time I was 12, 13, the National Front who were kind of overtly racist political party were quite active in the area that I was growing up. And I think I was probably 13 when I first went on a kind of anti-Nazi league march and was listening to The Specials who were a band who really articulated the need to push back against that kind of growing tide of racism. And that was really formative for me as were some of the friendships and relationships I had during my teens and twenties, and being close to people who'd experienced discrimination at the sharp end. Really, as you say, I'm a kind of white English man, I'd never really experienced any kind of discrimination or hardship as a result of my characteristics, but politically I was interested in getting alongside people who had. So that was where it came from a kind of values point of view, I think, but in terms of how I ended up doing that as part of my job as well, is, so I was quite late to psychology. I graduated when I was around 25 and one of the first jobs I had was a research job in Nottingham, looking at how and why people used acute psychiatric beds. I was really lucky in that part of the team who were doing that work was a trainee psychiatrist called Swaran Singh, who's now Professor of Social Psychiatry in Warwick, but at the time he was just sort of finding his feet as a psychiatrist. And he said to me one day, have you ever noticed how nearly everybody who comes into these wards on a section of the Mental Health Act is a young black man? And I said, no, I hadn't noticed because, you know, I was a young white man. I didn't need to notice things like that. I didn't need to recognise those inequalities because they didn't really affect me, but Swaran as someone from a minoritised background had noticed. And what he was able to do was tack onto the study that we were doing, an additional study, looking at the rates of sectioning and who got sectioned and why. And with the statistical help of Tim Croudace, we wrote a paper that showed that young black men were massively disproportionately admitted under sections, despite the fact that the severity of their presenting problems was no greater than anyone else's. So that got me really interested in inequalities in mental health care. So I was really lucky that I had someone who opened my eyes to that really at a formative stage in my career. And then I spent three years as an academic, a research assistant, research associate. The professor in charge of my department told me that I'd never be a very good academic, but I'd probably be okay as a clinician. So then I applied for clinical psychology and began to practice clinical psychology in East London, where the patient group we were working with was diverse. So from the moment that I began to learn how to be a therapist, it was learning how to be a therapist with people from different backgrounds to myself. So that's how I became interested in that quite early on in my career, really. Rachel: So it sounds like you found yourself in a time and place in your life where there are these movements going on around your natural interest and inclination to stand up against racism and discrimination. But then also these key figures that drew you in and were generous with their time and thinking and their experience to help you think about ways in which you could really enact that in your work. Andrew: Yeah, that's absolutely right. I was so lucky in that, that there were a number of people who took the time to kind of help my thinking develop really. And that was generally people from minoritised backgrounds themselves who could see I probably had some kind of enthusiasm or interest and who sort of put the time and effort into bringing me along. And I'm really grateful for that really, I was very lucky to have those experiences. Rachel: And it's evident from your own history of your involvement in this work. This isn't a new conversation. It's not something that we're arriving to just now in terms of a therapy community. However, the way in which we discuss these things often feels quite tentative and people are coming to it often quite new and without kind of fully formed ideas. One of the things that might be helpful to think about upfront as we're having this conversation is what kind of terminology we might use in this podcast and maybe more generally that is helpful, rather than alienating for folk as we talk about transcultural therapy. Andrew: Yeah, that's a really good question, Rachel. And it’s one of those things that I think when I think back about how we had those discussions, in the kind of mid to late nineties, the language that we use then was very different to the language that I would use when I first started writing about this in publications and the language that we use now is different again. And it's a constantly evolving language. And I think that's great because as therapists, we know that the way we describe the world helps us understand the world and so refining our language is really helpful. But there's a downside to that, which is, I think worrying about getting the language right can be a little bit paralysing for people and people can be so worried about saying the wrong thing that they say nothing. And I think one of the helpful positions to take is that if people are trying to do the right thing, trying to talk about things from a position of good intent, but whose language isn't quite up to date, what I think I've learned over the years is not to kind of really overtly correct them, but to just use language that I find more palatable and see if that kind of rubs off to give people that different opportunity to talk in different language about these kind of issues, because I would rather people had a go and got it a bit wrong than didn't have a go at all. But in terms of the language that we currently use, I mean, it's in a state of flux, I think, So, when I published the book Transcultural CBT, I used the term BME, Black and Minority Ethnic, because that was the most useful phrase around at the time. By the time it was published, that phrase was out of date and the preference was for Black Asian and Minority Ethnic. And so when we did the Positive Practice Guide, myself and Michelle, we used the term BAME because it seemed like the most useful, but we knew then that term was on its way to changing. And I think we even acknowledged that in the writing, that the language that we use at this moment in time will seem old fashioned by the time you read this almost. And so, the terms used now, that there's several that are competing in a way to become the definitive one. And so the terms people use, like from a minoritised community, is quite a useful one and why people prefer that to, say, being from a minority community, is that there's an idea that being minoritised is something that's done to you, to your community, it's about being excluded. But of course, that term has been flipped on its head by some academics in this field who prefer the term global majority. And why that's useful in some ways is it recognises that most people in the world are from a non-white background. And I think there are some settings where that's clearly quite useful to articulate an idea. But I always use what I call the mum test. And that's my mum is really bright, she left school at 15 and worked, when she did work, in a shop on the checkout until she was in her forties. And then through a friend of mine went into care work and was a really good care worker and worked with kids from diverse backgrounds. And I sometimes think the language that we use to talk about these things needs to make sense to my mum. Which is, you know, someone who's a frontline worker who gets on with doing the job and who wants to do the job, isn't discriminatory, but needs a language that they can make sense of. And so I always ask myself when we're thinking about these new terms, how would that land with my mum? Would she be able to make sense of it in order to do a better job by the people that she's supporting and looking after? So, I’m not entirely sure where I'm going with that other than to say that it's quite complicated and coming up with the terms that are going to be most useful is by no means an easy thing. And of course, it's not my role as a middle-aged white man to come up with them either, it’s sort of, I listen to what people are saying and prefer and kind of get alongside that when I can. Rachel: I loved where you started there where you talked about defining our language helps us define our thinking, which is important in therapy, but it sounds like what you're saying is it's not a final statement, it's an iterative process. In therapy we define our thinking, we have Socratic dialogue to understand what we're thinking so that we can then test that out and change that thinking or modify that thinking if it's helpful and useful and helps us communicate to ourselves and others in different ways. So it sounds like if we inhibit ourselves from speaking about these issues, we inhibit ourselves from learning and changing. Andrew: Yeah. And you've got to have that willingness to get it wrong. I've got it wrong so many times in my career, both as a therapist in the room, as a writer on this topic, you know, giving it a go means that at some point you're going to make mistakes, but you just fail again, but fail better next time. Rachel: Yeah, I can identify with that, and I can also identify with the idea that language can really challenge us and hit us in different ways. I remember the first time I heard that phrase you mentioned, global majority. It really stopped me in my tracks for a moment because suddenly you realise the inherent comfort in being part of a majority and that was just a helpful moment to, you know, have a little mini tiny insight into something, a baby step along the way to developing my understanding. Andrew: Yeah. That's a really nice example of just how a switch can go on. Rachel: Hopefully folk will forgive us if we are clumsy in this podcast and we can use language that people find helpful and not destructive. And given all that you've already said, it seems blatantly obvious that factors such as culture, language, ethnicity, religion, these things that are important parts of our identity as human beings would impact on the way mental health problems manifest in individuals and society at large and how people engage with and benefit from therapy also. But we're always interested in the evidence here that, that seems self-evident, but what is the evidence that these factors are important in mental health and the application of CBT? Andrew: I would say of the evidence that's out there, I'm probably on top of and able to articulate about a tenth of it, if that. So it's very much a kind of highly selective take from my point of view. Rachel: 10 percent is pretty good, Andrew, we’ll go with that. Andrew: We’ll go with that, it's a start. So emotional distress and what we might consider to be mental health difficulties occur in all cultures, in all contexts. People struggle with their feelings, with their experiences. But the frameworks within which they understand those can vary considerably, and the nature of those problems can vary too. So we know that in some communities at some points in time, certain kinds of distress will be greater, and that may be due to environment and what's going on, or it may be to do with how a particular community articulates and thinks about unusual experiences, or the things that are happening to that community at any one point in time. So all of our experiences are understood through the framework of our current culture. I can give an example of that from say panic, which is a fairly common problem that many people work with therapeutically. Now, whatever your cultural background, if you experience something as threatening, your fight or flight system will be activated and your heart will begin to beat faster amongst most other things. Now, if you're from a white Western background where we've had 30 or 40 years of really good public information about the risk of heart attacks and what to do if you have a heart attack, chances are you'll understand what's happened to you as a heart attack. This feels like a heart attack. This must be what a heart attack feels like. So then that, that burst of adrenaline is experienced as a potential heart attack and you'll act accordingly or kind of safety behaviour may be to call 999 or lie down on the floor or whatever seems sensible to you. But if you're from a culture that hasn't really experienced heart attacks, doesn't really talk about that as a kind of pressing health problem, but that may talk about particular kinds of supernatural forces that could act on the heart. When you get that burst of adrenaline and your heart starts to beat quicker, out of the blue, you'll interpret it through that lens. So you're still misinterpreting a bodily phenomena. So something about the underlying structure of what's going on is the same, but the phenomenology is different because the framework that you have for understanding is different. Does that kind of make sense? Rachel: Yeah. So I understand the world's going to influence how I understand what's happening to me. Andrew: Yeah. And then the thing that you do to fix it will vary. So if your belief is that's caused by a supernatural phenomena, the thing you do to make yourself safe would be probably to seek some kind of help that is supernatural in origin. Whereas if you believe it's a heart attack, you'll call 999. So it's your kind of, your subsequent behaviours are shaped by your cultural framework too. Rachel: So the way these problems present, the way they manifest for individuals can be quite different based on the culture and how they respond. And what's the evidence that the needs of these different communities, minoritised communities, are met well or otherwise in our mental health services in this country? Andrew: So we're really lucky in the UK and in England specifically that we've got the IAPT or NHS Talking Therapies data set. So that's unique, I think, in the world in giving us the ability to look at really large numbers of mental health consultations and see what happens. And we've known, from the IAPT data sets that in the early days of IAPT, so looking at the kind of new and pilot site, for example, people from minoritised backgrounds had as good an outcome as people from white backgrounds in therapy, probably because that team in the pilot site was multicultural in itself, had chosen to work in Newham, which was a famously multicultural area and had the kind of expertise to do that work. But we also know from that pilot is the access was lower for people from minoritised backgrounds. So some things were changed, including self-referral that enabled people from minoritised backgrounds to get better access. So we know that in some instances, at some times, access and outcomes can be as good for people from minoritised backgrounds, but if you look at the national picture in NHS Talking Therapies, we can see that both the access and the clinical outcomes have been worse for people from most, but not all minoritised backgrounds. So people from a Chinese background in Britain had as good a rate of access and outcomes as white service users right from the start, but compared to people from, say, a Bangladeshi or Pakistani background whose access rates were much lower and whose outcomes once in therapy were much lower. So we know that it's very uneven picture both between different teams and different ethnic groups. And that's the same for, look at, for example, psychosis services. And we know that you need to be much more unwell to get a service if you're from, for example, a black British background in psychosis services and the less likely to get kind of wraparound care and are more likely to be admitted still 30 years after Swaran and I's work highlighting this, still more likely to be admitted under the Mental Health Act. I think there's a lot of evidence from within England and the wider United Kingdom, that there's still these gaps. But the good news is, over the past few years within NHS Talking Therapies, the gaps have closed and so you can see that, for example, if you're from a black British background, your access and outcomes are now as good as people from a white background when accessing NHS Talking Therapies. So it is possible to close the gap, but it needs resources and effort, but there's still a long way to go for some other communities, like, for example, the Bangladeshi and Pakistani communities, but the Indian community has really closed the gap and it's almost equitable now. We've still got a way to go. Rachel: And what have the major initiatives been that have closed those gaps? What's changed, do you think? Andrew: I think we're lucky in, in both SMIs, Serious Mental Health Services in the UK and in NHS Talking Therapies, in having had really outstanding leadership around this. And I know more about NHS Talking Therapy, so it's probably better I talk about that more than the SMI field, but the kind of leadership who set national strategy and policy, recognise these gaps and put resources into closing them by getting people the training that they needed, giving people the kind of feedback from the data sets that we've got about what was going on, by ensuring there were frameworks available to help improve services. So that's been a real success story over the past few years in NHS Talking Therapies. And I know that there are similar initiatives going on in the kind of serious mental illness field, for example. And one of the reasons that's been the case is that it’s sort of outstanding leadership within the psychiatric professions, actually, who've really done a lot of that work in the SMI field. Where I think there's still a really big gap is in CAMHS. I think so little is known about whether children and young people from minoritised backgrounds get their mental health needs effectively met in CAMHS, because there aren't those kind of big data sets available that we've got in NHS Talking Therapies to monitor that closely, but small bits of research have shown that there are gaps but I'm not sure there's a national strategy to close them, really. Rachel: So like the whole issue of discrimination more broadly in our culture, it’s a huge issue, no one can say job done, but there are encouraging signs that these gaps can be closed if we focus on them if there's good leadership and a real sort of sense of energy and motivation to address those issues. Andrew: Yeah, absolutely. And one of the things I think has really helped as well is, if you look at workforce data, NHS Talking Therapies has a diverse workforce. So it's going to be much better placed to close those gaps than services, for example, traditionally clinical psychology services, which haven't been particularly diverse. I mean, that's changing slowly, but I do think one of the reasons for the success of NHS Talking Therapies, as well as the leadership, is that there's been a diverse workforce who've taken up those challenges and the same in SMI fields as well. I think, psychiatry has always been a very diverse field of medicine and that's really helped psychiatry to an SMI service to get the house in order. Rachel: So bringing this all into the therapy room, if you like, you have a really wonderful, practical, helpful chapter in your book about how to discuss ethnicity and culture with individuals we work with in therapy. I guess I'm not alone in having some anxieties that sometimes hold me back from attempting to adequately broach these areas of difference in therapy. And I'm wondering from your work and your experience, what you think it is holds therapists back in having conversations around these issues. Andrew: I think it's probably the same kind of thing that makes therapists avoidant of all sorts of things that would be helpful for their patients, like experiential learning and exposure and things like that. We're anxious about getting it wrong and because as cognitive behaviour therapists, we know that what we do when we're anxious about something is we avoid it, and we put a lot of effort into avoiding it. But I would say if people are a bit avoidant, do a bit applied practice and see what happens when you drop your avoidant behaviour a couple of times, and notice what happens to the therapeutic relationship, the engagement and how the session goes. And then you can compare, if I ask about these things and if I don't ask about these things, what difference do I notice and check it out experientially. But actually what we know from asking patients- I was involved in a bit of small-scale research some years back, just ask patients in therapy, do you want your therapist to ask about your ethnic background? And these were all patients who are service users from a kind of minoritised background themselves, unanimously said, I want to be asked, and it would improve the therapeutic relationship. So we know that's what patients want, but if you're not sure, and it's understandable people might be a little bit avoidant, drop your avoidant behaviour, be a good cognitive behaviour therapist and see what happens. Rachel: I think that’s really interesting what you said about it potentially improving the therapeutic relationship because I think that's possibly what often holds people back, they're worried about damaging the therapeutic relationship in some way if, as you said, they get it wrong and that can often drive that avoidance can’t it?. But actually the patients are saying, no, this is what we want. Andrew: And you might get it a little bit wrong, but it's better than getting it totally wrong by not asking. And I suppose, what's that phrase? Don't let the, don't let the good be the enemy of the great or the great be the enemy of the good. Something like that. But you know, give it a go. Give it a go. Rachel: And if we are to give it a go, if we are to, you know, try and get our mouths wrapped around some of these conversations in therapy. What is most helpful? What are the ways that you’ve found, or research and studies have found that there are helpful? You know, is it something we went to broach early on in therapy, or is it later on when we've got more of a trust built up, or do we need to ask permission to have these conversations, or is there anywhere in therapy it's particularly important to bring this up? Andrew: Yeah, I think it's a bit layered. Early on, the first time you're in a room with someone, you want to establish that good working relationship using all those non-specific therapy skills of active listening, unconditional positive regard, non-verbal skills to put someone at ease to build a degree of trust. But then I would say within the first sort of one or two sessions, and often within session one, as someone's begun to relax into it, just a simple question like, is it okay if I ask a little bit about who's at home? Now that enables you to start to draw out a genogram. So I'd recommend a genogram, whether you're working in adult or child services, as a way to map who's at home. And then you could say something like, I would say because I'm white, I'd describe my ethnicity as white. How would you describe yours? How would other people in this genogram describe their background? And so you begin to add to the genogram a sort of a bit of cultural mapping on that as trust is developed. And I would say in the first session, you might just ask about broad ethnic categories and you might begin to explore a little bit as trust is a bit more apparent, something about, for example, faith background, migration histories. So things that are a little bit more of a challenge than just, you know, I describe myself as British South Asian, or I describe myself as Jamaican, into a bit more about how people identify the individual you're working with and some family members. And then once you've really developed a richer relationship of trust, you can go on to more challenging topics like experiences of discrimination or Islamophobia or the kind of aspects of marginalisation. So you're building trust over time and taking more risks in terms of what you talk about as that trust and that therapeutic relationship grows, that's the kind of rough approach I would take. Rachel: It sounds like you're talking about early on really opening the door to those conversations and a nice sort of graduated approach to that. But I guess if the door is open, if people know that you're comfortable talking about those things, they can push the door open much wider if they want to at any point. You mentioned genograms, now a lot of therapists, particularly working in with children and in environments where we're thinking a lot about the system, the family system or wider system might be really familiar with using those. Some CBT therapists may never have used a genogram in their life. How would you describe that sort of simply as a tool? Andrew: So I suppose a genogram is a bit of a family tree, really and it's just a way of representing who's who in somebody's life and typically with genograms, there's some sort of introductions to genograms on YouTube you could take a look at, but you use lines to represent relationships between people and there's a sort of format for doing that, how you would show a kind of romantic relationship, how you would show children and siblings, and then shapes to represent people's gender. Now that's an interesting one because, when genograms were developed, it was a square represented male, and circle represented female. But now the way that people talk about their identities become much more kind of multifaceted and complicated. And there's a whole bunch of additional genogram shapes to represent, for example, trans, nonbinary identities. There are ways of doing genograms to show gay relationships that's all easy to find on the tutorials that are out there. One of the things I would say around doing that is, don’t assume heterosexuality when you're doing genograms and assume that someone's relationship is someone of the opposite sex and so just ask a little bit about who are they in a relationship with, can you tell me a bit more about them and try not to make those assumptions. Because if you do make those assumptions about heterosexuality, it then closes down discussions about sexuality as well, which is quite important or gender identity. It's quite simple, but it's also quite complicated, but start simply and start with the kind of ABCs of genograms and then develop your practice from there. Rachel: And it can be a lovely collaborative and pictorial tool that you can really share and get a lot of information out of. And as you're talking, it's reminding me of intersectionality in our identities and who we are and how actually a lot of what you talk about in your book on Transcultural Cognitive Therapy gives us hints and tips and clues as to how we might approach some of those other aspects of identity, like gender identity and other aspects that we often fumble around in therapy as therapists. When it comes to assessment and formulation of presenting problems in CBT, most CBT therapists or people using CBT as part of their therapy, usually have a list of assessment areas, you know, a couple of decades in, I still have my kind of prompt sheet when I'm doing the assessment, cause I forget things routinely, you know, they might be thinking about presenting problems, predisposing issues, precipitating, perpetuating, maintaining factors, goals, aspects of personal and family history and things like that. Are there ways in which we might need to adapt our assessments to provide us with important information about culture and ethnicity that might usefully inform our formulations for therapy? Andrew: Yeah, I think on the whole the things that people are already doing don't need much adaptation once you've started a discussion about difference, because those sort of predisposing, precipitating, maintaining factors, are there for most people's struggles, but what we include in those probably needs to be adapted. And I give one example of that, it's a topic that I didn't write enough about in the book, but that we wrote a little bit more about in the Positive Practice Guide, but that I've sort of tried to write about and think about more since, which is people's experiences of racism. And because the reason I didn't write about it in the book was that, you know, I'm a white man and I didn't need to have it forefront in my mind and it's only while I've been going out and doing training on this that, that people from minoritised backgrounds have pointed out that I needed to think more about it and do more about it in the therapy room. But if you think about experiences of racism, we know from the research that someone's from a minoritised background, or someone's from a LGBT background as well, for example, the more discrimination that you experience in your life, that's a cumulative risk factor for developing a mental health problem. So that experiences of racism can be a predisposing factor. But from our formulations, it might be that a particular incident of discrimination is the precipitating factor. So, it might be the thing that set off the thing that's got someone struggling and coming to see you. But actually, ongoing discrimination might actually be part of the maintaining factors. So those struggles that people have because of their characteristics can be predisposing, precipitating or maintaining. And one of the ways I sometimes formulate that is using a bit more a narrative formulation of why me, why now, why still, and so discrimination can fit into either of those kind of spheres really. So I think the basic stuff that everybody does well, still stands, it's still genuinely useful. And if you just add to that a kind of sensitivity to and willingness to think about people’s worldview, experiences, and the marginalisations. It just kind of enriches it really, rather than needing to reinvent it. Rachel: And we think a lot in therapy, don't we, about being curious and asking people and not making assumptions about people's experience, which all of this really, you know, points towards and then some, you know, asking those questions of people and being willing to hear about their experience. But I'm wondering, is there a line to walk between burdening a person with educating you about their ethnicity and culture and how it might inform their problem and empowering them to tell you and actually just educating ourselves? Andrew: It’s a great point, so I've been really influenced by systemic family therapy in the way that I've thought about adapting CBT. I got to do some systemic training early on in my career and really value the way that as a model, it was way ahead of CBT in its adaptation. But one of the things I think in systemic practice that they talk about is almost a relentless curiosity. I get the impression in some of the research or some of the practice literature, it's sort of relentlessly asking about someone's family life and dynamic. And I think that is potentially over intrusive. Actually, what you need to know about is just enough to help someone get better and if you want to learn about another culture, there’s loads of ways of doing that, that aren't in the therapy room. The therapy room is just for learning enough about that particular person and that particular moment in time to help them make some shifts. And the additional learning is what you do in your own time through books and films and getting involved in community associations and getting out into the world. Rachel: And I know that I've had colleagues and friends and even trainees on programs I've been involved in running that have at times, because they've come from a minoritised background, have felt burdened in providing that sort of expert advice to their white middle class therapist friends. Is that something we need to be cognisant of as well do you think? Andrew: Yeah I think that’s a really good point because if you think about the power structures within most mental health teams, it's usually people with my characteristics who are the most powerful, the best paid, the ones in the most senior positions, drawing on the expertise of people who are less powerful and less well paid within the organisation, who may not have the time and the capacity to educate everybody. And so I do think there's a sensitivity needed there that our colleagues and friends aren't resources to draw on. But if we are going to ask people's advice or thoughts or reflections, I think getting permission to ask is really useful. And one of the many things I've sort of taken from family therapy is not asking questions about something directly. So, to not say, can you tell me about how racism impacted on you when you were at school, for example, but to say, is it okay if at some point I ask about your experiences of racism at school and let me know when might be a good time? And so to shift the power dynamic away from you demanding a resource from someone, to checking if it's okay and giving them the choice about when that might take place and a choice not to do that at all. So I think that sort of shift in the way you might seek it out is useful. But ofcourse there are people in our networks who would very much see that as part of their role to do that as well and part of their job. And I'm thinking specifically about chaplaincy services. So, if you're lucky, you’ll work in a trust that's got a multi faith, multiethnic chaplaincy service and my experience is generally they see their job as in part helping staff in the hospital or in the trust understand the communities that are served. So that might be a resource that's a more kind of reasonable one to draw on because they absolutely see that as what they're there for. Whereas a colleague who's another therapist doesn't come to work to do that. Rachel: So again, some really fantastically practical ways to ask questions and who to ask them of as well that are really helpful there. You said that we just need to know enough to help folk. We don't need to keep going to be massively intrusive. So once we've established the problem presentation and informed ourselves around the kind of aspects we've spoken about, is it then just okay to roll straight ahead with the disorder specific evidence based models we have for the particular problem presentation? I'm thinking of, there was a quote in your book, Andrew, which hit me quite starkly when I read it. You said that there's no evidence to support the idea that because someone from a different culture meets the diagnostic criteria for a particular disorder, the problem can be formulated in the same way as it would be for a white service user in a Western context. That seemed like quite strong and potentially quite anxiety provoking statement for your average CBT therapist trained in the UK. I know the model, I've got to apply it. Can you say a bit more about that? And I think that example you gave about how the panic disorder, for example, might be experienced differently by an individual already started to suggest ways in which you may or may not apply some of the same strategies and approaches. Andrew: Yeah, we've got to be really modest about the limits of our knowledge, I think. And there's a whole world of research about the cross-cultural applicability of diagnostic categories, first of all, but because as cognitive behaviour therapists, we're not tied to diagnostic categories that closely, but we are tied to disorder specific models. And there's lots of thinking about the degree to which these are useful or not across different cultures, because we've got to be honest about the fact that most of the diagnostic categories and disorder specific models were developed by white researchers from their work with white patients. However, we also are beginning to realise that many of the patterns that we see, you can see in other cultures, perhaps not all cultures at all times, but in some cultures at some times. So you wouldn't want to throw out the models that we've got. But you'd need to hold them lightly, and I think what I mean by that is to have a kind of modesty about the models that we offer to patients and say, well, if we think about it in these terms, what am I missing? What might we need to add for this to make sense. What bits don't fit your experiences? And so be prepared to, even when someone looks like a real kind of real barn door case of a particular model that we're keen on, confident with and think we're going to use, to be prepared to modify or even fully abandon that if the patient doesn't have a sense of it reflecting their own experiences and the patterns that they've noticed. Now that's true for working with white service users as well. That willingness to hold our ideas lightly is important, but it's even more important when we're taking a particular model across cultures or into different faith groups or people with very different worldviews and experiences. So start with what you know, I guess, would be my advice but hold it lightly because we do know there are really good trials of CBT for OCD from lots of different cultural groups that have been effective. Great work done in North African Muslim communities using OCD that's had some modification to take into account faith and spirituality but is largely like we recognise CBT for OCD. So we know that these models travel fairly well, but with that person in the room at that time, just be prepared to be a little bit flexible. Rachel: You know we don't want to engage in a different kind of discrimination of not offering evidence-based treatments to people and assuming somehow that they're not going to be applicable. But I really liked that phrase, it's one my mum used to use a lot, hold things lightly. And it reminds me of that phrase we often use about CBT being collaborative empiricism, you know, this idea that we're finding out together and often I think when we adapt for difference of whatever sort, what we're doing is we're just refining our CBT to be better with all the people we work with. Andrew: I think when we step into that willingness to be flexible, and I like that phrase, kind of really collaborative and really empirical, all of our CBT gets better, doesn't it? You know, that flexibility, that willingness to get alongside people's lives, just makes us better therapists in general. Rachel: And I guess on that, you know, we've been thinking about how we discuss difference with individual clients. Is that only an issue when the person sitting in front of me is of a different cultural background or ethnicity or gender? Or is that something we should be thinking about with apparently very similar folk to ourselves? Andrew: Yeah, it is, isn't it? I mean, one of the reasons that we might want to hold that in mind are things like socioeconomic difference. It can be really helpful when we're working with service users who are really poor, you know, who missed appointments because they don't have the bus fare to get there, who are struggling to pay their bills to say, I recognise I'm in a steady job in the NHS, and some of those struggles you're having financially are ones that I don't currently have. I wonder how I can get alongside you to better understand what that's like? And likewise, around issues around sexuality, I think it can be equally useful to acknowledge difference and similarity when we're working with service users. But of course, all of us will have different levels of comfort with self-disclosure as well. And of course, self-disclosure is not something we're obliged to do, but nor is it something we're forbidden to do in CBT. We, all of us will be a different way along a spectrum of how useful we find disclosure and I think as long as we can rationalise that and have checked in using supervision, that the level of self-disclosure we're using is in the best interest of patients, you know, that can also be a kind of useful tool. And if I could give an example of that from my own life, I've married into a Punjabi family. Now, I don't talk about that routinely with patients, but there are sometimes in therapy when it has been useful for me to let someone know that I've had that experience and that it's sort of enhanced the therapeutic relationship. There is a sort of benefit to a level of disclosure of difference or similarity. But I don't think anybody is obliged to bring that as a therapist. Rachel: No. And presumably gives you lots of insights as you just live life with your family into the experiences people can have from multicultural backgrounds? Andrew: Yeah, I mean, it's more giving me insights into how little I know, despite what I think I might know. It’s been a good lesson in cultural humility. Rachel: So once we're then thinking about what we don't want to withhold CBT, we want to adapt, we want to hold it lightly, we want to do this curious and collaborative process. So how can we go about thinking about adapting CBT then without throwing the baby out with the bathwater or just entering a perpetual state of therapeutic drift? Do we have handrails? Are there best examples of how we can take a robust approach to adapting CBT in transcultural contexts? Andrew: I think on the whole, the models you will have been trained in and used will be useful. And the thing that needs adding is the willingness to think about different phenomenology, and what I mean by that, is different views about what things mean and how they impact on people's lives. And that can take all sorts of forms, it can be around the degree to which and the importance of other family members thoughts, feelings and behaviours so something that's a little bit like a systemic approach to CBT. Because in some families, the beliefs and behaviours of others can be as important as the beliefs and behaviours of the person that you're working with. Ofcourse that can be true in white service users and their families too. But for some minoritised communities, it's really important to be able to hold that idea that the problem exists within a system and there's a kind of collectivist approach to thinking about it that you might not be used to with the more individualised CBT. But other adaptations are, I mean, many of us from white backgrounds are from either sort of atheist, agnostic or fairly lightly religious worldviews. And I think being able to recognise that you'll be working with people who have very strong views about the world that are informed by faith, spirituality and the supernatural. And that's quite a different perspective on the world to the one that you might have. And just that willingness to get alongside that, to not see that as a sort of a faulty worldview that perhaps needs correcting or that can be safely ignored, but to just see it as one that a richer understanding of that will help you understand the dilemmas that people bring to therapy, or the stuckness they may find themselves having or why particular thoughts are especially abhorrent to them. And then I think lastly, it's just being willing to recognise that, as I said earlier, that those sort of predisposing and precipitating factors might be to do with discrimination of many kinds in a way that we're not trained to necessarily think about in mainstream CBT as usual. But that actually can be very readily incorporated into the models that we use. So they're the kind of, as you say, the handrails to bear in mind, really. Rachel: And there are different models of adapting CBT, aren't there? So you speak in your book about culturally adapted CBT and culturally sensitive CBT. Could you say a little bit about how those might differ? Andrew: Yeah. And it's one of those areas I keep changing my mind about, in the sort of five years, six years since I wrote it, it might even be longer now. So it's probably 10 years since I wrote it then, cause it takes a couple of years to get it out there into the world. What I think is that there are some examples of CBT that were, where researchers and clinicians from a particular ethnic or religious group took CBT and translated those ideas into a different language, and in a way that reflected the values and beliefs of their particular group. And then delivered CBT in that language with that framework and that's what I consider to be culturally adapted CBT. It's been done from the inside by people who are within a particular community, for people in that community. And we know that's effective and that works. But in a UK setting, most typically you'll have therapists from any one of a number of backgrounds working with service users from any one of a number of backgrounds. And so that culturally adapted approach may be of limited use, and what you need is a kind of an approach that I call culturally sensitive or culturally responsive that enables you to flex your use of the model to take into account that the kind of whole experience of the person that you're working with, but that's very flexible and adaptive. So I suppose one of those approaches, culturally adapted, is for a particular community by a particular community. Culturally responsive or culturally sensitive has that kind of wider applicability and it's probably more useful in more settings in the UK. Rachel: That's really helpful. And again, I know you've given examples of how that's been applied in PTSD, for example, in different settings and really usefully used. At risk of getting very esoteric and philosophic, are there any even more fundamental problems with the underlying assumptions of CBT that we need to engage in? For people out there that are thinking, well, you know, CBT largely formed in Western individualistic culture, the strong cultural norms or widely held assumptions about the locus of therapy being addressing the individual thinking and behaviours that are key in their maintenance. And that it is their responsibility to change that or within their power to address that, can that apply transculturally or are there other things we need to consider? Andrew: That's a really tough question. I'm going to, I'm going to have a go at it, but I probably won't have a very good go at it so apologies in advance. I think, you know, the therapies that we provide, and it's as true of any other kind of therapy as it is of CBT assumes that, that come in, meet in a kind of, health services setting for 50 minutes a week and thinking about your difficulties and what you might do differently is a kind of universally understood way of overcoming problems. And of course, we know that a lot of the problems that people come with are to do with things that are outside of their immediate control, which may be about housing, poverty, discrimination, climate collapse is another area that people are increasingly interested in. So making that assumption that the responsibility for change can be wholly with one individual and that 50 minutes a week thinking about it is enough to empower them to do that is a bit naive, isn't it really? And that's probably one of the reasons why not everybody gets better in therapy, you know, even the best trials with the most straightforward cases, 30 percent of people show no improvement. Within NHS Talking Therapies, if a service is getting a 55 percent recovery rate, it's doing really well. And I think that is a little bit about all those other factors. But I would say, and I really want to empower therapists around this, as a therapist, you can help someone have an impact on some of those other factors too. And that might be just as simple as someone who's in really substandard housing that's impacting on the health of themselves and their kids, in an unsafe neighbourhood whose mental and physical health is deteriorating as a result. You writing in a really clear and strongly worded letter to the housing authority about that can make a material difference to those processes. And you may not feel like you're particularly powerful sitting in a therapy room on your own, but a letter on headed noted paper that's sent to the right people and perhaps even copied to some other people can shift some of those other factors that aren't just about unhelpful behaviours or being over engaged with your thoughts. So actually, there's stuff that we can do as therapists that is effective. Now it's not to say that we ought to be social workers because we'd be poor social workers. We're not trained to be good social workers, but there are things that we can do that still might make a difference. And that includes things like liaising with the immigration services if someone's mental health is to do with uncertain immigration status and threat of being detained. Or referring them to someone who can do a benefits review if poverty is a big part of what they're struggling with. So there are things that we can do around the edges that might nudge things in the right direction, but I'm very much sympathetic to the idea that a lot of it is other things that takes political will to change in the long run. Rachel: Yeah. And that is an encouraging idea that, you know, we do have potentially some power. We can use what power we have in the face of what we see, often feels like, you know, growing picture of discrimination and poverty, et cetera. And I guess that kind of leads quite nicely to thinking about how this work can be personally challenging for us as therapists, because we can encounter shocking prejudice in the world as we're talking to our patients. We can also encounter shocking prejudice in ourselves as we do this work and that we are unaware of as unconscious biases that we bring that sometimes this work highlights to us in very stark ways. The mistakes we make in therapy can feel very high stakes, as we talked about, you know, not one even wanted to broach some of these conversations in case we get it wrong. If we're, whether we're recently trained or really experienced, it can still be hard to learn to adapt our practice or change our practice. So it strikes me that good supervision must be really important in this area. And I'm wondering what the role of supervision is in this work for the therapist. Andrew: I'm really glad you highlighted that this work can be a challenge therapist in all sorts of ways, including just being exposed to how tough people's lives are. And because we're a bit used to that in terms of being exposed to say people's trauma history and their experiences of, I don't know, childhood sexual abuse, violence and neglect. We're a bit trained for that, but we're less well trained for exposure to people's experiences of discrimination. And that can take a toll on us. And I think it's, you know, talking to colleagues from minoritised backgrounds who I think find this particularly painful when they're working with service users whose experiences of discrimination mirror their own so much, but also, you know, therapists from white backgrounds can find it difficult to be exposed to this world of discrimination that they've maybe been able to ignore up until that point. And I think having a supervisor that you trust, is a really good starting point, but very few supervisors have been trained in working with this kind of material. And what I would say is if you've got a supervisor who isn’t that comfortable in having these kinds of discussions, it's better to be upfront about that and to recognise and say, I noticed that when I brought that, that seemed quite a difficult topic for you. I wonder if there's ways that we can work together to make this a more kind of useful topic. Because responsibility for supervision going well is both the supervisors and the supervisees, and it's okay for you to raise that with the supervisor if they're not managing it very well. But I do think supervision is important and supervisors can help you recognise vicarious trauma and when that may be impacting on you and to help you do something about that or reduce its impact. But I think it is important to find supervisors who are capable of having those discussions or to nudge them towards doing better if they're not. Probably particularly important if you're a therapist from a minoritised background yourself, and if you don't feel like you get that kind of support in supervision to look for other ways of developing kind of peer support networks around that kind of work that might help sustain you. So we've got a long way to go, I think. Rachel: Yeah. Are there ways in which supervisors can access training or think differently, upskill that might help them in these areas? Andrew: Yeah, we've done bits within BABCP before. So myself and Michelle Brooks both do some supervisory training on thinking about difference and diversity, both how to help supervisees do better in this work, but also specifically how to support supervisees from minoritised backgrounds. So, keep an eye out on the BABCP's CPD program. We sometimes run things at conference as well. There are few opportunities, I'm afraid, probably there's more these days within clinical psychology training because many of the courses now as part of their push to have more diverse trainees include some training for supervisors on that. So if you're clinical psychologist and you have trainees, you probably got a good route in there. But for many cognitive behaviour therapists, just watch what BABCP is offering. Rachel: And I know from the clinical psychology world, there's lots of evidence emerging around both the negative impacts that people have had from poor, transcultural supervision, but also the positive effects that there can be when these things again are broached and made normal to speak about, that emotional processing is part of these things as part of supervision, as is a space in a non-shaming, non-blaming way to reflect on our own biases and assumptions that we come face to face with sometimes in this work. Andrew: Yeah. And good supervision can really help with that, can't it, in a way that sort of supports and challenges. Rachel: And you mentioned earlier on that an important aspect of culture for many people is their faith, their religious faith or their spirituality. And I think this is a huge topic and hopefully we'll do some further podcasts in this area, but it often isn't brought to the table explicitly in therapy. And you said one of the reasons might be because there may in the Western culture be sort of less strongly held or less commonly held faith beliefs. But I think even as therapists with faith, as I would identify, it can feel like a no-go area in therapy. Do you have thoughts about why we might be reluctant as CBT therapists to engage in conversations about faith? Andrew: Yeah. Cause we certainly are reluctant, aren't we? And yet if you're working with someone with a faith background, your faith shapes the way you see the world. It shapes your values, your actions, what you consider a good life to be, the things that you will want to do more of and not want to do at all. And I think to miss this misses an important part of many people's identity. But I think the kind of origins of psychological therapies and yeah, going right back to Freud is a world where God was considered to be not that important anymore. And so it's not been built in to our kind of any of our psychological therapy models. But if we think as cognitive behaviour therapists, we're interested in people's views of the world, then our views of the world is shaped by our faith and spirituality. So understanding that can be really useful. And I think understanding it can be a helpful way on people's pathway to recovery as well, because people's faith may give them very clear expectations of how they will live, what they will do. And if they're not able to do that as a result of their mental health difficulties, identifying the kind of barriers towards living a desired life can be a really useful therapeutic tool and a real motivating tool to help people make some shifts. But I would say, one of the things I do when I do training on this is I get people to work in pairs and ask your partner, what do you believe? Do you believe in God? What are your beliefs about what happens when you die? What do you believe about the supernatural? And it's usually one of the noisiest parts of the day, because people absolutely love being asked those questions. Because how often do even your closest friends say to you, what do you really believe? And why I do that is for two reasons. One, it helps people get used to asking that question. But the other is, it helps us understand our own position a little bit, because I think if we're working with someone and asking about their faith background, it's useful to just be able to recognise our own and recognise how our own faith background might shape the way we ask someone else about theirs and how we might see theirs as well. So I would recommend, if you don't get a chance to go to training on this, just find someone at work and say, look, I want to do this exercise. I just want to spend five or 10 minutes asking you about your faith. And then you can ask me about mine and see how it feels. Rachel: If nothing else, it'd be a wonderful behavioural experiment in the limits of Britishness and no-go topics in the workplace. Andrew: Yeah, I think it was Alistair Campbell who said, when he was working in Tony Blair's team, and someone asked about Blair's faith and Campbell said, we don't do God. Rachel: We don't do God. That's right. Yeah. And as a therapist with a faith myself, I think there is a sense of which often there are assumptions that faith of all different types can actually be a negative influence in people's life and experience. And we think about, you know, the kind of rituals and things people have sometimes in OCD or sort of perfectionistic standards, often faith is seen as feeding in a negative way. And it's really important, isn't it? To think about actually how these aspects might be positive, motivating, really goal enhancing aspects that we are working with as someone in therapy and that's true also, if they've got no faith at all, that they will have a worldview that is in a sense of a faith and informs how they want to live their lives and how they'll reach those goals. Andrew: I think we need to begin to think about faith and spirituality as an asset and something that's not problematic. That's something that can be, I think we can draw on, in order to help people make positive shifts. And also someone who has no faith, is an atheist, as you say, they'll still have a value system that's that shaped by other things and how we understand that and help them use that to make some positive shifts- I don't know if it's still the case, Rachel, but I remember reading research about general happiness as well. And I say this as someone, I'm an atheist and I'm really kind of quite a sort of, I'm very clear in my atheism, but the research evidence is that people who have a faith background are much happier than people who are atheist. Rachel: Well, that must explain why I skip into work every day, Andrew. Andrew: Yeah. And why I'm so grumpy. Rachel: Yeah, I think we both accept it's probably a bit more complex than that. So you obviously love this work, told us a story really how this has been personally important to you. It's been part of your professional life since way back. And I'm wondering what you've learned in that journey from the people you've worked with, because it's often how this work has the most impact on us isn't it? Through the individuals we sit with, we talk to, that we learn from. Andrew: Yeah. I think I've been really lucky. So I'm a middle aged white guy who got interested in this field fairly early on in its development. And I suppose I have really benefited from patience and willingness of both colleagues and patients from minoritised backgrounds to explain things to me and to help me understand life from their perspective and the challenges they face and the way that things need to be done differently to enable them to do better in mental health services. And, I think the things I've taken from that is realise the patience that others have shown me and that I want to pay that back a little bit by, you know, being available to people who are interested in this field, to give encouragement for people to step up and take on roles of developing expertise within it, as I was encouraged to do that by people, I think from a professional point of view, it is that kind of appreciating the patience of others and the encouragement of others and wanting to pay that forward a little bit. From, the kind of service users I've worked with therapeutically, it's a bit about how people have thrived, even in immense adversity and thinking about what it is that, that people have been able to draw on what kind of personal and familial and community resources have enabled people to do okay. And even sometimes really well, despite huge barriers to them doing okay. And that's really inspiring. It's been lovely to be alongside people's journeys and just see how they've drawn on resources to do well. Yeah. I've been really lucky. It's great being a therapist. Rachel: And can you tell us a little bit more about the work you're doing now, what the horizons are for you in terms of research, writing, training people? Andrew: Yeah continue to do training. I've stopped writing now. I think there's a new generation of people in this field who've got more to say and whose voices need to be heard. So, if anything, I'm encouraging people to write and I've had some opportunities to do that through, the Cognitive Behaviour Therapist Journal, and a few other forums. I've just sort of, I don't think my voice is the one that needs to be out there now, really. It's those, it's that next generation. Rachel: Okay. We're going to cancel the podcast. Cancel the podcast. Andrew's voice is not supposed to be, oh no, hang on. You still might have something to say. Andrew: Yeah, because it, and what I've got to say is listen to those new voices. Right, you know, through the BABCP journals and CBT Today, those voices are getting a platform and they're really vital and important with very new perspectives. So part of what I'm doing is actually stepping back, shutting up and encouraging others. Cause I think I'm at that stage in my career where that's the right thing to do really and, I’ve probably said most of what I'm going to say that's of any use. But the best thing I can do is give those other people a leg up to say it now. But I still get asked to do training, which is a real pleasure. And, just recently, been with my local NHS Talking Therapies team, spent a couple of days with them thinking about adaptation and supervision issues. I’m still involved in some training courses and doing small bits with the BABCP as well. I can safely say I'll never write anything else again. I think I've enjoyed writing while I've written, but I think it's the next generation's turn now and I'm really sort of at that point of worrying about the next generation and supporting, supervising that next generation and kind of waiting for them to fully take over and looking forward to seeing the next stages of this work that won't be by me you know, it will be by younger people from minoritised backgrounds mainly who will really who are already doing a great job of carrying it forward Rachel: And is there any work you would like to point people in the direction of already? And we can put some links in the podcast show notes as well? Andrew: Yeah, I mean absolutely no hesitation in saying look at the special issue of the Cognitive Behaviour Therapist on anti-racist practice. I think there's great papers being collated there. It's a fantastic resource, many of which is written by that next generation of writers. I think CBT Today always features something of interest in each issue that I recommend people take a look at and, I think they're probably the two most useful places for people to start. And I would say if you look at those resources and think that you've got something to add to that. Both of those publications are really welcoming of new voices. And even if you've got an idea that's a little bit half formed, get in touch with the editors and say, I'm thinking about this. What do you think? And you'll get encouragement and help to get it in a publishable form and get it out there. I'd really recommend people do that. Rachel: Fantastic. And I know Steph Curnow our host of Research Matters podcast and Managing Editor of the journals would echo that wholeheartedly. And maybe that's somewhere people might want to listen into the Research Matters podcast to get some ideas about the kind of research that is, is going out there. Andrew, in true CBT style, we like to summarise and think about what we're taking away from each session, but I pass the buck, you know, and I'm not a very good therapist in that sense, I force you to summarise. So, in time honoured fashion, what key message would you like to leave folk with regarding the work? Andrew: It can be a little bit uncomfortable doing this work, but the rewards for the people that you're working with and for you as a therapist are considerable. And so be in approach mode, not avoidance mode when you're thinking about diversity work, and you may not get it perfectly right, there may be things when you look back, you think, Oh, I wish I'd done that differently, but to try and to do your best is far better than not doing this work at all. And my guess is if you've got to the end of this podcast, then you are committed to this kind of work. You want to give it a go and so I would really encourage you to step into trying some of these ideas and see what happens. Rachel: That's so encouraging and inspiring. And I know you said you don't have much more to say, but I think people will really value what you've had to say today and learn loads from that, Andrew. So thank you so much for sharing all your wisdom, experience and knowledge in this area. thank you so much. Andrew: It's been a real pleasure. Rachel:  Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team That's You can also follow us on Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    

This episode, Rachel talks to Dr. Stirling Moorey about the role of CBT in supporting individuals with cancer. Dr Moorey is a consultant psychiatrist and a leading expert in psycho-oncology as well as the new BABCP President. He has worked extensively in the field of CBT and cancer since the 1980s, contributing to research, clinical practice, and supervision. They discuss how not everyone with cancer will need r want psychological interventions but how CBT and learning coping strategies can be effective for those who do and how therapists can look after themselves when working in this emotionally demanding area. Useful links: Books: Moorey, Stirling, and Steven Greer, Oxford Guide to CBT for People with Cancer, 2 edn, Oxford Guides to Cognitive Behavioural Therapy (Oxford, 2011; online edn, Oxford Academic, 1 June 2015) Papers: Serfaty, M., King, M., Nazareth, I., Moorey, S., Aspden, T., Mannix, K., Davis, S., Wood, J., & Jones, L. (2020). Effectiveness of cognitive-behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial. British Journal of Psychiatry, 216(4), 213-221.  Serfaty, M., King, M., Nazareth, I., Moorey, S., Aspden, T., Tookman, A., Mannix, K., Gola, A., Davis, S., Wood, J., & Jones, L. (2019). Manualised cognitive–behavioural therapy in treating depression in advanced cancer: The CanTalk RCT. Health Technology Assessment, 23(19), 1-106.  Serfaty, M., King, M., Nazareth, I., Tookman, A., Wood, J., Gola, A., Aspden, T., Mannix, K., Davis, S., Moorey, S., & Jones, L. (2016). The clinical and cost effectiveness of cognitive behavioural therapy plus treatment as usual for the treatment of depression in advanced cancer (CanTalk): study protocol for a randomised controlled trial. Trials, 17(1), Article 113.  Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Today I'm so pleased to welcome Dr Stirling Moorey to the podcast to talk about CBT and cancer. Dr Moorey is BABCP president elect and a recently retired consultant psychiatrist who's been practicing CBT since 1979 when he visited Beck Centre for Cognitive Therapy in Philadelphia for a medical student elective. He's a highly acclaimed clinician, researcher, and teacher, and has specialised in several clinical areas, including psycho-oncology. Stirling is particularly known for his research and work on the application of CBT for individuals with cancer. So thank you so much and welcome Stirling. Thank you for joining us. Stirling: Thank you. Thank you very much for inviting me. It's great to be on the podcast and really lovely to be contributing to what is the growing CPD offer of BABCP to our members. Rachel: And on our agenda today is an understanding of if and how CBT can be helpful to individuals with cancer and how we might apply CBT in this context. To start us off, I wonder if you could tell us a little bit about your journey into this work and what got you interested personally and professionally in working with CBT and specifically CBT with cancer. Stirling: Well, it's interesting. I think that this all began in about 1986 when I passed my membership of the Royal College of Psychiatrists and was looking for what the next job would be as a Senior Registrar. And looking for what might be research opportunities and Dr Stephen Greer, who was a wonderful clinician, but also a pioneer of research in psycho-oncology had received a large grant from what was then the Cancer Research Campaign, is now, Cancer Research UK to look at the effectiveness of psychological treatment in cancer and so he developed, was developing, what he called Adjuvant Psychological Therapy, which was a bit of a mix of some emotional support and CBT type components. So, because I was interested in and had some experience of CBT at that time, he was quite keen for me to come on board and be a member of the team. So that's how it started and really led to us doing some research but also producing our book, which was originally Adjuvant Psychological Therapy. It's gone through I think three or four editions now and has become the Oxford Guide to CBT for People with Cancer. So I got into it through really a research interest and my time at the Royal Marsden meant that we were doing quite a lot of clinical work in the liaison service as well as the research project. Rachel: And just to ask, briefly, Stirling, some people might not be familiar with that term adjuvant. What does that mean? What does that refer to? Stirling: So he called it Adjuvant Psychological Therapy because at that time, adjuvant chemotherapy was a treatment, that is still used, alongside what might be say a surgical removal of a cancer, and alongside that people would have a chemotherapy treatment. So he said, well why don't we sell this in a way to the oncologists by calling it Adjuvant Psychological Therapy, might make it more acceptable. Rachel: And do you think the fact that you had a medical background rather than, a sort of psychological background in terms of a psychology degree, that sort of pathway into psychological therapies, prepared you, drew you in particularly into this kind of work? Stirling: Yes I think I agree. I think that, having a medical background, I think gives you some advantages. It doesn't mean that many psychologists can't be very proficient at working with people with physical illness, but it does give you a different angle. I mean, I think one of the things that perhaps is unfortunate in the CBT world is that I think that biopsychosocial approach that doctors can bring, and nurses can bring is perhaps undervalued a little bit. So yeah, I think that adds a component to the psycho-oncology. Rachel: Perhaps I wonder if you can go places with your patients that perhaps psychological therapists might fear to go for that the fear that maybe their patients might think there's telling them it's all in their mind or, you know, being reductionist about what's going on for them. Stirling: I think that's right. I think that, to some degree, I don't know that being a medic necessarily comes up that often as an issue for patients. I think where the areas where it can be helpful is that you perhaps speak the language of the medical staff, doctors and nurses. So sometimes actually sort of interpreting in both directions, interpreting for the patient what some of these things mean, and vice versa, helping the doctors to understand. And sometimes we would have joint meetings with the oncologist or the nursing staff and again, that, that translation can be helpful, which perhaps is a little bit more difficult from someone who doesn't have a physical, medical background. Rachel: So you had this interest in CBT, this training in CBT, there was this momentum behind this particular area, there was funding for research into cancer. And we know now as then, but increasingly so cancer is undoubtedly a huge global concern. It's one of the most incurable diseases with, I understand, the second highest mortality rate after cardiovascular disease. Macmillan Cancer Support estimated in 2022 that there were approximately 3 million people living with cancer in the UK alone, with that number anticipated to rise exponentially up to sort of 5 million by 2040. And the NHS reports that one in two people will develop some form of cancer during their lifetime. So in that context, the context of the high mortality rates and the high prevalence of cancer, can you tell us a little bit about why we would be thinking about psychological interventions with cancer? Stirling: Yeah, I think that the good news on the psychological front is that we know that about 60 percent of people who go through a cancer diagnosis are going to be coping pretty well. They don't meet criteria for anxiety or depression, and I think that's very encouraging that there's a lot of resilience that we have. But, you know, 20 to 30 percent of people will experience symptoms of anxiety, depression and adjustment problems and that's a significant burden, I think for themselves and for health services in the past was largely unrecognised, but I think it's much more becoming recognized. People experience a whole range of reactions to cancer. The thing about cancer that I think makes it differ from other long term medical conditions is the threat to survival, is, is in our culture, associated very much more with cancer than with other conditions. But someone, say, with heart failure may actually have a much poorer prognosis than someone with cancer but in terms of the psychological impact because of the way in which we stigmatise and see the disease, that threat is often very profound. So fear of recurrence and progression is a big component of the psychological burden of cancer but then alongside that, there's also the impact of physical symptoms. There may be side effects from treatment, such as going through chemotherapy and losing your hair, having nausea, side effects from surgery, which may be major physical changes impacting body image. And also, often in later stage disease, physical symptoms such as fatigue and insomnia really impairing your capacity to cope. And plus the social impact of cancer for people losing, say their, their livelihood, losing their role, and the stigma that is still around. People don't quite know how to talk to someone with cancer. So a whole range of biological, psychological, and social impacts of cancer, that, as I say, fortunately, most people don't need psychological interventions beyond the usual support that might be necessary for any physical illness. But some people really do benefit from having a bit more of a of a look into how they're coping and how we might help them. Rachel: And that figure, you said that 60 percent figure is really striking because it's really not that long ago, as you say, so culturally cancer wasn't even spoken about, you know, it was the C word, wasn't it? People didn't even use it almost from sort of superstitious perspective, if I say it, it might get me, and to realise that, you know, 60 percent of people can adjust and cope, with respect to their psychological wellbeing seems quite extraordinary. I realised hearing that myself, you know, I have maybe some assumptions about how if this were to happen to me, it would be absolutely catastrophic and I might not be able to deal well with it. But also, easy to understand, given that sort of broad range of impacts that not only the problem itself brings, but also the treatment for the problem brings that people would need some support, potentially. So, you know, along those lines of, you know, ideas that are around and myths that we might want to bust or things that may or may not be true, we have a set of true/false statements that we often include in this podcast, which might open up some of those discussions for you. So first up, a majority of people who are diagnosed with cancer will die as a result of the disease? You may have addressed this a little bit. Stirling: Yeah, so that's no. So current figures are that something like 50 percent of people who have a diagnosis of cancer will survive for 10 years or more. And in an illness like, say breast cancer, actually the figures are that people are going to be likely to die from other causes before breast cancer causes them to die. That doesn't mean that actually there are an awful lot of people who will die from the disease, but it isn't inevitably a death sentence as people used to fear and increasingly more and more treatable, but with huge variation in survival rates. So if you're a young man and have a testicular tumour, you have an approaching a 98 percent chance of surviving. If you have pancreatic cancer, unfortunately, figures are really down still around 1 percent of people surviving five years or more. Rachel: That’s a huge variation as you say. but again, cause to pause when we think it's inevitably a death sentence when we hear those words. And how about, the next statement to people with cancer generally do not want psychological support, they just want their physical symptoms to be addressed? Stirling: I think probably on the balance, no, but it is a more nuanced sort of answer because, as you see in that figure of 60 percent of people not meeting criteria for any psychological disorder, those people may not necessarily want to have help. They may benefit from some support because there are still lots of issues that you need to be dealing with, even if that doesn't mean that you have a psychological morbidity that we would say requires sort of professional intervention. But for instance, in the first trial that we did, it was a sort of a screening trial in a way, looking at people who scored high on the health anxiety and depression scale. And they were offered either treatment or treatment as usual or Adjuvant Psychological Therapy and quite a percentage of them would say Oh, well, I’ll help with the trial. But as long as I’m in the control group because I don't really feel I need psychological support. And also looking at the outcomes of studies of CBT and other therapies in cancer, when you offer this to everyone, actually your effect sizes are quite low. If you target it for the people who have significant symptoms, then you get much better effect. So we don't have evidence that it's harmful to offer treatment when people are not hugely distressed, so that's where the nuance is that actually I think everyone would probably appreciate support, understanding, good communication but not necessarily a psychological treatment. Rachel: So psychologically informed approaches may be helpful for everyone, but it makes sense, doesn't it? If you didn't have depression, you wouldn't expect to see a huge impact on your depression if you had a depression treatment would you? So that, that makes perfect sense. So how about this one then Stirling with your passionate commitment to CBT over the years. CBT is too superficial an approach to have anything to offer the kinds of key existential anxieties and questions that people with cancer present with. Stirling: No, I would say to that, that CBT isn't an existential therapy per se, but, I think in terms of the threat to survival and the cognitions that we have around prognosis and the meanings of death are things that can be really can be addressed with a CBT approach. For instance, the sorts of existential concerns that people with incurable cancer have would be say around the process of dying, the pain that might be associated with that and the distress that might be associated with that. And I think that from a traditional CBT perspective can be examined in terms of the evidence and very often people have catastrophic fears, often based upon past experiences, with loved ones at times when perhaps pain control was not so good. So we can examine those beliefs. We can put people in touch with the palliative care team who are excellent at reassuring them about the ways in which pain can be controlled, etc. We can also, I've worked with the imagery that people have around dying and their own deaths, and I might share a little bit later, a very moving experience in using imagery work with one of my patients around that. And then the other area, other areas around projection into the future, what will happen to my family, again, what might I be able to do right now to maybe project into the future memories that I can leave with people. So all of these are very much within the CBT frame. In terms of what happens after death, maybe because we're not primarily an existential sort of therapy, there are other approaches that may address that. But we can work with fears about the consequences of if you believe in an afterlife of what that might mean for you by actually working together with sympathetic and compassionate rabbis, priests, imams to set up a sort of almost like a behavioural experiment that I'm fearing that something that, that I will go to hell. Well, let's actually get you talking to someone rather than just ruminating, being stuck in that guilt. Let's get you talking to someone who might be able to give you a compassionate view of what the future might look like. So all sorts of different things that can be taken from our CBT toolbox, even in this area. Rachel: So working with the patient's own cognitive and spiritual outlook in terms of things that are meaningful and valuable to them. So next statement. If people with cancer simply take a positive attitude to their illness, they'll be more likely to recover. Stirling: The answer to that is no. That first trial that we did, Stephen Greer was very interested in the sort of psychophysiological aspects of psycho-oncology because he'd done a study that had found that women with who'd had a mastectomy, who had a fighting spirit, were lot likely to survive longer than those who didn't. And so this trial was in part aimed at to seeing if we could improve prognosis. In fact, it was quite underpowered in terms of numbers. It did show that we could improve psychological adjustment, but no impact on disease. And subsequent studies have really showed that actually having an optimistic, positive approach doesn't have any impact on your prognosis but does have an impact on your well-being and your coping. Rachel: It's an idea that I think is so prevalent in our culture that somehow there's something that individuals can do just about how they fight cancer or how they, as you say, that, that term fighting spirit, how they man or woman up to it is going to affect the outcome. And that's very interesting to hear what the research says about that. Stirling: Again a sort of just a little also a caveat is there probably is some research that people who are depressed may have poorer prognosis, but whether that is a psycho-immunological effect or whether it's a sort of simply the fact that you perhaps engage less with treatment if you're depressed I don't know, but there's some suggestions that the helpless, hopeless stance may not be,so good. But not that if you think positively, you'll beat this. Rachel: Yeah, you can't think it away. Stirling: Yeah Rachel: So final statement for our true and false section then, treating people with cancer is unrelentingly depressing and difficult as a CBT therapist. Stirling: Very definitely no. There are strains and costs, I think, to working exclusively in this area, but I think one of the things that is most obvious when you're working with people with cancer is that an awful lot of people will have very good coping strategies but have decompensated as a result of the threats of the disease. So actually they can regain those strengths, they can remember those strengths, they have the resilience so they bounce back quite quickly with some brief treatment. There will also be other people who perhaps have longer term problems who already have a history of depression or mental illness who will be more like the patients we usually see in secondary care and so on but actually in many ways the patients that we're seeing are going to be easier to treat in a way and very rewarding to see that rebuilding of their skills quite quickly. Rachel: So, in contrast to what we might think, it's not a depressing prospect treating someone with depression where it's just a kind of downhill process. Actually, you can see this bouncing back, these rewards, these positive outcomes despite the picture of the illness. Stirling: And I’m not sure if this is on your list of myths, but a related myth I can tell you is that if you have incurable cancer then you're inevitably going to be depressed And actually, there's a meta-analysis that showed that the levels of anxiety and depression in people in palliative care who have cancer that can't be cured are around the same as those in people going into an oncology service. So actually, again, it's that resilience but our job is to help the people who perhaps aren't so resilient to cope better with the illness, whether it's either through fear of recurrence or through a knowledge that they are going to die and the negative impact of that on them. Rachel: So I think we've established quite clearly that when we're talking about CBT with folk with cancer, we're not talking about treating the cancer per se. We're not necessarily looking at the outcomes of the cancer diagnosis, but we're thinking about providing treatment for these associated psychological, but also social, and psychosocial functional changes, et cetera. Can you tell us a bit about evidence base and clinical recommendations for the application of CBT with cancer? Stirling: There have been a lot of studies of cognitive behavioural type interventions in cancer. They range from sort of more coping type strategies, often delivered in groups, delivered to people across the board, whether they have distress or not to more focused individual CBT in both second and third wave sort of approaches. And so generally, the finding is that CBT does have an impact on anxiety and depression. We know also that it can be helpful particularly with the insomnia in cancer and with pain and fatigue so lots of studies demonstrating that so overall the evidence is that CBT is an effective treatment and with suggestions that results can be there at least a year after the intervention. When you compare it, head-to-head with other treatments there isn't really evidence that it's more effective for people with cancer with their depression and anxiety. Rachel: So what other therapies has it been compared with? Stirling: So compared with more supportive type therapies, sort of emotional expressive supportive therapy, which is another sort of slightly more humanistic approach. So it's as with I think we could say with a great number of things, particularly depression not possible when you do head to heads to show benefit of CBT as being particularly more effective. Though with the cancer studies the effects, the sample sizes are often quite small, so it's quite difficult to show necessarily a more beneficial effect. We'll talk a little bit more, I think, about the study we did at St. Christopher's Hospice, where we trained nurses to, do CBT, first aid CBT, in patient’s homes when they were visiting them as clinical nurse specialists. And what we found there was an effect for anxiety but less of an effect for depression, but no more than the group who received usual support. And I think there is something about the support that you receive in a clinical setting, or if you have a controlled treatment that is supportive that is really important for people with cancer that actually then means that specific techniques like CBT are added in to that it's not really a placebo effect, but it's a basic effect of having a supportive relationship is a big component of what people benefit from when they're dealing with a serious physical illness. Rachel: So it sounds like there might be slightly different benefits across different treatment targets. So whether that's depression, anxiety and who it's delivered by and in what context. Stirling: I think of the impacts of physical symptoms like insomnia and pain that we would see a benefit of CBT. There have been a lot of studies that have actually compared CBT for insomnia, say, with an active treatment but my, my, my guess would be that for those, sort of more specific problem type areas, we would have some benefit. Yeah. Rachel: And is there a sense of differentiation in effectiveness across different types of cancer or different stages of cancer? Stirling: Again, this is, I think, not clear. There've been a number of studies that people with advanced cancer that have showed an effect. The study that we did, the CanTalk study that we did within IAPT, had some rather disappointing and surprising outcomes. And here, what we did was we helped clinicians who were working in IAPT to have one day a week training in CBT for people with cancer. And then the study took people with advanced cancer who were currently depressed and allocated them to treatment as usual or 10 sessions of CBT within IAPT. And it was a flat line, neither group actually showed any improvement. So we didn't even get a placebo type of CBT. So that was a large study of 200 people. It's not quite clear why there wasn't any effect there, but I think it does, it does tell us that it may be that the skills that you need for working with people with more advanced disease might need a bit more specialist sort of input. So that sort of brings us, I think, to the recommendation. So recommendations are that people with cancer should get a sort of a stepped care approach. That's the professionals in working in oncology services and so on should have some training in communication so that they can give appropriate support. But at the next level, we're talking about perhaps more telephone type support and input of group support and so on. Moving up to the next level, which is psychological treatment services within the cancer setting.  I think that there are lots of reasons why treating people with active cancer or with more advanced disease in IAPT is not appropriate. And I think in the, in the guidelines, really cancer is seen as a chronic illness, a long-term condition but Talking Therapist services are going to be focusing more on people who've recovered and the fear of recurrence problem. And we know that, for instance, if you follow up people after a successful treatment for their cancer, over time the incidence of depression is no different from that in the normal population, the healthy population but the incidence of anxiety disorders is four times as high. So I think this is where IAPT can offer something with perhaps some support from psycho-oncology services. but people with active cancer are probably best treated by psychological services embedded within the hospital because of those, you sort of started to talk at the beginning about what being a medic can bring to it. I think that actually working within that setting, can probably be more helpful than going out to a psychological treatment service separate from that. Rachel: So that multidisciplinary approach can really enhance and support the treatment. Stirling: Exactly. Yes. Absolutely. Rachel: So, given these recommendations, we have said that not anyone, not everyone by a long stretch will need psychological intervention. But for those who do or have some of these issues that might benefit from this kind of approach how widely available is psychological therapy for them? You know, would someone your typical individual diagnosed with cancer in the UK, for example, be likely to be offered psychological support at some point in their cancer treatment pathway? Stirling: It's very variable. Pathways sort of are now being developed in most areas, most regions and, and certainly, most hospitals would have, clinical nurse specialists who are working in cancer, who have some of those basic support skills and counselling skills, and some of them have CBT skills too but it's patchy still. It's patchy and many places don't have liaison psychiatry or psychological therapy services. So it's a I think still a little bit of a postcode lottery. Rachel: So it sounds like this is an area where dissemination is really important to enable people to have that equal access to that treatment that, that can, in the right circumstances with the right presentations be really helpful to them. Stirling: That's right. Yes, Rachel: In many areas in CBT currently, there've been really big developments in dissemination around offering self-help or supported self-help or technology assisted CBT to improve that. Is that something that's happening in cancer? Stirling: It is. There are sort of brief interventions, both more general ones and more specific ones for things like insomnia and fatigue and so on. Telephone based, computerised, all sorts of things. It makes sense to provide that, whether just how effective it is, I think, is still, in question and the meta-analyses that I've looked at, I've read, suggest that there's not enough data yet to know how effective those low intensity interventions might be. We would hope that they would be, for instance, if you take people who've recovered and have fear of recurrence, one meta-analysis found that it was more face to face treatment over a period of a month or more had a better outcome than the briefer telephone based treatments And so on. So I think it's early days, but you know, our hope is that we'll find that way of disseminating Another way of doing it is that Kath Mannix, who is a CBT therapist and palliative care consultant has developed is what she calls first aid CBT and this is an approach where we train physical health professionals, so clinical nurse specialists, but also a lot of oncologists have come on the training in basic CBT principles that they can use sort of generically in their work and these include really being able to develop a problem focus, being Socratic in their questioning, using some basic behavioural, maybe mainly behavioural activation, but some behavioural experiments and some simple cognitive restructuring. So the trial that we did at St. Christopher's where we randomly allocated nurses to either getting training or not, and then following up their patients, we found that for anxiety there was a significant reduction when the nurses who'd been trained were working with that. So that's another way as of actually trying to embed some of this in the work that, that the physical health professionals are doing. Rachel: And it does speak to, doesn't it, that importance of training and, evidence-based skills because those nurses are fantastic. I can imagine just having those folk involved in your lives would in itself have a positive effect, but the fact that there's that additive effect of this training really tells the story, doesn’t it? Stirling: I think probably the take home message from the nurses and from the study with that is that they are already trained in listening and supportive counselling skills. But what they found was that actually learning to step back and to do a five areas diagram, either on paper or just in their head, stopped them from doing what they, I think they hadn't realised that they were doing, which was reassuring, and which was problem solving. So simply creating that space and teaching people Socratic questioning, allowed them to maybe hold some of the anxiety that they were feeling in the situation. And we would think these are very experienced professionals who wouldn't be doing that. But we found what they were doing was automatically saying, oh you're feeling a bit anxious Well, I’ll get the social worker to see you or oh you've got some pain and you're really worried about that, let's think about how we might increase your pain control and they learnt to actually sit back And ask a little bit more about what the thoughts and feelings are around the pain, looking then at some of the safety behaviours they might be using or not jumping in straight away to reassure. Rachel: So allowing individuals to build that resilience to internalise those coping strategies to take charge of their own journey, if you like, rather than jumping in and trying to solve everything. Stirling: Exactly. Yes. Rachel: I'm guessing given what we've spoken about the multitude of problems that can present and presenting issues that we might be working with a CBT therapist in cancer there probably isn't such a thing as a generic CBT with cancer formulation. Are there key maintenance factors you might be targeting in this work across presentations? Stirling: Yeah. Yeah so, this is a whole day's workshop really… Rachel: Excellent. I'll give you five minutes. Stirling: in five minutes. So thinking about the sort of the adjustment model that I would use is, to think in terms, if you're formulating someone with cancer, to think in terms of two major threats. So the first one is a threat to survival, which is unique, not unique to cancer in terms of a life threatening illness, but it’s different from, say, something like diabetes or other long term conditions. So, what is the threat to survival? And we can understand that in terms of an adaptation of Lazarus and Falkman's model. So how do I understand the diagnosis? Is it something that I see as a death sentence? Is it something I see as a challenge? Is it something I see as a huge uncertain threat? And then how do I see my capacity to cope with that? So can I rise to the challenge? And if I feel that I can rise to the challenge and I have an optimistic view then that promotes a fighting spirit or what you might call a resourceful spirit to be able to deal with it. But then other people might be focusing very much on this is a loss or a harm, I can't do anything about it and therefore, I'm helpless and hopeless. So, firstly, understanding the threat to survival and then the second threat is really the threat to the self, the self-image. So threat to the image of yourself, maybe as a competent person who can be in control of your life, maybe threats to your perception of your body image which may be important to you. How is that changing? Threats to your social role and so on. So I think understanding generically the cancer in those terms is important and when we talk about maintenance factors, I think we have to remember that we're dealing here often not with a steady state which we would be in traditional anxiety or depression. We're dealing with a process of adjustment that is changing over time. So the threats will be changing as maybe the disease progresses or you experience treatment or you end treatment and so on. And again, in terms of maintenance factors, the difference between a coping strategy and a safety behaviour is less clear cut so, taking an example, any form of avoidance, we would want to get rid of in traditional CBT for anxiety or depression, but sometimes actually making a choice to focus your attention on something else is going to be an adaptive strategy. So in terms of what we know about effective coping. I've been quite impressed by a simple three C's mnemonic that someone has developed for coping with disasters, but it works very well with cancer. So it's about control. So if you're coping, you maybe have can exert control over the disease through complying with treatment, etc. But also control over other aspects of your life that you still can exert some control over by making sure that life goes on. Second C is coherence so it's giving meaning to your experience. We know that people who are able to actually make sense of the cancer in terms of how this fits into their life experience sometimes actually grow from it, sometimes even see benefits that they find in this horrible situation. And then the third C, which we have a lot of evidence for is that social support, connectedness really makes a big difference. And so if we think about the sorts of non-coping behaviours, they're very similar to what we see in anxiety and depressive disorders. So, avoidance is not generally not good, rumination and worry are generally not good. On the more interpersonal front then Actually, people can get stuck in reassurance seeking or over dependency but on the other hand, they can also get stuck in excessive self-reliance. So, actually, the beliefs that they have about it being a weakness to ask for help can prevent them from getting that connectedness and getting that social support. And so, I think, in terms of how we might formulate it, thinking about those threats to survival and to your self-image. And then looking at how those threats are processed and the coping strategies that may be using or you may not be using, that might be adaptive or maladaptive, but there isn't a single sort of statement about what the best way to cope with cancer is cause it's unique for every person. so that's. That's, yeah, we could go on, but that’s a brief overview. Rachel: That's very clear. I know we normally have a challenge to ask people to do that without boxes and arrows being an audio podcast and you did it beautifully, even without being without giving the challenge. And I guess, you know, there's lots that will be familiar to our listeners in there as therapists around thinking about those coping strategies in life that are seem to be ubiquitously unhelpful, like, you know, rumination and worry and avoidance or isolating oneself, et cetera. But again, in common with other problems that we might be intervening with the key factor of formulating the individual. So understanding whether avoidance is actually a positive or a negative coping strategy for that individual depend, I guess, on the function that it's having for them. Stirling: I think that I see that one way of thinking about the function is this something that is moving me towards something that's important or valuable or useful? Or is it something that I'm doing to try and move away from my emotional distress or from something else? So actually, if we're moving towards, sort of think about this in sort of ACT sort of terms, if it's moving towards a valued goal then that is going to often be more effective as a strategy than doing something just to actually reduce your distress if that makes sense?. Rachel: Yes, that makes a lot of sense as I'm thinking about how someone might, for example, be perceived as avoiding certain social situations that they feel a sense of discomfort in. And we might want to say, well, this is not furthering your connectedness. This is, you know, putting you in an environment where you might be more likely to ruminate and worry, but actually they might be exerting some control over how they're choosing to spend their time and how they're spending their time meaningfully and valued activities. Stirling: Exactly. And I think that, when you have relatively sort of reduced energy levels, if you're going through say a chemotherapy or radiotherapy, which we know makes people very fatigued, then actually making decisions about what's a wise thing to do here. And I think, as you say, but it also depends to some extent on whether that avoidance is driven by an anxiety about how you're going to come across to people, what they'll think of you versus is driven by actually it's I don't have the energy to see these people and perhaps use some of my coping strategies to deal with them not knowing what to say to me, not knowing how to ask about my situation, right now, I don't think I have the resources to do that, and that's fine. Rachel: So having asked the impossible question of you to condense a whole day's workshop on maintenance factors and models into a few minutes on this podcast, I wonder if I can ask yet another impossible question, which is there sort of a typical approach to then treating these issues, you know, given these key maintenance factors, what are the main cognitive behavioural strategies one might be using? Stirling: Well there isn't a typical approach and it depends, to some extent on the circumstances and the time you have. So working in palliative care and sometimes also working with people who are undergoing treatment, you have relatively short space of time. And so actually being much more problem focused can be really helpful and again, as I was saying that people have that capacity to cope already. So, if they're not, sort of very decompensated, then focusing on, oh, you've got some avoidance because of those social anxieties like you mentioned. Let's plan, map that out with a five areas model. Let's look at what the maintaining factors are. Let's get you going. With other people, if you have a little bit longer, I do find it really helpful to look at the developmental model to understand what the meaning of cancer is for you, why often it's around people having beliefs about needing to be in control and cancer par excellence is the threat that takes control away from you because you don't have control of your body, you don't have control of your treatment, etc. And so helping people to understand how that their past experiences, their current beliefs, how cancer sort of pulls the rug from under them, I think can be really helpful. And one piece of advice I think I would give to therapists is, if you can find some time to understand the meaning of cancer for the person, that can really help to engage them, I think more and it may be one of the things that perhaps was a bit lacking in the CANTORC trial. I don't know, because I think that talking therapies therapists, may not be so familiar because they go in with a problem descriptor, what's going on, what's the diagnosis, what's the model, let's get on with it. Actually creating that space to understand what does cancer mean to you, and therefore understanding why you're trying to cope with it in the way that you are is going to be helpful. In terms of strategies, I think, behavioural activation for people who are helpless and hopeless or depressed is really an effective treatment strategy because very often people sort of throw out the baby with the bathwater. Because I can't do some of these things I used to do, there's no point in doing anything. Because I can't be the person that I used to be, I've given up. So simple behavioural activation is often very helpful. As I've said, sort of behavioural experiments around the particular focus of something like social anxiety or fatigue leading to reduced activity and then cognitively the challenge really is what do we do when we're working with realistic negative automatic thoughts. How do we help people to evaluate whether thoughts are helpful or not, as well as whether they're realistic, which requires maybe a little bit of thoughtfulness around and sensitivity to how you deal with the cognitive elements of the response to cancer. Rachel: I wonder, we've talked a lot about sort of meaning and values and understanding. This is a dynamic process in which people are not in control of there's a reality of that. I wonder is there any place for an integration of or even indeed intention between sort of second wave and third wave approaches in CBT to these kinds of presentations. Stirling: Very definitely. I think firstly, we’ve always been using some of these third wave techniques. I think I'm going to be writing something for tCBT, for the Cognitive Behaviour Therapist updating the article I wrote on coping with adversity some years back and I’m thinking of calling it where coping with adversity where second and third waves meet because I think there's a danger that we throw out the second wave treatments, and just go for things like sort of mindfulness or ACT or something with people with sort of serious physical illnesses. And the second wave treatments can still help us because we know that, in terms of coping strategies, problem focused coping is one of the most effective coping strategies that people can use. So still being able to look at what are the problem areas that you're bringing, how can we help you do effective problem solving is going to be good for many people with early-stage disease and a good prognosis. We can do a lot of work around their catastrophic misinterpretations of what's going on and the possibility of they're coming to the conclusion that they're inevitably going to die when we have a lot of evidence against that. So all of those second wave can still be very helpful. And bringing in third wave things where you're facing, here's a problem that that can't be solved so how do I then manage this? And, I think there is sort of this rather false dichotomy between the two approaches and a treatment like Dialectical Behaviour Therapy very overtly actually deals with both. So the dialectic is actually we're about change and we're about acceptance. So bringing acceptance methods, I would be using mindfulness with most of the people with cancer. I introduce them to it as a way of accepting thoughts can be really helpful with the ruminations and worry and I'm increasingly using imagery as sort of based methods, which, now are they second wave or are they a third wave in the sense that I see them as more constructivist? They're not really about challenging the evidence, they're not about as sort of the positivist view of is this true or false, they're about can we create new realities here that are helpful to you. So yeah, so I would say yes, I think we can bring the two together. Rachel: And perhaps we've talked about, haven't we, another podcast which talks more in depth about this integration of second and third wave and there are all sorts of false dichotomies made and put out there. The idea that you can do second wave CBT without attending to someone's meaning and values seems to me like very bad CBT full stop but the idea that you wouldn't also formulate what things people can change in the third wave approaches also seems a very simplistic approach to helping anyone. I'm reminded of the serenity prayer as you're talking, this idea that the courage to change things I can, and the serenity to accept the things I can't. There's something about working across that space, isn't there? Stirling: Yeah, absolutely and the wisdom to tell the difference and that I think really sums up this this line of work. Rachel: And many of our listeners will be experienced at working with working with depression, anxiety using CBT, and you've talked about how perhaps the sort of direct treatment of this kind of area in transplanting that into Talking Therapies services might not be effective. There might be lots of reasons for that particularly around kind of understanding and pursuing the meaning of the cancer to individuals. Are there things that therapists should be aware of if they're trying to formulate and work with these presentations in the context of cancer and just trying to sort of wholesale transplant their skills across? Stirling: Yeah, so I think that the good news is that you have all the skills that you need. It's not that different working with someone with cancer and even someone with incurable cancer. So those as we've said those sort of maintenance factors are still there. You have this the skills, you have the Socratic questioning skills and so on. I think the first step is to really try to understand the person. So there's a danger that we get too caught up with the problem and get into problem solving too quickly. So firstly, really properly understanding what cancer means for this person and validating that experience for them that I think is a slight difference from how maybe you might be approaching some of these things in IAPT services sometimes. I think good therapists inevitably always treat the person. But, but remember that, this is a person who's going through a really often traumatic life experience, so that's one tip. The second one is really around empathy, and we'll talk a little bit more about this perhaps when we talk about how we look after ourselves, but you mentioned the existential issues in cancer and this is an area where actually we all have that existential issue of sorry to tell you Rachel, but you're going to die. Rachel: Now that comes as a shock to me, I thought I was the exception to the rule. Stirling: So that's universal and we spend a lot of our time pretending that we're not although intellectually we know we are, but when we're face to face with someone who perhaps is going to die or for whom that threat is very real, that can both activate our own issues about death, but we can also when we respond and relate to the person, we can get rather caught in thinking that we do understand what it's like for them. And so it's actually asking the silly question, what's so bad about dying? Because unless we understand that person what it's like, we can jump to the conclusions that we know. So that's one another area looking at your cognitive empathy. Are you really properly understanding what this person's experience and similarly in terms of a more emotional empathy. Am I getting dragged down by the sadness of this person's life because I can relate to it so well. Another tip is really thinking about how your behavioural activation work might need to be adapted if someone is physically less well. But again, this is something that in working with long term conditions people will be very familiar with. And then final tip on apparently realistic negative thoughts. And, I would suggest, a threefold approach to this. So, we can, first of all ask the question, to what extent is this true? What evidence do you have? So, that's our standard CBT question. That’s a more, that's a sort of a rational perspective on it. But another way that we also use a lot is to ask the question, is this helpful? So even if this thought is realistic, actually, is it helpful to you. So it may be for the person who's had thoughts about dying and is ruminating actually, those may be very accurate thoughts, but not that helpful. So can we help you to explore the pros and cons of this particular thought process or behaviour? And then the third approach is what I call the sort of more constructivist approach is, which regardless of if this is true or not, can we create alternative perspectives that might be more helpful for you? And, and there it's more being aware of perhaps times when the patient says things like, well, you know, it's brought my husband and I closer together and just asking that. Oh, well, how was that? How is that's happened? What have you learned there? And what's that told you about what’s important to you in life? How has that helped you to develop your strengths? which sort of steps outside of that Oh, I’ve got to find a negative thought and challenge it and actually we create new alternatives, it's building on people's strengths and the meaning that they give to life. Rachel: So it sounds like, you know, finding and amplifying the positives, not Pollyanna sort of, you know, invalidating way, but actually allowing people to, to notice in a sense, those things that are positive and meaningful to them, even in this negative place. I'm really struck listening to you about how every therapist might do well to do some of this work Because I'm often think when I'm, when we do these podcasts across different areas, there are lots of lessons to be learned that just make us better therapists. You know, there's things you've talked about, about really focusing in and understanding and validating the experience that the individual, whatever their problem is sitting in front of us, the thinking about, you know, how we empathise and not getting caught in kind of a false sense of cognitive empathy where we think we understand what they're doing, but really, searching for the individual meaning, and not getting caught up in our own thinking. And working on all those levels with negative thoughts, you know, is it realistic? Is it helpful? And are there other perspectives, other ways of looking at this even beyond that? And you did, you intimated that, one of the things, you know, we're concerned about on this podcast is about therapists looking after themselves for their own sake, as well as for that of their patients. And people might worry about their own emotional responses and resilience to this kind of work, particularly working with people who may be terminally ill or really in dark places and how that might interfere with their therapy. So being able to support those more balanced thoughts or helpful thinking or finding those positives or, you know, knowing that this is very real tragedy ahead for the individual getting lost in that. What's your advice for people approaching this work but concerned about their ability to contain the emotional content? Stirling: I think first thing really is to make sure that you're getting good supervision and that you feel safe to bring these issues to supervision. I think that having the third person's view on the relationship in therapy and what you're doing can help you to get that little bit of distance as well as support, noticing when you are getting sort of dragged in a bit too much to identifying. It’s always good, we don't do it very often, do we? But it's always good to actually look at our own negative thoughts sometimes and do a thought record and then I think if we do find ourselves getting very caught up with how terrible this person's experience is there might be some third wave strategies that might be quite helpful. There's a distinction that people sometimes make between empathy and compassion and between the idea of feeling with or feeling for and there's an interesting study that was done in which people were asked to imagine that they were experiencing the same thing as someone who was in a disaster or some traumatic event on the one hand. And then, as an alternative, people were asked to imagine what might it be like for that person. So there's a subtle difference, but even though those two sort of instructions were only subtly different, it made a difference to the extent to which the person, the imaginer, was distressed. So, when the subject was imagining I am this person, they had good empathy but they were also distressed. When they were imagining what might it be like for that person, they had pretty good empathy but were less distressed. And I think when we're using compassion type techniques to help people to do maybe a compassion meditation on the person's experience and helping them to sort of feeling for that person, that's what we're doing. There's also, sort of, an equanimity practice too that you can do in terms of imagining or just simple statements like, you know, I can't experience or change your pain. All I can do is what I can do to help relieve it. No matter how much I want,your pain is your pain. So it's actually helping people to separate out. And the third, that another, sort of third wave type technique, that you might use actually in the session is a brief sort of meditation that Kristin Neff, who's a self-compassion teacher uses which is breathing for yourself and for the other. So we recognise that I'm here with someone who's really in a very sad state. They've just got been given news that there's no more active treatment, for instance. Yeah. And so we simply do, one breath for them and then one breath for me, because actually I'm suffering too in being with you because I'm a human being. I relate to you. I understand to some degree how horrible that must be and so that's horrible for me too. So we say one for me and one for you So it might be breathing in one for me and one feeling for you, one sense of compassion for you helping to both ground you and recognise that it's okay to be upset in this situation rather than trying to force yourself to be always a therapist who is unmoved by the people you're working with. Rachel: And that word you just used moved is quite moving, even hearing about those, there's different approaches actually, and how they might help us both hold that empathic space but hold our own space so that we can be there for the client and not stepping too far into their pain so that we can't actually help them, support them with that pain. In other ways these problems can affect us. We know as we stand up at the top of the podcast, you know, one and two people, suffer or will suffer from cancer at some point in their life. Therapists are very likely to either suffer themselves or have friends, family members, colleagues, acquaintance who are suffering from cancer at any given moment. How would you advise therapists working with patients with cancer whilst also potentially dealing maybe with their own symptoms or in relationship with people in their personal lives with cancer and they're finding that challenging? Stirling: I think we have to look after ourselves. So it may be that if you have someone close to you who has cancer and that is very upsetting for you, it may be it's wise not to take on a cancer patient and obviously if you're working in a cancer setting that's not possible. But if you're working in other settings, I think that you know, we need to set some boundaries sometimes for ourselves. So that's one thing to bear in mind. If you're working in a cancer setting or, you have to take on the patient who has cancer, then I think from a cognitive perspective, it can be helpful to really do some sort of what you might call stimulus discrimination. So discrimination between how their experience is not the same as my experience. So it may be, so again, we jump to those conclusions that this is the same that if they've got a poor prognosis, then my family member has a poor prognosis. Well, it may be the case, but let's actually check that out so that we remain with a rational perspective of just how much is this resonating, that's another way. I think that, it’s about, then also this, I think, for, anyone working with cancer is being able to maybe compartmentalise a little bit and to say actually, when I'm going back to the home situation, that's going to be different from what I'm doing in the therapy situation which and that means sort of looking after ourselves because as a therapist we have responsibility for the other person, as a family member we don't have the same responsibility and we maybe have to be clear about what is my role here. I'm not necessarily I may be in a position of having to look after this person, but I may not be and I shouldn't make the assumption that I have full responsibility for this person's well-being. Rachel: And I’m just aware of a couple of really inspiring colleagues who sadly in the past, recent history have passed away with cancer themselves, you know, notably Hannah Murray, who I know was celebrated at the most recent BABCP conference, who did such amazing work in PTSD through her diagnosis and a colleague of mine in the Ministry of Defence, Jonathan Young, who gave some very inspiring talks and insights into his own experience with cancer as he was going through it was really drew a lot of meaning and value from what he could give the insights that he could provide and the reflections that he had during that time. And a real gift of that to his colleagues. And I know both of those individuals as will many more that we maybe don't know of go unsung, do work through these difficult scenarios and find tremendous value in continuing to do the work that inspires them. And that has so much meaning for them in terms of helping other people. Stirling: Yes and I think a lot of people a lot of people do that. As we've said it depends, everyone has their own way of coping and so I think. For many, therapists and professionals actually continuing to work, that, when we started our, we started our work Beck came and gave us a, a sort of a, an informal seminar. And I always remember one of the phrases he says is you can't control your death, but you can control your life. And so I think that many people continue working because that gives their life meaning, it's valuable but some other people may choose actually not to. They may say actually what I value in life is something different and so I’m going to give up work and do something different. So we again, it's that it's finding the meaning for you that is most helpful and as we've said that people may find that having the diagnosis of cancer makes them re-evaluate what's important to them. I think that often people in the helping professions recognise that actually helping people is what's important to me. So I'm going to continue doing that. But if you were working as a hedge fund manager, you might have a different attitude towards your work if you had cancer. Rachel: Not that we would like to suggest on this podcast that isn't a very valuable role in society. One of the wonderful things about being a therapist that we often reflect on in this podcast is the opportunity we have to see into the very intimate details of individuals lives. And, you know, at this moment where people are taking stock of what is important to them or grappling with these big questions in life, I'm wondering what you might have learned from the people you've worked with over the years or how that might've made a personal difference in your life. Stirling: Yes. I think working with any patients, we can find things that are inspiring but it's I think the courage that people with cancer has that is always, most I know it's quite moving that when the chips are down, people rise to the occasion. They may not have thought that they would, but they do. And seeing that, I think, for me, has always been very inspiring. I'm thinking of the, I don't see many patients individually now. I've mainly doing supervision and teaching, but the last person I worked with who was had incurable cholangiocarcinoma and what I found really very, moving about was that he was able to, actually say, I've lived my life. I've got no regrets about the way I've lived my life. I've achieved the things that I wanted to achieve. Maybe there were other things that I wanted to go on to achieve, but that he said that having cancer, actually made him, grateful for everything he had and jokingly he said that for the first time having been a cis-white male, he was experiencing what it was like to be in a minority, in a minority group. And the fellow feeling he had sitting in the waiting room with other people that we're actually, we're all in this together. And he was so positive that he- I asked him and he made a whole list of ways in which cancer had enriched his life which you know was absolutely incredible and he felt that by using one of the biggest shifts that he felt that he wasn't you know, particularly it was more of a meeting from time to help him with coping strategies rather than a treatment for a psychological disorder, but we did some mindfulness together and the key shift for him, I think, was in thinking that he said that, by being in the present moment, I can appreciate what I have now with a recognition that actually things are going to change in the future. So it brings an even greater appreciation of being pain free right now, without then ruminating about the pain that might come. So, that was very inspiring. And, I think I'm sure, I think he would be okay about me sharing one of the interventions that we used, because he was okay about me sharing these things, but He had a memory of his mother's death and of her being in pain, he wasn't sure whether she was conscious or not, and he wasn't so his interpretation was that she was in great distress. She was also very frail and had lost a lot of weight and this was sort of feeding into his own fear of his own death. And that he would inevitably die in a distressed state, and he had considered, if he could go into Dignitas or something like that because of his family. So first of all, we did some, more straightforward cognitive work around what evidence he had that actually she was in distress. And the fact is that it's much more a mind reading, we don't know if that person is aware or conscious or not, but we make the assumption that actually they're suffering. And so it’s difficult to hold that uncertainty, but we don't, we don't know that. And then we did some imagery work around his mother and the image that he chose was He had a memory of her being lost a lot of weight. He carried her somewhere and he had an image of lifting her and holding her in his arms and loving her and amazingly that image then transformed his own view of his own death. So his fear of death he said just went, I don't know how much that's true, but I think that's sort of illustrates you know just the power of imagery but also his capacity to engage with and use that to really transform, so I think he was a very inspiring man. Rachel: absolutely sounds like an inspiring man and, you know, really, it's really inspiring hearing about that work and understanding even that, you know, the worst things we can imagine, or the things that have the worst meaning for us can be transformed in terms of their emotional content when we get that different perspective on them and get what we need in those moments. I'm almost struggling to move on from that. I'm so, so, so struck by that image, but we have done a whistle stop tour of this today, Stirling, at many points, we've said that these would be whole days of workshops, lots to learn. If people do want to learn more about this work, where can they access training? Stirling: Well there aren't sort of formal training programs. I think that Kath Mannix is doing some training, but it's it tends to be more around professionals working in palliative care. So, looking up her name, you'll find stuff on that. I do periodically workshops for BABCP and if you're in a Talking Therapy service, then quite often I will do a one day top up for people on the long term conditions services. If services want to commission me to do an online or face to face workshop, they could always do that. And although our book is quite old in some ways now, it's about 12 years since we published the last edition. people still find it quite helpful; I think. So that's, I would, direct them to have a look at Cognitive Therapy, Oxford Guide to Cognitive Therapy for People with Cancer, still. Still in print, I think. Rachel: And we'll put that link in the show notes for people to be able to access us. I guess one of the things we've, that has been a theme of today is the fact that there is so much more to learn, so much more research to be done around the specificity of what helps, what those effects are and also in terms of training and disseminating this treatment, you know, and hopefully, you know, where we started was with you saying that you got interested in the area because there was some momentum and impetus behind researching this, but it sounds like that, that needs to keep going, that there are lots of future avenues to explore. So thank you so much, Stirling. And in CBT we like to summarise and think about what we're taking away from each session. So in time honoured fashion, what key message would you like to leave folk with regarding working with CBT with cancer. Stirling: Well, I think the key message is you have all the skills already, they just need to be perhaps tweaked a little bit for working with people facing a life-threatening illness. The important thing is to really understand the person in front of you rather than the problem they're bringing. And if you have that at the forefront of your mind then I think it will make it much easier to engage with and work with them. And two don't make assumptions about what they're feeling, how they're feeling it, how terrible their life might be, find out, and you often find that people have the strengths and resources to cope with this. But you just need to help them unlock them. Rachel: Wow. So, CBT is about working with people, not problems and meaning is key. Thank you so much for your time today it's been really fascinating talking to you and I think, whether people are working in this area or really quite unconnected areas in CBT, I think there's something to learn from what you've told us about the processes, the understanding, the interventions and these wonderful examples from working with your patients as well. So thank you so much. And to our listeners, thank you as always for the work you do. And until next time, look after yourself and look after each other. Thank you. Stirling: Thank you Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team That's You can also follow us on X and Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    

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