Far fewer of us are trained to think endocrinologically about social experience.

Social endocrinology is a field that sits at the intersection of biology, psychology, and social context.

It examines how hormones, particularly stress hormones like cortisol, respond to social conditions such as hierarchy, power, status, control, and belonging.

Despite its relevance, social endocrinology is rarely taught in clinical training. By chance one of the leading social endocrinology researchers was a teacher on my MSc course and I was hooked ever since. Over the last few months, I’ve been revisiting social endocrinology research on stress, hierarchy, and social rank in regards to workplaces in order to aid clinical work.

This article is a summary and if you’re a clinician I hope it helps with understanding clients, and if you’re a client, I hope it helps in understanding yourself!

Cortisol, Stress, and Hierarchy: A Brief Overview

Research into stress hormones and social hierarchy began in the 1980s, initially through studies of non-human primates living in stable hierarchies.

A consistent finding1 emerged:

• High status is associated with lower cortisol - but only when that status is stable.

• Low status and/or or threatened status, is associated with elevated cortisol.

Quite terrifyingly, or liberating, depending on which way you see it, Sapolsky, one of the early leaders of the research, concluded: ”I don’t think it’s possible to look at this whole range of ways in which our behaviour is being shaped by biology and see a shred of possibility of free will sitting in there.”2

The research has since spanned into humans and workplaces, which is incredibly helpful for understanding a range of mental health difficulties.

Across multiple studies:

• Individuals higher in organisational hierarchies tend to show lower baseline cortisol and lower anxiety, when their position feels secure3. Importantly, this is a felt sense. For those with imposter syndrome, social anxiety, self esteem difficulties and more, it could be theorised that the felt sense of security is never felt despite high status.
  

• When high status is unstable or under threat (e.g. restructures, big tasks going wrong, other people being promoted, lack of growth) cortisol increases, recovery from stress slows, and the physiological response begins to resemble that seen in chronically low-power positions4
  

• Unstable power and status reliably triggers a threat response5.
  

• The positive impact of status was meditated by a psychological sense of control that status often (but not always) confers.6

This particularly matters because cortisol influences:

• attention and threat scanning

• memory consolidation

• emotional reactivity

• behavioural inhibition or freezing

As therapists, we often see the symptoms of this in our therapy rooms, combined often with cognitions that sound like:

• “I’m not doing good enough”

• “I don’t belong here”

• “I’m an imposter”

• “One mistake could cost me everything”

The moment I used to hear ‘I’m not doing good enough’ I had a tendency to move towards a core belief or self esteem issue. Social endocrinology suggests this is how we are wired when it comes to these specific hierarchical environments. When this threat response combines with social/performance anxiety, low self esteem, anxiety in other difficulties, it likely enhances their intensity and symptoms.

It is also important to acknowledge that some environments exploit these biological threat responses on purpose, particularly where discrimination, exclusion, or unequal power are present, by keeping certain individuals or groups in a chronically low-status or unstable positions.

Hierarchy Is Not Always Obvious or Real

One important nuance is across literature is that hierarchy is not always specific, it can be:

• Structural (job titles, authority, seniority)

• Relational (friendship groups, family systems, society, community)

• Symbolic or projected (“everyone here is more competent than me”)

Two people can occupy the same objective position and experience entirely different biological stress responses, depending on their perception of the situation. This is where our work often comes in.

The Role of Control: External and Internal

The research consistently highlights sense of control as the key mediator between status and stress7.

Although not always explicitly defined, clinically this seems to include at least two dimensions:

External control

• “I have some influence over outcomes.”

• “There are actions I can take.”

• “I can prove myself and recover.”

Internal control

• “I can cope if this goes badly.”

• “I can regulate myself.”

• “I won’t collapse or be overwhelmed.”

When compromised, cortisol remains elevated - regardless of objective rank.

In my own clinical work, this understanding has been especially useful when working with clients in high-visibility or evaluative roles, including leadership positions, public-facing work, professional performance, or roles where credibility feels constantly under review. Positions where one’s performance or competence feels consequential, regardless of actual seniority.

Importantly, similar dynamics often emerge within family systems where status is implicitly organised around roles, comparison, or achievement. Some families operate with clear (if unspoken) hierarchies, such as the “successful one,” the “responsible one,” etc. However, most of the social endocrinology hierarchy research is focused on workplaces, due to the quantifiable hierarchical nature making it easier to evaluate.

Nonetheless, in these contexts, status evaluation can feel ongoing, and a person’s position in the family may feel constantly unstable. For individuals who grew up needing to maintain a particular role to preserve belonging, approval, or status, not only is this likely often attachment trauma that we’re used to working with, it also activates the endocrinological response we’re already programmed for.

Hello,

I know I’ve been a little quieter on Between Sessions over the last few months, thank you for being here.

The honest reason is that my clinical work has grown significantly. Between 1:1 work, groups, and now workshops, I found myself pretty stretched (in the best way), and this space became more neglected than I’d like.

That pause gave me time to reflect on the future of Between Sessions. I didn’t want to stop, but I also couldn’t maintain what it was. I’ve also held off (aka avoided) making changes out of fear of annoying the 1000+ people who have subscribed to what the substack currently is. So, I guess this is an exposure experiment for me, too!

For those who don’t know, my clinical focus is on social and performance anxiety, imposter syndrome, and the psychology of being seen - the quieter, often hidden forms of social fear.

This Substack originally held a broad mix of research and clinical skills. But over time, I’ve realised that the broader my focus became, the less depth I was able to offer.

So Between Sessions is shifting, not dramatically, but intentionally.

Going forward, the writing here will be more closely aligned with my clinical work and research interests, including:

• social psychology

• social and performance anxiety

• imposter syndrome

• self-esteem, visibility, and belonging

There will be less general “what’s new in research” coverage, and more depth on these specific themes. I’ll also update on conferences and anything I attend.

If this direction isn’t for you, I completely understand - and you can unsubscribe at any time.

If you stay, I hope this more focused direction brings greater clarity, depth, and usefulness.

Thank you for being here - I’m glad to be writing again. I hope you enjoy this article on working with public speaking anxiety.

Sophia :-)

This article accompanies the video above and reflects my clinical experience working extensively with social, performance, and visibility-based anxiety. It is not formal CPD. Please take what is useful, critique what isn’t, and adapt it to your own model, supervision, and context. Free resources are at the bottom.

Public speaking anxiety is one of the most common - and most misunderstood -presentations I see.

It often gets folded into “social anxiety” in a way that leaves both therapists and clients confused about what is actually driving the fear, and therefore how to work with it effectively.

This article breaks down how I conceptualise public speaking anxiety in practice, including:

• the overlap and distinction between social anxiety and performance anxiety

• why some clients don’t identify with the term social anxiety at all

• how fear of anxiety itself can sit alongside fear of judgment

• why environment, power, status, and identity matter far more than we often account for

• how I adapt formulation and intervention depending on what is maintaining the problem

Social Anxiety vs Performance Anxiety

At its core, social anxiety is about fear of negative evaluation - but that fear can be organised around different threats.

Clinically, I find it helpful to distinguish (loosely) between:

Interpersonal social anxiety

This is primarily about acceptance and belonging.

Examples:

• fear of saying the wrong thing at a party

• holding back in conversations to avoid appearing awkward

• concern about being rejected, excluded, or disliked

The central threat often sounds like: “If I am seen as I really am, I won’t be accepted.”

Performance-based anxiety

This is more about competence and status.

Examples:

• presentations

• speeches

• being observed while performing a role

The central threat often sounds like: “If I appear anxious or make a mistake, I’ll be seen as incompetent.”

This is why some people can be socially confident, warm, and relaxed, yet completely unravel when they have to speak publicly.

And why others experience every social interaction as a performance, where competence is constantly being evaluated.

These aren’t rigid categories.

A presentation to close colleagues, for example, often activates both competence and belonging threats.

Why Some Clients Reject the Label “Social Anxiety”

Many people with public speaking anxiety do not resonate with the public narrative of social anxiety - which is often framed as:

• shyness

• avoidance of social contact

• generalised interpersonal fear

The DSM-5 does acknowledge performance situations within social anxiety (particularly in adolescents), but sometimes diagnostically naming the problem is often far less important than collaboratively understanding it.

I generally use whatever language feels most accurate and helpful for the client- while remaining curious about which threat system is being activated.

Two Processes, Not One: External Threat and Internal Threat

This is where public speaking anxiety often becomes clinically complex.

For some clients, the anxiety is driven purely by the external social threat:

• being judged

• being evaluated

• being seen as incompetent

For others, there is a secondary internal process running alongside it.

The external trigger

The situation itself:

• standing up to speak

• being visible

• being evaluated by an audience

This maps neatly onto the classic Clark & Wells social anxiety model:

• fear of negative evaluation

• self-focused attention

• safety behaviours

• distorted self-imagery

The internal trigger: fear of anxiety itself

For many clients, particularly high-functioning ones, the dominant fear becomes:

“What if my anxiety gets out of control - and people see it?”

This can look similar to panic-attack maintenance, even when the person does not identify as having panic attacks.

The feared outcome is often:

• freezing

• mind going blank

• visible shaking

• dry mouth

• losing control in front of others

• having to stop because overwhelmed with anxiety

The problem is not just anxiety - it’s anxiety about anxiety, especially when visibility and consequence are high.

I have many clients come through who have tried CBT for public speaking already, and their previous treatment focused on de-sensitisation of physical sensations, essentially, the panic attack protocol.

Sometimes it helps. But the problem is, often these clients aren’t afraid of anxiety sensations generally (unlike in panic disorder, where generally any anxiety sensation could escalate into a possible panic attack).

They’re only afraid of the sensations in this environment, with these people. Desensitisation sometimes doesn’t help because they’re not afraid of the sensation itself, and some do not believe they’ll have a panic attack. They’re afraid more of the loss of control over anxiety being perceived in a social context.

Work here tends to focus on not trying to control anxiety, and undoing the nuanced safety behaviours that have built up around managing anxiety itself.

Why Environment Matters More Than We Think

A key clinical mistake I see (and made in my early days) is focusing too narrowly on the act of public speaking and not the the environment in which it occurs.

Many clients don’t have a problem with speaking.

They have a problem with speaking there, to those people, under those conditions.

Important questions to hold in mind (not necessarily all asked directly):

• Why this audience?

• What power dynamics are present?

• What would it mean if this group judged them negatively?

• Do they already feel “below”, different, or exposed in this environment?

• Are there identity factors (gender, class, race, age, background) increasing visibility or vulnerability?

For some clients, the feared consequence is concrete:

• career damage

• loss of opportunity

• financial risk

For others, it is relational:

• exposure as an imposter

• humiliation

• loss of belonging

And sometimes, humiliation is the endpoint.

Status, Hierarchy, and Social Rank

This is where social rank theory becomes particularly useful.

Social rank theory suggests that humans are biologically wired to monitor status, hierarchy, and relative position within groups. Our brains evolved to track whether we are above, equal to, or below others because social rank historically affected safety, access to resources, and belonging.

In public speaking and performance anxiety, the feared outcome is often not just making a mistake, but can also be a status drop:

• losing credibility

• being exposed as “not good enough to be here”

• falling in others’ eyes

Importantly, both low perceived rank (“I must prove myself”) and high perceived rank (“I can’t afford to fall”) can intensify anxiety. The brain responds not to objective status, but to felt rank in that moment.

Clinically, social rank theory helps us understand why anxiety escalates in hierarchical or evaluative environments - and why the fear often feels visceral, disproportionate, and hard to talk oneself out of.

Crucially, some environments are genuinely evaluative or discriminatory.

Therapy should not minimise this reality - but help clients differentiate between realistic risk and anxiety amplification.

Social Identity and Belonging Threat

Social identity theory adds another layer.

When a group represents:

• professional identity

• cultural belonging

• social class / culture

• values or meaning

Rejection or judgment from that group can feel like a threat to who the person is, not just how they performed.

For many people, work becomes their primary “tribe” - especially so if other sources of belonging are limited.

Risking judgment there can feel existential rather than situational.

Formulation: Keeping It Simple Without Missing What Matters

In practice, I usually:

• start with a standard social anxiety formulation

• layer in fear-of-fear only if it is clinically relevant

• distinguish between:

  • anticipatory anxiety

  • in-the-moment anxiety

  • post-event processing

I rarely draw complex dual-loop diagrams with clients unless it genuinely helps.

This level of complexity is often more useful for the therapist’s understanding than for the client’s.

Exposure When Opportunities Are Limited

Public speaking anxiety often involves infrequent but high-stakes events, which makes exposure work challenging.

Options may include:

• imaginal exposure for one-off events

• in-session audience simulations

• creative public experiments targeting visibility and/or performance

• VR-based exposure tools

• carefully structured real-world experiments

Groups like Toastmasters can be helpful - but can also inadvertently reinforce new safety behaviours if not held in mind before attending.

In my experience, feeling safe being seen in the environment must come before performance optimisation. That’s what I do in my group.

Trauma, Memory, and Relational Safety

For some clients, public speaking anxiety is exacerbated by:

• past humiliating experiences

• bullying

• relational trauma

• chronic social threat

Imagery re-scripting or EMDR can be powerful where a specific memory is driving the fear.

It’s also common for public speaking anxiety to sit on top of broader patterns of:

• social hyper-vigilance

• panic disorder

• significant relational trauma

• low self esteem

You don’t always need to go “there” - but it’s important to recognise when public speaking anxiety is a symptom, not the whole picture.

Free Resources

Evolution of the social brain & public speaking PDF

Evolution Brain

511KB ∙ PDF file

Download

Download

Maintenance Cycles PDF

Maintenance Cycles in Public Speaking

72.9KB ∙ PDF file

Download

Download

Safety Behaviour Guide

Safety Behaviours in Public Speaking Guide

340KB ∙ PDF file

Download

Download

List of Common Safety Behaviours

Common Safety Behaviours Public Speaking

39.6KB ∙ PDF file

Download

Download

List of Common Physical Symptoms

Common Physical Symptoms in Public Speaking Anxiety

50.9KB ∙ PDF file

Download

Download

I hope you found this helpful and I’d love to know your thoughts! How do you find public speaking anxiety, both as a client or practitioner?

Sophia

References

Anderson PL, Zimand E, Hodges LF, Rothbaum BO. Cognitive behavioral therapy for public-speaking anxiety using virtual reality for exposure. Depress Anxiety. 2005;22(3):156-8. doi: 10.1002/da.20090. PMID: 16231290.

Clark, D. M., & Wells, A. (1995).
A cognitive model of social phobia.
In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69–93). New York: Guilford Press.

Gilbert, P. (2000).
The relationship of shame, social anxiety and depression: The role of the evaluation of social rank.
Clinical Psychology & Psychotherapy, 7(3), 174–189.
https://doi.org/10.1002/1099-0879(200007)7:3<174::AID-CPP236>3.0.CO;2-U

Hofmann, S. G. (2007).
Cognitive factors that maintain social anxiety disorder: A comprehensive model and its treatment implications.
Cognitive Behaviour Therapy, 36(4), 193–209.
https://doi.org/10.1080/16506070701421313

Stein, M. B., & Stein, D. J. (2008).
Social anxiety disorder.
The Lancet, 371(9618), 1115–1125.
https://doi.org/10.1016/S0140-6736(08)60488-2
(PMID: 16231290)

Tajfel, H., & Turner, J. C. (1979).
An integrative theory of intergroup conflict.
In W. G. Austin & S. Worchel (Eds.), The social psychology of intergroup relations (pp. 33–47). Monterey, CA: Brooks/Cole.

Weeks, J. W., Heimberg, R. G., Rodebaugh, T. L., & Norton, P. J. (2008).
Exploring the relationship between fear of positive evaluation and social anxiety.
Journal of Anxiety Disorders, 22(3), 386–400.
https://doi.org/10.1016/j.janxdis.2007.04.009

Many people who have experienced trauma find that talking about what happened helps, but only to a point. Some describe feeling “stuck” even after years of therapy, aware of their triggers yet unable to change their bodily reactions. This is where Deep Brain Reorienting (DBR) offers a new perspective.

Developed by psychiatrist Dr. Frank Corrigan after years of clinical and neurobiological research, DBR approaches trauma not through stories or thoughts, but through the body’s earliest, instinctive responses to threat.

What is Deep Brain Reorienting (DBR) Therapy?

DBR is a trauma-focused psychotherapy that helps clients access and process the physiological foundations of traumatic experience. Rather than focusing on cognitive restructuring or exposure, DBR starts with the body’s natural orienting response that occur before conscious emotion or defence.

The approach is built on a simple idea: the human brain and body already know how to heal from trauma if the original sequence of reaction is allowed to complete safely.

By returning attention to these subtle, pre-verbal responses, DBR helps clients release the residual tension and shock that can keep traumatic memories locked in the nervous system. ¹

The Step By Step Process of DBR

First: Grounding

The therapist establishes safety through mindfulness-based awareness and gentle body-focused attention. The goal here is to anchor the client’s attention to present-moment body awareness so that when trauma arises, the client can stay connected to both the memory and current safety.

Second: Observing the Trauma

The therapist then asks the client to bring to mind a specific trigger, scene or situation (not the full trauma story) that activates the distress and the client is asked to briefly name or imagine the trigger to produce the minimal activation needed to generate the automatic orienting response (tension in the neck, changes in breathing, squinting the eyes etc.). The therapist observes these subtle changes and asks the client to notice what happens in their body.

Third: Emotional Processing

The therapist and the client work through the emotional responses more thoroughly. This can involve exploring the feelings and bodily sensations that arise more deeply, and the therapist guides the client to notice patterns or underlying emotions more explicitly.

Fourth: Integration

The therapist and client work together to make sense of the emotional and physical responses that came up in the previous steps. The therapist can help the client connect these insights with their overall experience, and find ways to incorporate new understanding and coping mechanisms. This step is essentially about reorganising the traumatic experience in the conscious awareness in a more adaptive way.

Fifth: Reorienting

The last step is about rewiring and reshaping the neural pathways that were affected by the trauma. During this step, the therapist helps the client to develop new, healthier responses and perspectives to reinforce positive change and to build resilience. In this step, the therapist and the client can practice new coping strategies for when they encounter a trigger in the future. These strategies could be breathing exercises or imagining places where they feel safe and relaxed.

The Theorised Science Behind DBR

DBR is proposed to work through the following mechanisms. (Lots of brain science here, scroll to the layman’s section below if feels overwhelming!).

The superior colliculus (SC) in the midbrain rapidly detects the approaching or threatening visual stimuli and converts them into instinctive defensive responses, such as fight or flight. It acts as a crucial bridge between sensory perception, motor coordination, and emotional processing, linking visual input with neck and eye movement control and signalling threat information to areas like the amygdala. ²³

The responses are given as orienting reflexes. The superior colliculi activate the muscles in the head and neck, including the eyes and forehead, to initiate movement for fight or flight response. ⁴ The activation of the superior colliculus is one of the first steps in the process of detecting and responding to trauma or threatening stimuli.

In DBR, the mechanism of this brain area is significant as it is responsible for orienting tension which refers to the subtle muscular tension around the eyes, neck and face that appears just as attention turns toward a memory or trigger, which is before emotional or defensive reactions occur. During therapy, the therapist asks the client to focus on the orienting tension when recalling the triggering memory, which helps the client stay grounded and not dissociate. ¹

The locus coeruleus (LC) is located in the part of the brainstem called the pons. It is another significant brain area for DBR as there is a two-way communication between the LC and SC. The LC helps control how strong and fast defensive reactions are. During distress, the LC becomes more active and sends signals to the SC, which makes the body react more quickly to threats. Thus, threatening stimuli can make instinctive fear responses happen faster and feel stronger, because the LC-SC pathway increases alertness and sensitivity to danger. ⁵

The final step of trauma activation that is significant for DBR is the activation of the pariaqueductal grey (PAG). The PAG is the escape and defensive command center of the brain, coordinating instinctive reactions to immediate threat. These reactions include fight, flight, or freeze as well as affective responses, namely, fear, greed, shame and rage.⁶ In DBR, it establishes the physiological sequences that therapists guide clients to notice, helping resolve frozen or dys-regulated trauma responses.

What This All Means in Layman’s Terms

When something feels threatening, the brain automatically gets the body ready to protect itself. First, it notices danger (through the eyes and head muscles), then it increases alertness and prepares for action, and finally it triggers instinctive reactions like fight, flight, or freeze.

In Deep Brain Reorienting (DBR) therapy, these same body and brain responses are gently worked with rather than avoided. By noticing the small physical tensions that appear before emotional reactions, like tightness around the eyes or neck, clients can stay grounded while processing painful memories. This helps the body and brain complete the trauma response naturally, instead of getting stuck in it.

In DBR, the goal is to facilitate the processing of memories by guiding them along a natural pathway of trauma activation, starting from the superior colliculus (SC) to the pariaqueductal grey (PAG). This ensures that the memory is encoded in a healthier, more adaptive manner.

Comparison with TF-CBT

Top-Down vs. Bottom-Up

Deep Brain Reorienting (DBR): Bottom-up approach. It targets subcortical trauma responses such as fight, flight and freeze through bodily sensation and implicit memory, calming the nervous system before conscious processing.

Cognitive Behavioural Therapy (CBT): Top-down approach. Focuses on conscious thought and beliefs, using exposure, reasoning and cognitive restructuring to change emotions and behaviours.

Explicit vs. Implicit

Deep Brain Reorienting (DBR): Focuses on implicit memory and consequential bodily procedural responses and emotions and analyses unconscious processing.

Cognitive Behavioural Therapy (CBT): Focuses on the explicit conscious thoughts, beliefs and recent events. May bright to light previously unconscious meanings.

Regulation vs. Completion

Deep Brain Reorienting (DBR): The goal is to calm and stabilise the nervous system when a trigger is encountered. The anticipated outcome is emotional and physiological regulation.

Cognitive Behavioural Therapy (CBT): The goal is to expose, resolve and restructure trauma-related thoughts and beliefs. The outcome is cognitive and behavioural closure; adaptive coping and less triggers in the present.

Recent Studies on DBR

A recent study, which included the founder of DBR, Dr. Frank Corrigan, as one of its researchers, investigated the impact of DBR on PTSD patients. 54 PTSD patients were randomly assigned to DBR and waitlist (control) groups.

The patients in the DBR group had 8 sessions of video conference based DBR. The PTSD symptoms severity was measured using the Clinician Administered PTSD scale (CAPS-5), at baseline, post-treatment and 3- month follow-up. The results indicated significant differences between the DBR and control groups, where there were significant decreases in PTSD severity in the DBR group, with a 36.6% reduction in pre- to post-treatment and a 48.6% reduction from baseline to 3-month follow-up of treatment.

On the other hand, there were no significant reductions of PTSD severity in the waitlist group.⁷ This study provides emerging evidence that DBR is a well tolerated and potentially effective treatment for PTSD.

Moving Forward with DBR. Could It Be Combined with CBT?

Deep Brain Reorienting (DBR) offers a revolutionary way to approach trauma by working with the body’s instinctive responses rather than the mind. By guiding trauma through its natural neural pathway, DBR helps release stuck tension, regulate emotions and reshape how the brain responds to threat. It is a newer therapy with limited research, but it does raise the question as to whether it may provide a bottom-up approach that could be combined with CBT?

Could focusing on the body’s instinctive responses be the break-though therapists have been searching for in trauma treatment?

REFERENCES

Deep Brain Reorienting. (n.d.). Deep Brain Reorienting – Trauma psychotherapy. https://deepbrainreorienting.com

Huang, L., Yuan, T., Tan, M., Xi, Y., Hu, Y., Tao, Q., Zhao, Z., Zheng, J., Han, Y., Xu, F., Luo, M., Sollars, P. J., Pu, M., Pickard, G. E., So, K.-F., & Ren, C. (2017). A retinoraphe projection regulates serotonergic activity and looming-evoked defensive behaviour. Nature Communications, 8, Article 14908. https://doi.org/10.1038/ncomms14908

Zhang, Q., Ma, H., Huo, L., Wang, S., Yang, Q., Ye, Z., Cao, J., Wu, S., Ma, C., & Shang, C. (2025). Neural mechanism of trigeminal nerve stimulation recovering defensive arousal responses in traumatic brain injury. Theranostics, 15(6), 2315– 2337. https://doi.org/10.7150/thno.106323

Zhou, J., Hormigo, S., Busel, N., & Castro-Alamancos, M. A. (2023). The orienting reflex reveals behavioral states set by demanding contexts: Role of the superior colliculus. The Journal of Neuroscience, 43(10), 1778–179 https://doi.org/10.1523/JNEUROSCI.1643-22.2023

Li, L., Zhang, Y., Zhang, X., & Zhang, Z. (2018). Stress accelerates defensive responses to looming in mice. Current Biology, 28(6), 1006–1012.e4 https://doi.org/10.1016/j.cub.2018.01.063

Lefler, Y. (2020). The role of the periaqueductal gray in escape behavior. Neuroscience, 437, 1–10. https://doi.org/10.1016/j.neuroscience.2019.10.020 7- Kearney, B. E., Corrigan, F. M., Frewen, P. A., Nevill, S., Harricharan, S., Andrews, K., Jetly, R., McKinnon, M. C., & Lanius, R. A. (2023). A randomized controlled trial of Deep Brain Reorienting: A neuroscientifically guided treatment for post-traumatic stress disorder. European Journal of Psychotraumatology, 14(2), 2240691. https://doi.org/10.1080/20008066.2023.2240691

I found myself absolutely exhausted on Fridays, ready to collapse for the weekend. And I realised - why? I only (I say only because this is way less people than I used to see) see around 12 people a week, and yet I’m tired.

I realised it’s because at the end of the day the stories stay with me. I exercise, do calming stuff etc. but I still feel what I’m hearing is sticking in my body more than anything.

So, I created what I needed with this recording. It’s a meditation for the deep feeling therapists who feel frazzled at the end of the day and feel they need a meditation that speaks DIRECTLY to them and gives their body permission to release all the stories they heard.

It’s not for everyone. Some people may find it cringe. That’s fine! But I thought I’d put it out there incase anyone feels they may need it too, or they know a therapist who might!

I’d love to hear your thoughts. I used it 3x last week and already feel 1000% times better and am enjoying my work much more.

Sophia xo

Music credit in the meditation: Clavier Music

What Exactly Is Rumination?

Most people occasionally reflect on the past, but rumination goes far beyond reflection. It involves a repetitive, uncontrollable focus on negative thoughts, feelings, or past events.

As Stenzel et al. (2015) define it, rumination consists of “thoughts and behaviours that focus attention on one’s negative feelings.”

Across definitions, three key features emerge:

• A focus on negative affect

• Repetitive, persistent thinking patterns

• Maintenance through negative reinforcement

In simple terms, rumination keeps people “stuck”, continually revisiting distressing experiences or regrets. Unlike worry, which tends to focus on future events and uncertainty, rumination is rooted in the past, sustaining cycles of low mood and self-criticism.

Neuroscientific findings have begun to map the brain mechanisms involved. Langenecker et al. (2023) identified reduced connectivity between the left posterior cingulate cortex and right inferior frontal gyrus in individuals with high rumination, patterns that appeared to shift following Rumination-Focused CBT, suggesting neural flexibility in response to treatment. This also suggests this is a real, neurological process, which can help shift shame from clients who blame themselves for their inability to stop.

Depressive Rumination: When Thinking Becomes a Trap

Nolen-Hoeksema (2000) described depressive rumination as persistent thinking about one’s symptoms of depression, an inward focus that maintains and intensifies low mood.

This may help explain why some individuals fail to respond to traditional CBT or antidepressant medication: the habit of rumination can maintain depressive symptoms despite otherwise effective treatment.

Qualitative research by Ciobotaru et al. (2024) provides rich insight into the lived experience of rumination. Participants described it as a kind of “mental theatre”, replaying painful scenes from the past in an effort to understand them, which instead fuels distress. Over time, this process depletes energy, motivation, and concentration, leading to fatigue and disrupted sleep.

For CBT practitioners, this raises a crucial question: if rumination sustains depression, should we target it more directly?

Introducing Rumination-Focused CBT (RF-CBT)

Traditional CBT has a strong evidence base and remains the first-line treatment for depression and anxiety. However, standard CBT typically addresses rumination only indirectly, by challenging negative thoughts or modifying behaviours.

Rumination-Focused CBT (Rf-CBT) was developed to go a step further. It places rumination itself at the centre of treatment, aiming to:

• Identify patterns of unhelpful repetitive thinking, understanding the functional reasons for rumination

• Disrupt habitual rumination loops

• Replace them with more constructive, flexible thinking styles

As Umegaki et al. (2021) note, Rf-CBT helps individuals shift from maladaptive to adaptive modes of processing, turning reflection into problem-solving rather than paralysis.

Early research is promising. Moeller et al. (2019) found that after 12–16 sessions of Rf-CBT, participants experienced significant reductions in depressive symptoms, particularly in cases where standard CBT had been less effective. This suggests that explicitly targeting rumination may improve treatment outcomes for persistent depression.

The Rumination and Worry Program: Making Rf-CBT More Accessible

Building on these ideas, Joubert et al. (2023) developed the Managing Rumination and Worry Program: an online adaptation of Rumination-Focused CBT.

This programme teaches participants to:

• Recognise when they are ruminating

• Understand the triggers and functions of rumination

• Practise strategies to disengage from unhelpful mental loops

Research by Upton et al. (2025) supports its effectiveness, showing that repetitive negative thinking (including both rumination and worry) reduces significantly over treatment. Interestingly, baseline levels of rumination predicted how much improvement participants experienced, reinforcing rumination as both a key symptom and a treatment target.

Looking Forward: The Future of Rf-CBT

Rumination is a common, trans-diagnostic process that cuts across depression, anxiety, and trauma-related difficulties. While traditional CBT remains effective for many, it may not fully address repetitive negative thinking in all clients.

Rf-CBT offers an important addition to the therapist’s toolkit, a way to directly target the thinking styles that maintain distress, particularly in clients who feel “stuck” despite prior therapy.

As our understanding of cognitive and neurobiological mechanisms deepens, therapies like Rf-CBT show how evidence-based practice can evolve — refining general approaches to meet specific needs.

Tell us, do you work directly with rumination?

References:

Brozovich, F. A., Goldin, P., Lee, I., Jazaieri, H., Heimberg, R. G., & Gross, J. J. (2014). The effect of rumination and reappraisal on social anxiety symptoms during Cognitive‐Behavioral therapy for social Anxiety Disorder. Journal of Clinical Psychology, 71(3), 208–218. https://doi.org/10.1002/jclp.22132

Dabbaghha, Z., & Mollazadeh, A. (2025). The Effectiveness of Compassion-based Therapy on Rumination and Concern in Patients with Type I Diabetes. Iranian Journal of Diabetes and Obesity. https://doi.org/10.18502/ijdo.v17i2.18849

Langenecker, S. A., Schreiner, M. W., Bessette, K. L., Roberts, H., Thomas, L., Dillahunt, A., Pocius, S. L., Feldman, D. A., Jago, D., Farstead, B., Pazdera, M., Kaufman, E., Galloway, J. A., Kerig, P. K., Bakian, A., Welsh, R. C., Jacobs, R. H., Crowell, S. E., & Watkins, E. R. (2023). Rumination-Focused Cognitive Behavioral therapy reduces rumination and targeted cross-network connectivity in youth with a history of depression: replication in a preregistered randomized clinical trial. Biological Psychiatry Global Open Science, 4(1), 1–10. https://doi.org/10.1016/j.bpsgos.2023.08.012

Moeller, S. B., Austin, S. F., Hvenegaard, M., Kistrup, M., Gran, S., & Watkins, E. (2019). Rumination-focused cognitive behaviour therapy for non-responsive chronic depression: an uncontrolled group study. Behavioural and Cognitive Psychotherapy, 48(3), 376–381. https://doi.org/10.1017/s1352465819000584

Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109(3), 504–511. https://doi.org/10.1037/0021-843x.109.3.504

Otto, M. W., Birk, J. L., Fitzgerald, H. E., Chauvin, G. V., Gold, A. K., & Carl, J. R. (2022). Stage models for major depression: Cognitive behavior therapy, mechanistic treatment targets, and the prevention of stage transition. Clinical Psychology Review, 95, 102172. https://doi.org/10.1016/j.cpr.2022.102172

Querstret, D., & Cropley, M. (2013). Assessing treatments used to reduce rumination and/or worry: A systematic review. Clinical Psychology Review, 33(8), 996–1009. Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741–756. https://doi.org/10.1016/s0005-7967(97)00022-3

Stenzel, K. L., Keller, J., Kirchner, L., Rief, W., & Berg, M. (2025). Efficacy of cognitive behavioral therapy in treating repetitive negative thinking, rumination, and worry – a transdiagnostic meta-analysis. Psychological Medicine, 55. https://doi.org/10.1017/s0033291725000017

Tulbure, B. T., Dudău, D. P., Marian, Ș., & Watkins, E. (2025). An internet-delivered Rumination-Focused CBT intervention for adults with depression and anxiety: A Randomized Controlled Trial. Behavior Therapy. https://doi.org/10.1016/j.beth.2024.12.004

Umegaki, Y., Nakagawa, A., Watkins, E., & Mullan, E. (2021). A Rumination-Focused Cognitive-Behavioral Therapy Self-Help Program to Reduce depressive rumination in High-Ruminating Japanese Female University Students: a Case series study. Cognitive and Behavioral Practice, 29(2), 468–484. https://doi.org/10.1016/j.cbpra.2021.01.003

Upton, E., Venkatesha, V., Joubert, A. E., Mahoney, A. E. J., Moulds, M. L., Werner-Seidler, A., & Newby, J. M. (2025). Mediators and Predictors of Treatment response in a brief online intervention for rumination and worry. Cognitive Therapy and Research. https://doi.org/10.1007/s10608-025-10593-2

Watkins, E. R. (2018). Rumination-Focused Cognitive-Behavioral Therapy for Depression. Guilford Press.

October 2025 Updates

➡️ OpenAI indicated plans to establish an online network of therapists that ChatGPT would route users to as needed. My next question, is how to we make sure ChatGPT knows about us as therapists? How will it choose who? Will it hire therapists itself?

In the launch, they say “that means going beyond crisis hotlines and considering how we might build a network of licensed professionals people could reach directly through ChatGPT.” This suggests OpenAI might be on the verge of putting together a list of online therapists globally. We’ll keep an eye on this and keep you updated!

➡️ Flow Neuroscience received TGA approval in Australia for its brain stimulation treatment, becoming the first at-home depression device approved in the country.

➡️ In Australia, Medibank expanded its coverage of psychedelic treatments to include Treatment-Resistant Depression.

➡️ A new pilot study examined the ketogenic diet as adjunct therapy for college students with major depressive disorder. The Nature article concluded that results indicate robust and sustained decreases in depression symptoms over 10–12 weeks.

➡️ Ireland’s 2026 Budget 2026 allocated nearly €1.6 billion for mental health services, marking a sixth consecutive annual increase and over 50% growth since 2020. However, it is still less than 6% of total health spending.

➡️ Health New Zealand launched Ask Groov, the country’s first endorsed AI-powered wellbeing guide for adults.

➡️ Exin Therapeutics (YC W25) invested $25M to build a neurotherapeutics lab in the Philippines for AI-driven brain disorder therapies.

➡️ Lyra Health launched a “clinical-grade” chatbot designed to provide evidence-based mental health support and resources.

➡️ OpenAI announced a new eight-member expert council on Well-Being and AI to guide the development of mental health-supportive AI experiences and safety measures.

➡️ A new study found that LLMs could identify human facial expressions with a high degree of accuracy. They study published in Nature Digital Health examined the ability of LLMs to identify human facial expressions and found that accuracy was highest in ChatGPT4o at 86%, 84% for Gemeni 2.0 Experimental, and 74% for Claude 3.5 Sonnet.

Since 1980, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has been the dominant framework for defining mental illness. Its promise was straightforward: standardising diagnostic criteria would improve consistency between clinicians and lay the groundwork for more rigorous scientific research. But over four decades on, many are asking whether that promise has been fulfilled.

Psychiatrist Nassir Ghaemi is among the critics calling for reform, and he’s not alone. He argues that the DSM prioritised reliability (agreement between clinicians) over validity (accurately reflecting underlying conditions), and in doing so, inadvertently stalled meaningful progress in psychiatric research and practice (Ghaemi, 2018).

The Psychiatry Letter

Why DSM is mostly false

Introduction…

Read more

2 years ago · 100 likes · 1 comment · Nassir Ghaemi

What the DSM Got Right and What It Missed

When DSM-III launched in 1980, it revolutionised psychiatry. Gone were the vague, Freudian descriptions. In came checklist-style criteria aimed at improving consistency across clinicians. It worked, at least in part. Therapists could now agree whether someone “had” or “didn’t have” a disorder.

But this emphasis on standardisation came at a cost.

The criteria were largely based on consensus, not science, and once agreement was achieved, the field stopped evolving. Ghaemi argues that the profession treated reliability as the destination, not the starting point (Ghaemi, 2013). As a result, diagnostic categories remained rigid, even as research began to show that many conditions overlap, interact, or defy the neat boundaries imposed by the manual.

The cracks became harder to ignore by the time DSM-5 was introduced. By the early 2010s, even major research institutions were voicing concerns. The U.S. National Institute of Mental Health (NIMH) publicly distanced itself from the DSM, calling for new approaches to understanding mental illness.

For clinicians, particularly in CBT, this raised an uncomfortable question: if even researchers doubt the system’s categories, how useful are they in guiding real-world practice?

When Labels Multiply but Clarity Shrinks

After DSM-III, each new edition brought more diagnostic categories, but not necessarily more diagnostic clarity. What began as an effort to standardise became what Ghaemi calls nosologomania: an explosion of new labels, many based more on expert opinion than robust scientific evidence (Ghaemi, 2013).

Clinicians began seeing clients with multiple overlapping diagnoses. Was it comorbidity, or were we just slicing up the same problem into artificial parts? For instance, symptoms of irritability, sleep disturbance, and poor concentration can appear in both generalised anxiety and major depression. Yet DSM’s checklist approach treats these as two separate conditions, when they may stem from a shared underlying mechanism (Van Praag, 1996).

Even more troubling, some changes were driven less by evidence and more by political compromise within the profession. New categories were added or removed based on consensus meetings, not experimental findings. In practice, this left many CBT clinicians treating clusters of symptoms that didn’t quite fit but still caused real distress.

A Medical Model or Just a Medical Metaphor?

DSM claims to follow the “medical model,” but in reality, it behaves quite differently from how medical diagnosis actually works. In most areas of medicine, diagnosis follows a hierarchical, rule-out process: if a patient has a cough and fever, doctors rule out pneumonia before diagnosing a common cold.

By contrast, DSM uses a flat checklist approach: if you meet five out of nine criteria, you get the diagnosis, even if those symptoms overlap with another disorder. There’s no clear “diagnostic hierarchy” to help clinicians distinguish primary vs secondary causes.

Take panic attacks, for example. In a hierarchical model, a clinician might first ask why the panic is happening: exploring whether it’s a symptom of complex trauma, PTSD, bipolar disorder, or another underlying process.

By contrast, the DSM’s categorical approach is descriptive rather than hierarchical. It allows multiple diagnoses if symptom criteria are met. As a result, a client presenting with panic symptoms might receive three separate diagnoses: panic disorder, complex PTSD, and bipolar disorder, even if the panic clearly stems from mood dysregulation or trauma responses.

This can inflate comorbidity rates and risk misdirecting treatment. For CBT clinicians, it might mean focusing on panic management techniques when the real therapeutic target lies elsewhere, such as emotional regulation or trauma processing.

Science Without Symptoms?

In 2013, the U.S. NIMH took a decisive step. Citing concerns with the scientific limitations of the DSM, it announced it would no longer fund research based solely on DSM-defined categories (Cuthbert & Insel, 2013). In its place, NIMH introduced the Research Domain Criteria (RDoC): a new framework grounded in neuroscience, behaviour, and genetics.

For researchers, this marked a promising shift toward biologically informed models of mental health. But for many clinicians, it felt disconnected from day-to-day practice.

How do you translate brain circuitry into meaningful interventions when your client is describing panic, guilt, or intrusive thoughts?

As psychiatrist Ghaemi puts it, the DSM is clinical but unscientific, while RDoC is scientific but unclinical (2018). What’s still missing is a model that bridges the gap, one that’s evidence-based but also grounded in clinical reality.

Building a Better System: Hierarchies and Dimensional Models

One response to this challenge comes from Krueger et al. (2018), who proposed a dimensional, hierarchical nosology, a model that maps symptoms onto broader spectra rather than discrete categories.

Originally developed for personality traits, the idea has expanded to cover a range of mental health conditions.

Ghaemi (2018) takes this further. He proposes a symptom-density hierarchy, placing severe, biologically rooted difficulties like bipolar disorder and schizophrenia at the top, and narrower, less impairing conditions like anxiety or specific phobias at the bottom.

In this model:

• Mood and psychotic disorders are treated as foundational.

• Personality disorders are seen as downstream effects.

• Comorbidity is reinterpreted as mislabelled symptom overlap.

For CBT clinicians, this matters. It could reshape how we prioritise treatment targets, and how we conceptualise complex cases.

But… What Does This Mean for Clinicians?

The takeaway? No system is perfect, but some are more useful than others.

Ghaemi’s (2018) call isn’t just to reject DSM or RDoC. It’s to rethink how we diagnose: to move from checklists to logic, from flat categories to layered understanding, and from consensus to science.

For CBT clinicians, this doesn’t mean abandoning what works. It means staying flexible. Diagnoses can guide, but they shouldn’t blind us to patterns, complexity, and clinical nuance.

The DSM won’t disappear overnight. But if it continues to dominate unchallenged, psychiatry risks staying stuck.

Should CBT clinicians quietly accept its limits, or push for something better? Tell us how you navigate diagnostic complexity in your practice or research!

References:

Cuthbert, B. N., & Insel, T. R. (2013). Toward precision medicine in psychiatry. Oxford University Press EBooks, 1076–1088. https://doi.org/10.1093/med/9780199934959.003.0083

Ghaemi, S. N. (2013). Taking disease seriously in DSM. World Psychiatry, 12(3), 210–212. https://doi.org/10.1002/wps.20082

Ghaemi, S. N. (2018). After the failure of DSM: clinical research on psychiatric diagnosis. World Psychiatry, 17(3), 301–302. https://doi.org/10.1002/wps.20563

Krueger, R. F., Kotov, R., Watson, D., Forbes, M. K., Eaton, N. R., Ruggero, C. J., Simms, L. J., Widiger, T. A., Achenbach, T. M., Bach, B., Bagby, R. M., Bornovalova, M. A., Carpenter, W. T., Chmielewski, M., Cicero, D. C., Clark, L. A., Conway, C., DeClercq, B., DeYoung, C. G., & Docherty, A. R. (2018). Progress in achieving quantitative classification of psychopathology. World Psychiatry, 17(3), 282–293. https://doi.org/10.1002/wps.20566

Van Praag, H. M. (1996). Comorbidity (Psycho) Analysed. British Journal of Psychiatry, 168(S30), 129–134. https://doi.org/10.1192/s0007125000298516

Content note from Sophia: This article discusses antepartum depression and its potential effects on mothers and children. While the discussion is research-focused, some readers may find the topic sensitive. We also recognise that people who do not identify as women also experience pregnancy. In this article, we use the term “pregnant women” because the current body of research is largely focused on women, but this language is not meant to exclude anyone.

Pregnancy and the transition to motherhood represent profound and life-altering experiences. These phases are accompanied by a complex interaction of physical, emotional, and psychological changes that can significantly impact a woman’s mental health. Among the most prevalent challenges is antepartum depression (ADS), which affects up to 20% of pregnant women during pregnancy.

ADS can severely impair a mother’s social and physical functioning, increase stress, and lower quality of life (Abbaszadeh et al., 2013). Importantly, the effects can extend beyond the mother, maternal depression during pregnancy is associated (not always) with complications in gestation, negative maternal health outcomes, and long-term cognitive, emotional, and behavioural difficulties in children exposed to depression in utero (Gentile, 2017).

Given the high prevalence and far-reaching implications of ADS, early and effective intervention is vital, not only to support maternal well-being but also to promote healthy developmental outcomes for the child.

Traditional Treatments and Their Limitations

Research has shown that Cognitive Behavioural Therapy (CBT) and Interpersonal Psychotherapy (IPT) are effective in reducing depressive symptoms in pregnant women. For example, van Ravesteyn et al. (2017) and Claridge (2013) demonstrated that these psychological interventions significantly improved symptom outcomes in women diagnosed with Major Depressive Disorder (MDD) during pregnancy.

However, despite their clinical effectiveness, as you may have found yourself, these traditional treatments are often met with low adherence and high dropout rates. The structured and time-intensive nature of CBT and IPT may not be feasible for many expectant mothers, particularly those facing social or logistical barriers. Additionally, exposure-based CBT has been criticised for potentially increasing physiological stress responses in anxious pregnant women, due to its confrontational nature.

These limitations highlight the need for alternative or complementary approaches, particularly those that enhance engagement and promote positive mental health, rather than focusing solely on symptom reduction.

For CBT practitioners, these findings raise important clinical questions. How might pregnancy affect engagement during therapy? Are standard CBT protocols sufficient for pregnant clients facing depression? What can we do to improve the effectiveness of treatment for these individuals?

Understanding Psychological Resilience

Resilience, as defined by Newman (2022), is “the ability to adapt in the face of trauma, adversity, tragedy, or even significant ongoing stressors.” It is a dynamic process that involves emotional strength, cognitive flexibility, and behavioural adaptability.

Tobe et al. (2020) found low levels of resilience have been associated with increased vulnerability to both antepartum and postpartum depression. This correlation suggests that bolstering resilience during pregnancy may serve as a protective factor against the onset or worsening of depressive symptoms.

Emerging Therapies: ACT, Mindfulness, and the Third Wave

Third-generation behavioural therapies, such as Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Cognitive Therapy (MBCT) emphasise resilience-building strategies to improve mental well-being. These approaches focus on enhancing psychological flexibility, promoting acceptance, and encouraging present-moment awareness.

A systematic review by Walker et al. (2022) evaluated 10 studies involving pregnant women over the age of 18 with depressive symptoms. Six studies examined the effectiveness of CBT for ADS; five of these found reductions in depressive symptoms.

Notably, all four studies exploring mindfulness-based interventions reported significant improvements compared to control conditions.

These findings are consistent with prior research. For instance, Sockol (2015) found that CBT led to significant reductions in depressive symptoms compared to control groups. Furthermore, postpartum interventions appeared more effective than antenatal interventions, and individualised treatment yielded better outcomes than group treatment, particularly among women who were non-white, single mothers with more than one child.

The Role of Resilience in Depression Prevention

Resilience Training as an Intervention

Resilience-based interventions are gaining attention as a promising component of ADS treatment. Joyce et al. (2018) observed that programs combining CBT and mindfulness practices positively influenced resilience levels. Similarly, Tobe et al. (2020) found that resilience mediated the relationship between anger during pregnancy and postnatal depression. These findings suggest a meaningful clinical application: by identifying individuals with high emotional distress (such as anger) and targeting them with resilience-building interventions, it may be possible to mitigate the risk of developing postnatal depression.

Practical Pathways to Enhancing Resilience and Clinical Implications

So, what does this mean for your clinical work?

According to Waugh and Koster (2015), there are several strategies to cultivate resilience in individuals experiencing depression:

• Improving Recovery from Minor Daily Stressors: enhancing stress recovery from everyday challenges can increase overall adaptability and reduce sensitivity to more severe stressors

• Promoting Positive Emotions During Stress: encouraging the experience of positive emotion, even in stressful situations, can buffer the emotional impact of adversity

• Training Psychological Flexibility: teaching individuals to identify situational demands and apply the most effective coping strategies supports long-term emotional regulation and adaptation

These resilience-focused strategies offer a more empowering, sustainable framework for mental health interventions, particularly during the sensitive perinatal period.

Conclusion: A Resilient Approach to Maternal Mental Health

Antepartum depression is a significant and multifaceted public health issue that affects not only pregnant women, but can also impact the wellbeing of their children. While traditional therapies like CBT and IPT remain valuable, their limitations highlight the need for more adaptive, accessible, and engaging approaches.

Resilience-based interventions, particularly those that incorporate mindfulness, acceptance, and psychological flexibility show more positive and long-term outcomes. By strengthening inner resources rather than solely focusing on symptom management, these approaches empower women to navigate the profound transitions of pregnancy and motherhood with greater emotional strength and adaptability.

Moving forward, clinical practice and research should continue to prioritise early identification of at-risk individuals, while developing and delivering interventions that foster resilience as a core component of maternal mental health.

We also note that much of the existing research has focused on reducing symptoms in the pregnant woman herself. While this is vital, there remains a large research gap in understanding how partners and broader support systems can play a role in treatment and resilience-building. Expanding research in this area could help shift the burden away from the individual and toward more collective, supportive approaches to maternal mental health.

Finally, it is important to underscore that associations between antepartum depression and child outcomes do not mean that mothers are at fault and that these outcomes are always guaranteed. They are not. Depression during pregnancy is not a choice. By focusing on resilience and support, we can move away from blame and toward empowering approaches that benefit both mother and child.

We’d love to hear from you:
How do you tailor your work for pregnant clients experiencing depression? Should therapy for these individuals focus more on enhancing psychological resilience and mindfulness practices rather than symptom reduction? Let us know your thoughts below!

References

Claridge, A. M. (2013). Efficacy of systemically oriented psychotherapies in the treatment of perinatal depression: a meta-analysis. Archives of Women’s Mental Health, 17(1), 3–15. https://doi.org/10.1007/s00737-013-0391-6

Joyce, S., Shand, F., Tighe, J., Laurent, S. J., Bryant, R. A., & Harvey, S. B. (2018). Road to resilience: a systematic review and meta-analysis of resilience training programmes and interventions. BMJ Open, 8(6), e017858. https://doi.org/10.1136/bmjopen-2017-017858

Newman, R. (2022). The road to resilience. Apa.org. https://www.apa.org/monitor/oct02/pp

Sockol, L. E. (2015). A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. Journal of Affective Disorders, 177, 7–21. https://doi.org/10.1016/j.jad.2015.01.052

Tobe, H., Kita, S., Hayashi, M., Umeshita, K., & Kamibeppu, K. (2020). Mediating effect of resilience during pregnancy on the association between maternal trait anger and postnatal depression. Comprehensive Psychiatry, 102, 152190. https://doi.org/10.1016/j.comppsych.2020.152190

van Ravesteyn, L. M., Lambregtse - van den Berg, M. P., Hoogendijk, W. J. G., & Kamperman, A. M. (2017). Interventions to treat mental disorders during pregnancy: A systematic review and multiple treatment meta-analysis. PLoS ONE, 12(3). https://doi.org/10.1371/journal.pone.0173397

Walker, A. L., Witteveen, A. B., Otten, R. H. J., Verhoeven, C. J., Henrichs, J., & de Jonge, A. (2022). Resilience-enhancing interventions for antepartum depressive symptoms: systematic review. BJPsych Open, 8(3), 1–12. https://doi.org/10.1192/bjo.2022.60

Waugh, C. E., & Koster, E. H. W. (2015). A resilience framework for promoting stable remission from depression. Clinical Psychology Review, 41, 49–60. https://doi.org/10.1016/j.cpr.2014.05.004

1. “There is no such thing as a resistant client” — Richard Schwartz on IFS

Richard Schwartz (founder of Internal Family Systems) reminded us that resistance is never about a client being “difficult.” Instead, what looks like resistance are simply protective parts doing their job.

• The underlying theory of IFS is that we are made up of parts, and there can be 1000s. For example, just writing this now there’s an excited part of me to share with you, a part that wants to do well, a part that doesn’t want this article to go badly, and a part that wonders if anyone will even care?

• In evidence based therapies like CBT/DBT and more, we often see resistant clients as a problem. I remember even going to a lecture where the lecturer said if a client hadn’t done their CBT homework, he cancels the session until they’ve done it. We’re trained to look at barriers, to a lack of motivation, what’s getting in the way?

• But in IFS, Schwartz argued we don’t try to logic resistance away (as CBT sometimes does), but instead approach it with curiosity and respect — we see it as a resistant part.

• Instead of saying ‘what got in the way of you doing the between session task?’ it might sound like asking ‘what part of you blocked you from doing it… and what is it trying to protect you from?’. This allows us to get to the root of the resistance.

• This reframing was striking—especially when you think about the language we often use in supervision and case notes (“the client is resistant”). What if we shifted to “a part is protecting them”?

2. Is CBT Going “Out of Fashion” in Trauma Work?

I was fortunate enough to attend a talk with David Nutt and Bessel Van Der Kork (author of the Body Keeps the Score) on the future of trauma work. Nutt, a British researcher and neuropsychopharamacologist, described how he used to work with those who basically developed CBT protocols in Oxford, but had to leave.

He made a provocative statement (not in these exact words, but this is what I wrote down!). He accepted CBT can be helpful, but that we’re at a place where we know thought work is not enough. In fact, he went as far to say that CBT is erudite, academic, and not always effective for trauma. When I say the audience leaped up in applause, I mean it!

• We’ve known for a while that CBT doesn’t work for everyone, particularly those with complex trauma.

• The trauma field is leaning more towards body-based, relational, and parts-informed approaches (IFS, somatic therapies, attachment-focused work, EMDR).

• CBT was still recognised as useful, but not as a sole intervention.

• This doesn’t mean CBT is dead—but it does mean we need to think carefully about its limits and when to integrate other modalities.

I have to say, when working with trauma I often use EMDR and see a limitation to CBT/cognitive based therapies. But it was an interesting environment. CBT is a ‘gold standard therapy’ on paper, but at this conference, I would say the general vibe I was getting from people (both speakers AND the audience) was that it was the most disliked/seen as ‘basic’ when it comes to trauma.

3. Psychedelics Are the Future

Another recurring theme was the role of psychedelics in trauma treatment.

• The research evidence is stacking up, particularly around MDMA-assisted psychotherapy.

• What struck me was not just the clinical trials, but the way leading trauma clinicians are beginning to speak of psychedelics as a serious part of the therapeutic toolkit, not just an experimental edge.

• Nearly every leader in the field I saw, Bessel Van Der Kork, Gabor Mate, David Nutt, and more, spoke of the power of psychedelic assisted therapy.

It feels like we’re at the early edge of a paradigm shift here. It did also make me think - for therapists worried about AI replacing jobs — this is a type of therapy that could not be delivered by AI.

4. Moving Beyond “PTSD” — Bessel van der Kolk

Bessel van der Kolk challenged the very definitions of trauma we often work with.

• Trauma is not just PTSD.

• Many clients don’t fit neatly into diagnostic categories, and yet they live with the daily consequences of trauma on body, brain, and relationships.

• He spoke of trauma as a current, sensory and emotional imprint that alters how the brain and body process experiences and memories.

• Importantly, the aim of any trauma work, he suggested, is to allow the individual to separate what happened to them, from who they are. This struck me as incredibly important. We often work towards goals of reducing flashbacks, minimising ptsd scores etc. but in reality — this is the key goal.

• For van der Kolk, trauma is a powerful event that exceeds an individual’s coping capacity, leaving them stuck in a state of heightened fear and helplessness.

• The conversation felt like it was shifting towards trauma as a spectrum—not a discrete disorder that only happens on specific events.

This broadening lens helps us recognise trauma where it has historically been overlooked.

5. Disorganised Attachment: The “New Borderline” and Couples Counselling

Frank Anderson MD (who also spoke very openly about his own trauma healing, which was truly amazing) and Janina Fisher PhD spoke about disorganised attachment as today’s working framework for much of what we used to cluster under “borderline personality disorder.”

• Disorganised attachment captures the push-pull dynamic we see in many trauma clients—longing for closeness while fearing it.

• This reframing moves us away from pathologising “borderline” behaviour and towards a more compassionate, attachment-informed understanding.

• Janina Fisher spoke about how in her couples work, she frames the problem as the trauma. In a crude, but perfectly summary statement: man, we’d have such a great relationship if it wasn’t for that damn trauma! In this way - it’s the couple vs the attachment trauma, not the couple vs each other.

Final Thoughts

Leaving the Oxford Trauma Conference, I felt both excited and a little overwhelmed, but in the best way! The field is moving fast: from parts work to psychedelics to rethinking core definitions of trauma.

One of the key takeaways is that in general — both for therapists and clients — we’re moving away from an understanding of mental health that is solely mental. There’s a recognition that it is a full body experience. To quote neuroscientist Tara Swart, there is so psychology without biology, and visa versa.

For therapists, the challenge is not to chase every new modality, but to stay curious and flexible—integrating new insights while honouring what still works.

I’ll be unpacking some of these themes (especially the IFS insights) in more detail in the coming weeks. But for now, these five big ideas capture what felt most alive in the conversations at Oxford.

👉 Which of these resonates most with your practice? Hit reply or leave a comment—I’d love to know what sparks your interest!!!

Sidenote: if you’re thinking of attending the conference next year, I’d recommend staying in Oxford! I commuted from London and I regret it as I missed out on a lot of the socialising/networking, as well as just being totally exhausted!

Author: Sophia Spencer, Between Sessions Founder

Steve has kindly agreed for me to share his updates with you here monthly. Please note I have selected updates I think relevant to our community, and his list is much much bigger and comprehensive. Do check out the Hemingway Report for further updates!

I hope you enjoy! These updates will come monthly.

Sophia (Between Sessions Founder) x

I always welcome feedback, do drop me an email at hello@betweensessions.org for any feedback or questions!

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September Mental Health Industry Updates 2025

➡️ UK-based HelloSelf launched Companion, an AI tool designed for clients to use between sessions. We’ll be covering this in greater detail soon.

➡️ Seven Starling raised $8M to expand their virtual women’s behavioural health platform across the US.

➡️ The Royal College of Psychiatrists in the UK published a position statement concluding there is limited high-quality evidence for psychedelics’ efficacy and calling for further research.

➡️ Headway announced the expansion of its Electronic Health Record into a “fully connected, insurance-native platform for mental health”. This will provide their 60,000+ providers with AI-assisted notes, integrated telehealth, and simplified billing.

➡️ California passed landmark AI chatbot safeguards (SB 243), implementing new protections for vulnerable users, especially minors, from harm caused by unregulated chatbots.

➡️ New research from Pew found that 46% of Americans believe AI should play a role in providing mental health support to people.

➡️ The FDA published Lykos Therapeutics‘ Complete Response Letter rejecting their MDMA for PTSD application. They cited concerns regarding the reliability of the safety data as the lack of durability of the treatment as the reasons for their rejection.

➡️ London headquartered Unmind, who also provide free access to their app for NHS staff, secured an additional $26M in growth capital from Trinity Capital. This comes just after their $35M raise that was announced in July of this year.

Something I often get asked by therapists are thing like:

• “Where do I even start with setting goals for my practice?”

• “How do I actually stay consistent when my caseload is packed?”

• ”How am I supposed to post on instagram, record videos, market myself and work 9-5?”

• “Is there a way to grow without burning out?” 👀

I’m so excited to bring you an expert to discuss this. Someone outside of the therapy world, who specialises in consistency and goals.

BUT, before we go into it. I want to lay the groundwork. Many therapists feel uncomfortable about having conversations about money, charging more, or feeling embaressed by saying they want to earn a high salary. Between Sessions is a shame-free place. I am a firm believer that therapists do their best work when they’re not working from financial scarcity and can see an amount of clients that allows them to truly engage in the work rather than thinking ‘how will I get through 5 clients today?’.

And while using tools like problem-solving and behavioural activation gets us a step forward, I wanted to introduce you to someone who lives this stuff.

Enter our amazing guest author: Kayla Jury. Author of Having it All here on Substack.

Professional nerd. Part Hermione Granger, part Carrie Bradshaw. Curriculum consultant and coach who has built multiple six-figure businesses, moved cross-country, and somehow still finds time to write a YA fantasy series. (Yes, really.)

Kayla has a gift for turning big, exciting dreams into actual, tangible - you can live it, breath it and feel it results - without the hustle-till-you-drop vibe. In this guest post, she’s sharing her no-fluff process for setting goals and following through, so you can grow a practice you love and keep your sanity.

Take it away, Kayla! 🎤

Sophia invited me to write an article for all of you on consistency with your business practice - and when she did, I agreed right away. Because I KNOW so intimately what it is like to care so deeply about the work you do and have that be the most important thing to you while simultaneously wanting your biz to grow. Because really you just focus on helping people, not be stressed about money, and in fact actually go have time and money freedom to do fun things in your life!

So today we are going to dig right in!

Let’s be real - most of us didn’t become therapists because we love building spreadsheets or setting quarterly business goals. You became a therapist because you wanted to help people.

But here’s the catch: building and sustaining a private practice is its own kind of therapy work. It asks you to dream about the practice you want, then show up day after day to make it real.

And if you don’t know how to set clear goals - and stick with them - you’ll find yourself in the same cycle many therapists do: excited to grow one week, exhausted and avoiding admin the next.

Here’s what I want you to know: goal-setting doesn’t have to be heavy, overwhelming, or one more “should” on your list. Done right, it can actually feel energizing, supportive, and sustainable.

I’ve learned this firsthand - from teaching classrooms full of students, to running a six-figure coaching business, to now consulting and helping professionals like you. And the one thing that has always made the difference? Consistency.

Not perfection. Not overworking. Just consistent action that matches the vision you have for your practice and your life.

Consistency sounds simple: just keep showing up (**rolls eyes). But if you’ve ever promised yourself you’d “finally stay on top of admin” or “post every week” and then found yourself ghosting your own goal - welcome to being human.

The good news? You’re not broken. The reasons consistency is hard are surprisingly universal and once you can name them, you can actually outsmart them.

But first - let’s start with setting your goal!

We’ve been talking a lot lately in my own community about goals and one question keeps popping up:

How do I even know what goal to set?

Should you start a private practice? Write a book? Buy a house? Move across the country? Grow on YouTube? Start your own Substack? Have a team? Be a Solopreneur?

That “where do I even begin?” spiral is real.

I get it. I’ve been setting and achieving wildly different kinds of goals my whole life: podium finishes in marathons and Spartan races (after growing up unable to afford sports), teaching and training teachers, launching a six-figure coaching business, moving cross-country, and now living in New York while building a consulting business, writing a YA fantasy series, and running a Substack with paying subscribers.

And after years of trying, testing, and tweaking, here’s what I’ve learned: goal-setting is less about finding the “perfect” goal and more about creating a process that carries you from idea to reality.

This is the process I return to every time - whether I’m training for a race or launching a new offer. And yes, it works beautifully for therapists ready to grow a private practice without burning out.

1. Get a Super-Clear Vision

Skip this and you’ll wander (I know from personal experience!). Your practice goal isn’t just “fill my caseload” or “earn six figures.” Ask: What does my ideal day actually look like? Are you working evenings? From home or a shared office? Seeing ten clients or twenty? Journal the details - pen to paper. Let your future day unfold from the moment you wake up to the time you shut the laptop to when your head hits the pillow again that night.

2. Identify the Feelings

Knowing how future you feels during this time is actually the ultimate goal that you want. You don’t run a marathon because you want to run a marathon - you run a marathon because you want to feel proud. Or dedicated. Or like you are capable. Those feelings are actually your goal. It’s the same in your practice. What does future you feel when she is in that perfect day?

The MAGIC is that you can start tapping into those feelings NOW. And that actually helps you feel more progress, it helps you feel more successful, and it actually brings you to your goal faster. If you start seeing where you are already capable - BOOM quantum leap to the result you are really looking for!

Go back and reread everything you wrote in your vision. What is that person thinking all day? What are they feeling all day - and make a big ol’ list. Write them alllll down.

3. Know Where You’re Starting

Google Maps can’t give directions if you don’t drop a starting pin. Be honest about where you are - client load, income, systems - and also where you already feel those future self feelings. This isn’t self-critique; it’s data. This is how we know where to build from.

Do you already have 2 clients but future you has 10?

Do you already have 25 clients at $100 a session, but future you has 5 at $500 a session?

Do you already post once in a while on your blog, but future you posts weekly?

4. Brain-Dump Every Possible Action

Make a long, no-filter list of every action that could move you closer: outreach, website updates, new referral partnerships etc. Write down all the good ideas and yes, all the bad ideas. The ones that make your body say ‘no way’ help clarify the actions you DON’T want to take (so that you don’t end up doing a ‘should’) and help you see the ones that would be fun and easy to take instead!

5. Choose Aligned Action (this is my fave!)

Filter that giant list down by asking: 1. What would be fun? 2. What would be simple? 3. What would be easy?

You should have a couple left, from there ask - what would be the best return on my investment of time/money/effort?

Consistency isn’t about doing everything, it’s about choosing the actions that fit your life and then actually doing them. And this filter allows you to do the things you will actually stay consistent with (we will break down all of that soon too! Promise.) while also being things that will move the needle!

6. Define Progress Markers

One of the fastest routes to burnout is measuring success with only one yardstick (like revenue or client count). Track other signs of progress: more referrals, easier scheduling, shorter admin hours, even a lighter emotional load at the end of the week. IMO you can never have enough progress markers to help you know that you are on your way. The more markers you see, the more positive momentum you will build and the more energy you’ll have to keep going.

7. Build Consistency

This is where dreams turn into reality. Consistency isn’t about working more; it’s about trusting yourself to keep showing up. And while I could just put a small blurb here on a few bullet points of what to do - I know that this can be the trickiest part of goal setting and goal getting.

I believe that consistency is the thing that makes the difference between wishing and actually achieving.

How to Stay Consistent

Here are the four biggest culprits I see that keep you inconsistent (and yes, I’ve fallen into every single one):

1. You Don’t Actually Like the Thing

This one sounds obvious but it’s actually really sneaky. Maybe you decided you “should” write a weekly blog or offer Saturday sessions because someone said that’s what successful therapists do. But if you dread every minute of it, you’re not going to keep showing up.

>> >> Before you label yourself “inconsistent,” ask: Do I even like this? If not, what’s another way to reach the same outcome that would actually feel good? If it were FUN what would I choose?

>> >> Be thoughtful when choosing your aligned action above - so that you don’t fall into this one!

2. You Went Too Big, Too Fast

Sometimes we love the goal so much we try to do everything at once. You launch a new Substack and suddenly commit to daily posts, daily notes, and daily comments - until life catches up and you burn out.

Or maybe you went all in on IG, Substack, and email newsletter at the same time.
Or you decided that networking was going to be your thing and you signed up for 8 events this month and after the 3rd you’re exhausted and regretting it.

>> >> Instead, write down a list of allll the things that you want to do on your way there. Then break them out into smaller steps - like climbing a staircase. Then, you commit to, for the next two weeks, just being on that first step of the staircase. After you’ve been able to keep that one up, keep it going and move up to the next staircase. Now you will be doing both. And so forth, and so on.

This is what I have coined the next nudge - the smallest sustainable step. Master that, then add the next layer. Small steps build real momentum.

3. Your “Why” Isn’t Strong Enough

Without a reason that lights you up today, the hard days will win. If your only why is a far-off result (“someday I’ll have 1,000 subscribers,” “someday I’ll make six figures”), it’s too easy to quit when progress feels slow.

>> >> Get curious: Why does this matter to me right now? Journal it. Make it personal. A strong why makes showing up feel inevitable. What would having 1,000 subscribers feel like? Why will it matter in the world? How will it affect your mission?

What would making $100,000 do for you in your life? Why does that matter to you?

Staying connected to your WHY helps you find purpose in what you are doing now every time. You will see the importance of writing for your 49 (for now) followers. You will feel how that $250 client payment is enough right now.

4. It Doesn’t Match the Life You Actually Want

This is the sneakiest one. You might think you want a schedule full of clients and speaking at conferences (oh wait, this is me. 🫠 But maybe you too, lol.) or a trendy social presence until you try it and realize it doesn’t fit the life you’re building.

This is where the vision part of your goal setting really matters, and why not to skip it. BUT still, sometimes you are envisioning something that turns out, its not what you thought.

>> >> Treat every new habit like an experiment. If it doesn’t align with the way you truly want to live, give yourself permission to pivot. Freedom lives on the other side of that honesty.

You’ve now got the framework to choose the right goal for you and stay consistent with it - clear vision, aligned action, and the four biggest reasons people fall off track.

But here’s the truth: most people will read this and nod along…and then slide right back into “someday.”

You’ve seen how consistency builds trust. You know the steps.

The only question left is: what’s your next move?

Steady and Unstoppable is here to help you make it.

Inside this mini-course I’ll walk you through how to:

• turn tiny promises into unshakable self-belief

• break the start–stop cycle for good

• grow your practice without burning out

If you’re ready to stop restarting and finally trust yourself to show up consistently, confidently, and on your own terms - then I’m giving you EARLY access! And because Sophia is the bomb, I’m giving you an exclusive discount that I reserve for only my paid Substack community. If you’re ready to get support to stay consistent and grow your practice, I want to be here to help you do it! Use the code: SUBSTACKER for your exclusive discount!

➡️ CLICK HERE FOR YOUR SNEAK PEEK!

p.s. Sign up before October 6 and you’ll get a little extra magic - bonus coaching + guidance inside the community from the moment you join until the day we officially kick off

I hope you enjoyed Kayla’s guest post! I for one am definitely going to be taking this into my next private practice goals. Tell us in the comments what you think!! Sophia x

If you’ve ever thought about leaving the NHS — or even just dipping a toe into private practice — you probably know the feeling:

• Torn between security and freedom

• Guilty for wanting something different

• Afraid you won’t “make it” outside the system

• Wondering if private practice is really possible for you

• Not knowing where to even start

I know, because I’ve been there. Leaving the NHS was a difficult decision — and one of mu best.

This isn’t a workshop on “how to build a private practice” or a business masterclass.

It’s a space for honesty, hope, and conversation about what it really feels like to step into private work.

What We’ll Explore Together

• The psychological barriers that keep therapists stuck in the NHS (even when they’re burned out)

• The fears no one talks about: money, identity, and belonging

• The beliefs you may have internalised i.e. I need 2 years experience for EMDR training, I need years of experience to go private etc.

• What changes when you choose private practice — and what doesn’t

• Why it’s not just about business skills, but nervous system safety and visibility

• A hopeful picture of what’s possible for you - I’m talking freedom, global working, a full case load and out-earning your nhs salary 3x. Yes I’m not kidding.

Who This Is For

• NHS therapists who are curious about private practice, or who have just started but don’t know where to go

• Therapists already doing some private work who want to feel less alone

• Anyone at the crossroads, wondering if leaving the NHS is really worth it

Details

🗓 Date: Friday 26th of September
⏰ Time: 15:30pm BST Time (I know you NHS therapists try to keep Fri afternoon free!)
📍 Location: GoogleMeet - Link will be posted in the subscriber chat the day before
💌 Free to attend

Will be recorded for those who can’t attend.

****RECORDING BELOW****

How to Join

👉 Sign up by subscribing to my Substack. You’ll get the link and the replay straight to your inbox. Please note the replay will be edited — as this will be a private, open conversion and I will edit out anything I think should not ‘live forever’ on the internet.

About Your Host

I’m Sophia Spencer, an NHS CBT therapist turned private practitioner, writer, and coach. I work fully in private practice for myself (not working for a company). I see half the amount of clients I used to in the NHS, less complexity, and out-earn my NHS salary by a big margin. I don’t say this to show off, I say it so you know there are other alternatives. If you’re like me and found yourself googling other careers you could do instead of therapy, I get it. But the problem might not be the job, it could be the workplace and the type of work.

✨ Come join me live — bring your questions, your fears, and your hopes.

You’ll leave with a clearer sense of possibility, and maybe the first step toward a life where you can just be.

As a specialist in social anxiety, imposter syndrome and belonging, here are my favourite theories that I integrate into my psycho-education and practice.

Many of these theories are decades old, but their clinical relevance remains striking. Understanding them can help therapists normalise client experiences, reframe shame, and design interventions that go beyond symptom reduction.

Social Rank Theory: Why Clients Feel Inferior

Social rank theory proposes that humans, like other primates, are wired to detect hierarchy and monitor their position within groups (Gilbert, 2001). When people feel lower in rank, they may experience anxiety, shame, or depression.

Clinical relevance:

• Clients with social anxiety, depression and/or high self-criticism, are often feeling the visceral sensation of ‘low rank’ even if they may not have language to express this. They may reference shame and not belonging.

• Imposter syndrome in high-achieving professionals may reflect the same rank-scanning system at work in modern settings.

• Reframing these reactions as evolutionary survival responses can reduce shame and open space for compassion.

Important note: For clients experiencing true discrimination from the society they live in, their environment is actively creating and reinforcing feelings of inferiority. In theses situations, this theory needs to be handled with delicate care — in contrast to environments where the problem is not actively or meaningfully reinforced externally, but driven internally by the client’s own rank-sensitive nervous system.

Social Identity Theory: Belonging and the “In-Between”

Developed by Tajfel & Turner (1979), social identity theory explains how group memberships (e.g., profession, culture, gender) form a core part of self-concept. People seek positive identity through in-groups and may distance from out-groups.

Clinical relevance:

• Clients who have outgrown old identities but do not feel at home in new ones often experience distress during this “identity liminal” phase. This often happens when clients leave one community (whether that’s class, religion, geographical area, sports team, secondary school — it’s whatever community is important to the client) but don’t feel at home in new ones yet

• The above can happen at significant life transition e.g. school to university, university to work, home to moving out, growing up in poverty to having wealth etc.

• Minority stress can be understood, amongst other things, through the constant tension of being positioned as “out-group.”

• Therapy can help clients integrate multiple identities and find safety in self-belonging, not only group validation.

• Self esteem work focuses heavily on identity without referencing the attachment to a group.

The Belongingness Hypothesis: Why Exclusion Hurts So Much

Baumeister and Leary’s (1995) belongingness hypothesis argues that humans have a fundamental need to form and maintain strong, stable interpersonal bonds. Brene Brown in particular, has brought this theory into the present day with her work on belonging and vulnerability.

Yet, we talk little about belonging in CBT, despite it being a core psychological drive, as essential as food or shelter. When this need is unmet, distress can result in many difficulties we see and we may misunderstand this as maladaptive thinking.

Clinical relevance:

• Social anxiety: The intense fear of rejection is not irrational — it reflects a survival system wired to avoid exclusion.

• Loneliness and depression: Chronic lack of belonging correlates with poorer mental and physical health outcomes.

• Self esteem: Without a sense of belonging, one can feel excluded, leading to negative self-concept.

• Therapy itself: The therapeutic alliance can serve as a “secure base” where belonging needs are temporarily met, modelling what safe connection feels like. Yet, we don’t want the client to feel that therapy is the only place they can belong, which makes them feel more excluded from day-to-day life.

Therapeutic suggestions:

• Normalise the pain of exclusion: Clients often believe they are “too sensitive.” Framing belonging as a universal human need reduces shame.

• Work with attachment and rank wounds together: Belongingness theory helps integrate insights from both attachment and social rank frameworks.

• Reframe growth: The goal isn’t just symptom reduction, but helping clients experience authentic belonging without performance or self-erasure.

Integrating Social Psychology Into Practice

Social psychology reminds us that distress rarely arises in a vacuum. Shame, anxiety, and imposter feelings are not simply maladaptive thoughts — they are human responses to hierarchy, identity, power, and belonging needs.

For therapists, weaving these theories into practice does two things:

1. It normalises what clients experience as deeply human rather than uniquely broken.

2. It gives us frameworks for working not only with thoughts and behaviours, but with the social forces that shape them.

The therapeutic task, then, is not simply to reduce symptoms, but to help clients feel safe enough to bring their authentic self into relationships and groups — without hiding, performing, or fearing exclusion.

In that sense, social psychology doesn’t just add theory to our work. It strengthens the heart of therapy: helping people move from outsider to insider, and to reclaim a sense of belonging that starts within.

Want to learn more about this work? Do check out my website or connect with me on instagram! What do you think? Is this helpful for your practice?

References

Asch, S. E. (1951). Effects of group pressure upon the modification and distortion of judgments. Groups, leadership, and men, 177–190.

Baumeister, R. F., & Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117(3), 497–529. https://doi.org/10.1037/0033-2909.117.3.497

Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. Springer Science & Business Media.

Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7(2), 117–140. https://doi.org/10.1177/001872675400700202

Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press.

French, J. R. P., & Raven, B. (1959). The bases of social power. In D. Cartwright (Ed.), Studies in social power (pp. 150–167). University of Michigan.

Gilbert, P. (2001). Evolution and social anxiety: The role of attraction, social competition, and social hierarchies. Psychiatric Clinics of North America, 24(4), 723–751. https://doi.org/10.1016/S0193-953X(05)70260-4

Heider, F. (1958). The psychology of interpersonal relations. Wiley.

Tajfel, H., & Turner, J. C. (1979). An integrative theory of intergroup conflict. In W. G. Austin & S. Worchel (Eds.), The social psychology of intergroup relations (pp. 33–47). Brooks/Cole.

Tajfel, H., Billig, M. G., Bundy, R. P., & Flament, C. (1971). Social categorization and intergroup behaviour. European Journal of Social Psychology, 1(2), 149–178. https://doi.org/10.1002/ejsp.2420010202

Weiner, B. (1985). An attributional theory of achievement motivation and emotion. Psychological Review, 92(4), 548–573. https://doi.org/10.1037/0033-295X.92.4.548

These moments capture a tension many CBT therapists recognise: the gap between what we emphasise in treatment and what clients actually find most meaningful.

Depression continues to be one of the most common and debilitating mental health conditions worldwide. Despite advances in neuroscience, psychology, and public awareness, depression still disrupts millions of lives and creates immense challenges for health systems.

Among available treatments, cognitive behavioural therapy (CBT) remains one of the most widely researched and recommended psychological approaches. It is often positioned as a first-line treatment, supported by decades of evidence demonstrating its effectiveness in reducing depressive symptoms and preventing relapse [1,4].

However, research trials and clinical manuals only tell part of the story. The real-world experience of receiving CBT does not always align neatly with what therapists emphasise or what treatment guidelines prescribe. This tension between evidence-based priorities and lived experience has been increasingly recognised in recent years.

A new study by Yarwood and colleagues (2025) brings fresh insight by directly comparing what therapists and people with lived experience of CBT for depression identify as the most important components of therapy [5]. Their findings highlight important areas of agreement, but also notable gaps that deserve careful attention.

What the Yarwood Study Found

Yarwood et al. (2025) conducted a Delphi study involving two groups: experienced CBT therapists and people who had received CBT for depression. Both groups were asked to rate the importance of different therapy components and qualities.

✅ Consensus areas:

• Therapist qualities: Both groups placed strong emphasis on qualities such as being trustworthy, non-judgmental, empathetic, and knowledgeable. These were seen as essential foundations of therapy.

• Cognitive restructuring: There was widespread agreement on the importance of helping people identify and reframe unhelpful thoughts. This reinforced its role as a central pillar of CBT for depression.
  

❌ Divergence areas:

• Behavioural activation and homework: Therapists prioritised these techniques more than patients did. While therapists saw them as core interventions, people with lived experience often described them as less central or more burdensome.

• Psychoeducation and behavioural experiments: Therapists rated these highly, but patients placed less emphasis on them.

• Process factors: Patients highlighted the importance of session pacing, length, and flexibility. Therapists, by contrast, did not prioritise these aspects to the same degree.

• Mindfulness: Both groups showed mixed opinions, with no clear consensus. Some saw it as a valuable addition, while others considered it optional or unrelated to core CBT.

➡️ In practice, this highlights where our training aligns with what clients value, and where the gaps in understanding can leave them feeling less engaged.

Comparing with Broader Research

The Yarwood study builds on a growing body of work examining what makes CBT effective. For example, Taylor et al. (2019) established expert consensus on the most effective components of CBT for adults with depression.

Key elements included a strong therapeutic alliance, clear rationale for treatment, structured activity monitoring, relapse prevention, homework, therapist competence, and flexibility in scheduling [3].

While this study focused on depression, similar components, particularly alliance, cognitive restructuring, and exposure, are consistently highlighted in the anxiety treatment literature, though often through reviews and clinical guidelines rather than formal consensus studies.

This aligns with some of Yarwood’s findings, especially the emphasis on the alliance and structured techniques, but also shows that different populations may value components differently.

Meta-analyses further reinforce the picture of complexity. Angelakis et al. (2022) found that both simple and complex CBT protocols reduce depression, but more comprehensive approaches lead to stronger long-term outcomes [4].

Here’s the dilemma: clients often want something simpler and more flexible, but as therapists we know that keeping certain structured elements is what really protects against relapse.

Taken together, the research suggests that while CBT has robust evidence for its effectiveness, how it is experienced can differ depending on whether the perspective is professional or personal.

Practical Reflections For Therapists

The study by Yarwood et al. (2025) offers several important lessons for how CBT is delivered in practice.

1. Therapist qualities remain the cornerstone.

Regardless of technique, people consistently value trust, empathy, and collaboration. No manualised method can replace the sense of safety and understanding that comes from a strong therapeutic relationship. This reminds us that relational skills deserve as much training focus as technical competence.

2. Cognitive restructuring is essential, but requires flexibility.

Helping individuals challenge unhelpful thoughts remains a powerful tool. But not everyone responds well to structured worksheets or thought records. Some may prefer more conversational approaches or imagery-based techniques. Therapists may need to adapt formats so that the process feels less mechanical and more personally meaningful [1,5].

3. Behavioural activation needs reframing, not discarding.

While patients rated it lower, behavioural activation has decades of evidence supporting its effectiveness [4]. The challenge lies in presentation. Instead of framing it as a prescribed “task,” it may resonate more when described as a way to reconnect with enjoyable or meaningful activities, to rediscover mastery, or to test out beliefs in daily life. This reframing could increase engagement and reduce resistance.

4. Process factors deserve greater attention.

Patients emphasised aspects such as pacing, flexibility, and session length. These factors may not always feature prominently in manuals but can make or break engagement. Asking simple check-in questions such as, “Is the pace working for you?” or “Would a shorter or longer session be more useful?” can improve the therapy experience [5].

5. Mindfulness is best offered as optional.

While mindfulness-based cognitive therapy has proven benefits, particularly for relapse prevention, it does not resonate with everyone [4]. Offering it as an optional tool, rather than a mandatory component, respects individual differences while still keeping it available for those who are open to it.

6. Homework and psychoeducation need purpose and clarity.

Patients often see homework as an added burden rather than a helpful practice. Clarifying its role as a way to strengthen skills between sessions can shift perceptions. Similarly, psychoeducation is most effective when brief, directly relevant, and linked to a person’s goals [5].

Moving Forward

The most important message from Yarwood et al. (2025) is that CBT must remain responsive to the people receiving it. Evidence-based methods are crucial, but therapy also needs to reflect client priorities. Several steps could help move practice and research in this direction:

• Co-designed research: Involving patients in shaping therapy protocols and outcome measures can ensure that lived experience is built into the design from the start.

• Training emphasis: Professional training programmes should balance teaching technical CBT skills with relational skills and responsiveness to process factors.

• Routine feedback: Building structured feedback into therapy (e.g., brief check-ins at the end of sessions) can help therapists identify when pacing, delivery, or techniques need adjustment.

• System-level flexibility: Services could consider offering different formats , such as shorter, more frequent sessions, or blended digital and in-person approaches , to reflect diverse needs.

In the end, the work asks us to remain humble, listening as much as guiding, and to adapt so therapy feels collaborative, not prescriptive. What therapists prioritise and what patients value do not always match. Aligning these perspectives does not mean discarding evidence-based techniques, but rather integrating them in ways that feel accessible and meaningful.

By listening more closely to lived experience, adapting delivery styles, and maintaining flexibility, CBT can continue to evolve as both an effective and a human therapy. In this way, the future of CBT lies not only in scientific validation but also in the everyday realities of those who experience it.

How do you approach this balance in your own practice? Do you find yourself leaning more toward evidence-based fidelity, or tailoring interventions to client preferences, even if that means adjusting the “textbook” CBT approach?

Share your experiences and reflections below, we would love to hear how you navigate this challenge in your therapy rooms.

References

[1] Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press.

[2] Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. Routledge.

[3] Taylor, C. D. J., Abramowitz, J. S., McKay, D., & Storch, E. A. (2019). An expert consensus on the most effective components of cognitive behavioural therapy for adults with depression: A modified Delphi study. Journal of Affective Disorders, 253, 117–126. https://doi.org/10.1016/j.jad.2019.04.050

[4] Angelakis, I., Huggett, C., Gooding, P., Panagioti, M., & Hodkinson, A. (2022). Effectiveness of cognitive–behavioural therapies of varying complexity in reducing depression in adults: systematic review and network meta-analysis. The British Journal of Psychiatry, 221(2), 459-467.

[5] Yarwood, B., Angelakis, I., & Taylor, R. (2025). Importance of CBT components in the treatment of depression: a comparative Delphi study of therapists and experts by experience. The Cognitive Behaviour Therapist, 18, e20.

What is Short Term Psychodynamic Therapy (STPP)?

Short Term Psychodynamic Therapy is another option for patients who may not respond to CBT or other approaches. Psychodynamic Therapy focuses on the unconscious and its involvement in developing and maintaining mental health disorders. There are several approaches under this umbrella with most sharing pillars based upon objects relations theory, attachment theory and drive theory.2

How does it compare to CBT?

Cognitive Behavioural Therapy (CBT) and STPP are fundamentally different therapies with different principles, CBT is fundamentally rooted in our own perception of events and subsequent behaviour3.

Alternately, Short Term Psychotherapy focuses heavily on unresolved conflicts and past experiences. Kaluzeviciute‐Moreton and Lloyd (2024)4 identify what they refer to as a ‘turf war’ between CBT therapists and those specialised in Psychodynamic therapy but are the two approaches all that different in outcomes?

The effectiveness of each has been compared by a multitude of research papers. Malkomsen et al. (2025) explored and examined modern improvements to both methods5.

For one group, a traditional method of CBT for depression was administered. In the STPP group connections behind past experiences to current ones were examined, aiming to reduce depressive symptoms.

Patient's depressive symptoms improved in both groups, however limited statistical significance was recorded between the two approaches.

Research supporting both STPP and CBTT is numerous; with reductions in depression and an increased quality of life reported in both6.

This is in line with other comparative studies that conclude both options as effective whilst suggesting the benefits of offering patients a range of therapeutic options7.

What about therapy and medication?

Di Salvo et al. (2024)8 found the addition of STPP alongside medication can improve hospitalisation rates and cost effectiveness, sustaining long term results at 12 months. Similarly, combining antidepressant and CBT has been observed to have improved results9.

Who wins the turf war?

Both Cognitive Behavioural Therapy and Psychodynamic therapy are similarly effective in treating depression.

As Yan (2024)10 highlight, understanding variables that moderate how effective each option is needs to be a priority for future research, allowing professions to make educated decisions regarding what treatment option to take when treating a patient.

Importantly, Leichsenring et al. (2024)11 argue the World Health Organisation needs to take additional steps to equally endorse evidence-based psychodynamic therapy compared to their endorsement of CBT.

Each approach seemingly has similar effectiveness and in some situations, each approach shares many similarities. Indeed even analysis of patients post-therapy interviews who received either Psychodynamic Therapy or Cognitive Behavioural Therapy concluded the important elements to the improvement of patients' symptoms had ‘striking’ similarities12.

Regardless of the theoretical differences, it could be inferred that CBT and STPP, in practice, may be more similar than different when it comes to outcomes.

Panic disorders usually begin in adolescence, peaking around age 15.5, with a prevalence of 1 to 3% among 11 to 19 year olds.

Although the onset and peak of panic disorder occur during adolescence, most studies on its symptoms have only included adults. Thus, it remains unclear whether adolescent panic disorder presents the same symptom patterns and clinical impact.

This gap in the literature is significant, given that early onset of the disorder is associated with worse outcomes, including long-term anxiety, school disruption, substance abuse, and suicidal behaviour.1

Why does Panic Disorder strike in adolescence?

Cognitive Changes

Adolescence is not only a stage of bodily changes but also the unique period of development of higher-order cognitions. These include abstract thinking, hypothetical (“what if”) thinking, and cause-and-effect (consequential) reasoning.

The changes in the body and in the mind, could mismatch and lead to erroneous interpretation of body sensations. Teens begin experiencing new bodily sensations during puberty including dizziness, shortness of breath or racing heart.2 With their developing ability to think abstractly and reason using “what if” scenarios, an adolescent might interpret a normal increase in heart rate after climbing stairs as a sign of serious medical problem (What if I am having a heart attack?).

Because of their hypothetical reasoning and focus on possible negative consequences, they may start avoiding physical activity or constantly checking their pulse as a safety-seeking behaviour, even though the sensation itself is harmless.

Examples of this process can be observed both in school life and in social contexts; which could be the possible reason why adolescents with panic disorder usually show school non-attendance. Almost every teen has faced the dreaded moment of standing in front of the whole class to give a presentation - a nerve wracking experience that rarely feels fun or easy.

With newly developed hypothetical reasoning skills, a teen who notices their hand shaking and heart pounding in front of the whole class might think: “What if I completely forget what I say? What if they laugh at me? What if I faint in front of everyone?”

The consequential thoughts turn a normal stress response into a feared catastrophe and possible panic attack once the on-set of physical symptoms becomes relentless. As a result, the student might try and avoid presentations, skip school, or read directly from notes to reduce the chance of embarrassment, which are all forms of safety-seeking behaviour.

Neurobiological Changes

The main brain regions that are affected in panic disorder are the amygdala and the prefrontal cortex (PFC), in both adults and adolescents. Amygdala is the centre for emotion processing, mostly associated with fear. It is responsible for fast fear response to perceived threats.3

The other region affected is the PFC, which has different subdivisions, including attention regulation, memory processing, response inhibition and emotion regulation. It helps with cognitive reappraisal and down-regulating fear responses by controlling amygdala activity.4 Adolescents and adults with panic disorder both show decreased connectivity between amygdala and the PFC5. It is also important to note that this is a normal feature of the adolescent brain, even without being diagnosed with the disorder, which shows the increased tendency of adolescents experiencing panic disorder symptoms.

The impact of reduced connectivity between the amygdala and PFC means less top-down regulation of fear; not making sense of what you are feeling.6 Therefore, instead of calming themselves with rational reappraisal, adolescents may be more prone to catastrophic thoughts when they notice bodily sensations (e.g., dizziness, rapid heartbeat), increasing vulnerability to panic symptoms.

Clark’s Model

Clark’s model of panic disorder describes the behavioural and cognitive patterns believed to be central to the development and maintenance of the condition, which are considered specific to panic disorder. A caveat to this model is that it is only applicable to adults, as studies on this model only included participants above the age of 18.

The cognitive model suggests that panic attacks happen due to the misinterpretation of normal body sensations as dangerous, termed a “catastrophic misinterpretation”.

The thought of this misinterpretation and believing that it will lead to a catastrophe, is called having a “catastrophic cognition”.

To give an example, a student giving a class presentation experiencing light-headedness might understand this as a sign that they are going to faint. The “catastrophic cognition” here is the “I’m going to faint”, and the “catastrophic misinterpretation” is the “I feel lightheaded, so I will faint”. This makes the individual hyper-aware of their body sensations and similar sensations will hint that another catastrophe is coming. To avoid this happening, they use safety-seeking behaviours.7 As mentioned earlier, in the context of giving a class presentation, these could be reading directly from notes or avoiding coming to school on presentation days.

Spotting the Red Flags of Panic Disorder in Adolescents

McCall et al. (2025)¹ is one of the few studies which focuses on adolescence PD. Their research aimed to describe the clinical characteristics of adolescents with panic disorder. They also compared the symptoms of panic disorder in teens with other anxiety disorders and with healthy controls. The study also aimed to find out whether three components of Clark’s model exist in adolescents with panic disorder: panic (catastrophic) cognitions, fear of body sensations, and safety-seeking behaviours.

Findings

Panic Disorder VS. Anxiety Disorders in Adolescents

Panic Disorder group showed:

• Higher overall anxiety severity

• More frequent and severe panic symptoms

• Higher depressive symptoms

• Greater school impairment, including: increased school refusal, more absenteeism

• Greater social impairment (difficulty maintaining friendships, avoiding social settings

• More emergency healthcare use (likely due to panic attacks being mistaken for physical illness)

Panic Disorder Symptom Severity

The analysis indicated that panic (catastrophic) cognitions, fear of bodily sensation, and safety-seeking behaviours are positively correlated with panic disorder symptom severity. When compared to the anxiety disorders group and healthy group, adolescents with panic disorders showed the highest catastrophic thoughts, greater fear of body sensations and more safety-seeking behaviours.

Implications for CBT

These findings implicate the importance of distinguishing between anxiety disorders and panic disorder in adolescents. In addition, for CBT therapists, the results show that the core principles of Clark’s cognitive model of panic disorder can be adopted for younger clients.

Therapist Takeaways:

• Catastrophic cognitions matter in adolescence: Adolescents with panic disorder show more panic-related catastrophic thoughts than peers with or without anxiety.

• Safety behaviours maintain symptoms: Avoidance and in-situation coping prevent new learning and keep panic happening.

• CBT focus is crucial: Target catastrophic misinterpretations and safety behaviours through behavioural experiments.

• Developmental sensitivity: Adapt CBT techniques to be age-appropriate, engaging, and mindful of social/peer contexts.

Spotting and addressing catastrophic thoughts and safety behaviours early can prevent years of disruption and distress. Every school refusal, or avoided presentation, could be a chance to intervene.

What’s your go-to strategy for teen panic? Share your thoughts below!

We’re writing with some exciting news about the future of Between Sessions.

Starting today (20th August), we're making our Substack completely free for everyone.

This decision comes from wanting to make our content accessible to as many people as possible, and to remove any barriers that might prevent someone from benefiting from what we share here.

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Moving forward

Going free means we can focus entirely on creating valuable content without worrying about paywalls or subscription tiers. You'll get the same quality content you've come to expect - actually, probably even more of it.

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Deprivation may be linked to a number of stresses, such as food poverty, disability benefits and caring roles, all of which may impact the development of mental health issues and outcomes from psychological therapy.

For CBT practitioners, these findings raise important clinical questions. How might deprivation affect engagement during therapy? Are standard CBT protocols sufficient for clients facing ongoing deprivation? What can we do to improve the effectiveness of treatment for these individuals?

The Evidence: What the Research Tells Us

Richardson et al. (2025) analysed data from 128 participants (predominantly female), assessing PTSD symptoms using the PTSD Checklist for DSM-5 (PCL-5)2, pre- and post-intervention, in order to measure levels of symptom reduction. Participants living in more deprived neighbourhoods showed significantly smaller reductions in PTSD symptoms compared to those from less deprived areas.

This pattern reflects earlier research3, who identified low socioeconomic status as a key risk factor for a range of mental health conditions, including PTSD. Similarly, Finegan et al. (2020)4 found that individuals from economically deprived areas tend to report more severe anxiety and depression symptoms after treatment through IAPT services, and often require longer interventions.

These findings suggest a clear trend: socioeconomic deprivation is not only associated with greater vulnerability to trauma-related disorders, but may also limit the extent to which individuals benefit from psychological therapy.

Understanding the Relationship Between Therapy Outcomes and Deprivation

Several interlinked factors may explain this reduced effectiveness of treatment:

• Ongoing exposure to stress and trauma, including repeated victimisation

• Risk management priorities, such as safeguarding concerns or physical health conditions, which may divert focus away from trauma work

• Therapeutic avoidance, where clinicians may hesitate to use trauma-focused CBT components such as memory reliving with clients to prevent re-traumatisation

• Higher emotional and cognitive load, which can reduce engagement and retention

Furthermore, clients experiencing poverty may face practical barriers such as inconsistent appointment attendance due to caring responsibilities, financial instability, or limited access to reliable transport and/or digital resources.

Clinical Implications for CBT Therapists

So, what does this mean for your clinical work?

• Adaptation, not dilution: Be cautious not to dilute trauma-focused components with clients experiencing deprivation. Evidence-based trauma treatments may require additional preparation and support.

• Longer treatment: Clients from more deprived backgrounds may benefit from extended or phased interventions.

• Holistic support: Recognise that therapy alone may not be sufficient to treat PTSD for deprived individuals. Collaborating with crime victim support, housing organisations, or financial support advisors may help address external stressors that interfere with engagement during treatment.

• Alternative modalities: Where appropriate, consider therapies like Eye Movement Desensitisation and Reprocessing (EMDR), which may be less verbally intensive and potentially less distressing for individuals unable to articulate or tolerate trauma narratives.

Towards Trauma-Informed, Equity-Aware Practice

Understanding the broader social context in which your clients live is essential for delivering the most effective CBT. Socioeconomic deprivation is not just a background variable, it actively shapes symptom expression, treatment engagement, and the potential for recovery.

Integrating this awareness into assessments and structure of therapy can lead to more compassionate, targeted, and realistic planning, to ensure individuals can experience the maximal benefit of treatment.

This line of research calls for an evolution in the delivery of therapy to ensure they are responsive to the needs of clients facing systemic disadvantage. While more studies are needed, it is clear that effective PTSD treatment must consider the social and economic realities of each client, and not just their symptoms.

We’d love to hear from you:
How do you tailor your trauma work for clients affected by poverty and deprivation? Should services offer integrated practical support alongside therapy? Let us know your thoughts below!

CBT therapists often face a major hurdle: how do you safely expose clients to distressing scenarios when those situations are too dangerous, distant, or difficult to recreate?

Virtual reality exposure therapy (VRET) is rapidly emerging as a practical solution. It blends immersive technology with CBT techniques to offer flexible, controlled exposure.

But how realistic is this for everyday clinicians, and how effective is it in practice?

What exactly is VRET?

Virtual reality exposure therapy (VRET) is the use of immersive virtual simulations to support graded exposure, a foundational CBT technique. By placing clients in computer-generated environments that replicate their fears, therapists can tailor exposures in a structured, paced, and safe manner.

Traditional exposure therapy typically uses either imaginal or in vivo techniques, each with limitations. Imaginal exposure may feel too abstract for some clients, while in vivo exposure is often impractical, particularly when feared situations involve combat, hospitals, or specific phobias that are hard to recreate.

VRET bridges this gap by offering multi-sensory realism without the logistical or ethical concerns of real-world exposure.

This approach is especially relevant in treating PTSD and phobias, where real-life exposure can be emotionally overwhelming.

How VRET is Already Enhancing CBT and Therapeutic Practice

Recent studies suggest VRET can replicate, and in some cases enhance, the benefits of traditional CBT exposure by offering greater control, safety, and adaptability.

VRET is being integrated into treatment for phobias and PTSD1. It shows that VR-based exposure aligns well with CBT's core components, such as desensitisation, cognitive restructuring, and coping skill reinforcement.

Folke et al. (2023) demonstrated its real-world impact by showing reduced PTSD symptoms in Danish veterans after tailored VR sessions that recreated combat environments2. Likewise, van Loenen et al. (2022) found VRET comparable to traditional CBT across anxiety disorders, OCD, and trauma-related conditions3.

Mayer et al. (2022) explored VRET in clients with claustrophobia and found that modifying scene intensity and personalising scenarios enhanced patient engagement4. Another example includes the use of VRET for social anxiety, where patients can rehearse public speaking or attend virtual social events¹. This flexibility makes VR uniquely suited for disorders involving avoidance.

What Should Therapists Watch Out For?

Therapists remain central to the VRET process, the technology is a tool, not a replacement.

But several factors must be considered:

• Not all clients tolerate VR equally: some may experience nausea or find the virtual world emotionally flat¹.

• Others may over-rely on tech without engaging fully with the therapeutic process.

Therapists also face structural barriers, such as access to quality VR equipment, training, and ethical concerns around data privacy. And yet, as studies like those by Mayer et al. (2022)⁴ and Jin et al. (2023)⁵ show, client interest in VR tools is growing, especially among those who struggle with traditional exposure methods.

While the potential of VR is clear, integration into clinical settings can be complex:

• Therapists may lack training in VR operation or be unsure how to integrate it with CBT protocols.

• Clinics must consider practical concerns, such as cleaning equipment between sessions, ensuring sufficient internet connectivity for app-based platforms, or managing licensing for VR content libraries.

Where Is VRET Already Being Used in CBT?

So, how is this being applied in therapy rooms today?

In practice, virtual reality exposure therapy (VRET) has been applied to a wide range of anxiety-related triggers. Studies included in the 2024 review highlighted its successful use in simulating the following scenarios:

• Arachnophobia: Clients confronted increasingly realistic spider simulations, enabling gradual exposure without needing real-life contact¹.

• Combat-related PTSD: Veterans engaged in virtual recreations of military environments, such as patrols and explosions, within a safe therapeutic setting².

• Medical trauma: ICU environments were simulated to help individuals process anxiety related to hospitalisation and intensive care³.

However, successful implementation depends on thoughtful planning. Therapists must:

• Select or tailor VR scenarios that reflect individualised triggers

• Monitor closely for emotional distress or cyber-sickness

• Include structured debriefing and coping strategy reinforcement after sessions

When delivered with clinical care, VRET offers immersive, flexible exposure without sacrificing safety or therapist oversight.

Expanding Access to Home-Based VRET

One major strength of VRET is its potential for accessibility. As portable headsets become more affordable and user-friendly, clients with mobility limitations, agoraphobia, or those living in remote areas may be able to access exposure therapy from home or in blended formats.

Studies have highlighted this flexibility as a key factor in user satisfaction5. Mobile VR platforms, such as those using smartphone headsets and app-based scenarios, may also allow therapists to scale exposure work without needing expensive installations.

What’s Next for VRET in Everyday Practice?

VRET isn’t a universal fix, but it offers significant promise6. With affordability improving and client openness growing, it may soon become a regular feature in CBT toolkits, particularly for clients with avoidance-based symptoms.

Future research should continue to explore optimal session design, long-term effects, and training requirements for therapists. Studies might also examine how VRET compares with in vivo exposure across different disorders, or whether hybrid models, such as VR combined with imaginal techniques, can improve outcomes. Longitudinal research is especially important for understanding how durable these gains are over time, particularly in cases involving complex trauma.

Refinements in VR design may further improve its effectiveness. For example, increasing the realism of scenarios, through richer sensory cues or interactive virtual characters, could boost emotional engagement.

Some clients may also benefit from the therapist being physically present during sessions, depending on the severity or interpersonal nature of their triggers. Tailoring scenarios to accommodate comorbid issues, like social anxiety or agoraphobia, may also support more nuanced exposure.

However, the takeaway is clear:

“The use of VR in the treatment of mental disorders […] opens up new opportunities for safe and effective exposure to stressful stimuli¹.”

Why? Because many of these clients aren’t worried about a hypothetical illness, they already have a diagnosis.

That’s where the Health Anxiety Inventory for Medical settings (HAI-M) comes in. A recent paper published in The Cognitive Behaviour Therapist Journal outlines the development and validation of this updated tool [1].

The HAI-M was designed to address a major gap in how we assess health anxiety in clients with chronic illnesses. For CBT professionals working in general practice, hospital settings, or integrated care, this update is worth knowing about.

The Problem with Standard Measures

The original SHAI has been widely used to assess health anxiety in the general population. It’s reliable and has solid psychometric properties [2]. But when administered to people who do have medical conditions, like chronic pain, multiple sclerosis, or ME/CFS, some of the questions can feel invalidating or off-base.

For example, asking whether someone is worried about becoming ill doesn’t quite fit when that person already has a diagnosis. And suggesting that bodily symptoms are being imagined can trigger defensiveness or disengagement. Clinicians often report that these tools feel like they’re pathologising normal concern [3].

The reality is, not all health-related worry is excessive. In clients managing chronic illnesses, a baseline level of concern or symptom monitoring may be appropriate, even necessary. But distinguishing between adaptive vigilance and clinically significant anxiety requires nuance, and the right tools.

When those tools aren't sensitive to context, the therapeutic relationship can suffer. Clients may feel misunderstood or dismissed. And practitioners may struggle to create a working formulation that explains the interplay between medical symptoms and cognitive processes. This is where the HAI-M fills an important clinical need.

The HAI-M: What Changed?

To address these concerns, researchers Colenutt and Daniels used a Delphi method with both clinicians and people living with chronic conditions to adapt the SHAI [1]. A Delphi method, for context, involves structured rounds of expert consultation aimed at reaching consensus on how to improve or design a measure.

The result is the 12-item HAI-M, which:

• Removes or rewords items that imply illness is imagined or unfounded

• Uses language that validates the presence of real symptoms

• Retains core elements that measure health-related worry, reassurance-seeking, and preoccupation

Participants also found it more acceptable than the original SHAI, describing it as more reflective of their lived experience. This higher acceptability is a critical factor in health settings, where client dropout and therapeutic alliance are already areas of concern [4].

Unlike the SHAI, which was developed to assess health anxiety in the general population, the HAI-M was created with the voices of people with long-term conditions baked into its design. That alone sets it apart from most other measures in our toolbox.

How This Applies in Practice

Professionals working in health or mental health settings may already be familiar with the challenges of assessing health anxiety in medical populations. The HAI-M offers a practical, brief tool that can improve therapeutic alliance and help guide formulation.

In clinical use, the HAI-M can help:

• Screen for health anxiety in clients with known diagnoses

• Track symptom change over time

• Clarify whether a client’s worry is proportionate or driven by cognitive distortions

• Identify patterns that may benefit from targeted interventions such as behavioral experiments or cognitive restructuring

For example, a client with a long-term pain condition may score high on items related to worry or excessive checking. This can open up a discussion about patterns of reassurance-seeking, avoidance, or hypervigilance, all of which can be targeted with standard CBT techniques [5].

The HAI-M is especially useful in distinguishing between understandable concern about symptoms and health anxiety that is causing significant distress or functional impairment. It also supports more sensitive and collaborative treatment planning. Clients with chronic health conditions often report feeling misunderstood or dismissed by mental health providers. Using a measure that validates their experience while still helping assess the impact of anxiety can improve rapport and engagement.

The measure may also prove useful in multidisciplinary or stepped care settings. For example, being able to identify when symptom-related anxiety is contributing to increased GP visits or avoidant behavior can help improve coordination and outcomes. In health-focused CBT work, where brief intervention models are becoming more common, tools like the HAI-M help clinicians make quick but meaningful decisions about treatment priorities.

Comparing SHAI and HAI-M

One of the major advantages of the HAI-M is that it allows for greater clinical nuance. Rather than forcing practitioners to choose between dismissing valid medical concerns and pathologising adaptive behavior, it provides a framework for exploring the "excessive" part of health anxiety without denying the real challenges of living with chronic illness.

The removal of certain SHAI items that implied symptoms were imagined makes it more likely that clients will engage meaningfully with the questionnaire. The wording of HAI-M items encourages reflection rather than defensiveness, making it a better entry point into deeper therapeutic work.

In CBT settings where time is often limited, a tool that promotes buy-in while offering reliable, targeted information about symptom patterns is invaluable. The HAI-M enables clinicians to move beyond vague health-related concerns into structured intervention planning, all while maintaining a respectful, validating tone.

Using the HAI-M in Clinical Work

The HAI-M is brief and easy to administer, making it a good candidate for early assessment.

It can be used to:

• Inform a collaborative CBT case formulation

• Identify triggers and maintaining factors

• Monitor change over time, particularly if health anxiety is a treatment target
  

In situations where health anxiety is suspected but not clearly articulated, the measure can help bring this into focus in a non-confrontational way. It supports a respectful and person-centred approach.

For clinicians newer to working in health psychology or physical health contexts, the HAI-M also functions as a guide. The structure and phrasing of items help cue clinicians into the cognitive and behavioral patterns worth exploring.

Additionally, services aiming to standardize health anxiety assessments across teams may find the HAI-M particularly useful. Its specificity for medical settings makes it easier to integrate into routine care, and its development process ensures it aligns with the lived realities of many patients [6].

Accessing the HAI-M

The HAI-M is available in full within the published article by Colenutt & Daniels [1]. It contains instructions for administration and scoring. While formal clinical cut-offs are still being validated, preliminary research has suggested that scores of 18 or above may indicate clinically significant health anxiety in medical populations [5]. Clinicians are encouraged to interpret scores alongside contextual clinical judgment.

Additionally, services aiming to standardise health anxiety assessments across teams may find the HAI-M particularly useful. Its specificity for medical settings makes it easier to integrate into routine care, and its development process ensures it aligns with the lived realities of many patients [6].

Moving Forward

Assessment tools shape how clients understand their own experiences. Using a measure like the HAI-M communicates that anxiety and physical illness are not mutually exclusive, and that both can be treated with care and skill.

Future research will likely establish clinical cut-offs, explore broader populations, and evaluate sensitivity to change post-treatment. But even now, the HAI-M is a step forward for those working to provide tailored, evidence-based support to people navigating health-related worries alongside chronic conditions.

This tool reflects a wider shift toward validating, context-sensitive approaches in CBT assessment. It respects the reality of physical illness while still giving clinicians the information they need to target maladaptive thought patterns and behaviors.

In an increasingly complex healthcare environment, tools that bridge the gap between medical and psychological needs are more essential than ever. The HAI-M shows that with thoughtful design and collaboration between clinicians and clients, our assessment tools can better reflect the lived experiences of those we support.

Share your thoughts:
Are you supporting clients who experience health anxiety alongside chronic illness? What approaches have you found helpful in this context?

Author: Kavya Suresh Kumar

References

[1] Colenutt, J., & Daniels, J. (2025). Adaptation and validation of the Health Anxiety Inventory (short version) for medical settings. The Cognitive Behaviour Therapist, 18, e13. https://doi.org/10.1017/S1754470X24000120

[2] Salkovskis, P. M., Rimes, K. A., Warwick, H. M. C., & Clark, D. M. (2002). The Health Anxiety Inventory: Development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine, 32(5), 843–853. https://doi.org/10.1017/S0033291702005822

[3] Abramowitz, J. S., Olatunji, B. O., & Deacon, B. J. (2007). Health anxiety, hypochondriasis, and the anxiety disorders. Behavior Therapy, 38(1), 86–94. https://doi.org/10.1016/j.beth.2006.05.001

[4] Fink, P., Ørnbøl, E., & Christensen, K. S. (2010). The outcome of health anxiety in primary care. British Journal of Psychiatry, 197(6), 439–446. https://doi.org/10.1371/journal.pone.0009873

[5] Österman, S., Axelsson, E., Lindefors, N. et al. (2022). The 14-item short health anxiety inventory (SHAI-14) used as a screening tool: appropriate interpretation and diagnostic accuracy of the Swedish version. BMC Psychiatry 22, 701. https://doi.org/10.1186/s12888-022-04367-3

[6] Rief, W., & Barsky, A. J. (2005). Psychobiological perspectives on somatoform disorders. Psychoneuroendocrinology, 30(10), 996–1002. https://doi.org/10.1016/j.psyneuen.2005.03.018