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

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.

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

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!

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

Maladaptive Daydreaming (MD) is a mental health issue where a person experiences realistic daydreaming for excessive amounts of time to escape from reality and cope with emotional distress. This is a coping mechanism occurring as a response to adverse experiences like trauma, abuse or loneliness, particularly when experienced in childhood.

However, causes are not limited to these distinctions. MD is common for people with mental health conditions, including those with anxiety disorders, attention deficit hyperactivity disorders (ADHD), specific types of depression, obsessive-compulsive disorder (OCD) and dissociative disorders, used as an unhealthy way to cope and adapt to a problem and described by some as a compulsive behaviour.

Previous literature exploring this condition has been limited. Whilst it holds a strong grounding in definitions and general understanding of the concept, it remains youthful, with emerging pilot intervention studies and assessment criteria.

A new psychological formulation model, developed by Lucas & Bone (2025)1, presents a promising new framework that could revolutionise assessment and intervention in clinical settings.

We explore the strengths and potential limitations of this new formulation model for maladaptive daydreaming, and how this framework contributes to advancing understanding, assessment, and treatment of this condition.

When assessing the model, we will investigate:

· Does the model identify clear mechanisms (e.g., emotional triggers, cognitive distortions, behavioural reinforcements)?

· Does the model offer actionable strategies or intervention points for therapists?

Understanding The Context of Daydreaming - Healthy vs. Maladaptive

MD symptoms tend to fall into two categories – daydreaming behaviour, and how the person feels about their daydreaming. MD can be much more vivid and intense with lots of detail compared to ‘ordinary’ daydreaming. They tend to be complex with elaborate plots and repeated characters, sometimes compared to those in films and tv shows.

MD creates disconnect from the world around the person, creating emotional attachments to characters, scenarios and their imagined lives to replace painful real-life events and reactions.

Those who experience MD tend to experience negative feelings and effects, with daydreaming interfering with hobbies, relationships, work, education and general functioning of everyday tasks (negatively impacting the persons quality of life). Guilt and shame are also reported as a common experience, and due to the ‘compulsive’ nature of the condition, people struggle to reduce/completely stop daydreaming, consequently leading to further distress.

It is also reported that patients face problems with managing emotions, as well as trouble with executive functioning. It is important to investigate this phenomenon because despite insufficient research in this area, one study in Israel found that MD affects 2.5% of adults, and 4.3% of young adults (student sample)2, reflecting how large cohorts may be experiencing a condition that thus far has not been officially recognised, leading to so many people undiagnosed and untreated.

From the little we do know, it appears to be extremely disruptive to those who experience it and potentially life-threatening, with a recent study in the US reporting that suspected MD participants were more than twice as likely to have recently attempted suicide despite controlling for psychological distress, as well as associations with other factors such as loneliness, heavy drinking and psychotic experiences3.

MD tends to be more common in younger adults and teenagers, so its threat is concerning for the younger generation. The framework by Lucas and Bone aims to address a significant gap in understanding by offering a structured cognitive-behavioural model. MD is characterised as a compulsive cycle of vivid, immersive fantasies that interfere with daily functioning and cause psychological distress, so this framework aims to clarify the phenomenon and equip therapists with a resource for conceptualisation and intervention.

Core Mechanisms Underpinning Maladaptive Daydreaming

Lucas & Bone (2025) propose a cognitive-behavioural formulation that captures maladaptive daydreaming as a self-reinforcing cycle, driven by identifiable psychological mechanisms.

Emotional Triggers

MD is often precipitated by negative emotional states including loneliness, anxiety, boredom and stress, and these emotional triggers can lead to coping mechanisms like retreating into fantasy. There may be individual ‘critical incidents’ such as relationship breakdowns or job loss and bullying which reinforce escapist tendencies. These fantasies are positively reinforcing in the short term, providing immediate emotional relief.

“The daydream becomes a refuge when emotions in the real world feel overwhelming.”

Cognitive Distortions and Core Beliefs

MD centres around holding distorted and negative core beliefs and assumptions that are self-deprecating regarding the self, world and future, echoing Beck’s cognitive triad4. These negative beliefs, such as ‘Nobody likes me’, ‘I will never be successful’ and ‘Everyone is out to get me’ reinforce a cycle of self-deprecation, which fantasies and daydreaming attempt to counteract. The imagined world becomes an escape and comforts the individual by offering self-worth, validation and an idealised identity construction.

“Themes often centre on the life ‘I wish I had’ or the person ‘I wish I was.’”

Behavioural Reinforcement Cycles

Daydreaming behaviour is sustained through a feedback loop:

· Triggers (perpetuating factors e.g. music, emotions, media cues)

· Pleasurable immersion (fantasy offers connection to created others, skill, acceptance and admiration, self-assurance, pride in accepting oneself, motivation for the life you would like to have)

· Negative aftermath (internal states/appraisals of shame, guilt, loss of control, worry for future, disappointment as fantasy life will never compare, low self-esteem)

· Functional impact (reduced time to study or work, missed opportunities)

· Renewed withdrawal (disappointment in reality, particularly when comparing, causing yearning and return to the fantasy world and hypnotic behaviour to escape)

The cyclical nature ensures that when individuals attempt to reduce daydreaming, the lack of emotional reward in real life can lead to experiencing ‘withdrawal’ type experiences, resulting in ‘bingeing’ and comparing their real to idealised self.

Actionable Strategies and Intervention Points

A key strength of Lucas & Bone’s (2025) model is it can be used as a clinical formulation tool for therapists to use for case conceptualisation and therapeutic planning.

A. Visual Formulation Mapping

Visual formulation mapping allows therapists to co-construct a visual model with clients, consisting of:

· Pre-disposing factors (e.g. childhood experiences - Cognitive theory suggests the role of early life experiences contribute to beliefs/assumptions about oneself, hence creating absorption of mental fantasies and sensory/emotional lucidity.

· Triggers

· Cognitive distortions

· Fantasy/content themes

· Reinforcement cycles

This allows clients to observe a visual representation of behaviour, allowing for externalisation and a non-judgmental understanding of what it happening. This also allows the individual to draw their own conclusions and identify patterns, assisted by the therapist.

B. Addressing Core Beliefs

Targeting underlying beliefs through cognitive restructuring or schema therapy can assist in reducing the emotional drive behind daydreaming and fantasy immersion. By challenging thoughts in behavioural experiments surrounding only being accepted, loved and skilled in these fantasies, we can assist clients in acknowledging their real-life connections, support circles and successes.

C. Behavioural Interventions

· Identify and modify cues (e.g. use of headphones, isolation)

· Implement activity to replace daydreaming with meaningful engagement (e.g. social activities, a new hobby)

· Encourage ‘mindful immersion’ to build awareness around daydreaming urges

· Educate on the idea of short-term positive and long-term negative reinforcement cycles

D. Emotional Regulation Skills

Maladaptive daydreaming is frequently a response to difficult emotions, and so clients may benefit from:

· Emotion regulation skills (e.g. from DBT or ACT)

· Distress tolerance techniques

· Psychoeducation regarding emotional awareness and acceptance

E. Exploration of Fantasy Themes

Analysing themes and characters within fantasies can be extremely informative and beneficial through therapeutic exploration. What can they tell us about the client’s needs and desires? Are they being met in the real world? If not, how can we implement changes into the individual’s world to make their lives more fulfilling, and how can we assist in this? By investigating how imagined roles relate to real world deficits and traumas, we can create bridges between inner worlds and real-life change.

Clinical Implications

This formulation offers a flexible, individualised approach for CBT therapists to integrate into their existing practice. We can target real-world problems and enhance the individual’s well-being whilst encouraging disengagement in maladaptive coping styles, aiding in their personal understanding of unhealthy mechanisms. However, challenges remain:

· Not all clients possess a reflective capacity, which is problematic as client insight is required

· There are few empirically validated treatments for MD, so more research is required

· Additional training may be needed for therapists to confidently address MD directly

Nonetheless, this framework is a promising route forwards and a useful guide for therapists to use alongside existing CBT tools for emotional regulation, behavioural activation and schema work.

Moving Forward

The research concluded that there is substantial evidence to support the “classification of MD as a distinct dissociative mental health issue that causes clinical levels of distress and functional impairment.” Lucas & Bone’s model represents a pivotal step in recognising maladaptive daydreaming as a legitimate and treatable clinical concern. By clearly identifying mechanisms and interventions, this can effectively support clinicians’ service, supporting and scaffolding clients between the pain of reality and the pull of imagined perfection. Despite the need for more theoretical grounding and empirically validated treatments, this framework appears to be an exciting step in the right direction.

Discussion

What do you think? As therapists, how can we balance validation of the emotional role that fantasy plays whilst encouraging engagement with a more grounded life? We would love to hear your thoughts!

Author: Sophie Mouldycliff

Over-exclusion is common: 57% of clients excluded from NHS talking therapies were drinking below the NICE threshold of 15 units/day.

CBT works for dual diagnosis: Meta-analyses show moderate to large benefits for anxiety, depression, and substance use when treated together.

Use formulation, not checklists: Assess function and impairment rather than automatically excluding based on substance use alone.

Coordinate care for higher risk: Use shared care with addiction services rather than complete exclusion from therapy.

In the NHS, agency work, and in private practice, it’s not unusual to see referrals that mention something like “a few drinks most nights” alongside anxiety or depression. Often, this seemingly minor detail leads to a quick triage decision: “Refer to alcohol services.” But this kind of automatic exclusion can close the door on effective treatment.

The recent audit by Khodayar and colleagues backs up this concern: in one south London talking therapies service, 57% of clients excluded for alcohol use were drinking below the 15-unit/day NICE threshold. This suggests a systematic pattern of over-exclusion that aligns poorly with both best practice guidelines and the flexible, formulation-based philosophy of CBT.

Substance Use and Mental Health: A Nuanced Picture

How Common Is It?

(Note: In psychological treatment research, an effect size of 0.2 is considered small, 0.5 moderate, and 0.8 large. These values help interpret the strength of therapy effects across studies.)

Globally, anxiety and depression frequently co-occur with substance use. A major meta-analysis of psychosocial interventions found that therapy produced moderate benefits for both anxiety and alcohol use (effect sizes ranged from g = 0.29 to 0.44), and large benefits when depression was also present (g = 0.88) [2].

Another review focusing specifically on CBT showed modest but meaningful improvements for both depression and substance use symptoms (g ≈ 0.25) [3].

While some of these numbers might seem small, they are clinically significant, especially in complex co-morbid presentations where even modest gains represent important progress.

What Do Guidelines Say?

NICE and NHS guidance recommend specialist referral for clients drinking > 15 UK units/day, but not exclusion for moderate or low-risk use [7]. CBT is recognised as effective for both mental health and substance use issues; it typically integrates functional analysis and relapse prevention [9].

What the Audit Really Tells Us

In the Cambridge audit of 5,273 NHS Talking Therapy referrals (Jan–Jul 2018), 678 were declined, with 50 citing substance use. Key findings:

1. 57% consumed below the 15-unit/day threshold [1].

2. Clinician rationales included fears of poor therapy outcomes, assumptions that substance use was primary, and the belief that these clients belonged in addiction services [1].

Taken together, these findings suggest clinicians may be overgeneralising risk, potentially denying effective therapy to those who could benefit greatly.

Why CBT Works in Co-morbid Cases

Core CBT Principles

CBT helps explore how thoughts, feelings, and behaviours interact, not in isolation, but as part of the person’s lived experience. In co-morbid presentations, substance use often serves a specific function, like numbing overwhelming anxiety or avoiding painful self-beliefs. For example, a client might drink to quiet intrusive thoughts tied to guilt or shame. CBT gives us tools to unpack these patterns and collaboratively build healthier ways to cope, without judgment [9].

Evidence of Efficacy

• Meta-analysis: 53 RCTs showed CBT had a small but significant effect (g ≈ 0.15) for alcohol and drug use, with stronger effects when combined with other interventions [4].

• Psychosocial comorbidity review: moderate effects for anxiety and substance use, with bigger effects on depression [2].

• Depression + substance use: CBT showed durable benefits in depression and substance use outcomes [3].

• Integrated approaches (e.g., trans-diagnostic or unified protocols) are promising, with emerging evidence of better retention and symptom change [6].

Related Therapies and Adaptations

Behavioural Activation, Acceptance and Commitment Therapy (ACT), and Unified Protocols are gaining traction. A pilot study found that Behavioural Activation delivered alongside substance use treatment improved both mood and use outcomes [5]. Integrated ACT protocols among alcohol and trauma/PTSD clients showed high completion (67%) and symptom improvement [6].

Practical Guidance for Informed Inclusion

Based on the evidence and clinical logic, here’s a refined framework for CBT clinicians:

Routine Screening

Use structured tools like AUDIT‑C, AUDIT‑10, or ASSIST‑Lite to objectively gauge risk [8]. Go beyond consumption: assess functional impairment, health, and motivation.

Formulation‑Driven Decisions

Instead of checklist exclusion, ask:

• Is substance use impairing participation?

• Does the client want help for it?

• Does it serve an avoidance or self-soothing function?

• What would a CBT formulation look like?

If substance use is manageable and coherent within a formulation, there's a strong rationale for inclusion.

Shared Care for Higher Risk

For clients showing moderate-to-high risk (e.g., high daily units, polydrug use, comorbid physical health issues), coordinated care with addiction services is warranted. Joint risk assessment, shared goals, and liaison meetings can support safe, effective therapy.

Therapist Competence and Reflection

Clinician belief matters. Regular supervision and training in substance use, shared care, and integration of therapies (e.g., ACT, Unified Protocol) can shift practice away from exclusionary heuristics and toward informed inclusion [6].

Binge Drinking and Health Risks: A Nuanced Consideration

While many clients excluded from therapy were drinking below the NICE threshold, the audit found that some engaged in high-risk patterns like binge drinking, or used substances such as methadone, crack, or chemsex-related drugs, which introduced additional risks; medical, psychological, and social [1].

These were valid grounds for pause and reflect the importance of not equating 'below threshold' with ‘safe’. In such cases, structured risk assessment and a collaborative care approach remain essential.

Acknowledging Data Limitations

It's also worth noting that the audit data came from a single NHS Talking Therapies service in London, with assessments carried out by a mix of clinicians (including Psychological Wellbeing Practitioners and CBT Therapists). This means the findings might not generalise across all services, but they do offer valuable insights into national patterns of decision-making that warrant attention [1].

Case Examples

Clinician Reflection Challenge

Think of your own recent case where substance use influenced your decision. Ask:

• Did you use a standardised tool?

• Were assumptions more influential than data?

• Could substance use have become a formulation target rather than a reason to exclude?

• What can you do to integrate care in future referrals?
  

Final Takeaway

The audit findings from Khodayar et al. offer a clear signal: current practice often errs on exclusion, even for low-risk substance users [1]. Yet, the evidence shows CBT is effective and adaptable,even when substance use is present [2–6]. With structured assessment, shared care, and clinician reflection, CBT therapists can confidently offer talking therapies to a broader range of clients,treating the person behind the substance, not just the substance behind the referral.

Share your thoughts: How do you navigate decisions around including clients with substance use in CBT? Share your formulation strategies, tools, or lessons from practice!

References

[1] Khodayar P., Charman A., Parry G. D., & Hepworth N. (2024). What leads clinicians to exclude drug and alcohol users from NHS Talking Therapies services? An audit of decision-making within clinical records. The Cognitive Behaviour Therapist, 17, E53. https://doi.org/10.1017/S1754470X23000277

[2] O'Leary-Barrett, M., et al. (2023). Psychosocial interventions for comorbid substance use and anxiety disorders: A systematic review and meta-analysis. Campbell Systematic Reviews. https://doi.org/10.1002/cl2.1243

[3] Watkins, K. E., et al. (2010). The effectiveness of combining depression and substance use treatment. Psychiatric Services, 61(8), 862–870. https://doi.org/10.1176/ps.2010.61.8.862

[4] Magill, M., & Ray, L. A. (2009). Cognitive-behavioral treatment with adult alcohol and illicit drug users: A meta-analysis of randomized controlled trials. Journal of Studies on Alcohol and Drugs, 70(4), 516–527. https://doi.org/10.15288/jsad.2009.70.516

[5] Dimidjian, S., et al. (2011). Behavioral activation and substance use: A pilot study. Behaviour Research and Therapy, 49(12), 866–874. https://doi.org/10.1016/j.brat.2011.09.001

[6] Twohig, M. P., & Levin, M. E. (2017). Acceptance and Commitment Therapy as a treatment for anxiety and depression: A review. Psychiatric Clinics of North America, 40(4), 751–770. https://doi.org/10.1016/j.psc.2017.08.009

[7] NICE (National Institute for Health and Care Excellence). (2021). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (CG115). https://www.nice.org.uk/guidance/cg115

[8] Babor, T. F., et al. (2001). AUDIT: The Alcohol Use Disorders Identification Test – Guidelines for Use in Primary Care. World Health Organization. https://apps.who.int/iris/handle/10665/67205

[9] NIDA. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). https://nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition

While CBT offers frameworks for treating depression and anxiety, grief related distress; when it becomes prolonged and functionally impairing, often falls outside of standard conventional protocols.

Therapists may ask: How do I differentiate between normal grief and a disorder that requires targeted intervention? Or Is CBT even effective for something as deeply personal as grief?

In the wake of the COVID-19 pandemic, suicide rates, unexpected deaths, and social isolation contributed to a significant rise in complex bereavement presentations in clinical settings1. Yet many therapists still lack specific training to support individuals with prolonged grief disorder (PGD), leading to treatment mismatches, diagnostic errors, or patients disengaging from therapy.

We examine a recent NHS CBT pilot of treatment for Prolonged Grief Disorder Therapy (PGFT) and consider the clinical implications for CBT therapists: Can PGDT be effectively delivered in the NHS setting? And how might it enhance outcomes for clients experiencing PGD?

What is PGD?

PGD is a recently formalised diagnosis which has now been recognised in both the ICD-11 and DSM-5. It describes a persistent and debilitating grief response lasting at least six months after a bereavement, characterised by symptoms like an intense yearning for the deceased, emotional numbness and difficulty re-engaging with life2.

PGD follows a distinct course and does not typically respond to generalised treatments for mood or anxiety disorders. This distinction is imperative for CBT clinicians where structured protocol based treatments are the norm.

Historically, grief was considered a non-pathological human experience unless it triggered another diagnosable disorder. However, over the past two decades research has supported the idea that some individuals experience a form of grief so prolonged and impairing that it becomes a disorder.

In response, Dr Katherine Shear and colleagues developed PGDT, an intervention combining CBT, exposure-based techniques, and attachment informed strategies3.

PGDT has demonstrated significant clinical effectiveness, yet its integration into routine care remains limited.

Current State of Prolonged Grief Interventions

The 2024 pilot study4 reported significant clinical improvements among participants and highlighted PGDT’s compatibility with core CBT principles, such as structured goal setting, cognitive restructuring, and behavioural activation.

Practically, therapists followed a 10–12 session model that included psycho-education, loss-processing tasks (for example, guided imagery), behavioural experiments, and future goal setting5.

Therapy included:

• Understanding grief

• Managing grief-related emotions

• Imagining a promising future post loss

• Strengthening relationships

• Telling the story of the death

• Living with reminders of loss

• Connecting with memories of the deceased.

Techniques used include monitoring, psycho-education, goal setting, imaginal/guided revisiting, situational revisiting, and an imaginal conversation.

PGDT’s structure allowed therapists to hold space for both emotional processing and practical change, helping clients move from “grief stuckness” to re-engagement with life.

Importantly, therapists involved in the pilot reported increased confidence in working with grief, with several noting the value of guided imaginal techniques to access avoided thoughts and feelings.

Nonetheless, widespread implementation requires systemic changes. Services would need to invest in training and supervision, adjust clinical outcome measures to capture grief specific changes, and ensure cultural sensitivity in the application of PGDT.

This pilot serves as one of the first examples of PGDT being embedded within NHS Talking Therapies, suggesting that therapists can be trained to deliver grief specific interventions effectively with appropriate supervision and guidance. Yet, outside of this pilot, most services and therapists still lack a clear standardised approach.

Despite the increased prevalence of prolonged grief following COVID-19, especially among those experiencing multiple or traumatic losses there remains no nationally commissioned grief pathway across NHS Talking Therapies in England, leaving local services to decide how, or whether, to respond.

Key Considerations and Challenges for Therapists

The integration of PGDT into CBT raises many clinical, ethical, and operational considerations.

On one hand, structured interventions offer clarity and containment for both therapist and client. PGDT’s focus on grief specific processes such as revisiting the loss narrative, addressing avoidance, and restoring life goals resonates with CBT’s directive approach.

However, some clinicians express concern that grief, particularly when rooted in cultural or spiritual traditions, may resist understandably being “treated” in a clinical sense. As one NHS clinician noted during the 2024 pilot, “The challenge is balancing a protocol with the deeply human side of grief. You need to know when to push and when to sit in silence”6.

Another key limitation is the emotional demand PGDT places on therapists. Revisiting loss narratives and facilitating imaginal conversations with the deceased, as PGDT encourages, can be intense for clinicians not used to working with bereavement in such depth. Vigorous supervision structures and sufficient training time are therefore imperative.

In addition, grief presentations are often complicated by co-morbidities such as trauma or substance use, which may require integrated or staged interventions. Without clear diagnostic boundaries, there is a risk of either over pathologising normal grief or under-recognising clinical PGD, both of which can impair therapeutic progress7.

Key Takeaways

The integration of PGDT into NHS Talking Therapies marks a significant shift in how we conceptualise and treat complex bereavement. As the 2024 pilot demonstrates, CBT informed grief interventions can be both effective and practical, especially when supported by adequate training and clinical oversight.

However, to truly meet the needs of clients experiencing Prolonged Grief Disorder, we need more than pilot studies. Additional research in how grief specific care can be sustainably embedded into mainstream psychological services and therapies is necessary.

This includes updating clinical competencies, developing consistent referral pathways, and ensuring therapists feel emotionally and culturally equipped to navigate the complexities of grief.

Moving forward, questions remain:

• Should grief be treated as a discrete clinical issue, or should we take a broader approach that blends therapeutic models with compassion-focused, culturally informed support?

• As CBT therapists, we must ask ourselves what it means to “treat” grief especially in a society still grappling with mass bereavement and loss.

• Are we able to maintain the structure of evidence-based practice while honouring the deeply personal and, at times, profound dimensions of loss?

Continued dialogue, innovation, and interdisciplinary learning will be vital in shaping the future of grief care within psychological services. This interview with Katherine Shear also provides further helpful information.

What do you think? Is grief better supported outside of protocol driven models? Or have you found CBT or other therapies helpful for your clients?

Author: Jessica Rodrigues

Despite its prevalence, mental health services often lack a culturally sensitive understanding of this phenomenon and the specific support it requires. CBT – though originally developed within Western frameworks – holds considerable potential for supporting individuals experiencing acculturative stress.

Making this work, though, means developing approaches that put cultural understanding first and recognise how psychologically demanding it can be to adapt across cultures.

What is Acculturative Stress and How Can Therapists Work With It?

Acculturative stress1 refers to the psychological strain that arises from the challenges of adapting to a new culture. When individuals enter a new cultural environment, they encounter unfamiliar languages, social norms, and institutional systems. These elements demand psychological adjustment.

However, when the demands of adaptation exceed a person’s coping resources, acculturative stress can result. Such difficulties are especially pronounced in situations involving discrimination, cultural separation, loss, or significant incongruence between one’s heritage culture and the host society. Over time, these distressing experiences can compound, increasing the risk of various mental health issues.

Substantial research has linked acculturative stress to elevated levels of depression and anxiety. Evidence also points to a heightened risk for substance use, trauma-related disorders, and identity confusion.

CBT for Acculturative Stress: Evidence from Refugee Interventions

A growing body of research highlights the effectiveness of CBT in alleviating acculturative stress and its associated mental health difficulties. Its efficacy is particularly evident when interventions are culturally adapted to the target population and grounded in an understanding of the unique challenges tied to distinct cultural identities and migration experiences.

One encouraging example from the literature involves culturally adapted CBT delivered in a group format to Afghan refugees in Germany2. The use of group format was not merely for efficiency, but intentionally designed to foster connection and reduce social isolation, aligning with the collectivist value of Afghan culture. The therapy was conducted in Farsi and symptoms were framed using culturally familiar metaphors.

For instance, Khod-Khori (“eating oneself”) was used to convey worry and rumination while gooshe-gir (“corner sitting”) captured the concept of social withdrawal. Rather than relying on DSM diagnostic labels, these idiomatic expressions facilitated psychoeducation in a way that was accessible and non-pathologising.

Crucially, trauma exposure therapy was not used in this context. While exposure-based methods can be effective, the ongoing instability experienced by this population, such as insecure asylum status, can make direct trauma processing overwhelming or even counterproductive.

Instead trauma was addressed trans-diagnostically through common symptom clusters such as sleep disturbances and intrusive thoughts. Participants were also guided through evidence-based breathing exercises, mindfulness techniques and loving-kindness meditation. Study results demonstrated significant reductions in psychological distress, including depressive, somatic, and PTSD symptoms. These improvements were maintained at a one-year follow up, alongside enhancements in quality of life.

Adapting CBT for Cultural Relevance and Acculturative Stress: Tips for Therapists

Adapting the Theoretical Alignment
CBT’s foundational assumptions may not align seamlessly with a client’s cultural values. For instance, its emphasis on individual locus of control can clash with collectivist values that prioritise social cohesion and family harmony. A therapist might inadvertently frame beliefs such as dependence on others, prioritising harmony, or avoiding disruption as dysfunctional. These potential clashes must be navigated through the lens of cultural competence.

This does not require abandoning CBT principles, but rather reframing them through culturally acceptable ways – changing the form of expression while maintaining the functional goals of CBT3.

CBT for Acculturative Stress Goes Beyond Cultural Adaptation
Culturally adapted CBT refers to the broader practice of modifying CBT principles to make them more resonant with a client’s cultural background. This includes adapting language, metaphors, beliefs about the origins of mental health problems, and respecting cultural norms and values. While CBT for acculturative stress typically requires cultural adaptation, its core focus is on placing the distress of cross-cultural adjustment at the center of therapy. CBT techniques are then applied to help clients process and cope with their experiences of acculturation-related stress.

Psycho-education and Normalisation of Acculturative Stress
The therapist should support the client in understanding the process of acculturative stress and its psychological impacts. The distress should be acknowledged as a common and expected experience, rather than a personal failure.

The client’s emotional responses should be validated as legitimate, and their decision to seek help reframed as an act of courage and resilience, rather than weakness4.

Cognitive Restructuring of Acculturation-related Maladaptive Cognitions
CBT relies on identifying maladaptive cognitions and evaluating their accuracy. However, when these thoughts involve experiences of discrimination or exclusion, it is crucial not to invalidate them, as they may reflect real and repeated events. Instead, the therapist can work with the client to explore the meaning of these experiences and help prevent the internalisation of others’ bias or the development of self-blaming interpretations.

Language Barriers
Language barriers present a significant challenge for CBT, a modality that relies heavily on verbal communication. When therapist and client do not share common fluent language, the therapeutic process can be disrupted, leading to misunderstandings, reduced engagement, and potentially adverse outcomes. This issue is particularly critical for individuals experiencing acculturative stress, many of whom already face social exclusion and communication difficulties in their daily life.

However, there is also potential for meaningful adaptation. Collaborating with qualified interpreters as part of a three-way therapeutic alliance can greatly enhance accessibility5. Additional solutions include matching clients with bilingual clinicians and translating therapy materials into the client native language to support comprehension and retention.

Moving Forward

CBT for acculturative stress centres the client's cultural adjustment experience within the therapeutic process, utilising culturally sensitive methods to support meaningful change. This approach requires humility, cultural awareness, and collaboration between the therapist and client.

When adapted thoughtfully, CBT can offer a powerful and effective pathway for healing in the context of cross-cultural transitions. Nevertheless, CBT for acculturative stress remains under-researched. Both research and clinical practice should work to bridge this gap, fostering a deeper understanding of the migration experience and its psychological impact on individuals from diverse backgrounds. I

In what other ways, can we continue to adapt our practice to better meet the needs of clients navigating acculturative stress? Tell us your thoughts and join the conversation.

Author: Farah Haj Amor

Fast Facts

• Coaching effectively complements CBT for low self-esteem when used in later treatment stages

• CBT challenges negative beliefs while coaching builds future-focused strengths and goals

• Research shows coaching significantly improves self-esteem through goal-setting and action planning

• Early use risks bypassing unresolved trauma - timing and clinical judgement are crucial

CBT is one of the most evidence-based interventions for low self-esteem. However, as psychological services become increasingly integrated with wellbeing and performance-focused approaches, clinicians are exploring whether coaching principles may offer additional value, particularly in cases where low self-esteem persists despite cognitive restructuring.

Can coaching be a useful adjunct to CBT in this context? The answer is nuanced.

Understanding the difference

CBT is a structured, problem-focused therapy grounded in psychological theory and often targets distress or dysfunction. Coaching, by contrast, typically centres on goal achievement and potential realisation in the absence of clinical distress.

However, the overlap is growing, particularly in the domain of “cognitive behavioural coaching” (CBC), which applies CBT principles in a coaching context.

• Focus:

CBT typically focuses on identifying the root of negative self-beliefs and challenging them through cognitive restructuring and behavioural experiments. Coaching, by contrast, is more future-focused, helping clients build a desired self-image through strengths-based goal setting.

• Use of the past:

CBT often draws on the client’s early experiences to understand the development of their core beliefs and safety behaviours. Coaching is less interested in the past and more concerned with present actions and future possibilities.

• Role of the practitioner:

A CBT therapist uses structured protocols to guide the client through psychoeducation, formulation and behavioural change. A coach may take a more facilitative stance, encouraging the client to generate their own solutions and action steps.

Essentially, both approaches can increase self-efficacy, but they take different paths to achieve this.

The case for integration

Research from Grant (2003, 2012)1 has demonstrated that coaching interventions can significantly improve self-esteem, particularly when based on self-reflection, goal setting and action planning.

A study by Wildflower and Palmer (2017)2 reviewed the outcomes of coaching within NHS and educational settings, noting improved confidence and resilience among participants. Palmer and Szymanska (2007)3 argue that cognitive behavioural coaching techniques, such as guided discovery, socratic questioning and behavioural experimentation, can help individuals move from a “problem-saturated” identity to one more focused on strengths and aspirations.

This approach could be particularly relevant in the later stages of CBT for low self-esteem, where clients are consolidating gains and beginning to re-engage with broader life goals.

How CBT therapists might use coaching in practice

A CBT therapist can incorporate coaching elements by weaving them into the later phases of treatment once safety behaviours have been reduced and negative self-beliefs have softened.

For example:

• Values clarification: After addressing maladaptive core beliefs, the therapist might help the client identify personal values and long-term aspirations, supporting identity development beyond symptom relief.

• Self-efficacy building: Encouraging clients to track and celebrate small wins builds a sense of agency, shifting the self-concept from “I can’t” to “I am becoming more capable.”

• Strengths-based language: The therapist might intentionally highlight the client’s resilience, effort and growth, fostering a more affirmative internal narrative.

Crucially, these techniques still sit within a formulation-driven, evidence-based CBT framework, but allow the work to transition toward growth and flourishing.

Cautions and considerations

Despite these benefits, there are important caveats. Coaching is not a substitute for therapy in cases of clinical distress. When used indiscriminately or too early in the therapeutic process, coaching goals may risk bypassing unresolved trauma or entrenched schemas.

It is also worth noting that many coaching approaches are not regulated or standardised in the way that CBT is. The British Psychological Society has highlighted the need for greater integration of coaching psychology within mental health services but stresses the importance of practitioner competence and supervision.

Conclusions

Ultimately, integrating coaching into CBT for low self-esteem may be most effective when it is deliberate, collaborative and tailored to the client’s stage of recovery. For example, early sessions might focus on addressing core beliefs and emotional regulation, while later sessions incorporate coaching-style goal setting and values-based action to support identity development and long-term self-worth. By helping clients move from “I am not good enough” to “I am becoming who I want to be,” coaching can offer a useful and affirming complement to traditional CBT, when used judiciously.

Author: Francesca Harland is a CBT psychotherapist and low-self esteem specialist.

Fast Facts

• VRM enhances emotional regulation for anxiety and depression

• Three weekly sessions over 10 weeks showed significant benefits

• Multi-sensory environments offer alternatives to traditional mindfulness

• Demographics impact effectiveness across age and gender groups

What if your clients could step into a calming, immersive virtual environment at the push of a button—one designed to enhance emotional regulation and reduce anxiety? Virtual Reality Meditation (VRM) is gaining significant attention, offering a technology-driven approach to mindfulness that could complement traditional CBT techniques and replace pharmacological approaches.

Traditional strategies don't always resonate with every client, prompting us to seek new ways to help patients regulate emotions and manage distress. Recent research suggests that VR meditation may enhance emotional regulation and significantly improve the treatment of depression and anxiety.1

Lee et al. (2024)2 also found that VR meditation can boost emotional regulation by increasing the Coherence Achievement Score (CAS), a measure of heart rhythm consistency linked to psychological well-being.

But the question remains: does this translate to real-world clinical benefits? As anxiety and depression rates continue to climb3, therapists need accessible, engaging tools that align with CBT principles. Could IVRM make mental health support more effective?

The Evolving Role of Technology in Mental Health Treatment

Systematic reviews now indicate that digital interventions can effectively support emotional regulation, particularly for individuals with Major Depressive Disorder (MDD) and Generalised Anxiety Disorder (GAD)4.

Mindfulness-Based Cognitive Therapy (MBCT) has shown promise in improving emotional regulation, and now, technology-enhanced interventions like IVRM are emerging as potential game-changers.

IVRM combines mindfulness practices with virtual reality technology to create immersive, interactive experiences that promote emotional regulation.

In this study, participants used the Oculus Quest 2 headset to enter a realistic, three-dimensional virtual environment, where they explored calming natural landscapes such as beaches, forests, and open meadows, accompanied by soothing sounds like birdsong or gentle waves.

The IVRM offered a variety of guided meditation programs, enabling participants to choose sessions specifically designed to reduce stress, improve sleep patterns, and alleviate depression. This multi-sensory experience blended visual, auditory, and guided instruction, delivering a personalised and deeply immersive meditation.

How can CBT therapists incorporate IVRM into their practice? And should they?

Lee et al. (2024) research suggests IVRM has emerged as a promising tool for enhancing emotional regulation in clients with depression and anxiety.

Who Benefits Most—and Who May Struggle?

However, not all clients responded the same way. Demographic factors, such as age and gender, can influence how clients respond to IVRM. For example, older adults in the study reported higher anxiety levels post-intervention, suggesting they may need additional guidance and support when using VR tools.

Similarly, gender differences were noted, with men experiencing lower anxiety levels than women, emphasising the importance of tailoring treatment to ensure all clients benefit from IVRM. The study found that IVRM's positive impact on emotional regulation may persist over time.

One major advantage is IVRM's customisability—clients can choose calming, nature-based environments, offering an alternative for those who find traditional mindfulness challenging.

Other Considerations

While this study is valuable, it is limited by the small sample size (n=26) and single-arm design, which affects the generalisability of the findings. Client acceptance of technology is another crucial factor to consider. Some clients may feel uncomfortable or unfamiliar with virtual reality, potentially affecting their willingness to engage in IVRM.

Therapists can address these concerns through gradual exposure and education, helping to increase client engagement and improve outcomes. However, the implementation in clinical practice comes with challenges. Clinicians will require training in VR technology to implement it effectively in therapy. Ensuring therapists and clients feel confident using the technology is also essential for its success.

Additionally, the costs associated with VR equipment and ongoing support for clients need to be considered to ensure that IVRM remains an accessible and sustainable treatment option.

Key Takeaways for CBT Therapists

• IVRM can enhance emotional regulation, making it a useful adjunct to CBT for clients struggling with traditional mindfulness techniques.

• Demographic factors matter—older clients may need more structured support, while gender differences in response should be considered.

• Personalisation is key—offering tailored IVRM experiences based on client preferences may maximise engagement and outcomes.

Moving Forward

The exploration of IVRM as a treatment for MDD and GAD shows great promise for improving emotional regulation and reducing symptoms. IVRM offers a personalised and engaging approach, which can help overcome some of the barriers faced by traditional therapies.

However, more rigorous research and ensuring patient acceptance of technology are essential for its successful integration into clinical practice.

Looking ahead, several key questions emerge: How can we make IVRM accessible to clients who might not be familiar with technology? What steps can we take to improve clinician training in using VR tools? And, as mental health treatments evolve, how do we strike the right balance between technological innovation and the essential human connection in therapy?

Is Virtual Reality Meditation a breakthrough in CBT, or just a high-tech distraction? How do you see it fitting into your practice—if at all? Share your thoughts.

Author: Sarah Kerr

Fast Facts

• Moral injury occurs when actions violate one's moral code, worsening PTSD symptoms

• Religious conflicts often create spiritual distress in moral injury cases

• Incorporating patients' beliefs into CT-PTSD reduces guilt and shame

• Anonymous consultation with spiritual leaders can guide treatment approaches

• Both practitioner and patient beliefs influence treatment effectiveness

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When individuals experience moral injury, they may face profound spiritual conflicts and guilt, especially if they've committed or witnessed acts that contradict their spiritual values. This often creates a distressing internal struggle between competing values (such as doing the duties of a job versus faith teachings), leading to feelings of alienation from their Higher Power or a sense of having failed their faith.

Moral injury is the psychological distress arising from actions (or often lack thereof) that violate an individual's deeply held moral code.1

Moral injury is often recognised among veterans and healthcare workers due to the heightened potential to witness acts of violence and/or the failure to protect those in need. However, a moral injury can be any violation of one’s ethical code. Additionally, patients with moral injury have been shown to have more severe PTSD and depression2.

By not accounting for religion and moral injury in PTSD treatment, we can often neglect an integral part of the traumatic experience. This may make CT-PTSD less cohesive and effective. This is particularly so as religious and spiritual beliefs can be tested and strained by traumatic experiences, particularly those of moral injury.

How Do We Adapt TF-CBT (CT-PTSD) for Moral Injury To Incorporate Religion?

Incorporating the patients’ beliefs into CT-PTSD has been shown to be effective in reducing guilt and shame. But how?

When addressing spiritual care in trauma treatment, practitioners should consider which approach they're taking from the continuum of spiritual care34:

Moving from spiritually avoidant care toward more integrated approaches allows therapists to better address moral injury in trauma treatment. For clients whose moral injury intersects with religious beliefs, approaches 3 and 4 may be particularly beneficial.

The National Centre for PTSD (USA) recommend the following questions during assessment5:

• Do you see yourself as a religious or spiritual person? If so, in what way?

• Are you affiliated with a religious or spiritual community?

• Were you raised in any particular faith or spiritual ideology? Do you still identify with that group, or any other group? Are there other groups that have an important influence on your spirituality?

• What are your ultimate values? What do you think your life is about, or what your ultimate goals are? What kinds of life goals are you most excited about?

• Has the traumatic event affected your religiousness [or spirituality] and if so, in what ways?

• Has your religion or spirituality been involved in the way you have coped with this event? If so, how?

• Do you have an interest in your mental health care incorporating a focus on your religion or spirituality? If so, how?

Their guidance aligns with Beck’s guide6 for exploring culture, spirituality, and religion with patients in CBT. Practical considerations for therapists to successfully integrate moral injury into PTSD treatment include:

• In early sessions, open initial conversations about spirituality, religion, and culture with the patient, and how this may relate (or not) to moral injury.
  

• If possible, seeking religious guidance from experts when looking at events linked to distorted cognition or if they have difficulty recovering from the moral injury. This may involve inviting experts to sessions depending on client preference.
  
  If a patient brings spiritual concerns, a conversation about involving religious leaders may be helpful7. If the client does not want to work with a religious or spiritual professional, it can be helpful for practitioners to do an anonymous consult with appropriate spiritual leaders to help better understand the tenets of their patient’s religion8.

Considerations for practitioners when working with moral injury and religion

As well as adapting CT-PTSD for moral injury, practitioners can consider how beliefs can practically influence the therapy they offer.

When working with individuals who have experienced a moral injury:

- Think about how our own beliefs may impact our position in working with moral injury and religion.

- If you are experiencing discomfort with talking about and incorporating religion into CT-PTSD, education and support can help. Supervision can allow you to recognise your intersecting identity and remain patient-focused.

Moving Forward

When working with patients who have suffered a moral injury that has resulted in or coupled with their PTSD, it is crucial to understand how both our own and the patient's beliefs can influence CT-PTSD.

Looking for and then initiating conversations about potentially important ethical beliefs is integral to helping the patient overcome their moral injury and PTSD.

Adapting CT-PTSD to account for moral injury has been effective but does require the practitioner to engage with available education and support, and awareness of the spiritual care continuum.

Do you think it is essential to consider a patient's religious, spiritual, or cultural beliefs in CT-PTSD? How have you worked with this before?

Author: Siona-Lee Hemming

Related Articles:

• TF-CBT works for complex trauma, not just single-event experiences

• The approach doesn't require clients to relive trauma in vivid detail

• TF-CBT is flexible and can be adapted for diverse clients and co-morbid conditions

• Recent innovations include digital delivery and culturally-sensitive adaptations

Have you ever had a client express concern about starting trauma-focused CBT (TF-CBT) by saying, "I don’t want to relive my trauma," or ask if it’s only meant for people with a single traumatic experience? If so, you’re not alone.

Many therapists also hesitate to use TF-CBT, unsure whether it’s the right approach for clients with complex trauma, multiple diagnoses, or diverse cultural backgrounds.

Despite decades of research validating TF-CBT as one of the most effective treatments for PTSD, myths and misunderstandings persist. So, what does the latest research really say about TF-CBT? And how can we ensure we’re using this approach in a way that truly benefits our clients?

What Are the Most Common Misconceptions?

1. "TF-CBT Is Only for Single-Event Trauma" Many believe that TF-CBT works best for individuals who’ve experienced a single traumatic event, such as a car accident or assault. In reality, TF-CBT has been successfully adapted for people with complex trauma histories, including survivors of childhood abuse, domestic violence, and repeated exposure to traumatic events.1
   
   Practical Tip: If a client expresses doubts because they’ve experienced multiple traumas, acknowledge their concerns and explain that TF-CBT can be tailored to address their specific experiences. You might say, “It’s true that everyone’s trauma story is different, and TF-CBT can be adjusted to fit your unique history.”
   

2. "Clients Must Retell Their Trauma in Detail" Clients (and even some therapists) often think TF-CBT means talking about every traumatic moment in vivid detail. But that’s not the case. In reality, TF-CBT’s trauma processing is designed to be gradual and safe, with a focus on shifting unhelpful beliefs and reducing emotional distress.2
   

   
   Practical Tip: Many clients worry that trauma-focused therapy means reliving every painful memory. It’s important to explain that the real goal is to help them change how those memories and specific hotspots within these affect them—without diving into every detail.
   

3. "TF-CBT Is Too Rigid and Protocol-Driven" Some view TF-CBT as overly structured or “one-size-fits-all.” While it does follow a framework, TF-CBT allows significant flexibility. Clinicians can modify pacing, incorporate grounding exercises, or borrow strategies from other therapies, like Acceptance and Commitment Therapy (ACT), depending on the client’s needs.3
   
   Practical Tip: Every client moves at their own pace. If someone needs more time to build trust or feel grounded, that’s okay—let their progress set the rhythm. You can say, “This framework is here to guide us, but we’ll take it step by step to match where you are.”. However, for those in organisations that determine a pre-set amount of sessions, this can be challenging, and may be worth discussing with your employer and client.
   

4. "It’s Not Effective for Clients with Co-morbid Conditions" Since PTSD often occurs alongside conditions like depression, anxiety, or substance use disorders, some therapists assume TF-CBT won’t be effective for these clients. However, research shows that TF-CBT not only reduces PTSD symptoms but can also improve comorbid conditions by addressing underlying trauma.4
   
   Practical Tip: Clients sometimes think TF-CBT only targets PTSD symptoms, but it can also help with things like anxiety, depression, or even sleep problems. Let them know it’s designed to address the bigger picture. For example, you might explain, “Because trauma affects many aspects of life, working through it can often relieve symptoms of anxiety, depression, or other difficulties, too.”
   

5. "TF-CBT Only Works for Certain Demographics" There’s a lingering belief that TF-CBT is primarily suited to Western, highly-educated clients. However, studies have shown its effectiveness across different cultures, languages, and populations—including refugees, children in low-resource settings, and clients from marginalised communities.5
   
   Practical Tip: When you’re working with clients from different cultural backgrounds, take time to understand what healing looks like for them. Maybe that means incorporating storytelling, spirituality, or family support.

Why Misconceptions Matter: How They Shape Therapy Outcomes

Trauma-Focused CBT (TF-CBT) is one of the most effective treatments for trauma, but for the majority of CBT therapists, if we are honest—misconceptions about it can get in the way.

Some therapists assume it’s rigid, that it only works for single-event trauma, or that it doesn’t fit clients with complex issues. And that’s a issue because those myths can stop both clients and clinicians from getting the most out of this powerful approach.

The truth? These misunderstandings can directly impact real people. A client who fears they’ll have to relive their trauma might avoid therapy altogether. Meanwhile, a therapist unsure about using TF-CBT with clients from diverse backgrounds or with complex trauma might hesitate to even try it and stay within other approaches that feel ‘safer’—and those are missed chances for healing.

So how do we fix that? By challenging outdated assumptions, staying curious about new research, and being willing to adapt TF-CBT to meet clients where they are. That’s how we maximise its potential.

Key Reasons to Bust These Myths:

• Empowering Clients: Avoiding trauma because it feels too overwhelming is understandable—but it can keep clients stuck. TF-CBT provides a safe, structured way to face that fear, helping clients build resilience and take back control of their lives.

• Keeping Up with Research: Many misconceptions come from training that is now out of date or not in line with the latest research. Staying current with research helps therapists feel confident and provide the best care possible.

• Feeling competent: Many therapists feel they need additional training on top of their CBT training to work with trauma. The evidence suggests this may not be true, but it is challenging the myths we hold about our training and approach.

What’s Next for TF-CBT?

TF-CBT isn’t standing still. Research is expanding how and where it can be used:

• Digital TF-CBT: Online programs are opening doors for people who might not have access to in-person care—whether they live in remote areas or just need a more flexible option.6

• Cultural Adaptations: New research is helping therapists make TF-CBT more inclusive, so clients from diverse backgrounds feel seen and supported.7

• Neuroscience Breakthroughs: We’re also learning more about how TF-CBT actually changes the brain, giving us deeper insights into why it works so well.8

The bottom line? When we stay open to new ideas and keep adapting TF-CBT to meet clients’ unique needs, it stays dynamic, flexible, and—most importantly—effective. And that’s exactly what clients deserve.

Share Your Thoughts

What strategies have helped you overcome client hesitations about trauma-focused therapy? Share your experiences in the comments below.

Author: Kavya Suresh Kumar for Between Sessions

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What if the very survival strategy that once protected them is now the biggest obstacle to their healing, regardless of diagnosis?

Between Sessions is excited to collaborate with Charlotte Bailey, an integrative, trauma-trained psychotherapist passionate about helping people-pleasers address the root cause of guilt, anxiety, and self-sacrifice. Drawing from CBT, EMDR, and Schema Therapy, in this webinar she helps us understand the deep-rooted patterns behind people-pleasing so that as CBT therapists, we understand how to work with this trans-diagnostic symptom.

People-Pleasing: Considerations for CBT Therapists

This webinar explores people-pleasing as a trans-diagnostic coping strategy, examining its origins and how it presents across various mental health difficulties. It highlights practical CBT interventions to help clients break free from automatic compliance patterns while also considering countertransference dynamics that may arise in therapy.

• Understanding people-pleasing: Recognising it as a learned protective response rather than a fixed personality trait.

• Origins and maintenance factors: Exploring how attachment experiences, early conditioning, trauma, and neurodivergence contribute to people-pleasing.

• Trans-diagnostic perspective: Understanding how people-pleasing manifests across GAD, depression, perfectionism, burnout, OCD, and other difficulties.

• CBT interventions: Applying the Five Areas Model, challenging unhelpful beliefs, using behavioural experiments, and introducing graded assertiveness work to manage distress.

• Therapeutic considerations: Recognising how people-pleasing may show up in the therapy room and what to be aware of as a therapist.

This session equips therapists with strategies to recognise, formulate, and work effectively with people-pleasing tendencies while addressing the emotional challenges clients may face when breaking these patterns.

About Charlotte

Charlotte Bailey is an integrative, trauma-trained psychotherapist passionate about helping people-pleasers address the root cause of guilt, anxiety, and self-sacrifice. Drawing from CBT, EMDR, and Schema Therapy, she helps clients uncover the deep-rooted patterns behind people-pleasing so they can build self-worth, set boundaries with confidence, and embrace their authentic selves.

As the podcast host of Let’s Talk People-Pleasing!, Charlotte combines personal experience with professional expertise to offer a trauma-informed yet down-to-earth and relatable perspective on breaking free from people-pleasing habits.

Beyond therapy, she mentors fellow therapists, helping them navigate client challenges and show up authentically in their practice.

Follow her on Instagram and check out here website Charlotte Bailey Therapies to learn more!