In this episode of Research Matters, host Steph Curnow talks to Dr. Alex Lau-Zhu, lead author of the paper “Flashforward Mental Imagery in Adolescents: Exploring Developmental Differences and Ass...

We’re back! Let’s Talk about CBT has been on hiatus for a little while but now it is back with a brand-new host Helen Macdonald, the Senior Clinical Advisor for the BABCP. Each episode Helen will be talking to experts in the different fields of CBT and also to those who have experienced CBT, what it was like for them and how it helped. This episode Helen is talking to one of the BABCP’s Experts by Experience, Paul Edwards. Paul experienced PTSD after working for many years in the police. He talks to Helen about the first time he went for CBT and what you can expect when you first see a CBT therapist. The conversation covers various topics, including anxiety, depression, phobias, living with a long-term health condition, and the role of measures and outcomes in therapy. In this conversation, Helen MacDonald and Paul discuss the importance of seeking help for mental health struggles and the role of CBT in managing anxiety and other conditions. They also talk about the importance of finding an accredited and registered therapy and how you can find one. If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X or email us at . Useful links: For more on CBT the BABCP website is www.babcp.com Accredited therapists can be found at Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF   Transcript: Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the senior clinical advisor for the British Association for Behavioural and Cognitive Psychotherapies. I'm really delighted today to be joined by Paul Edwards, who is going to talk to us about his experience of CBT. And Paul, I would like to start by asking you to introduce yourself and tell us a bit about you. Paul: Helen, thank you. I guess the first thing it probably is important to tell the listeners is how we met and why I'm talking to you now. So, we originally met about four years ago when you were at the other side of a desk at a university doing an assessment on accreditation of a CBT course, and I was sitting there as somebody who uses his own lived experience, to talk to the students, about what it's like from this side of the fence or this side of the desk or this side of the couch, I suppose, And then from that I was asked if I'd like to apply for a role that was being advertised by the BABCP, as advising as a lived experience person. And I guess my background is, is a little bit that I actually was diagnosed with PTSD back in 2009 now, as a result of work that I undertook as a police officer and unfortunately, still suffered until 2016 when I had to retire and had to reach out. to another, another psychologist because I'd already had dealings with psychologists, but, they were no longer available to me. And I actually found what was called at the time, the IAPT service, which was the Improving Access to Psychological Therapies. And after about 18 months treatment, I said, can I give something back and can I volunteer? And my life just changed. So, we met. Yeah, four years ago, probably now. Helen: thank you so much, Paul. And we're really grateful to you for sharing those experiences. And you said about having PTSD, Post Traumatic Stress Disorder, and how it ultimately led to you having to retire. And then you found someone who could help. Would you like to just tell us a bit about what someone might not know about being on the receiving end of CBT? Paul: I feel that actual CBT is like a physiotherapy for the brain. And it's about if you go to the doctors and they diagnose you with a calf strain, they'll send you to the physio and they'll give you a series of exercises to do in between your sessions with your physio to hopefully make your calf better. And CBT is very much, for me, like that, in as much that you have your sessions with your therapist, but it's your hard work in between those sessions to utilize the tools and exercises that you've been given, to make you better. And then when you go back to your next session, you discuss that and you see, over time that you're honing those tools to actually sometimes realising that you're not using those tools at all, but you are, you're using them on a daily basis, but they become so ingrained in changing the way you think positively and also taking out the negativity about how you can improve. And, and yeah, it works sometimes, and it doesn't work sometimes and it's bloody hard work and it is shattering, but it works for me. Helen: Thank you, Paul. And I think it's really important when you say it's hard work, the way you described it there sounds like the therapist was like the coach telling you how to or working with you to. look at how you were thinking and what you were doing and agreeing things that you could change and practice that were going to lead to a better quality of life. At the same time though, you're thinking about things that are really difficult. Paul: Yeah. Helen: And when you say it was shattering and it was really difficult, was it worth it? Paul: Oh God. Yeah, absolutely. I remember way back in about 2018, it would be, that there was, there was a fantastic person who helped me when I was coming up for retirement. And we talked about what I was going to do when I, when I left the police and I was, you know, I said, you know, well, I don't know, but maybe I've always fancied being a TV extra and, That was it. And I saw her about 18 months later, and she said, God, Paul, you look so much better. You're not grey anymore. You know, what have you done about this? And it was like, she said I was a different person. Do I still struggle? Yes. Have I got a different outlook on life? Yes. Do I still have to take care of myself? Yes. But, I've got a great life now. I'm living the dream is my, is my phrase. It is such a better place to be where I am now. Helen: I'm really pleased to hear that, Paul. So, the hard work that you put into changing things for the better has really paid off and that doesn't mean that everything's perfect or that you're just doing positive thinking in the face of difficulty, you've got a different approach to handling those difficulties and you've got a better quality of life. Paul: Yeah, absolutely. And don't get me wrong, I had some great psychologists before 2016, but I concentrated on other things and we dealt with other traumas and dealt with it in other ways and using other, other ways of working. I became subjected to probably re traumatising myself because of the horrendous things I'd seen and heard. So, it was about just changing my thought processes and, and my psychologist said, Well, you know, we don't want to re traumatise you, let's look at something different. Let's look at a different part and see if we can change that. And, and that was, very difficult, but it meant that I had to look into myself again and be honest with myself and start thinking about my honesty and what I was going to tell my psychologist because I wanted to protect that psychologist because I didn't want them to hear and talk about the things that I'd had to witness because I didn't think it was fair, but I then understood that I needed to and that my psychologist would be taken care of. Which was, which was lovely. So, I became able to be honest with myself, which therefore I can be honest with my therapist. Helen: Thank you, Paul. And what I'm hearing there is that one of your instincts, if you like, in that situation was to protect the therapist from hearing difficult stuff. And actually the therapist themselves have their own opportunity to talk about what's difficult for them. So, the person who's coming for therapy can speak freely, although I'm saying that it's quite difficult to do. And certainly Post Traumatic Stress Disorder isn't the only thing that people go for CBT about, there are a number of different anxiety difficulties, depression, and also a wider range of things, including how to live well with a long term health condition and your experience could perhaps really help in terms of somebody going for their first session, not knowing what to expect. As a CBT therapist, I have never had somebody lie down on a couch. So, tell us a little bit about what you think people should know if they are thinking of going for CBT or if they think that somebody they care about might benefit from CBT. What's it like going for that first appointment? Paul: Bloody difficult. It's very difficult because by the very nature of the illnesses that we have that we want to go and speak to a psychologist, often we're either losing confidence or we're, we're anxious about going. So I have a phrase now and it's called smiley eyes and it, and it was developed because the very first time that I walked up to the, the place that I had my CBT in 2016, the receptionist opened the door and had these most amazing engaging smiley eyes and it, it drew me in. And I thought, wow. And then when I walked through the door and saw the psychologist again, it was like having a chat. It was, I feel that for me, I know now, I know now. And I've spoken to a number of psychologists who say it's not just having a chat. It is to me. And that is the gift of a very good psychologist, that they are giving you all these wonderful things. But it's got to be a collaboration. It's got to be like having a chat. We don't want to be lectured, often. I didn't want to have homework because I hated homework at school. So, it was a matter of going in and, and talking with my psychologist about how it worked for me as an individual, and that was the one thing that with the three psychologists that I saw, they all treated me as an individual, which I think is very, very important, because what works for one person doesn't work for another. Helen: So it's really important that you trust the person and you make a connection. A good therapist will make you feel at ease, make you feel as safe as you can to talk about difficult stuff. And it's important that you do get on with each other because you're working closely together. You use the word collaboration and it's definitely got to be about working together. Although you said earlier, you're not sure about the word expert, you're the expert on what's happening to you, even though the therapist will have some expertise in what might help, the kind of things to do and so there was something very important about that initial warmth and greeting from the service as well as the therapist. Paul: Oh, absolutely. And you know, as I said earlier, I'm honoured to speak at some universities to students who are learning how to be therapists. And the one thing I always say to them is think about if somebody tells you their innermost thoughts, they might never have told anybody and they might have only just realised it and accepted it themselves. So think about if you were sitting, thinking about, should I put in this thesis to my lecturer? I'm not sure about it. And how nervous you feel. Think about that person on the other side of the, you know, your therapy room or your zoom call or your telephone call, thinking about that. What they're going to be feeling. So to get through the door, we've probably been through where we've got to admit it to ourselves. We then got to admit it to somebody else. Sometimes we've then got to book the appointment. We then got to get in the car to get the appointment or turn on the computer. And then we've got to actually physically get there and walk through. And then when we're asked the question, we're going to tell you. We've been through a lot of steps every single time that we go for therapy. It's not just the first time, it's every time because things develop. So, you know, it's, it's fantastic to have the ability to want to tell someone that. So when I say it's fantastic to have the ability, I mean, in the therapist, having the ability to, to make it that you want to tell them that because you trust them. Helen: So that first appointment, it might take quite a bit of determination to turn up in spite of probably feeling nervous and not completely knowing what to expect, but a good therapist will really make the effort to connect with you and then gently try to find out what the main things are that you have come for help with and give you space to work out how you want to say what you want to say so that you both got , a shared understanding of what's going on.So your therapist really does know, or has a good sense of what might help. So, when you think about that very first session and what your expectations were and what you know now about having CBT, what would you say are the main things that are different? Paul: Oh, well, I don't actually remember my first session because I was so poorly. I found out afterwards there was three of us in the room because the psychologist had a student in there, but I was, I, I didn't know, but I still remember those smiley eyes and I remember the smiley eyes of the receptionist. And I remember the smiley eyes of my therapist. And I knew I was in the right place. I felt that this person cared for me and was interested and, you know, please don't think that the, the psychologist before I didn't feel that, you know, they were fantastic, but I was in a different place. I didn't accept it myself. I had different boundaries. I wanted to stay in the police. I, you know, I thought, well, if I, you know, if I admit this, I'm not going to have my, my job and I can't do my job. So a hundred percent of me was giving to my job. And unfortunately, that meant that the rest of my life couldn't cope, but my job and my professionalism never waned because I made sure of that, but it meant that I hadn't got the room in my head and the space in my head for family and friends. And it was at the point that I realized that. It wasn't going to be helpful for the rest of my life that I had to say, you know what, I'm going to have to, something's going to have to give now. And unfortunately, that was, you know, my career, but up until that point, I'm proud to say that I worked at the highest level and I gave a hundred percent. Now I realised that I have to have a life work balance rather than a work life balance, because I put life first. And I say that to everybody have a life work balance. It doesn't mean you can't have a good work ethic. It doesn't mean you can't work hard. It's just what's important in that. So what's the difference between the first session then and the first session now? Well, I didn't remember the first session. Now, I know that that psychologist was there to help me and there to test me and to look at my weaknesses. Look at my issues, but also look at my strengths and make me realize I'd got some because I didn't realise I had. Helen: That's really important, Paul, and thank you for sharing what that was like. I really appreciate that you've been so open and up front with me about those experiences. Paul: So let's turn this round to you then Helen as a therapist And you talked about lots of conditions, and things that people could have help with seeing a CBT therapist because obviously I have PTSD and I have the associated anxiety and depression and I still deal with that. What are the other things that people can have help with that they, some that they do have heard, have heard of, but other things that they might not know can be helped by CBT? Helen: Well, that's a really good question. And I would say that CBT is particularly good at helping people with anxiety and depression. So different kinds of anxiety, many people will have heard, for example, of Obsessive-Compulsive Disorder, OCD, or Generalized Anxiety Disorder where people worry a lot, and it's very ordinary to worry, but when it gets out of hand, other things like phobias, for example, where the anxiety is much more than you'd expect for the amount of danger people sometimes worry too much about getting ill or being ill, so they might have an illness anxiety. Those are very common anxiety difficulties that people have. CBT, I mean, you've already mentioned this, but CBT is also very good for depression. Whether that's a relatively short term episode of really low mood, or whether it's more severe and ongoing, then perhaps the less well known things that CBT is good for. For example, helping people live well if they have a psychotic disorder, maybe hearing voices, for example, or having beliefs that are quite extreme and unusual, and want to have help with that. It's also very good for living with a long term health condition where there isn't anything medical that can cure the condition, but for example, living well with something like diabetes or long term pain. Paul: interestingly, you spoke about phobias then, Is the work that a good therapist doing just in the, the consulting room or just over, the, this telephone or, or do you do other things? I'm thinking of somebody I knew who had a phobia of, particular escalators and heights, and they were told to go out and do that. You know, try and go on an escalator and, they managed to get up to the top floor of Selfridges in Birmingham because that's where the shoes were and that helped. But would you just, you know, would you just talk about these things, or do you go out and about or do you encourage people to, to do these with you and without? Helen: Again, that's, that's a really good point, Paul, and the psychotherapy answer is it depends. So let's think about some examples. So sometimes you will be mostly in the therapist's office or, and as you've mentioned, sometimes on the phone or it can be on a video call. but sometimes it's really, really useful to go out and do something together. And when you said about somebody who's afraid of being on an escalator, sometimes it really helps to find a way of doing that step by step and doing it together. So, whether that's together with someone else that you trust or with the therapist, you might start off by finding what's the easiest escalator that we've got locally that we can use and let's do that together. And let me walk up the stairs and wait for you and you do it on your own, but I'll be there waiting. Then you do it on your own and come back down and meet me. Then go and do it with a friend and then do it on your own. So, there's a process of doing this step by step. So you are facing the fear, you are challenging how difficult it is to do this when you're anxious. But you find a place where you can take the anxiety with you successfully, so we don't drop you in the deep end. We don't suddenly say, right, you're going all the way to the fifth floor now. We start one step at a time, but we do know that you want to get to the shoes or whatever your own personal goal and motivation is there's got to be a good reason to do it gives you something to aim towards, but also when you've done it, there's a real sense of achievement. And if I'm honest as a therapist, it's delightful for me as well as for the person I'm working with when we do achieve that. Sometimes it isn't necessarily that we're facing a phobia, but it might be that we're testing out something. Maybe, I believe that it's really harmful for me to leave something untidy or only check something once. We might do an experiment and test out what it's like to change what we're doing at the moment and see what happens. And again, it's about agreeing it together. It's not my job to tell somebody what to go and do. It's my job to work with somebody to make sure that they've got the tools they need to take their anxiety with them. And sometimes that anxiety will get less, it'll get more manageable. Sometimes it goes away altogether, but that's not something I would promise. What I would do is work my very hardest to make the anxiety so that the person can manage it successfully and live their life to the full, even if they do still have some. Paul: And, and for me, I think one of the things that I remember is that my, you know, my mental health manifested itself in physical symptoms as well. So it was like when I was thinking about things, I was feeling sick, I was feeling tearful. and that's, that's to be expected at times, isn't it? And, and even when you're facing your fears or you’re talking through what you're experiencing. It's, it's, it's a normal thing. And, and even when I had pure CBT, it can be exhausting. And I said to my therapist, please. Tell people that, you know, your therapy doesn't end in the session. And it's okay to say to people, well, go and have a little walk around, make sure you can get somebody to pick you up or make sure you can get home or make sure you've got a bit of a safe space for half an hour afterwards and you haven't got to, you know, maybe pick the kids up or whatever, because that that's important time for you as well. Helen: That's a really important message. Yes, I agree with you there, Paul, is making sure that you're okay, give yourself a bit of space and processing time and trying to make it so that you don't have to dash straight off to pick up the kids or go back to work immediately, trying to arrange it so that you've got a little bit of breathing space to just make sure you're okay, maybe make a note of important things that you want to think about later, but not immediately dashing off to do something that requires all your concentration. And I agree with you, it is tiring. You said at the beginning it's just having a chat and now you've talked about all the things that you actually do in a session. It's a tiring chat and tiring to talk about how it feels, tiring to think about different ways of doing things, tiring to challenge some of the assumptions that we make about things. Yes it is having a chat, but really can be quite tiring. Paul: And I think that the one thing that you said in there as well, you know, you talk about what would you recommend. Take a pen and paper. Because often you cannot remember. everything you put it in there. So, make notes if you need to. Your therapist will be making notes, so why can't you? And also, you know, I think about some of the tasks I was given in between my sessions, rather than calling it my homework, my tasks I was given in between sessions to, I suffered particularly with, staying awake at night thinking about conversations I was going to have with the person I was going to see the next day and it manifested itself I would actually make up the conversations with every single possible answer that I could have- and guess what- 99 times out of 100 I never even saw the person let alone had the conversation. So it was about even if I'm thinking in the middle of the night, you know, what I'm going to do, just write it down, get rid of it, you know, and I guess that's, you know, coming back again, Helen to put in the, the ball in your court and saying, well, what, what techniques are there for people? Helen: Well, one of the things that you're saying there about keeping a note and writing things down can be very useful, partly to make sure that we don't forget things, but also so that it isn't going round and round in your head. The, and because it's very individual, there may be a combination of things like step by step facing something that makes you anxious, step by step changing what you're doing to improve your mood. So perhaps testing out what it's like to do something that you perhaps think you're not going to enjoy, but to see whether it actually gives you some sense of satisfaction or gives you some positive feedback, testing out whether a different way of doing something works better. So there's a combination of understanding what's going on, testing out different ways of doing things, making plans to balance what things you're doing. Sometimes there may be things about resting better. So you said about getting a better night's sleep and a lot of people will feel that they could manage everything a bit better if they slept better. So that can be important. Testing out different ways of approaching things, asking is that reasonable to say that to myself? Sometimes people are thinking quite harsh things about themselves or thinking that they can't change things. But with that approach of, well, let's see, if we test something out different and see if that works. So there's a combination of different things that the therapist might do but it should always be very much the, you're a team, you're working together, your therapist is right there alongside you. Even when you've agreed you're going to do something between sessions, it's that the therapist has agreed this with you. You've thought about what might happen if you do this and how you're going to handle it. And as you've said, sometimes it's a surprise that it goes much better than we thought it was going to. So, so we're testing our predictions and sometimes it's a surprise. It's almost like being a scientist. You're doing experiments, you're testing things out, you're seeing what happens if you do this. And the therapist will have some ideas about the kind of things that will work. but you're the one doing, doing the actual doing of it. Paul: And little things like, you know, I, I remember, I was taught a lovely technique and it's called the 5, 4, 3, 2, 1, technique about when you're anxious. And it's about, I guess it's about grounding yourself in the here and now and not, trying to worry about what you're anxious about so you try and get back into what is there now. Can you just explain that? I mean, I know I know I'm really fortunate. I practice it so much. I probably call it the 2-1 So could you just explain how what that is in a more eloquent way than myself? Helen: I think you explained that really well, Paul, but what we're talking about is doing things that help you manage anxiety when it's starting to get in the way and bringing yourself back to in the here and now. And for example, it might be, can I describe things that I can see around me? Can I see five things that are green? Can I feel my feet on the floor? Tell whether it's windy and all of those things will help to make me aware of being in the here and now and that the anxiety is a feeling, but I don't have to be carried away by it. Paul: And there's another lovely one that, I, you know, when people are worrying about things and, it's basically about putting something in a box and only giving yourself a certain time during the day to worry about those things when you open the box and often when you've got that time to yourself. So give yourself a specific time where you, you know, are not worrying about the kids or in going to sport or doing whatever. So you've got yourself half an hour and that's your worry time in essence. And, you know, I use it on my phone and it's like, well, what am I worrying about? I'll put that in my worry box and then I'll only allow myself to look at that between seven and half past tonight. And by the time I've got there, I'll be done. I'm not worrying about the five things. I might be worrying slightly about one of them, but that's more manageable. And then I can deal with that. So what's the thought behind? I guess I've explained it, but what, what's the psychological thought behind that? And, and who would have devised that? I mean, who are these people who have devised CBT in the past? Because we haven't even explored that yet. Helen: Well, so firstly, the, the worry box idea, Paul, is it's a really clever psychological technique is that we can tell ourselves that we're going to worry about this properly later. Right now, we're busy doing something else, but we've made an appointment with ourselves where we can worry properly about it. And like you've said, if we reassure ourselves that actually, we are, we're going to deal with what's going on through our mind. It reassures our mind and allows it not to run away with us. And then when we do come to it, we can check, well, how much of a problem is this really? And if it's not really much of a problem, it's easier to let it go. And if it really is a problem, we've made space to actually think about, well, what can I do about it then? so that technique and so many of the other techniques that are part of Cognitive and Behavioural psychotherapies have been developed in two directions, I suppose. In one direction, it's about working with real people and seeing what happens to them, and checking what works, and then looking at lots of other people and seeing whether those sorts of things work. So, we would call that practice based evidence. So, it's from doing the actual work of working with people. From the other direction, then, there is more laboratory kind of science about understanding as much as we can about how people behave and why we do what we do, and then if that is the case, then this particular technique ought to work. Let's ask people if they're willing to test it out and see whether it works, and if it works, we can include that in our toolkit. Either way, CBT is developed from trying to work out what it is that works and doing that. So, so that's why we think that evidence is important, why it's important to be scientific about it as far as we can, even though it's also really, really important that we're working with human beings here. We're working with people and never losing sight of. That connection and collaboration and working together. So although we don't often use the word art and science, it is very much that combination Paul: And I guess that's where the measures and outcomes, you know, come into the science part and the evidence base. So, so for me, it's about just a question of if I wanted to read up on the history of CBT, which actually I have done a little. Who are the people who have probably started it and made the most influence in the last 50 years, because BABCP is 50 years old now, so I guess we're going back before that to the start of CBT maybe, but who's been influential in that last 50 years as well? Helen: Well, there are so many really incredible researchers and therapists, it's very hard to name just a few. One of the most influential though would be Professor Aaron T. Beck, who was one of the first people to really look into the way that people think has a big impact on how they feel. And so challenging, testing out whether those thoughts make sense and experimenting with doing things differently, very much influenced by his work and, and he's very, very well known in our field, from, The Behavioural side, there've been some laboratory experiments with animals a hundred years ago. And I must admit nowadays, I'm not sure that we would regard it as very ethical. Understanding from people-there was somebody called BF Skinner, who very much helped us to understand that we do things because we get a reward from them and we stop doing things because we don't or because they feel, they make us feel worse. But that's a long time ago now. And more recently in the field, we have many researchers all over the world, a combination of people in the States, in the UK, but also in the wider global network. There's some incredible work being done in Japan, in India, you name it. There's some incredible work going on in CBT and it all adds to how can we help people better with their mental health? Paul: and I think that for me as the patient and, and being part of the BABCP family, as I like to, to think I'm part of now, I've been very honoured to meet some very learned people who are members of the BABCP. And it, it astounds me that, you know, when I talk to them, although it shouldn't, they're just the most amazing people and I'm very lucky that I've got a couple of signed books as well from people that I take around, when I do my TV extra work. And one of them is a fascinating book by Helen Macdonald, believe it or not on long term conditions that, that I thoroughly recommend people, read, and another one and another area that I don't think we've touched on that. I was honoured to speak with is, a guy called, Professor Glenn Waller, who writes about eating disorders. So eating disorders. It's one of those things that people maybe don't think about when they think of CBT, but certainly Glenn Waller has been very informative in that. And how, how do you feel about the work in that area? And, and how important that may be. I know we'll probably go on in a bit about how people can access, CBT and, you know, and NHS and private, but I think for me is the certain things that maybe we need to bring into the CBT family in NHS services and eating disorders for me would be one is, you know, what are your thoughts about those areas and other areas that you'd like to see brought into more primary care? Helen: Again, thank you for bringing that up, Paul. And very much so eating disorders are important. and CBT has a really good evidence base there and eating disorders is a really good example of where somebody working in CBT in combination with a team of other professionals, can be particularly helpful. So perhaps working with occupational therapists, social workers, doctors, for example. And you mentioned our book about persistent pain, which is another example of working together with a team. So we wrote that book together with a doctor and with a physiotherapist. Paul: Yeah, yeah. Helen: And so sometimes depending on what the difficulties are, working together as a team of professionals is the best way forward. There are other areas which I haven't mentioned for example people with personality issues which again can be seen as quite severe but there is help available and at the moment there is more training available for people to be able to become therapists to help with those issues. And whether it's in primary care in the NHS or in secondary care or in hospital services, there are CBT therapists more available than they used to be and this is developing all the time. And I did notice just then, Paul, that you said about, whether you access CBT on the NHS and, and you received CBT through the NHS, but there are other ways of accessing CBT. Paul: That was going to be my very next question is how do we as patients feel, happy that the therapist we are seeing is professionally trained, has got a, a good background and for want of a phrase that I'm going to pinch off, do what it says on the tin. But do what it says on the tin because I, I am aware that CBT therapists aren't protected by title. So unfortunately, there are people who, could advertise as CBT therapist when they haven't had specific training or they don't have continual development. So, The NHS, if you're accessing through the NHS, through NHS Talking Therapies or anything, they will be accredited. So, you know, you can do that online, you can do it via your GP. More so for the protection of the public and the making sure that the public are happy. What have the BABCP done to ensure that the psychotherapists that they have within them do what they say it does on the tin. Helen: yes, that's a number of very important points you're making there, Paul. And first point, do check that your therapist is qualified. You mentioned accredited. So a CBT psychotherapist will, or should be, Accredited which means that they can be on the CBT Register UK and Ireland. That's a register which is recognised by the Professional Standards Authority, which is the nearest you can get to being on a register like doctors and nurses. But at the moment, anyone can actually call themselves a psychotherapist. So it's important to check our register at BABCP. We have CBT therapists, but we have other people who use Cognitive and Behavioural therapies. Some of those people are called Wellbeing Practitioners that are probably most well known in England. We also have people who are called Evidence Based Parent Trainers who work with the parents of children and on that register, everybody has met the qualifications, the professional development, they're having supervision, and they have to show that they work in a professional and ethical way and that covers the whole of Ireland, Scotland, Wales and England. So do check that your therapist is on that Register and feel free to ask your therapist any other questions about specialist areas. For example, if they have qualifications to work particularly with children, particularly with eating disorders, or particularly from, with people from different backgrounds. Do feel free to ask and a good therapist will always be happy to answer those questions and provide you with any evidence that you need to feel comfortable you're working with the right person. Paul: that's the key, isn't it? Because if it's your hard-earned money, you want to make sure that you've got the right person. And for me, I would say if they're not prepared to answer the question, look on that register and find somebody who will, because there's many fantastic therapists out there. Helen: And what we'll do is make sure that all of those links, any information about us that we've spoken in this episode will be linked to on our show page. Paul, we're just about out of time. So, what would you say are the absolute key messages that you want our listeners to take away from this episode? What the most important messages, Paul: If you're struggling, don't wait. If you're struggling, please don't wait. Don't wait until you think that you're at the end of your tether for want of a better phrase, you know, nip it in the bud if you can at the start, but even if you are further down the line, please just reach out. And like you say, Helen, there's, there's various ways you can reach out. You can reach out via the NHS. You can reach out privately. I think we could probably talk for another hour or two about a CBT from my perspective and, and how much it's, it has meant to me. But also what I will say is I wish I'd have known now what, or should I say I wish I knew then what I knew now about being able to, to, to open myself up, more than, you know, telling someone and protecting them as well, because there was stuff that I had to re-enter therapy in 2021. And it took me till then to tell my therapist something because I was like disgusted with myself for having seen and heard it so much. But actually, it was really important in my continual development, but yeah, don't wait, just, just, you know, reach out and understand that you will have to work hard yourself, but it is worth it at the end. If you want to run a marathon. You're not going to run a marathon by just doing the training sessions when you see your PT once a week. And you are going to get cramp, and you are going to get muscle sores, and you are going to get hard work in between. But when you complete that marathon, or even a half marathon, or even 5k, or even 100 meters, it's really worth it. Helen: Paul, thank you so much for joining us today. We're really grateful for you speaking with me and it's wonderful to hear all your experiences and for you to share that, to encourage people to seek help if they need it and what might work. Thank you. Paul: Pleasure. Thanks Helen.

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