Let's Talk about CBT: A solid return on investment

In this special episode celebrating World CBT Day 2025, we explore this year's theme: CBT: A Solid Return on Investment. Host Helen Macdonald, Senior Clinical Advisor at BABCP, is joined by a range of voices reflecting on the impact, value, and future of CBT.

We hear from:

• Dr. Adrian Whittington, National Clinical Lead for Psychological Professions at NHS England, about the rollout and outcomes of NHS Talking Therapies.
• Dr. Stirling Moorey, BABCP President, on the historical development of CBT and its increasing relevance and recognition over the decades.
• Nic, a former CBT client, who shares how therapy helped him manage anxiety linked to a long-term health condition.
• Dr. Saiqa Naz, past president of BABCP, who discusses her personal journey into CBT and her commitment to inclusion, diversity, and working with underrepresented communities

This episode offers a rich blend of lived experience, clinical insight, and future vision, showing how CBT continues to be a wise investment for individuals, services, and society as a whole.

Further information and links:

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Find support via NHS Talking Therapies

Discover more about World CBT Day

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This podcast was produced by Steph Curnow

Transcript:

Helen: Hello, and welcome to Let's Talk About CBT, the podcast where we talk about cognitive and behavioural psychotherapies, what they are, what they can do, and what they can't. I'm Helen Macdonald, your host. I'm the Senior Clinical Advisor for the British Association for Behavioural and Cognitive Psychotherapies.

Welcome to this special episode of Let's Talk about CBT celebrating World CBT Day. World. CBT Day takes place every year on the 7th of April, and this year's theme is CBT: A Solid Return on Investment. In this episode, we're exploring just what that means- I will be speaking with Adrian Whittington, who's the National Clinical Lead for Psychological Professions at NHS England and with Stirling Moorey, who's our current BABCP President about how CBT has developed over time and the importance of continued investment in it.

We'll also hear a personal story from Nic, who is a former client of Stirling's, who shares how CBT helped him manage anxiety and improve his quality of life. Finally, I sit down with Saiqa Naz who is past president of BABCP to talk about her journey into CBT from starting out in the Improving Access to Psychological Therapies services, to completing a clinical psychology doctorate, and how she embodies the idea of CBT being a real return on investment.

We hope you enjoy this episode and the range of voices reflecting on the impact and value of CBT. Let's get started! Here's my conversation with Adrian and Stirling….

Adrian, would you introduce yourself please?

Adrian: Yes. Hi. I am Adrian Whittington. I'm National Clinical Lead for Psychological Professions at NHS England, which means within England I'm the professional lead for psychologists, psychological therapists, and psychological practitioners.

Helen: Thank you, Stirling, please introduce yourself.

Stirling: Hi, I'm Stirling Moorey. I am currently the president of the BABCP and I'm a retired psychiatrist and really have been around in the CBT world since 1979. So, Adrian is speaking about CBT today and in the UK particularly and I'll just give a bit of a view of what it's been like to be in the CBT world for this length of time.

Helen: Thank you very much. And so Stirling, if we come to you first, that's a long career- you must have seen a lot of developments over the years. Tell us a bit about what you've seen and how things have developed.

Stirling: Indeed, I mean, so right at the very beginning when I was a medical student, cognitive therapy was just being invented. And so we had BT, Behaviour Therapy, but not the CBT that we have today. And so it was quite sort of revolutionary. The behaviour therapists look down their nose a little bit at it, the psychoanalytic therapists very much looked down their nose, and I remember at one point talking to a psychoanalyst who told me that being a CBT therapist was a bit like playing a tin whistle compared to being a concert violinist. I think things have changed since then. So, over the years, what's happened is that really from the work of pioneers like Isaac Marks in behaviour therapy, Aaron Beck in cognitive therapy, for the first time psychotherapists started to actually address what evidence do we have that this works? And using randomised control trials. And this has been really powerful. It was revolutionary at the time because people thought you couldn't manualise therapy but Beck and others managed to do that. I think that's been the legacy of that, is that the services that are recognised to be really effective and are spread out across the UK that Adrian will talk about, have resulted from us gathering evidence that CBT works. The other thing that's happened is that really up until the early 2000s, we were using CBT in a lot of contexts in the UK, evidence accumulating that it was effective for anxiety disorders, depression, but other things like eating disorders, psychosis, long-term conditions, various things but they were all being delivered within a hodgepodge of services really. And I remember when the IAPT services that Adrian will be talking about, were about to be developed, my chief executive in my trust said this is amazing, it's like moving cognitive therapy from being a cottage industry into therapy mills as he called them. So, we have therapy mills across the UK, which are proving very effective in helping people with anxiety and depression. And it was that revolutionary input of David Clarke and Lord Layard who said, actually, we can work this out as a way to deliver therapy effectively and efficiently, not just in these services here and there, but across the whole country. So there's been so much change and now CBT is there for everyone.

I suppose just finally thinking about what its impact in public consciousness has been, although people maybe have heard of it and maybe witnessed people who've received it, there've been some subtle changes, I think in our perspective on the world that have been influenced by CBT. I think people from the behavioural side now are recognising that a lot of our behaviour is learned in our everyday life. We have habits and people notice they have bad habits and go to podcasts to try and get them to rid them of their bad habits. And people are really aware of cognitive bias- it's there in the media all the time, that recognition that our thinking is not always that rational and straight, for good or ill. And then the third thing is there's a new wave of CBT that's come along that's called the third wave of CBT is really looking at how we can look in and just be aware and notice our thought processes. And so the whole field of mindfulness is very popular these days. So CBT, I think even if people aren't aware of what CBT is as a therapy, it has perfused our consciousness.

Helen: Thank you very much, Stirling. That sounds like a whole symphony orchestra, not just a tin whistle from what you've been saying during your career. And thank you because that perspective of many years in the field and how things have developed, it leads us nicely to speaking with Adrian about, you mentioned IAPT, which stood for Improving Access to Psychological Therapies. I'm going to hand over to Adrian to ask him a bit about that project, how it came about and what happened.

Adrian: Absolutely. Thanks Helen. Well, of course I'm a relative newcomer to the field having been trained as a psychologist 30 years ago and done my additional CBT training, I think 19 years ago, including under Stirling's tutelage as one of my training supervisors. So, it's great to join this session today with Stirling. So, NHS Talking Therapies as it is now was called Improving Access to Psychological Therapies is really something we're very proud of and feel as a sort of world leading program in implementing psychological therapies at scale. As Stirling's mentioned, David Clark and Lord Richard Layard were instrumental in founding the service and arguing successfully for its initial funding and have really been sort of fundamental to its success ever since. It's received investment every year, under every government since 2008 in the UK and it is just an England service so it's important to also remember there's other parts of the UK that don't have the same sort of service at the moment. It really makes a public promise, which is that it will deliver NICE guided psychological treatments. So NICE are our evidence-based, practice guidelines in, in the UK and, sort of established by independent panels of experts for each type of condition. So it makes a public promise, it will only deliver NICE recommended treatments, psychological treatments, that the therapists that deliver them will be fully trained and properly supervised and that it will publicly reveal its outcome data, anonymised, of course, but for the whole country so that we can see at a national scale, but also locally, how the service is performing, and the service can learn and the best performers can show what they're doing that's being so successful, to produce the best outcomes and other services can, can seek to learn from that and implement some of the same strategies.

So we now have a sort of situation where for a number of years, the service has met its objective of 50% of those who coming into the service, are recovering completely from anxiety or depression and about two thirds, improving reliably, during the course of treatment. But it didn't start there, of course, in the early days of talking therapies, as it was then, we would be sort of more around the 30% recovery mark, and it really is through the sort of publication of outcomes and the ability of the service to learn and improve as it goes. That we've reached the 50% objective, and I think we can go further. I'll just mention something about the sort of return on investment point, 'cause I know that's the sort of important theme for today. The latest modelling that we have from London School of Economics shows that a course of talking therapies pays for itself within two years. So the benefits that are generated for the economy are such that within two years post-treatment, the course has paid for itself. We've also got some very exciting evidence coming out of other parts of the world, so there's a Norwegian study recently using, looking at service that is very close in, in sort of style and operation to NHS Talking Therapies that suggests that over a six year period, the benefits economically of investing in a course of talking therapies are fivefold. So in other words, the economy gets out five times more than it puts in over a six year period. So I think that the indications are very clear that the return on investment is there, and there's of course a lot further that we could go. There's a lot more that we could do and perhaps we'll have an opportunity to talk about that.

Helen: Well, yes, and thank you Adrian. And what I heard you say there is not only is the CBT itself, and as Stirling was saying, the CBT itself is evidence-based, we know that it works. And what you've just been saying is about the way that we offer that to people, the way that people can have access to that is also important. It's not just that the therapy itself works, but the fact that we're measuring outcomes and working all the time to improve outcomes. So the whole system, not just the individual on the receiving end, is really important here. And I just wondered for people listening who are perhaps not familiar with sort of measuring outcomes and things, 50% doesn't sound like an awful lot- and you did say that we might be able to improve on that. I just wondered if you could say with treatment before we had CBT widely available in England and what kind of outcomes were people looking at or why is 50% good when we'd be kind of hoping for a hundred?

Adrian: Of course, and of course we hope that every individual who uses the service will recover. But it's not always possible to achieve full recovery within a course of treatment. And this is of course true of physical health treatments as well. But what has happened through the innovation of NHS Talking Therapies is that we now know exactly what's being achieved. And we didn't in fact know this at scale before. So we knew through research trials, which are of course a slightly rarefied version of treatment as usual, where there are sort of very high quality aspects being sort of added in; the state-of-the-art supervision, making sure the therapists are fully compliant with the treatment being delivered as expected. And we know that in those trials it was possible to achieve upwards of 50% recovery rate. So, actually for depression. I think the more real world type of trials was around 50%, but we know it's possible to get much higher than that with some of the anxiety disorders, with some of the specific CBT treatments for those. So, I think we can go further. We thought 50% was pretty stretching, I think when the service was launched. And of course it's taken a while to get there, but we have now stabilised at 50 and so I think it is actually time to push on and see if we can push that further.

Helen: And can I ask Stirling, do you have any thoughts about this?

Stirling: Yeah, so sort of sharing again, my long, long in the tooth sort of view on this. So when I went to the Centre for Cognitive Therapy in 1979, they'd just published the first trial of CBT for depression. And, at that time, medication was the gold standard, and they were told there's no way in which you're going to be able to meet the level of recovery that we get with medication. But that level of recovery is only 50-60%, at the best. And of course that trial showed that it did, that the recovery rate was equivalent or if anything slightly better than the gold standard of medication. And so I think, it would be wonderful, wouldn't it, if we could get a hundred percent of people better. But, in the real world there are so many factors that will influence that. And even in the best designed clinical trials where you get the best medication delivery and adherence, or the best psychotherapy for depression, we're only talking as Adrian says, about 50 to 60%. So if we're getting something equivalent to that out there in the real world in the talking therapies, I think we're doing pretty well.

Helen: And I think it's really important to hear that we are doing the best we can with what works and investing in treatments that really do make a difference, the best that we can do. So going on from there, Stirling, can I ask you how you see the future? I mean, how do you see things going forward and what would you like to see?

Stirling: Well, I think, there's been this tremendous investment in talking therapies for common mental health conditions, which were in the past were sort of looked and that has, sort of, as Adrian was saying produced tremendous results. What we need is to be looking at evidence-based therapies in secondary mental health care where we know that, for instance, CBT for psychosis is a very helpful treatment alongside the usual drug treatment and support. And in eating disorders and, in various areas. So looking at how we might be able to bring in some of the lessons learned from the Talking Therapies program, so that these areas can have both greater investment, which I think is really important and a way of actually delivering evidence-based treatment and evaluating it. And I think there are some interesting developments that, again, Adrian may be able to talk about in that area. So I would like that to happen and the other thing is that for some disorders, CBT is very clearly the most effective treatment. For others, we have a range of evidence-based therapies, and I think that is what's quite nice about the Talking Therapies approach is it isn't limited to one. It's saying if something is effective and we can actually find a way of delivering it effectively, then that can be in the mix too.

Helen: Thank you very much. Well, I think Stirling has invited you to talk about future developments there, Adrian, what are your thoughts?

Adrian: Absolutely. Well, of course, the NHS talking therapy service for anxiety and depression mustn't stand still. So, it's currently seeing about 670,000 patients per year. We know though that's only actually a very small proportion of people who experience anxiety and depression. So there's a lot further we can go on reaching people who could benefit, and that's really important that we continue to do that. And the service also, despite its huge success isn't perfect. We know that there's wait times that are longer than we would like for people to start treatment. So although, people are sort of reaching the sort of assessment point pretty rapidly and having that first contact pretty rapidly, there can be waits that are longer than we would like for treatment to start. So, for that reason, we've been successful in securing additional investment in the service over the next five years that will help us reach more people and reach them faster. And it will do that particularly by increasing the number of high intensity therapists in the service, so those are the people delivering psychotherapy rather than the guided self-help, including CBT therapists. So that's a really important investment that we want to see through, to maximise the benefits, seeing more people for treatment and enhancing as well our recovery rates. We think we can get the recovery rates up. But as Stirling said, there's obviously a whole lot of other potential groups who could benefit from talking therapies or psychological therapies that currently don't often receive a service. And we just wouldn't accept this in other areas of medicine, that, in cancer care, you wouldn't accept that radiotherapy isn't available and so people will just have to make do with chemotherapy. In this case, there's a very clear moral argument for us rolling out the success of psychological therapies to those other conditions, so psychosis, bipolar disorder, experiences that are sometimes classified as personality disorder, eating disorders, key examples. And we do have ambitions to further rollout access to those therapies for those conditions. We've done quite a lot over the last few years to train additional therapists in existing services, but we know that the method of delivery there is a bit challenging because there's so much other pressure on those services so it's hard for people to protect time just to deliver therapies. So really in the next phase of this, what we would like to see is, services that whose main focus is delivering the therapy, working very closely with hand in hand with sort of more traditional community mental health services because of course, for these groups, it might be necessary in many cases for there to be a sort of multidisciplinary approach, other team members involved. It will be a bit different to the talking therapies approach for anxiety and depression. So we're very keen to push that forward and we're working to sort of further the cause of that additional investment. We're not quite there yet.

Helen: Thank you, and it must be really heartening for people listening to hear that the intention is to make sure that as many people as possible who can benefit from those treatments that work are going to have access to it. You did just mention there that services are under pressure and it does make me think that we talk sometimes you, you hear things in the media about services being under a lot of pressure. Is there anything that we can say from a CBT perspective about, looking after the staff or, anything else that we can do to make sure that the people delivering the services do as well as they can.

Adrian: Well, I suppose, it may seem obvious, but sometimes we forget that unless you have well staff, you can't have staff who can truly help patients. And so it is really important that we get this right and that we make sure that there's a sort of, psychologically safe environment within which teams are working. And of course that doesn't mean stress-free environment, but it does mean an environment where the sort of inevitable pressure is dealt with in a constructive way. People are able to speak up to improve things, et cetera. And that's the sense in which I mean psychological safety. It's teams where people can work constructively together, even when the going gets tough.

Helen: Thank you. I don't know if you've got anything to add about that. Stirling, I know that staff wellbeing is a subject dear to your heart.

Stirling: Yes, indeed. I mean, it's one of the things that I want if, if a president of the BABCP can make any difference at all. it's, the hope is that perhaps, we can start to look at staff wellbeing, and maybe on, on a number of levels, that sometimes the attention to burnout has been focused very much on the individual and making them more resilient. And that's important. But we know that actually the factors that are perhaps more important in burnout are more systemic, they're more things to do with the pressure of face-to-face and the system, the service in which the person's working. So I'd really be keen to start looking at what services do that job well, where are the ones where that retain their staff, where staff are satisfied, where they feel able, as Adrian says, to speak up and how do we roll that out? How do we make services that perhaps are not doing quite so well aware of that, because it has a knock on effect everywhere. And particularly the key thing is as you say, if you don't have well therapists, then they can't be so helpful to their patients.

Helen: Thank you. and I know that we haven't necessarily mentioned this overtly while we've been speaking, but my understanding is that services that make sure they're really paying attention to things like diversity in their staff team and making sure that they properly promote access for people from all sorts of different backgrounds are likely to do better. And I don't know if you wanted to say anything specifically about that.

Adrian: Yeah, I mean, it's a really important point, that you raise about dealing appropriately with equality, diversity, and inclusion, and it's something that we know from the data and talking therapies, where we've got further to go. I think. ofcourse, we want to achieve and offer the same sorts of outcomes for people of all backgrounds, and all different protected characteristics who make use of the service. That hasn't always been the case and it still isn't always the case. And so that needs to change. We need that to be a sort of relentless focus. And I think actually, having, some staff teams where everyone feels welcome, included and free from harassment and bullying is vitally important to creating those outcomes for patients. But I suppose one thing that I do want to reflect on is that through the sort of gathering and publication of data, we've been able to do exactly what was referring to earlier in this sort of domain, which is learn from the services that are doing really a lot better with diversity and try to spread that learning. And, we still see disparities and we want to iron those out. But the fact that you see disparities and that some services are able to achieve just as good results or better results, for example, working with ethnic minority patients compared to white patients, suggests that is possible and we need to find out what they're doing and make sure that learning spreads. And that's what we've been trying to do. And sort of, if you look at this data at national scale, we have seen really significant improvements in that sort of equality of outcome, but a lot further to go and still some really troubling hotspots where we would like to iron out inequalities.

Stirling: I agree. We've got a long way to go. I suppose from my perspective, having been teaching since the 1980s, what's changed is in the faces that I see in front of me in our CBT courses, is they're no longer exclusively white middle class people. And I think that the talking therapies initiative has really worked very hard to make the workforce more diverse. And I see that in the people that I'm teaching, but we still have a long way to go, particularly in serving diverse communities.

Helen: Well, it's been really interesting to speak with you both about this and some really interesting developments over the years and interesting views of what's going to happen in the future and exciting things that are going to happen in the future. Just wondered whether you have a key message that you would like people to hear or, one specific experience that highlights that theme about CBT being a solid return on investment. I'm going to ask Adrian first and then go to Stirling. So what are your thoughts, Adrian?

Adrian: I mean, in terms of a key experience, the key experience that I've had is working in the services and seeing people recover and lives be transformed. And that's actually the return on investment that's most important. But if I have one message that's more to those who might be decision makers, in governments for example, it would be investing in talking therapy through a range of different conditions, helps to grow your economy and it reduces use of other healthcare services.

Helen: Thank you very much, Adrian. Stirling?

Stirling: I'd echo that. Really, that's exactly what I was going to say. That CBT can be helpful both on the very much the personal level, which is what's the most important thing, but also economically, there's an argument there. I think just backing that up, so we want to speak to people who might be funding these services in the UK or elsewhere, but also, I think I'd like to maybe speak to some of those people who haven't had CBT or have heard certain things about it. There are a lot of myths about this approach, that it's sort of ultra rational, that it doesn't address feelings, all sorts of things. And I hope that, we've started today perhaps a bit of a conversation about how it can be more, it is more, nuanced than that. And it's about, like any talking therapy, helping real people. And I'll be interviewing a client who's received some CBT who will speak from that very personal viewpoint, how it can change lives and maybe a good return on investment.

Helen: Thank you very much. I'm really grateful to you both and we'll put some links to more information, in the show notes that go with this recording but it just leaves it with me to say thank you very much indeed, Adrian, and thank you Stirling. Really appreciate you speaking with me today.

Coming up now, Stirling is speaking with a former client, Nic

Stirling: Hello, I'm Stirling Moorey. I'm president of BABCP and a cognitive behaviour therapist and on world CBT Day where we're thinking about CBT as a good return on investment, the most important aspect of all of this is the clinical impact is what this does to help people who are coming to terms with problems in all sorts of areas of life. And I'm very pleased today to have with me a client who I've worked with, Nic Allen, who's going to tell us a little bit about his experience of CBT. So welcome Nick.

Nic: Hi there. Thank you.

Stirling: Hi. so maybe if we kick off by you telling us a little bit about what brought you to consider having a course of therapy and why CBT.

Nic: Yeah. So, I think my experience with anxiety related conditions had been going on for a couple of years. And initially I don't think I was entirely aware that I was suffering from an anxiety related condition. So to provide a little bit of background on myself, I. I have a, inherited heart condition, hypertrophic cardiomyopathy, which has led to like a few lifestyle changes with my life, but generally I've been fit and healthy. And in my early thirties I started to experience some kind of changes in symptoms in my general life, which I think in hindsight probably were related to anxiety more so than anything else. They culminated in panic attacks, so kind of sporadic panic attacks, but several, like a year, maybe once every few months, as well as some kind of baseline anxiety that I was living with day to day. And ultimately what it was that led me to seeking help for CBT was, I tried a couple of different things, I'd gone down the route of speaking to cardiologists and assuming that maybe some of my symptoms were cardiac related. I tried a few kind of like mindfulness type things but ultimately it got to the point where the anxiety was getting in the way of my everyday life. So it was getting in the way of being able to do certain kind of like medical procedures to look after myself and just generally getting in the way of things like holidays and work and things like that. And then via recommendation from a family friend, got in touch with yourself and then, yeah, took it from there.

Stirling: Yeah. Thank you. And so the anxiety was beginning to have quite an impact on your everyday life. Was it?

Nic: Yeah, absolutely. And I think it wasn't entirely clear at the time, and I think in hindsight it's become more clear how much that was having an impact. So it was, the interplay between the anxiety and living with a heart condition meant that, I think I was hypersensitive to any kind of symptoms of physical discomfort, which meant that I was living quite like a limited life. So anytime I felt vulnerable or fragile, whether it's cardiac related or not, I was changing my lifestyle. I was not going out, I was not leaving the house, I was not traveling on certain forms of transport or going to busy places, it was really going in the way of everyday life. And then, yeah, the worst-case scenarios were panic attacks, which meant things like having to leave restaurants in the middle of a meal, all sorts of things like that.

Stirling: So in addition to the panics, your life was sort of understandably becoming more restrictive because if you're fearful that there might be something seriously wrong with your heart, it makes sense not to take risks really.

Nic: Yeah, absolutely. And there was also the kind of, the interplay with physical symptoms of anxiety. So, specifically for myself, I think I felt, kind of impacts on digestion and specifically indigestion and heartburn. And obviously the interplay between the feeling of heartburn and a discomfort in my chest and having a heart condition meant that I was quickly getting into these kind of, these like vicious cycles where it was self-perpetuating. And that was both unpleasant in the immediate term, the physical sensations, but also help to like perpetuate the anxiety.

Stirling: So you've begun to talk a little bit about how perhaps a cognitive behavioural model helped you to understand what was going on. So maybe if we move on to what happened in, in treatment and, maybe starting with what in CBT we call the formulation, which is finding a way of making sense of people's symptoms. So tell us a little bit more about what you learned there.

Nic: Yeah, this was really interesting. This was one of the first things we did together and was one of the kind of first tangible resources I had to help process these thoughts. The formulation, I guess for anyone who's not familiar, and my experience of it was a diagram which sketched out my thoughts. So thoughts that would go through my my brain when I was feeling anxious, the physical sensations that I would then experience as a result of this. So that would be things like heart racing and sweaty palms. Linking that back to a trigger which would trigger all of these things. And then the safety behaviours that I would take when I experience these thoughts and it's kind of hard to visualise, but all of these are connected with different areas indicating how they interact with each other. And I think having this formulation, something that I could look at, visualise, memorise, started to help me make sense of what was going on when I was experiencing these things because, prior to that, it was very hard to get my head around it. I didn't understand the theory, but what I could understand was something was definitely wrong because I was feeling physical symptoms and I was feeling discomfort and pain and fear to the point where in these worst moments, it felt life threatening. It felt like I was about to collapse and die. So to not be able to understand where that's coming from and how all of these things interact with each other meant that I found it very hard to process, and the formulation was the first step towards being able to process this.

Stirling: Yeah. Yeah. Great. And help to guide us a little bit in the work we did together. Yeah. So what were the things that you found most helpful about the therapy?

Nic: Where to begin and so many things. Honestly, I don't know where to begin because take taking a step back, it's been absolutely life changing. It's helped me process these kind of experiences and these, these feelings and basically the mental health issues. I was struggling in a way that I didn't think was possible, I thought it was something that I was probably stuck with or it was just a side effect of life. So at a high level, it's been huge. I think if we want to talk specifics, maybe going from like early on that even the formulation. Initially that started to explain how I could be getting physical symptoms like a racing heart, and then those symptoms potentially not being cardiac related, they're not being related to having hypertrophic cardiomyopathy, potentially they're related to anxiety. And trying to understand like how that all works together, where the anxiety might come from, it started to give me almost a path to understand that, ah, maybe this isn't just, I've got this inherited heart condition which means I'm destined to be ill for the rest of my life. And then, yeah, it's almost like by beginning to understand what might be going wrong, that then I felt empowered to be able to tackle it and tackle it together with yourself.

Stirling: Great. And you've mentioned this idea of safety behaviours, which is things that we do when we're anxious to try and keep ourselves safe in various ways. So it'd be interesting to unpack those a little bit. We mentioned earlier how your life was getting more restricted and you were avoiding certain things. we did some experiments to overcome some of that avoidance, didn't we? How did, how did that play out?

Nic: Yeah, this was a really interesting part of CBT for me to learn, I guess, both for the process and then actually try it out myself, the concept of experiments and it was really powerful for me. So some of the safety behaviours, just to list a couple of ones, were things like holding my partner's hand, seeking reassurance from even my partner or phoning my sister, potentially doing like little things like drinking a sugary drink or something like that. All of these things, which I thought in the moment were things that were keeping me safe and helping me. And I think by working through CBT with yourself, Stirling we were able to, I guess, like rationally analyse whether they actually were keeping me safe, was holding my partner's hand going to prevent me from having a cardiac arrest and rationally, obviously it is not going to. So by understanding that it gave me a chance to process what I was doing, and then that allowed us to formulate these experiments which we could run. So when I was feeling anxious, when I was potentially getting into a situation where these safety behaviours would appeal to me, I could proactively test not doing the safety behaviour, which was a little scary to begin with but I was able to do it, especially in a kind of gradual way. And then we could see the results and see whether anything got better or worse and see whether the safety behaviours were actually helping. And, unsurprisingly, they weren't helping. But it was one thing to know, it is another thing to prove it to myself via experiments.

Stirling: Yeah, absolutely. And, you've mentioned also how it's tricky when you have a physical condition to disentangle some of the sensations that you're getting from what might be anxiety related or might be normal sensations. Would you tell us a little bit more about how you managed to do that over the course of the therapy?

Nic: Yeah, this was really interesting, and this is something that early on in the therapy I was worried I wouldn't be able to get kind of conclusive evidence on like, how would I ever know something isn't my heart condition? How would I know it definitely is anxiety? And I think a couple of things. I think we established that one- I may never get a hundred percent certainty on this stuff that I will have to live with some element of uncertainty, but that's also true for almost everybody, if not everyone, so that became easier to accept. The other was just observations of these experiments, both kind of proactive experiments and kind of accidental natural experiments. So if ever I was in a situation where either I deliberately avoided the safety behaviour and then saw that the physical sensations of say heart racing, hands getting sweaty, didn't happen. That's more evidence for the fact that there probably was an anxiety spiral that was what was causing a or panic spiral that was what was causing the symptoms. And I think by building up this bank of evidence, I guess a natural experiment would be an example of where potentially I was in an anxiety inducing situation, but didn't realise it. I was distracted by something, something unusual had happened and I was distracted by something in the background, a TV being on in a situation when typically I would get anxious and then realising afterwards, oh, that was unusual. Like typically I would've got anxious there, but because I was watching TV I didn't get anxious, which again is more great evidence for the fact that it's probably not a heart condition, because a heart condition wouldn't respond to that. It probably is an anxiety condition that is causing this stuff.

And yeah, by building this bank of evidence week on week, it just got to the point where it just made sense that it was anxiety and I was not able even to convince myself. I just truly believed that it was that, and then almost because I believed that, it became easier to keep testing it and keep pushing the envelope further and further with more difficult experiments to the point where it felt almost like I was training myself. It was almost like going to the gym, but for my mind, kind of building up this resilience to these situations. And the stronger I got the more I reinforced that those conditions pro the root of it probably was anxiety.

Stirling: One of the things that you mentioned, a little bit earlier was. getting reassurance from your partner and and so on. And, it might be helpful to people who are perhaps partners and friends of people with anxiety problems who are going through CBT to hear a bit about how she helped.

Nic: Yeah, absolutely. So, my partner Isabel has been incredibly helpful throughout all of this, both in terms of encouraging me to get help and also supporting me when we're doing this. In terms of what maybe potentially advice to people who are in similar situations. One I would suggest, if you are taking course of CBT, inviting your partner along to come to a session. So we did a session together myself, Isabel, and Stirling, that was incredibly useful. In terms of kind of small, practical tips that help for me, I think, an important step forward was when Isabel and I discussed the, I guess, what to do in a situation where anxiety is setting in. So that would be I think prior to this, whilst I would give into safety behaviours, people around me would also give into safety behaviours and it almost like facilitate these safety behaviours. So Isabelle would be holding my hand and would be reassuring me. Whereas once we've established this formulation and I've shared that with her, she was able to tell me, kind of coach me through it. So say like, okay, if an anxiety situation is arising, then to lean into the anxiety, remember what we've discussed in therapy, try and like ride out the wave of it, remember that it will pass. But also be reassuring in a kind of, in a useful way, which would be something along the lines of acknowledging the situation is real, acknowledging that it is this, it is uncomfortable, but that you can handle it and work your way through it rather than, so instead of it being a safety behaviour, kind of being a bit more of a coach.

Stirling: Great. Thank you so much for sharing those experiences and talking about them so clearly. Anything else that you'd like to say and particularly anything that you would say to people who might be considering whether CBT would be helpful for them?

Nic: Yeah, I think. I think for me, I was probably sceptical before starting this whole process, and then I'd say midway through, I'd say it was possibly after four sessions, there was, it felt like there was a big breakthrough and suddenly things started to get so much better. And towards the end of the sessions I was, I completely changed my opinion, almost to the point that I started to feel like we should be teaching this in schools, some of these skills. I felt like it was something that I just wish I'd known years ago. In terms of like my decision to do it, that decisions I made when I filled out the initial form to get in touch. I think honestly it was one of the best decisions I made in my life, particularly when it comes to like return on investment for it. So in terms of things I've done for myself, that was probably the most impactful thing that I've ever spent money on. I was fortunate to get some support from my workplace, I know it can be expensive, or it can seem expensive. The way I was trying to think about it, it was comparing it to save the price of something like a holiday and maybe having to kind of forgo a particular holiday and instead do this. And in terms of like return on what I've got from that, this has changed my life more so than a holiday would. I do still enjoy going on holiday, of course.

Stirling: Yeah. Thank you. And just to say to people that the other part of this podcast, we were talking about CBT available on the NHS and the Talking Therapy Services are also there to provide help with anxiety disorders and depression. So thanks very much indeed, Nick. Thanks so much for coming on and sharing your experiences today.

Nic: No. Thank you so much for having me.

Helen: And coming up now I'm speaking with Saiqa Naz, who is past president of BABCP

Helen: Saiqa, would you like to introduce yourself?

Saiqa: Hello, I am Saiqa Naz. I am past president of BABCP, so I was president until November 2024. I'm a clinical psychologist and also a CBT therapist and I work in a learning disabilities service.

Helen: Thank you, and one of the reasons why I said you were a solid return on investment is that you were part of a big government project in England, which involved investing very heavily in CBT in what was called the Improving Access to Psychological Therapies Project, which is now called NHS Talking therapies for anxiety and depression. Can you tell us a bit about your personal journey as part of that?

Saiqa: Yeah, so I actually studied in Sheffield, completed my undergraduate, and then I went back to Rochdale, which is my hometown. Beautiful Rochdale, a small town north of Manchester for those people who have not heard. But I struggled. I struggled to find any paid work related to psychology. I struggled to find voluntary work related to psychology, and the transport links were not that great which meant I couldn't leave, come and go, quite easily. So I was in this small town struggling to find any form of experience, and eventually found a little job as a support worker and then I had another job to, to earn a bit more income. So yeah, I was doing like two jobs concurrently. And then the IAPT initiative came along and I was offered a job as a low intensity practitioner or a psychological wellbeing practitioner and then I moved back to Sheffield. So that's how I came into the NHS.

Helen: Okay, so perhaps if you say a little bit more about what training as a psychological well wellbeing practitioner did for you, and then a bit more about your career after that, cause you're not still working in that role.

Saiqa: No, I'm not working in that role, but I'm still using those interventions. I think everybody should learn those interventions, if I'm honest with you. And I think that role gave me a nice introduction to the NHS supervision, you know, learning difference between clinical supervision and line management supervision. I was quite heavily involved in developing groups, the stress, delivering stress management course or managing lower mood. So I really developed my skillset in a range of ways, you know, one-to-one therapy, group therapy, did supervision, developing projects, started to do more outreach work around ethnic minority communities, started to do a bit of thinking around those groups. And that work still stays with me, I don't think I've ever really left it behind.

Helen: So even at that early stage in your career in the NHS, you were thinking about the value of developing yourself as a diverse individual, if you'll forgive me saying so. And we know that was one of the things that the IAPT Project bought, brought in was a more diverse workforce, which perhaps intending to be more representative the communities that people come from.

Saiqa: Absolutely. And so many years later it still is representative of the communities. And I think that is the beauty of the initiative is that I wasn't an afterthought- thanks David and Lord Layard. But I think when they were thinking about it, they obviously thought about us in their thinking in those early stages. And actually when I applied for the job, I can't remember exactly what it said, but it did allude to having knowledge of a different community or knowing a different language. And actually part of my interview was in Urdu at that time 'cause I was tested and I don't think we see that. I think some of that has been lost somewhere actually 'cause those early days where the money was there, the thinking was there, the will was there we've managed to produce a quite a diverse workforce.

Helen: Okay. and that's one of the things that I'm hearing from what you're saying is that you, your particular skills and your own background were particularly valuable and the investment of resources in training people from different backgrounds and who are really embedded in the communities that they served was genuine in enhancing and enriching what we could offer. And being taught CBT skills, which are evidence-based and most likely to help people with the common mental health problems that you were working with in that role. What about when you then went on to do further training? Because you haven't really stopped. Tell us more.

Saiqa: No. Then I went on to do my CBT training. I did that in Manchester and actually moved back to my hometown. And, I felt like I was giving back to my communities and that not just people who looked like me, I think just the town as a whole. There's some quite deprived areas, so there's four boroughs, and I had a day in each of those boroughs, so I felt like I was learning about the town, but I was also able to give back to the town. So I'm quite passionate about it. Yeah, it was tricky getting those videos in to pass. I had one attempt left and my friend said, you know, jump through the hoops. I took a generalized anxiety disorder and PTSD as my training cases and my supervisor John Storey is looking at me. He said, you're spinning a lot of plates Saiqa. And I said, oh, that's because I'm comfortable with depression and so I thought I'll bring something different in. And then when it came to doing the videos, it was, I took some really tough cases in, and they weren't quite meeting the criteria of passing the videos. And I had one attempt left, or I may never been sat here talking to you, Helen, but managed to get through.

Helen: And I think you'll be really speaking to the experience of some of the CBT therapists that are sitting here listening to what you're saying. The challenge of doing the CBT training can be one of the most difficult things that people attempt. So given that you did succeed, and here you are sitting talking with me, is there anything that you would say really helped you to get through those challenges that really did I don't know, improve your access as a clinician to being able to provide this service.

Saiqa: Yeah, I think while I was training, there was a group of us and maybe called the Specials because we'd meet for breakfast in the coffee shop, get there a bit early, and then we'd always be the ones that submitting our work just on the deadline or do the night before? Yeah, the all-nighters. So we were the little group

Helen: The last-minute deadline group.

Saiqa: The last minute deadline group, absolutely. So we did the training, but we ended up forming this lifelong sisterhood of friendship, which I really value, and they're really important and really big part of my support network. I think even continuing my journey. So you get a lot from the training that I think is really valuable and the camaraderie because everyone's going, oh, I'm going to fail if I get thrown off, if I don't pass this video, or I'm not meeting the CTSR…

Helen: So what I'm hearing is that actually you invest a lot of yourself in the training but it's worth it. And those connections with the other people who are in the same boat really helps to get you through.

Saiqa: Absolutely. And you know, you're more confident as a clinician when you come through because people have been watching your videos. You have to quickly get over then, oh, that angle on my face doesn't look right, and why did I do that? Oh, why was that looking, you know, why did I pull that face?

You just need to get over those anxieties if you want to get through it. That's what I'll say to anybody who's in on the course now or thinking about it. And, but as a consequence, because lots of people have had to look at your work and input it into it, and you can refine your skills. I think when you do have those stats later on, you can say, it's not just coming from me, people have looked at my work and actually, it's okay. It's not that bad.

Helen: Yeah, and actually everybody else other than you as the trainee on the camera, my experience is that actually focusing on the client is what gets you through that and trying not to focus too much on whether you've got the right angle or whether your hair looks funny in that outfit.

Saiqa: And am I good enough to be here? Do you know if you're from an underrepresented group, the imposter does come with you. I think you don't lose it. It's there and you don't want to reveal yourself, but. I don't, maybe it's, as I'm getting older, I'm like, yeah, this is just who I'm am.

Helen: I do think it's really important though to acknowledge that the training is hugely demanding, and then if you do come from a minoritised group, you've got additional challenges, and often intersectional challenges. However, you're sitting here talking to me and your career advanced even further after being qualified as a CBT therapist. Tell me what made you decide to train in another profession, even though you were already fully qualified and experienced as a CBT therapist.

Saiqa: Yeah, it's a good question. I think when I first started, when I was doing my undergraduate, I wasn't so aware of CBT and I think we probably could get better at bringing CBT into colleges and undergraduate courses because when I was thinking what am I going to do with my degree, CBT I don't think came up in my research. But then I was on the CBT path because that was the opportunity given to me and I went on the CBT path but I think part of it was, I was aware that it has its limitations. So I'm working people with complex trauma, with interpersonal difficulties and I think I was thinking, oh, then other ways of working with people apart from CBT and maybe I just need to have the humility to go okay, park the CBT for a while, do the training. But I also wanted the training to give me opportunities and open the other doors that, again, traditional CBT therapists are not provided with around leadership or managing services. So I think I was thinking longer term career, it'll give me opportunities, but I wanted to do research as well. So there's multiple reasons why I did it, but I have to say, every single service I went to in placement, there was some form of CBT there. And I've come out of that training even bigger fan of CBT if I'm honest with you, I'm like, yeah, evidence based. Okay, what are we doing? Not what am I doing, what's the evidence saying that we should be doing for this person? So that level of humility, I think that approach brings is really important.

Helen: Yeah. Thank you. So I know that you work clinically now with people who have learning disabilities. Can you tell us, it's one of the areas that we hear about perhaps a bit less in CBT sometimes. Can you tell us a bit about investing in working with people who do have learning disabilities?

Saiqa: Oh, you know, I'm quite big on inclusion and equality and interrogating systems that exclude people. I think I can't keep my mouth shut. But I think as clinicians, it's all of our responsibilities and roles and when we notice who's not in the room, that we then speak. I went to learning disabilities and I've been shocked at the level of underinvestment. And to me, it almost feels like they're the forgotten group. If I'm honest, like I think nationally they've been overlooked and forgotten. And also in our services, you know, some people who have let's call it milder learning disabilities, can access mainstream services. We've got to make room for those people, you know? So I think, I'm trying to think about adapting CBT in that context. And that's what I'm focusing on at the moment is, but again, you know, not digressing too much because don't want to do too much of a drift. And it's not CBT. But what I really want us to do as a workforce is really think collectively about people with learning difficulties and also learning disabilities because they're not in the room. They don't have the social care in place or the care needs in place to enable them to access conferences or sit at tables. So I think we need to be advocates for them and then create space and room for them to come and sit with us.

Helen: Thank you. So I'm hearing that you are absolutely a living example of CBT being a solid return in investment in terms of just your own journey through your career and how you've invested of yourself and you've been able to take advantage of the investment in training in CBT but also your own focus on inclusion, making sure that we are more representative, that we do more to make sure that underrepresented groups do genuinely have that access and the opportunity to have better evidence-based interventions to help improve quality of life and so on. Is it too much to ask you where you see yourself in five years' time?

Saiqa: Oh gosh, sat on the beach, like retired. No, I think, do you know when we talk about being a solid return on investment, a lot of this inclusion work, Helen, it's been done outside in our own time, you know, evenings, weekends, annual leave, holidays my family going what you doing Saiqa, we are at the airport! You know. Right. And I think what really want to see is some of this work embedded into systems, infrastructure because ultimately it's still a nine to five job, isn't it? And I hold their inclusion values. Yeah. I'm trying to convince myself it's a nine to five job but yeah, I think I'll still be involved somehow. I think maybe a little bit more around research because again, people like myself are actually, I don't know, somebody from my background in leading projects and research, to be fair know millions of pounds are invested, Actually, maybe that's where I might be in research and hold onto my clinical work. Yeah.

Helen: Saiqa, thank you so much for talking with me today. It's an absolute pleasure to be speaking with you.

Saiqa: Thanks for having me, Helen.