When I first took over as Editor-in-Chief of the Cognitive Behaviour Therapist (tCBT), I was extremely excited to hear that there was already a planned (and almost completed) forthcoming Special Issue on Complexity in Cognitive Behaviour Therapist (CBT) being Guest Edited by Claire Lomax and Stephen Barton from Newcastle University, UK (Lomax & Barton, 2017).

Complexity in CBT is a topic that is relatively little written about and I would argue previously ill-defined. Yet it is something that is central to our day-to-day clinical work, particularly the formulations and interventions that we develop and deliver with our patients. We talk about complex patients and may even use the term complexity as an explanation for those patients that have failed to respond to our interventions, but what is complexity? Are we actually talking about the problem being complex or the person? Is complexity located within the individual or the system around them? And what role does the therapist play in this? What about our wider clinical knowledge of the problem in question? If the patient does have a complex problem(s), how can we formulate this and communicate it in a way that has a shared meaning with our colleagues?

Over the course of the seven articles (and a podcast from Paul Salkovskis and Claire Lomax on the topic) complexity within CBT is examined, discussed, formulated (with case examples) to provide a snapshot of current thinking on this fascinating topic.

In the podcast introduction, Paul Salkovskis (2018) asks some challenging questions around the notion of complexity, arguing that many of the patient problems that are currently defined as complex are actually because there is a lack of understanding of the problem, referencing the fact that agoraphobia with panic attacks was once seen as complex before a model had been developed to understand the problem and guide our interventions.

Within the Special Issue there are articles that attempt to provide a model for understanding what working with complexity might mean in practice. For example, Barton, Armstrong, Wicks, Freeman and Meyer (2017) propose key classes of features in depression (biological, psychological and social) that lead to what they define as complexity by interfering with, or complicating, four aspects of therapy: access, readiness, alliance and maintenance factors. This framework provides a language and structure to conceptualise complexity factors and the interplay between them.

The Special Issue also includes articles:

  • On how to use simple formulations to achieve change within complex eating disorder presentations where co-morbidity is the norm (Mountford, Tatham, Turner & Waller, 2017)
  • Describing interventions for a young person where the complexity is due to co-morbid and interacting physical and mental health problems (Bennett, Heyman, Varadkar, Coughtrey & Shafran, 2017)
  • Exploring the complexities around delivering CBT with a population of mentally disordered offender patients (Ferrito & Estelle, 2017)
  • Examining what complexity is, and is not, amongst patients with obsessive-compulsive and related disorders illustrated by five case examples (Sündermann & Veale, 2017)
  • Exploring and defining the phenomenology of persistent complex bereavement disorder (PCBD) and prolonged grief disorders (PGD) and how this differs or overlaps with depression and PTSD (Duffy & Wild, 2017). The authors present a new integrated CBT model for how to work with complex bereavement and grief based on the maintaining processes and interventions within models for related disorders.

Each of these articles is clinically focussed and based around the experience, knowledge and expertise of the authors and the CBT field. However there are different ways to approach the notion of complexity beyond those explored in this issue, such as the work of Delgadillo, Huey, Bennett & McMillan (2017) who have used an actuarial, data-driven method of classifying complex cases based on their individual characteristics and their clinical outcomes in order to develop a way of matching therapeutic input to need.

Such empirical research and the clinical wisdom contained within this special issue are likely to provoke clinician reflection and debate as to what we actually mean when we refer to ‘complex problems’ or ‘complex patients’, and when we need to develop complex formulations and when we need to keep our formulations simple and maintain fidelity to specific CBT models.

I am extremely grateful to the authors who have shared their work and the Guest Editors for bringing a focus to this challenging but essential topic.

All articles and the free podcast can be downloaded here.

To receive first notification and a link to access full tCBT articles (without logging in) as soon as they are published follow the tCBT twitter feed @theCBTJournal.


Barton, S., Armstrong, P., Wicks, L., Freeman, E., & Meyer, T. (2017). Treating complex depression with cognitive behavioural therapy. The Cognitive Behaviour Therapist, 10, E17. doi:10.1017/S1754470X17000149

Bennett, S., Heyman, I., Varadkar, S., Coughtrey, A., & Shafran, R. (2017). Simple or complex? A case study of physical and mental health co-morbidity. The Cognitive Behaviour Therapist, 10, E18. doi:10.1017/S1754470X1700006X

Delgadillo J, Huey D, Bennett H & McMillan D (2017) Case complexity as a guide for psychological treatment selection. Journal of Consulting and Clinical Psychology, 85(9), 835-853. doi: 10.1037/ccp0000231

Duffy, M., & Wild, J. (2017). A cognitive approach to persistent complex bereavement disorder (PCBD). The Cognitive Behaviour Therapist, 10, E16. doi:10.1017/S1754470X17000034

Ferrito, M., & Moore, E. (2017). An exploratory study on the issues and challenges clinicians encounter in the application of cognitive behavioural therapy with mentally disordered offender patients. The Cognitive Behaviour Therapist, 10, E19. doi:10.1017/S1754470X17000150

Lomax, C., & Barton, S. (2017). Editorial for Special Issue: Complexity within Cognitive Behaviour Therapy. The Cognitive Behaviour Therapist, 10, E13. doi:10.1017/S1754470X17000137

Lomax, C. & Salkovskis, P. (2018). Complexity in CBT Podcast (Downloaded from https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/special-issues/complexity-within-cognitive-behavioural-therapy on 5 August 2018)

Mountford, V., Tatham, M., Turner, H., & Waller, G. (2017). Complexity in eating disorders: A case for simple or complex formulation and treatment? The Cognitive Behaviour Therapist, 10, E14. doi:10.1017/S1754470X17000162

Sündermann, O., & Veale, D. (2017). Complexity in obsessive-compulsive and body dysmorphic disorder – a functional approach to complex difficulties. The Cognitive Behaviour Therapist, 10, E15. doi:10.1017/S1754470X17000113

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