COGNITIVE BEHAVIOURAL THERAPY

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COGNITIVE BEHAVIOURAL THERAPY
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A.T.BECK, 1976

• Beck's main argument was that depression was
  instituted by one's view of oneself, instead of
  one having a negative view of oneself due to
  depression
• Beck argued that negative automatic thoughts,
  generated by dysfunctional beliefs, were the
  cause of depressive symptoms, and not vice versa

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BECKS NEGATIVE COGNITIVE TRIAD
THE WORLD
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KEY CONCEPTS IN CBT

• Cognitive refers to how people think about and
  create meaning about situations, symptoms and
  events in their lives
• How they develop beliefs about themselves, others
  and the world
• Uses techniques to help people become more aware
  of how they reason, and the automatic thoughts
  that they have that give meaning to things

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COGNITIVE INTERVENTIONS

• Use of socratic questioning style to explore
  meanings and beliefs guided discovery
• Explores the possibility of thinking differently
  and more helpfully
• Then carry out behavioural experiments to test
  out these new ways of thinking
• Develop new ways of perceiving and acting
• Move from extreme and unhelpful ways of seeing
  things to a more helpful and balanced way

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BEHAVIOURAL COMPONENT

• Refers to the way people respond when distressed
• Avoidance, reduced activity, other unhelpful
  behaviours act to perpetuate the problems and
  make patient feel worse
• Aim is to gradually test out assumptions and
  change unhelpful behaviour

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SITUATION Having a bad day, so go out shopping.
Friend walks by and ignores you
UNHELPFUL
HELPFUL

• He/she ignored me - they dont like me
• Low, sad, rejected
• Stomach cramps, nausea, low energy
• Go home and avoid them

• He/she looks preoccupied. I wonder if somethings
  wrong?
• Concern for the other person
• None, feel comfortable
• Get in touch to make sure they are OK

Thoughts
Emotions
Physical
Action
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FORMULATION BASED CBT

• Formal psychotherapy, when self-help not possible
• Trained and supervised therapist with skills to
  develop therapeutic alliance
• Collaborative approach through assessment,
  formulation and intervention
• Here and now, problem-focused
• Breaks down problems into separate parts, using
  guided discovery
• Thoughts, emotions, physical feelings and
  behaviour
• How they affect each other. Helpful/unhelpful.
  Realistic/unrealistic
• Aim to change/manage unhelpful thoughts and
  behaviours
• Using various cognitive and/or behavioural
  techniques
• Application of learned techniques between
  sessions, homework
• Frequent re-evaluation against formulation and
  change of direction if necessary

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FORMULATION
CORE BELIEFS/UNDERLYING ASSUMPTIONS
EMOTIONS
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IN SUMMARY, CBT IS

• Psychotherapy that talks about
• How we think about self, others, world
• How what we do affects our thoughts and feeling
• CBT helps us to change how we think (cognitive)
  and what we do (behavioural)

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WHOM FOR?

• Individuals
• Families
• Groups
• Irrespective of ability, culture, race, gender or
  sexual orientation

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WHAT DOES CBT WORK FOR?

• Anxiety disorders, including GAD
• Panic
• Phobias
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Bulimia
• Depression

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BEING DEVELOPED FOR

• Psychosis
• Schizophrenia
• Bi-polar disorder
• Anger control
• Pain
• Adjustment to physical ill-health
• Insomnia
• Early dementia

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EVIDENCE BASE FOR CBT

• Robust
• Based on RCTs and single-case methodologies
• Supported by recent reviews by NICE and SIGN etc

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EFFECTIVENESS FOR DEPRESSION

• As/more effective as drugs
• Effects maintained a year after treatment (cf
  ADs)
• Better tolerated than ADs, especially in severe
  to very severe depression
• CBT ADs better than ADs alone especially for
  severe depression
• CBT has relapse-prevention effect

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EFFECTIVENESS FOR ANXIETY

• Recommended by NICE for GAD
• As effective as drugs
• Effect maintained long-term
• More effective than psychodynamic therapy and
  non-specific therapies

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MENTAL ILL-HEALTH IN PALLIATIVE CARE

• Emotional distress common in palliative care
  patients
• Anxiety and depression also common
• Most palliative care clinicians not mental health
  trained
• The psychological support they offer may be
  sufficient for most patients with transient
  emotional distress
• No evidence that these skills are adequate for
  persistent anxiety, depression or adjustment
  disorder

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PLACE OF CBT IN PALLIATIVE CARE

• Effective for depression, anxiety and panic in
  patients with physical health problems, eg
  chronic pain, IBS, cancer
• No formal studies in palliative care setting
• Likely to be helpful based on work with cancer
  patients
• Usefulness likely to be the management of
  adjustment disorder, generalised anxiety
  disorder, panic, depression

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DELIVERY OF CBT

• Referral to CBT therapist
• Increases number of clinicians involved
• Delay
• Travel
• Requires stamina
• Requires time
• Costly

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BRIEF TRAINING IN CBT

• Equivalent of 12 days training plus supervision
  over 6 months
• Thereafter two groups ongoing supervision and no
  supervision
• Assessment using CBT competency scale
• Gain in CBT competency significant (p0.001)
• After 6 months skill levels dropped in those who
  discontinued supervision
• Those who continued supervision gained skills and
  maintained confidence (p0.007)

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REFERENCES

• Roth A, Fonagy P. (2005). What Works for Whom A
  Critical Review of Psychotherapy Research. Second
  Edition. The Guildford Press.
• Mannix K A, Blackburn I M, Garland A, Gracie J,
  Moorey S, Reid B, Standart S, Scott J. (2006)
  Effectiveness of Brief Training In Cognitive
  Behaviour Therapy Techniques for Palliative Care
  Practitioners. Palliative Medicine 20 579-584
• National Institute for Clinical Excellence.
  (2004) Clinical Guideline 23
• National Institute for Clinical Excellence.
  (2004) Clinical Guideline 22
• Scottish Intercollegiate Guidelines Network.
  Publications 44, 76, 84