A One Day Skills-Based Workshop Online 2021 Paul Blenkiron

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Introduction to CBT

A One Day

Skills-Based Workshop

Online 2021

Paul Blenkiron

www.rcpsych.ac.uk

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CBT in Practice 2021

• A range of three skills-based courses online -designed to help you implement Cognitive Behaviour Therapy within your practice and service.

• Led by trainer: Dr Paul Blenkiron, Consultant Psychiatrist, TEWV NHS, York, [email protected] Twitter @PaulMindDoctor

• Organised by The Royal College of Psychiatrists

https://www.rcpsych.ac.uk/events/conferences

• [email protected] Tel: 0208 618 4143

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CBT in Practice 2021

• Three one-day practical workshops + course materials

• You can attend all of them or just one or two

• RCPsych, 21 Prescot St, London, E1 8AD, 9.30 to 4pm

• Suitable for psychiatrists, nurses, psychologists, GPs

• No prior experience is assumed. Focus on adults

• Online via Zoom

Introduction to

CBT

Managing

Depression

Managing

Anxiety

Thurs 18 March Thurs 15 April Mon 17 May

We’re on Zoom Today – Ground Rules

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CBT-R: The new normal? Emerging evidence that Internet (remote)

delivered CBT is as effective as face to face

CBT in primary care for health anxiety &

associated depression (JAMA Psych.

doi:10.1001/jamapsychiatry.2020.0940)

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About this Workshop

• Teaching techniques:

– Interactive presentation, pair work, group work,

role play, Video clips, humour, analogy, quiz

• Facilitator:

– Paul Blenkiron: Consultant Psychiatrist, York

– Honorary Professor, Hull-York Medical School

– CBT Tutor for Core Trainees, TEWV Medical Education

– BABCP-accredited (British Association for Behavioural and Cognitive

Psychotherapies)

– @PaulMindDoctor [email protected]

– https://uk.linkedin.com/in/paul-blenkiron-55a90563

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Learning Objectives

After this workshop, you will be able to:

1. Define psychotherapy and its core components

2. Understand CBT and its core components

3. Demonstrate awareness of suitability for CBT

4. Assess a patient using the five areas approach

5. Begin to apply the skills of guided discovery

Resources: This Powerpoint - and the CBT

Patient Materials on Word e-mailed to you

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Plan for the Day

• 9.30 Start & Introduction: What is psychotherapy?

• 10.15 Training & College requirements

• 10.30 What is CBT? Agenda setting

• 11.30 Coffee

• 11.50 Suitability for CBT & Evidence Base

• 12.45 Lunch

• 1.30 CBT Assessment & Skills Practice: Guided Discovery + Five Areas

• 3.00 Tea

• 3.20 Practicalities, Resources, Quiz, Feedback

• 4.00 Close

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C.B.T. =

Compulsory Basic Training

Some automatic negative thoughts…

• When’s the coffee break?

• Oh no… psychotherapy training … another hoop to jump through on the way to the CASC/ CPD/ Revalidation/ Retirement…..

• I’m not a psychologist, leave me alone

• I’m a crap therapist

• Anyone who thinks I’m going to become a therapist needs their head examined

• What’s schemata with me?

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What is Psychotherapy?

Work in small groups (15 minutes)….

1. Define ‘psychotherapy’ (one sentence)

2. What do all psychotherapies have in common?

3. Name 5 therapies promoted by NICE

4. Which is the ‘best’? (ie the most ….. effective/ interesting/ well known/ popular/ costly/ newest/ easiest to practice)?

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Definition of Psychotherapy

• “A treatment which makes use of the

relationship between therapist & patient to

produce changes in thoughts, feelings and

behaviour”

ie

• It is a psychological (‘talking’) treatment for

psychological problems.

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All Psychotherapies Involve:

• A therapeutic conversation ie talking = exchange of information + instillation of hope (what about self help, computers, deaf patients?)

• A therapeutic relationship (alliance) between therapist and ‘client’/patient

• A therapeutic rationale ie an explanation ‘followed’ by therapist & patient (? ‘religion’)

• A therapeutic base ie regular meetings in time & place (does it have to be 1 hour every week?)

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Quotes

‘You cannot teach a man anything; you can only

help him find it within himself’.

Galileo Galilei, 1564 – 1642

‘We're in the business of putting ourselves out of

business. That should always be a therapist's goal’.

Christine Padesky, 2006

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NICE Approved Therapies

• CBT: many types, eg individual, group, guided, computerised, ERP (OCD),

trauma focussed (PTSD), CBT for eating disorders, psychosis, mindfulness)

• Behavioural activation (a type of CBT - depression)

• Behavioural couples therapy (depression)

• Interpersonal therapy (IPT – depression and bulimia)

• Counselling (depression if patient requests it)

• Short-term psychodynamic therapy (depression if patient requests it)

• Family therapy (anorexia) + interventions (schizophrenia)

• ‘Psychoanalytical principles’ (schizophrenia)

• Art therapy (schizophrenia)

• Dialectical behaviour therapy (DBT for BPD), CAT for anorexia

• Peer support programmes (physical illness)

• Motivational interviewing (substance misuse, young p.)

• Problem solving (self harm) – (reduces recurrence 2016 Cochrane)

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NICE Stepped Care Approach

for Anxiety & Depression

http://www.iapt.nhs.uk/silo/files/iapt-data-handbook-appendicies-v2-word-version.doc

The IAPT Data Handbook Including the IAPT Data Standard Version 2.0.1, June 2011

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Psychotherapy:

Core Training

Minimum psychotherapy training requirements: (for entry to MRCPsych CASC exam, logbook evidenced)

• Attend a ‘case based discussion group’ for at least a year (eg yr 1 Balint group) +

• Undertake 2 supervised psychotherapy cases in ‘2 modalities and over 2 durations’ (between CT1-3: eg CBT, dynamic, family, systemic therapy)

http://www.rcpsych.ac.uk/files/pdfversion/OP69.pdf pp 74-77

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Psychotherapy Training:

Aims

• Account for clinical phenomena in psychological terms

• Deploy advanced communication skills and E.I.

• Deliver basic psychotherapeutic treatments and strategies where appropriate

• Refer patients appropriately for formal psychotherapy

• Jointly manage patients receiving psychotherapy

Ref: http://www.rcpsych.ac.uk/files/pdfversion/OP69.pdf pp 74-77

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Trainee Assessment

• Logbook evidence of attendanceat Case based discussion groups, CBT workshops and supervision

• CBT competencies: 1 session audio-recording: self

assessed eg CTRS + extract played in supervision, evaluation forms

• 2 SAPEs = Supervisor’s Assessment of Psychotherapy

Expertise (by the supervisor): 1 by end of CT2 + other by end of CT3

• 1 WPBA eg ACE = Assessment of Clinical Expertise (by

another supervisor = presentation of a completed case): before CASC

• Higher trainees in GAP and OP: ARCP = 2

psychotherapy experiences in 3 yrs, one must be face to face with 8 contacts over 12

months, contact [email protected], pasted in notes pages view below, for more info

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What is CBT?

Whole group discussion:

What qualities of cognitive behaviour

therapy help to make it ….

a) the same

b) different

….. to other psychotherapies?

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What is CBT?

CBT is a family of psychological treatments that teach us how to feel better by changing the way we feel think and behave……

• Here and now • Problem/disorder focus• Collaborative/self help style• Homework• Structured/measured• Evidence based (NICE)• https://youtube/ZRijYOJp5e0 2 min Intro

Video with Jo Brand

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CBT: A Different Perspective

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CBT Triangle

Use Analogies to Introduce CBT to Patients:

Noise in the Night, Friend Passes By

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Noise in the Night

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Cognitive Therapy

Made Simple: 2 Quotes

• People are disturbed not by events, but by the view they take of them

(Epictetus, stoic philosopher, AD 55-135)

• Our life is what our thoughts make it

(Marcus Aurelius, emperor AD 161-180)

It’s how you see the world that counts…

event interpretation emotional response

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Depression and Negative Thinking

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Behaviour Therapy

Made Simple: 2 Rules

• Doing something that’s maintaining the problem? ……..Then stop doing it! (eg ruminating, checking, controlling, seeking reassurance, safety behaviours)

• Avoiding something related to the problem? ……….Then start doing it again! (eg face fears, set goals, graded exposure)

Do more of the same if it’s working, do something different if it’s not... ‘If you always do what you always did, you’ll always get what you always got’ (www.thedecider.org.uk)

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Depression and Inactivity:

A Vicious Circle

Introduction to wk1:

mood disorders

SensationHeart racing,

sweaty

InterpretationI’m having a heart attack

EmotionFear, panic

Panic : A Vicious Circle

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‘CHANGE VIEW’

10 Facts about CBT:

• Change: your thoughts & behaviours

• Homework: practice makes perfect

• Action: don’t just talk, do!

• Need: pinpoint the problem

• Goals: move towards them

• Evidence: shows CBT can work

• View: events from a different angle

• I can do it: self help approach

• Experience: test out your beliefs

• Write it down: to remember progressRCPsych CBT Leaflet (Blenkiron 2016) http://www.rcpsych.ac.uk/mentalhealthinformation/

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CBT Assessment: Five Areas

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Pair Work:

Explaining CBT to Patients:

• Clinician: You are seeing a patient with

anxiety and depression in your job. Explain

CBT in a nutshell to your patient in 3 minutes.

See how many essential parts of CBT you can

get in!

• Patient: You’ve had some ‘counselling before.

Clarify how CBT is a) similar and b) different to

this

• Swap roles and repeat

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What is CBT? Notes

CBT similarities to other talking treatments….

CBT differences from other therapies…..

Explaining CBT

to Patients

• CBT is a talking treatment that helps you learn more helpful ways of thinking & reacting in everyday situations.

• C stands for ‘cognitive’ (what you think). You learn to spot when you are being negative and self-critical. You challenge thoughts such as ‘I’m useless’ or ‘Its all going to go wrong’ . You develop more helpful, realistic thinking habits by asking: ‘What’s the evidence this is true?’, ‘What’s another way to view this?’ or ‘How would I advise a friend in my situation?’

• B stands for ‘behaviour’ (what you do). You might keep a daily diary of activities – then set goals to do things that you have been avoiding, test out any fears you have and give you a sense of achievement.

• T stands for ‘therapy’ (what you learn). CBT works best if you practice new skills as ‘homework’. This helps you stay well in the future too.

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Common Myths About CBT

• CBT is just positive thinking

• CBT relies on techniques but forgets the person

• CBT does not deal with feelings

• CBT does not address the real causes of distress

• CBT is a single psychotherapy

• CBT is simple and quick

• CBT works for everything

• CBT is just for specialists

4. Plan

5. Intervention

6. Evaluate

7. Summarise

Review and revise formulation

as more information emerges

Assessment

Formulation

Engagement

1.

2.

3.

these 3

‘stages’

overlap

Steps in CBT

Staying well plan

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Structure of a Typical

CBT Course• Session 1: Assessment: Typical example (5 areas), problem

definition, CBT discussion, suitability, rating scales

• Session 2: Background Other info, contract, goals/ targets

• Sessions 3-7: CBT Formulation (maintaining), interventions

• Session 8: Review session Progress, goals, rating scales

• Sessions 9-13: CBT Interventions ? rules/beliefs

• Session 14-15: Summary Learning, relapse prevention plan

• Session 16: Final review & discharge

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Structure of a Typical

CBT Session• Welcome – ‘how are you?’Establish rapport, briefly review key events

• Bridge from last session “ Anything that you wanted to say or that

bothered you about our last session? What did you get out of it?”

• Set agenda “ What do you want to work on today/get out of this session?”

• Review homework “ What did you get done/ feel was most useful ?”

• Discuss issues Maintain empathy. Summarise. Feedback.Relate to their goals

• Agree new homework Collaborative. S.M.A.R.T. Relevant. Troubleshoot

• Summary & feedback “Can you summarise what we covered today?

Anything you think I got wrong? What’s the most important thing you’ve learned?”

Video 2 & Pair Work

Setting the Agenda15 mins

• Video (5 mins): Paul has social anxiety. His

therapist clarifies the agenda for this session.

• On your own, as you watch, write down the:

a) content: main topics they agree to discuss

b) structure: useful phrases & skills Laura uses

• Then in breakout pairs (10 mins)

– 1) share your answers above

– 2) role play agenda setting yourself (end of the

video - agree content, order, timings)• ,

Video 2 - Feedback:

Setting the Agenda

• SKILLS: Ask agenda Q, discuss briefly, empathise, clarify,

summarise, check understanding, agree order & timing, start..

USEFUL PHRASES…• So Paul, what would you like to put on the agenda for our session today?....

• OK, it sounds like there are 2 things you’d like to discuss….

• One is how to cope with the work meeting next week that that you are getting quite

stressed about….

• The other thing you’d like to cover is feeling lonely in the flat and your housemates

going out without you.

• Have I got that right or is there anything you’d like to change?

• And which issue do you want to work on first?

• OK Paul, we’ve got about 45 mins left in this session. How much time shall we

spend on X and how much on Y?

• Great, so we’ll spend XX mins on each. Let’s start by….. 42

Plan for Staying Well (Relapse Prevention):

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Oversimplification or Clarity?

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Break 20 mins

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Who is Suitable

for CBT?

• Did you do the ‘homework’ preparation for this workshop?

• This included reading the following articles: Blenkiron P. Who is suitable for cognitive behavioural therapy? Journal of the Royal Society of Medicine 1999; 92: 222-229 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297171/

Padesky, C.A. (1993). Socratic Questioning: Changing Minds or Guiding Discovery? Keynote address, European Congress of Behavioural and Cognitive Therapies, London, September 24.

http://www.feltoninstitute.org/approach/Socratic_Questioning.pdf

• (If you had difficulty, consider how hard it is for distressed patients to do homework!!)

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Video Clip 2:

CBT Suitability

• Dr Martin Ellingham has a blood phobia.

He consults a therapist for the first time….

(3mins)

Questions

• Is he suitable for a CBT approach? Why?

• How did the therapist do?! Research across therapies shows that a good client outcome is related to the

therapist’s skill (metacompetence). One study of IAPT workers (Branson & Shafran

BACP 2015) found that superior CBT clinical skill & performance is associated with

a) higher degree class b) agreeableness as personality trait & c) (weakly) younger age

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Group Work• 15 mins for all questions then 5 mins to feedback

1. CBT works for… List the mental disorders/ problems for which there is an

evidence base that CBT can help (eg NICE guidelines):

2. Patients you see… Summarise the range of patients you currently see.

Describe two patients you think may be suitable for CBT and say why…

3. Suitability for CBT… List the features you would be looking for at a 1st

assessment in a patient that would make them more or less suitable for CBT:

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CBT Works for…

• Everything!? - especially anxiety and depression (regardless of age/I.Q.)

• Not a panacea – eg less evidence for efficacy in anorexia & personality disorders

• CBT won’t work quickly in people who:

• Attend because others want CBT ‘done’ to them

• Don’t write down anything or do any ‘homework’

• Want to know ‘why?’ but not ‘what/how to change?’

• Just want a pleasant chat (light bulbs) • 2016 review Cochrane metanalysis Hawton CBT inc problem solving reduces no of people self harming repetition by 6%

Some General TruthsProsser et al, BJPsych 2016

• Patients often prefer therapy to drugs

• Of therapies, CBT more evidence for efficacy

• CBT or drugs alone often equally effective

• Combining CBT with drugs is more effective

• CBT requires more effort than prescribing

• Financial incentives/ advertising favour drugs

• Psychiatrists mainly diagnose & prescribe

• Drugs = ‘biological’, CBT=‘psychosocial’ (myth?)

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How Effective is CBT?

0

10

20

30

40

50

60

70

80

90

100

% complete

therapy and

achieve

sustained

excellent

outcome

Panic

Disorder

Social

Phobia

PTSD

(Adapted from Salkovskis, 2002)

GAD OCD Depression

& Specific PhobiasCBT & antidepressants equally effective

for initial treatment of depression - with similar discontinuation

rates (BMJ 2015 Meta-analysis of 11 trials, Amick et al 355:h6019)

CBT: The Evidencehttps://www.aipc.net.au/articles/the-efficacy-of-CBT-treatment -for-depression/

• Superior to waiting list, controls + supportive ‘TAU’

• At least as effective as other therapies & medication -Improves symptoms, functioning & QoL

• Longer lasting effects than medication (at least halves relapse rate on stopping: 31%

ending CBT v 76% in those stopping meds)

• Adding CBT to meds reduces relapse rate by 61%

• Individual face to face CBT is most potent but group, guided self help &

computerised CBT also effective

• Average CBT completion rate is about ¾ (74%)

across different conditions ie ¼ drop out (Fenandez et al 2015 N= 20K metanalysis)

Hollen et al 2005 , Kaltenthaler 2008, Reger & Gahm 2009, Vittengl 2009, Beltman et al 2010, Otto, 2013, Amick et al 2015

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Suitability for CBT

More suitable

From history/referral letter……

• Specific & focused problem

• Single problem or diagnosis (Axis I-mental ‘illness’ eg panic, depression)

• No drug or alcohol misuse/psychosis

• Acute problem of recent onset

• First contact with psychiatric services

And when seen face to face….

• Good therapeutic alliance

• Can be focused in sessions

• Can identify emotions & thoughts

• Can relate to CBT model (‘five areas’)

• Can agree goals (written down)

• Takes personal responsibility for change

• Optimistic

Less suitable

• General & pervasive problem

• Multiple/complex/severe problems (Axis II – personality disorders)

• Substance use/active psychosis

• Chronic long-term problem

• History of treatment failure

• Problems in therapeutic relationship

• Vague & circumstantial in sessions

• Unable to access thoughts/ emotions

• Can’t link thoughts, feelings & actions

• Cannot specify desired changes

• Does not accept self-help model

• Hopeless

CBT in Older Age:

Adaptations

• Intergenerational attitudes: ‘doctor knows best’

v CBT self help’ (‘old dog, new tricks’ – how old were you when you stopped learning how to do

things?. ‘If I had those problems/was your age/had poor health, I’d be depressed too.’ Gym trainer analogy. How did you

cope when you were 30? 50?)

• IT skills: paper v. smart phone apps ( either is fine)

• Physical comorbidity: arthritis, poor sight, CVA

• Patient story-telling: agree to interrupt!

• Memory problems: CBT possible if mild cognitive impairment, contraindicated in

delirium or significant dementia: use frequent repetitions, pictures, keep it simple, homework folder, record

sessions, relatives as co therapists, focus on doing (BA) and recording goals

https://www.bcmj.org/articles/cognitive-behavioral-therapy-older-adults

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Not Suitable for CBT:

Warning Bells!

• Grabbing at smoke.... Patient can’t agree a short written definition of main problem within first hour of meeting (‘all over the place’)

• Black couch not toolkit.. More interested in ‘whys?’ (past events) than current ‘whats?’ (skills I can learn to cope/change/stop relapse)

• Amnesia…. Can’t describe a recent typical example of problem

• Passive…. Regards CBT as something ‘done’ to them (it’s not ECT)

• Homework phobia…. Regards therapy as feeling better for an hour a week - but no need to work on it between sessions

• Pen phobia…. Reluctant to write anything down (if it wasn’t written down, it didn’t happen’)

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CBT Change Techniques

• Increasing understanding

• Increasing activity

• Facing feared situations

• Reducing unhelpful behaviours

• Finding more helpful thoughts & beliefs

• Finding more helpful ways of coping

• Problem-solving

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Therapeutic Change

• ‘I’m all in favour of progress; its change I

don’t like’ (Mark Twain)

• Paradoxical Questioning: ‘Devil’s Advocate’

• Motivational Matrix: Pros and Cons

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Lunchtime

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Plan for the

Afternoon • 1.30 CBT assessment – recap, style & useful Qs

• 1.50 Video Clip: Carl’s Lunch – Guided discovery

& Five areas approach

• 2.10 Skills Practice 1: My Journey to Work

• 2.30 Video Clip: Sharon’s Job - Asking useful Qs:

• 2.40 Skills Practice 2: My Career

• 3.00 Break

• 3.20 CBT in Practice & What’s new?

• 3.40 Resources, Quiz, Evaluation

• 4.00 Close

Recap – What is CBT?

CBT is a family of talking therapies,

all based on the idea that thoughts,

feelings, what we do, and how our

bodies feel, are all connected.

If we change one of these, we can

alter all the others.

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Situation/ event/ stress

Thoughts (images, memories, etc)

Emotions

Behaviour Physical

reactions

CBT:Putting the pieces

together

The ‘generic’ CBT

formulation

organises

assessment

information

It shows what

caused the problem

and what keeps it

going ……

(Generic means ‘fits all’. There are

also specific CBT formulations for

different problems)

Our ‘core beliefs’ & assumptions (‘rules for living’)

(Early) Life events

Causal fa

cto

rsM

ain

tain

ing f

acto

rs

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Homework in CBT‘Action Plans’

• An essential part of CBT – 98% of therapists use it

• Leads to better outcomes – up to 4 x faster recovery

• Can be anything therapist and client agree is helpful –

related to work in that session or the therapy goals. Examples: reading info, completing rating scales, keeping a diary, doing behavioural experiments to ‘test it out’, graded

exposure, surveys, writing own learning/‘staying well’ plan. Homework now called ‘Action Plans’ by Beck Institute in USA

• Review homework at the start of session (‘agenda’)

then agree & record new homework near the end

• However, homework completion can be as low as 12-

50% - how can we improve this….?

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Did You Do

The Homework?

• Research shows homework is more likely to be completed if:

• Client is ‘motivated’ ie pros & cons of change discussed 1st

• Client understands reasons for doing and potential benefits

• Client agrees and writes down homework task in session 1st

• Client feels supported

• Client remembers the homework eg text /phone alert

• Therapist provides a written worksheet/ materials

• Therapist always reviews homework

• Homework is clear – not too complicated

• Homework is personalised to the client eg metaphors

References: Beck 1979, Bryant 1999, Dunn 2002, Helbig 2004, Aguilera 2011, Harris 2015

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The Style of CBT

• Agenda-setting & use of structure

• Guided discovery/Socratic questioning -

use of open questions & summarising

‘Ask, Don’t Tell’

• Collaboration - elicit feedback &

understanding

• Learning skills - information giving

• Practice between sessions – self help

The Collaborative Style of CBT

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‘We are going on a journey: you have the baggage.…

and I have the map….’

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The Therapeutic

Relationship in CBT

• How do therapies work? Generic v Specific Factors(Therapeutic relationship, therapist skill, empathy, warmth, regard, listening, time, placebo, client expectation, VERSUS skills eg homework, thought challenge, formulation, behave expts)

• Therapist skill & experience IS related to outcome Metacompetance a key skill BUT therapeutic relationship accounts for only 6% of outcomes variation in psychotherapy research (E=0.27 small (0.27) effect size (Moorey, 2019)

• But skills & content Do matter: A 'good enough' alliance is necessary but not sufficient for effective therapy:

• Time course studies: getting better in CBT leads to an improved relationship ie early improvement predicts final success

• CBT is a ‘doing’ therapy. (eg BEs/Exposure > Assessment/Talking

• So get going!

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Assessment in CBT:

Useful Questions

Introduction

• What’s your main problem?

• Can we go through a recent typical example?

• 5 Ws: what, where, when, who with, why

• What happened before/during/after the problem occurred?(ABC: antecedents, behaviour, consequences)

Five Areas

• What was the trigger or situation

• What went through your mind?

• What emotions did you experience?

• How did you feel physically?

• What did you do?

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Assessment in CBT:

Useful Questions (cont)

Generalise… the example to other situations:

• F.I.N.D. (frequency,

intensity, no., duration):

• How often does the

problem occur?

• How distressing is it?

• How many times?

• How long does it last?

Maintaining Factors

• What do you do to cope?

• How helpful is it? (short v. long term)

• What makes the problem better/worse?

• What is keeping the problem going? (Unhelpful thoughts, safety behaviours, avoiding, checking, substance use)

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Video Clip 3: Carl’s Lunch

As you watch this Video (11mins)…

• Write down the 4 stages of guided discovery (Socratic questioning)

• Complete the ‘5 areas’ on your CBT assessment form – situation, thoughts, feelings, behaviour + physical reactions

• What helpful questions did Christine Padesky ask Carl?

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4 Stages of

Guided Discovery‘To find yourself, think for yourself’. Socrates 470-399 BC

1. Ask informational questions ‘So where you when this

happened…?’

2. Listen empathically ‘It sounds like you were really

angry about that….’

3. Summarise frequently ‘Let me see if I’ve got this

right… you felt Charlie was ignoring you..’

4. Synthesise ie help patient put it all together ‘how

does this fit with how you felt? How would you like to

have reacted? Ask, don’t tell!

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The Five Areas Model

Situation

Charlie was 20mins late for lunch

Thoughts

He forgot, he’s ignoring me

People at work think

I’m not important

Physical

reactions

Tight

Not breathing freely

Behaviours

Blew up at him

Got sandwich out of a

machine

Emotions

Angry

Churned up

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Skills Practice 1:

My Journey Here• Work in pairs: ‘patient’ + ‘therapist’ = 5 min interview + 5

mins mutual feedback. Then swap roles = 20 mins total

• Patient: Be guided by therapist. Don’t speak unless prompted

• Therapist: use a collaborative, guided discovery style:

1. Give an introduction: ‘I’d like you to describe your journey to work today (or your last journey), from the moment you woke up till you got here. Is that OK?

2. Focus on one ‘key’ time point. Ask questions about the 5 areas. : situation, thoughts, feelings, behaviours, physical reactions.

3. Summarise what you hear - frequently and at the end

• Feedback: how did it feel using this style? Compare it to your usual approach as a psychiatrist

7676

Video Clip 4:

Guided Discovery

• Sharon is depressed about her job.

• How does this therapist’s style differ from

your own?

• Write down 3 helpful questions that Christine

Padesky asks.

• Anything here you could incorporate into your

daily practice?

Motivational Interviewing: Some Good Questions to Evoke Change

▪ How would you like things to be different? What would be

good things about …….?

▪ What would you like your life to be like 5 years from now?

▪ If you could make this change now by magic, how might

things be better for you?

▪ When else in your life have you made a significant change

like this? How did you do it?

▪ What personal strengths do you have that will help you

succeed in making this change?

▪ Who could offer you support in making this change?

▪ Discuss Pros v cons of

Staying the same v changing (2x2 table) 77

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Skills Practice 2:

My Career• Aims: Practice guided discovery. Build motivation for change

• Work in pairs: 5 mins each then swap

• Help your colleague address one area they are considering

for change in their professional life eg next career ‘move’,

developing a special interest, changing job role, addressing

a conflict or personal dilemma

• Only allowed to do 2 things: ask questions and summarise.

NO direct advice or opinions allowed

• Complete a ‘motivation (2x2) matrix’ : pros v. cons of staying

the same v. change: feedback if time

Summary:

Socratic QuestioningA person is more likely to integrate and accept that which is reached by his own reasoning process” (Miller 1983).

What it is

• An inquisitive questioning style

• Helps them find their own

answers to their problems

• Ask, Listen, Summarise,

Synthesise

• Non-confrontational but skilful

• Non-leading - but has purpose

• Encourages more helpful ways

of thinking & reacting

What it is not

• A therapy ‘prescription’

• Seeking to persuade with

logic or evidence

• Warning of negative

consequences

• Setting a plan without

negotiation

• Arguing, disagreeing,

challenging, interpreting,

criticising or blaming

79

80

Break- 20 mins

What’s New in CBT?2021 Update

• CBT & Covid-19: challenges, delivery

• CBT is a family of therapies, not just one

• CBT really can change your brain

• IAPT expansion (‘LTCs’) – but ½ drop out

• Now recommended for bipolar depression

• Prevents transition to psychosis but ? oversold for psychosis (ES 0.16)

• Mindfulness for ?everything (don’t stop meds)

• The Future: Apps, CCBT, Robot Therapists….NHS Digital Apps Library https://apps.beta.nhs.uk/about-us eg Silver Cloud - more evidence needed

81

CBT Self Help & Apps: 2021 Update

• CBT-based self help is effective in treating and preventing

anxiety & depression, and is significantly better than being on a waiting list . (BMJ 2019, 365, 1947).

• ‘Compelling’ evidence (over 50 RCTs & Meta-analyses eg Delgadillo, J,

2017: Guided Self Help in a Brave New World: BJPsych, 212, 65-66 doi: 10.1192/bjp.2017.17 Effects

vary from small to moderately big - Pooled effect size v. controls (Hedges’ g) = 0.20-0.70

• NICE recommends it (as part of ‘stepped care’) for unipolar

depression, panic disorder, social anxiety, bulimia, insomnia

• Guided self help (professional-assisted) more

effective than unguided self help. ‘Help’ = as little as 2 hrs contact over 3 months total, minimises client

drop out. Includes: Phone, group psycho-ed classes, web based chat, book, computer (MoodGym) Face

to face CBT has fewer drop outs than phone or computer based.

• Apps – need more evidence eg Silver Cloud . See NHS Digital Apps

Library https://apps.beta.nhs.uk/about-us

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Books on CBT

• Introductory books for Professionals

1. Westbrook, D., Kennerley, H. & Kirk, J. (2007). An Introduction to CBT. London: Sage Publications.

2. Blenkiron P. (2010) Stories & Analogies in CBT. Wiley-Blackwell http://www.amazon.co.uk/Stories-Analogies-Cognitive-Paul-Blenkiron/dp/047005896X/ref=sr_1_4?ie=UTF8&s=books&qid=1242745779&sr=8-4

3. David, L. (2006) Using CBT in General Practice: The 10 Minute Consultation. Scion.

• CBT books for the Public

1. Greenberger, D. & Padesky, C.A. (2015). Mind over Mood. Guilford.

2. Williams, C. (2012). Overcoming Depression: a Five Areas Approach. London: Arnold. Also Overcoming Anxiety, Stress & Panic (2012)

• Reading Well - National Books on Prescription Scheme

http://readingagency.org.uk/adults/quick-guides/reading-well/ core list of 30 expert-endorsed CBT self help books

8484

‘Books On Prescription’

Scheme for Englandhttps://reading-well.org.uk/

• Four expert-endorsed book lists (each with 30 titles) - freely available in 97% public libraries:1. Adult Mental Health ( 2013, updated 2018)

2. Dementia/Carers (2015)

3. Young People (12-18 years, 2016)

4. Physical Health (Long Term Conditions, 2017)

5. Children ( age 7 to 11) and Families (2019)

• Aim to help people understand & manage common mental health conditions (esp. guided self help): CBT-based & working within NICE guidelines

• Key Partners: The Reading Agency charity, Society of Chief Librarians, Arts Council,RCPsych, BPS, RCGPs, RCN, IAPT, BABCP, MIND, Young MINDs

Introduction to CBT Paul Blenkiron85

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8 Great CBT Websites 2020

• Free Web-based CBT self help programmes: http://www.livinglifetothefull.comhttp://moodgym.anu.edu.au

http://mindfulnessforstudents.co.uk/resources/

• Free patient information on CBT/mental disorders:

http://www.rcpsych.ac.uk/mentalhealthinfo UK College website

http://www.ntw.nhs.uk/pic Northumberland Tyne & Wear self help booklets

http://www.getselfhelp.co.uk/ Great CBT resources from one therapist

http://readingagency.org.uk/adults/quick-guides/reading-well/National Books on Prescription Scheme 30 self help CBT Books endorsed by experts

NHS Digital Apps Library https://apps.beta.nhs.uk/about-us

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CBT Quiz

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Quiz: Psychotherapy

1. Name 5 characteristics that all

psychotherapies hold in common….

90

Quiz: NICE

2. List 5 psychotherapies that are

promoted in current NICE guidelines….

91

Quiz: What is CBT?

3. True or false? The following are core characteristics of CBT as a therapy…

a) interpretation of thoughts and feelings

b) homework between sessions

c) testing out beliefs in reality

d) a collaborative approach

e) patient writes down/ records learning

92

Quiz: Suitability

4. True or false? The following suggest a patient is less likely to be suitable for CBT...

a) Unable to concentrate

b) Mild learning disability

c) Age over 75

d) Tends to intellectualise problems

e) Consumes over 50 units of alcohol a week

93

Quiz: CBT in Practice

5. True or false? A good cognitive behavioural

therapist will …

a) directly challenge a patient’s negative thoughts

b) directly answer some questions

c) always complete the formulation by session 4

d) work on core beliefs before tackling maintaining

thoughts and behaviours

e) limit short term CBT to 20 sessions maximum

94

Quiz: Guided Discovery

6. a) Name 4 stages in guided discovery…

b) Which Greek philosopher taught that

the answers to important questions lie

within ourselves?

95

Quiz: The CBT Family

7. True or False: The following are types of

CBT….

a) Schema Mode Therapy

b) Mindfulness

c) Compassionate Mind Therapy

d) Rogerian Therapy

e) Human Givens Approach

96

Quiz: CBT Outcomes

8. Evidence has shown that an improved

outcome in CBT is associated with:

a) the patient doing ‘homework’

b) the skill & experience of the therapist

c) face to face CBT (rather than pure self help)

d) being flexible in each session rather than

following a structure

e) having an Axis 1 mental disorder rather than a

dual diagnosis/personality disorder

97

CBT Quiz: Answers

Q1. All psychotherapies involve:– Talking (therapeutic conversation)

– Therapeutic relationship/alliance

– Exchange of information

– Instillation of hope

– Therapeutic rationale/explanation

– Ventilation of emotion

– Regular meetings time/place

– Aiming for change (at some level)

– Active rather than passive engagement

Max = 5 points

98

CBT Quiz: Answers

Q2. NICE guidelines support the following types of psychotherapy:

• CBT (many types, eg individual, group, computerised, ERP for OCD,

trauma focussed for PTSD, CBT for eating disorders, mindfulness)

• Behavioural activation (depression)

• Behavioural couples therapy (depression)

• Interpersonal therapy (IPT)

• Counselling (depression)

• Short-term psychodynamic therapy (depression)

• Family therapy (anorexia) + interventions (schizo)

• ‘Psychoanalytical principles’ (schizo)

• Art therapy (schizo)

• Dialectical behaviour therapy (DBT for BPD)

• Peer support programmes (physical illness)

• Motivational interviewing (substance misuse, young p.)

• Problem solving (self harm)

Max = 5 points

99

CBT Quiz: Answers

Q3: What is CBT? FTTTT ‘Interpretation’ = dynamic

Q4: Suitability: TFFTT Age & IQ are no bar

Q5: A good therapist: FTFFT

Q6: Guided discovery a) Ask Qs, listen, summarise, synthesise b) Socrates

Q7: CBT Family: TTTFF

Q8: Outcome: TTTFT Add up your score (out of 40)

100

Workshop Evaluation

• Please complete the Feedback Forms….

• You will then receive an attendance

certificate

101

Homework

• Review through today’s workshop slides (e-mailed) and your notes

• Reflect: What have you learned? How could it change your practice?

• Reinforce: Practice taking a history using the 5 areas approach from a patient in your work

• Read this useful article about basic CBT

skills: https://doi.org/10.1136/bmj.l5360 Brief behaviour

change strategies for distressed patients: Gumm et al,

BMJ 24 Sept 2019; 366:15360 (See infographic at end of this talk)

Further CBT Training

• The BABCP has a list of UK CBT training

courses

• BABCP Careers Guide [PDF]

• http://www.babcp.com/Training/Training.aspx

• Level 2 Course Accreditation: course has been assessed as providing training to the

standards for BABCP Accreditation (no. of training hours , supervision, no of assessed cases , other criteria)

• Level 1 Course Accreditation: course has been assessed as providing training to the

quality standards for Accreditation but does not cover the full requirements – further training required

• Advertised Courses: these are not endorsed by BABCP but are accepted for advertising

102

103

The End

Thank you

[email protected] @PaulMindDoctor

Additional Slides not in

Workshop

104

Behaviour

Change:

Basic CBT

Skills

See:

BMJ 24 Sept

2019;

366:15360,

doi:

https://doi.org

/10.1136/bmj.l

5360

Brief

behaviour

change

strategies

for

distressed

patients

in

primary care

.

.

.

.

.

.

Remote Consultations

106

What is DBT?Dialectical Behaviour Therapy

• DBT is a 3rd Generation Type of CBT: focus on resolving contradictions, acceptance as well as change

• Effective for EUPD (borderline PD): reduces self harm, anger, depression, drug misuse, increases distress

tolerance, self esteem & social adjustment, mindfulness, ability to manage rapid mood swings, interpersonal effectiveness (Linehan 1993 & 17 RCTs, NICE)

• Comprises 1:1 therapy: chain analysis of problem behaviour plus skills training group weekly 2.5 hrs with homework and review. ?phone consultation in working hrs. Promotes 4 'TIPP' skills to use instead of self harm when angry/emotionally aroused T= temperature

(tipping the temp of face with cold water (hold breath + put face in bowel of cold water for 30-60 secs, or splash cold water on face or use cold compress/ice pack - induces diving reflex

+ reduces HR. Works quickly, better than self harm (caution in anorexia) b) I= Intense aerobic exercise 20 mins c) P= Paced breathing (slow abdo 6/min) d) Paired muscle relaxation

(similar to Progressive MR).

• PDs in CMHTs: use ‘Structured Clinical Management’ Key elements (as

effective alone as DBT or other therapies for PD, Davison 2016?) = reliable appts (assertive follow up reason for DNAs), 3/12 reviews, clear short & long term goals, a collaborative care

plan, a detailed crisis plan. Then prep for DBT skills or full package DBT includes grounding/ safe place techniques. Be aware of the 'Drama triangle‘ The Persecutor (‘Its all your fault’),

Victim (‘Poor me’) & Rescuer (‘let me help you’)

• NB EUPD = ‘FRIED’(Feelings of abandonment, relationship difficulties, Identity issues, emotional dysregulation, deliberate self harm) VERSUS

• Complex PTSD = ‘RAH’ + ‘END’ (Re-experiencing, Avoidance, Hyperarousal) + )Emotional dysregulation = severe &

pervasive problems in affect regulation + Negative self-concept = persistent beliefs about self as diminished, defeated or worthless + Disturbed relationships: feeling cut off/distant

persistent difficulties in sustaining relationships/feeling close to others) Distinct but can overlap: 25% CPTSD cases have BPD (Bisson J, 2019).

CPTSD commoner than PTSD. See NICE https://www.nice.org.uk/guidance/ng116/chapter/recommendations#complex-ptsd & World Health Organisation (WHO): International

………..Classification of Diseases, 11th Revision 2018. Starts 1.1.22 https://www.who.int/classifications/icd

CBT in Older Age: Myths

• It must be terrible getting old (cultural assumptions)

• Older people don’t want therapy (ask them, explain CBT properly)

• If I had those problems, I’d be depressed too (is everyone with poor physical health/age over 75/living alone depressed?)

• CBT can’t make much of a difference to older

people’s lives (no evidence for an age cut off for CBT efficacy)

• You can’t teach an old dog

new tricks (What age were you when you stopped learning things?

eg radio, TV recall this week? How would you have coped with these problems when

…………………………………………………………………………………..you were 30?)

• See https://www.bcmj.org/articles/cognitive-behavioral-therapy-older-adults

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CBT in Older Age:

Adaptations

• Intergenerational attitudes: ‘doctor knows best’

v CBT self help (‘gym trainer analogy’)

• IT skills: paper v. smart phone apps ( either is fine)

• Physical comorbidity: arthritis, poor sight, CVA

• Patient story-telling: agree to interrupt!

• Memory problems: CBT possible if mild cognitive impairment, contraindicated in

delirium or significant dementia: use frequent repetitions, pictures, keep it simple, homework folder, record

sessions, relatives as co therapists, focus on doing (BA) and recording goals

• Ref CBT with Older People. Laidlow et al , Wiley, 2003109

CBT in Old Age:

The Big Picture

110

111

I Can’t do CBT –

I’m a Psychiatrist!

• Thought: ‘I can’t do CBT. I’ve no time or

skills to fit CBT into my busy job. It’s just

not practical…’

• Brainstorm practical ways of introducing

CBT ideas and techniques to your patients

within your daily work as a psychiatrist (without

referring to a psychologist!)

112

I Can’t do CBT…. Or Can I? Options for Busy Jobbing Psychiatrists

CBT Skills

• Take basic psychiatric history differently (eg 5 systems, maintaining cycles, summarise frequently)

• Keep it simple + practical: 1 or 2 ‘SMART’ targets, 1 or 2 ways of thinking differently, here and now

• Work with whatever the patient finds helpful / memorable – metaphors, life events, humour

• Draw biological ideas into formulation (physical Sx, drugs, neurotransmitters)

• Set homework to return or post: show a selective interest in it on review (‘Show me one thing you found useful/learned’)

Time Management

• Support, ‘start off’ or supervise CBT done by others eg CMHT worker, named IP nurse, psychologist, IAPT, core trainee

• Use CBT techniques, not ‘full’ CBT package

• Use self help as ‘co-therapist’: computer/website/books/phone calls/patient records sessions to playback

• Encourage patients to record learning in personal book (in & between meetings) and for ‘relapse prevention’

Communication

• Explain depression + promote CBT eg RCPsych leaflets, NICE User-Carers Guides

• Draw simple diagrams in clinic or ward meetings, agreed with and handed to patients

• Use handouts eg common thinking styles, diary, info paper or e-mail to patients

• Write down main points for patient at end of conversation as a ‘prescription’ TTO

• Copy letters to patients containing ‘formulation’ or ‘vicious circle’ and reinforcing homework tasks

Attitudes

• Have faith in what you do: cite evidence base/NICE/personal successes

• Don’t get drawn into therapeutic nihilism by patients

• Don’t assume patients have tried CBT previously or that ‘CBT doesn’t work for me’

• Remember your unique skills as consultant: psychiatrist: biopsychosocial, holistic care

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Summary:

CBT in Practice

CBT

Changing behaviour, thoughts, feelings Education, Socratic Qs, Paradoxical Qs, define problem, goals, motivation,

metaphor, story, experiments

Reinforce Message

Ask Patient to summarise

Self Help info, homework

Review LaterTrouble shoot blocks

What have you learned?

Write it down!

Involve OthersMDT professionals,

family, friends