I was quite surprised with the creativeness of the article published on the Guardian last September 9th 2008 by Darian Leader. Slightly disappointed with the fact that readers are not able to comment on the article. Don't take me wrong, although it's nicely written, with points, ideas and even references to historical figures that make history sound something really funny and interesting, his knowledge of CBT is futile, shallow and deserves a profound need of appropriate education.
Anyway... I won't bore you readers with the actual facts of how CBT works and what it really means, because this has already been extensively discussed elsewhere.
A few points to consider, however with regards to this particular article is the misunderstanding that CBT is interested merely in the reduction of symptoms. Let me frame it once and for all that CBT is interested in supporting people, from all backgrounds, in developing behavioural and cognitive repertoire that are functional, helpful, and supportive for minimising human suffering, thus in many ways improving people's quality of life. That may or may not be necessarily linked to the reduction of symptoms!
Let's not create confusion between measuring outcomes for the sake of it, and measuring outcomes as a way to improve patient care and to give direction to therapy, which is often something forgotten in less evidence-based psychotherapy models. Behavioural psychology is scientifically based, because it is scientific, testable, and interested in prioritising what works over what doesn't.
On top of all that, I think Darian Leader misleads readers to believe there is only one type of CBT. Cognitive Behavioural Psychotherapy is a broad term referred to more than 20 individual models of CBT, where each one of them has a certain defined characteristic. The Aaron Beck's 'Cognitive Therapy' (60's-till today) is very different than the more philosophically based Albert Ellis work on 'Rational-Emotive Behaviour Therapy' for instance. Furthermore, we have other models which are more mindfulness-based like the 'Acceptance and Commitment Therapy' of Hayes et al. and the 'Mindfulness-based Cognitive Therapy' of Segal et al. The latter models are considered the third wave of cognitive and behavioural psychotherapy, where the reduction of symptoms is not a priority, but refers to the contextual understanding of mental health (please see Relational Frame Theory, by Hayes et al. 1999 for details).
CBT is a big umbrella term for all types of Behavioural and Cognitive Psychotherapies, and some therapists even prefer to use its therapies in a eclectic and integrative way, rather than rigidly focused on one particular model. Some are more behavioural, some more cognitive based. Although recent findings do point out to the importance of behavioural components over cognition, as well as the impact of metacognition on quality of life and mental health (Wells et al.)
The CBT community is rather disappointed -obviously - with articles like this that seem to really miss the bigger picture. The IAPT (Improving Access to Psychological Therapies) programme is not just benefiting CBT. I for instance for a service that is receiving government funding for the provision of all types of counselling and psychotherapy models. The Department of Health has become, nevertheless, more vigilant with regards to making sure these services are evaluating outcomes, and I do agree that a more flexible system for evaluating outcomes should be put in place.
My invitation is that we therapists start working together into ameliorating our protocols for helping people live more vital lives, not necessarily without symptoms, as Darian Leader suggests CBT does - rather wrongly, for the reasons stated in this article. So we ought to be working together without being personal about the fact that Evidence-based treatments, i.e. treatment protocols that work for improving patient care will receive more funding (especially within the NHS) than those which don't.
And if we can, once and for all, understand that CBT is not just the well propagated Cognitive Therapy by Dr. Aaron Beck; then we will start really progressing at adequately transforming people's lives through the use of legitimate and evidence-based journalism!
Thursday, 11 September 2008
Issues surrounding the IAPT's Programme
Some of you have probably heard of the 'Improving Access to Psychological Therapies Programme' set out by the Department of Health. This morning I had the pleasure to hear journalist Kati Whitaker from BBC Radio 4 (Woman's Hour) investigating Government's plan to make Cognitive Behavioural Therapy (CBT) more widely available. The IAPT Programme aims to help nearly a million of patients who suffer with depression and anxiety. Following successful NHS pilot schemes in Doncaster and Newham (east London), programmes are being set up in twenty new areas - and three and a half thousand new CBT therapists are being recruited.
The programme unveiled not only advantages of the IAPT but focused also on the issues surrounding the scheme, including the suspicion by experts and academics that the most vulnerable patients will lose out on the access to vital drugs and highly qualified counsellors.
The 29-year-old Kate had been suffering from depression since her early years at university. She had seen counsellors and GP's in surgeries that as she mentions tended to focus on the why's and meanings for her depression but that she claimed were not enough to 'move her forward'. It was not until she had received CBT in combination with drug therapy that she had experienced improvements in her symptoms.
Professor John Taylor, president of the BABCP, shows his appreciation for the Government's scheme to make CBT more widely available and explains on a nutshell the principles of CBT as method for clinical intervention.
The interview continues by exploring what other experts in the field of Psychotherapy are saying about this scheme. Andrew Samuels, Professor of Analytical Psychology at University of Essex, calls for re-evaluation of how these schemes are being administered and adds his perspective that other Psychotherapeutic models may serve better patients whose problems are more deep-rooted and past oriented, as opposed to what he says is the core of CBT intervention: the here and now. He also shows his concern about the most vulnerable people receiving on the 'cheap' psychological therapies by professionals who receive very little and quick training.
On the issue exposed by Professor Andrew Samuels, experts disagree that CBT is based only on the here and now, and urge that this simplistic view of CBT be challenged. In e-mail exchange (BABCP at Jiscmail.ac.uk) Professor Stephen Palmer, PhD, adds that: "The working in the 'present' aspect being portrayed negatively by others means that they avoid mentioning that we look at beliefs which developed historically. Perhaps BABCP could issue a press release or two explaining that complex cases may involve more than just a chat about the here and now!"
Some other experts suggest that there should be flexibility on the system, and that improvements ought to be made in the delivery of a broad range of services, that aren't just CBT based. A rather difficult task, in my view, since the National Institute for Health and Clinical Excellence (NICE) seems to be very much centred on CBT approaches in the deliverance of Psychological therapies for the treatment of most Anxiety disorders and Depression as well as more complex disorders even.
In discussion with colleagues at St Thomas Hospital (London) it is clear that the NICE Guidelines are recommendations based on research that focus on the efficacy of Psychological treatments in the various areas they propose CBT works efficiently. Nevertheless it is important to be said that the argument in favour of CBT is not only based on the assumption that this is the case because the model is relatively cheaper and briefer than other Psychological therapies, but that most of the research at present seems to be CBT oriented. The answer to the problem, one would assume, is that other schools of Psychological therapies ought to be engaged in more evidence based research methodologies to account for the efficiency of their Psychotherapeutic models, and in so doing, making sure that attention is directed towards these findings.
The programme at BBC Radio 4 continues by giving a brief explanation of self-help computerised CBT programmes (like Beating the Blues). Professor John Taylor shows his understanding on the subject and compares the importance of these with other self-help materials like books and tapes as way to help people alleviate their symptoms. Research suggest, however, that these methods may only be suitable to help people suffering from mild-moderate depression and so complex cases ought to be accompanied by the intervention of fully qualified professionals.
At the end of the programme Kati Whitaker refers to widespread application of CBT, and that recently research has suggested that CBT can also be very effective in helping people to manage to cope with more physical symptoms (for example diabetes, irritable bowel syndrome, fibromyalgia, etc).
The programme was presented by Jane Garvey at BBC Radio 4 on 18/02/08 for those of you would like to hear it again on their website.
The programme unveiled not only advantages of the IAPT but focused also on the issues surrounding the scheme, including the suspicion by experts and academics that the most vulnerable patients will lose out on the access to vital drugs and highly qualified counsellors.
The 29-year-old Kate had been suffering from depression since her early years at university. She had seen counsellors and GP's in surgeries that as she mentions tended to focus on the why's and meanings for her depression but that she claimed were not enough to 'move her forward'. It was not until she had received CBT in combination with drug therapy that she had experienced improvements in her symptoms.
Professor John Taylor, president of the BABCP, shows his appreciation for the Government's scheme to make CBT more widely available and explains on a nutshell the principles of CBT as method for clinical intervention.
The interview continues by exploring what other experts in the field of Psychotherapy are saying about this scheme. Andrew Samuels, Professor of Analytical Psychology at University of Essex, calls for re-evaluation of how these schemes are being administered and adds his perspective that other Psychotherapeutic models may serve better patients whose problems are more deep-rooted and past oriented, as opposed to what he says is the core of CBT intervention: the here and now. He also shows his concern about the most vulnerable people receiving on the 'cheap' psychological therapies by professionals who receive very little and quick training.
On the issue exposed by Professor Andrew Samuels, experts disagree that CBT is based only on the here and now, and urge that this simplistic view of CBT be challenged. In e-mail exchange (BABCP at Jiscmail.ac.uk) Professor Stephen Palmer, PhD, adds that: "The working in the 'present' aspect being portrayed negatively by others means that they avoid mentioning that we look at beliefs which developed historically. Perhaps BABCP could issue a press release or two explaining that complex cases may involve more than just a chat about the here and now!"
Some other experts suggest that there should be flexibility on the system, and that improvements ought to be made in the delivery of a broad range of services, that aren't just CBT based. A rather difficult task, in my view, since the National Institute for Health and Clinical Excellence (NICE) seems to be very much centred on CBT approaches in the deliverance of Psychological therapies for the treatment of most Anxiety disorders and Depression as well as more complex disorders even.
In discussion with colleagues at St Thomas Hospital (London) it is clear that the NICE Guidelines are recommendations based on research that focus on the efficacy of Psychological treatments in the various areas they propose CBT works efficiently. Nevertheless it is important to be said that the argument in favour of CBT is not only based on the assumption that this is the case because the model is relatively cheaper and briefer than other Psychological therapies, but that most of the research at present seems to be CBT oriented. The answer to the problem, one would assume, is that other schools of Psychological therapies ought to be engaged in more evidence based research methodologies to account for the efficiency of their Psychotherapeutic models, and in so doing, making sure that attention is directed towards these findings.
The programme at BBC Radio 4 continues by giving a brief explanation of self-help computerised CBT programmes (like Beating the Blues). Professor John Taylor shows his understanding on the subject and compares the importance of these with other self-help materials like books and tapes as way to help people alleviate their symptoms. Research suggest, however, that these methods may only be suitable to help people suffering from mild-moderate depression and so complex cases ought to be accompanied by the intervention of fully qualified professionals.
At the end of the programme Kati Whitaker refers to widespread application of CBT, and that recently research has suggested that CBT can also be very effective in helping people to manage to cope with more physical symptoms (for example diabetes, irritable bowel syndrome, fibromyalgia, etc).
The programme was presented by Jane Garvey at BBC Radio 4 on 18/02/08 for those of you would like to hear it again on their website.
Acceptance and Mindfulness
I would like to share with you all a very challenging experience I had in the past few weeks. I was getting caught up in the webs of the big spider I call 'the mind' and suddenly I saw myself immersing in this sadness and frustration that I didn't know much of. At work and in my personal life I am usually the support my clients and close friends will turn to for advice and psychological intervention. However at this time, it was me, and me only that was sitting on the chair in front of my mind's eye. In sorrow for god knows what, I distracted myself with every second, resisting to accept my frustration and sadness. It was clear I was having one of 'those days' but like most of us it took me a little while to find the right way out of there, or may I say the 'way in'.
If you have not heard of Mindfulness yet, get used to it because this seems to be where a new wave of cognitive behavioural therapy is leaning towards. In a nutshell the idea is to:
1 - Accept your reactions and be present
2 - Choose a valued direction
3 - Take action
(Acronym ACT borrowed from Acceptance and Commitment Therapy)
What i meant to say with 'finding the way in' was basically what I tried yesterday with great success. In talks with a good friend of mine, who lives with me, I realised that only through living that frustration and sadness deeply I would be able to understand it fully. So whilst traditional CBT aims at disputing negative thinking and expanding horizons through the practice of more helpful behaviours, mindfulness is all about being present with our deepest emotions and fears. And so let's have a have look at what FEAR really means in the eyes of ACT theory:
Fusion with your thoughts
Evaluation of experience
Avoidance of your experience
Reason giving for your behavior
Similarly I found that through my work of coaching pscyhology the acronym FEAR is seen not very differently: False Evidence Appearing Real.
The point is I was fearing to sit with my struggling frustration and sadness (independent to what these were refering to). I had the belief that I had to do something about them, rather than to sit with them and listen to how they really felt within my being. So I stopped watching videos, reading books, and exploring techniques to distract my experience, and prepared myself for something really great: sitting with the frustration and sadness that was in me. i did not want to know where it came from or why I was feelng like that anymore. I stopped ruminating over the analytical and instead I stood right in the middle of it. I had a nice shower, put all the lights of my room off, and lied on my back in bed with my arms away from my body and my legs away from each other. I relaxed my whole body and became aware of how it felt to be me with all that frustration and sadness that was there as well. i did not challenge the experience at all. I let go of the disputing of my irrational beliefs or the contents of my cognitive material, and simply allowed myself to experience the emotion. A simple decision and twenty minutes of revelation. I rolled to the side, closed my eyes and slept through the night.
The result was waking up feeling much better, looking forward to continuing my day and planning to share with you this experience that has been of great value to me.
Suddenly I am here now, aware of the results of therapy that I did on my own, as part of personal development and self-discovery, and glad I feel strong enough and transparent enough to share these with you.
Valuable things I take from this experience:
1 - To let go of the pain, sit with the pain
2 - Good coping comes with good accepting
3 - Effective therapy can only be achieved when we ourselves need it too.
Reading:
Hayes, Steven C.; Spencer Smith (2005). Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy. New Harbinger Publications. ISBN.
Hayes, Steven C.; Kirk D. Strosahl (2004). A Practical Guide to Acceptance and Commitment Therapy. Springer. ISBN.
Hayes, Steven C.; Kirk D. Strosahl, Kelly G. Wilson (2003). Acceptance and Commitment Therapy : An Experiential Approach to Behavior Change. The Guilford Press. ISBN.
If you have not heard of Mindfulness yet, get used to it because this seems to be where a new wave of cognitive behavioural therapy is leaning towards. In a nutshell the idea is to:
1 - Accept your reactions and be present
2 - Choose a valued direction
3 - Take action
(Acronym ACT borrowed from Acceptance and Commitment Therapy)
What i meant to say with 'finding the way in' was basically what I tried yesterday with great success. In talks with a good friend of mine, who lives with me, I realised that only through living that frustration and sadness deeply I would be able to understand it fully. So whilst traditional CBT aims at disputing negative thinking and expanding horizons through the practice of more helpful behaviours, mindfulness is all about being present with our deepest emotions and fears. And so let's have a have look at what FEAR really means in the eyes of ACT theory:
Fusion with your thoughts
Evaluation of experience
Avoidance of your experience
Reason giving for your behavior
Similarly I found that through my work of coaching pscyhology the acronym FEAR is seen not very differently: False Evidence Appearing Real.
The point is I was fearing to sit with my struggling frustration and sadness (independent to what these were refering to). I had the belief that I had to do something about them, rather than to sit with them and listen to how they really felt within my being. So I stopped watching videos, reading books, and exploring techniques to distract my experience, and prepared myself for something really great: sitting with the frustration and sadness that was in me. i did not want to know where it came from or why I was feelng like that anymore. I stopped ruminating over the analytical and instead I stood right in the middle of it. I had a nice shower, put all the lights of my room off, and lied on my back in bed with my arms away from my body and my legs away from each other. I relaxed my whole body and became aware of how it felt to be me with all that frustration and sadness that was there as well. i did not challenge the experience at all. I let go of the disputing of my irrational beliefs or the contents of my cognitive material, and simply allowed myself to experience the emotion. A simple decision and twenty minutes of revelation. I rolled to the side, closed my eyes and slept through the night.
The result was waking up feeling much better, looking forward to continuing my day and planning to share with you this experience that has been of great value to me.
Suddenly I am here now, aware of the results of therapy that I did on my own, as part of personal development and self-discovery, and glad I feel strong enough and transparent enough to share these with you.
Valuable things I take from this experience:
1 - To let go of the pain, sit with the pain
2 - Good coping comes with good accepting
3 - Effective therapy can only be achieved when we ourselves need it too.
Reading:
Hayes, Steven C.; Spencer Smith (2005). Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy. New Harbinger Publications. ISBN.
Hayes, Steven C.; Kirk D. Strosahl (2004). A Practical Guide to Acceptance and Commitment Therapy. Springer. ISBN.
Hayes, Steven C.; Kirk D. Strosahl, Kelly G. Wilson (2003). Acceptance and Commitment Therapy : An Experiential Approach to Behavior Change. The Guilford Press. ISBN.
'What's going through my head?"
Last night we got into a very interesting discussion after seeing Christine Padesky's performance on video. We got a good feel on how to conduct Cognitive Therapy, and it is indeed quite magical the way she conducts the session. Very flowing.
It seems however the issues that the client was bringing to the session raised a few reactions from the group watching it. Some thought the client's problems were not really 'pathological' and in anyway different from problems that we all face 'normally' from time to time. Others felt the need to share thoughts on the experience of pain, suffering and emotional disturbance, to say ultimately, I guess, that not everything in life is seen by people in the same way. In other words, what appears to be a problem for X may not be a problem for Y.
There are few lessons we can extract from this: A) that when a client does come with a problem and searches for help to go through this, we need to let go of our personal belief systems, yet making recognition of them, and working with them, to best serve the client's need. Emotional pain cannot be measured, and indeed what somebody might consider a problem, somebody else might work very effectively around it. B) that from time to time, we 'therapists', will bring our own baggage and belief systems to therapy in response to client's experience of pain and suffering, and that this isn't necessarily wrong or right, but just one more process, that we can build on, in order to be able to deliver to clients the support they need.
'What's going through my head?' is an interesting question that we have to bring to the therapeutic process if we really want to overcome personal beliefs and limitations, for the purposes of greater therapeutic alliance and keep therapy effective."
It seems however the issues that the client was bringing to the session raised a few reactions from the group watching it. Some thought the client's problems were not really 'pathological' and in anyway different from problems that we all face 'normally' from time to time. Others felt the need to share thoughts on the experience of pain, suffering and emotional disturbance, to say ultimately, I guess, that not everything in life is seen by people in the same way. In other words, what appears to be a problem for X may not be a problem for Y.
There are few lessons we can extract from this: A) that when a client does come with a problem and searches for help to go through this, we need to let go of our personal belief systems, yet making recognition of them, and working with them, to best serve the client's need. Emotional pain cannot be measured, and indeed what somebody might consider a problem, somebody else might work very effectively around it. B) that from time to time, we 'therapists', will bring our own baggage and belief systems to therapy in response to client's experience of pain and suffering, and that this isn't necessarily wrong or right, but just one more process, that we can build on, in order to be able to deliver to clients the support they need.
'What's going through my head?' is an interesting question that we have to bring to the therapeutic process if we really want to overcome personal beliefs and limitations, for the purposes of greater therapeutic alliance and keep therapy effective."
Role of Empathy in Patient Care
The Role of Empathy in Patient Care
This a paper I wrote about a few recent findings in Psychology that I thought would be interesting to share with you.
--------------------------------------------------------
The role of empathy in patient care: physician-patient communication as a key factor to management of disease and patient compliance.
Vitor Borges Friary, BSc
Psychology Student
Department of Haematology, St. Thomas’ Hospital, London, UK
October 8, 2007
Recent fMRI research findings suggest that doctors control their own brains’ pain responses to treat their patients (Cheng et al., 2007). Professor in Psychology and Psychiatry, Jean Decety and colleagues from the University of Chicago, report that apparently physicians learn to “shut off” the portion of their brain that helps them appreciate the pain their patients experience while treating them and instead activate a portion of the brain connected with controlling emotions. For Decety, this new study casts light on the mechanisms involved in empathy and empathic concern. In the interest of health psychology this could lead us to a better understanding of the processes of physician-patient relationship and their various dynamics, from diagnosis and assessment of pain to treatment planning, and ultimately how these influence on the overall management of disease.
Some studies have focused on the relationship between physician-patient communication and adherence to antiretroviral treatment (Herrera et al, 2004), and results suggested that overcoming these communication barriers is essential to ensure optimal treatment outcomes. Another recent study show that Patients with advanced cancer often suffer from untreated psychiatric disorders. Dr. Michael Miovic and Dr. Susan Block from the Dana Farber Cancer Institute and Brigham and Women's Hospital in Boston review the published literature of psychiatric illnesses in cancer patients. They found that 50 percent or more of patients with advanced or terminal cancer suffer from at least one of three major psychiatric disorders: adjustment disorders, anxiety disorders and depressive disorders. These disorders have distinct symptoms that oncologists can screen for and manage through medications or referral to mental health professionals and/or support groups.
These findings suggest that empathic communication between physicians and patients is a key factor in the deliverance of good patient care, and point out to the importance of tackling these difficulties as a way to insure professional mental health support is both delivered and appropriately sustained. In fact, as some other recent researches show, improving physician empathic communication skills should increase patient satisfaction and compliance (Kim et al., 2004). Health providers who wish to improve patient satisfaction and compliance should first identify components of their empathic communication needing improvement and then try to refine their skills to better serve patients.
REFERENCES
Cheng et al., Expertise Modulates the Perception of Pain in Others, Current Biology (2007), doi:10.1016/j.cub.2007.09.020
Michael Miovic, Susan Block (2007) Article: "Psychiatric Disorders in Advanced Cancer," CANCER; Published Online: September 10, 2007 (DOI: 10.1002/cncr. 22980); Print Issue Date: October 15, 2007.
Herrera C, Caballero M, Campero L, Kendall T. Int Conf AIDS. 2004 Jul 11-16; 15: abstract no. MoOrD1086. National Institute of Public Health, Cuernavaca, Mexico
Kim S. S., Kaplowitz, S., Johnston, M. V. (2004). Evaluation & the Health Professions, Vol. 27, No. 3, 237-251 DOI: 10.1177/0163278704267037, Sage Publications, US.
This a paper I wrote about a few recent findings in Psychology that I thought would be interesting to share with you.
--------------------------------------------------------
The role of empathy in patient care: physician-patient communication as a key factor to management of disease and patient compliance.
Vitor Borges Friary, BSc
Psychology Student
Department of Haematology, St. Thomas’ Hospital, London, UK
October 8, 2007
Recent fMRI research findings suggest that doctors control their own brains’ pain responses to treat their patients (Cheng et al., 2007). Professor in Psychology and Psychiatry, Jean Decety and colleagues from the University of Chicago, report that apparently physicians learn to “shut off” the portion of their brain that helps them appreciate the pain their patients experience while treating them and instead activate a portion of the brain connected with controlling emotions. For Decety, this new study casts light on the mechanisms involved in empathy and empathic concern. In the interest of health psychology this could lead us to a better understanding of the processes of physician-patient relationship and their various dynamics, from diagnosis and assessment of pain to treatment planning, and ultimately how these influence on the overall management of disease.
Some studies have focused on the relationship between physician-patient communication and adherence to antiretroviral treatment (Herrera et al, 2004), and results suggested that overcoming these communication barriers is essential to ensure optimal treatment outcomes. Another recent study show that Patients with advanced cancer often suffer from untreated psychiatric disorders. Dr. Michael Miovic and Dr. Susan Block from the Dana Farber Cancer Institute and Brigham and Women's Hospital in Boston review the published literature of psychiatric illnesses in cancer patients. They found that 50 percent or more of patients with advanced or terminal cancer suffer from at least one of three major psychiatric disorders: adjustment disorders, anxiety disorders and depressive disorders. These disorders have distinct symptoms that oncologists can screen for and manage through medications or referral to mental health professionals and/or support groups.
These findings suggest that empathic communication between physicians and patients is a key factor in the deliverance of good patient care, and point out to the importance of tackling these difficulties as a way to insure professional mental health support is both delivered and appropriately sustained. In fact, as some other recent researches show, improving physician empathic communication skills should increase patient satisfaction and compliance (Kim et al., 2004). Health providers who wish to improve patient satisfaction and compliance should first identify components of their empathic communication needing improvement and then try to refine their skills to better serve patients.
REFERENCES
Cheng et al., Expertise Modulates the Perception of Pain in Others, Current Biology (2007), doi:10.1016/j.cub.2007.09.020
Michael Miovic, Susan Block (2007) Article: "Psychiatric Disorders in Advanced Cancer," CANCER; Published Online: September 10, 2007 (DOI: 10.1002/cncr. 22980); Print Issue Date: October 15, 2007.
Herrera C, Caballero M, Campero L, Kendall T. Int Conf AIDS. 2004 Jul 11-16; 15: abstract no. MoOrD1086. National Institute of Public Health, Cuernavaca, Mexico
Kim S. S., Kaplowitz, S., Johnston, M. V. (2004). Evaluation & the Health Professions, Vol. 27, No. 3, 237-251 DOI: 10.1177/0163278704267037, Sage Publications, US.
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