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Volume 46 Number 4 • December 2018 Beet the stress and make thyme for you - Page 16
BABCP
Imperial House, Hornby Street, Bury BL9 5BN
contents
Tel: 0161 705 4304
Email: babcp@babcp.com
www.babcp.com
Main Feature
Volume 46 Number 4
December 2018
“
Welcome to the final issue of the year. I hope that 2018
has been a good year and you are looking forward to
the new year, as we are.
As always, we have a range of interesting articles
16 Beet the stress and make
thyme for you
Gardening to relieve stress
from the world of CBT, with our main feature on Features
gardening as a stress buster my particular favourite.
I enjoy getting to spend time in the garden, it is so 6 Helping clients while they wait for CBT
therapeutic. 7 Being human
Thanks as always to all our contributors - if you have 10 Can Wales thrive?
any ideas for future articles, please get in touch. 12 No place like home
”
18 Therapist’s experience of therapy
20 Who benefits from cultural
Peter Elliott adaptations?
Managing Editor
peter.elliott@babcp.com 22 Housing insecurity and mental health
Contributors 28 Deeds not words
Also in this issue
Gail Beacham, Maggie Fookes, Luciana Forzisi, Kuba Grzegrzolka,
Martin Groom, Adela Kacorova, Lucy Maddox, Marcia Manderson,
Saiqa Naz, Paul Salkovskis, Alex Turner
t
From the Presiden
CBT Today is the official magazine of the British Association for
3
Behavioural & Cognitive Psychotherapies, the lead organisation for
CBT in the UK and Ireland. The magazine is published four times a year
Accreditation
and posted free to all members.
Back issues can be downloaded from www.babcp.com/cbttoday 4
Disclaimer 4-5 News
The views and opinions expressed in this issue of CBT Today are those of the individual
Book review
contributors, and do not necessarily reflect the views of BABCP, its Trustees or employees.
Next deadline 13
WCBCT Congress
9.00am on 28 January 2019 (for distribution week commencing 22 February 2019)
14-15
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d SIG
25-27 Branch an
© Copyright 2018 by the British Association for Behavioural & Cognitive Psychotherapies
unless otherwise indicated. No part of this publication may be reproduced, stored in a
workshops
retrieval system nor transmitted by electronic, mechanical, photocopying, recordings or
otherwise, without the prior permission of the copyright owner.
2 December 2018
welcome
From the President:
Being strategic as a special interest group and professional organisation
The BABCP has now formally adopted the up a task force to develop this work, considering the
designation of a professional organisation. This does professional needs of this group across all of our
not replace our original designation as a special regions/countries. Just for starters, the Conference
interest group (which we still are) but rather extends Strategy committee is working on how to do this for
this into the professional area and in doing so the Spring workshops and the Annual Conference.
provides a clearer context for future developments
in relation to professional activity. This shift had In terms of diversity and inclusion, we intend to
already taken place, so we are now recognising it in work closely with the WOMGENE SIG (Women and
order to support our members, activities more Gender Minorities Special Interest Group) and the
effectively in a number of ways. Equality and Culture SIG. This does not mean that we
will be neglecting the other branches and SIGs; the
As a member, you will be familiar with accreditation, need for improving inclusion cuts across all, of
but you may not be aware that over half of all course. Then there is the inclusion of People with
members are now accredited with the BABCP. We Personal Experience (PPE) of MH problems and CBT
accredit courses as well as individuals, with close to (service users, sufferers, their loved ones).
fifty such accreditations being in place, with further
increases in the pipeline. As an organisation we The BABCP has long endorsed the need for PPE
regularly comment on a range of developments involvement, and as our representative on the
such as news stories and professional consultations, EABCT board I am actively working to increase all
representing the views of professionals applying types of inclusion in EABCT activities. We are now
CBT in a wide range of areas. seeking to further strengthen this activity, an effort
being co-ordinated by our Senior Clinical Advisor
Overall, the professional body designation means Lucy Maddox and PPE Board representative Bill
that we will increase our focus on developing and Davidson. We will be looking for further help from
clarifying the scope of professional activities the membership, so again watch out for this,
undertaken by our members in their capacity as CBT alongside our developing policy for public
therapists. We hope that you will agree that the engagement, which will be circulated to the
increased proportion of members whose CBT membership shortly.
informed or focused professional work is not
regulated or recognised by other professional All of this relies on a hard working and dedicated
organisations makes this a particularly important team at head office. I have now had the chance to
development by the BABCP. meet with these amazing people a couple of times;
I’m sure you will all want to join me in thanking
As an organisation we have been involved for some them for their work on our behalf. As the
time now in considering our strategic objectives (our organisation has steadily grown and evolved in
‘mission statement’) as a CBT focused professional terms of its activities, this has been challenging for
group. Following a great deal of background work, our administrative structures. In particular, it has
the Board and National Committees Forum have become clear over the last few years that there are a
recently approved a draft strategic document to be number of potential gaps in the provision of
sent out for consultation by the full membership. So support for membership and professional activities,
please watch both the website and your email, as this mostly filled by head office staff efforts. At its last
two-page document will be headed your way with meeting the Board agreed, following careful
an invitation to comment. We hope to respond to the consideration of a range of detailed briefings, to
feedback we receive and adopt the new strategic embark on a re-organisation of head office provision
plan at the AGM in September. This will then require both in terms of structure and scope. We expect to
the further development of more specific be able to advise you of these improvements and
implementation plans. Once you have seen the how they may impact on the provisions made by
document, we are very keen to hear from people BABCP to you in the next issue of CBT Today. The aim
who might like to be involved in such work at Branch is to increase efficiency, transparency and
and/or national levels. effectiveness in terms of the Associations ability to
meet our strategic objectives. And yours.
A major priority for us in the coming couple of years
is to develop and implement inclusion strategies.
There are several strands to this. A pressing one is to
recognise the importance of Low Intensity therapists
(including PWPs), and towards this end we are
reviewing options for accreditation. We hope to set Paul Salkovskis, BABCP President
Let us know your thoughts by emailing babcp@babcp.com
December 2018 3
Tribute to
Charlie McConnochie
Charlie McConnochie, BABCP’s Senior Accreditation Liaison standards for Course Accreditation,
Officer for many years, retired recently and we would like Accreditation of Supervisors and
to extend our thanks for his many years of service to Trainers, and latterly, standard setting
the Association. for Accreditation of Psychological
Wellbeing Practitioners, Children and
Charlie will be known to many of you, either through his Young People’s Practitioners and
role with BABCP, or his work in CBT and in training for the last Parenting Practitioners.
20 years.
From 2011 onwards Charlie headed a growing team of ALO’s,
He initially trained as a counsellor and was COSCA Accredited, during which time his role evolved to include more
becoming a BABCP member in 1997 and was involved for management while never losing touch with the practical
many years in setting up and providing CBT training to aspects of Accreditation.
counsellors in Scotland through COSCA.
In 2011 Charlie was one of the first members to be awarded
At this time, he was associated with an expansion of interest the distinction of BABCP Fellow, awarded to recognise
in CBT in Scotland across the disciplines. Charlie was a co- members who have made a significant contribution to the
founder of The Centre of Therapy and Counselling Studies in advancement of behavioural and cognitive psychotherapies.
Glasgow and developed the SCOTACS Diploma there in 1995
which is validated by COSCA. Charlie’s contribution will be remembered by those who
worked with him as characterised by his operating style -
The contribution he has made to Accreditation services rigorous, consistent, diplomatic, hardworking, sensitive and
has been significant, as a valuable and valued member of full of integrity. This style was always implemented with
the office team. From his initial appointment as the first Charlie’s great sense of humour and Scottish sociability.
Accreditation Liaison Officer (ALO) he has been closely
involved in developing processes and implementation of We wish him a long, happy and fulfilling retirement.
in brief...
Accreditation
How do I know when to reaccredit?
The new annual online reaccreditation process launched in July 2018. Fully accredited members will
be due to reaccredit every year on the anniversary of their Full Accreditation. The only exception to
this is if you have Supervisor and/or Trainer Accreditation. If this is the case, you will reaccredit on the
anniversary of the latest award.
Calling If you can’t remember when you were Fully accredited, it is easy to check on the CBT Register UK,
East Midlands which is in the Public section of our website under ‘Find a Therapist’. As certificates are no longer
members issued at Reaccreditation, the Register is also where employers and other members of the public
should check your accreditation status.
Our East Midlands branch You will receive an email inviting you to reaccredit. If there is any delay with this, don’t worry, you will
recently held their AGM remain accredited throughout. Accreditation does not automatically expire on your reaccreditation
and they are currently in date and the Accreditation team make several attempts to contact anyone to
need of a branch member resolve any problems before they lapsed. Please only contact the
to fill the vacant Secretary Accreditation Admin office if you have not been invited to reaccredit six
role. If you are a member weeks after your due date.
living in the East Midlands
and you want to know Members with Supervisor and/or Trainer accreditation can check their due
more about how you can date with the Accreditation admin team by emailing
help shape the work of the accreditation.admin@babcp.com or calling 0161 705 4304, option 1, option 2.
branch, please email
east-midlands@babcp.com
4 December 2018
news
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December 2018 5
Having timely access to CBT in the NHS is difficult, writes Martin Groom
Helping clients while
they wait for CBT
People often have to wait longer than they expect treatment. They explained they were under the
or wish. We know this can lead to distress and an impression that seminars were their treatment!
increase in the acuity and chronicity of the problem.
The Leeds IAPT Service developed a series of trans- The seminars all aim to clarify patient and therapist
diagnostic seminars aimed to support people while roles in CBT, introduce trans-diagnostic processes
they wait for CBT. These were initially delivered as a (thinking, behaviour, attention and memory) in the
large group seminar and now as streaming videos. maintenance of psychological distress and provide a
smorgasbord of self-help techniques each relating
Jaime Delgadillo and I researched how attending to a maintenance process.
these seminars impacted on attendance and
outcome. We found the seminars significantly Although each seminar stands up on its own I often
improved treatment retention, but not overall encourage clients to review Manage Your Mind first
improvement symptom reductions at the end of if presenting with a predominately anxious or worry
treatment compared to routine practice. presentation and Do what Matters if the main
problem is low mood. We hypothesised that the
Feedback from attendees was collected and collated seminars would be useful to any common mental
across all seminars and found them highly relevant, health problem. An exception is perhaps PTSD as
helpful and increased their confidence in and processes specific to trauma are not covered in the
understanding of CBT. Importantly many reported materials. For this reason I suggest signposting
that it helped them cope. Anecdotally some clients to alternative resources if PTSD is thought to
attendees made rapid gains. One participant who be the predominant problem.
moved into recovery following attending the
seminars but still awaiting treatment expressed The table below outlines the content of each
surprise when eventually they were offered seminar.
Seminar Title Main Theme Topics covered Role induction and
socialisation across
seminars
Manage Your Mind Worry/negative predictions Worry and rumination; fight and CBT’s are human too and
flight response; attention biases; experience the same phenomena
reasoning biases; the role of
avoidance; intolerance of Setting agendas
uncertainty; rules for living
An empirical approach
Do What Matters Low mood/avoidance Problem definitions in CBT;
experiential avoidance; values Formulation and developing a
assessment; goal setting; TRAP curiosity about what keeps
and TRAC strategy problems going
Cope With Your Feelings Understanding Emotion Feelings and the brain; primary
and secondary emotions;
reasoning biases; attention
biases; maladaptive behaviours;
emotion regulation strategies
Any feedback on this is welcome. You can email Martin at martingroom@nhs.net
Members can access the findings of Martin and Jaime’s research ‘Using Psychoeductaion and Role
Induction to Improve Completion Rates in Cognitive Behavioural Therapy’ in Vol 45 Issue2 of Behavioural
and Cognitive Psychotherapy journal by logging in to the members area of the BABCP website
The three seminars, Mange Your Mind, Do What Matters and Cope with Your Feelings along with the
companion PDF booklet of the same name can be found at
www.leedscommunityhealthcare.nhs.uk/iapt/resources/
6 December 2018
feature
© Andrea Ucini at Anna Goodwin Illustration
Being human
As a therapist, how should I grieve after a
patient’s suicide? asks Lucy Maddox
Social worker Beth lost her patient Toby to Beth (names have been changed for this article) is
a social worker based in the USA. As I interview her
suicide, but didn’t feel entitled to process it over Skype, she rifles through paperwork looking
for an envelope with the name Toby on it, which
as a personal loss. Why do we treat personal contains a photograph, a funeral card and some
drawings. One of the things on Beth’s busy desk is
and professional grief differently, and how a stone, which she tells me Toby had liked to hold
can we support professionals who suffer while he was in group therapy sessions or 1:1s.
Toby had been Beth’s patient, and he died from
traumatic losses? suicide seven years ago.
“I’ll never forget,” she says.“It was a Friday.”
Toby was a day patient on a programme for young
people with complex mental health problems.
“He was refusing to leave my office,” says Beth.“He
was holding his head in his arms and crying and
saying ‘make it stop’.”
Toby was up against a constellation of difficulties.
He had been adopted as a baby by a family with
strong religious beliefs that he did not share and
he struggled with school. He was experiencing low
moods and paranoid thoughts and had taken
“
overdoses. Nonetheless, he was attending the
programme, taking medication and engaging in
talking therapies.
Although recent figures are scarce, it is
estimated that approximately half of “He was sad,” says Beth.“But he was also funny and
sarcastic and a skateboarder and into rock music.
psychiatrists and 1 in 5 psychologists in the He was the cool kid but also incredibly vulnerable.
He was lonely.”
USA experience a patient dying by suicide.
”
Continued overleaf
December 2018 7
feature
impacted,” says Professor Julie Cerel, President of
Being human
“
the American Association of Suicidology and a
suicidologist at the University of Kentucky.“In
Continued Larger studies fact, our work has found that 135 people are
exposed to each suicide; that is, they know the
show person who died. And up to a third of those are
approximately
profoundly impacted.”
40 per cent of Beth’s initial reaction was to throw herself into
work, but the emotional repercussions were huge.
bereaved “I was tremendously sad and shocked and guilty. I
therapists
just remember crying a load. I felt shame. I wasn’t
sleeping well. Then for a year or so afterwards I was
In the weeks before his death, Toby had become
preoccupied with unusual explanations for his
report a unable to make decisions… I checked so much
with other people. I would also worry about what
adoption.“He was really just trying to learn patient suicide I’d have for dinner, because what if I made the
something about being loved and being not loved
and being abandoned,” says Beth. as traumatic. wrong choice? And it took me a while to realise:
wow, this is because I feel like I made a wrong decision
even though the decision wasn’t solely mine.”
”
That Friday, Beth was very worried.“I went to the
psychiatrist and said,‘We either need to send him There is a lack of research into clinician reactions to
to the emergency room or try to admit him to patient suicide, and one big reason is reluctance to
hospital,’” she says. talk about it. Self-blame, shame and – particularly in
the USA – fear of legal action can all be silencing.
Toby was assessed but not admitted overnight.
Other team members thought it would be better “Professionals often feel the same emotions as
for Toby to be at home, with the option of other people who have losses, and have the added
returning if needed. This sort of clinical decision- burden of guilt,” says Cerel.“But the guilt, which is
making can be excruciating, balancing positive often similar to family members’ reactions of
risk-taking with keeping a young person safe. wishing they could have done more, can be
Members of a team don’t always agree on which construed as admission of not doing enough
way to err and Beth disagreed. clinically and could lead to litigation. Most
clinicians do not feel they can be open about their
“When his parents came to pick him up, I said,‘Toby reactions to patient suicide.”
has had a really hard day, he’s not doing well, you
may want to keep an extra eye on him,’” recalls Despite low levels of research, there’s a growing
Beth.“I said,‘Don’t hesitate to call or bring him to body of evidence around professional grief. Dr Jane
the emergency room.’ He left and I said,‘I’ll see Tillman, a psychologist at the Austen Riggs Center
you soon.’” in Massachusetts, conducted an early qualitative
study in the field. She interviewed 12 therapists
Beth was on call that weekend. and found eight common themes in their reactions
to patient suicide, including trauma responses,
“I got a call first thing Saturday saying,‘He’s in the emotional grief reactions, a sense of crisis, effects
intensive care unit, will you come?’” on relationships with colleagues and effects on
work with other patients.
On Friday night, while his family were eating
downstairs, Toby had gone to the bathroom and One participant described feeling “deeply
shot himself. He survived, but with severe brain traumatised”, Tillman recalls.“He noticed that every
damage, and a few days later his life support was time the phone rings in the middle of the night or
turned off. at some unexpected time, he gets this rush of
adrenaline. He says,‘That’s not even how I found
Although recent figures are scarce, it is estimated out about the death of the patient, but even years
that approximately half of psychiatrists and one in later, I think a patient has killed themselves.’”
five psychologists in the USA experience a patient
dying by suicide. In the UK last year there were Larger studies show approximately 40 per cent of
5,821 suicides registered: 10 deaths per 100,000 bereaved therapists report a patient suicide as
people. We know that the effects are devastating traumatic. Common reactions include shame, self-
for family and friends left behind. Less is known blame, horror and a feeling of loss of hope, or else
about the reactions of professionals. What if the thinking that they were somehow naive or
person who has died is your patient? grandiose for thinking they could help.
The ripples of feeling that radiate out from a Tillman thinks that talking is vital – for trainees and
suicide spread widely.“Often people think that qualified professionals.“I often say in workshops,
only a handful of close family members are ‘Raise your hand if you’re a supervisor,’” she says.
8 December 2018
news
“Lots of people raise their hand.‘Raise your hand if you’ve had
any training on what to do if your supervisee has a patient kill
themselves?’ No one raises their hand.
New look journals
Since the Cognitive Behaviour Therapist was launched ten years
“This is not an unexpected horrible thing that only happens to ago, both CBT and the world of academic publishing has
bad clinicians,”Tillman continues.“This is part of being in the changed. Along with our publishers at Cambridge University
field, and we have to find ways to learn about it, so people don’t Press, we decided it was time to refresh the look of tCBT with a
feel so alone. It’s not unusual to be distressed; it’s not a stunning new cover page and logo plus a new clean and easy to
weakness. It’s a terrible part of professional life.” read colour template for articles shared across both the
Cerel thinks grief following suicide is “similar to grief following Cognitive Behaviour Therapist and Behavioural and Cognitive
other sudden deaths, but different in that the people left Psychotherapy.
behind often feel like there is something they could have
directly done to prevent the death. They ask why for extended The aim is to make the journal as attractive as possible both to
readers and authors, reflecting the high quality of the content
periods of time.”
and clinical usefulness of the articles to today’s CBT therapists.
We are also looking into how to make tCBT as accessible to
Beth still thinks about Toby, but didn’t feel safe to talk about
BABCP members as possible. We know from feedback just how
him at work.“I don’t think I felt the right to process it as a valuable some of the articles are to clinicians, but as an electronic
personal traumatic loss. It was a professional traumatic loss but journal that doesn’t land on your
it felt very personal.” doormat on a regular basis, it currently
takes a bit more effort to keep up to
For all the professional and theoretical frameworks, ultimately date on new articles and then to log in
losing a patient to suicide is a bereavement, albeit in a and read or download them.
complicated situation. It brings with it the messy human
emotions of any grief. We hope to add tCBT articles to the
members alerts in the future and in the
Beth understands that – and wants other professionals to as meantime follow the twitter feed for the
well.“We enter into human relationships,” she says.“We bring our journal @theCBTJournal to find out
whole selves to them and so when we have a loss we feel it with instantly about new articles and access
our whole selves too, and that’s okay. People should know it’s full free text version at the CORE links.
okay to grieve and to feel it.”
Advertisement
“How do you recover?” asks Beth.“You don’t. But holding in mind,
‘What do you need as an individual when you’re grieving?’ –
there should be some normalisation around that.”
If you have been affected by any of the issues in this
article, you can contact the Samaritans at 116 123
Dr Lucy Maddox is a consultant clinical psychologist and
writer. After working for many years in NHS inpatient
adolescent services, she now works part time for BABCP
as our senior clinical adviser. She also works clinically for
Action for Children in Bristol and is a visiting lecturer
for UCL.
Lucy has written a popular psychology book on child
development called Blueprint: How our childhood makes us who
we are published in March 2018. She was a British Science
Association Media Fellow in 2013. You can follow Lucy on Twitter
@lucy_maddox
Lucy’s writing does not express the opinion of any of the
organisations she works for in her clinical or academic roles.
This article was not written as part of Lucy’s work with BABCP.
This article was first published by Wellcome on
mosaicscience.com and is republished here under a
Creative Commons licence.
Sign up to the newsletter at
www.mosaicscience.com/#newsletter
December 2018 9
feature
(ABOVE) Lynwen Roberts, Tamsin Speight, David Clark, Julie Evans, Keith Fearns, Maggie Fookes, Stephanie Hastings
Can Wales Thrive?
In February 2018 BABCP wrote an open letter to the The publication of the Matrics, which is based on
the Scottish Matrix, represented a major turning
Welsh Government Health Minister Vaughan Gething point and has been welcomed by those delivering
psychological therapies in Wales.
following the publication of the Matrics Cymru (Welsh
Matrix). The letter once again raised concerns about the The Welsh branches have always acknowledged
the good work of the Welsh Government in
levels of funding identified to deliver the Matrics, but also overhauling mental health provision as a whole.
that the infrastructure to ensure timely and equal access Much has been done to develop an integrated,
holistic mental health service, with aims to cut
throughout Wales to evidence-based psychological waiting times, and to strengthen assessment and
therapies was not yet in place. care planning processes. Appropriate priority has
been given to major issues such as suicide
prevention, and a strength of the Vision in Wales is
the emphasis on using non-mental health services
to promote wellbeing, initiatives that are non-
stigmatising and inclusive.
However it has taken time to enact the vision for
psychological therapies initially set out in The
Welsh Measure (Mental Health) 2010. If delivered,
the Matrics should give us a decent chance of
achieving that, because at its heart are the core
10 December 2018feature
components that have been identified from the mental health is really important to pursue”.
IAPT experience as essential to the provision of
effective treatments – namely early intervention There were many important messages in Professor
from appropriately trained and supervised Clark’s address including some – by now familiar –
practitioners, using an evidence-based treatment economic arguments which bore repeating to a
and collecting regular outcome data to evaluate new audience, and also some interesting new
what we do. conclusions from the recent evaluation of IAPT
data. Importantly to those promoting CBT is the
The concern about funding and infrastructure hypothesis that where patients do not improve or
remains. More money has been made available for recover after treatment it is not necessarily the
mental health services and for psychological treatment itself that has been ineffective, rather it
therapies specifically but we still operate in a is the manner in which it is delivered in particular if
climate of austerity and the concerns raised in patients have waited too long to receive it, or it is
February have not been assuaged by the amount suboptimal because of financial constraints
that has been made available. These financial (arbitrary limits on session numbers) or training or
restrictions impact on all mental health provision. fidelity issues.
Welsh branches therefore feel that the economic Professor Clark went on to deliver the workshop on
argument for the provision of effective treatments CBT for Social Anxiety Disorder which illustrated
“
is even more persuasive, if you have got less in the just what can be done in practice. Tying in nicely
first place it is important to use it well. We are with the theme he outlined the personal and
therefore taking every opportunity to promote economic cost of untreated Social Anxiety
cognitive behavioural therapies and to make the Disorder. The point was powerfully made that Welsh branches
therefore feel
economic case for investing in good access to effective treatment exists and can be life-changing
psychological therapies – both to the Welsh for people who might otherwise struggle in
Government and to the Health Boards who have
ultimate responsibility to develop services.
most spheres of their lives. The treatment model
and structure was presented with an emphasis
that the
on how to achieve those all-important early economic
It was therefore with great pleasure that an
invitation was extended to Professor David Clark to
treatment gains.
argument for
address the School of Psychology at Bangor From our point of view the event was a success the provision of
University on “Thrive: how better psychological and we are very grateful to Professor Clark for his
therapy transforms lives and saves money”. The support. Without a doubt many of the guests who effective
address, repeated the following day ahead of a
workshop on CBT for Social Anxiety Disorder
attend these events already share our aspirations
and are working hard to realise them but the links
treatments is
hosted by the North West Wales Branch, included are valuable nonetheless. We continue to seek even more
dialogue with the people that can influence
persuasive, if
conclusions from the most recent research into
outcomes from IAPT schemes throughout England. funding as we hope they will be interested in the
The local BABCP branch worked in partnership
with the School of Psychology at Bangor University
possibility that full investment in the Matrics could
ultimately save money.
you have got
and the local Health Board to facilitate these less in the first
place it is
events and to make the training available to as Our next opportunity will be on 7 March 2019 in
many local clinicians and trainees as possible. Cardiff when Kate Davidson offers training on
Invitations were extended to both presentations to
suicide and self-harm reduction and will include a
presentation on the Scottish Matrix. Full details will
important to use
heads of services in the local Health Board, and to are available at www.babcp.com/training. it well.
Professor Rhiannon Edwards and Dr Llinos Spencer
”
from the Centre for Health Economics and Maggie Fookes is a CBT therapist in North Wales
Medicines Evaluation at Bangor University. The and a member of the BABCP North West Wales
latter are currently writing the Wellness in Work and CBT4Wales committees.
report for Public Health Wales and the invitation
was therefore timely. The presentations were well
received and seem to have made their mark with
Dr Spencer feeding back after the event that more
information on IAPT would be included in the
Wellness in Work report commenting that:“The
wellbeing of workers is central to productivity and
a strong economy, therefore any improvements in
December 2018 11As a Mental
Health Nurse
prior to training
as a Cognitive
Behaviour
Therapist, I have
always been
reluctant to
make the move
to a team where
clients are
placed on yet
another waiting
list in order to
I believe that this may increase the amount of time setting where the client feels safe – often their own
access much clients find it difficult to attend work or education, home – we are able to explore and formulate
needed may increase the risk of relapse and thus risk emotionally difficult and complex issues.
increasing the negative impact of mental health
treatment, says issues and detrimentally affect the clients’ view of A further benefit of visiting clients at home is
Gail Beacham their ability to cope. becoming aware of their skills, achievements and
strengths. This has made it easier to include a
I have been very lucky to be employed as a Clinical positive formulation as advocated by Helen
Nurse Specialist within the East Cork Home Based Kennerley. The aim of this is to inspire hope,
Treatment Team. This is a small team set up and led increase motivation and encourage clients to face
by Consultant Psychiatrist Dr Catherine McCarthy and tackle often very challenging issues. I am able
and another Clinical Nurse Specialist with a to see clients several times a week if required and
qualification in DBT. Due to minimal resources and have found that this enables them to progress and
covering a large area we have to use our skills in a maintain confidence and motivation in order to
very innovative way. Many clients who attend have practice homework tasks facilitating new learning.
co morbidity. It has been noted by Kessler et al
2005 that 55 per cent of clients have a single DSM- A range of issues have been treated using this
IV diagnosis, 22 per cent have two diagnosis and approach including; Health Anxiety, Generalised
23 per cent have three or more. I believe this Anxiety, Depression, Panic Disorder both with and
demonstrates the need for a multi-skilled approach. without Agoraphobia, Social Anxiety and Intrusive
Thoughts.
After clients are admitted to the team and their
condition stabilised – and if they would benefit In the case of a young client who was newly
from CBT – rather than refer on to another team diagnosed with Bipolar Disorder, once her
we have decided to explore the results of me condition was stabilised it became apparent that
continuing to work with them for a longer period she was also experiencing Social Phobia. She had a
of time. The aim being to promote an improved goal of attending college and was able to avail of
understanding of thoughts, emotions, bodily CBT as part of her treatment plan whilst remaining
sensations and maintenance cycles using under the review of her trusted psychiatrist. Her
individual formulations and to facilitate treatment thoughts and fears of what people thought of her
using evidence-based CBT treatment models. We Bipolar illness were included into her formulation.
then collaboratively explore and plan relapse She reported that random symptoms began to
management. During this time clients will remain make sense. She learned skills to differentiate
under regular psychiatric medical review. between mood changes due to her Bipolar illness
and ones due to her negative automatic thoughts.
As the clients have already been working closely A positive data log was used as part of her
with the team, good therapeutic relationships and recovery and relapse management and she
goals have already been established. We have collaborated in treatment using Clark and Wells’
usually also formed a good relationship with their model for Social Phobia. Following eight sessions
family or carer who may become involved and act of CBT she felt able to attend college.
as ‘co therapist’ in order to continue to support the
client following discharge. Case conceptualisation I believe progress was made so quickly due to her
has already commenced, and due to providing a already having trust in the service and being able
compassionate, non-judgmental approach in a to provide appropriate interventions at the right
12 December 2018feature
time. This view was supported by the client who been a positive experience for staff working within
reported,“CBT came at the right time, due to not the team. However, due to small staff numbers we
being put on a waiting list I was able to work are limited to how many clients we are able to
through my Social Anxiety when I needed to most”. admit to our team.
Impact Future
Client and carer feedback from adopting this As we are a small team we hope to over time increase
approach has so far been positive. Comments our staff and resources and be able to provide home
include;“I never knew what was happening in my based treatment for a larger number of clients. We
body before” from a client with Panic Disorder.“I hope this will reduce the need for clients to be
didn’t know there was something I could do to get admitted to hospital and if admitted reduce the
better” and “all these symptoms finally make sense” amount of time spent. We aim to promote recovery
from a client with health anxiety. Many clients have and build resilience by enabling clients to better
also commented on their relief at not having to tell understand and manage their symptoms.
their story to another stranger. Questionnaires
completed prior to and after treatment show a
reduction of symptoms and importantly no clients Gail Beacham is a Clinical Nurse Specialist in
so far have discontinued treatment. It has also Cobh, County Cork
book review
Manage Your Mind
Gillian Butler, Nick Grey & Tony Hope
Gillian Butler, Nick Grey and Tony Hope have written the third edition of Manage Your Mind with the
purpose of helping people overcome their mental health difficulties and achieve overall wellbeing.
This new version builds on previous versions by including – in addition to traditional CBT concepts –
influences from positive psychology and third wave CBT (Acceptance and Commitment Therapy,
Compassion Focused Therapy and Mindfulness). The main themes of the book are intended to help
us understand ourselves better, to suggest practical techniques to cope with life and feel better, and
to help develop better relationships with others. The authors draw on current literature and research in mental health to offer
practical guidance on how to deal with specific mood related difficulties and stressful life events, and they explain the way our
minds function and how we might get caught up in unhelpful patterns.
Each chapter explains the topic or problem area covered by giving examples of the mental health scenario being explored, uses
clinical examples or life stories, suggests exercises for how to do deal with the difficulties or area discussed, and looks at the
possible blocks to succeeding in the skill. For example, in chapters 20-22, the authors tackle the problem of overcoming difficulties
and how to deal with them. In doing this, they present several examples of approaches that can be helpful, including the need for
change, to face problems and take action, problem solving techniques, and suggest completing exercises (such as mini
experiments or trying out problem solving by taking STEPs) that can help demonstrate the value of the approaches. In chapter 22,
they discuss in detail the problem of stress, its definition, its signs and how to deal with stress.
The authors succeed in achieving their goal of integration by bringing together a wide range of topics and approaches. In
contrast, many other CBT or third wave CBT books tend to be focused on a specific problem area or theoretical model. This book
allows the reader to explore, in one book, a range of difficulties that can coexist at once or at different stages across a lifetime.
Clients to whom I have recommended this book have found it very helpful and empowering. People have commented repeatedly
that they like the book’s use of quotes, examples, summary boxes, exercises, the tone and range of topics.
For clinicians that desire to integrate different approaches and new research into their practice, this book will prove helpful, as it
challenges the notion that practitioners must adhere to one theoretical model.
Luciana Forzisi
December 2018 1314 December 2018
December 2018 15
Working in mental health can be incredibly
Beet the
rewarding, but we are all too aware of the
worryingly high rates of burnout amongst mental
health professionals. The BABCP, alongside other
organisations, are working hard to raise awareness
around compassion fatigue and the need to value
our own wellbeing. Having just completed my
stress and make
training in High Intensity CBT, I tried to use many of
the popular stress-management strategies during
the intensive course, for example, exercise and
yoga. However, one unexpected activity came out
thyme
on top; gardening.
Having worked in target-driven IAPT services,
I am familiar with managing high caseloads and
the dangers of burnout. When I progressed to do
my High Intensity CBT training, I was mindful of
the importance of looking after myself during a
for you
stressful year. During the course, I often felt
incompetent and like an imposter; not an
uncommon experience. As the deadlines
intensified and my caseload was increasing,
I noticed my stress levels rising. Having recently
acquired a small garden, I decided to do some
gardening.
Adela Kacorova The result surprised me; when I was digging,
planting or weeding, the garden became my
takes a look sanctuary. Even though I was never interested in
at gardening as gardening growing up, I came to realise that
looking after growing, living things was incredibly
a stress buster satisfying. I became engrossed in mindful activity
and felt a deep sense of calm. The courgette plant
did not require a risk assessment, the raspberry
bush did not need any empathy and my roses did
not need formulating (just pruning!). In the garden,
I could just ‘be’.
Over the coming months, my partner and I planted
a new lawn, created a flower border and started a
small vegetable patch. Having now finished the
course, I reflect on my experience and
acknowledge that the training was paradoxically
easier than other, less demanding courses I have
done. Whilst gardening cannot take all of the
credit, it proved itself one of my most effective
stress-management strategies. For me, the most
rewarding aspect was the sense of achievement it
gave me.
Sometimes, therapy sessions with clients felt
laborious and it took time to see clients’ symptoms
improve. In contrast, in my garden I quickly saw the
product of my labour and felt instantly uplifted.
Gardening forced me to focus externally, be present
and helped me to leave my work behind. During
the hot summer months, I watered the garden
twice a day which gave me structure and purpose,
mirroring behavioural activation work which we
commonly use when treating depression.
It also forced me out of the house when deadlines
were looming and the more strenuous tasks, like
16 December 2018feature
digging, were good exercise. Such physical activity
not only increases serotonin, but also decreases
cortisol, our main stress hormone. Additionally,
home grown produce can encourage a good
quality, balanced diet and I relished cooking the
organic vegetables which we harvested.
When reflecting on this, I wondered why I found
gardening so helpful. My investigations lead me to
the ‘Biophilia hypothesis’, which suggests that we
all have an innate need to connect to our natural
environment. I found that this hypothesis resulted
in two main theories. Firstly, Roger Ulrich proposed
that by viewing nature, we can support our
physiological recovery from stress and discussed
this in his Stress Reduction Theory (1983).
Fundamentally, he argued that nature can be
beneficial because of its aesthetics, which are
relaxing and can trigger the calming
parasympathetic nervous system response.
Secondly, Stephen Kaplan proposed the Attention
Restoration Theory (1989) which states that nature
allows us to replenish depleted ‘directed’ attention the years and is another option, although waiting
“
(attention that requires effort and is limited). In lists can be a deterrent. Gardening does not require
other words, natural environments are restorative expertise or expensive equipment and studies
for our attention fatigue and can help to decrease
The result
show that people enjoy gardening, even if they did
stress and prevent future stress. not have a prior interest in this area.
In my experience, I can relate to both schools of surprised me; My hope is that this article has planted a seed,
dangled the carrot and will inspire others in our
thought. Being in my garden, watching the bees
pollinating my flowers and the squirrels playing in
when I was profession to take a leaf out of my book and try
gardening or at least increase their contact with
the trees certainly helped me to switch off from digging, planting nature in some form. Personally, I know this is
my day-to-day stressors and the experience always
felt restorative. As well as that, the diversity of or weeding, the something I will continue to do, as I adjust to
working as a qualified CBT Therapist. Gardening is
colours and shapes in the garden was
aesthetically pleasing and I would often happily
garden became a great hobby all year round and with the winter
ahead, there is plenty to be getting on with…
spend an afternoon with a cup of tea, observing my sanctuary.
the natural world.
”
You can find the compassion fatigue resources
My experience appears to be mirrored in the mentioned in Adela’s article at
research literature. In fact, a recent study carried https://www.babcp.com/Therapists/
out with Swedish public healthcare workers Compassion-Fatigue.aspx
showed that nature-based stress management can
decrease burnout and sick leave, as well as
increasing work ability. Different labels have been
used over the years for nature-based interventions,
ranging from ‘therapeutic horticulture’ and
‘ecotherapy’ to ‘green care’.
Regardless of what label we use, everyone has
access to nature in some form and can reap the
benefits, if they wish. Furthermore, gardening can
be an enjoyable, stress-relieving hobby, whether or
not you have a garden. Hanging baskets outside
your window, having plant pots outside your front
door or simply getting indoor plants can make a
huge difference. Balcony gardening is now all the
rage in many urban areas. Community gardening
can also provide a non-threatening space for
individuals to garden together and helps to fight
isolation and loneliness.
Allotment popularity has grown exponentially over
December 2018 17A therapist’s
experience of
therapy
Kuba Grzegrzolka provides CBT Today In light of the pressures placed on to
therapists working within busy target-oriented
with a first-hand experience of the IAPT services, it is important to take into
consideration how the process of therapy is
differences in how the process of therapy experienced by them.
might be experienced by the clinician CBT therapists within IAPT services are observing
delivering CBT as compared to Method of an increasing amount of CBT books, articles, and
treatment protocols that are being published with
Levels (MOL) approach the main aim of making therapy evidence-based
and more effective. Although improving the
current knowledge of CBT is an exciting initiative,
it brings several challenges for therapists.
How do we decide which methods or protocols to
use? How do we keep track of the relentlessly
growing evidence-base? What should we do when
a client’s presentation does not match the
proposed CBT protocol? The protocol-based and
expert-led approach to therapy results in pressure
18 December 2018feature
on the therapist to make the right choices. In A CBT therapist ‘collaboratively’ agrees with the
“
recent years working within IAPT, I have had the client on a homework task that is often based on
opportunity to deliver both low-intensity and high- worksheets e.g. thought record diary. However, the
intensity CBT as well as a therapy known as responsibility of being the expert leads to a sense
Method of Levels (MOL), an emerging of powerlessness when the client does not engage MOL is a
transdiagnostic approach. in between-session work. This is a common
struggle for CBT therapists with clients agreeing to
transdiagnostic
Although I noted effective clinical outcomes with the homework task but not completing it, putting approach to
therapy that is
both approaches, MOL positively impacted on my in minimal effort, modifying the task, or even doing
experience of clinical work and gave me a sense of the task for the therapist rather than for
freedom and fulfilment. I would like to outline
several differences between how these approaches
themselves. This puts the therapist in an
unpleasant ‘teacher’ role reminding the client of
grounded in the
might be experienced by a therapist. the importance of such work. Perceptual
MOL is a transdiagnostic approach to therapy that On the other hand, MOL therapists do not set Control Theory
is grounded in the Perceptual Control Theory homework tasks. By directing the client’s (PCT), which
(PCT), which explains psychological distress as a awareness into internal conflict and relevant
loss of control. An MOL therapist’s stance and higher level goals, a natural process of explains
understanding of the client’s problems are shaped
by the same theoretical principles regardless of the
reorganisation is triggered. Reorganisation is a trial-
and-error process of change in the person’s
psychological
disorder. The therapist delivering MOL helps the hierarchy of goals. This process occurs naturally distress as a
client without the need to offer suggestions or between the sessions giving the client the full
direct them to specific answers. By letting go of control of what they do between the sessions. This loss of control.
their own agenda they become open to the client’s also leads to the therapist’s satisfaction of being
”
perception of the problems. able to observe the client’s independent decisions
and changes both in and out the sessions.
In such a client-led approach the therapist
experiences the freedom and joy of being open to Both approaches have their strengths and
see what unfolds next in the naturally flowing limitations when it comes to therapist’s experience.
conversation. The expert-led CBT, on the other A CBT therapist feels satisfaction when they
hand, puts pressure on the therapist to successfully manage to follow the recommended
idiosyncratically fit the client’s presentation into treatment protocol. However, they might beat
the recommended formulation model and to themselves up and ruminate on the decisions
follow the recommended treatment protocol. This made when things do not go as planned. MOL
leads to the therapist trying to fit the client’s therapists might feel confident and reassured
difficulties into a pre-existing model and as a result knowing that their work is based on a strong
becoming ‘controlling’ of the client and the course scientific theory, though they might need to learn
of the session. to tolerate uncertainty of not having much control
of the therapy process.
Even though PCT is a dense and complex theory
based on mathematical models, the MOL therapist Exchanging my experiences with other MOL
has only two goals – (1) helping the client to talk therapists helped me to realise how MOL makes
about the problem and (2) directing their attention the therapeutic work more exciting. Being able to
to the background thoughts representing observe the change process happening ‘live’ in the
important goals and values. session, results in most clinicians experiencing a
‘buzz’ afterwards. There is rapidly growing
Comparing this to the multiple goals in CBT with at evidence that MOL can be effectively used across a
least twelve different items recommended by the range of mental health problems. It might be an
Cognitive Therapy Scale Revised (CTS-R) to be approach that can help reduce stress levels among
important in therapy, shows a clear difference IAPT staff, increase their job satisfaction, and make
between pressures and complexity of what is the process of therapy more natural. MOL might
expected from therapist, and how this might help to shift away from focusing on protocols and
impact on their sense of fulfilment from therapy. diagnostic clusters of symptoms, to recognising
the individual person and their unique problems.
Being open to what the client wants to talk about
in the session also means the MOL therapist does Jakub (Kuba) Grzegrzolka is a Trainee Cognitive
not need to prepare beforehand. The time used by Behavioural Therapist at Northpoint Wellbeing,
the CBT therapist for session preparation can be Leeds IAPT
used by the MOL therapist for other responsibilities
or for further learning or training. This is
empowering for the therapist because it results in
reduced stress, more control, and reduced
responsibility of potentially bringing the ‘wrong’
agenda item to the session. This is similar with the
between-session work the client engages in.
December 2018 19I have recently completed my MSc in Cognitive At this point in my assessment process I make a
Behavioural Psychotherapy, where my research was point of gathering information about:
centred specifically on the Black, Asian and
Minority Ethnic (BAME) groups, mainly in the UK • Racial Identity
and US, where therapeutic practices are like • Cultural idioms of mental health (how specific
psychotherapeutic practices in the UK, in terms of communities experience their mentally ill health)
service delivery around the mental health needs • Family hierarchical structures
of individuals. • Religious/spiritual beliefs
Cultural Adaptations?
Marcia Manderson asks: Who benefits from
Two of the main categories that my research All the above can strongly influence the client’s
highlighted were: values and beliefs and be integral to the client’s
core beliefs.
• The need for cultural adaptations in CBT
• Which adaptations were effective, and to whom Addressing these cultural nuances allows us to
avoid a breakdown in communication between
The need for cultural adaptations was born out of clients and therapists that can often lead to early
the fact that as migration increases in the UK, many disengagement in the therapeutic process.
cultural groups are not accessing mental health Whilst conducting our assessments questions
services, and mental illness is becoming more could be asked around family migration, hierarchy,
prevalent in the form of depression, anxiety and social stigma, and race. With that in mind
psychosis. This is costing the health service a lot of Psychoeducational material can be adapted to
money, as individuals are failing to access early reflect cultural idioms, and interventions can reflect
intervention services and more serious illnesses are what each individual use as healing within their
arising as a result. Some are not detected until own communities, such as incorporation their
clients are hospitalised with poor mental health religious beliefs and values into the therapeutic
or display help-seeking behaviours that can lead process. If we can ask such questions, that may
to incarceration. seem uncomfortable initially, there is evidence
that clients welcome your interest and tend to
The BAME groups themselves can experience engage better in therapy and recovery rates are
social stigma within their own communities, as higher, as patients are reported to feel understood
having mental distress can bring shame on their and less isolated.
families. This often acts as a barrier to individuals
accessing therapy. Case study
Some of the reasons cited for poor access to Rachel, 19, (not her real name) came to see me in
mental health services were that BAME groups felt 2017, as result of a recent sexual assault. A university
misunderstood by their GP or therapist, and felt student that lived on campus, away from her
they lacked a clear rationale for the given home town.
intervention. There was often a language barrier
between patients and professionals as well as no Initial presentation: Depression
knowledge of westernised mental health Background: Black Caribbean
presentations for BAME individuals. Religion: Practicing Christian
Strong influences: Grandmother, Mother, Father
Something as simple as how we experience mental and Sister
distress in the west (through unhelpful thoughts,
painful emotions), are often experienced as Rachel’s assessment incorporated asking a detailed
somatisations in some cultural groups. Cultural family history, and questions around her parents
idioms of distress can vary between groups, so and grandparent’s values and beliefs. We drew a
how can we become more culturally aware in family tree, so that we could clearly see the
our practices? influences and hierarchy of her family network.
As a therapist, I am passionate around transcultural We discussed Rachel’s personal values and beliefs
ways of working to create a broader understanding and her family’s religious beliefs and cultural
of the needs of BAME groups and generate better values, and there emerged a clash. In session we
therapeutic outcomes rates. noticed that the family values were triggering a
portion of Rachel’s depressive symptoms, as she
I work transculturally as a trauma informed shared some of her family’s cultural values but had
therapist and Cognitive Behavioural assimilated western values into her daily life and
Psychotherapist. As a black female therapist, my her parents had yet to do so, this was a dichotomy
main concern is that by default I am very aware of for her.
many culturally differences in the therapy room,
but I am mindful that this may not be the case for During the initial assessment we discussed race,
all therapists. Rachel’s identity as a young black female and what
that meant to her. She expressed that her religion
However, when I work with some cultural groups I and race were important to her and they were
recognise that I have no knowledge of how their sometimes in contrast, and that she was forced to
cultural nuances affect their daily lives. hide the student life she led from her family as she
20 December 2018You can also read
