CBT Today Vol 46 Issue 4 (Dec 2018)

Volume 46 Number 4 • December 2018

Beet the stress and make thyme for you - Page 16

BABCP Imperial House, Hornby Street, Bury BL9 5BN Tel: 0161 705 4304 Email: babcp@babcp.com

contents Main Feature

www.babcp.com

Volume 46 Number 4 December 2018

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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 from the world of CBT, with our main feature on gardening as a stress buster my particular favourite.

I enjoy getting to spend time in the garden, it is so therapeutic.

Thanks as always to all our contributors - if you have any ideas for future articles, please get in touch.

Peter Elliott Managing Editor peter.elliott@babcp.com

”

Contributors

16 Beet the stress and make thyme for you Gardening to relieve stress

Features 6

Helping clients while they wait for CBT

7

Being human

10 Can Wales thrive?

12 No place like home 18 Therapist’s experience of therapy 20 Who benefits from cultural adaptations?

22 Housing insecurity and mental health 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 CBT Today is the official magazine of the British Association for Behavioural & Cognitive Psychotherapies, the lead organisation for CBT in the UK and Ireland. The magazine is published four times a year and posted free to all members.

Back issues can be downloaded from www.babcp.com/cbttoday

Disclaimer The views and opinions expressed in this issue of CBT Today are those of the individual contributors, and do not necessarily reflect the views of BABCP, its Trustees or employees.

Next deadline 9.00am on 28 January 2019 (for distribution week commencing 22 February 2019)

Advertising For enquiries about advertising in CBT Today, please email advertising@babcp.com. © Copyright 2018 by the British Association for Behavioural & Cognitive Psychotherapies unless otherwise indicated. No part of this publication may be reproduced, stored in a retrieval system nor transmitted by electronic, mechanical, photocopying, recordings or otherwise, without the prior permission of the copyright owner.

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December 2018

3 4 4-5 13 14-15

t From the Presiden Accreditation News

Book review WCBCT Congress

d SIG 25-27 Branch an workshops

welcome

From the President: Being strategic as a special interest group and professional organisation The BABCP has now formally adopted the designation of a professional organisation. This does not replace our original designation as a special interest group (which we still are) but rather extends this into the professional area and in doing so provides a clearer context for future developments in relation to professional activity. This shift had already taken place, so we are now recognising it in order to support our members, activities more effectively in a number of ways.

As a member, you will be familiar with accreditation, but you may not be aware that over half of all members are now accredited with the BABCP. We accredit courses as well as individuals, with close to fifty such accreditations being in place, with further increases in the pipeline. As an organisation we regularly comment on a range of developments such as news stories and professional consultations, representing the views of professionals applying CBT in a wide range of areas.

Overall, the professional body designation means that we will increase our focus on developing and clarifying the scope of professional activities undertaken by our members in their capacity as CBT therapists. We hope that you will agree that the increased proportion of members whose CBT informed or focused professional work is not regulated or recognised by other professional organisations makes this a particularly important development by the BABCP. As an organisation we have been involved for some time now in considering our strategic objectives (our ‘mission statement’) as a CBT focused professional group. Following a great deal of background work, the Board and National Committees Forum have recently approved a draft strategic document to be sent out for consultation by the full membership. So please watch both the website and your email, as this two-page document will be headed your way with an invitation to comment. We hope to respond to the feedback we receive and adopt the new strategic plan at the AGM in September. This will then require the further development of more specific implementation plans. Once you have seen the document, we are very keen to hear from people who might like to be involved in such work at Branch and/or national levels.

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

up a task force to develop this work, considering the professional needs of this group across all of our regions/countries. Just for starters, the Conference Strategy committee is working on how to do this for the Spring workshops and the Annual Conference.

In terms of diversity and inclusion, we intend to work closely with the WOMGENE SIG (Women and Gender Minorities Special Interest Group) and the Equality and Culture SIG. This does not mean that we will be neglecting the other branches and SIGs; the need for improving inclusion cuts across all, of course. Then there is the inclusion of People with Personal Experience (PPE) of MH problems and CBT (service users, sufferers, their loved ones).

The BABCP has long endorsed the need for PPE involvement, and as our representative on the EABCT board I am actively working to increase all types of inclusion in EABCT activities. We are now seeking to further strengthen this activity, an effort being co-ordinated by our Senior Clinical Advisor Lucy Maddox and PPE Board representative Bill Davidson. We will be looking for further help from the membership, so again watch out for this, alongside our developing policy for public engagement, which will be circulated to the membership shortly.

All of this relies on a hard working and dedicated team at head office. I have now had the chance to meet with these amazing people a couple of times; I’m sure you will all want to join me in thanking them for their work on our behalf. As the organisation has steadily grown and evolved in terms of its activities, this has been challenging for our administrative structures. In particular, it has become clear over the last few years that there are a number of potential gaps in the provision of support for membership and professional activities, mostly filled by head office staff efforts. At its last meeting the Board agreed, following careful consideration of a range of detailed briefings, to embark on a re-organisation of head office provision both in terms of structure and scope. We expect to be able to advise you of these improvements and how they may impact on the provisions made by BABCP to you in the next issue of CBT Today. The aim is to increase efficiency, transparency and effectiveness in terms of the Associations ability to meet our strategic objectives. And yours.

Paul Salkovskis, BABCP President

Let us know your thoughts by emailing babcp@babcp.com

December 2018

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Tribute to Charlie McConnochie Charlie McConnochie, BABCP’s Senior Accreditation Liaison Officer for many years, retired recently and we would like to extend our thanks for his many years of service to the Association.

Charlie will be known to many of you, either through his role with BABCP, or his work in CBT and in training for the last 20 years.

He initially trained as a counsellor and was COSCA Accredited, becoming a BABCP member in 1997 and was involved for many years in setting up and providing CBT training to counsellors in Scotland through COSCA. At this time, he was associated with an expansion of interest in CBT in Scotland across the disciplines. Charlie was a cofounder of The Centre of Therapy and Counselling Studies in Glasgow and developed the SCOTACS Diploma there in 1995 which is validated by COSCA. The contribution he has made to Accreditation services has been significant, as a valuable and valued member of the office team. From his initial appointment as the first Accreditation Liaison Officer (ALO) he has been closely involved in developing processes and implementation of

in brief...

standards for Course Accreditation, Accreditation of Supervisors and Trainers, and latterly, standard setting for Accreditation of Psychological Wellbeing Practitioners, Children and Young People’s Practitioners and Parenting Practitioners.

From 2011 onwards Charlie headed a growing team of ALO’s, during which time his role evolved to include more management while never losing touch with the practical aspects of Accreditation.

In 2011 Charlie was one of the first members to be awarded the distinction of BABCP Fellow, awarded to recognise members who have made a significant contribution to the advancement of behavioural and cognitive psychotherapies.

Charlie’s contribution will be remembered by those who worked with him as characterised by his operating style rigorous, consistent, diplomatic, hardworking, sensitive and full of integrity. This style was always implemented with Charlie’s great sense of humour and Scottish sociability.

We wish him a long, happy and fulfilling retirement.

Accreditation How do I know when to reaccredit?

Calling East Midlands members Our East Midlands branch recently held their AGM and they are currently in need of a branch member to fill the vacant Secretary role. If you are a member living in the East Midlands and you want to know more about how you can help shape the work of the branch, please email east-midlands@babcp.com 4

December 2018

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.

If you can’t remember when you were Fully accredited, it is easy to check on the CBT Register UK, which is in the Public section of our website under ‘Find a Therapist’. As certificates are no longer issued at Reaccreditation, the Register is also where employers and other members of the public should check your accreditation status.

You will receive an email inviting you to reaccredit. If there is any delay with this, don’t worry, you will remain accredited throughout. Accreditation does not automatically expire on your reaccreditation date and the Accreditation team make several attempts to contact anyone to resolve any problems before they lapsed. Please only contact the Accreditation Admin office if you have not been invited to reaccredit six weeks after your due date.

Members with Supervisor and/or Trainer accreditation can check their due date with the Accreditation admin team by emailing accreditation.admin@babcp.com or calling 0161 705 4304, option 1, option 2.

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Conversion therapy Memorandum of Understanding Since the release of the latest Memorandum of Understanding (as reported in CBT Today Sep 2018), we are continuing our pledge to do all we can to end conversion therapy. This harmful practice is damaging to LGBTQ individuals, assuming that sexual identity is something that should be ‘cured’. More organisations are continuing to sign up to the pledge and we hope to share more information soon.

BABCP Conference and Workshops 2019 University of Bath, 3 – 5 September The BABCP Scientific Committee invite you to submit proposals for Workshops, Symposia, Clinical Skills Classes, Panel Discussions and Roundtable Debates.

The closing date for submissions is 20 January.

Symposia abstracts must be received by 3 February.

ALSO:

Open Papers and Po ster submissions are op en. The closing date is 25 March.

Go to www.babcp.com/conferences now to submit or to find out more

Podcasts

We hope you enjoyed listening to our series of podcasts ‘Let’s Talk About CBT’. We are developing ideas for future episodes, so watch this space! All podcasts are still available to download at letstalkaboutcbt.libsyn.com

December 2018

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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 or wish. We know this can lead to distress and an increase in the acuity and chronicity of the problem.

The Leeds IAPT Service developed a series of transdiagnostic seminars aimed to support people while they wait for CBT. These were initially delivered as a large group seminar and now as streaming videos.

Jaime Delgadillo and I researched how attending these seminars impacted on attendance and outcome. We found the seminars significantly improved treatment retention, but not overall improvement symptom reductions at the end of treatment compared to routine practice.

Feedback from attendees was collected and collated across all seminars and found them highly relevant, helpful and increased their confidence in and understanding of CBT. Importantly many reported that it helped them cope. Anecdotally some attendees made rapid gains. One participant who moved into recovery following attending the seminars but still awaiting treatment expressed surprise when eventually they were offered

treatment. They explained they were under the impression that seminars were their treatment!

The seminars all aim to clarify patient and therapist roles in CBT, introduce trans-diagnostic processes (thinking, behaviour, attention and memory) in the maintenance of psychological distress and provide a smorgasbord of self-help techniques each relating to a maintenance process.

Although each seminar stands up on its own I often encourage clients to review Manage Your Mind first if presenting with a predominately anxious or worry presentation and Do what Matters if the main problem is low mood. We hypothesised that the seminars would be useful to any common mental health problem. An exception is perhaps PTSD as processes specific to trauma are not covered in the materials. For this reason I suggest signposting clients to alternative resources if PTSD is thought to be the predominant problem.

The table below outlines the content of each seminar.

Seminar Title

Main Theme

Topics covered

Role induction and socialisation across seminars

Manage Your Mind

Worry/negative predictions

Worry and rumination; fight and flight response; attention biases; reasoning biases; the role of avoidance; intolerance of uncertainty; rules for living

CBT’s are human too and experience the same phenomena Setting agendas An empirical approach

Do What Matters

Cope With Your Feelings

Low mood/avoidance

Understanding Emotion

Problem definitions in CBT; experiential avoidance; values assessment; goal setting; TRAP and TRAC strategy

Formulation and developing a curiosity about what keeps problems going

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 suicide, but didn’t feel entitled to process it as a personal loss. Why do we treat personal and professional grief differently, and how can we support professionals who suffer traumatic losses?

Beth (names have been changed for this article) is a social worker based in the USA. As I interview her over Skype, she rifles through paperwork looking for an envelope with the name Toby on it, which contains a photograph, a funeral card and some drawings. One of the things on Beth’s busy desk is a stone, which she tells me Toby had liked to hold while he was in group therapy sessions or 1:1s.

Toby had been Beth’s patient, and he died from 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’.”

“

Although recent figures are scarce, it is estimated that approximately half of psychiatrists and 1 in 5 psychologists in the USA experience a patient dying by suicide.

”

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.

“He was sad,” says Beth.“But he was also funny and sarcastic and a skateboarder and into rock music.

He was the cool kid but also incredibly vulnerable.

He was lonely.”

Continued overleaf December 2018

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feature

Being human Continued

In the weeks before his death, Toby had become preoccupied with unusual explanations for his adoption.“He was really just trying to learn something about being loved and being not loved and being abandoned,” says Beth.

That Friday, Beth was very worried.“I went to the psychiatrist and said,‘We either need to send him to the emergency room or try to admit him to hospital,’” she says.

Toby was assessed but not admitted overnight.

Other team members thought it would be better for Toby to be at home, with the option of returning if needed. This sort of clinical decisionmaking can be excruciating, balancing positive risk-taking with keeping a young person safe.

Members of a team don’t always agree on which way to err and Beth disagreed.

“When his parents came to pick him up, I said,‘Toby has had a really hard day, he’s not doing well, you may want to keep an extra eye on him,’” recalls Beth.“I said,‘Don’t hesitate to call or bring him to the emergency room.’ He left and I said,‘I’ll see you soon.’”

Beth was on call that weekend.

“I got a call first thing Saturday saying,‘He’s in the intensive care unit, will you come?’”

On Friday night, while his family were eating downstairs, Toby had gone to the bathroom and shot himself. He survived, but with severe brain damage, and a few days later his life support was turned off.

Although recent figures are scarce, it is estimated that approximately half of psychiatrists and one in five psychologists in the USA experience a patient dying by suicide. In the UK last year there were 5,821 suicides registered: 10 deaths per 100,000 people. We know that the effects are devastating for family and friends left behind. Less is known about the reactions of professionals. What if the person who has died is your patient?

The ripples of feeling that radiate out from a suicide spread widely.“Often people think that only a handful of close family members are 8

December 2018

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Larger studies show approximately 40 per cent of bereaved therapists report a patient suicide as traumatic.

”

impacted,” says Professor Julie Cerel, President of the American Association of Suicidology and a suicidologist at the University of Kentucky.“In fact, our work has found that 135 people are exposed to each suicide; that is, they know the person who died. And up to a third of those are profoundly impacted.”

Beth’s initial reaction was to throw herself into work, but the emotional repercussions were huge.

“I was tremendously sad and shocked and guilty. I just remember crying a load. I felt shame. I wasn’t sleeping well. Then for a year or so afterwards I was unable to make decisions… I checked so much with other people. I would also worry about what I’d have for dinner, because what if I made the 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.”

There is a lack of research into clinician reactions to patient suicide, and one big reason is reluctance to talk about it. Self-blame, shame and – particularly in the USA – fear of legal action can all be silencing.

“Professionals often feel the same emotions as other people who have losses, and have the added burden of guilt,” says Cerel.“But the guilt, which is often similar to family members’ reactions of wishing they could have done more, can be construed as admission of not doing enough clinically and could lead to litigation. Most clinicians do not feel they can be open about their reactions to patient suicide.”

Despite low levels of research, there’s a growing body of evidence around professional grief. Dr Jane Tillman, a psychologist at the Austen Riggs Center in Massachusetts, conducted an early qualitative study in the field. She interviewed 12 therapists and found eight common themes in their reactions to patient suicide, including trauma responses, emotional grief reactions, a sense of crisis, effects on relationships with colleagues and effects on work with other patients.

One participant described feeling “deeply traumatised”, Tillman recalls.“He noticed that every time the phone rings in the middle of the night or at some unexpected time, he gets this rush of adrenaline. He says,‘That’s not even how I found out about the death of the patient, but even years later, I think a patient has killed themselves.’”

Larger studies show approximately 40 per cent of bereaved therapists report a patient suicide as traumatic. Common reactions include shame, selfblame, horror and a feeling of loss of hope, or else thinking that they were somehow naive or grandiose for thinking they could help.

Tillman thinks that talking is vital – for trainees and qualified professionals.“I often say in workshops, ‘Raise your hand if you’re a supervisor,’” she says.

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.

“This is not an unexpected horrible thing that only happens to bad clinicians,”Tillman continues.“This is part of being in the field, and we have to find ways to learn about it, so people don’t feel so alone. It’s not unusual to be distressed; it’s not a weakness. It’s a terrible part of professional life.”

Cerel thinks grief following suicide is “similar to grief following other sudden deaths, but different in that the people left behind often feel like there is something they could have directly done to prevent the death. They ask why for extended periods of time.”

Beth still thinks about Toby, but didn’t feel safe to talk about him at work.“I don’t think I felt the right to process it as a personal traumatic loss. It was a professional traumatic loss but it felt very personal.”

For all the professional and theoretical frameworks, ultimately losing a patient to suicide is a bereavement, albeit in a complicated situation. It brings with it the messy human emotions of any grief.

Beth understands that – and wants other professionals to as well.“We enter into human relationships,” she says.“We bring our whole selves to them and so when we have a loss we feel it with our whole selves too, and that’s okay. People should know it’s okay to grieve and to feel it.”

“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.”

New look journals Since the Cognitive Behaviour Therapist was launched ten years ago, both CBT and the world of academic publishing has changed. Along with our publishers at Cambridge University Press, we decided it was time to refresh the look of tCBT with a stunning new cover page and logo plus a new clean and easy to read colour template for articles shared across both the Cognitive Behaviour Therapist and Behavioural and Cognitive Psychotherapy.

The aim is to make the journal as attractive as possible both to readers and authors, reflecting the high quality of the content and clinical usefulness of the articles to today’s CBT therapists.

We are also looking into how to make tCBT as accessible to BABCP members as possible. We know from feedback just how valuable some of the articles are to clinicians, but as an electronic journal that doesn’t land on your doormat on a regular basis, it currently takes a bit more effort to keep up to date on new articles and then to log in and read or download them.

We hope to add tCBT articles to the members alerts in the future and in the meantime follow the twitter feed for the journal @theCBTJournal to find out instantly about new articles and access full free text version at the CORE links.

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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

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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 Welsh Government Health Minister Vaughan Gething following the publication of the Matrics Cymru (Welsh Matrix). The letter once again raised concerns about the levels of funding identified to deliver the Matrics, but also that the infrastructure to ensure timely and equal access throughout Wales to evidence-based psychological therapies was not yet in place.

The publication of the Matrics, which is based on the Scottish Matrix, represented a major turning point and has been welcomed by those delivering psychological therapies in Wales.

The Welsh branches have always acknowledged the good work of the Welsh Government in overhauling mental health provision as a whole.

Much has been done to develop an integrated, holistic mental health service, with aims to cut waiting times, and to strengthen assessment and 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 nonstigmatising 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 2018

feature components that have been identified from the IAPT experience as essential to the provision of effective treatments – namely early intervention from appropriately trained and supervised practitioners, using an evidence-based treatment and collecting regular outcome data to evaluate what we do.

The concern about funding and infrastructure remains. More money has been made available for mental health services and for psychological therapies specifically but we still operate in a climate of austerity and the concerns raised in February have not been assuaged by the amount that has been made available. These financial restrictions impact on all mental health provision.

Welsh branches therefore feel that the economic argument for the provision of effective treatments is even more persuasive, if you have got less in the first place it is important to use it well. We are therefore taking every opportunity to promote cognitive behavioural therapies and to make the economic case for investing in good access to psychological therapies – both to the Welsh Government and to the Health Boards who have ultimate responsibility to develop services.

It was therefore with great pleasure that an invitation was extended to Professor David Clark to address the School of Psychology at Bangor University on “Thrive: how better psychological therapy transforms lives and saves money”. The address, repeated the following day ahead of a workshop on CBT for Social Anxiety Disorder hosted by the North West Wales Branch, included conclusions from the most recent research into outcomes from IAPT schemes throughout England.

The local BABCP branch worked in partnership with the School of Psychology at Bangor University and the local Health Board to facilitate these events and to make the training available to as many local clinicians and trainees as possible.

Invitations were extended to both presentations to heads of services in the local Health Board, and to Professor Rhiannon Edwards and Dr Llinos Spencer from the Centre for Health Economics and Medicines Evaluation at Bangor University. The latter are currently writing the Wellness in Work 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

mental health is really important to pursue”.

There were many important messages in Professor Clark’s address including some – by now familiar – economic arguments which bore repeating to a new audience, and also some interesting new conclusions from the recent evaluation of IAPT data. Importantly to those promoting CBT is the hypothesis that where patients do not improve or recover after treatment it is not necessarily the treatment itself that has been ineffective, rather it is the manner in which it is delivered in particular if patients have waited too long to receive it, or it is suboptimal because of financial constraints (arbitrary limits on session numbers) or training or fidelity issues.

Professor Clark went on to deliver the workshop on CBT for Social Anxiety Disorder which illustrated just what can be done in practice. Tying in nicely with the theme he outlined the personal and economic cost of untreated Social Anxiety Disorder. The point was powerfully made that effective treatment exists and can be life-changing for people who might otherwise struggle in most spheres of their lives. The treatment model and structure was presented with an emphasis on how to achieve those all-important early treatment gains.

From our point of view the event was a success and we are very grateful to Professor Clark for his support. Without a doubt many of the guests who attend these events already share our aspirations and are working hard to realise them but the links are valuable nonetheless. We continue to seek dialogue with the people that can influence funding as we hope they will be interested in the possibility that full investment in the Matrics could ultimately save money.

Our next opportunity will be on 7 March 2019 in Cardiff when Kate Davidson offers training on suicide and self-harm reduction and will include a presentation on the Scottish Matrix. Full details will are available at www.babcp.com/training.

Maggie Fookes is a CBT therapist in North Wales and a member of the BABCP North West Wales and CBT4Wales committees.

“

Welsh branches therefore feel that the economic argument for the provision of effective treatments is even more persuasive, if you have got less in the first place it is important to use it well.

” December 2018 11

As 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 access much needed treatment, says Gail Beacham

I believe that this may increase the amount of time clients find it difficult to attend work or education, may increase the risk of relapse and thus risk increasing the negative impact of mental health issues and detrimentally affect the clients’ view of their ability to cope.

I have been very lucky to be employed as a Clinical Nurse Specialist within the East Cork Home Based Treatment Team. This is a small team set up and led

by Consultant Psychiatrist Dr Catherine McCarthy and another Clinical Nurse Specialist with a qualification in DBT. Due to minimal resources and covering a large area we have to use our skills in a very innovative way. Many clients who attend have co morbidity. It has been noted by Kessler et al 2005 that 55 per cent of clients have a single DSMIV diagnosis, 22 per cent have two diagnosis and 23 per cent have three or more. I believe this demonstrates the need for a multi-skilled approach.

After clients are admitted to the team and their condition stabilised – and if they would benefit from CBT – rather than refer on to another team we have decided to explore the results of me continuing to work with them for a longer period of time. The aim being to promote an improved understanding of thoughts, emotions, bodily sensations and maintenance cycles using individual formulations and to facilitate treatment using evidence-based CBT treatment models. We then collaboratively explore and plan relapse management. During this time clients will remain under regular psychiatric medical review.

As the clients have already been working closely with the team, good therapeutic relationships and goals have already been established. We have usually also formed a good relationship with their family or carer who may become involved and act as ‘co therapist’ in order to continue to support the client following discharge. Case conceptualisation has already commenced, and due to providing a compassionate, non-judgmental approach in a

12 December 2018

setting where the client feels safe – often their own home – we are able to explore and formulate emotionally difficult and complex issues.

A further benefit of visiting clients at home is becoming aware of their skills, achievements and strengths. This has made it easier to include a positive formulation as advocated by Helen Kennerley. The aim of this is to inspire hope, increase motivation and encourage clients to face and tackle often very challenging issues. I am able to see clients several times a week if required and have found that this enables them to progress and maintain confidence and motivation in order to practice homework tasks facilitating new learning.

A range of issues have been treated using this approach including; Health Anxiety, Generalised Anxiety, Depression, Panic Disorder both with and without Agoraphobia, Social Anxiety and Intrusive Thoughts.

In the case of a young client who was newly diagnosed with Bipolar Disorder, once her condition was stabilised it became apparent that she was also experiencing Social Phobia. She had a goal of attending college and was able to avail of CBT as part of her treatment plan whilst remaining under the review of her trusted psychiatrist. Her thoughts and fears of what people thought of her Bipolar illness were included into her formulation.

She reported that random symptoms began to make sense. She learned skills to differentiate between mood changes due to her Bipolar illness and ones due to her negative automatic thoughts.

A positive data log was used as part of her recovery and relapse management and she collaborated in treatment using Clark and Wells’ model for Social Phobia. Following eight sessions of CBT she felt able to attend college.

I believe progress was made so quickly due to her already having trust in the service and being able to provide appropriate interventions at the right

feature time. This view was supported by the client who reported,“CBT came at the right time, due to not being put on a waiting list I was able to work through my Social Anxiety when I needed to most”.

been a positive experience for staff working within the team. However, due to small staff numbers we are limited to how many clients we are able to admit to our team.

Impact

Future

Client and carer feedback from adopting this approach has so far been positive. Comments include;“I never knew what was happening in my body before” from a client with Panic Disorder.“I didn’t know there was something I could do to get better” and “all these symptoms finally make sense” from a client with health anxiety. Many clients have also commented on their relief at not having to tell their story to another stranger. Questionnaires completed prior to and after treatment show a reduction of symptoms and importantly no clients so far have discontinued treatment. It has also

As we are a small team we hope to over time increase our staff and resources and be able to provide home based treatment for a larger number of clients. We hope this will reduce the need for clients to be admitted to hospital and if admitted reduce the amount of time spent. We aim to promote recovery and build resilience by enabling clients to better understand and manage their symptoms.

Gail Beacham is a Clinical Nurse Specialist in 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 13

14 December 2018

December 2018 15

Beet the

stress and make

thyme for you Adela Kacorova takes a look at gardening as a stress buster

Working in mental health can be incredibly 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 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 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 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.

The result surprised me; when I was digging, planting or weeding, the garden became my sanctuary. Even though I was never interested in gardening growing up, I came to realise that looking after growing, living things was incredibly 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 2018

feature 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 (attention that requires effort and is limited). In other words, natural environments are restorative for our attention fatigue and can help to decrease stress and prevent future stress.

In my experience, I can relate to both schools of thought. Being in my garden, watching the bees pollinating my flowers and the squirrels playing in the trees certainly helped me to switch off from my day-to-day stressors and the experience always felt restorative. As well as that, the diversity of colours and shapes in the garden was aesthetically pleasing and I would often happily spend an afternoon with a cup of tea, observing the natural world.

My experience appears to be mirrored in the research literature. In fact, a recent study carried out with Swedish public healthcare workers 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’.

“

The result surprised me; when I was digging, planting or weeding, the garden became my sanctuary.

”

the years and is another option, although waiting lists can be a deterrent. Gardening does not require expertise or expensive equipment and studies show that people enjoy gardening, even if they did not have a prior interest in this area.

My hope is that this article has planted a seed, dangled the carrot and will inspire others in our profession to take a leaf out of my book and try gardening or at least increase their contact with nature in some form. Personally, I know this is something I will continue to do, as I adjust to working as a qualified CBT Therapist. Gardening is a great hobby all year round and with the winter ahead, there is plenty to be getting on with…

You can find the compassion fatigue resources mentioned in Adela’s article at https://www.babcp.com/Therapists/ Compassion-Fatigue.aspx

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 17

A therapist’s experience of therapy Kuba Grzegrzolka provides CBT Today with a first-hand experience of the differences in how the process of therapy might be experienced by the clinician delivering CBT as compared to Method of Levels (MOL) approach

In light of the pressures placed on to therapists working within busy target-oriented IAPT services, it is important to take into consideration how the process of therapy is experienced by them.

CBT therapists within IAPT services are observing an increasing amount of CBT books, articles, and treatment protocols that are being published with 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 2018

feature on the therapist to make the right choices. In recent years working within IAPT, I have had the opportunity to deliver both low-intensity and highintensity CBT as well as a therapy known as Method of Levels (MOL), an emerging transdiagnostic approach.

Although I noted effective clinical outcomes with both approaches, MOL positively impacted on my experience of clinical work and gave me a sense of freedom and fulfilment. I would like to outline several differences between how these approaches might be experienced by a therapist.

MOL is a transdiagnostic approach to therapy that is grounded in the Perceptual Control Theory (PCT), which explains psychological distress as a loss of control. An MOL therapist’s stance and understanding of the client’s problems are shaped by the same theoretical principles regardless of the disorder. The therapist delivering MOL helps the client without the need to offer suggestions or direct them to specific answers. By letting go of their own agenda they become open to the client’s perception of the problems.

In such a client-led approach the therapist experiences the freedom and joy of being open to see what unfolds next in the naturally flowing conversation. The expert-led CBT, on the other hand, puts pressure on the therapist to idiosyncratically fit the client’s presentation into the recommended formulation model and to follow the recommended treatment protocol. This leads to the therapist trying to fit the client’s difficulties into a pre-existing model and as a result becoming ‘controlling’ of the client and the course of the session.

Even though PCT is a dense and complex theory based on mathematical models, the MOL therapist has only two goals – (1) helping the client to talk about the problem and (2) directing their attention to the background thoughts representing important goals and values.

Comparing this to the multiple goals in CBT with at least twelve different items recommended by the Cognitive Therapy Scale Revised (CTS-R) to be important in therapy, shows a clear difference between pressures and complexity of what is expected from therapist, and how this might impact on their sense of fulfilment from therapy.

Being open to what the client wants to talk about in the session also means the MOL therapist does not need to prepare beforehand. The time used by the CBT therapist for session preparation can be 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.

A CBT therapist ‘collaboratively’ agrees with the client on a homework task that is often based on worksheets e.g. thought record diary. However, the responsibility of being the expert leads to a sense of powerlessness when the client does not engage in between-session work. This is a common struggle for CBT therapists with clients agreeing to the homework task but not completing it, putting in minimal effort, modifying the task, or even doing the task for the therapist rather than for themselves. This puts the therapist in an unpleasant ‘teacher’ role reminding the client of the importance of such work.

On the other hand, MOL therapists do not set homework tasks. By directing the client’s awareness into internal conflict and relevant higher level goals, a natural process of reorganisation is triggered. Reorganisation is a trialand-error process of change in the person’s hierarchy of goals. This process occurs naturally between the sessions giving the client the full control of what they do between the sessions. This also leads to the therapist’s satisfaction of being able to observe the client’s independent decisions and changes both in and out the sessions.

Both approaches have their strengths and limitations when it comes to therapist’s experience.

A CBT therapist feels satisfaction when they successfully manage to follow the recommended treatment protocol. However, they might beat themselves up and ruminate on the decisions made when things do not go as planned. MOL therapists might feel confident and reassured knowing that their work is based on a strong scientific theory, though they might need to learn to tolerate uncertainty of not having much control of the therapy process.

“

MOL is a transdiagnostic approach to therapy that is grounded in the Perceptual Control Theory (PCT), which explains psychological distress as a loss of control.

”

Exchanging my experiences with other MOL therapists helped me to realise how MOL makes the therapeutic work more exciting. Being able to observe the change process happening ‘live’ in the session, results in most clinicians experiencing a ‘buzz’ afterwards. There is rapidly growing evidence that MOL can be effectively used across a range of mental health problems. It might be an approach that can help reduce stress levels among IAPT staff, increase their job satisfaction, and make the process of therapy more natural. MOL might help to shift away from focusing on protocols and diagnostic clusters of symptoms, to recognising the individual person and their unique problems.

Jakub (Kuba) Grzegrzolka is a Trainee Cognitive Behavioural Therapist at Northpoint Wellbeing, Leeds IAPT

December 2018 19

Cultural Adaptations?

Marcia Manderson asks: Who benefits from

I have recently completed my MSc in Cognitive Behavioural Psychotherapy, where my research was centred specifically on the Black, Asian and Minority Ethnic (BAME) groups, mainly in the UK and US, where therapeutic practices are like psychotherapeutic practices in the UK, in terms of service delivery around the mental health needs of individuals.

At this point in my assessment process I make a point of gathering information about:

Two of the main categories that my research highlighted were:

All the above can strongly influence the client’s 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 The need for cultural adaptations was born out of the fact that as migration increases in the UK, many cultural groups are not accessing mental health services, and mental illness is becoming more prevalent in the form of depression, anxiety and psychosis. This is costing the health service a lot of money, as individuals are failing to access early intervention services and more serious illnesses are arising as a result. Some are not detected until clients are hospitalised with poor mental health or display help-seeking behaviours that can lead to incarceration.

The BAME groups themselves can experience social stigma within their own communities, as having mental distress can bring shame on their families. This often acts as a barrier to individuals accessing therapy.

Some of the reasons cited for poor access to mental health services were that BAME groups felt misunderstood by their GP or therapist, and felt they lacked a clear rationale for the given intervention. There was often a language barrier between patients and professionals as well as no knowledge of westernised mental health presentations for BAME individuals.

Something as simple as how we experience mental distress in the west (through unhelpful thoughts, painful emotions), are often experienced as somatisations in some cultural groups. Cultural idioms of distress can vary between groups, so how can we become more culturally aware in our practices?

As a therapist, I am passionate around transcultural ways of working to create a broader understanding of the needs of BAME groups and generate better therapeutic outcomes rates.

I work transculturally as a trauma informed therapist and Cognitive Behavioural Psychotherapist. As a black female therapist, my main concern is that by default I am very aware of many culturally differences in the therapy room, but I am mindful that this may not be the case for all therapists.

However, when I work with some cultural groups I recognise that I have no knowledge of how their cultural nuances affect their daily lives.

20 December 2018

• Racial Identity • Cultural idioms of mental health (how specific communities experience their mentally ill health) • Family hierarchical structures • Religious/spiritual beliefs

Addressing these cultural nuances allows us to avoid a breakdown in communication between clients and therapists that can often lead to early disengagement in the therapeutic process.

Whilst conducting our assessments questions could be asked around family migration, hierarchy, social stigma, and race. With that in mind Psychoeducational material can be adapted to reflect cultural idioms, and interventions can reflect what each individual use as healing within their own communities, such as incorporation their religious beliefs and values into the therapeutic process. If we can ask such questions, that may seem uncomfortable initially, there is evidence that clients welcome your interest and tend to engage better in therapy and recovery rates are higher, as patients are reported to feel understood and less isolated.

Case study Rachel, 19, (not her real name) came to see me in 2017, as result of a recent sexual assault. A university student that lived on campus, away from her home town.

Initial presentation: Depression Background: Black Caribbean Religion: Practicing Christian Strong influences: Grandmother, Mother, Father and Sister Rachel’s assessment incorporated asking a detailed family history, and questions around her parents and grandparent’s values and beliefs. We drew a family tree, so that we could clearly see the influences and hierarchy of her family network.

We discussed Rachel’s personal values and beliefs and her family’s religious beliefs and cultural values, and there emerged a clash. In session we noticed that the family values were triggering a portion of Rachel’s depressive symptoms, as she shared some of her family’s cultural values but had assimilated western values into her daily life and her parents had yet to do so, this was a dichotomy for her.

During the initial assessment we discussed race, Rachel’s identity as a young black female and what that meant to her. She expressed that her religion and race were important to her and they were sometimes in contrast, and that she was forced to hide the student life she led from her family as she

feature knew they would not approve.

you feel that has affected you?” How can we truly understand each other without this knowledge?

Her family’s’ beliefs about how Rachel should lead her life meant that they influenced her daily life and placed many conditions upon her that she felt she could not attain. One example was that they did not want her to work whilst at university and had stated that they would cease to pay her maintenance if she did not agree. It was their belief that she had everything she needed and that study was enough, she did not need to work or socialise as it lead to ‘untoward behaviour’.

Secondly, we need to address religion and spirituality as part of the assessment process. I feel this is vital when working with cultures different that our own. It may be an important part of their identity, and if we do not involve their religious beliefs into our therapeutic process, the client could easily disengage from therapy as they may feel unseen and misunderstood.

These conditions affected her self-esteem, need for attachment, and increased her risk-taking coping strategies, which led to her depression and eventually a breakdown of her mental health and wellbeing, as she became quite isolated, but still maintained to her family the belief that she was the person they expected her to be.

Thirdly, we need to look at the hierarchy within the family structures of our clients, as many BAME clients come from family structures that are dissimilar from those of clients in the west. As therapists we need to understand how these structures work, and our client’s place within it, to understand the importance and influence of their wider community, traditions and how these family networks impact the client’s beliefs.

Through knowing and asking about Rachel’s family’s beliefs and values, and not just her own values and beliefs, we were able to look at incorporating her need to maintain her religious beliefs, and the values she shared with her family, whilst separating herself from the family’s expectations into her intervention.

I believe our curiosity will always be appreciated by our clients and will enhance the therapeutic alliance between ourselves and BAME communities for the better, to enable us to become truly culturally competent therapists.

We did a lot of cognitive work, around her entrenched unaccommodating negative assumptions and she could eventually find more positive ways of looking at herself and find a way to accept her cultural identity as someone who straddles two cultures residing in a western society. She was able to uncover her own sense of self, as opposed to keeping the self that was trying to please her parents and grandparents, without losing her religious and cultural identity.

When designing a behavioural experiment with Rachel it was important to make it culturally specific. Therefore, her intervention was centred on her religion and her helping with the younger children at her church, as this was important to her, this was incorporated into an activity schedule.

I feel that if her assessment had not incorporated her specific cultural nuances, religious beliefs, genealogy and race, we would not have been able to understand how her mental health had been compromised and how important her culture and maintaining her sense of belonging was. We would not have been able to apply culturally appropriate interventions and I feel the outcome results would have been less positive.

A system change is needed, almost like a 360degree healthcare check, where we need to overhaul training providers to insist that cultural competence is taught and adhered to, as a mandatory module of CBT training. It may be beneficial to deliver training to GPs around how to recognise cultural distress and give them confidence to ask the right questions to make a correct diagnosis. We need to educate communities around how mental health services work in the UK and what mental ill health means, so we can have open dialogues and give clear rationales for specific disorders to reduce the fear around accessing mental health services.

“

The BAME groups themselves can experience social stigma within their own communities, as having mental distress can bring shame on their families.

This often acts as a barrier to individuals accessing therapy.

”

Marcia Manderson is a Therapeutic Counsellor and Cognitive Behavioural Psychotherapist, working for Survivors Manchester as a Trauma Informed Therapist around male sexual abuse and rape and a Cognitive Behavioural Therapist with Lancashire Care Foundation Trust (NHS) in the Mindsmatter Talking Therapy team.

Learning Objectives Firstly, as therapists who work in a multi-cultural society we need to learn how to ask questions that might be uncomfortable to begin with, not be afraid of being deemed as racist or ignorant. We can learn a lot about others by asking questions like,“Does your race influence how you view the world, or equally how you feel others see you?”, “Have you ever experienced racism, and how do December 2018 21

“

Instability and uncertainty about where we live has become an increasing feature of British society.

Alex Turner chats to activists, psychologists and academics about its impact on mental wellbeing

”

In June 2017, Saiqa Naz attended a housing regeneration consultation in her home town Rochdale, a place with some of the highest deprivation rates and one of the highest antidepressant prescribing rates in the country

insecurity and mental health Housing

I worked in the IAPT service in Rochdale for four years and continue to be involved in the community in a voluntary capacity. I do this through my fondness for the town and its wonderful people, so I was dismayed when I found myself surrounded by elderly people crying at this consultation.

They told me they had been excited about going, to give their input into what refurbishments they would like in their existing homes but were told their housing association instead planned to demolish over 500 homes, which would be replaced with around 120 townhouses.

I discovered that the housing association, Rochdale Boroughwide Housing (RBH), only consulted 68 residents about the decision to demolish the homes, which are on the College Bank estate (also known as the Seven Sisters flats) and neighbouring Lower Falinge.

That is 68 people, across two estates totalling 1,200 homes. At College Bank, about 50 per cent of that 22 December 2018

number were also against the idea being proposed, so I wasn’t sure why it was being selected as the preferred option.

RBH received £518,000 from the government for conducting consultations and making plans for the regeneration schemes. They have confirmed that structurally there is nothing wrong with the buildings, but they are planning on demolishing them because it would cost a lot to refurbish them.

Residents have not received independent legal advice. It is highly unlikely that comprehensive risk assessments of those with mental health problems have taken place before housing people in the higher flats.

Residents are to be offered around £6,000 in compensation. Nobody can say whether this will affect people’s benefits. People were also told they would be moved to a ‘town centre’ location.

Nobody knows where these properties are, nor how these proposals affect their tenancies.

More recently I have also been supporting a couple

feature of residents with mental health problems and have seen how regeneration and the threat of losing your home without being told exactly where you will be moved to has had. In CBT, after a comprehensive assessment, we develop a shared formulation to understand the person’s problem and work collaboratively on it – for example, we wouldn’t complete panic induction exercises without the person understanding their problem.

As many of us work with people living in social housing, it is important to be aware of what is happening around the country and the impact it is having on people’s mental health. It is for this reason I invited Alex Turner to write the following article. I would like to add Alex is a freelance journalist but has not received any payment for writing this submission. Thank you Alex!

Pulling the rug Instability and uncertainty about where we live has become an increasing feature of British society. Alex Turner chats to activists, psychologists and academics about its impact on mental wellbeing.

It is an often-spouted cliche that moving house – alongside divorce and the death of loved ones – is one of the most stressful experiences you can go through.

For many people who move voluntarily that may be an exaggeration. But with the interconnected housing crises that have gripped much of the UK over the past few years, housing insecurity, which sees people being forced to relocate, has become more and more common.

With house prices soaring in many areas, research published by the estate agency Knight Frank earlier this year suggested almost a quarter of British households could be renting in the private sector by the end of 2021. In the UK, once a fixed tenancy has expired, most people renting privately can be told to leave with two months notice, in a so-called ‘no-fault eviction’. Government data shows that in 2016-17, 18,750 households in England alone became homeless because of the end of a shorthold tenancy – almost triple the figure for 2010-11.

At the same time social housing has been ebbing away, with overall social rented homes in England reducing by more than 150,000 in the past four years. Most have been sold via Right to Buy, but there has also been widespread demolition.

Campaigners in London, for example, reckon that nearly 8,000 homes could be torn down in the capital over the next 10 years.

The knock-on effects have been stark. There has been a very visible rise in rough-sleeper numbers in most urban areas. Meanwhile almost 80,000 households – up from 49,000 in 2011 and

including more than 100,000 children – were in temporary accommodation during the first three months of 2018.

For increasing numbers of people, especially but not exclusively around London, the experience of temporary accommodation may involve being sent away from their home area, as well as being shunted from one short-term dwelling to another.

Since 2011, councils have also been allowed to discharge their duty to homeless households by finding them a private-rented tenancy, potentially meaning their upheaval doesn't end in a new home that is stable for the long term.

Research published in 2016 by Leeds University's Kate Hardy and her colleague Tom Gillespie, drew attention to the impact such insecure housing can have on mental health. The two academics interviewed 64 people who had approached Newham Council – one of the most prolific local authorities at sending homeless people out-ofborough – with housing issues over late 2015 and early 2016. They found 89 per cent mentioned worsening mental health due to their housing situation – with nine per cent describing suicidal thoughts, more than double the rate among the general population.

"On reflection it might sound stupid, but we were surprised it was so extreme," Hardy recalls. "The question we asked, which a was general health question, was 'Has this experience affected you in any way?' People could have said anything – like their asthma was worse, for instance – and I think if we’d asked directly about mental health we might have had 100 per cent."

In the wake of the research findings, 80 people – including other academics, activists and mental health professionals – attended a meeting in East London last year to discuss the links between housing problems and psychological distress. From the meeting, a new group, the Housing and Mental Health Network, was created, which has since been exploring ways to highlight and address the issue in the longer term.

"Before, when we had a stronger social housing system, periods of homelessness for families tended to end quite quickly – but they can now be living in temporary accommodation for years," says Caroline Bradley, a clinical psychologist active in the network.

"From being a crisis model, it's now long-term, producing chronic levels of stress and pressure, and research indicates this can often outlast the period of homelessness."

A paper Bradley co-authored in 2017 highlighted the developmental risks children who live through Continued overleaf

“

With house prices soaring in many areas, research published by the estate agency Knight Frank earlier this year suggested almost a quarter of British households could be renting in the private sector by the end of 2021

”

December 2018 23

feature Housing insecurity and mental health Continued periods of homelessness and unsettled accommodation can face – exacerbated by their parents' distress, which is harder to conceal if sharing cramped accommodation.

"Instead of seeing mental ill-health as a disorder within someone we are saying, 'You are putting people in unliveable situations and they are having extreme reactions,'" Bradley says of the Housing and Mental Health Network's perspective. "You could make an argument that they are depressed because they all happen to have depression. No – the world they are living in is making then depressed."

While people trapped in the temporary accommodation system face particularly acute strain on their mental health, Bradley acknowledges that regeneration projects which result in demolition of estates can also be traumatic. In London in particular, such schemes have become more controversial, with secure tenants sometimes dispersed far from familiar neighbourhoods, while people who have bought their homes are left unable to access the local housing market because of social housing's inherently lower values.

Nola Edwards, who chairs the residents' association at the Foxhill estate in Bath – which has some of the highest property values outside London – had recent first-hand experience of this process. In June, Foxhill residents won a judicial review quashing outline planning permission to demolish and redevelop up to 542 homes on the estate, because Bath and North East Somerset Council was found not to have considered how traumatic this could be for elderly residents and people with disabilities.

Curo, the housing association in charge of excouncil homes in the city, had withdrawn its plans, which had been proceeding for five years, shortly before the court hearing in the face of protests.

"The regeneration plans definitely affected some people very badly," says Edwards. "Several people were prescribed antidepressants because they struggled so much, while another young woman paid out of her own money for counselling.

"It's the uncertainty; years of it," she adds. "It pulls the rug out from under everything."

Edwards' observations chime with research carried out by Paul Watt, a professor of urban studies at Birkbeck, University of London, who has worked extensively with council estate residents who have been displaced from demolished homes.

"I'm just finished a paper that looked at 46 displacees' experiences," he says. "What is interesting is that nearly three quarters of them were rehoused in the same neighbourhood – they

24 December 2018

weren't being kicked out to John O'Groats – yet many of them, perhaps a third, found the displacement experience traumatic."

Watt – who stresses that he is not a psychologist – describes what he terms 'displacement anxiety', stemming from people's experience of a "ruptured sense of place", during the period when homes are threatened. Afterwards, when people have been rehoused, he adds, it can be as if longstanding communities have been "chucked in the air, and they haven't come together again".

He also notes that consultation processes that do not meaningfully engage residents' options can make the experience worse. At Foxhill, residents complained that initial consultation documents made no mention of potential demolition, meaning people got on board with the scheme and subsequently felt blindsided when they learned they could lose their homes. Elsewhere, such as in Rochdale where two estates are under threat, tenants and residents have reported decisions apparently being made where only a tiny proportion of people have had an input, leaving many others anxious and disempowered.

Regeneration can be done sensitively, Watt points out – and may be necessary when homes are poor in the first place – but that means "starting from a different place". London mayor Sadiq Khan's decision to make funding for schemes in the capital dependent on resident ballots is a step forward, he acknowledges.

"If you're talking about what would improve residents' wellbeing, that's around a whole bunch of things – are there play facilities, are they overcrowded, how responsive is the landlord to doing repairs – that can affect people's mental health," Watt says. "You wouldn’t start with, let's knock these homes down – I’m not against regeneration that improves people's lives, but actions are too often effectively decided before meaningful consultation is put in place."

Bradley, meanwhile, argues that moving the wider conversation about housing and mental health forward means looking beyond how you deal with symptoms, and focusing instead on the structural causes of people's problems.

"The best outcome for mental health is when people live in more equal societies," she says.

"Fundamentally, you cannot expect people to perform in situations that are set up for them not to be able to. There is space for activism, in people getting support from others who have been in similar situations – there are ways to support and go forward, but we can only do so much when we can’t all access secure housing."

feature North East & Cumbria Branch

South & West Wales Branch

presents

presents

CBT for Body Dysmorphic Disorder with Steve Shaw 1 February 2019 Newcastle

Integrating Schema and CBT Practice with Dr Arnie Reed 15 & 16 May 2019 Port Talbot

Trauma Focused Cognitive Therapy for PTSD with Dr Nick Grey 10 & 11 April 2019 Grasmere

To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com

Compassion Special Interest Group

Equality & Culture SIG

presents

presents

Compassion Focused staff support and supervision

Why behaviour change is required for inclusion and all of our wellbeing

with Kate Lucre

and launch of Special Issue of the Cognitive Behaviour Therapist ‘Cultural Adaptations of CBT’ 26 January 2019 Manchester

14 March 2019 Birmingham December 2018 25

CBASP SIG presents

CBASP Intensive Training three-day workshop with Marianne Liebing-Wilson, Dr Massimo Tarsia, Erin Graham & Jonathan Linstead 30 January – 1 February 2019 Barnsley

presents

Working with suicidal thinking and self-harm behaviour & Scottish Matrix update with Professor Kate Davidson 7 March 2019 Cardiff

To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com

East Midlands Branch & DBT SIG

Couples SIG

presents

presents

Group Supervision and Networking for Couples Therapists 21 January 2019

Couples Based Interventions for treating Eating Disorders with Melanie Fischer Phd 8 February 2019

Integrating CBT and Third Wave Therapies – a two-day workshop with Dr Fiona Kennedy 18 & 19 March 2019 Derby 26 December 2018

Both events will be held in London

branches and special interest groups Liverpool Branch

Eastern Counties Branch

presents

presents

Compassion Focused Therapy from the inside out

Treating Disgust across the Disorders

with Tobyn Bell

with Professor David Veale 21 March 2019 Ipswich

6 February 2019 Crosby To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com

East Kent Coastal Branch

Devon & Cornwall Branch

presents

presents

Treating Body Dysmorphic Disorder and body image problems With Professor David Veale

Compassionate Supervision with Tobyn Bell 25 January 2019 Buckfast

21 February 2019 Faversham

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branches and special interest groups

Deeds not words It has been just over a year since Saiqa Naz was elected chair of BABCP’s Equality and Culture Special Interest Group. Here she takes this opportunity to reflect upon her learning with CBT Today readers.

I often say to people that I was a bit naive about what I initially thought the focus of my role would be. One of my plans was to trawl through the resources used by IAPT services to work with BAME communities across England and prepare a resource pack to share with everyone. But that has proved to be difficult and I have had to remove my rose-tinted glasses as often therapists have looked to me to develop and provide them with resources.

Other therapists lack confidence in working with people from different cultural backgrounds to themselves and do not feel supported by their services. It has got me wondering that with IAPT celebrating it's tenth anniversary this year having received substantial amounts of funding over the past decade, why are therapists expected to work with diverse communities without adequate support and resources? By adequate I mean basic therapy worksheets translated into other languages...grrr!

Some services may argue that their figures show their services are performing well with BAME communities, for example. If this was the case, then why are BAME communities still typically underrepresented in primary care and overrepresented in secondary care? The trend should surely be the opposite? Who is monitoring the number of men, or people with hearing or visual impairments receiving therapy? What concerns me most is that nobody in a position of authority i.e. in the government do not seem to be asking these important questions around inclusion and pushing for solutions, as the status quo is not working.

This leads me on to what is now the focus of the Equality and Culture SIG work. It really is a shame to have to do this, but we are reminding therapists and mental health services of their duty of care to all communities. It is all of our responsibility to ensure we have adequate training, resources and ongoing support to work with all diverse communities whether that be men, the BAME community, LGBT community, working class people, elderly or those who require other adjustments.

There would be an uproar if medical professionals were expected to operate on patients without the correct tools. Why should mental health be any different? We are, after all, advocating for parity of esteem between physical and mental health. It is the responsibility of service managers to develop good working relationships and work more collaboratively with commissioners to ensure their services receive adequate funding to meet the needs of all service users that are representative of the local population and provide high quality care for all. I will take this opportunity to remind us all that we have a legal obligation to help all those covered under the protected characteristics of the Equalities Act 2010.

Members of the Equality and Culture SIG are delivering workshops to give therapists confidence in developing cultural competency and updating the IAPT Positive Practice Guide.

Services need to develop resources. Commissioners need to either allocate more funding or ring-fence existing funding to be 28 December 2018

used towards working with other communities. It is frustrating when those in charge of policies and funding talk about the importance of doing more for BAME mental health and other underrepresented groups without having serious conversations around the resources required to do the work. Emmeline Pankhurst’s motto ‘Deeds not words’ comes to mind!

My fear is that with IAPT expanding into physical health conditions, the inequalities of core IAPT will be overlooked and unresolved, and yet again underrepresented groups will further be disadvantaged in the new integrated pathways. The more IAPT expands and the longer the agenda of inclusion is overlooked, the more ingrained inequality will be in mental health services and the harder it will become to redress these inequalities.

We cannot use stigma as an excuse and lay the blame on diverse communities for being underrepresented in primary care mental health services and overrepresented in secondary care. Stigma also exists is White British communities. We need to broaden our minds and question what other factors are contributing to mental health inequalities. Perhaps we need to take a closer look at ourselves first. I believe that is where the answers lie.

Saiqa Naz, Chair BABCP Equality & Culture Special Interest Group You can follow Saiqa on Twitter @saiqa_naz To join the Equality & Culture SIG please email equality-sig@babcp.com Saiqa previously authored ‘Working with Diversitywhose responsibility is it and what needs to change?’ which was published in the February 2018 issue of CBT Today.

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